Principles of Electrosurgery, feat. Dr. Gary Frishman

Here’s the RoshReview Question of the Week:

A 45-year-old woman in the postoperative recovery unit develops dyspnea. Her serum sodium is 130 mEq/L. Which of the following was the most likely distending medium used during her hysteroscopic monopolar fibroid resection?

• 1.5% glycine

• 5% mannitol

• Lactated Ringer solution

• Normal saline

Check your answer and get a sweet deal on RoshReview at the links above!

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Today we welcome Dr. Gary Frishman to the podcast. He is a clinical professor of obstetrics and gynecology at the Warren Alpert Medical School of Brown University, and has served in varying leadership capacities at Brown as a residency program director and in other organizations, such as for MIGS Fellowship at ABOG, and within ASRM, SRS, and AAGL. While we were residents at Brown, Dr. Frishman used to share his wisdom with us on electrosurgery and we have wanted to put this podcast together for a long time! It’s more than just cut and coag!

What is electrosurgery?

• Delivery of radio frequency waves that heat up tissue, which then causes tissue desiccation.

  • Cautery: not a specific term for this!

  • Electrosurgery represents alternating current where the body is part of the conductive circuit.

    • Modulating the delivery of this electricity is how we can get differing tissue effects.

Monopolar and Bipolar

• Bipolar: movement of electricity from one point to another direct point.

  • i.e., bipolar forceps, LigaSure device (has two ends)

  • More precise delivery of energy, less smoke.

• Monopolar: movement of electricity from one point (in dispersive fashion) to a return point.

  • i.e., the “grounding pad” when you are using a Bovie / electrosurgical instrument.

    • Energy still goes through body, to a second electrode and back to the machine!

Modifying the Delivery of Energy

• Waveforms:

  • Think about energy delivered as a garden hose with a spray nozzle at the end.

    • The amount of energy delivered is your watts setting on the machine (i.e., 35W).

      • This you can adjust linearly — you can go up to 40W, or down to 30W, but it’s a linear adjustment — less efficient.

    • If you adjust your spigot at the end of the nozzle, that is another way to adjust your energy delivery. Like if you get a dispersed spray (sprays all over the wall) versus a fine spray (that gives you a directed, straight line of water).

      • Cut: the directed, fine, straight line of water spray

      • Coag: the dispersed spray that goes everywhere

        • The energy is still our original 35W, it’s just differently applied!

    • Importantly, the cut and coag settings also are different in the time energy is applied.

      • Cut: energy is constantly applied — so, for example, 100W of energy delivered over 100 seconds.

        • Clinically, this delivers good cutting, but poor hemostasis.

      • Coag: energy is applied in bursts, and it’s only on 6% of the time — so 100W of energy delivered over 6 seconds.

        • It’s an uncontrolled, massive burst!

        • Clinically, this delivers a lot of lateral spread, and you get good hemostasis, but not great cutting.

      • Blend curve: tries to get you both: excellent cutting, excellent hemostasis, little thermal damage.

• Spot size:

  • You can also adjust the spot size of energy delivery by changing the tip of delivery instrument (i.e., Bovie)

    • By flattening the tip, you make the spot size larger — much larger surface area to deliver energy across.

    • By using the fine point of the tip, your spot size is much smaller — delivers energy to more concentrated area (i.e., needle tip electrodes).

Complications of Electrosurgery

• Direct coupling

  • Accidentally touch something metal with your electrosurgery device

    • i.e., touching a retractor or a laparoscope, which is in turn touching something else

    • Good news — just like with the “spot size,” if you touch a retractor, it’s such a large surface area it’s unlikely to cause damage. However, with smaller instruments, this can modify injury and cause injury.

      • Plastic trocars help prevent this in laparoscopic surgery.

• Insulation failure

  • Tiny cracks in an instrument that can cause insulation to fail — as you might get inadvertent direct coupling from the device if electricity is leaking out through the insulation.

    • Fortunately this is very uncommon.

    • If there are gross breaks — don’t use the instrument.

    • Limit the use of coag (i.e., use cut exclusively) to prevent this kind of injury.

• Capacitive coupling

  • Two conductors separated by an insulator

    • Energy is stored in the separated conductor, and can then deliver energy.

      • Less likely to occur with cut than coag

      • Jewelery and electrosurgery - a possible (though rare) complication of wearing jewelry in surgery.

Role of Tissue Resistance

• Electricity heats up water in the cell

  • Cut: heats up water in the cell very rapidly, and it explodes.

  • Coag: heats up water in cell more slowly, and energy dissipates laterally.

