St. Louis' Best Newspaper Columnist

We take a break from our normal OB/GYN postings to congratulate Evan Benn for being named St. Louis' Best Columnist (courtesy Riverfront Times)! Evan writes a column for the Post-Dispatch that features our wonderful local beer and fare.

Evan does have strong ties to the program. His wife is one of our fantastic second year residents and he also provides great tips on where to eat and what to drink. Evan was also recently named "Mayor of WashU OB/GYN" courtesy of Foursquare. Though the Foursquare award is a dubious one, the RFT one is not. You can follow Evan on twitter @EvanBenn. Congrats Evan!

TS

Congratulations!

Big Props to R3 Lindsay Reed for receiving a "Resident of the Year Award" from the Washington University School of Medicine Class of 2011! This is a tremendous honor and we are all very proud of her.

Resident Journal Club

The resident Journal Club featured a recent article in NEJM regarding Valproic Acid Exposure and the risk of Congenital Malformations.

The article was presented by R3 Shayna Norman and the discussion led by R4 Dan Czarnecki. The highlights of the article are listed below and the discussion questions follow the summary. Big thanks to Dr. Norman and Dr. Czarnecki for doing a great job!

NEJM Study Summary:

Objective: This was a retrospective case control study performed to investigate if the use of valproic acid monotherapy in the first trimester infers an increased risk for congenital malformations other than spina bifida.

Study design/Results: Utilizing the EUROCAT antiepileptic database ,and previously identified 14 malformations from prior cohort studies, the authors found that in comparison to no antiepileptic drug (AED) exposure, valproic acid leads to significant increase in the risk for spina bifida, ASD, cleft palate, hypospadias, polydactyly, and craniosynostosis. The associations persisted when comparing exposure to monotherapy of a different AED, except craniosynostosis.

Strengths: Minimally affected by recall bias, large study population, type of antiepileptic used was known in 99.9% of cases, and monotherapy was well delineated, diverse study population (14 countries), able to control for chromosomal abnormalities.

Weaknesses: Basis for defining cases (14 malformations) dependent on literature review, no information on type or severity of epilepsy, dosage, or outcome data, could cause confounding, no baseline comparison between cases and controls, difficult to apply to general population given all cases and controls had congenital malformations.

Impact: Valproic acid use in the first trimester should be avoided if possible due to its known teratogenic effects. Valproic Acid is pregnancy category D, illustrating that there are some cases in which the benefits may outweigh the risks of congenital anomalies. This study has reaffirmed this classification. Further study on dosage and indication is warranted as well as investigation into long term outcomes

Discussion questions:

1. How were Valproic Acid-associated malformations chosen from the literature? Was this the best way to choose outcomes? How would you characterize their method? Why do you think they did it this way?
2. Essentially, what type of study was this? Who were the cases? Who were the controls?
3. Were these the most appropriate control groups? Do we know if cases and controls were similar-appearing groups? Could there be confounders?
4. What are the main issues when using databases as the foundation for your study design? Did these issues affect this study?
5. Is any Valproic Acid exposure the same? Do we have the necessary information in this study to draw a cause/effect relationship?
6. Are all the results this study reports as significantly different actually statistically and/or clinically significant? What does an odds ratio of 12.7 mean in table 3? How can some of the wide confidence intervals be explained?
7. What is the difference between risk associated with elevated odds ratios and absolute risk?
8. How should we counsel a patient who is well-controlled on Valproic Acid for her epilepsy and would like to conceive? Should we offer first trimester terminations for exposures?

OB 201 Starts Today!

Today is a great day for a variety of reason. First, the NFL kicks off (Go Colts!) and Drew Brees (Boiler Up!) takes on that flip flopper and the Vikings.

More importantly, Dr. Anthony Odibo kicks off our OB module with a lecture on Cervical Insufficiency and Cerclage. I dare you to pubmed him. We're extremely fortunate to have such prestigious faculty willing to participate in resident education and today's lecture is a prime example of that.

Our monthly Journal Club follows Dr. Odibo's lecture and it will be led - as always - by Dr. Alison Cahill. I dare you to pubmed her as well. Today's Journal Club focuses on medications and potential adverse neonatal effects.

See you all there. And if I don't, watch the video on line!

Tony

New study by Dr. Cahill

Huge study on the horizon for Dr. Alison Cahill and company.

“The technology became accepted practice before we knew if it worked or not. The stillbirth rate has not changed, and the rate of cerebral palsy has increased,” says Alison Cahill, MD, assistant professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis and a Robert Wood Johnson Foundation physician faculty scholar. “We also believe EFM has had a negative effect by contributing to the drastic rise in cesarean section rates in the past 20 years.”

Cahill and her colleagues at the School of Medicine have received a five-year, $3.5 million grant from the National Institute of Child Health and Human Development to better understand the link between fetal heart decreases during labor and brain damage to newborns. The scientists will compare fetal heart rate patterns to neonatal outcomes in 7,000 term deliveries.

From the STL Post-Dispatch

Dr. Matthew Powell with some quotes in today's article regarding BRCA.


"For years, women with a rare gene mutation that puts them at higher risk for cancer have chosen to have their healthy breasts and ovaries surgically removed as a preventive measure.
New data on the subject, released today, suggest the surgeries do reduce a woman's risk of developing breast and ovarian cancers and improve her chances of living longer.
"It's just verifying what we already would expect to be true," said Dr. Matthew Powell, assistant professor of gynecology at Washington University School of Medicine. "Now we have longer-term follow up and more concrete numbers for our patients to really grasp."
The study is the largest to date to find advantages for preventive surgery for women who carry BRCA gene mutations (found in fewer than 1 percent of the general population).
Women with the faulty genes have a dramatically higher cancer risk than other women — five times greater for breast cancer and at least 10 times greater for ovarian cancer.
The study, appearing in today's Journal of the American Medical Association, found benefits for women with two different BRCA gene variants whether they had previously had breast cancer or not."