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Volume 6, No. 9, September 2008
Features
American College of Obstetricians and Gynecologists
ACOG Practice Bulletin #96 Alternatives to Hysterectomy in the Management of Leiomyomas
Uterine leiomyomas (also called fibroids) are the most
common solid pelvic tumors in women and the leading indication for hysterectomy.
Although many women with uterine leiomyomas are asymptomatic and can be monitored
without treatment, some will require more active measures. Hysterectomy remains
the most common surgical treatment for leiomyomas because it is the only definitive
treatment and eliminates the possibility of recurrence. Many women seek an alternative
to hysterectomy because they desire future childbearing or wish to retain their
uteri even if they have completed childbearing. As alternatives to hysterectomy
become increasingly available, the efficacies and risks of these treatments are
important to delineate. The purpose of this bulletin is to review the literature
about medical and surgical alternatives to hysterectomy and to offer treatment
recommendations.
The following recommendations and conclusions are based on good and
consistent scientific evidence (Level A):
- Abdominal myomectomy is a safe and effective alternative to hysterectomy for treatment of women with symptomatic leiomyomas.
- Based on long- and short-term outcomes, uterine artery embolization is a safe and effective option for appropriately selected women who wish to retain their uteri.
- Gonadotropin-releasing hormone agonists have been shown to improve hematologic parameters, shorten hospital stay, and decrease blood loss, operating time, and postoperative pain when given for 2–3 months preoperatively. Benefits of preoperative use of GnRH agonists should be weighed against their cost and side effects for individual patients.
- Several studies suggest that the infiltration of vasopressin into the myometrium decreases blood loss at the time of myomectomy.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- The clinical diagnosis of rapidly growing leiomyomas should not be used as an indication for myomectomy or hysterectomy.
- Hysteroscopic myomectomy is an accepted method for the management of abnormal uterine bleeding caused by submucosal leiomyomas.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- There is insufficient evidence to support hysterectomy for asymptomatic leiomyomas solely to improve detection of adnexal masses, to prevent impairment of renal function, or to rule out malignancy.
- Leiomyomas should not be considered the cause of infertility, or significant component of infertility, without completing a basic fertility evaluation to assess the woman and her partner.
- Hormone therapy may cause some modest increase in uterine leiomyoma size but does not appear to have an impact on clinical symptoms. Therefore, this treatment option should not be withheld from women who desire or need such therapy.
- The effect of uterine artery embolization on pregnancy remains understudied.
American College of Obstetricians and Gynecologists. ACOG practice bulletin #96. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008 Aug;112(2 Pt 1):387-400. http://www.ncbi.nlm.nih.gov/pubmed/18669742
ACOG Committee Opinion #411 Routine Human Immunodeficiency Virus Screening
ABSTRACT: The American College of Obstetricians and Gynecologists recommends routine human immunodeficiency virus (HIV) screening for women aged 19–64 years and targeted screening for women with risk factors outside of that age range. Ideally, opt-out HIV screening should be performed, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care, unless the patient declines testing (1). The American College of Obstetricians and Gynecologists recommends that obstetrician–gynecologists annually review patients’ risk factors for HIV and assess the need for retesting.
American College of Obstetricians and Gynecologists. ACOG committee opinion.
Routine human immunodeficiency virus screening. Obstet Gynecol. 2008 Aug;112(2
Pt 1):401-3.
http://www.ncbi.nlm.nih.gov/pubmed/18669743
ACOG Committee Opinion #412 Aromatase Inhibitors in Gynecologic Practice
ABSTRACT:
Aromatase inhibitors appear to be effective as an adjuvant treatment for early-stage
and late-stage breast cancer. Their role in chemoprevention of breast cancer
in high-risk patients remains to be defined. Side effects of aromatase inhibitors
in postmenopausal women are due to estrogen-lowering action at the target tissues
and include hot flushes, vaginal dryness, arthralgias, and decreased bone mineral
density. In reproductive-aged women, aromatase inhibitors stimulate gonadotropin
secretion and increase ovarian follicular activity. The role of aromatase inhibitors
in the treatment of endometriosis and in ovulation induction is still being investigated.
American College of Obstetricians and Gynecologists. ACOG committee opinion.
Aromatase inhibitors in gynecologic practice. Obstet Gynecol. 2008 Aug;112(2
Pt 1):405-7.
http://www.ncbi.nlm.nih.gov/pubmed/18669744
ACOG Committee Opinion #413 Age-Related Fertility Decline
ABSTRACT:
Age is a significant factor influencing a woman’s ability to
conceive. Social trends have led to deferred childbearing, and an increasing
number of women are experiencing age-related infertility and pregnancy loss.
Women older than 35 years should receive expedited evaluation and treatment after
6 months of failed attempts to conceive, or earlier if clinically indicated.
American College of Obstetricians and Gynecologists. ACOG committee opinion.
Age-related fertility decline. Obstet Gynecol. 2008 Aug;112(2 Pt 1):409-11. http://www.ncbi.nlm.nih.gov/pubmed/18669745
ACOG Committee Opinion #414 Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome and Women of Color
ABSTRACT: In the United States, women of color (primarily African-American and Hispanic women) comprise most new cases of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) among women. Most women of color acquire the disease from heterosexual contact, often from a partner who has undisclosed risk factors for HIV infection. Safe-sex practices, especially consistent condom use, must be emphasized for all women, particularly for women of color. A combination of testing, education, and brief behavioral interventions can help reduce the rate of HIV infection and its complications among women of color.
American College of Obstetricians and Gynecologists. ACOG committee opinion.
Human immunodeficiency virus and acquired immunodeficiency syndrome and women
of color. Obstet Gynecol. 2008 Aug;112(2 Pt 1):413-6. http://www.ncbi.nlm.nih.gov/pubmed/18669746
Rapid human immunodeficiency virus testing on labor and delivery
This
article, from the “In the Trenches” series of Obstetrics & Gynecology,
provides expert answers to questions about Rapid HIV testing on Labor and Delivery
units. If your Labor and Delivery Unit doesn’t offer rapid HIV testing
yet, this may be a useful resource in anticipating issues that may arise.
Rahangdale L, Cohan D. Rapid human immunodeficiency virus testing on labor and
delivery.
Obstet Gynecol. 2008 Jul;112(1):159-63. http://www.ncbi.nlm.nih.gov/pubmed/18591321
American Family Physician
Spontaneous Vaginal Delivery
ABSTRACT: Vaginal delivery is a natural process that usually does not require significant medical intervention. Management guided by current knowledge of the relevant screening tests and normal labor process can greatly increase the probability of an uncomplicated delivery and postpartum course. All women should be screened for group B streptococcus; women who test positive should be treated with antibiotics during labor. Routine human immunodeficiency virus screening of all pregnant women, and treatment with antiretroviral medication for those who test positive, can reduce perinatal transmission of the infection. Once a woman is in labor, management should focus on the goal of delivering a healthy newborn while minimizing discomfort and complications for the mother. In a patient who tests negative for group B streptococcus, delaying admission to the labor ward until she is in active labor decreases the number of possible medical interventions during labor and delivery. Once a patient has been admitted to the hospital, providing her with continuous emotional support can improve delivery outcomes and the birthing experience. Epidural analgesia is effective for pain control and should not be discontinued late in labor to reduce the need for operative vaginal delivery. Epidurals prolong labor, but do not increase the risk of cesarean delivery. Research has shown that labor may not progress as rapidly as historically reported; this should be considered before intervening for dystocia. Routine episiotomy increases morbidity and should be abandoned. Once the infant has been delivered, active management of the third stage of labor decreases the risk of postpartum hemorrhage.
Patterson DA, Winslow M, Matus CD. Spontaneous Vaginal Delivery.Am Fam Physician. 2008;78(3):336-341, 343-344. http://www.aafp.org/afp/20080801/336.html
Patient Information: Labor and Delivery: What You Should Know?
http://www.aafp.org/afp/20080801/343ph.html
Evaluation and Treatment of Enuresis
ABSTRACT: Enuresis is defined as repeated, spontaneous voiding of urine during sleep in a child five years or older. It affects 5 to 7 million children in the United States. Primary nocturnal enuresis is caused by a disparity between bladder capacity and nocturnal urine production and failure of the child to awaken in response to a full bladder. Less commonly, enuresis is secondary to a medical, psychological, or behavioral problem. A diagnosis usually can be made with a history focusing on enuresis and a physical examination followed by urinalysis. Imaging and urodynamic studies generally are not needed unless specifically indicated (e.g., to exclude suspected neurologic or urologic disease). Primary nocturnal enuresis almost always resolves spontaneously over time. Treatment should be delayed until the child is able and willing to adhere to the treatment program; medications are rarely indicated in children younger than seven years. If the condition is not distressing to the child, treatment is not needed. However, parents should be reassured about their child's physical and emotional health and counseled about eliminating guilt, shame, and punishment. Enuresis alarms are effective in children with primary nocturnal enuresis and should be considered for older, motivated children from cooperative families when behavioral measures are unsuccessful. Desmopressin is most effective in children with nocturnal polyuria and normal bladder capacity. Patients respond to desmopressin more quickly than to alarm systems. Combined treatment is effective for resistant cases.
Ramakrishnan K. Evaluation and Treatment of Enuresis Am Fam Physician. 2008;78(4):489-496, 498. http://www.aafp.org/afp/20080815/489.html
Patient Education: “Enuresis: What You Should Know” http://www.aafp.org/afp/20080815/498ph.htmlAHRQ
New AHRQ Tool Helps Hospitals Evaluate Disaster Drills
Hospitals can now identify the most important strengths and weaknesses in their disaster response plans using a new tool from the U.S. Department of Health and Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ).
Ensuring that hospitals are prepared to respond appropriately during any type
of disaster situation—manmade or natural—is a priority for HHS. Beginning
in September, hospitals participating in the Hospital Preparedness Program, administered
through HHS, will be required to provide executive summaries of the results of
disaster drills they conduct. AHRQ's new Tool for Evaluating Core Elements
of Hospital Disaster Drills can help hospitals meet this requirement.
Hospital disaster response drills are real-time tests of a facility's readiness
to respond to a sudden demand for services resulting from a community-wide disaster.
Routine evaluation of these drills can help a hospital make sure it is ready
to meet community needs and provide high-quality care during a disaster event.
"This tool is a critical first step in helping hospitals evaluate their
disaster plans to find out what works and what doesn't," said AHRQ Director
Carolyn M. Clancy, M.D. "That knowledge can help hospitals make important
changes to their response plans now before a disaster strikes." The tool
is a series of evidence-based modules that provide standardized checklists to
document observations during a disaster drill. Using the observations, hospitals
can identify areas for improvement, make appropriate changes and set benchmarks
to track those changes over time.
The individual modules assess the adequacy of response by different functional "zones" set
up within a hospital during a disaster: command center, decontamination, triage
and treatment. A pre-drill module is also included, and a debrief module helps
capture feedback from all participants, including observations that occur across
multiple functional zones. The new evidence-based tool is an abridged version
of a more comprehensive evidence report developed by AHRQ's Johns Hopkins University
Evidence-based Practice Center in Baltimore. The new version singles out only
the most critical elements that all hospitals should evaluate during disaster
drills.
AHRQ's Evidence-based Practice Centers are part of an important federal effort to compare alternative treatments for significant health conditions and make the findings public. AHRQ's role in national emergency preparedness efforts is to conduct and support research and to develop tools and resources that communities can use to improve public health preparedness.
The Tool for Evaluating Core Elements of Hospital Disaster Drills is available on the AHRQ Web site at: http://www.ahrq.gov/prep/drillelements. Single, free copies can be ordered by sending an E-mail to ahrqpubs@ahrq.hhs.gov or by calling 1-800-358-9295.
For more information about the Hospital Preparedness Program, visit http://www.hhs.gov/aspr/opeo/hpp.Ask A Librarian - Diane Cooper, IHS National Library Informationist
Last month we re-introduced Diane Cooper, the Indian Health Service Librarian at the Health Sciences Research Library. This month she has kindly provided examples of the medical information that she can help us to access, efficiently and electronically, through the HSRL. Ms. Cooper’s contact information follows the excerpts below.
Article 1
"Men who eat soy regularly may face a fertility risk, investigators here
have found. Among men seen at a fertility clinic, those who reported eating as
much as a half serving daily had a sperm concentration that was 41 million/mL
less than that of men who ate no soy, Jorge E. Chavarro, M.D., Sc.D., of the
Harvard School of Public Health, and co-authors reported online in Human
Reproduction. "
Chavarro JE, Toth TL, Sadio SM, Hauser R. Soy food and isoflavone intake in relation to semen quality parameters among men from an infertility clinic. Hum Reprod. 2008 Jul 23. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/18650557
Article 2
"Commonly used treatments for unexplained infertility may be ineffective
in raising the odds of pregnancy, researchers found.
The live birth rate was similar whether couples continued to try for pregnancy
naturally, used oral clomiphene (Serophene, Clomid), or had unstimulated intrauterine
insemination (17% versus 14% and 23%), reported Siladitya Bhattacharya, M.D.,
of the University of Aberdeen, and colleagues online in the BMJ. "
Bhattacharya S, Harrild K, Mollison J, et al. Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial. BMJ. 2008 Aug 7;337:a716. doi: 10.1136/bmj.a716. http://www.ncbi.nlm.nih.gov/pubmed/18687718
Diane Cooper, Librarian
As your partner at the HSRL, I’m here to help you meet your information needs. If you need to find information at either patient point-of-care or as background information for a specific project, I can help. I am here to save you time and ensure you get the information you need. As your information needs evolve, I will expand and enhance my skills and work hard to stay on top of the latest information resources useful to the Indian Health Service.