• Electricity follows path of least resistance

  • As tissue dessicates (water removed), it becomes harder for electricity to pass through.

  • Think about a car on cruise control, set to a speed of 30W:

    • If you’re going uphill, you’re going slower unless car adjusts — higher tissue resistance.

    • If you’re going downhill, you’re going faster unless car adjusts — lower tissue resistance.

• Newer generators measure tissue resistance and can adjust your energy appropriately!

  • Newest bipolar instruments also take surgeon out of equation entirely — and automatically adjust energy to resistance and shut off automatically when resistance is so high energy can’t pass.'

• Importantly, if you’re using monopolar — electricity will go around high-resistance areas! This is how you can get capacitive coupling to jewelry and other areas.

  • A “grounding pad” is usually very large to help accommodate for this and prevent this injury.

    • It’s also in two halves, and both must be connected to make the machine work.

    • Bipolar instruments reduce this risk significantly.

Fulguration

• Taking the tip of the device and placing it close to, but not on the tissue — may have heard of this as “arcing” the device.

  • Use coag on this because you want a huge burst of energy to leap across the space.

  • This energy “follows the blood” back to the original bleeder.

Cutting on Skin??

• You can! But you need to know how to deliver energy — need a small spot size and to use cut.

  • A dozen RCTs and a meta analysis show safety, less bleeding, and potentially even less pain.

Dermatoses of Pregnancy, feat. Dr. Laura Hanks

Here’s the RoshReview Question of the Week!

A 30-year-old G1 woman presents at 34 weeks gestation to the office with severe itching and a rash that suddenly developed across her abdomen starting around her umbilicus. The rash is mostly urticarial papules and plaques, but there are a few scattered bullae. Which of the following is required to confirm the suspected diagnosis?

• Clinical presentation alone

• Skin biopsy

• Skin scrapings for herpes, nucleic acid amplification test

• Skin scrapings for Tzanck prep

Check your answer at the links above and get a special deal on RoshReview!

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Today we welcome to the podcast Dr. Laura Hanks, who is an Assistant Professor in the Dept. of OB/GYN at the University of Wisconsin - Madison. She was previously in private practice in Olympia, WA, and did her residency training at the University of Rochester in New York.

Dermatoses are a pretty confusing topic — so if you have access to some textbooks through your medical school or residency libraries, Dr. Hanks bookmarked a few good chapters:

• Gabbe’s Obstetrics. Normal and Problem Pregnancies. 8th edition. Chapter 56: Skin disease in pregnancy.  

• Habif’s Clinical Dermatology. Chapter 6: Urticaria, Angioedema and Pruritus. 

• Creasy and Resnik’s Maternal-Fetal Medicine. 8th edition. Chapter 69: The Skin and Pregnancy. 

What are dermatoses?

• Dermatoses of pregnancy refers to a group of skin diseases encountered predominantly during pregnancy or immediately postpartum.

• In general there is a lack of understanding of the pathogenesis of most of these conditions and therefore a lack of specific diagnostic criteria.

In the podcast, we use a case: 36y G1 at 22 weeks who develops severe pruritus of abdomen, spreading to thighs.

Differential Dx of Dermatoses

• Pruritis of pregnancy (pruritis gravidarum)

• Reported in 1.5-2% of pregnancies and occurs most frequently over the abdomen.

• Usually just pruritus and no rash

• Often presents in the 3rd trimester

• Intrahepatic Cholestasis of pregnancy

  • Covered previously on the podcast!

• Reversible form of hormonally triggered cholestasis

• Runs in families and typically recurs in subsequent pregnancies

• Severe pruritus with no primary skin lesions

• Pruritus on palms and soles that later becomes more generalized

• Itching correlates with elevated serum bile acid levels and sometimes aminotransferases

• Bile acids can pass into fetal circulation and cause placental anoxia and cardiac depression which can preclude premature birth, stillbirth, neonatal respiratory distress syndrome, vitamin K deficiency and coagulopathy in the other and newborn.

• Polymorphic eruption of pregnancy (PEP) or pruritic urticarial papules and plaques of pregnancy (PUPPPs)

• Affects 1 in 130 to 1 in 300 (0.6%) in the US.

• This often presents in the 3rd trimester or postpartum with resolution during the postpartum period more commonly in primigravidae pts

• Abdominal distension causes damage to the connective tissue that in turn triggers an inflammatory response.

• Associated with multiple gestation due to higher levels of progesterone, which has been shown to aggravate the inflammatory process at the tissue level.

• Intensely pruritic urticarial rash with erythematous edematous papules and plaques that starts in the abdominal striae and spares the umbilicus. Can include urticarial and sometimes vesicular, purpuric, or targetoid lesions similar to PG or erythema multiforme. Lesions usually spare the palms and soles.

