Journals Watch - Epidurals and childhood cancers

Too busy to read all the latest journals? Let Dr Gwen Lewis bring you up to date with the research.

Epidural anaesthesia during labour was shown to be related to fewer incidences of vaginal prolapse (Photograph: SPL)
Epidural anaesthesia during labour was shown to be related to fewer incidences of vaginal prolapse (Photograph: SPL)

Epidurals may help prevent prolapse
BJOG 2010; doi 10.1111/ji1471-0528.2010.02704.x

I regularly see patients with symptoms of prolapse. I realise that vaginal delivery is a risk factor but I was not aware that tearing of the levator ani muscle occurs in 15-35 per cent of vaginal deliveries.

This Australian study was a prospective review of 488 women in their first pregnancy to determine whether any risk factor during delivery may result in levator trauma. The women were interviewed during pregnancy and an ultrasound scan of the pelvic floor was performed.

They were then reviewed three to four months after delivery and the scan repeated.

In those who delivered by caesarean section, no cases of levator trauma were noted while, in those having a vaginal delivery, 13 per cent were found to have levator avulsion. Forceps delivery resulted in a threeto fourfold increase in levator trauma.

The longer the second stage of labour, the higher the risk of microtrauma to the levator muscles. It was found that in those women having an epidural in labour there was a lower incidence of trauma to the muscles, possibly due to relaxation of the muscles through paralysis.

Is this another reason to recommend an epidural?

Smoking and genital warts
Sex Transm Infect 2010; 86: 258-62
As a medical student, and while working in a genitourinary medicine clinic, I was taught that smokers were more likely to develop genital warts and that the warts were more resistant to treatment. I had never actually seen any evidence for this so was interested to read this Scandinavian study.

More than 58,000 women were randomly sent a questionnaire on lifestyle and health. Women who had smoked reported a lower age of first intercourse and more sexual partners than those who had never smoked.

Sexual behaviour strongly influenced the risk of developing genital warts, and smokers had an increased risk compared with non-smokers.

Interestingly, the risk of developing genital warts increased by 0.6 per cent for each cigarette smoked daily.

Following up patients with childhood cancers
Med J Aust 2010; 193: 258-61
Fortunately cancers in children are uncommon and each GP will see very few children who have had cancer.

In this Australian study, rates of late mortality and second cancers in a cohort of 896 childhood cancer survivors were observed in a New South Wales population over a period of 27 years from 1972 to 1999. Standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs) were used as measures of relative risk.

The SMR and SIR were 7.46 and 4.98 times higher respectively in the cancer survivors. The leading causes of death included recurrence of the primary tumour (55 per cent) and second cancers (12 per cent) as well as treatment-related complications (17 per cent).

Bone and thyroid cancers, melanoma and CNS malignancies were the most frequently observed second cancers.

Children who had had leukaemia, soft tissue sarcoma and Hodgkin's lymphoma were most likely to develop a second cancer.

This increased risk is large so we should be vigilant in these children and into their adult life.

Diabetic foot ulcers and depression
Am J Med 2010; 123: 748-54
Assessing depression in diabetics is part of the QOF so the results of this study from the US are of value to us in the UK. In studies, 11.5 per cent of diabetics have been found to have depression.

A total of 3,474 adults with type-2 diabetes and no previous foot ulcers or amputations were assessed over a mean follow-up of 4.1 years. Both major and minor depression was assessed by the patient health questionnaire-9 (PHQ9), which is commonly used in the UK, and the incidence of diabetic foot ulcers noted.

Other factors including duration of diabetes and control via HbA1c measurement, socioeconomic factors and smoking were adjusted for.

Patients with major depression were found to have a twofold increased risk of diabetic foot ulcers compared with those who were not depressed. Minor depression had no such increased risk.

More care should be taken in assessment of neurological and vascular problems in diabetic patients who are depressed.

Safety of home births
Am J Obstet Gynaecol 2010; 203: 243e1-243e8
There has been a lot of attention given recently to the safety of home births. This study reviewed maternal and neonatal safety of planned home versus planned hospital births.

Births were reviewed from 12 studies from North America, Europe and Australia involving 342,056 planned home and 207,551 planned hospital deliveries.

During a home birth, there was a lesser likelihood of intervention in the form of epidural analgesia, fetal heart rate monitoring and episiotomy and also less risk of vaginal laceration or infection.

However, there was a twoto threefold increase in the incidence of neonatal mortality.

This was striking because, in general, the women planning a home birth were of similar or often lower obstetric risk to those who were planning hospital delivery.

The results do not encourage me to actively discuss home delivery with my pregnant patients.

  • Dr Lewis is a GP in Windsor, Berkshire, and a member of our team who regularly review the journals.
CPD IMPACT: earn more credits

These further action points allow you to earn more credits by increasing the time spent and the impact achieved.

  • Undertake a search of women who have had home deliveries. Find out the neonatal mortality rate in your local area for both women delivering at home and in hospital. Discuss whether home delivery is a safe option in your local area.
  • Undertake a search of patients within the practice population who suffered a cancer in childhood and ensure that they have been assessed recently for health problems.
  • Ensure that all type-2 diabetic patients are fully assessed and that those with high depression scores in the PHQ9 have been fully screened for neurological and vascular foot and leg complications.

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