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Comparing Levonorgestrel IUDs


Recorded on September 20, 2023 at 8 pm ET

FREE for ObGFirst® Members and ObG Resident CORE™ Members!

Includes CME


Faculty: Natasha Schimmoeller MD
Moderator: Karla Loken, DO

Free for ObGFirst members & ObG Resident CORE™ Members

Please here to register


Not an ObGFirst member?

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What is ObG GrandRounds Live™?  

ObG GrandRounds Live is a monthly, virtual Grand Rounds experience jointly provided by Postgraduate Institute for Medicine and the ObG Project

  • Free for ObGFirst Members
  • Including top speakers with panel discussions and Q&A opportunity  
  • Women’s Health topics that are practical and will impact your practice  
  • Can’t make the live event?  It will be recorded
  • Want CME? Instructions will be sent out to registrants following the live event 

ObG GrandRounds Live is FREE for ObGFirst® Members and ObG Resident CORE™ Members:  

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high-quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:

Natasha Schimmoeller, MD has nothing to disclose
The PIM and ObGProject planners and others have nothing to disclose

Joint Accreditation Statement

This image has an empty alt attribute; its file name is Joint-Accreditation-Logo2.png

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education 

Postgraduate Institute for Medicine designates this live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

ACOG Clinical Consensus on the Treatment of Urinary Tract Infections in Pregnancy 

SUMMARY:   

Urinary tract infections (UTIs) are one of the most common infections in pregnancy, occurring in about 8% of all pregnancies and range from asymptomatic bacteriuria to acute pyelonephritis. They are associated with adverse pregnancy outcomes such as preterm birth and low birth weight, therefore the timely identification and treatment of these is essential. Anatomic changes during pregnancy increase the risk for UTIs, such as ureteral dilation, the mechanical compression of ureters by the uterus causing urinary stasis, contributing to bacteria colonization and ascending infection. E coli remains the most common identified pathogen. Given the high rates of antibiotic resistance to this organism, the selection of first line therapy must avoid antibiotics such as  amoxicillin and ampicillin. Treatment of symptomatic bacteriuria decreases the risk of pyelonephritis, which can cause significant maternal complications such as DIC and ARDS, as well as fetal complications such as preterm birth. Patients with hemoglobinopathy have higher rates of cystitis and asymptomatic bacteriuria.

Recommendations  

Asymptomatic Bacteriuria (ASB) 

  • Screen once early in pregnancy  
  • If culture ≥100,000 CFU/mL treatment should be started with antiobiotics adjusted once culture results are available if necessary 
    • Cefalexin: 250 to 500 mgs q6hr po 5 to 7 days  
    • Fosfomycin: 3 g po once  
    • Amoxicillin: 500 mg po q8hr for 5 to 7 days | 875 mg po q12hr for 5 to 7 days | Avoid starting prior to culture results due to high resistance  
    • Amoxicillin-clavulanate: 500 mg po q8hr for 5 to 7 days | 875 mg po q12hr for 5 to 7 days | Avoid starting prior to culture results due to high resistance 
    • ‘Reasonable to offer’ if no other alternatives available  
      • Nitrofurantoin: 100 mgs q12hr po 5 to 7 days 
      • Sulfamethoxazole-trimethoprim: 800/160 mgs q12hrs po 5o to 7 days 
    • Insufficient evidence for repeat screening following treatment  
  • Presence of Group B strep 
    • Treat if ≥100,000 CFU/mL 
    • If <100,000 CFU/mL do not treat but it is an indication for group B streptococcus prophylaxis at the time of delivery 

Note: Low risk for anaphylaxis, cephalosporin treatment is appropriate | High risk for anaphylaxis should be treated with alternative regimen  

Acute Cystitis 

  • Initiate treatment for symptomatic relief based on the following  
    • Clinical signs: Dysuria | Hematuria | Frequency | Nocturia  
    • Urinalysis: Consistent with UTI 
  • Confirmed by urine culture of ≥100,000 organisms  
  • Treatment regimen is the same as ASB  (see above) 
    • If symptoms persist  
      • Repeat cultures  
      • Consider daily prophylaxis preferably single daily dose if recurrent infection (≥2 UTIs during pregnancy)  