• This is a clinical diagnosis with no lab findings and no indication for biopsies. If a biopsy is preformed it will often show a nonspecific perivascular lymphohistiocytic infiltrate +/- eosinophils

• There are also no known risks to the fetus.

• Impetigo herpetiformis or pustular psoriasis of pregnancy

• Often associated with reduced calcium or Vitamin D

• Eruption usually during 3rd trimester, most cases resolve postpartum

• Characterized by numerous grouped, discrete, sterile pustules at the periphery of erythematous patches

• Lesions typically originate on flexures and progress to trunk. Spares face, palms and soles.

• Constitutional symptoms can be common including fever, malaise, diarrhea and vomiting with dehydration.

• Lab findings include a luekocytosis, elevated erythrocyte sedimentation rate, hypocalcemia and decreased vitamin D levels

• Risk of stillbirth and fetal abnormalities secondary to placental insufficiency

• Maternal prognosis is very good with early diagnosis and aggressive treatment, however the increased risk of perinatal mortality may persist despite maternal treatment

• Diagnosis is based on histopathology that shows typical features of pustular psoriasis. Direct and indirect skin immunofluorescence is negative

• Pemphigoid gestationis

• Unfortunately sometimes referred to has herpes gestationis, however it is not related to infection by herpesvirus. This synonym was used to refer to the grouped (herpetiform) nature of the blisters, which often are not herpetiform.

  • It is best to avoid the term herpes gestationis because of the risk for misleading patients and misinformed health care workers; not using the term avoids potentially inappropriate treatments for herpesvirus.

• Rate in the US is 1 in 50,000 (0.002%)

• Often presents in 2nd or 3rd trimester and sometimes postpartum (25%) with extremely pruritic, urticarial lesions that typically begin on the abdomen and trunk, that commonly involve the umbilicus. These urticarial plaques can then very quickly progress to widespread bullous lesions that may affect palms of hands and soles of feet. There is often a flare at the time of delivery with resolution during the postpartum period.

• Lesions can be similar to PUPPs, however PUPPs lesions begin in abdominal striae and spares the umbilicus unlike PG.

• Suggested pathogenesis is complement-fixing IgG antibodies and complement C3 react with amniotic epithelium of placental tissues and basement membrane of the skin causing an autoimmune response resulting in tissue damage and blister formation.

• Definitive diagnosis is based on biopsies of the lesions that will show skin direct immunofluorescence shows linear deposition of IgG and C3 along basement membrane.

  • PG recognizes the same antigen as bullous pemphigoid and they do share certain features; however PG itself is confined only to pregnant women and women affected by gestational trophoblastic disease.

• Skin histopathology shows a spongiotic epidermis and marked papillary derma edema and an eosinophilic infiltrate

• There is an association between PG and Graves, therefore if you have a pt with PG that is an indication to check thyroid function tests

• Given the increased risk of small for gestational age infants and preterm delivery, it is recommended to monitor growth US after diagnosis.

• Unfortunately, there are risks to the fetus which include being born with lesions that are transient due to passive transfer of IgG1 antibodies, increased risk of SGA, preterm birth and IUFD.

• Atopic eruption of pregnancy

• This accounts for over 50% of pruritic dermatoses in pregnancy.

• Most likely presents in the 1st and 2nd trimester with resolution in the postpartum period. This earlier onset may help distinguish from other dermatoses in pregnancy.

• Features of patchy eczema and papular/prurigo lesions that are located on flexural surfaces, neck, chest, and trunk

• Serum IgE is elevated

• No known risk to the fetus

• Prurigo of pregnancy

• In the US this occurs in 1 in 300 to 1 in 450 pregnancies

• Presents in the 2nd and 3rd trimester

• Grouped excoriated or crusted papules over the extensor extremities and occasionally the abdomen

• There are no laboratory findings. There may be elevated IgE levels on serologic tests. Previous reports of unfavorable fetal outcomes have not been confirmed.

• Pruritic folliculitis of pregnancy or follicular papulopustular eruption

• Rare, exact prevalence is unknown (~30 cases reported). Etiology remains unknown

• Presents as pruritic follicular erythematous papules and pustules that primarily affect the trunk in the 2nd and 3rd trimester.

• Biopsy is usually unhelpful, however histopathology is that of folliculitis. Special stains, skin immunofluorescence and serologies are negative.

• There may be an association with decreased birthweight

• And don’t forget derm conditions that are not unique to pregnancy!