Benefit from a Content Expert
I have provided clinical and health-related information services to healthcare providers and systems in academic and rural settings in Kentucky, Nevada, and California. With a Master’s in Library and Information Science and extensive experience providing information to providers in outreach areas, I am qualified to provide the Indian Health Service with up-to-date and credible information services. As your direct link to the HSRL and partner in your work, I can support you in the following ways:
- Help with complex and difficult literature searches to support direct patient care and patient care activities
- Participate and be a partner in IHS projects and development team activities
- Assist in manuscript preparation (verify references; editing)
- Set up current awareness alerts in your field of interest
- Create customized databases in bibliographic software programs (Endnote; Reference Manager) to organize your information for easy retrieval when you need it
- Provide instruction on how to search literature databases and other information resources more efficiently
Tips to Get You Started
Here’s a tip to make finding information a little easier. Try using PubMed’s “Clinical Queries” for a quick and easy source of evidence-based medicine information. Let me know if I can help you get started.
Diane Cooper, MSLS
Biomedical Information Consultant for IHS
Division of Library Services
National Institutes of Health
Bethesda, MD 20892
301.594.2449
cooperd@mail.nih.gov
Health Services Research Library (HSRL)
http://hsrl.nihlibrary.nih.gov
Behavioral Health Insights - Peter Stuart, IHS Psychiatry Consultant
Psychiatric disorders in pregnant and postpartum women in the United States
CONTEXT: Psychiatric disorders and substance use during pregnancy are associated with adverse outcomes for mothers and their offspring. Information about the epidemiology of these conditions in this population is lacking.
OBJECTIVE: To examine sociodemographic correlates, rates of DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking among past-year pregnant and postpartum women in the United States. DESIGN: National survey.
SETTING: Face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions.
PARTICIPANTS: A total of 43 093 respondents were interviewed, of whom 14 549 were women 18 to 50 years old with known past-year pregnancy status.
MAIN OUTCOME MEASURES: Prevalence of 12-month DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking.
RESULTS: Past-year pregnant and postpartum women had significantly lower rates of alcohol use disorders and any substance use, except illicit drug use, than nonpregnant women. In addition, currently pregnant women had a lower risk of having any mood disorder than nonpregnant women. The only exception was the significantly higher prevalence of major depressive disorder in postpartum than in nonpregnant women. Age, marital status, health status, stressful life events, and history of traumatic experiences were all significantly associated with higher risk of psychiatric disorders in pregnant and postpartum women. Lifetime and past-year treatment-seeking rates for any psychiatric disorder were significantly lower among past-year pregnant than nonpregnant women with psychiatric disorders. Most women with a current psychiatric disorder did not receive any mental health care in the 12 months prior to the survey regardless of pregnancy status.
CONCLUSIONS: Pregnancy per se is not associated with increased risk of the most prevalent mental disorders, although the risk of major depressive disorder may be increased during the postpartum period. Groups of pregnant women with particularly high prevalence of psychiatric disorders were identified. Low rates of maternal mental health care underscore the need to improve recognition and delivery of treatment for mental disorders occurring during pregnancy and the postpartum period.
Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008 Jul;65(7):805-15. http://www.ncbi.nlm.nih.gov/pubmed/18606953
CCC Editorial Comment:
An excellent review of the interface between generalized adult mental illness and the postpartum period can be found in the following case review from the New England Journal of Medicine. Although the whole article is not available on-line without a subscription, the IHS librarian is available to assist with on-line access for a vast array of medical resources, including this article, for many health care professionals providing care to Native American/Alaska Native women. See “Ask a Librarian” above for details.
Case records of the Massachusetts General Hospital. Case 24-2008. A 35-year-old woman with postpartum confusion, agitation, and delusions
Dr. Alexia E. Koukopoulos (Psychiatry): A 35-year-old woman was admitted to the inpatient psychiatry service of this hospital 5 days after the birth of her first child because of confusion, agitation, and delusions. The patient had been well until approximately 2 years earlier, when insomnia, auditory hallucinations, and disorientation, followed by severe depression and suicidal ideation, developed. After two inpatient psychiatric admissions, a diagnosis of bipolar disorder was made. The patient's symptoms were controlled with lithium, 900 mg at bedtime, and citalopram, 40 mg per day, for the next 9 months. One year before admission, she was seen in consultation . . .
Viguera AC, Emmerich AD, Cohen LS. Case records of the Massachusetts General Hospital. Case 24-2008. A 35-year-old woman with postpartum confusion, agitation, and delusions. N Engl J Med. 2008 Jul 31;359(5):509-15. http://www.ncbi.nlm.nih.gov/pubmed/18669430
Breastfeeding - Suzan Murphy
Infant Feeding in Disasters
Scenario: Flooding, hurricane/cyclone, earthquake, blizzard, fires, mud slides, power outages, unsafe water, extreme heat wave, tornado, tsunami/tidal wave, massive evacuation for environmental/political unrest or?
Question: How to feed the babies?
If the baby is formula fed, the concerns will be:
- Availability of formula - ready to feed will be the safest choice
- Access to safe water - decontaminate or use bottled water
- Clean environment for preparation and cleaning of bottles and nipples
- Availability of a person who can correctly mix formula
- Access to refrigeration for prepared/opened formula
If the baby is breastfed, the questions may be:
Can the mother breastfeed with the stress of a disaster?
Yes -
Women have breastfed through many disasters, wars, and famines. It will help to offer support and encouragement that:
- Stress does not dry up a mother’s milk supply.
- Breastfeeding causes hormones to be released to relieve anxiety and stress for moms.
- The quality of human milk does not vary significantly with maternal diet changes. Even if the mother is not able to eat well, the important nutrients will not be impacted.
- Human milk will supply a major portion of nutrient need in the first year of life and beyond if other safe foods and liquids are not available.
- Breast milk is always the right temperature and matches her baby’s nutrient needs. It will prevent hypothermia and many illnesses for her baby.
Can the mother receive immunizations while breastfeeding?
Yes -
- Routine immunizations like mumps, rubella, tetanus, diphtheria, pertussis, influenza, Streptococcus pneumoniae, Neisseria meningitides, hepatitis A, hepatitis B, varicella, and inactivated polio are safe for breastfeeding mothers and their infants/children.
What about illnesses that can be part of disasters?
- See www.cdc.gov for information about managing breastfeeding women and specific diseases.
What if the mother and baby or toddler have recently stopped breastfeeding
- can breastfeeding be started again?
Yes -
- Encourage the mom to offer the breast to her child. It may take several days or weeks of frequent nursing, but her milk can come back. Suckling every 2 hours with skin-to-skin contact are magic for restoring breast milk supply. Please note that re-lactation may be faster with a younger infant.
- Monitor the baby for adequate hydration and nutritional status.
- Assure the mom that her milk will be fine. Breast milk is a dynamic fluid, always being cleaned, recycled, and restored. It has not spoiled or become outdated in her body.
For more information and downloadable materials, please consult:
American Academy of Pediatrics - Infant Nutrition during a Disaster – Breastfeeding
and other Options (www.aap.org)
Center for Disease Control for Disaster Safety (www.cdc.gov).
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs
Publication Examines Prevention of Injury and Violence within the Mission of Maternal and Child Health
Weaving a Safety Net: Integrating Injury and Violence Prevention into Maternal and Child Health Programs explores how injury and violence prevention (IVP) activities can be integrated into maternal and child health (MCH) programs and services at both state and local levels. The publication, produced by the Children's Safety Net, begins with a discussion of why MCH programs should be interested in IVP initiatives, which MCH services could include IVP, what types of IVP interventions can be used, and what resources and training MCH providers need.
Integration opportunities are presented in the following areas: (1) infant and child health programs, (2) adolescent health programs, (3) programs serving children with special health care needs, and (4) women's health programs. A Massachusetts case study is also included.
The publication
is available at
http://notes.edc.org/HHD/CSN/csnpubs.nsf/cb5858598bf707d58525686d005ec222/
b7b0fdd1dd05c719852574720075c654/$FILE/Weaving%20a%20Safety%20Net.pdf.
Elder Care News - Bruce Finke, Elder Care Initiative
Hospitalization increases fracture risk in elderly
BACKGROUND: Hospitalization may cause bone loss and decrease physical function; however, the risk of fracture following hospitalization is not known.
METHODS: A prospective study of a cohort of 3075 white and black women and men, aged 70 to 79 years, recruited from 2 communities from 1997 to 1998. Incident hospitalizations and fractures were validated by medical records by investigators blinded to patient groupings. Analyses of the association between hospitalization, length of stay, number of admissions, and risk of fracture were adjusted for age, race, sex, and other potential confounding factors.
RESULTS: During follow-up with a mean duration of 6.6 years, 2030 (66%) of the 3075 participants were admitted to a hospital and 809 (26%) were admitted 3 or more times; 285 experienced a fracture, including 74 hip fractures. After adjusting for age, race, and sex, those who had any hospitalization had a 2-fold increased risk of fracture (hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.57-2.57), including an increased risk of hip fracture (HR, 2.15; 95% CI, 1.32-3.50). Those who were hospitalized twice during the follow-up period had a 2.42-fold increased risk of hip fracture (95% CI, 1.16-5.05), and 3 or more hospital stays indicated a 3.66-fold increased relative hazard for hip fracture (95% CI, 1.78-7.53).
CONCLUSIONS: Hospitalizations, particularly multiple admissions, are very common in elderly individuals and are strongly associated with an increased risk of hip and other types of fracture. Hospitalizations present opportunities to take measures to reduce the risk of fractures.
Gardner RL, Harris F, Vittinghoff E, Cummings SR. The risk of fracture following hospitalization in older women and men. Arch Intern Med. 2008 Aug 11;168(15):1671-7. http://www.ncbi.nlm.nih.gov/pubmed/18695081
Family Planning
Beyond the 6 week postpartum check; try 3 weeks instead…
Introduction: The 6-week postpartum visit is an anachronism. Performing the initial pelvic examination at this duration after delivery is based upon statements in old textbooks and teachings from a time when infection was prevalent and before modern methods of contraception were available. The basis for this clinical advice was derived from the understanding that a 6-week period of time would result in sufficient involution of the changes of pregnancy to allow an effective pelvic examination that would confirm the return of normal pelvic anatomy. Many women resume sexual activity before the sixth postpartum week, and because ovulation frequently occurs before 6 weeks, the obstetrical tradition of scheduling the postpartum visit at 6 weeks should be changed. A 3-week visit would be more effective in preventing postpartum conception by initiating effective contraception at this time, instead of after the 6-week visit. There is no reason why a complete physical examination cannot be deferred in an asymptomatic woman until the 3-month follow-up visit that is part of good contraceptive care.
CCC Editorial Comment:
This article provides an excellent overview of optimal postpartum contraception care. Benchmarks about when women really resume intercourse (32-60% by 6 weeks in a variety of international studies), when ovulation resumes (on average 4 weeks postpartum in non-nursing mothers), and that ovulation precedes menstruation more than 50% of the time. Lactational amenorrhea can convey a level of protection similar to OCPs, however if supplemental feedings are introduced or menses return then ovulation resumes quickly. The authors recommend adherence to the “Rule of 3’s”: 1.) For fully breastfeeding women, a contraceptive method should be started in the 3rd postpartum month. 2.) After spontaneous or elective abortion of a pregnancy of <12 weeks, contraception should be started immediately. 3.) After a pregnancy of 12 weeks or more, contraception should be started by the 3rd week postpartum.
Individual contraceptive methods are addressed in detail:
-Progestin-only pills can be started immediately and should be started by the
third week or month as above.
-Combined oral contraceptives (as well as transdermal and vaginal combined methods)
can be started in the third week or the third month as above.
-Depo-Provera and implants (such as Implanon) may be placed immediately postpartum.
-IUDs can be placed 4-8 weeks postpartum or within 15 minutes of delivery.
-Because of the increased risk of clotting disorders in the immediate postpartum
period; strong consideration should be given to use of a non-estrogen containing
method from 3 to 7 weeks postpartum.
Although the full text article is not available without a subscription, this is a great example of resources that are available through the Health Sciences Research Library. See “Ask a Librarian” above.
Speroff L, Mishell DR Jr. The postpartum visit: it's time for a change in order to optimally initiate contraception. Contraception. 2008 Aug;78(2):90-8. Epub 2008 Jun 12. http://www.ncbi.nlm.nih.gov/pubmed/18672108
Featured Website
NICHCY-National Dissemination Center for Children with Disabilities
We are the center that provides information to the nation on:
- disabilities in children and youth;
- programs and services for infants, children, and youth with disabilities;
- IDEA, the nation's special education law;
- No Child Left Behind, the nation's general education law; and research-based information on effective practices for children with disabilities.
Anyone can use our services - families, educators, administrators, journalists, students. Our special focus is children and youth (birth to age 22). Here, on our Web site, you'll find an abundance of information on:
- Specific disabilities
- Early intervention services for infants and toddlers
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- Research on effective educational practices
- Resources and connections in every state
- IEPs (individualized education programs)
- Parent materials
- Disability organizations
- Professional associations
- Education rights and what the law requires
- Transition to
adult life
…and much, much more!
http://www.nichcy.org/Pages/Home.aspx
Frequently Asked Questions
- What is the most effective way to monitor thyroid changes in pregnancy?