Pyelonephritis 

  • Signs and symptoms  
    • Fever ≥38° degrees C | Nausea and vomiting  
    • Flank pain | CVA tenderness | Renal ultrasonography abnormalities  
    • CBC: Leukocytosis | Bandemia | thrombocytopenia | Anemia  
    • Abnormal urinalysis  
    • May present with preterm labor or severe sequelae (e.g., sepsis)  

Note: Remain suspicious even if only some of the above is present (e.g., fever and UTI)  

  • Inpatient treatment recommended for fluid hydration and empiric antibiotics   
  • Start parenteral antibiotics prior to culture report  
    • Ampicillin 2g IV q6hr and gentamycin 1.5 mg/kg q8hr or 5 mg/kg IV q24hr 
    • Ceftriaxone 1g IV q24hr 
    • Aztreonam (can be used with beta-lactam allergy) 1g IV q8 to 12hr  
    • Cefepime 1g IV q12hr 
  • Adjust antibiotics as needed after urine culture results are available    
  • 14 day total course of therapy 
  • Follow up suppressive therapy may be considered  

KEY POINTS:   

  • Asymptomatic bacteriuria 
    • Screen as early as possible 
    • No evidence for repeating screening during pregnancy, including diabetes or spinal cord injury  
    • Routine dipsticks are not clinically useful and do not detect ASB 
    • A midstream urine culture is recommended 
      • Clean catch specimens do not decrease perineal contamination   
  • Cystitis
    • Leukocyte esterase or pyuria has a 97% sensitivity but not specific, due to white cells normally found in vagina/vulva 
    • Nitrates are 94 to 98% specific, but not all bacteria produce nitrates 
    • Use of antibiotics should be guided by sensitivities and safety profiles 
    • Nitrofurantoin is a reasonable first line treatment choice 
      • Patients with known G6PD deficiency should avoid this antibiotic  
    • Recurrent UTIs occur in 4% to 5% of pregnancies and suppressive regimens include 
      • Nitrofurantoin: 100 mg daily  
      • Cephalexin 250 to 500 mg daily  
  • Pyelonephritis 
    • Can cause preterm labor, labor, ARDS, sepsis, acute renal insufficiency 
    • Differential diagnosis includes  
      • Nephrolithiasis 
      • Chorioamnionitis 
      • Renal abscess 
      • Urosepsis without pyelonephritis 
    • Blood cultures may not be clinically useful 
    • Majority of patients have clinical improvement in 48 to 72 hours 
    • Recurrent pyelonephritis occurs in 25% of patients before delivery 
    • Consideration of a daily suppressive therapy is the same as for cystitis 

Primary Sources – Learn More  

ACOG Clinical Consensus 4: Urinary Tract Infections in Pregnant Individuals 

Reasonable Accommodations for Pregnant Workers 

Effective on June 27, 2023, the Pregnant Workers Fairness Act (PWFA) is a new law that requires covered employers to provide “reasonable accommodations” to a worker’s known limitations related to pregnancy, childbirth, or related medical conditions, unless the accommodation will cause the employer an “undue hardship”. Covered employers are private and public sector employers with at least 15 employees, Congress, federal agencies, employment agencies, and labor organizations. The law is limited to accommodations only. Other laws cover discrimination against workers on the basis of pregnancy, childbirth, or related medical conditions. It also does not replace other state or federal law that protect pregnant workers.  

Reasonable accommodations could include but are not limited to  

  • The ability to sit or drink water
  • Receive closer parking
  • Flexible hours 
  • Appropriately sized uniforms and safety apparel 
  • Additional break time to use the bathroom, eat, and rest 
  • Take leave or time off to recover from childbirth 
  • Be excused from strenuous activities and/or activities that involve exposure to compounds not safe for pregnancy 

The employer and worker must discuss the accommodation before the worker is required to accept it. The employer cannot deny a job or other employment opportunities to a qualified worker based on the need for a reasonable accommodation.  