  • Allergic contact dermatitis

  • Drug reaction

  • Atopic dermatitis or eczema

  • Erythema multiform

  • Scabies

  • Superficial fungal infections

  • Folliculitis

  • Urticaria

  • Vasculitis

  • Secondary syphilis

View fullsize

Habif’s Clinical Dermatology

In the case, we obtain an H&P —

• She began itching on her upper thighs that then spread to her abdomen, chest, back and arms over several days.

• She then experienced severe pruritus on the palms of her hands and soles of her feet. She described having to take her shoes off at work and soak them in ice baths and often sleeping with an ice pack between her hands to sooth the itching.

• Benadryl did not seem to help neither did OTC steroid creams.

• On exam there were numerous pink-salmon colored annula papules and plaques as well as urticaria with scale within umbilicus, flank, thighs and back. On bilateral medial aspects of feet there were pink-red vesicles with petechial border. 

What next? Dermatology referral and biopsies.

Biopsy results: Positive linear deposition of IgG and C3 antibodies along the basement membrane, suggestive of pemphigoid gestationis!

Treating Dermatoses

• Generally, same treatment principles apply to all of the specific dermatoses of pregnancy.

  • Milder disease is treated with topical emollients, calamine lotion, cool compresses or baths, and topical corticosteroids.

    • Topical corticosteroids (e.g., hydrocortisone, triamcinolone) are classified as FDA pregnancy category C drugs in the old system, but they are still widely used during pregnancy when the possible benefits outweigh the risks for minimal percutaneous absorption.

• Intrahepatic cholestasis of pregnancy

  • Ursodeoxycholic acid 15 mg/kg/day daily, BID or TID until delivery

• PUPPs

  • Topical antipruritic medications, topical steroids and oral antihistamines.

  • In cases of severe pruritis, a short course of oral steroids can be used.

• Impetigo herpetiformis

  • Systemic steroids are first-line with prednisone dose up to 60-80 mg/day

  • Calcium and vitamin D replacement as needed. Can lead to remission of eruption

• Pemphigoid gestationis

  • The cornerstone for treatment of Pemphigoid gestationis is oral steroids. Therapy should be directed toward suppressing new lesions and relieving intense pruritus.

  • The majority of patients will respond rapidly to a relatively low-dose of prednisone (20 to 40 mg/day), however the dose may need to be uptitrated according to clinical response as high as 180 mg/day

    • Prednisone should be tapered slowly once new blister formation is suppressed

  • ~75% of patients will experience resolution or at least improvement in the late 3rd trimester, but b/c PG typically flares at delivery, steroid dose can be increased in anticipation of birth.

  • Patients at risk for prolonged or chronic PG are often older with higher parity, more widespread lesions and a history of PG in a prior pregnancy.

• Atopic eruption of pregnancy

  • Topical steroids, antihistamines, UVB phototherapy

• Prurigo of Pregnancy

  • Moderately potent topical steroids and oral antihistamines

  • Short course of oral steroids is rarely required

• Pruritic folliculitis of pregnancy

  • Low-potency or midpotent topical steroids, benzolyl peroxide and UVB.

Ultimately, the patient in our podcast went on to deliver this pregnancy at 38w4d after a cesarean section for fetal indications, without any signs of neonatal blistering (can be seen in 5-10% of babies of mothers with PG!).

The patient ultimately went on to become pregnant a second time, and this time had lesions at 13 weeks. By 25 weeks, prednisone was no longer providing relief!

• Treating refractory PG

  • A number of alternative treatments have been tested, including:

    • Intravenous immune globulin (IVIG)

    • Plasmapheresis

    • Rituximab

    • Cyclosporine A

    • Azathioprine

    • Dapsone and MTX can sometimes be used postpartum

  • With shared decision making the pt, her MFM and dermatologist elected to proceed with IVIG infusions which were 3 consecutive days every month until the end of pregnancy.

  • Her symptoms improved but never completely resolved during pregnancy and she continued the prednisone along with IVIG. She had a scheduled repeat c-section at 37w3d with stress-dose steroids given at delivery. She gave birth to a healthy male infant weighing 8lbs 1oz without any lesions.

PLOT TWIST!  The patient was Laura, and the MFM was Nick!

IVIG Infusions worked once we got them going! ;)

The ARRIVE Trial

Here’s the RoshReview Question of the Week!

A 32-year-old G1P0 woman at 39 weeks gestation is admitted for induction of labor. Her induction is started with vaginal misoprostol. Cervical ripening by this method is caused by the action of which of the following substances?

• Phospholipase A2

• Prostaglandin E1

• Prostaglandin E2

• Prostaglandin F2 alpha

Check out the links above to see if you got this week’s question correct!