- Should we obtain a TSH, FT4, FT3 q 4 weeks, or just follow TSH q 6 weeks?
Below are a few thoughts on thyroid function testing. If your lab package has some particular ‘deal’ whereby they bundle tests to make them cheaper, then that might negate the physiologic issues below, but you should at least make sure such a lab bundle includes the following…..
#1
If you had only one test you could order to evaluate thyroid function during
pregnancy, it would be the free T4*.
A rare patient will have hyperthyroidism manifested by a suppressed TSH and a normal free T4, but an elevated free T3, so called “T3-toxicosis”. While this is an uncommon entity, measurement of free T3 may be helpful in the evaluation of the woman who has clinical signs of hyperthyroidism, but has a normal free T4.
Thyroid function testing should always be combined with the clinical evaluation. Iodide levels decrease during pregnancy because of fetal iodine uptake, as well as increased maternal renal clearance of iodine. This may result in a significant increase in the size of the thyroid gland during gestation, which is usually physiologic rather than pathologic. The effect of hCG on this increase in thyroid volume during pregnancy has been alluded to above.
Likewise, the fatigue, weight changes, hyperdynamic circulation, and other normal pregnancy alterations may lead one to suspect thyroid disease. As with everything else in clinical medicine, one needs to put the whole picture together: symptoms, physical findings, and laboratory assessment.
Remember that TSH does not cross the placenta to the fetus, but small amounts of thyroxine do, as do iodine, the various thyroid receptor immunoglobulins (more on them later as well), and the thioamides used to treat hyperthyroidism, propylthiouracil (PTU) and methimazole.
*Depending on your lab package this may be cheaper ordered as a Free Thyroxine Index
#2
The next best test to manage thyroid disease in pregnancy would be a TSH….
A mainstay of thyroid function evaluation is TSH testing; such testing is now performed using monoclonal antibodies, making it more sensitive than the original radioimmunoassay. The American Association of Clinical Endocrinologists and the American Thyroid Association recommend TSH testing as the initial test for the screening and evaluation of symptomatic disease for all men and women. The free component is the biologically active portion and is not subject to change in conditions that alter TBG, such as pregnancy.
In a pregnant patient suspected of being hyperthyroid or hypothyroid, TSH and FT4 or FTI should be measured. Free thyroxine assessment by either direct immunoradiometric or chemiluminescent methods generally is available and preferred over the equilibrium dialysis method. However, FTI can be calculated as the product of TT4 and RT3U if FT4 is not available. Measurement of FT3 usually is only pursued in patients with thyrotoxicosis with suppressed TSH but normal FT4 measurements. Elevated FT3 indicates T3 toxicosis, which may occur before excessive FT4 production develops
but…
….Thyroid stimulating hormone (TSH) values must be also interpreted with caution during pregnancy. The newer third generation monoclonal immunoassays for TSH may be spuriously lowered during pregnancy. The increase in chorionic gonadotrophin (hCG) during pregnancy may inhibit hypothalamic thyrotropin releasing hormone (TRH) and result in a reduction of maternal TSH levels, sometimes to undetectable levels, making it appear that the patient has hyperthyroidism, even though she remains clinically euthyroid. There is close structural homology between both the hCG and the TSH molecules and their receptors, and this may explain these effects.
Thyroid binding globulin (TBG) is increased in pregnancy as a result of estrogen induced stimulation of its synthesis. This results in seemingly abnormally high values for total thyroxine (total T4) and total triiodothyronine (total T3), and low values for the resin T3 uptake (RT3U), commonly ordered tests for the evaluation of thyroid function in non-pregnant women.
To make it more interesting, the thyroid glands of normal pregnant women may be stimulated by high levels of hCG to secrete slightly excess amounts of T4 and to undergo a further suppression of TSH. The stimulation of the high levels of hCG may also result in a physiologic increase in size of the gland.
Free thyroxine (free T4) levels remain the most reliable test of thyroid function during pregnancy.
Other thoughts….
How often to re-test?…..If you are using the lab to f/u up a medication change, then the lab test should be repeated not sooner than every 4 weeks. If the pt is asymptomatic, then q 6 wk would be OK.
If no medication changes are made and the pt is asymptomatic, then q trimester is OK
Hyperemesis
Some providers routinely use various TFTs to follow pts with hyperemesis, though
ACOG has stated “….There is no need to measure TFTs routinely in
women with hyperemesis…..”
ACOG based that on a prospective study that showed that biochemical hyperthyroidism resolved in all of the women without treatment by 18 weeks of gestation
(In a prospective study of 67 women with singleton pregnancies and hyperemesis, 66% were found to have biochemical hyperthyroidism with an undetectable level of TSH or elevated FTI or both. The biochemical hyperthyroidism resolved in all of the women without treatment by 18 weeks of gestation.)
In those cases the TSH and FTI values really are not valid for that till at least 18-20 weeks
And lastly ACOG’s Practice Bulletin says
“….Thyroid function tests are not indicated in asymptomatic pregnant women with slightly enlarged thyroid glands…..”
References:
Perinatology Corner Modules
Thyroid Diseases in Pregnancy
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/Thyr01.cfm
Thyroid disease in pregnancy.
ACOG Practice Bulletin No. 37.
American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;100:387–396
http://www.acog.org/publications/educational_bulletins/pb037.cfm
(The ACOG Practice Bulletins are also in the ACOG Compendium which your nearest IHS OB dept can probably send you their extra copies of, if you don’t get them already. As all ACOG members get a Compendium each year up here we send our extras to our local field hospitals each year. You can also become an Associate member of ACOG and get all their education materials. Your department will pay the fees. If you have questions, please let me know)
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
Quote of the month
“My country right or wrong is something no true patriot would say…It
is like saying, ‘My mother, drunk or sober’””
G. K. Chesterton
Article of Interest
Prevention and Control of Influenza
Recommendations of the Advisory Committee on Immunization Practices (ACIP)
July 17, 2008 (Early Release);1-60
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1.htm
This
report updates the 2007 recommendations by CDC's Advisory Committee on Immunization
Practices (ACIP) regarding the use of influenza vaccine and antiviral agents.
Principal updates and changes include 1) a new recommendation that annual vaccination
be administered to all children aged 5--18 years, beginning in the 2008--09 influenza
season, if feasible, but no later than the 2009--10 influenza season; 2) a recommendation
that annual vaccination of all children aged 6 months through 4 years (59 months)
continue to be a primary focus of vaccination efforts because these children
are at higher risk for influenza complications compared with older children;
3) a new recommendation that either trivalent inactivated influenza vaccine or
live, attenuated influenza vaccine (LAIV) be used when vaccinating healthy persons
aged 2 through 49 years (the previous recommendation was to administer LAIV to
person aged 5--49 years
The age at which LAIV can be administered has been expanded include children
ages 2- 5 years of age. LAIV can be administered to persons with minor acute
illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without
fever). However, if nasal congestion is present that might impede delivery of
the vaccine to the mucosa, deferral of administration should be considered until
resolution of the illness.
The effectiveness or safety of LAIV is not known for the following groups, and these persons should not be vaccinated with LAIV:
- persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs.
- persons aged <2 years or those aged >50 years;
- persons with any of the underlying medical conditions that serve as an indication for routine influenza vaccination, including asthma, reactive airways disease, or other chronic disorders of the pulmonary or cardiovascular systems; other underlying medical conditions, including such metabolic diseases as diabetes, renal dysfunction, and hemoglobinopathies; or known or suspected immunodeficiency diseases or immunosuppressed states;
- children aged 2--4 years whose parents or caregivers report that a health-care provider has told them during the preceding 12 months that their child had wheezing or asthma, or whose medical record indicates a wheezing episode has occurred during the preceding 12 months;
- children or adolescents receiving aspirin or other salicylates (because of the association of Reye syndrome with wild-type influenza virus infection);
- persons with a history of GBS after influenza vaccination; or
- pregnant women.
Editorial Comment
These latest recommendations from ACIP make flu vaccination nearly universal. For those caring for children this means that the VFC program will cover flu vaccine for all children ages 6 months through 18 years. They also expand the use of LAIV to children between the ages of 2 to 5 years and practitioners may wish to consider the use of LAIV in this age group. Practitioners may wish to consider alternative ways of delivering vaccine to their patients; this could include walk-in flu vaccine clinics and the use of schools or community centers outside of usual health care settings to administer flu vaccines.
A model school program is described in this article:
A pilot study of the effectiveness of a school-based influenza vaccination program.
Pediatrics. 2005 Dec;116(6):e868-73.
Infectious Disease Updates
Rosalyn Singleton, MD
Rotavirus activity decreased in the U.S. in 2007-8
Rotavirus is the leading cause of severe acute gastroenteritis among infants and young children, accounting for an estimated 55,000--70,000 hospitalizations and 250,000 emergency department visits in the United States annually. In winter months, approximately 50% of hospitalizations and ED visits and 30% of outpatient visits for acute gastroenteritis among children aged <3 years are caused by rotavirus. In February 2006, a human-bovine rotavirus vaccine, RotaTeq® (RV5, rota-pentavalent, Merck & Co., Inc.) was recommended for routine use among U.S. infants. To summarize rotavirus activity during the 2007--08 season, CDC analyzed data from the National Respiratory and Enteric Virus Surveillance System and New Vaccine Surveillance Network. When compared with the 15 previous seasons spanning 1991--2006, rotavirus activity during the current season appeared delayed in onset by 2--4 months and diminished in magnitude by >50%.
Rotarix® licensed in the U.S.
A new rotavirus vaccine (Rotarix®, RV1, rota-monovalent, GlaxoSmithKline) was licensed on April 3, 2008. On June 25, 2008, the ACIP voted on new recommendations for the use of rotavirus vaccine: http://www.cdc.gvo/vaccines/recs/provisional/downloads/rota-7-1-08-508.pdf
Routine administration
- RotaTeq (rota-pent) is a 3-dose series recommended at 2, 4, and 6 months of age
- Rotarix® (rota-mono) is a 2-dose series recommended at 2 and 4 months of age
- The first dose of either vaccine should be administered between age 6 weeks and age 14 weeks 6 days (new maximum age of first dose)
- Minimum interval between each dose is 4 weeks
- All doses should be administered by age 8 months 0 days.
Interchangeability of Rotavirus vaccines
- ACIP prefers completion of series with same vaccine, but any combination of 3 doses is allowed.
Contraindications
- History of anaphylaxis after previous dose or vaccine component.
- Latex rubber is contained in Rotarix® (rota-mono) applicator – infants with anaphylactic allergy to latex should not receive Rotarix®
Recent literature on American Indian/Alaskan Native Health
Michael L. Bartholomew, MD
Rutman S., Park A, Castor M, ATaualii M, Forquera R. Urban American Indian and Alaska Native Youth: Youth Risk Behavior Survey 1997-2003. Matern Child Health J. 2008 May 16. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/18483839
Urban American Indian and Alaska Native Youth: Youth Risk Behavior Survey 1997-2003
Studies to date of American Indian and Alaska Native (AI/AN) youth behavior and health status tend to focus on non-urban youths. Studies that specifically address urban Indians tend to be regionally specific and their results cannot be extrapolated to a national level1. The number of AI/AN people living in urban areas continues to grow. In the 2000 U.S. Census, 2.8 million of the 4.1 million persons reporting AI/AN race resided in urban areas. With a large percentage of this population being less than 18 years, it is important to understand and examine the health status and health behaviors of this group.
The purpose of this study is to identify and examine the health risk behaviors in urban AI/AN youth by analyzing aggregate data from 4 survey years (1997, 1999, 2001, 2003) of the YRBS.
The Youth Risk Behavior Survey (YRBS) is a self reported questionnaire administered to high school students (grades 9-12) biennially by the Centers for Disease Control and Prevention (CDC) to monitor the health risk behaviors. The survey divides behaviors that lead to morbidity and mortality in 6 risk areas: behaviors that result in unintentional injuries and violence; tobacco use; alcohol and drug use, behaviors that contribute to unintended pregnancy and sexually transmitted diseases; physical inactivity; and dietary behaviors including weight status.
Of the behaviors that measure unintentional injury, safety, and violence, eleven of the sixteen measures were found to be higher in urban AI/AN youth than white youth including school-related safety and violence. Urban AI/AN youth were more likely to be in a physical fight, requiring medical treatment for injuries related to a physical fight, physically hurt by a boy/girlfriend, physically forced to have unwanted sex, carrying a weapon in the past year and carrying a gun in the past month. Of the 5 suicidal ideation and related behavior measurements, four were higher in the urban AI/AN youth than their white counterparts including attempted suicide (threefold higher) and injury from suicide attempt (fivefold higher).
In regards to tobacco use only 2 of the 16 measures were significantly higher in the AI/AN youth: smoking a cigarette before age 13 (33.1% vs. 18.4%) and smoking cigarettes at school in the last month (20.7% vs. 12.9%).
AI/AN youth were more likely to have consumed alcohol prior to age 13 and have had alcohol at school in the past month. Of the 15 questions addressing illegal drug use (including marijuana, cocaine, heroin, steroids, and injection drugs), AI/AN youth had higher reported use than their white counterparts. There was no difference between AI/AN and white youth in the reported use (lifetime or current) of glue, methamphetamines, hallucinogens and ecstasy.
American Indian/Alaska Native youth had a higher percentage sexual intercourse, first sexual intercourse before age 13, sexual intercourse with multiple partners (>4), sexual intercourse with greater than or equal to 1 person in the past three months and having been pregnant or making someone pregnant.
