Abuse of women and children in a Philippine community.

This retrospective study describes the demographic profiles, types of injuries and characteristics of abusers of 1354 women and children survivors of domestic violence who sought medical care from the obstetrics and gynecology resident and attending staff in the Women and Children Protection Unit in Vicente Sotto Memorial Medical Center from 1 January 1997 to 31 December 1998. Thirty-nine percent of these patients were sexually abused; their peak age was 11-20 years. Almost 75% of sexual abusers were from outside of the household. The highest incidence of physical abuse occurred in ages 26-35 years. Seventy-five percent of this form of abuse was in the home and perpetrated by husbands and live-in partners. Our data add to the expanding literature demonstrating the existence of family violence throughout the world. The role of our Protection Unit in responding to the victims of family violence is in keeping with the responsibilities and the ethical obligations all obstetrician-gynecologists have to the safety, physical and psychological needs of the women they serve.

The effect of a pill inserter on vaginal misoprostol dosing.

OBJECTIVE: To determine whether the method of placing a 25-microg misoprostol chip into the posterior fornix to achieve cervical ripening affects the drug's efficacy. METHODS: A pill inserter was used to place a misoprostol chip into the posterior fornix for the purpose of cervical ripening prior to induction of labor. Data from a control group were obtained by retrospective chart review. RESULTS: The control and study groups contained 49 patients each. Compared to placing the misoprostol chip with a lubricated finger, the use of the pill inserter resulted in statistically significantly more patients receiving only one dose. This occurred either because a Bishop score of 8 or greater was achieved or because repeat dosing was disallowed secondary to the onset of uterine contractions. Although the total number of patients subsequently requiring oxytocin was significantly increased, there was no difference in the use of oxytocin for either induction or augmentation of labor. The lengths of the latent and active phases of labor did not differ between the two groups. CONCLUSION: The number of doses of a 25-microg misoprostol chip for cervical ripening that result in uterine contractions, with or without a change in the Bishop score, is affected by the method used to place it in the vagina.

Clinical experience reported by candidates for the American Board of Obstetrics and Gynecology 1995 and 1997 oral examinations.

OBJECTIVE: The purpose of this study was to report the clinical experience collated from the 1995 and 1997 case list summary sheets of United States and Canadian active candidates who were completing the American Board of Obstetrics and Gynecology oral examination for the first time. STUDY DESIGN: Data from the case list summary sheets were entered into a computerized database and collated. Data from active candidates who had subspecialty training and from other international graduates were excluded. RESULTS: The difference in the ratio of men to women candidates between 1995 and 1997 was statistically significant (P =.02). Both years, 31% of the major operations were hysterectomies, of which 60% and 62.5%, respectively, were performed through an abdominal incision. The mean total cesarean delivery rate was 20.5% in 1995 and 19.7% in 1997. The ratio of primary to repeat cesarean deliveries was 2 to 1 in both years. The ratio of forceps to vacuum extraction deliveries was 3:7 in 1995 and 2:5 in 1997. CONCLUSION: This data set provides a national overview of the clinical experiences of a relatively homogeneous group of practicing obstetrician-gynecologists who have recently completed their training.

A survey of medical students' opinions about complementary and alternative medicine.

OBJECTIVE: We wished to determine third-year medical students' opinions and knowledge related to complementary and alternative medicine (CAM) in a school with no formal or elective course on the subject. STUDY DESIGN: A questionnaire was offered to third-year medical students during their 8-week rotation on obstetrics and gynecology. RESULTS: Most students had been exposed to CAM therapies, knew that the majority of the American public was using CAM, believed that some CAM interventions were useful, and did not believe CAM therapies were a threat to public health. Most students had insufficient knowledge or understanding of the safety or lack of it for 10 of the more common CAM modalities. Most respondents thought these interventions were useful, but would not refer the patient nor dissuade her from using them. There were no significant differences in responses between men and women or related to the time in the year of the clerkship. CONCLUSION: Medical students in this school self-identified an interest about the clinical usefulness of 10 CAM modalities, but did not have sufficient knowledge about the safety for 10 of the more common CAM modalities. Including CAM topics in the medical school curriculum would better prepare physicians to respond to patient inquiries about CAM and thereby to fulfill their role as patient advocates.

The clinical use of intrauterine pressure catheters.

We question the need for an intrauterine pressure catheter (IUPC) to monitor uterine contractions during the induction or augmentation of labor with oxytocin, or to verify adequate uterine contractions to support the diagnosis of arrest of labor. There are appropriately conducted clinical trials demonstrating that uterine contraction frequency in spontaneous, induced and augmented labors obtained with the use of external tocography is sufficient for the clinical management of labor. The value of an IUPC is further diluted by the inherent variability of pressure recordings with its use and the potential of the infrequent risks associated with insertion. Particularly pertinent is the fact that the use of an IUPC for this indication has never been proved to have a positive effect on maternal or neonatal outcome.