Employers are required to provide reasonable accommodations unless they would cause an undue hardship on the employer’s operations. Therefore, an employer must demonstrate significant difficulty or expense before denying the accommodation.  

The Equal Employment Opportunity Commission (EEOC) will be charged with investigations under this act.  

Resources 

What You Should Know About the Pregnant Workers Fairness Act https://www.eeoc.gov/wysk/what-you-should-know-about-pregnant-workers-fairness-act 

Pregnancy During Surgical Training: Are Residency Programs Truly Supporting Their Trainees? (Castillo-Angeles et al., 2022) 

ACOG Committee Opinion 733: Employment Considerations During Pregnancy and the Postpartum Period

ISPD Guidance on the Use of Non-Invasive Prenatal Testing for Chromosomal Conditions in Singleton Pregnancies 

SUMMARY:   

The ISPD consensus statement addresses screening using NIPT for the detection of chromosomal conditions in singleton pregnancies. NIPT for the three most common aneuploidies can be used as either a first line screening test for all pregnant individuals or as a follow up screen for those at high risk by serum analyte screening. A baseline sonogram to document viability, gestational dating, and to evaluate the number of fetuses should be performed prior to screening.  

What Is Cell-free DNA Screening? 

  • NIPT is a blood test that utilizes cell-free DNA technology to predict the risk for fetal genetic disorders during pregnancy 
  • In 2011, NIPT was introduced as a screen for T21 (Down syndrome) 
  • Today, NIPT for prenatal screening cover the most common aneuploidies (T21, T13 and T18), as well as sex chromosomes and may also include some microdeletions and single gene genetic disorders 

How Does It Work? 

  • DNA fragments can be found floating in the blood of all individuals 
  • In every pregnant person, there is DNA from 
    • Maternal fragments 
  • Fragments of placental DNA felt to reflect the fetal contribution 
  • Fetal Fraction 
    • The percentage of fetal DNA found in maternal blood is known as the fetal fraction | Typical range 3% to 13% of maternal cfDNA 
    • The fetal fraction is critical to the success of testing | Minimum required approximately 2% to 4% 
    • Sensitivity drops with lower fetal fraction and if too low, test failure will result 
  • Testing is usually performed at about 10 weeks gestation, but can be performed until term 

Indications  

  • Common fetal aneuploidies 
    • Trisomy 13, 18, and 21 
    • NIPT is the most accurate screening test for these aneuploidies and can therefore be offered in primary or contingent screening models 
  • Sex chromosome aneuploidies 
    • May be added after appropriate counseling 
  • Insufficient data to implement for 
    • Rare autosomal trisomies 
    • Submicroscopic deletions 
    • Duplication/deletion syndrome 

Laboratory Issues 

  • False positive results can occur 
  • Pathways should be established to manage a ‘no call’ result, in which a result cannot be obtained due to a low fetal fraction 
    • No call results are associated with aneuploidies or other adverse outcomes 
    • Can be associated with a maternal malignancy or fibroids 
  • Diagnostic testing should be offered with chromosomal microarray if  
    • Fetal anomaly is seen 
    • Nuchal translucency measurement is ≥3.5 mm 

KEY POINTS:  

NIPT for screening for fetal aneuploidy screening    

  • Should be implemented as a first line screening test for the common aneuploidies (T21, T13 and T18)  
  • Should be offered to an individual found to be at high risk for aneuploidy 
  • Sex chromosome aneuploidy screening can be added if appropriate prenatal counseling is performed 
  • Pretest counseling should be available 
  • Downstream clinical services should be available for a screen positive test result 
  • Confirm positive screening results with invasive testing  

Learn More- Primary Sources 

Position statement from the International Society for Prenatal Diagnosis on the use of non‐invasive prenatal testing for the detection of fetal chromosomal conditions in singleton pregnancies 

Vasa Previa: Risk Factor, DX, and Management


July 19, 2023 at 8 pm ET

FREE for ObGFirst® Members and ObG Resident CORE™ Members!