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Actual Title: Labor Induction vs. Expectant Management in Low-Risk Nulliparous Women 

ARRIVE = A Randomized tRial of Induction Verses Expectant Management

Background: 

• Who did the study? 

  • As many big studies in Ob/Gyn, it was done by the MFMU and the Eunice Kennedy Shriver National Institute of Child Health and Human Development 

  • First author was Dr. William Grobman from Northwestern University (now at Ohio State!)

  • The study was done in 41 hospitals participating in the MFMU 

• Where was the study published? 

  • Published in NEJM in August 2018 

• Why was the study done? 

  • In previous observational trials, there was worse perinatal outcomes when delivery before 39w0d was done without medical indication than when there was delivery at full term 

  • However, there was also thought that delivery after 41 weeks can lead to increased perinatal risks (ie. increasing risk of stillbirth) 

  • There was also thought that induction of labor should be avoided if there was no reason to induce  (ie. elective induction) because induction led to increased cesarean section and possible adverse maternal outcomes 

  • There was one previous study in the UK of 619 women 35 years and older that showed increased risk of c-section 

• What was the objective? 

  • Test if elective induction at 39 weeks would result in lower risk of composite outcome of perinatal death or severe neonatal complication than expectant management among low-risk nulliparous women 

  • So key things: 

    • Purpose of the trial was to look at NEONATAL outcomes (not mom!) 

    • Second: the population they studied was low-risk nulliparous patients, not everyone! 

Methods

• Who was in the study? 

  • As we said above, the study was done at 41 centers in the United States that were part of the MFMU (ie. most were large academic centers) 

  • Low-risk nulliparous patients were included in the study 

    • Low risk = no maternal or fetal indication to be delivered before 40w5d (ie. hypertensive disorders, fetal growth restriction etc) 

  • They had to be 34w0d-38w6d at the time of enrollment 

    • Patient had to be certain of LMP or if dating was done with ultrasound before 21w0d 

  • Had to have live, singleton fetus in vertex presentation with no contraindication to vaginal delivery and no C/S planned 

  • Patients who were consented to participate were assessed again between 38w0d and 38w6d to ensure they did not have new indication for delivery that would make them ineligible 

    • Patients who were in labor or who had PROM or bleeding were not eligible 

• How was the study done?

  • Patients who were eligible were randomized in 1:1 ratio to either:

    • Labor induction - assigned to undergo induction of labor at 39w0d-39w4d 

    • Expectant management - had to forego elective induction before 40w5d, and had to have delivery initiated no later than 42w2d 

    • Of note: no specific induction protocol for either group 

  • Randomization was stratified to site 

  • Participants were then followed and data was abstracted from their chart

  • Patients also had interview to rate their labor pain on Likert Scale and also rate their experience with Labor Agentry Scale 

• What outcomes did they look for?

  • Primary outcome: composite of perinatal death or severe neonatal complications

    • Consisted of one or more of many things (don’t have to list all): perinatal death, need for respiratory support within 72 hours after birth, Apgar of 3 or less at 5 min, HIE, seizure, infection, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension requiring vasopressor support 

  • Main secondary outcome: cesarean section 

    • Lots of other neonatal secondary outcomes and maternal secondary outcomes that we don’t need to list 

  • Other prespecified subgroups: race, age >/= 35 or <35, BMI, modified Bishop score at time of randomization of <5 vs. 5 or more 

Results 

• Participants 

  • Recruited from March 2014 - August 2017

  • Out of 22,533 eligible women, 6106 (27%) consented and were randomized

    • 3062 in induction and 3044 to expectant management 

    • 63% had unfavorable Bishops (<5) 

    • Both groups were similar  

  • 3 in induction group and 7 in expectant management group were lost to follow-up 

  • 6% of induction group and 4.6% of expectant management group had protocol violation 

• Outcomes 

  • Those in induction group had shorter median time from randomization to delivery than in expectant management group (7 vs. 12 days) 

  • Women in induction group underwent delivery at a significantly earlier median gestational age (39.3 wks IQR 39.1-39.6 vs. 40.0 IQR 39.3-40.7 weeks) 

  • Primary outcome 

    • Occured in 4.3% of neonates in induction group vs. 5.4% in the expectant management group (RR 0.8, 95% CI 0.64-1.00) 

    • Did not change after adjustment for previous pregnancy loss 

    • Neonates in induction group had shorter duration of respiratory support and total hospital stay 

      • Other secondary outcomes for neonates were the same 

  • Secondary outcomes for mom 

    • Cesarean delivery was 18.6% in IOL group vs. 22.2% in expectant management group (RR 0.84, 95% CI 0.76-0.93), p<0.001 