The no-show rate in a high-risk obstetric clinic.

We wished to determine the reasons for an average missed appointment rate of 28% in a high-risk pregnancy clinic. Only 41% of the 261 women in the study group could be reached by telephone. The reasons included not having a phone, the phone had been disconnected, incorrect phone number on the chart, the patient had moved, and the patient did not respond to the answering machine message. The reasons for missing the appointment included lack of transportation, scheduling problems, overslept or forgot, presence of a sick child or relative, and lack of child care. The response of patients to assessing prenatal care may reflect their priority of medical care relative to other priorities associated with day-to-day existence. There may be a baseline missed appointment rate for prenatal care in lower socioeconomic populations of women. The commitment of personnel time and energy to attempt to modify the no-show rate should be reexamined.

Uterine rupture and dehiscence associated with intravaginal misoprostol cervical ripening.

OBJECTIVE: To evaluate if the prostaglandin E1 analogue misoprostol, when used as an agent for cervical ripening, is associated with uterine rupture. STUDY DESIGN: We performed a two-year retrospective chart review to determine the incidence of uterine rupture in patients with a previous cesarean delivery undergoing cervical ripening or the induction of labor. RESULTS: Uterine dehiscence occurred in 1 and uterine rupture occurred in 3 of 48 women with a prior cesarean delivery treated with 50 micrograms doses of intravaginal misoprostol for cervical ripening. Uterine rupture was found in 1 of 89 women who had an oxytocin infusion for induction of labor and none of the 24 patients who received intravaginal prostaglandin E2 placed for cervical ripening. CONCLUSION: Intravaginal misoprostol appears to be associated with an increased incidence of uterine rupture when used in patients undergoing a trial of labor after cesarean.

Cervimetry: a review of methods for measuring cervical dilatation during labor.

Several different methods of measuring cervical dilatation have been described. In this article, we review those methods and examine findings from studies using them. Although many instruments have been developed to measure cervical dilatation during labor and their use as a research tool has been established, no device has yet been successfully used for clinical obstetrics. The ideal device has not yet been developed; however, because repeated digital cervical examinations are time consuming for the clinician, are poorly reproducible, and are uncomfortable for the patient, continued efforts to develop a cervimeter suitable for clinical use is a worthwhile endeavor.

Traumatic liver rupture in pregnancy.

Two pregnant women, 1 in the second trimester and 1 in the third trimester, sustained blunt liver trauma as unrestrained drivers in motor vehicle accidents. One patient had an overt injury that was apparent on computerized tomography and underwent surgical exploration when nonreassuring fetal monitoring occurred. The second patient, discharged after 23 hours of normal observation, returned a day later with overt intra-abdominal hemorrhage from an obvious liver laceration.

Response of obstetrics and gynecology program directors to a domestic violence lecture module.

OBJECTIVE: Our goal was to determine the use by obstetrics and gynecology residency program directors of The American College of Obstetricians and Gynecologists' domestic violence slide lecture module and the opinions of the directors regarding its efficacy. STUDY DESIGN: A 6-question survey was mailed to 289 directors of accredited obstetrics and gynecology programs in the United States and Canada 9 and 13 months after a learning module on domestic violence was mailed to these same persons. The questions related to receipt and use of the module in the curriculum, target audiences, future plans for integration of the module into curricula, and recommendations for future supplemental topics in the same format. RESULTS: The return rate for the survey was 57% (164/289). The responses represented university-affiliated, community- and military-based programs with representation from all geographic areas of the country. Fourteen directors who had no recollection of receiving the package were sent a second set. The lecture had been presented by 72% of the respondents' departments to audiences of residents (89%), medical students (55%), practicing physicians (41%), and the lay public (11%). Two thirds of the nonusers and 87% of the users intended to use the module as a formal lecture in the curriculum of both residents and medical students in the coming school year. Recommendations for future supplemental lecture packages included abuse during pregnancy, screening women with different cultural backgrounds, and how to ask tough questions. CONCLUSION: The majority of obstetrics and gynecology resident program directors who responded to the survey integrated or will integrate an American College of Obstetricians and Gynecologists-created learning module on domestic violence into their residents' and medical students' formal curricula.

Comparison of elective and empiric cerclage and the role of emergency cerclage.