Includes CME


Faculty: Andrei Rebarber, MD
Moderator: Brian Hines, MD

Free for ObGFirst members & ObG Resident CORE™ Members

Please here to register


Not an ObGFirst member?

Subscribe Now! Click here for a free month trial ($9 monthly subscription post-trial – cancellable at any time)

What is ObG GrandRounds Live™?  

ObG GrandRounds Live is a monthly, virtual Grand Rounds experience jointly provided by Postgraduate Institute for Medicine and the ObG Project

  • Free for ObGFirst Members
  • Including top speakers with panel discussions and Q&A opportunity  
  • Women’s Health topics that are practical and will impact your practice  
  • Can’t make the live event?  It will be recorded
  • Want CME? Instructions will be sent out to registrants following the live event 

ObG GrandRounds Live is FREE for ObGFirst® Members and ObG Resident CORE™ Members:  

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high-quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:

Andrei Rebarber, MD has nothing to disclose
The PIM and ObGProject planners and others have nothing to disclose

Joint Accreditation Statement

This image has an empty alt attribute; its file name is Joint-Accreditation-Logo2.png

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education 

Postgraduate Institute for Medicine designates this live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

ASRM Guideline: Preimplantation Genetic Testing for Monogenic Disorders 

SUMMARY:  

Preimplantation genetic testing (PGT) for monogenic disorders (M) is a form of preimplantation genetic diagnosis. It is an adjunct to assisted reproductive technology (ART) using in vitro fertilization (IVF) to evaluate embryos by genetic testing, preventing the inheritance of serious disorders in the majority of cases. Because of the wider use of prenatal and preconception genetic carrier screening, more disorders are being identified by PGT-M.  

What is Preimplantation Genetic Testing? 

  • Most often, it consists of a biopsy performed at the blastocyst stage, allowing 5 to 10 cells to be removed for further genetic testing. The goal is to identify unaffected embryos for transfer. There are different types of testing, depending on genetic disorder that is being assessed. 

PGT-M  

  • Most complex form of PGT 
  • PGT-M should always be considered an optional test 

Indications 

  • Severe childhood onset conditions  
    • Constitutes the majority of indications for PGT-M   
    • Generally there is a lack specific treatment or intervention, such as Tay Sachs disease 
  • HLA matching  
    • PGT-M is used to identify embryos that have a compatible human leukocyte antigen (HLA) match to become a potential HLA matched stem cell donor to a recipient sibling affected with a specific hematopoietic disorder 
    • PGT-M is then also used to test the embryos for the same disorder to prevent an affected embryo from being transferred   
    • HLA are autosomal recessive, therefore, each sibling has a chance of a 25% match with another sibling, given the same parents 
  • Adult-onset conditions 
    • PGT-M can be used to identify significant adult-onset conditions, such as HBOC 

Key Points 

  • Genetic counseling  
    • Pretest genetic counseling is essential and should include information about the potential identification of incidental findings 
    • Patients may benefit from genetic counseling once PGT-M results are available, to help guide decision making regarding embryo transfer 
  • Prenatal diagnosis should be offered to all patients who have undergone PGT-M both to confirm the testing results and to screen for other genetic conditions not tested for with PGT-M 
  • PGT-M is not recommended for disorders in which there is no clinical utility, such as variants of unknown significance (VUS

Learn More- Primary Sources: 

ISPD: Indications and management of preimplantation genetic testing for monogenic conditions: a committee opinion. 

ACOG Guidance: Female Sexual Dysfunction

SUMMARY:

Female sexual dysfunction is relatively prevalent. Approximately 43% of American women report sexual problems. However, women are unlikely to report sexual dysfunction with providers unless asked. Dysfunction includes various conditions which report personal distress in one or more of the following areas: desire, arousal, orgasm, or pain. 