    • HTN disorders of pregnancy was 9.1% in IOL group vs 14.1% in expectant management group (RR 0.64, 95% CI 0.56-0.74), p<0.001 

    • Of note, interestingly there were also higher scores on LAS both immediately after and 4-8 weeks after delivery in the IOL group 

    • Median labor pain was also reported as less (8 vs. 9) in IOL group vs. expectant management group 

      • Of note though, for LAS and median labor pain score, the scores were statistically significant but overall difference was small 

    • Women in the IOL group spent more time on the labor and delivery unity but their postpartum stay was shorter 

    • Subgroup analyses showed no significant difference between group differences 

Discussion 

• What happened after the study? 

  • Don’t know about your hospitals, but we have begun offering 39 week inductions to all nulliparous patients if they desire them 

    • ACOG also made a statement that reasonable to offer 39 week induction as long as we also take patient preference into consideration 

  • It is not “recommended” but offered 

  • Why? 

    • Some people take this to mean that by having IOL at 39 weeks that we are not only not changing neonatal outcomes, we are also decreasing CS rates and HTN disorders of pregnancy per this study 

    • They also would argue that there is no difference in LAS or pain overall (and if anything, patients feel more agentry and less pain) with IOL

  • What’s the other side of the story? 

    • In 2018, the ACNM responded to the ARRIVE Trial study results 

    • Discussed that potentially by increasing IOLs, we are also increasing the use of hospital resources (ie. staff, capacity of hospital beds, etc) 

    • Also stated that the study criteria were very strict (low risk, nulliparous), and discussed that we should be careful of broadening the outcomes and applying IOL to all patients 

    • Basically: concern that we will be offering IOL to everyone without knowing the actual implications 

  • More to the story 

    • There was a lot of concern about cost and hospital resources , so in 2020 Einerson et al came out with a study looking at cost 

    • Reviewed health-system cost of elective IOL at 39 weeks vs. expectant management in Utah hospitals 

      • No cost difference between expectant vs. IOL 

        • Maternal outpatient antenatal cost were 47% lower in the induction arm, and intrapartum and delivery costs were 16.9% higher 

• How do we practice now? 

  • One study did look at rates of IOL pre and post ARRIVE 

    • Gilroy et al looked at rates of IOL in the country in patients who were nulliparous who started prenatal care by 12 weeks and delivered at 39 weeks or later  

    • There was a significant increase in IOL after ARRIVE 

      • 36.1% vs 30.2%, OR 1.36

      • Also more likely to deliver by 39w6d (42.8% vs. 39.9%) 

      • Less likely to have a CS (27.3% vs. 27.9%) ← but that is a much higher rate than 18% in ARRIVE 

The Twin Birth Study

Here’s the RoshReview Question of the Week:

Which of the following needs to be met to undergo vaginal delivery with a monochorionic-diamniotic twin pregnancy with vertex twin A?

• Estimated fetal weight of twin B < 1,500 g

• Growth discordance < 20%

• Minimum 24 weeks gestation

• Vertex-vertex presentation

Check your answer and get a special RoshReview deal for listeners at the links above!

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Actual title: A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy

https://www.nejm.org/doi/full/10.1056/nejmoa1214939 

Background:

• Where was the study published?

  • NEJM, October 3, 2013

• Why was the study done?

  • Tthrough the 1990s and 2000s there was a significant rise in twin births in the USA, likely attributed to advancing maternal age (when twinning is more common spontaneously) and the use of reproductive technology – ovulation induction and IVF.

  • In the wake of the Term Breech trial, as well as some observational studies looking at twins specifically, there was concern that breech birth risks could be extended to twins – and practice was changing!

    • In 1995, 53.9% of twin births were by CS. By 2008, this number was 75%. 

  • Not all observational studies were in agreement about the risk of “breech extraction” of a second twin, specifically – so a new study was planned and performed.

• Who performed the study?

  • The “Twin Birth Study Collaborative Group” – a large multinational collaborative, but with the main site at the University of Toronto and funded by the Canadian Institutes of Health Research – the same funders that brought you the Term Breech Trial!

    • You’ll note a lot of similarities (but also some important differences!) between this study and the Term Breech Trial. We definitely recommend a compare-contrast session!

• What was the research objective?

  • To compare the risk of fetal/neonatal death or serious morbidity between planned cesarean or planned vaginal delivery for twin pregnancies between 32w0d and 38w6d, if the presenting twin was in cephalic presentation. 

Methods:

• Who participated and when?

  • Recruitment between December 13, 2003 and April 4, 2011 at 106 centers in 25 countries.

