October 16, 2013

DynaMed EBM Journal Volume 8, Issue 42

DynaMed Weekly Updates

Quick Links

Join Mailing List



Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: October 16, 2013

Expiration Date: October 16, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1210393W


Last week 647 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 256 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

In Twin Pregnancy with Cephalic Presentation of First Twin, Planned Vaginal Delivery Does Not Increase Neonatal Risks Compared to Planned Cesarean Delivery
Reference: (N Engl J Med 2013 Oct 3;369(14):1295) (level 1 [likely reliable] evidence)

Twin pregnancies are associated with greater perinatal risks than singleton pregnancies, and due in part to caution over these risks, rates of elective cesarean births for twins have increased worldwide in recent years. Some observational data have suggested that vaginal delivery may increase adverse outcomes compared to elective cesarean, but there has been no strong evidence to recommend a policy of planned cesarean delivery in pregnancies without specific indications. A recent large randomized trial compared the delivery strategies of planned vaginal delivery and planned cesarean section in 2,804 twin pregnancies in which the first twin was presenting cephalically.

Women with twin pregnancy (gestational age 32 weeks to 38 weeks and 6 days) were randomized to planned vaginal delivery (with cesarean section only if indicated) vs. planned cesarean section. Inclusion criteria included first twin in cephalic presentation and expected birth weight of both twins 1,500-4,000 g (3.3-8.8 lbs) confirmed by ultrasound < 7 days before randomization. In cases of noncephalic presentation of the second twin in the planned vaginal delivery group, the delivery method was at the discretion of the obstetrician, and could include total breech extraction, external cephalic version with cephalic vaginal delivery, or cesarean section. Exclusion criteria included monoamniotic twins, fetal reduction at ≥ 13 weeks gestational age, and contraindication to labor or vaginal delivery. Mothers and neonates were followed to 28 days after delivery. The primary outcome was a composite of fetal or neonatal death and serious neonatal morbidity.

Cesarean deliveries were performed in 90.7% of the planned cesarean group. In the planned vaginal delivery group, 39% had cesarean delivery for both twins and 4.2% had cesarean for the second twin only. The rates of the composite primary outcome were 1.9% with planned vaginal delivery vs. 2.2% with planned cesarean (not significant). Fetal or neonatal death occurred in 0.6% with planned vaginal delivery and 0.9% with cesarean, and serious neonatal morbidity occurred in 1.3% of each group. There were no significant differences in rates of maternal death or serious morbidity between groups. This trial suggests one way in which the current high rates of cesarean section may safely be reduced.

For more information, see the Multiple gestation topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Events

American Academy of Pediatrics (AAP), October 24 - 29, 2013
Deputy Editor Mike Woods, MD, MS, FAAP, will be attending the AAP conference, held at the Orange County Convention Center in Orlando, Florida. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the AAP website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at an event, please contact us at DynaMedCommunity@ebscohost.com.

Call for Peer Reviews

We are currently seeking reviewers for:

Postdates pregnancy

Tocolytics for treatment of preterm labor