  1. Types of Sexual Dysfunction
  2. Possible Etiologies
  3. Clinical Considerations and Recommendations
  4. Treatment 

Types of Sexual Dysfunction (DSM-5)  

Female Sexual Interest/Arousal Disorder 

  • Lack of or significant decrease in 
    • Interest in sexual activity 
    • Erotic thoughts or fantasies 
    • Excitement or pleasure during sexual activity 
    • Genital or non-genital sensations during sexual activity 

Female Orgasmic Disorder 

  • Often related to new onset of other conditions 
    • Medical |Anatomic | Relational | Behavioral |Psychologic  
  • Changes related to orgasm include 
    • Marked delay | Infrequency | Absence | Reduced intensity of orgasmic sensations 

Genito-pelvic Pain/Penetration Disorder 

  • Previously vaginismus and dyspareunia 
  • Can be lifelong or acquired 
  • One or more of the following 
    • Difficulty having intercourse 
    • Severe pain during intercourse 
    • Severe fear or anxiety about pain anticipating, during and/or resulting from vaginal penetration 
    • Tensing or tightening of the pelvic floor muscles during attempted vaginal penetration 

Substance/Medication-Induced Sexual Dysfunction 

  • Disturbance in sexual function that occurs during or soon after changes in substance and/or medication known to have the capacity to induce sexual changes 

Other Specified or Unspecified Sexual Dysfunction 

  • Distressing symptoms characteristic of sexual dysfunction that do not meet the criteria of one of the DSM-5 defined categories 
  • Pregnancy-related sexual dysfunction 
  • Menopausal-related sexual dysfunction 

Possible Etiologies  

  • Hypertension 
  • Diabetes 
    • Chronic high blood glucose is linked to decreased desire, arousal, and orgasm 
  • Medications 
  • Postpartum period 
  • Medication 
    • Psychiatric drugs, including but not limited to: Antidepressants | Lithium |Risperidone 
    • Cardiovascular drugs 
    • Antihistamines  
    • Naproxen 

Clinical Considerations and Recommendations

Screening 

  • Initiate a clinical discussion of sexual function during routine care visits 
  • If possible sexual dysfunction presents, an extended visit may be required including 
    • Comprehensive sexual history 
    • Physical examination to evaluate for gynecologic etiologies 
  • Laboratory testing typically not necessary 

Diagnosis 

  • Made according to the DSM-5 and classified as female sexual dysfunction when symptoms persist for at least 6 months 
    • Exception: substance and/or medication-induced sexual dysfunction 
  • Symptoms must result in significant personal distress 
  • Women often experience more than one type of female sexual dysfunction simultaneously 
  • A woman may still benefit from evaluation and treatment even if their symptoms do not meet DSM-5 criteria 

Treatment 

Psychologic Interventions 

  • Sexual skills training | Cognitive-behavioral therapy | Mindfulness-based therapy | Couples therapy 
  • Patient should consult a mental health professional having expertise in treating female sexual dysfunction 

Estrogen Therapy 

  • Low-dose vaginal estrogen therapy is preferred for female sexual dysfunction due to genitourinary syndrome of menopause (GSM) 
    • Vaginal tablets | Gels | Creams | Rings 
    • All equally effective  
  • Low-dose systemic hormone therapy can be a viable alternative 

Transdermal Testosterone 

  • Mixed evidence on the safety and efficacy of androgen therapy for female sexual dysfunction 
  • Testosterone is not FDA approved for female sexual dysfunction 

Sildenafil Citrate 

  • Should not be used outside of clinical trials 

Filbanserin 

  • A serotonin receptor agonist/antagonist 
  • FDA approved for treatment option for hypoactive sexual desire disorder in premenopausal women without depression 
  • Alcohol use during treatment creates an increased risk of syncope and hypotension 

Bupropion 

  • A norepinephrine-dopamine reuptake inhibitor 
  • May improve symptoms for antidepressant-induced female sexual dysfunction 

Dilation 

  • Several prescription and OTC products available 
  • Aid to alleviate vaginismus or correct vaginal stenosis 

Physical Therapy 

  • May benefit women with dyspareunia due to vaginismus or general pelvic floor dysfunction 

Medications 

  • Intravaginal prasterone is FDA approved for post-menopausal women experiencing moderate-to-severe dyspareunia 

Lubricants 

  • Lubricants do not cure underlying causes of female sexual dysfunction 
  • May help alleviate dyspareunia due to vaginal dryness 