  • Enrolled 1392 patients in the planned cesarean group and 1392 patients in the planned vaginal delivery group.

• Eligibility:

  • Needed to have:

    • Twin pregnancy between 32w and 38w6d

    • First twin in cephalic presentation

    • Both fetuses alive with EFW between 1500g and 4000g, confirmed by ultrasound within 7 days before randomization

  • Exclusions:

    • Monoamniotic twins

    • Lethal fetal anomalies

    • Other contraindication to labor or vaginal delivery (including 2nd twin being “substantially larger” than the first)

    • Prior cesarean with vertical incision or more than one LTCS

• Management:

  • Delivery by cesarean or by labor induction was planned between 37w5d and 38w6d

  • If in the CD group, if the first twin delivered vaginally, then a c-section was attempted for the second twin if logistically possible.

  • In the VD group:

    • Continuous EFM was “recommended” during active labor

    • Use of oxytocin and epidural analgesia were left to OB provider discretion

    • After delivery of first twin, use of US was “encouraged” to check second twin presentation

      • If cephalic, amniotomy was delayed until head was engaged and SVD anticipated, unless for other OB indication

      • If non-cephalic, OB decided on best delivery option – spontaneous or assisted breech delivery, total breech extraction +/- internal podalic version, ECV and vaginal cephalic delivery, or intrapartum CD

    • Deliveries were attended by qualified OB experienced in twin delivery, defined as a OB who judged themselves to be experienced at twin delivery and whose department head agreed with this judgment (similarly to Term Breech Trial).

• Outcomes:

  • Primary: fetal/neonatal mortality or serious neonatal morbidity, assessed up to 28 days after birth.

    • Morbidities included many of the same things in the Term Breech Trial, and were serious neonatal morbidities (for the sake of brevity, we won’t list them out).

  • Secondary: maternal death or serious maternal morbidity, assessed up to 28 days after delivery.

    • Again, this was very similar to the Term Breech Trial. 

  • A number of subgroup analyses were planned for the primary outcome, including by nulliparity; gestational age at randomization; maternal age; presentation of the second twin; chorionicity; and the perinatal mortality rate in the mother’s country of residence. 

Results

• Who was recruited?

  • Outcome data was available for 1392 women (2783 fetuses/infants) in the cesarean group and 1392 women (2782 fetuses/infants) in the vaginal delivery group. 

  • Baseline characteristics were overall similar, and most patients (82.4%) underwent randomization between 32w0d and 36w6d. 

    • More than half of the infants in each group were born at 37w0d or later. 

      • Around 5-6% in each group were between 32w and 33w6d, and another 42% between 34w0d to 36w6d. 

    • The time from randomization to delivery was similar but slightly different between groups (12.4 vs 13.3 days).

• In the planned CD group: 

  • 90% had CD

  • 1% had a combined vaginal-cesarean delivery, and 

  • 9% had both twins vaginally.

    • Almost 60% of the CDs were performed before the onset of labor.

• In the planned VD group:

  • 56% delivered both twins vaginally, 

  • 4% had a combined vaginal-cesarean delivery, and 

  • 40% had a cesarean for both twins.

    • Of those in the VD group who had a CD, 67.5% of them were performed during labor (or another way to look at it, 32.5% had a CD prior to labor in the planned VD group).

  • 95% had an experienced OB present, according to the study definition

• Primary Outcome:

  • The frequency of composite primary outcome did not differ between planned CD (60, or 2.2%) and planned VD (52, or 1.9%) groups.

    • The only variable that appeared to modify the risk of the primary outcome was earlier gestational age at randomization. 

    • The number of deaths in each group was 24 (0.9%) in CD group and 17 (0.6%) in VD group. 

      • 11 of these deaths in the CD group and 8 in the VD group were before labor onset.

  • In subgroup analyses, there was no significant interaction with the primary outcome with respect to parity, gestational age at randomization, presentation of the second twin, chorionicity, or national perinatal mortality rate. 

  • The second twin was more likely than the first to have the primary outcome, but this was not different between the groups. 

• Secondary outcome:

  • There were no differences in primary maternal composite outcome rates (7.3% CD, 8.5% VD). 

Impact

• What is the impact of all of this, and what are we doing now?

  • This paper certainly helped to encourage the training and planning of vaginal delivery of the second twin, including by breech delivery by stating that no increased risk was seen with a policy of planned vaginal delivery. 

    • In ACOG PB 231 on multifetal gestation, it notes that vaginal delivery of a non-cephalic second twin is reasonable, provided an OB with experience is present.