Lastly, in regards to physical activity and dietary behaviors, urban AI/AN adolescents watched at least 3 hours of television on an average school day (45.1% AI/AN vs. 31.7% white) and 38.7% of urban AI/AN youth described themselves as slightly or very overweight as compared to 28.8% of white youth.
The authors cite five limitations to their study. First, there were small numbers of AI/AN in the study (513 AI/AN youths of the 52,364 urban sample), thus making trend analysis difficult. Second, YRBS questions have not been validated on AI/AN populations, allowing for interpretation of the questions to possibly affect the responses. Third, underreporting of unhealthy behaviors (illegal drug use, alcohol consumption) and over-reporting of healthy behaviors such as exercise may occur in self-reported surveys. Fourth, the survey is not representative to each metropolitan area thus making generalizations of the results unreliable. Lastly, the results are of those youth that attend school and does not taking into account high school dropouts, thus possibly underestimating the prevalence of high-risk behaviors.
Few studies explore the health status of urban AI/AN youth on a national level. Most studies focus solely on AI/AN youth that reside on reservations or rural areas of the country. This study illustrates the high-risk health behaviors that are specific to urban AI/AN youth. By identifying and focusing on these behaviors, health promotion and disease prevention programs as well as intervention programs can be tailored to address the needs of this population.
Additional information and resources on Urban Indian Health:
- Indian Health Service: Urban Health Programs. http://www.ihs.gov/NonMedicalPrograms/Urban/Urban_index.asp
- National Council of Urban Indian Health. http://www.ncuih.org/index.html
- Urban Indian Health Institute. http://www.uihi.org/
Reference:
1. Dixon, M, Roubideaux,Y (2001). Promises to Keep: Public Health Policy for American Indians & Alaska Natives n the 21st Century. Washington D.C.: American Public Health Association. 121-134.
Special Announcement
CDC -TV is currently making the soon to be released animated
version of all 4 Eagle Books available for viewing on the internet
at http://www.cdc.gov/CDCTV/
The animated version of the Eagle Book series (Through the Eyes of the Eagle, Knees Lifted High, Plate Full of Color, and Tricky Treats) has been created for availability on DVD from the Native Diabetes Wellness Program (NDWP), Division of Diabetes Translation (DDT), Centers for Disease Control and Prevention (CDC).
The full featured DVD can be used in many ways as an interactive tool with parents, teachers and communities to engage children in activities and discussions about healthy eating and the joy of being active while looking to traditional ways to stay healthy and prevent type 2 diabetes.
The author of the original Eagle Books, Georgia Perez, provides the narration for the animated videos. Children and adults from the Standing Rock Sioux tribal nation bring the book characters alive with their creative voice talent. The DVD has many special features including:
- Three American Indian language translations of the books (Chickasaw, Paiute, Shoshone)
- Spanish translations
- Closed Captioning (CC) and Video Descriptions (for the Deaf/Hard of Hearing/Blind and Visually Impaired)
- Information about the author and illustrators
- Resources for children, parents, teachers and communities
To assist teachers and parents the DVD can be stopped and started for listening to elders, demonstrating fun ways to be active, describing the many colored fruits and vegetables from Mother Earth, and deciding what is a “sometimes” or “everyday” food selection. Teachers and parents may also find the DVD can be used as a read-along tool to accompany the print copies of the Eagle Books.
Join the fun and watch the Eagle Books characters and beautiful artwork by Patrick Rolo and Lisa Fifeild come alive on the DVD and the internet today.
If you have questions about the animation please contact Cherryll Ranger chr4@cdc.govInformation Technology - Theresa Cullen, Chief Information Officer, IHS
Office of Information Technology Newsletter
Please follow this link to the summer edition of the Office of Information Technology newsletter. You will find security tips, web updates, information on the Health Information Management Conference (December 2008) and more!
Thanks for your ongoing
support of information technology within the Indian Health Service.
http://www.ihs.gov/misc/links_gateway/sub_categories.cfm?sub_cat_id=060903
International Health Update - Claire Wendland, Madison, WI
Active tuberculosis more likely in diabetics: a new meta-analysis has serious global health implications
The World Health Organization estimates that one third of the world’s population is infected with tuberculosis. Fortunately, in most people the infection remains quiescent. Only about one in ten of those infected go on to develop the active disease that damages their own bodies and puts them at risk for infecting others. Anything that changes the rate of conversion to active tuberculosis, for better or for worse, has significant public health implications. In recent years, for instance, the link between HIV and TB has attracted much attention: immune suppression related to HIV puts patients at dramatically increased risk for active tuberculosis. But HIV is not the only such condition.
Clinicians have suspected a connection between diabetes and active TB for almost a century. A causative connection is biologically plausible, because diabetes impairs host immunity. Studies in diabetic mice show diminished T-cell response to infection with M. tuberculosis – a response that is critical to keeping infectious bacilli contained. In addition, human studies show reduced production of interferon, impaired neutrophil activity and decreased leukocyte bactericidal action with rising HbA1c. A new meta-analysis now confirms the long-suspected association between active tuberculosis and diabetes mellitus, and explores the implications for public health internationally.
Two epidemiologists looked at all available good-quality research comparing active tuberculosis in adults with and without DM. (They were particularly interested in cohorts with a confirmed prior diagnosis of DM, because direction of causation can be tricky: tuberculosis induces a hyperglycemia that resolves with treatment.) They found thirteen studies: seven from North America, including two in Native American communities, and the remainder from Europe, Central America and Asia. Despite different geographic regions, study designs, and background incidences of TB, they found a consistently significant association between DM and active TB. The relative risk of active TB was doubled for diabetics in areas where background incidence of TB was low, more than tripled where background incidence is high. In addition, the relative risk seemed to be substantially higher in younger people.
The public health implications are profound. The global burden of diabetes is expected to double by 2030. Some of the fastest rates of increase are seen in India and China, also huge population centers with high background rates of TB and relatively young mean ages. Already, the authors calculate that DM probably accounts for about 15% of all active TB cases in India. These findings make even more urgent the need for investigation of – and intervention into – social determinants of diabetes mellitus. In the mean time, they also have practical implications. Public health practitioners may want to seek out people with DM for tuberculosis case-finding, and clinicians have one more good reason to work with their patients toward diabetes prevention.
Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Medicine 5(7):e152, July 2008.
http://www.ncbi.nlm.nih.gov/pubmed/18630984MCH Alert
State Analysis Assesses Relationship between Pre-Pregnancy Maternal Obesity and Risk of Infant Death
"This analysis indicates
that maternal obesity is associated with increased odds of infant death," state
the authors of an article published in the July-August 2008 issue of Public Health
Reports.
Consistent with the increasing focus on weight and health outcomes for the general
population, maternal pre-pregnancy weight is also being assessed for its impact
on perinatal health outcomes. In March 2004, Florida implemented a revised birth
record that includes maternal height and pre-pregnancy weight. The addition of
these two measures made it possible to conduct population-based analyses using
body mass index (BMI). The purpose of the analysis, as presented in the article,
was to assess and quantify the relationship between pre-pregnancy BMI and risk
of infant death for the 2004 Florida birth cohort.
Data were drawn from the Florida
resident birth records for the period March-December 2004. A total of 166,301
resident birth records were linked to 1,015 infant death records for the analysis.
BMI calculations were used to classify maternal pre-pregnancy weight into five
categories as defined by clinical guidelines: underweight, normal, overweight,
obese, and morbidly obese. Infant death was used as the dependent variable and
the BMI categories as dummy variables in the first model. Maternal race, marital
status, age, education, tobacco use, first birth, and trimester of entry into
prenatal care were included in subsequent models to adjust for potential confounders.
These variables were also assessed as potential effect modifiers for the BMI
variables. The extent of the potential influence of maternal diabetes mellitus,
hypertension, and preeclampsia was also determined by comparing adjusted odds
rations (AORs) for women without the specified conditions to the AORs for all
women.
The authors found that:
- Infants born to women who were obese had odds of infant death that were 23% higher than the odds for the reference group of infants born to women with normal BMIs.
- The association between maternal pre-pregnancy weight and infant death was more pronounced for infants born to women classified as morbidly obese, with odds of infant death that were 70% higher than odds for the reference group.
- The results were not substantially affected by presence or absence of the specified maternal conditions as recorded on the birth record.
- Only the maternal race variable was associated with statistically significant effect modification (AORs were significantly different for black vs. non-black women).
- "The integration of an important component of preconception health and obesity prevention into effective community-based interventions may lead to beneficial outcomes for the overall population, including women of childbearing age," the authors conclude.
Thompson DR, Clark CL, Wood B, et al. 2008. Maternal obesity and risk of infant
death based on Florida birth records for 2004. Public Health Reports 123(4):487-493.
Abstract available at http://www.publichealthreports.org/userfiles/123_4/487-493.pdf.
Readers: More information is available from the following MCH Library resources:
-Infant Mortality: Knowledge Path at http://www.mchlibrary.info/KnowledgePaths/kp_infmort.html
-Preconception and Pregnancy: Knowledge Path at http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html
Study Investigates Alcohol Consumption during Pregnancy and the Risk of Early Fetal Death
"In this large retrospective cohort study of
more than 650,000 pregnancies, we report elevated risks of stillbirth among mothers
who admit to alcohol ingestion during pregnancy," state the authors of an
article published in the August 2008 issue of Alcohol. Alcohol intake during
pregnancy is correlated with myriad adverse birth outcomes. The validity of previous
studies of the relationship between maternal alcohol intake and fetal death (i.e.,
stillbirth) has been questioned owing to study-design considerations, small sample
sizes, errors in classification of exposure, and failure to account for confounding
factors. Finally, most published studies of maternal drinking and fetal death
do not distinguish between fetal deaths that occur at different
stages of pregnancy. The article presents findings from a study to investigate
the independent association between alcohol consumption during pregnancy and
early fetal death using a large population-based data set.
Data for the study were drawn from the Missouri maternally linked cohort data
files for the period 1989-1997. In this data set, siblings are linked to their
biologic mothers using unique identifiers.
Following delivery (live birth or fetal death), information was obtained from
the women regarding sociodemographic factors (including alcohol intake during
pregnancy) and other pregnancy-related experiences. The analysis included only
births within the gestational age range of 20-44 weeks, separated into categories
of early (less than 28 weeks' gestation) and late (28 or more weeks' gestation)
fetal death. The analyses determined differences in sociodemographic
characteristics and maternal pregnancy complications between nondrinking and
drinking women, with adjusted estimates derived by using nondrinking women as
the reference group.
The authors found that:
- A total of 3,508 counts of fetal death were identified in the entire study sample, yielding a fetal death rate of 5.4 per 1,000; the rate among drinking women was 8.3 per 1,000, and the rate among the reference group (nondrinking women) was 5.3 per 1,000.
- The risk of fetal death was 40% higher among drinking women compared to nondrinking women. Notably, the risk of early fetal death was 80% higher among drinking women compared to nondrinking women, whereas the risk of late fetal death exhibited a 20% increase that did not reach statistical significance.
- Among women who consumed five or more drinks per week during pregnancy, the risk of fetal death was 70% higher, compared to nondrinking women.
- The elevated risk for early or late fetal death among drinking women did not reach statistical significance when broken down by level of alcohol intake.
- The greatest risk for experiencing fetal death, early or late, was exhibited among women who reported drinking during pregnancy but failed to provide information on the number of drinks they consumed per week.
The exact pathway by which alcohol predisposes to stillbirth remains to be
determined," state
the authors. However, they conclude, "our findings will prove beneficial
in counseling pregnant mothers or women intending to conceive on the risks associated
with alcohol abuse in
pregnancy."
Aliyu MH, Wilson RE, Zoorob R, et al. 2008. Alcohol consumption
during pregnancy and the risk of early stillbirth among singletons. Alcohol 42(5):369-374.
Abstract available at
http://www.ncbi.nlm.nih.gov/pubmed/18562153.
Readers: More information is available from the following MCH Library resource:
Substance Use During Pregnancy: Bibliography at
http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_subusepreg.
html&-MaxRecords=all&-DoScript=auto_search_subusepreg&-search
MCH Headlines - Judy Thierry HQE
New United States Infant Mortality Statistics Released
Mortality Statistics from the 2005 Period Linked Birth/Infant Death Data
Set
OBJECTIVES: This report presents 2005 period infant mortality statistics from the linked birth/infant death data file by a variety of maternal and infant characteristics. The linked file differs from the mortality file, which is based entirely on death certificate data.
METHODS: Descriptive tabulations of data are presented and interpreted. Excluding rates by cause of death, the infant mortality rate is now published with two decimal places.
RESULTS: The U.S. infant mortality rate was 6.86 infant deaths per 1,000 live births in 2005, which is statistically unchanged from 6.78 in 2004. Infant mortality rates ranged from 4.89 deaths per 1,000 live births for Asian or Pacific Islander (API) mothers to 13.63 for non-Hispanic black mothers. Among Hispanics, rates ranged from 4.42 for Cuban mothers to 8.30 for Puerto Rican mothers. Infant mortality rates were higher for infants who were born in multiple deliveries or whose mothers were born in the 50 states and the District of Columbia or were unmarried. Infant mortality was also higher for male infants and infants born preterm or at low birthweight. The neonatal mortality rate was essentially unchanged from 2004 (4.52) to 2005 (4.54). The postneonatal mortality rate increased 3 percent from 2.25 in 2004 to 2.32 in 2005. Infants born at the lowest gestational ages and birthweights have a large impact on overall U.S. infant mortality. For example, more than one-half (55 percent) of all infant deaths in the United States in 2005 occurred to the 2 percent of infants born very preterm (less than 32 weeks of gestation). Infant mortality rates for late preterm infants (34–36 weeks of gestation) were three times those for term infants (37–41 weeks). The three leading causes of infant death—congenital malformations, low birthweight, and sudden infant death syndrome (SIDS)—accounted for 44 percent all infant deaths. The percentage of infant deaths that were ‘‘preterm-related’’ increased from 34.6 percent in 2000 to 36.5 percent in 2005. The preterm-related infant mortality rate for non-Hispanic black mothers was 3.4 times higher and the rate for Puerto Rican mothers was 87 percent higher than the rate for non-Hispanic white mothers.