KEY POINTS:

  • Dysfunction includes various conditions in which personal distress is reported in ≥1 of the following areas 
  • Desire | Arousal | Orgasm | Pain 
  • Initiate a clinical discussion of sexual function during routine care visits 
  • Diagnoses made according to the DSM-5 classified female sexual dysfunction when symptoms persist for at least 6 months 
  • A person may still benefit from evaluation and treatment even if their symptoms do not meet DSM-5 criteria 

Learn More: Primary Sources 

Female Sexual Dysfunction | ACOG 

Psychiatry Online | DSM Library (subscription required) 

Diabetes and sexual dysfunction: current perspectives | NCBI 

Psychotropic medications on sexual health | NCBI 

NAMS: Nonhormone Therapy Position Statement 2023

SUMMARY:

An advisory panel was selected to review current literature regarding nonhormone therapy based on levels of evidence. In the treatment of vasomotor symptoms in women within ten years of menopause and who are not candidates for or who decline hormone therapy, evidence-based nonhormone options such as behavioral therapies, medications such as SSRIs or gabapentin, and weight loss should be discussed and considered.  

Vasomotor Post Menopausal Symptoms  

  • Vasomotor symptoms (VMS) 
    • Defined as hot flashes and night sweats  
  • Incidence 
    • Mean 7 to 10 years 
    • 30% >10 years 
  • Standard Management 
    • Hormone therapy 
    • First line recommended treatment 
    • Underutilized therapy 
  • Contraindications 
    • Estrogen sensitive tumors 
    • Coronary artery disease/myocardial infarction history 
    • Stroke 
    • Venous thromboembolism 

Recommended Nonhormone Techniques and Therapies  

  • Mind-Body Techniques 
    • Clinical hypnosis 
    • Cognitive behavior therapy 
  • Prescription Medications 
    • SSRIs and SNRIs demonstrate mild to moderate improvement 
      • Ecitalopram 10 to 20 mgs/day 
      • Paroxetine salt 7.5 mg/day 
      • Paroxetine 10 to 25 mg/day 
      • Citalopram 10 to 20 mg/day 
      • Desvenlafaxine 100 to 150 mg/day (start at 25 to 50 mg/day) 
      • Venlafaxine 37.5 to 150 mg/day (start at 37.5 mg/day) 
    • Gabapentin 
      • 900 to 2400 mg/day in divided doses (start with 100 to 300 mg at night, add 300 mg at night, then an AM dose of 300 mg) 
    • Fezolinetant 
      • Neurokinin B antagonist 
      • 45 mg/day 
    • Oxybutynin 
      • 2.5 to 5.0 mg twice daily or 15 mg extended release daily 
      • Long term use may be associated with cognitive decline in older adults 
  • Weight loss 

NOT Recommended 

  • Yoga | Diet | Cooling techniques | Weight loss | Relaxation techniques  
  • All dietary supplements/cannabinoids 
  • Acupuncture 
  • Chiropractic manipulations 
  • Stellate ganglion block may alleviate moderate to severe VMS but is associated with risk of transient seizures or bleeding 
  • Medical therapies not recommended 
    • Pregabalin 
    • Clonidine 
    • Suvorexant  

  

KEY POINTS: 

  • Vasomotor symptoms occur in up to 80% of postmenopausal women 
  • Mean duration 7 to 9 years 
    • >10 years for one third of women 
  • Hormone therapy is underutilized in symptomatic women 
  • Hormone therapy is the most effective treatment for vasomotor sympytoms and is indicated for  
    • Women younger than age <60 years 
    • Are within 10 years of menopause 
    • Are without contraindications including 
      • Estrogen sensitive malignancies 
      • Coronary artery disease/myocardial infarction 
      • Thromboembolism/stroke 
        • Inherited high risk for thromboembolic disease. 
  • Recommended nonhormone therapies: Prescription 
    • SSRIs/SNRIs 
    • Gabapentin 
    • Oxybutynin 
    • Fezolinetant 
  • Recommended therapies: Nonprescription 
    • Cognitive based therapy 
    • Clinical hypnosis 
    • Weight loss 
    • Stellate ganglion block 
  • Not recommended or insufficient evidence  
    • Supplements or herbal remedies 
      • Soy extracts 
    • Yoga and exercise 
    • Cooling techniques 
    • Cannabinoids 
    • Acupuncture 
    • Chiropractic interventions 