We describe the maternal, obstetric, and neonatal outcomes of patients undergoing elective, empiric, and emergency cervical cerclage at our institution in an attempt to determine predictive factors for adverse perinatal and maternal outcomes. A retrospective chart review was conducted on patients who underwent cervical cerclage placement over a 7-year time span. Of 55 charts, 40 contained complete peripartum data satisfactory for review; 7 elective, 15 empiric, and 18 emergency cerclages were analyzed. There was no perinatal mortality in the elective group, and 5/7 patients delivered at term. The empiric population experienced a 20% neonatal mortality; 6/15 gestations progressed to term. The perinatal mortality was 44% in the emergency group and 2/18 patients delivered at term. Relative to neonatal outcome, elective cerclage was statistically significantly better than emergent cerclage; there was no statistically significant difference between the elective and empiric groups nor between the empiric and emergent groups. This relatively small series with a large number of variables appeared to favor an elective procedure rather than an empiric one. Although emergent cerclage was associated with only a 56% neonatal survival, it did have value in some patients.

Magnesium sulfate, maternal hypothermia, and fetal bradycardia with loss of heart rate variability.

BACKGROUND: Fetal bradycardia and decreased heart rate variability can indicate a nonreassuring fetal status. However, there can be iatrogenic, physiologic, or pathologic causes. CASE: A patient in premature labor received toxic levels of magnesium sulfate for tocolysis. Elevated maternal serum magnesium levels correlated inversely with maternal temperature and both fetal heart rate and fetal heart rate variability. There was also a relative decrease of the maternal heart rate from baseline. When the magnesium levels returned to normal, these vital signs returned to normal. CONCLUSION: Magnesium sulfate therapy can result in maternal hypothermia and a decrease in fetal heart rate and heart rate variability. Maternal hypothermia might be the cause of fetal bradycardia. A direct action of magnesium on the fetal heart might be the cause of heart rate variability.

Cervical ripening.

In conclusion, no pharmacologic method presently used in the hospital to ripen the cervix has attained the level of standard of care for application in most office or clinic outpatient settings. Published data are accumulating that support the safety of the prostaglandin preparations for this purpose. Sweeping the membranes in the office and clinic does have sufficient data to support its continued use for this purpose.

Urine protein dipstick measurements. A screen for a standard, 24-hour urine collection.

OBJECTIVE: To determine if the sum of urine protein dipstick values recorded during every void can be used to screen for patients who need a standard, 24-hour urine collection for determination of protein excretion. STUDY DESIGN: Thirty inpatient and 17 outpatient pregnant women undergoing 24-hour urine collection for protein concentration were enrolled. The volume, dipstick protein values and time of void were recorded. The 24-hour quantitative analysis of protein excretion performed by the laboratory was compared to the 24-hour sum of the products of each voided volume and dipstick value (dipstick factor). RESULTS: The dipstick factor significantly correlated with the total 24-hour protein excretion (correlation coefficient 0.84, P < 1 x 10(-7)). A dipstick factor of > or = 300 mg, indicated proteinuria with a sensitivity of 96%, specificity of 90%, positive predictive value of 92% and negative predictive value of 95%. Separately, we found differences in the amount of protein excretion when the 24-hour period was divided into six 4-hour periods, using analysis of variance. Paired t test analysis of the mean protein excretion from 16:00 to 04:00 showed significantly higher results than did the protein excretion from 04:01 to 16:00 (1,197 +/- 356 mg vs. 674 +/- 158 mg, P < .0001). CONCLUSION: The sum of dipstick factors in a 24-hour period is a reliable screening test for identifying patients who need the standard laboratory test for proteinuria.

Charting progress.

Logbooks can be considered aggregate databases that registered nurses (RNs) have the primary responsibility of completing in most health care settings. However, RNs may be unaware of the many uses for the information contained in logbooks and the importance of these entries (Paine et al., 1988). Labor and delivery (L&D) logs provide an essential source of vital statistics birth data for the medical records staff. These data bits are used for reporting statistics, projecting trends, and planning future care for pregnant women.

Personal health among midlife women hospital employees.

We hypothesized that women employees working in a hospital environment would be particularly attuned to aspects of personal health, well-being, and disease prevention. We performed an observational study at a local hospital, offering free assessments in its outpatient women's wellness screening program to women employees aged 39-60 years. Data from the first 60 women to enroll in the program are presented as a test of our hypothesis. Undiagnosed hypertension, abnormal lipid profiles, glucose intolerance, alcohol abuse, abnormal cervical cytology, breast masses, depression, or combinations of these were found in 49 of the 60 women. Twenty-one women were obese. Most women with abnormal findings did not follow specific personalized recommendations for remedial follow-up, including referral to a specialist. An important percentage of midlife women employees at this hospital exhibited unhealthful personal behaviors, had unrecognized disease, and did not use recommended health screening practices. The data emphasize the benefit for employees who participate in medical facility worksite health promotion programs.