Mathews TJ, MacDorman MF. Infant mortality statistics from the 2005 period linked birth/infant death data set. National vital statistics reports; vol 57 no 2. Hyattsville, MD: National Center for Health Statistics. 2008. http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_02.pdf
Smoking During Pregnancy Increases Risk for Birth Defect
BACKGROUND: There is evidence for an effect of cigarette smoking on risk of oral clefts. There are also hypothetical pathways for a biologic effect involving toxic chemicals in cigarette smoke.
METHODS: We performed a combined case-control and family-triad study of babies born with oral clefts in Norway in the period 1996 to 2001, with 88% participation among cases (n = 573) and 76% participation among controls (n = 763). Mothers completed a questionnaire 4 months after birth of the baby. DNA was collected from parents and children, and assayed for genes related to detoxification of compounds of cigarette smoke (NAT1, NAT2, CYP1A1, GSTP1, GSTT1, and GSTM1).
RESULTS: For isolated cleft lip (with or without cleft palate) there was a dose-response effect of smoking in the first trimester. The odds ratio rose from 1.6 (95% confidence interval = 1.0-2.5) for passive smoking to 1.9 (0.9-4.0) for mothers who smoked more than 10 cigarettes per day. There was little evidence of an association with cleft palate. Genetic analyses used both case-control and family-triad data. In case-triads we found an association between a NAT2 haplotype and isolated cleft lip (relative risk of 1.6 with 1 copy of the allele and 2.5 with 2 copies), but with little evidence of interaction with smoking. Other genes did not show associations, and previously described interactions with smoking were not confirmed.
CONCLUSION: First-trimester smoking was clearly associated with risk of cleft lip. This effect was not modified by variants of genes related to detoxification of compounds of cigarette smoke.
Lie RT, Wilcox AJ, Taylor J, Gjessing HK, Saugstad OD, Aabyholm F, Vindenes H. Maternal smoking and oral clefts: the role of detoxification pathway genes. Epidemiology. 2008 Jul;19(4):606-15. http://www.ncbi.nlm.nih.gov/pubmed/18449058
”There's No Place like Home... For Sex Education”
Planned
Parenthood of Southwestern Oregon has developed an award-winning book called “There's
No Place Like Home... For Sex Education.” Written
by Mary Gossart, Vice President of Education and Training, this book is now available
as age-specific chapters on their web site. Features include relevant, age-appropriate
sexuality information, useful strategies, communication hints, and suggested
resources to support you in your efforts.
You can also print/download pdf order form to purchase the printed spiral-bound
version of this book:
- Photocopied, bound version of “There’s No Place Like Home... For Sex Education” is available in English or Spanish @ $8.00 per copy.
- The Native American adaptation is available in a master copy @ $20.00 per copy. This copy can be used for photocopying purposes. http://www.noplacelikehome.org/nativeamerican.php
You’ll be encouraged to know that family-based sexuality education can:
-create an opportunity to share family values
-provide accurate information to children
-build effective decision-making skills
-counteract negative and exploitive sexual messages in the media.
http://www.noplacelikehome.org/index.php
Conference Announcement: Childhood Obesity/Diabetes Prevention in Indian Country: Making Physical Activity Count
The purpose of this national conference is to enhance the skills and knowledge of persons engaged in American Indian/Alaska Native community and school-based physical activity programs designed to reduce the incidence and prevalence of childhood obesity and type 2 diabetes mellitus (T2DM). The conference will focus on ways that health care providers and educators can initiate or improve physical activity outcome measurements that target American Indian and Alaska Native (AI/AN) children and youth.
Location:
December 2-4, 2008 San Diego, California at the Town
and Country Resort & Convention Center. Town & Country Resort & Convention
Center 500 Hotel Circle North San Diego, CA 92108 (619) 291-8770
Abstract submission 1 Sept 08: http://www.nartc.fcm.arizona.edu/conference/
For questions about the abstract, please contact Rob Young at 520-621-5075 or
by e-mail at
rsy@U.Arizona.edu.
Deadline registration Sept 30: ($160) limited to 250 participants.
Medical Mystery Tour - Neil Murphy, Southcentral Foundation; ANMC
Fetal Heart Monitoring: The answers
Last month we asked you seven simple questions about a very common entity, fetal heart rate monitoring. Here are the answers to those questions, plus a little perspective.
First of all electronic fetal heart rate (FHR) monitoring was introduced widely without evidence of its benefit or a common terminology. In 1997 the National Institute of Child Health and Human Development (NICHD) published recommendations for standardized terminology. The terminology was subsequently accepted by the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and detailed in the ACOG’s Practice Bulletin Number 70. The NICHD terminology was also subsequently accepted by the American College of Nurse-Midwives.
1.) A complete description of a fetal heart rate (FHR) tracing requires a qualitative and quantitative description of beat-to-beat variability.
False
Variability is quantitated as the amplitude of the fetal heart rate fluctuations from peak to trough in beats per minute. An amplitude range that is not detectable is defined as absent variability. If the range is detectable, but less than or equal to 5 beats per minute, it is termed minimal variability; if the range is 6 to 25 beats per minute, it is termed moderate variability; and a range greater that 25 beats per minute is termed marked variability.
Normal variability is between 6 to 25 beats per minute.
What terms are missing from the above discussion?
The terms ‘short term’ and ‘long term’ variability have
been dropped. Hence there is no longer a qualitative aspect to the description
of variability, only quantitative.
What is the significance of variability?
Variability is an excellent indicator of myocardial contractility and the connection
between the central nervous system and the myocardium. In other words, if there
is good variability, then that is a good indirect measure of an intact loop between
the fetal heart and central nervous system.
In your description, please note if there are known causes of decreased variability, e. g. magnesium sulfate.
Once we lose variability, or variability is diminished, we start observing situations that are interfering with that loop, or in extreme cases, we may be seeing complete myocardial depression. Hence, loss of variability is a powerful sign of anaerobic glycolysis within the myocardium.
The corollary is that normal variability (6 - 25 bpm), much like fetal heart accelerations, is highly predictive of the absence of metabolic academia. Thus, in the presence of moderate variability, an umbilical artery pH should be in the normal range with the absence of a significant base deficit.
2.) According to standardized National Institute of Child Health and Human Development (NICHD) definitions, the normal FHR range is 110-160 beats per minute
True
First, let us take a brief tangent….how do you define fetal heart baseline?
The fetal heart baseline is the mean fetal heart rounded to increments of 5 beats
per minute (bpm) in a 10-minute segment. It excludes periodic or episodic changes,
periods of marked variability and segments that differ by more than 25 beats
per minute from the baseline. And the baseline must be at least 2 minutes in
any 10 minute segment in order to assign a baseline.
Back to the question
Yes the normal range is 110-160 beats per minute, hence less than 110 is bradycardia
and over 160 is tachycardia.
Please note that some clinicians used to use less than 120 beats per minute to define bradycardia, but the new standardized definition is 110 beats per minute. Causes of bradycardia can include certain drugs (see ACOG Practice Bulletin for drugs), fetal heart block, as well as uteroplacental insufficiency and fetal acidosis.
3) According to standardized NICHD definitions, an amplitude range of between 6 and 25 beats per minute is termed ‘marked variability’
False
Normal variability is between 6 to 25 beats per minute. A range greater that 25 beats per minute is termed marked variability. Please see the discussion under number one, above.
A saltatory pattern refers to excessive variability, with amplitude greater than 25 bpm and cycles of three to six times per minute. The etiology is uncertain, but is probably related to mild, compensated fetal hypoxemia and increased alpha-adrenergic activity.
4) Before 32 weeks, a fetal heart rate acceleration is defined as a visually apparent increase in rate at least 10 beats per minute above the baseline lasting between 10 seconds and 2 minutes
True
Good pick up. Yes, before 32 weeks the acme of the acceleration should 10 beats or more, while after 32 weeks the acme of the acceleration should be 15 beats per minute or more.
How about the duration of the acceleration?
Before 32 weeks, the duration should be 10 seconds or more, but less than 2 minutes.
After 32 weeks, the duration should be 15 seconds or more, but less than 2 minutes.
What is the significance of adequate accelerations?
The presence of adequate accelerations virtually excludes metabolic academia.
In other words, the fetus is responding well to central nervous system input
and is not acidotic.
What if the acceleration has to be induced with acoustic stimulation or manual
palpation?
Regardless of the stimuli, the significance of a spontaneous or induced acceleration
is the same reassurance.
5) According to standardized NICHD terminology, a variable FHR deceleration reaches its nadir more than 30 seconds after its onset
False
A variable deceleration is an abrupt (onset to nadir less than 30 sec), visually apparent decrease in the FHR below the baseline. The decrease in FHR is 15 beats per min or more, with a duration of 15 sec or more but less than 2 minutes.
How about the terms mild, moderate, or severe variable contractions?
Those terms are not recommended.
Instead, one should describe what you are actually seeing, e. g., an abrupt deceleration
of 60 beats per minute lasting 60 seconds - would replace what many used to term
severe variable deceleration.
How about early decelerations?
Early decelerations are in association with a uterine contraction as a visually
apparent, gradual (onset to nadir 30 sec or more) decrease in FHR with return
to baseline. The nadir of the deceleration occurs at the same time as the peak
of the contraction.
Often early decelerations are associated with head compression, or some other kind of vagal response.
How about late decelerations?
Found in association with a uterine contraction, a visually apparent, gradual
(onset to nadir 30 sec or more) decrease in FHR with return to baseline.
Onset, nadir, and recovery of the deceleration occur after the beginning, peak,
and end of the contraction, respectively
What is the clinical significance?
A.) Variable decelerations are transient episodes of hypoxemia, such as during
a contraction or temporary cord compression, are generally well-tolerated by
the fetus.
On the other hand, variable decelerations with a late component, e. g., with delayed return to baseline until after the contraction, are associated decreased fetal pH. Other features suggestive of acidosis include loss of variability, rebound tachycardia, duration longer than 60 seconds, and FHR nadir less than 70 bpm. These tend to become persistent and progressively deeper and of longer duration over time.
B.) In the late deceleration the acidosis will initially depress the central nervous system and cause the deceleration. The acidosis will build during the contraction and peak after the contraction, e. g., the delayed nadir of the late deceleration. With further acidosis the heart itself could be affected directly.
Late decelerations with a nadir ≤15 bpm below baseline rate are a reflex central nervous system response to hypoxia, while late decelerations with a nadir ≥45 bpm below baseline rate can be due, at least in part, to direct myocardial depression and humoral factors. The latter two can be associated with a fall in fetal pH and perinatal morbidity and mortality. Recurrent late decelerations (i.e., occurring with ≥50 percent of contractions in a 20-minute segment) with absent variability are especially predictive of current or impending fetal acidosis.
6) A prolonged FHR deceleration lasts between 2 and 10 minutes
True
A prolonged FHR deceleration is a visually apparent decrease in the FHR below the baseline. Deceleration is 15 beats per min or more, lasting 2 min or more but less than 10 min from onset to return to baseline.
A prolonged FHR deceleration reflects interruption of normal oxygen delivery. If not relieved with mitigating measures it can be a pathological condition of the fetus that is likely to cause fetal or neonatal death or damage if left uncorrected. If recurrent these can be, but not always, associated with fetal acidemia and hypoxemia. These metabolic changes are highly correlated with decompensated fetal homeostasis, but are not necessarily present with all nonreassuring fetal heart rate patterns.
7) Fetal heart rate accelerations and moderate variability are highly predictive of the absence of metabolic academia
True
Normal FHR variability is strongly associated (98 percent) with an umbilical pH >7.15.
FHR accelerations are an important finding because their presence almost always indicates that the fetus is not acidotic.
On the flip side….
The combination of undetectable or minimal FHR variability and late or variable
decelerations is the FHR pattern most predictive of acidemia, although only about
23 percent of fetuses with these findings will be acidotic.
The absence of FHR variability is thought to be a result of cerebral hypoxemia and acidosis, and signifies failure of fetal compensatory mechanisms to maintain adequate oxygenation of the brain. Thus, absence of variability is typically accompanied by changes in FHR baseline or periodic decelerations when the fetus is distressed. Nonhypoxia-related causes of diminished variability include anencephaly and other central nervous system defects, use of some centrally acting drugs (e.g., opiates, magnesium sulfate, atropine), sepsis, defective cardiac conduction (e.g., complete heart block), and quiet fetal sleep.
Resources
Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin No. 70. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:1453–61.
(Reaffirmed 2007)
http://www.ncbi.nlm.nih.gov/pubmed/16319279
To learn more about the results of the National Institute of Child Health and Human Development Research Planning Workshop, go here
Electronic fetal heart rate monitoring: research guidelines for interpretation.
National Institute of Child Health and Human Development Research Planning Workshop.