Learn More – Primary Sources: (Level 3) 

The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society 

ACOG Guidance: Pregnancy and Listeria Exposure

SUMMARY: Listeria infection is primarily a foodborne illness resulting from consumption of food contaminated with Listeria monocytogenes. Maternal infection may present as a non-specific, flu-like illness. Fetal and neonatal infections risk severe consequences. 

Background 

  • Listeriosis is a foodborne illness resulting from consumption of food contaminated with Listeria 
    • Listeria is an aerobic and facultative anaerobic, gram-positive bacillus 
  • Incidence of listeriosis associated with pregnancy is 13 times that of the general population 

Maternal and Perinatal Outcomes 

  • Maternal infection may be asymptomatic 
  • Symptomatic infection generally presents as a non-specific, flu-like illness  
    • Mild myalgias or mild nausea or diarrhea 
  • Fetal and neonatal infections include severe risks 
    • Fetal loss | Preterm labor | Neonatal sepsis | Meningitis | Death 
    • Approximately 1/5 pregnancies with listeriosis will result in spontaneous abortion or stillbirth 

Prevention 

  • Women are advised to avoid high-risk foods during pregnancy 
    • Hot dogs | Lunch meats | Cold cuts 
    • Refrigerated pate and meat spreads 
    • Refrigerated smoked seafood 
    • Raw, unpasteurized milk or soft cheeses 
    • Unwashed raw produce 

CDC LISTERIA PREVENTION  

Tap Below to See CDC Page

Management 

Asymptomatic 

  • Consumption of a product that was recalled or had implicated listeria contamination  
    • No testing or treatment is indicated  
    • Advise patient to return if she becomes symptomatic within 2 months of eating the implicated product 

Exposed, Mildly Symptomatic but Afebrile 

  • Minor GI or flu-like symptoms 
    • Can manage expectantly (as asymptomatic above) or 
    • Blood cultures can be ordered   
      • Instruct laboratory of diphtheroid morphology and not to confuse with contaminant 
    • Positive blood cultures: Standard antimicrobial treatment (see below)  
  • Fetal surveillance  
    • Individualize based on concern regarding infection and clinical findings  

Exposed, Febrile with Symptoms Consistent with Listeriosis 

  • Exposed pregnant woman with a fever > 38.1°C (100.6°F) and signs and symptoms consistent with listeriosis but no other etiology  
    • Test and treat concurrently for presumptive listeriosis 
  • Diagnosis is made primarily be blood culture 
    • Placental cultures should be obtained in the event of delivery 
    • Notify state public health department following diagnostic confirmation 
    • If blood cultures negative and symptoms resolve, can stop antibiotics  
  • Fetal surveillance 
    • Advised if listeriosis diagnosed or highly suspected  

Antibiotic Treatment  

  • IV ampicillin: ≥ 6g/day for 14 days to 21 days 
  • IV Gentamicin is frequently added to the regimen 
  • Allergy to ampicillin and/or penicillin 
    • Trimethoprim with sulfamethoxazole  

KEY POINTS: 

  • Listeriosis is an illness resulting from consumption of food contaminated with Listeria 
  • Listeriosis presents severe risks to maternal and fetal health and survival 
  • Asymptomatic patients do not require treatment or testing 
  • Symptomatic afebrile patients should be monitored and consider obtaining blood cultures 
  • Symptomatic febrile patients should undergo testing by blood culture and treatment with IV ampicillin 
  • Stool culture is not recommended for the diagnosis of listeriosis 

Primary Sources – Learn More

Management of Pregnant Women with Presumptive Exposure to Listera monocytogenes

CDC: People at Risk – Pregnant Women and Newborns | Listeria  

CDC: Prevent Listeria | Listeria  

CDC: Information for Health Professionals and Laboratories | Listeria  

CDC: Listeria Outbreaks | Listeria  

Stillbirth: Present and Future


Recorded on June 21, 2023 at 8 pm ET

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Faculty: Tracy Shevell, MD
Moderator: Brian Hines, MD

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Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high-quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

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In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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Oregon Court Strikes Jury Instructions regarding Guarantee of Results in Medical Malpractice Case 

As part of the patient-physician relationship, consent for treatment is given. Physicians explain the risks, benefits, and limitations of treatment Nowhere in that consent is a guaranteed good outcome given. It is not possible.  