    • That’s key – it’s apparent in this paper that, compared with the Term Breech Trial, there was more emphasis on patient counseling / selection (i.e., 13 day median from randomization to delivery, protocolized assessment of EFW by US within 7 days, 95% presence of “experienced OB”). 

      • And this is heavily noted in the conclusions of the paper – stating “only centers that can provide OB management as specified by the protocol, including ability to perform a CD within 30 minutes if necessary” should undertake this.

• Methodologically, this group responded to many criticisms of the Term Breech Trial:

  • An improved randomization scheme that was block-based, stratified by gestational age and parity.

  • Improved use of ultrasound and CTG in labor, as well as higher standard of care at all sites to prevent misappropriation of primary outcome.

  • More explicit counseling – happening weeks before delivery on average, rather than in labor!

• And finally - and most importantly - this represents a well-selected, high-resource, best-case scenario work.

  • For our US listeners who mostly practice in centers where there is ability to perform cesarean within 30 minutes, the Twin Birth Study included:

    • Twins delivering between 32w0d and 38w6d

    • With EFW estimated by US within 7 days of delivery, ranging from 1500g - 4000g

      • Second twin not significantly larger (with expert opinion putting this around a max of 15% discordance)

    • Ability to perform CD within 30 minutes, and use CTG and intrapartum US

    • With someone with experience and ability to perform breech extraction and internal podalic version available 

Budgeting, feat. Mike Foley

We’re back with another special Wednesday episode this week, again brought to you in part by the SMFM Thrive Initiative! SMFM Thrive is a wellness program for MFMs - but we hope that this week’s podcast will be helpful even to those outside of MFM land!

Michael Foley rejoins us today to talk budgeting!

Michael is a comprehensive financial advisor who runs his practice out of Scottsdale, Arizona, under North Star Resource Group. Michael was trained at Duke University and holds his Certified Financial Planner designation alongside his Certified Student Loan Professional designation. Although Michael serves a diverse group of clients with their financial and student loan needs, with two physician parents, Michael has found a specialty in working with those in the healthcare space. Separate from the financial plan and his role as financial planner, Michael may recommend the purchase of specific investment or insurance products or accounts. These product recommendations are not part of the financial plan and you are under no obligation to follow them. Financial Professionals do not provide specific tax/legal advice and this information should not be considered as such. You should always consult your tax/legal advisor regarding your own specific tax/legal situation.

How to build a budget

• Spreadsheet or app to identify normal and regular expenses and regular income to identify surplus income.

  • What comes in?

  • What goes out?

  • What is left over?

Research for budgeting hacks

• Brain scan study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656877/

  • Same cognitive energy to save for our future self as it does to give money to someone else.

• Make the decision once and then automate, automate, automate.

• Setting up hurdles

  • We tend to see better results when there is a separation between your everyday checking account and your emergency reserve.

  • Look at a separate high yield online savings account at a separate bank

    • Takes 1-2 business days to transfer

    • Enough time to feel a bit guilty but it is there if you need it.

• Positive psychology research

  • Identify those things that actually bring you happiness and fulfillment

  • Some may cost less than you think.

    • Get the most bang for your buck from a fulfillment standpoint.

• PERMA exercise

  • Positive Emotion, Engagement, Relationships, Meaning, Accomplishment.

  • These are your real goals... not a dollar amount in your bank account!

Triaging your surplus income in residency vs in practice.

• Establish the basics- like checking basic vitals – if a patient tells you that they want to start to train for a marathon, but they have high blood pressure, knee issues, and they have no training plan. Can you go out there and start running? Absolutely. But you might want to address some other issues first.

  • Emergency reserve

  • Cash ready for upcoming expenses

  • Insurances- DI, Life, Umbrella

  • Debt repayment plan

  • Then preventative care- like starting to work out, eat healthy, etc.

  • Retirement savings

  • Medium term savings- nonretirement

  • Once maxed out all other retirement options, then look towards other tax advantaged accounts as a business owner or through 7702 max funded life insurance contracts.

• How to know if you can afford something?

  • Are you on track for your short and long term goals and have savings automated, then you can spend the rest and not feel guilty about it?

Common mistakes

• Only focusing on your student loans: I’m going to continue living like a resident and pay off all of my loans”

• Building up fixed expenses right out of training before working with an advisor to help you identify some of your longer-term goals.

• Raising fixed expenses can limit your surplus income very quickly

• Not able to hit goals? Make more money or spend less money. Going backwards in lifestyle expenses is rough.

Need some budgeting help?

• Michael’s Bio: https://www.northstarfinancial.com/advisors/michael-foley/

• To schedule an initial consultation with Michael click here.