Am J Obstet Gynecol. 1997 Dec;177(6):1385-90.
http://www.ncbi.nlm.nih.gov/pubmed/9423739
Medscape*
A sample of CME offerings on the Medscape website:
Needle-Length Guidelines
for Thigh and Shoulder Vaccinations May Need Revision
http://www.medscape.com/viewarticle/579120
A 34-Year-Old Pregnant Woman with Acute Severe Abdominal Pain
http://www.medscape.com/viewprogram/17086
Must-Block Television! Reducing Screen Time Improves Body Mass Index
Among Young Children: A Best Evidence Review
http://www.medscape.com/viewprogram/17017
Practical Strategies for Implementing HPV Vaccination Into Your Practice
http://www.medscape.com/viewprogram/15706
The Spectrum and Treatment of Gastrointestinal Disorders During Pregnancy
http://www.medscape.com/viewprogram/15730
The Practical Clinical Application of the NAMS 2008 Position Statement
on Estrogen and Progestogen Use in Postmenopausal Women
http://www.medscape.com/viewprogram/15625
Targeting the Interplay of Obesity, Insulin Resistance and Mixed Dyslipidemia:
An Integrative Approach to Reducing Cardiometabolic Risk
http://www.medscape.com/viewprogram/14920
General Links to Medscape:
Ask the
Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.
Menopause Management
HRT May Improve Health-Related Quality of Life in Postmenopausal Women
OBJECTIVE: To assess the effect of combined hormone replacement therapy (HRT) on health related quality of life. DESIGN: Randomised placebo controlled double blind trial.
SETTING: General practices in United Kingdom (384), Australia (94), and New Zealand (24). PARTICIPANTS: Postmenopausal women aged 50-69 at randomisation; 3721 women with a uterus were randomised to combined oestrogen and progestogen (n=1862) or placebo (n=1859). Data on health related quality of life at one year were available from 1043 and 1087 women, respectively.
INTERVENTIONS: Conjugated equine oestrogen 0.625 mg plus medroxyprogesterone acetate 2.5/5.0 mg or matched placebo orally daily for one year.
MAIN OUTCOME MEASURES: Health related quality of life and psychological wellbeing as measured by the women's health questionnaire. Changes in emotional and physical menopausal symptoms as measured by a symptoms questionnaire and depression by the Centre for Epidemiological Studies depression scale (CES-D). Overall health related quality of life and overall quality of life as measured by the European quality of life instrument (EuroQol) and visual analogue scale, respectively.
RESULTS: After one year small but significant improvements were observed in three of nine components of the women's health questionnaire for those taking combined HRT compared with those taking placebo: vasomotor symptoms (P<0.001), sexual functioning (P<0.001), and sleep problems (P<0.001). Significantly fewer women in the combined HRT group reported hot flushes (P<0.001), night sweats (P<0.001), aching joints and muscles (P=0.001), insomnia (P<0.001), and vaginal dryness (P<0.001) than in the placebo group, but greater proportions reported breast tenderness (P<0.001) or vaginal discharge (P<0.001). Hot flushes were experienced in the combined HRT and placebo groups by 30% and 29% at trial entry and 9% and 25% at one year, respectively. No significant differences in other menopausal symptoms, depression, or overall quality of life were observed at one year.
CONCLUSIONS: Combined HRT started many years after the menopause
can improve health related quality of life.
Welton AJ, Vickers MR, Kim J, Ford D, Lawton BA, Maclennan AH, Meredith SK, Martin
J, Meade TW; for the WISDOM team. Health related quality of life after combined
hormone replacement therapy: randomised controlled trial. BMJ. 2008 Aug 21;337:a1190.
doi: 10.1136/bmj.a1190. http://www.ncbi.nlm.nih.gov/pubmed/18719013
Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society
OBJECTIVE: To update for both clinicians and the lay public the evidence-based position statement published by The North American Menopause Society (NAMS) in March 2007 regarding its recommendations for menopausal hormone therapy (HT) for postmenopausal women, with consideration for the therapeutic benefit-risk ratio at various times through menopause and beyond.
DESIGN: An Advisory Panel of clinicians and researchers expert in the field of women's health was enlisted to review the March 2007 NAMS position statement, evaluate new evidence through an evidence-based analysis, and reach consensus on recommendations. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees as an official NAMS position statement. The document was provided to other interested organizations to seek their endorsement.
RESULTS: Current evidence supports a consensus regarding the role of HT in postmenopausal women, when potential therapeutic benefits and risks around the time of menopause are considered. This paper lists all these areas along with explanatory comments. Conclusions that vary from the 2007 position statement are highlighted. Addenda include a discussion of risk concepts, a new component not included in the 2007 paper, and a recommended list of areas for future HT research. A suggested reading list of key references is also provided.
CONCLUSIONS: Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both. The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause in previously untreated women.
Utian WH, Archer DF, Bachmann GA, Gallagher C, Grodstein F, Heiman JR, et al. Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society. Menopause. 2008 Jul-Aug;15(4 Pt 1):584-602. http://www.ncbi.nlm.nih.gov/pubmed/18580541
Midwives Corner - Lisa Allee, CNM, 4 Corners Regional Health Center, Red Mesa, AZ
Centering Pregnancy - A Model of Group Prenatal Care
Centering Pregnancy is a model of group prenatal care that is being used in numerous sites around the country. Prenatal care provided through the Centering model differs from clinic visits in a number of ways. First, there is no waiting room!! Women arrive and their appointment begins right then. Second, women get to spend two hours with their provider at each appointment! Third, women are actively involved in their care. Women are taught at the first group how to do aspects of their prenatal care themselves—blood pressure, weight, and urine dip—and how to chart and keep track of these results. Each subsequent session then begins with about a half hour of women doing these things and rotating through “mat time” with the midwife. Mat time is private time with the midwife (or physician) where the woman can report private concerns or questions and fundal height and fetal heart tones are checked. Once everyone has done their vitals and seen the midwife the group comes into a circle. During the circle time a topic for the day is discussed and activities occur. This is not a didactic class—it is a group session, which means that the midwife and a co-facilitator facilitate the session, asking questions and helping the group discover information they already know or new information. The topic of the day is usually just a jumping off point and the discussion can flow into many more areas of interest to the group.
There are a number of IHS sites offering Centering groups as an alternative to clinic-based prenatal visits and more sites are exploring offering it soon. The Four Corners Chapter of the American College of Nurse Midwives received a grant from the March of Dimes to support and expand Centering on the Navajo Nation. Part of the grant is to make a promotional DVD about Centering. The interviews with patients that have gone through Centering for their prenatal care have been astonishing and yet also not surprising. The words coming out of these women’s mouths say everything that Centering says it does—they report feeling empowered to make good decisions for themselves and their children, they report learning more than they ever did or would of in clinic, they report connecting with other women and realizing they are not alone in their experiences, they report increased confidence, they report learning from the others in the group, they report having fun, they report enjoyment of the longer time spent with their midwife or doctor, they report loving Centering. They also report wanting to continue groups past the immediate post partum—this has been requested by so many Centering participants nation-wide that the national Centering folks have develop Centering Parenting that provides well baby care through the first year.
There has been concern expressed by staff at several IHS sites on the Navajo Nation that Centering is not compatible with Navajo tradition, that Navajo women won’t like it, and that privacy issues will keep it from working. The interviews with Navajo women who have done Centering belay these concerns. These Navajo women clearly liked Centering for their prenatal care! They spoke about privacy and reported that at first they felt shy, but as they got to know the group they felt more comfortable sharing. Everyone also clearly understood that it was their choice what personal information they wanted to share or not share with the group—there was no pressure to do otherwise. A number of comments were made that even though there was a subject or question that they didn’t feel comfortable sharing or asking about another woman would bring it up and, thus, they were able to learn about the subject after all because of the other woman. As for Navajo tradition some interviewees spoke to how Centering met their traditional needs, one example being that the group was held outside the building where the ER was and, thus, kept her from having to go into a place where people die as she was taught not to do when she was pregnant. Centering is based on an eons-old, global-wide, crossing-all-cultures tradition of women gathering to discuss, support, and learn from each other about all things female—menses, pregnancy, breastfeeding, childrearing, menopause, etc. A Navajo specific example is Ki’nal’da’ the puberty ceremony for young women where women gather to talk and teach the young woman about being an adult woman. The Centering model can expand on this tradition and allows for the time to teach young women more about Navajo traditions—time that rarely is found in a 10-15 minute clinic visit!
The interviews and filming also revealed wonderful aspects of Centering for partners and other family members, but that will have to wait for another column as space is running out….
If you are interested in Centering Pregnancy please check out the Centering website www.centeringhealthcare.org and look for informational sessions at most IHS maternal-child health meetings. AND please join the IHS Centering Pregnancy list serve by emailing me at lisa.allee@ihs.gov!!!
Navajo News - John Balintona, Shiprock
Overview of Navajo Area Gynecology Services
Below is a survey of the sites in the Navajo Area that provide gynecologic surgery services. The survey can be used as a guide for fellow practitioners and referring sites as to the capabilities of the various NAIHS sites.
| Chinle | Fort Defiance | GIMC | Shiprock | Tuba City | ||
|---|---|---|---|---|---|---|
| Pelvic Surgery | Abdominal Hyst | Yes | Yes | Yes | Yes | Yes |
| Vaginal Hyst | Yes | Yes | Yes | Yes | Yes | |
| LAVH | Yes | Yes | Yes | Yes | Yes | |
| Endometrial Ablation |
Novasure | No | No | No | Novasure | |
| Operative laparoscopy | Yes | Yes | Yes | Yes | Yes | |
| Operative hysteroscopy | Yes | No | Yes | No | Yes | |
| Prolapse Surgery | Vaginal approach | Yes | Yes | Yes | Yes | Yes |
| Abdominal approach | Yes | Yes | No | Yes | No | |
| Synthetic mesh | No | No | No | Yes | Yes | |
| Family Planning | Tubal Sterilization | Filshie | Coag/Hulka/ | Fallope Ring | Coag | Coag/Filshie/Bands/Hulka |
| Essure | No | No | No | Yes | Yes | |
| Nuva Ring |
Yes | Yes | No | Yes | Yes | |
| Mirena IUD | Yes | Yes | Yes | Yes | Yes | |
| Paraguard IUD | Yes | Yes | Yes | Yes | Yes | |
| Implanon | Yes | No | Yes | No | Yes | |
| Fertility Enhancement | Oral ovulation drugs | Yes | Yes | Yes | Yes | Yes |
| Injectable ovulation drugs | No | No | No | No | Yes | |
| Reanastamosis | No | No | No | Yes | Yes | |
| Cervical Dysplasia | Colposcopy | Yes | Yes | Yes | Yes | Yes |
| Cryotherapy | Yes | Yes | No | Yes | Yes | |
| Laser | No | No | No | No | No | |
| LEEP/CKC | Yes | Yes | Yes | Yes | Yes | |
| Urogynecology | Simple cystometry | Yes | Yes | Yes | Yes | Yes |
| Complex Urodynamics | Yes | No | Yes | No | Yes | |
| Mid-urethral slings | TVT/TVT-O | TVT | TVT | TVT/TVT-O | TVT/TVT- O | |
| Abdominal urethropexy | Yes | Yes | No | Yes | Yes | |
| Diagnostic cystoscopy | Yes | Yes | Yes | Yes | Yes | |
| Operative cystoscopy | No | No | No | Yes* | Yes* | |
| *contract urologist | ||||||
Nurses Corner - Sandra Haldane, HQE
Nurse Anesthesia (CRNA) Training Opportunity
The Indian Health Service Headquarters Division of Nursing (DNS) is accepting applications for long term training in Nurse Anesthesia at the Uniformed Services University of Health Sciences (USUHS). Application materials are attached. Deadline for submission of all materials is 5:00 PM Eastern time, September 19, 2008. Through agreement with USUHS, a maximum of three PHS/IHS nurse anesthesia students can be accepted into the USUHS Graduate School of Nursing Nurse Anesthesia Program annually however; under this announcement, only one student will be supported by the DNS (pending availability of FY 2009 funds). Any additional students will require a funding commitment from their facility.
We highly encourage Indian health hospitals who offer services requiring anesthesia to consider sponsoring their own student. We know the annual cost of one fulltime CRNA contractor in the Indian health system today is running between $300,000 and $360,000. Currently the annual cost of an O6 CRNA with over 20 years active duty, including their incentive special pay ($40,000/annually) runs about $220,000. COs graduating from LTT under this program incur a 5-year obligation to provide service in the Indian health system. As an obligated CRNA, their maximum incentive special pay is $5,000 annually. The current vacancy rate for CRNAs in the Indian health system is 34% or about 18 positions. By training our own CRNAs, not only do we build loyalty within our employees, we increase access to surgical services, improve the quality of anesthesia services, and we do so at a significant cost saving to our system.
For more information, please contact: Sandra.Haldane@ihs.gov
Nurses provide effective, and cost-effective, depression care for cancer patients
BACKGROUND: Major depressive disorder severely impairs the quality of life of patients with medical disorders such as cancer, but evidence to guide its management is scarce. We aimed to assess the efficacy and cost of a nurse-delivered complex intervention that was designed to treat major depressive disorder in patients who have cancer.
METHODS: We did a randomised trial in a regional cancer centre in Scotland, UK. 200 outpatients who had cancer with a prognosis of greater than 6 months and major depressive disorder (identified by screening) were eligible and agreed to take part. Their mean age was 56.6 (SD 11.9) years, and 141 (71%) were women. We randomly assigned 99 of these participants to usual care, and 101 to usual care plus the intervention, with minimisation for sex, age, diagnosis, and extent of disease. The intervention was delivered by a cancer nurse at the centre over an average of seven sessions. The primary outcome was the difference in mean score on the self-reported Symptom Checklist-20 depression scale (range 0 to 4) at 3 months after randomisation. Analysis was by intention to treat. This trial is registered as ISRCTN84767225.