Prior to November 2022, Oregon juries in medical malpractice cases were instructed “Physicians are not negligent merely because their efforts were unsuccessful. A physician does not guarantee a good result by undertaking to perform a service.” This instruction evolved from a series of cases where it was established that a physician does not guarantee a cure. Despite that lack of guarantee, a patient could still sue a physician for medical malpractice, alleging a bad outcome due to the physician’s failure to follow a particular standard of care that caused injury to a patient. 

In November 2022, the appellate court of Oregon in Martineau v. Willamette Medical Center ruled that this instruction should no longer be part of the uniform civil jury instruction. The court found issue with the instruction as it obscures the fact that the correct focus is on application of 

the standard of care. In addition, the meaning of “result” has a broader meaning than “cure”. Therefore, the statement that “[a] physician does not guarantee a good result by undertaking 

to perform a service” is incorrect when stated—as it is in the instruction—as a universal principle. 

Let’s turn to the underlying medical facts. Mr. Martineau sought care in the emergency room for chest pain and other complaints. One physician examined him and ordered a chest X-ray that the radiology physician read. The ordering physician however reviewed the X-ray and electrocardiogram of a different patient. He concluded that that the patient did not have an urgent cardiovascular problem or need further testing immediately. To the contrary, Mr. Martineau did have an urgent cardiovascular problem and died the next day.  

The plaintiff personal representative of Mr. Martineau filed a lawsuit for wrongful death or, in the alternative, the loss of chance of recovery followed, alleging medical malpractice by the ordering physician, emergency room group, and the radiology physicians. The jury returned a verdict in favor of the defendants.  

The appellate judges found two problems with the instruction. First, it takes away from the focus on the standard of care which is the issue to be decided because the guarantee of a good “result” is incorrect as a universal principle. Second, any benefit that it would add to a jury’s understanding of the law was significantly outweighed its potential to confuse a jury. In summary, the statement is likely to mislead a jury and should not have been given by the court.  

Next, the appellate court considered where the error was harmless or detrimental. The plaintiff’s theory was that defendants negligently failed to recognize the urgency of the decedent’s condition when he came to the emergency room. If they had, they would have determined he needed a CT scan and performed emergency surgery to save his life.  

In summary, the risk of giving the jury the instructions that a good result was not promised might cause the jury to reason that the defendants’ duty did not require them to order a CT scan because the CT scan was the “good result”. The CT scan was the primary focus of the plaintiff’s case.  

In its decision, the appellate court deemed the error was not harmless because the instruction was misleading. The jury could have reasoned that even though the radiology defendants’ and the ER defendants’ did not meet the standard of care, the defendants nevertheless were not negligent because a good result was not promised. The difference between a result and care are exemplified in this case. The defendant physicians were obligated to evaluate the deceased patient in accord with a standard of care that included testing and a CT scan.  

The AMA vehemently opposes the striking down of this jury instruction regarding the nonguaranteed of a good result. “Medical negligence liability [should] remain based on legal fault, and not medical results.” If the decision were to stand, it opens the door for juries to succumb to their sympathies about the plaintiff and injuries rather than to focus on the legal standard of care.” Recently, the appellate court decision was submitted for review by the Supreme Court of Oregon. The AMA and Oregon Medical Association have submitted an amicus brief asking for the appellate decision to be reversed.  

Resources 

Juries must be instructed that bad outcomes aren’t always negligence

The Anatomy of a Malpractice Lawsuit 

The Medical Malpractice Deposition: A Review for Radiologist-Defendants