FINDINGS:
Primary outcome data were missing for four patients. For 196 patients for whom
we had data at 3 months, the adjusted difference in mean Symptom Checklist-20
depression score, between those who received the intervention and those who did
not, was 0.34 (95% CI 0.13-0.55). This treatment effect was sustained at 6 and
12 months. The intervention also improved anxiety and fatigue but not pain or
physical functioning. It cost an additional pound sterling 5278 (US$10 556) per
quality-adjusted life-year gained.
INTERPRETATION: The intervention-Depression Care for People with Cancer-offers
a model for the management of major depressive disorder in patients with cancer
and other medical disorders who are attending specialist medical services that
is feasible, acceptable, and potentially cost effective.
Strong V, Waters R, Hibberd C, Murray G, Wall L, Walker J, McHugh G, Walker A, Sharpe M. Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet. 2008 Jul 5;372(9632):40-8. http://www.ncbi.nlm.nih.gov/pubmed/18603157
Registered Nurses' Use of Electronic Health Records: Findings From a National Survey
OBJECTIVE: (1) To determine the proportion of the registered nurse (RN) workforce that uses a minimally functional electronic health record (EHR) system; (2) to assess the relationship between EHR use and beliefs about quality of care and quality improvement activities; and (3) to determine whether EHR use is associated with less time spent on paperwork and documentation and more time spent in direct patient care.
DESIGN: Data were collected
through use of a 6-page survey mailed to a nationally representative sample of
RNs. The study is cross-sectional and examines associations between EHR use and
measures of quality and time spent on patient care-related tasks.
Measurements: A minimally functional EHR was defined as routine use of electronic
patient demographics; electronic ordering of tests, procedures, or drugs; electronic
clinical and patient notes; electronic access to test results; and electronic
decision support. RNs were categorized into those employed in practices or hospitals
where 0 functionalities were in routine use, 1 to 4 functionalities were in routine
use, or 5 functionalities were in routine use.
RESULTS: Fewer than 1 in 5 RNs work in healthcare settings that have adopted a minimally functional EHR. Use was related to measures of nursing excellence and increased efforts at quality improvement. There were no differences between RNs using an EHR and those not using one on time spent in patient care-related tasks.
CONCLUSION: This study is the first to provide national data on RNs' use of EHRs. It suggests important relationships between EHR use, quality improvement, and nursing excellence.
Catherine DesRoches, DrPH; Karen Donelan, ScD; Peter Buerhaus, RN, ScD; Li Zhonghe, MS The Medscape Journal of Medicine July 2008 http://www.medscape.com/viewarticle/574733
Office of Women's Health, CDC
Some highlights from the recent on-line newsletter:
Female College Soccer Players
The risk of potentially devastating tears to an important knee
ligament may be reduced in female college soccer players by an alternative warm-up
program that focuses on stretching, strengthening, and improving balance and
movements, according to a CDC study published online this week in The American
Journal of Sports Medicine. The program can be done without additional equipment
or extensive training that other prevention programs may require.
http://www.cdc.gov/media/pressrel/2008/r080725.htm
Gardasil Vaccine and Its Safety
Consumers, parents, health care professionals
and others have raised questions regarding the safety of the human papillomavirus
(HPV) vaccine, Gardasil. FDA and CDC take all concerns about vaccine safety seriously,
and have been closely monitoring the safety of Gardasil. Based on ongoing assessments
of vaccine safety information, FDA and CDC continue to find that Gardasil is
a safe and effective vaccine. FDA and CDC continue to monitor the safety
of this vaccine, with the public’s health and safety our top priority.
http://www.cdc.gov/vaccinesafety/vaers/FDA_and_CDC_Statement.htm
Summary Feature - http://www.cdc.gov/Features/HPVvaccineSafety/
Preventing Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities: CDC's Demonstration Projects
The CDC funded 10 demonstration projects
in Fiscal Year 2000 to develop, implement, and evaluate culturally competent
IPV/SV prevention strategies targeted for specific racial/ethnic minority groups. Preventing
Intimate Partner Violence and Sexual Violence in Racial/Ethnic Minority Communities:
CDC's Demonstration Projects summarizes
the work of the funded projects. The purpose of the document is to describe approaches
and highlight challenges and lessons learned in the development, implementation,
and evaluation of IPV/SV prevention programs for racial/ethnic minority populations.
http://www.cdc.gov/ncipc/dvp/PreventingIntimatePartnerViolence.htm
For
more information about women’s health, visit: www.cdc.gov/women.
To subscribe to the monthly CDC Office of Women’s Health Newsletter, send
an e-mail to: owh@cdc.gov.
Osteoporosis
Low Serum Vitamin D Linked to Increased Hip Fracture Risk in Postmenopausal Women
BACKGROUND: The relationship between serum 25-hydroxyvitamin D [25(OH) vitamin D] concentration and hip fractures is unclear.
OBJECTIVE: To see whether low serum 25(OH) vitamin D concentrations are associated with hip fractures in community-dwelling women.
DESIGN: Nested case-control study.
SETTING: 40 clinical centers in the United States.
PARTICIPANTS: 400 case-patients with incident hip fracture and 400 control participants matched on the basis of age, race or ethnicity, and date of blood draw. Both groups were selected from 39 795 postmenopausal women who were not using estrogens or other bone-active therapies and who had not had a previous hip fracture.
MEASUREMENTS: Serum 25(OH) vitamin D was measured and patients were followed for a median of 7.1 years (range, 0.7 to 9.3 years) to assess fractures.
RESULTS: Mean serum 25(OH) vitamin D concentrations were lower in case-patients than in control participants (55.95 nmol/L [SD, 20.28] vs. 59.60 nmol/L [SD, 18.05]; P = 0.007), and lower serum 25(OH) vitamin D concentrations increased hip fracture risk (adjusted odds ratio for each 25-nmol/L decrease, 1.33 [95% CI, 1.06 to 1.68]). Women with the lowest 25(OH) vitamin D concentrations (< or =47.5 nmol/L) had a higher fracture risk than did those with the highest concentrations (> or =70.7 nmol/L) (adjusted odds ratio, 1.71 [CI, 1.05 to 2.79]), and the risk increased statistically significantly across quartiles of serum 25(OH) vitamin D concentration (P for trend = 0.016). This association was independent of number of falls, physical function, frailty, renal function, and sex-steroid hormone levels and seemed to be partially mediated by bone resorption.
LIMITATIONS: Few case-patients were nonwhite women. Bone mineral density and parathyroid hormone levels were not accounted for in the analysis.
CONCLUSION: Low serum 25(OH) vitamin D concentrations are associated with a higher risk for hip fracture.
Cauley JA, Lacroix AZ, Wu L, Horwitz M, Danielson ME, Bauer DC, et al. Serum 25-hydroxyvitamin D concentrations and risk for hip fractures. Ann Intern Med. 2008 Aug 19;149(4):242-50. http://www.ncbi.nlm.nih.gov/pubmed/18711154
Summary for patients in: Ann Intern Med. 2008 Aug 19;149(4):I42.
Patient Information
Protect Your Baby from Group B Strep
This page describes what group B strep is, how it impacts a newborn, how to prevent Group B Strep, what can be done before and during labor, and where to get more information. E-cards are also available.
CDC Feature - http://www.cdc.gov/Features/GroupBStrep/
Brochure and other information - http://www.cdc.gov/groupbstrep/general/protect-your-baby-GBS.htm
Making Sense of Your HPV and Pap Test Results (Plain language Patient brochure)
This 17 page brochure explains the meaning of Pap and HPV
test results and answers common patient questions about HPV, such as how to talk
to your partner about HPV. It includes ‘questions to ask your doctor’ to
help prepare women for next steps, and a glossary of terms. It has been tested
with 30-65 year-old African American, Hispanic, and Caucasian women.
http://www.cdc.gov/std/Hpv/pap/
Perinatology Picks - George Gilson, MFM, ANMC
Methods of delivering the placenta at caesarean section
BACKGROUND: Worldwide, caesarean section is the most common major operation performed on women. Some of the reported short-term morbidities include haemorrhage, postoperative fever and endometritis. The method of delivering the placenta is one procedure that may contribute to an increase or decrease in the morbidity of caesarean section. Two common methods used to deliver the placenta at caesarean section are cord traction and manual removal.
OBJECTIVES: To compare the effects of manual removal of the placenta with cord traction at caesarean section.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2007).
SELECTION CRITERIA: All randomised controlled trials comparing manual removal and cord traction or spontaneous of delivery of the placenta.
DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies and extracted data.
MAIN RESULTS: We included 15 studies (4694 women). There was significant heterogeneity for the duration of surgery, blood loss and haematological outcomes. The only possible contributing factor found was greater protection from blood loss in two trials in which cord traction was combined with uterine massage. A random-effects model meta-analysis was used for these outcomes. Manual removal of the placenta was associated with more endometritis (relative risk (RR) 1.64, 95% confidence interval (CI) 1.42 to 1.90; 4134 women, 13 trials); more blood loss (ml) (weighted mean difference (WMD) 94.42 ml, 95% CI 17.19 to 171.64; 2001 women, eight trials); more blood loss > 1000 ml (RR 1.81, 95% CI 1.44 to 2.28; 872 women, two trials); lower haematocrit after delivery (%) (WMD -1.55, 95% CI -3.09 to -0.01; 384 women, two trials); greater haematocrit fall after delivery (%) (WMD 0.39, 95% CI 0.00 to 0.78; 1777 women, five trials); longer duration of hospital stay (days) (WMD 0.39 days, 95% CI 0.17 to 0.61; 546 women, three trials).The duration of surgery was shorter in one trial but not overall. There were no significant differences in feto-maternal haemorrhage, blood transfusion, puerperal fever (numbers studied for these outcomes were small).
AUTHORS' CONCLUSIONS: Delivery of the placenta with cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay. Future trials should provide information on interval between the delivery of the infant and of the placenta, change in lochia, blood splashing during placental removal and uterine pain after operation, as well as the effects of delayed cord clamping.
Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004737. http://www.ncbi.nlm.nih.gov/pubmed/18646109
Limit maximum oxytocin doses to 20 mu/min in patients attempting VBAC
OBJECTIVE: The objective of the study was to more precisely estimate the effect of maximum oxytocin dose on uterine rupture risk in patients attempting vaginal birth after cesarean (VBAC) by considering timing and duration of therapy.
STUDY DESIGN: A nested case-control study was conducted within a multicenter, retrospective cohort study of more than 25,000 women with at least 1 prior cesarean delivery, comparing cases of uterine rupture with controls (no rupture) while attempting VBAC. Time-to-event analyses were performed to examine the effect of maximum oxytocin dose on the risk of uterine rupture considering therapy duration, while adjusting for confounders.
RESULTS: Within the nested case-control study of 804 patients, 272 were exposed to oxytocin: 62 cases of uterine rupture and 210 controls. Maximum oxytocin ranges above 20 mU/min increased the risk of uterine rupture 4-fold or greater (21-30 mU/min: hazard ratio [HR] 3.92, 95% confidence interval [CI], 1.06 to 14.52; 31-40 mU/min: HR 4.57, 95% CI, 1.00 to 20.82). CONCLUSION: These findings support a maximum oxytocin dose of 20 mU/min in VBAC trials to avoid an unacceptably high risk of uterine rupture.
Cahill AG, Waterman BM, Stamilio
DM, Odibo AO, Allsworth JE, Evanoff B, Macones GA.
Higher maximum doses of oxytocin are associated with an unacceptably high risk
for uterine rupture in patients attempting vaginal birth after cesarean delivery.
Am J Obstet Gynecol. 2008 Jul;199(1):32.e1-5. Epub 2008 May 2. http://www.ncbi.nlm.nih.gov/pubmed/18455132
Acute myocardial infarction associated with pregnancy
Acute myocardial infarction (AMI) during pregnancy or the early post-partum period is rare but has been shown to be associated with poor maternal as well as fetal outcome. Major changes in both diagnosis and treatment of AMI in the nonpregnant patient have lead to improved outcome which may also affect pregnant patients. The purpose of this paper is to review available information related to the pathophysiology and clinical profile and provide recommendations for the diagnosis and management of AMI occurring during pregnancy and the early post-partum period.
Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. J Am Coll Cardiol. 2008 Jul 15;52(3):171-80. http://www.ncbi.nlm.nih.gov/pubmed/18617065
A national study of the complications of lupus in pregnancy
OBJECTIVE: This study was undertaken to determine the risk of rare complications during pregnancy for women with systemic lupus erythematosus.
STUDY DESIGN: By using the Nationwide Inpatient Sample from 2000-2003, we compared maternal and pregnancy complications for all pregnancy-related admissions for women with and without systemic lupus erythematosus.
RESULTS: Of more than 16.7 million admissions for childbirth over the 4 years, 13,555 were to women with systemic lupus erythematosus. Maternal mortality was 20-fold higher among women with systemic lupus erythematosus. The risks for thrombosis, infection, thrombocytopenia, and transfusion were each 3- to 7-fold higher for women with systemic lupus erythematosus. Lupus patients also had a higher risk for cesarean sections (odds ratio: 1.7), preterm labor (odds ratio: 2.4), and preeclampsia (odds ratio: 3.0) than other women. Women with systemic lupus erythematosus were more likely to have other medical conditions, including diabetes, hypertension, and thrombophilia, that are associated with adverse pregnancy outcomes. CONCLUSION: Women with systemic lupus erythematosus are at increased risk for serious medical and pregnancy complications during pregnancy.
Clowse ME, Jamison M, Myers E, James AH. A national study of the complications of lupus in pregnancy. Am J Obstet Gynecol. 2008 Aug;199(2):127.e1-6. Epub 2008 May 5. http://www.ncbi.nlm.nih.gov/pubmed/18456233
Urinalysis vs urine protein-creatinine ratio to predict significant proteinuria in pregnancy
OBJECTIVE: To compare the urine protein-creatinine ratio with urinalysis to predict significant proteinuria (>or=300 mg per day).
STUDY DESIGN: A total of 116 paired spot urine samples and 24-h urine collections were obtained prospectively from women at risk for preeclampsia. Urine protein-creatinine ratio and urinalysis were compared to the 24-h urine collection.
RESULT: The urine protein-creatinine ratio had better discriminatory power than urinalysis: the receiver operating characteristic curve had a greater area under the curve, 0.89 (95% confidence interval (CI) 0.83 to 0.95) vs 0.71 (95% CI 0.64 to 0.77, P<0.001). When matched for clinically relevant specificity, urine protein-creatinine ratio (cutoff >or=0.28) is more sensitive than urinalysis (cutoff >or=1+): 66 vs 41%, P=0.001 (with 95 and 100% specificity, respectively). Furthermore, the urine protein-creatinine ratio predicted the absence or presence of proteinuria in 64% of patients; urinalysis predicted this in only 19%.
CONCLUSION: The urine protein-creatinine ratio is a better screening test. It provides early information for more patients.
Dwyer BK, Gorman M, Carroll IR, Druzin M. Urinalysis vs urine protein-creatinine ratio to predict significant proteinuria in pregnancy. J Perinatol. 2008 Jul;28(7):461-7. Epub 2008 Feb 21. http://www.ncbi.nlm.nih.gov/pubmed/18288120
Primary Care Discussion Forum - Ann Bullock, Cherokee, NC
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
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http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Questions on how to subscribe, contact ANNBULL@nc-cherokee.com
STD Corner - Lori de Ravello, National IHS STD Program
Take the sex out of STI screening!
Views of young women on implementing Chlamydia screening in General Practice
BACKGROUND: Australia is developing a Chlamydia screening program. This study aimed to determine the attitudes of young women to the introduction of Chlamydia screening in Australian General Practice.
METHODS: In-depth face-to-face interviews with 24 young women from across Victoria, Australia, attending a randomly selected sample of general practices.
RESULTS: Young women reported that they would accept age-based screening for Chlamydia in general practice, during both sexual-health and non-sexual-health related consultations. Trust in their general practitioner (GP) was reported to be a major factor in the acceptability of Chlamydia screening. The women felt Chlamydia screening should be offered to all young women rather than targeted at "high risk" women based on sexual history and they particularly emphasised the importance of normalising Chlamydia screening. The women reported that they did not want to be asked to provide a sexual history as part of being asked to have a Chlamydia test. Some reported that they would lie if asked how many partners they had had
CONCLUSION: Women do not want a sexual history taken when being asked to have a Chlamydia test while attending a general practitioner. They prefer the offer of Chlamydia screening to be based on age rather than assessment of sexual risk. Chlamydia screening needs to be normalised and destigmatised.
Pavlin NL, Parker R, Fairley CK, Gunn JM, Hocking J. Take the sex out of STI screening! Views of young women on implementing Chlamydia screening in General Practice. BMC Infect Dis. 2008 May 9;8:62. http://www.ncbi.nlm.nih.gov/pubmed/18471280
Barbara Stillwater, Alaska State Diabetes Program
Increased risk of cardiovascular disease in young women following gestational diabetes mellitus
OBJECTIVE: To determine whether women with gestational diabetes mellitus (GDM) have an increased risk of cardiovascular disease (CVD) following pregnancy.
RESEARCH DESIGN AND METHODS: All women aged 20-49 years with live births between April 1994 and March 1997 in Ontario, Canada, were identified. Women with GDM were matched with 10 women without GDM and were followed for CVD.
RESULTS: The matched cohorts included 8,191 women with GDM and 81,262 women without GDM. Mean age at entry was 31 years, and median follow-up was 11.5 years. The hazard ratio for CVD events was 1.71 (95% CI 1.08-2.69). After adjustment for subsequent type 2 diabetes, the hazard ratio was attenuated (1.13 [95% CI 0.67-1.89]).
CONCLUSIONS: Young women with GDM had a substantially increased risk for CVD compared with women without GDM. Much of this increased risk was attributable to subsequent development of type 2 diabetes.
Shah BR, Retnakaran R, Booth GL. Increased risk of cardiovascular disease in young women following gestational diabetes mellitus. Diabetes Care. 2008 Aug;31(8):1668-9. Epub 2008 May 16. http://www.ncbi.nlm.nih.gov/pubmed/18487472
Interviewed about this study, the authors offered the following comments: “In summary, women with GDM are at increased risk for CVD events compared with women without GDM, and much of this risk is attributable to the subsequent development of type 2 diabetes,” Dr. Shah and colleagues conclude. “As diabetes prevention interventions in women with a history of GDM have also been shown to slow progression of atherosclerosis, this study highlights the importance of diabetes prevention for this high-risk population.”
Women's Health Headlines, Carolyn Aoyama, HQE
Dating Violence a significant public health problem for adolescents
OBJECTIVE: Dating violence is an important but understudied public health concern in adolescents. This study sought to examine the lifetime prevalence of serious forms of dating violence in 12- to 17- year-olds, risk and protective factors associated with dating violence, and the relation between dating violence and mental health.
METHOD: A nationally representative sample of adolescents (N = 3,614) completed a telephone-based interview that assessed serious forms of dating violence (i.e., sexual assault, physical assault, and/or drug/alcohol-facilitated rape perpetrated by a girlfriend, boyfriend, or other dating partner).
RESULTS: Prevalence of dating violence was 1.6% (2.7% of girls, 0.6% of boys), equating to approximately 400,000 adolescents in the U.S. population. Risk factors included older age, female sex, experience of other potentially traumatic events, and experience of recent life stressors. Findings also suggested that dating violence is associated with posttraumatic stress disorder and major depressive episode after controlling for demographic variables, other traumatic stressors, and stressful events.
CONCLUSIONS: These findings indicate that dating violence is a significant public health problem in adolescent populations that should be addressed through early detection, prevention, and intervention.
Wolitzky-Taylor KB, Ruggiero KJ, Danielson CK, Resnick HS, Hanson RF, Smith DW, Saunders BE, Kilpatrick DG. Prevalence and correlates of dating violence in a national sample of adolescents. J Am Acad Child Adolesc Psychiatry. 2008 Jul;47(7):755-62. http://www.ncbi.nlm.nih.gov/pubmed/18520962
Colorado Regional Conference on the Health Care Response to Domestic Violence
Denver, CO; December 7-9, 2008
“Incidences of domestic violence result in nearly 2 million injuries
and 1,300 deaths annually in the United States (CDC, 2003)”.
As a health professional, you are in an ideal position to prevent, detect and effectively intervene in situations of violence against women and children. This three-day conference will educate health care providers on optimal ways to intervene, identify and screen for domestic violence among patients. A practical approach to helping victims of domestic violence will be emphasized, along with best practices and the introduction of new initiatives from Colorado and Rocky Mountain region.
Four workshop tracks will be available: clinical responses, specialized populations, model programs and specialty areas. Who should attend: Physicians, nurses, physician assistants, nurse practitioners, nurse midwives, dentists, dental hygienists, physical therapists, health care administrators, health policy makers, behavioral and mental health providers, social workers, students of the health sciences, victims/survivors and advocates for victims of domestic violence.
Sponsored by: Center on Domestic Violence at the University of Colorado Denver School of Public Affairs; Kaiser Permanente. www.ucdenver.edu/domesticviolence/conference
Take your advocacy to the next level! Starting spring 2009, the UC Denver Center on Domestic Violence is offering a certificate in interpersonal violence prevention, identification and intervention for health professionals.
For more information contact the Center on Domestic Violence at 303-315-2489 or cdv@ucdenver.edu.
Conference Announcement: Sowing Seeds of Academic Change-Nurturing New Paradigms
Save the Date: April 24-25, 2009, Minneapolis, MN
The Academy on Violence and Abuse will host a two day conference that brings
together researchers into the health effects of violence and abuse with the deans
and faculty of health professions schools to change how health professionals
are trained.
The AVA is an academic and health professional membership organization working to integrate teaching about the health effects of abuse into the educational curricula of the health professions. For more information, visit www.avahealth.org.
Save the dates
Postgraduate Course on Obstetric, Neonatal and Gynecologic Care
- September 14-18, 2008
- Salt Lake City , Utah
- Comprehensive Women’s Health Update for Nurses, Advanced Practice Nurses, and Physicians
- NRP offered as pre-conference session
- Contact Yvonne Malloy, ymalloy@acog.org, for more information
Medical Providers’ Best Practices Conference, 3rd Annual
- November 18-19, 2008; Sacramento, CA
- California Area Indian Health Service
- More information: 916.930.3937 or IHS-CAOGPRA@ihs.gov
2008 Indian Health Information Management Conference, “Managing Health Information Technology to Improve Performance and Outcomes”
- December 15 – 19, 2008 ; Phoenix, Arizona
- Information at: http://www.ihs.gov/cio/ihimc/
First International Meeting on Indigenous Women’s Health/Third International Meeting on Indigenous Child Health Conference; Many Voices into One Song
- Women’s Health March 4-6, 2009
- Child Health March 6-8, 2009
- Albuquerque , NM
- Joint conference of Women’s Health and Children’s Health Providers from Canada and the United States
Advances in Indian Health Conference
- April 21-24, 2009 in Albuquerque, NM
- Indian Health's conference for primary care providers and nurses
- 28 hours of CME/CE credit
- Optional Diabetes track
- Contact the Course Director, Dr. Ann Bullock, at annbull@nc-cherokee.com for more information.
What's new on the ITU MCH web pages?
OB/GYN CCC Transition: Dr. Howe is the new CCC; Dr. Murphy retains yeoman’s role on MCH webpage
As our readers are undoubtedly aware, Neil Murphy is the founding editor of the CCC Corner and has continued the newsletter with unflagging dedication since its inception in 2003. His enthusiasm for education, evidence-based medicine, international collaboration, and the promotion of electronic healthcare resources is incredible. After over 8 years as the Indian Health Service Chief Clinical Consultant for Ob/Gyn and 6 years as the editor of the CCC Corner, he has now decided to take a well-earned break from these duties. Thank you, Dr. Murphy, for a job well done.
As the new CCC and the new editor of the CCC Corner, it seems appropriate that we re-introduce Dr. Howe. Dr. Howe grew up in Vermont and, after completing her undergraduate studies in Biology and Anthropology and African Studies, served as a Peace Corps Volunteer in the Democratic Republic of Congo from 1985 to 1989. She completed my medical degree at the University of Vermont and Ob/Gyn residency at the University of Colorado. Since 1997 Dr. Howe has worked at Chinle Comprehensive Health Care Facility in the Navajo Nation. In Chinle, she works with an extraordinary team of Midwives, Nurses, and Ob/Gyns as they provide full-scope Women’s Health care and prepare to move into a brand new outpatient clinic.
Although Dr. Howe assumed her duties as CCC on June 1st, she has gradually increased her responsibility for the CCC Corner newsletter over the past several months. She is continuing to learn “on the job” both about the Chief Clinical Consultant role and about the contributions of her predecessors to the care of American Indian and Alaska Native women.
If you have questions for Dr. Howe or suggestions, or contributions for the CCC Corner, please let her know. Dr. Howe can be reached at jean.howe@ihs.gov.
For an overview of the history of the OB/GYN CCC, please follow the link below to last month’s issue. http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=8_08col
We are very happy to report that Dr. Murphy continues his clinical work at Alaska Native Medical Center and remains actively involved in efforts to maximize the health of Native women. As you read this CCCC issue, you will find several items that he has authored.
In 2000 Dr. Murphy began to create the MCH suite of websites that offers up to the moment evidence based resources to all tribal and Indian Health staff and patients. The MCH complex of websites, which now contains hundreds of pages and thousands of subpages, includes online continuing medical education modules, a monthly online newsletter, hundreds of frequently asked questions, and a wide variety of MCH specific content.
The MCH site also serves as a portal for easy access to UpToDate, the Indian Health virtual online library, and the ACOG Postgraduate Course Reference text, to name a few others. Some have intimated that the MCH complex of resources is the best developed of all www.ihs.gov clinical websites. The MCH sites have been used as a best practice resource for many other www.ihs.gov web based resources.
But the MCH sites can be better. To that end, please visit the MCH home page
and take a quick tour and please let us know your thoughts. http://www.ihs.gov/MedicalPrograms/MCH/index.cfm
If you have questions for Dr. Murphy or suggestions, or contributions for the
MCH web pages, please let him know. Dr. Murphy can be reached at nmurphy@scf.cc.
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The August 2008 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Jean Howe, MD, MPH is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Howe is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to American Indian and Alaska Native women and also indigenous peoples around the world. Please don't hesitate to contact her by e-mail (jean.howe@ihs.gov) or phone at (928) 674-7422.
