Prenatal nutrition: special considerations.

Awareness of the importance of nutrition during pregnancy has increased in recent years.Pregnancy outcomes vary by prepregnant weight as well as gestational weight gain. Inappropriate gain may have both short- and long-term consequences for mother and infant. This review article includes the newly released US Institute of Medicine prenatal weight gain guidelines, as well as the Dietary Reference Intakes for the US and selected European societies.Food safety topics are discussed including Listeria, Toxoplasma, peanuts, mercury and other contaminants. Preconceptual nutrition is discussed, as are specific at-risk prenatal nutrients, including folic acid, choline, vitamin B12, omega-3 fatty acids, iodine, calcium, vitamin D, and iron. Current controversies are discussed and practical suggestions are given to safely optimize nutrient intake. As part of the medical team, a local Registered Dietitian or other nutrition professional can give much more detailed guidance and support for a pregnant woman given her particular risk factors, including her pre-existing medical conditions and cultural concerns, and will emphasize nutritional quality rather than just pounds gained.

Perinatal mortality and its relationship to the reporting of low-birthweight infants.

OBJECTIVES: This study examined changes in the reporting of very low-birthweight infants in Alabama from 1974 to 1994 and the impact on perinatal mortality rates. METHODS: Linked live birth, neonatal death, and stillbirth records of infants born weighing less than 1500 g were compared. RESULTS: The changes in mortality over time ranged from a drop from 100% to 92% in the under-500-g group to a drop from 39% to 4% in the 1000-to 1499-g group. The percentage of total births weighing less than 500 g increased by 155%; the percentage of 1000- to 1499-g births increased by only 7%. As a result, the percentage of neonatal mortality attributable to live births below 500 g increased from 3% to 32%. CONCLUSIONS: Increased reporting of births below 500 g has masked improvements in neonatal mortality.

Family planning: an essential component of prenatal care.

This nation's traditional approach to improving maternal and infant health has been prenatal care. But evidence is mounting that additional progress in reducing maternal and infant morbidity and mortality will depend, at least in part, on the care that a woman receives before she conceives. The studies reviewed in this paper indicate that increasing the interval between deliveries and preventing or delaying pregnancies among women at high risk could lower the rate of low birthweight (LBW). Since reducing the rate of unintended pregnancies would also reduce the number of pregnancies in women at high risk of LBW because of race, age, late or no prenatal care, and unhealthy behaviors, the prevention of unintended pregnancies would also reduce LBW. Unfortunately, prenatal care, as experienced by many women, devotes little attention to these family planning issues. Many women do not realize the importance of family planning to their own health and that of their children. Prenatal care providers should include instruction about the importance of pregnancy planning and encourage women to continue receiving health care between pregnancies. If the health of women and infants is to be improved, society must be willing to provide health services to women of reproductive age even when they are not pregnant.

Gestational diabetes survey.

OBJECTIVE: Our purpose was to determine how residents in obstetrics and gynecology and fellows in maternal-fetal medicine are currently being trained to diagnose and manage gestational diabetes mellitus. STUDY DESIGN: Questionnaires were mailed to 202 obstetrics and gynecology residency program directors and 78 maternal-fetal medicine fellowship directors. RESULTS: Sixty-four (82%) of the maternal-fetal medicine directors versus 142 (70%) of the residency directors responded. Universal screening, use of a 50 gm glucose challenge with a 1-hour-postingestion sample, no requirements for fasting before the screening test, use of two abnormal values on the 3-hour glucose tolerance test to define gestational diabetes mellitus, and initiation of insulin for elevated fasting glucose levels in spite of diet therapy were each recommended by > 90% of the respondents. CONCLUSION: Although the optimal management of gestational diabetes mellitus remains controversial, program directors are in general agreement with many aspects of the diagnosis and management.

Comparison of problem-based and traditional education on student performance in the obstetrics and gynecology clerkship.

OBJECTIVE: To evaluate the hypothesis that students trained in problem-based learning during basic sciences will have an advantage over traditionally trained students during clinical activities because of greater experience in patient care settings. METHODS: A retrospective study encompassing the academic years 1985-1990 compared students' clinical performance during an obstetrics and gynecology third-year clerkship based on the method of basic science education (problem-based 78, traditional 228). RESULTS: No statistical difference could be demonstrated in student performance based on the basic science educational method and controlling for the timing of rotation. CONCLUSIONS: Participation in a problem-based curriculum does not affect students' performance on standardized objective examinations within the clinical curriculum. Using current evaluation tools, there is no measurable difference in clinical evaluations between basic science education by traditional versus problem-based learning methods.

Sources of stress and support for the pregnant resident.

In order to clarify the sources of stress and support for pregnant residents, in 1985 the author conducted a retrospective national survey of women obstetricians and gynecologists, surgeons, and psychiatrists. Questionnaires were mailed to 2,000 physicians; 1,197 responded; 373 (31%) had experienced pregnancy during residency. They indicated that major sources of stress included frequency of call, fatigue, long hours, and too little time with spouse or partner. Women medical staff were perceived as supportive, whereas male counterparts were felt to be neutral at best. Most residents had worked up to delivery or to scheduled maternity leave; only 19 had needed medical leave more than a month prior to due date. Maternity leave of less than six weeks was felt to be inadequate, especially for first-time mothers. The author makes recommendations to help minimize problems for pregnant residents and their programs.

Conservative management of transverse fractures of the sacrum with neurological features. A report of four cases.

Transverse fractures of the sacrum with neurological complications have been studied in four patients illustrating the following features: diagnosis is often delayed, there are radiological difficulties in making the diagnosis, and the indications for surgery are not well defined. Specific radiographic views are recommended. All the cases presented in this report responded well to conservative management.

Pregnancy during residency: I. The decision "to be or not to be".

Almost 50% of married female residents become pregnant during their residency. The desire to have a baby and a concern about age influence the decision to become pregnant. Career concerns, financial issues, and child care are less important. In addition, support of the faculty or house staff is not a crucial factor in decision making. In this study, over 25% of the pregnancies were unplanned. The female residents who had unplanned pregnancies had an increased likelihood of having a conflict between their desire to have a baby and their fear of not achieving career expectations.

Pregnancy during residency: II. Obstetric complications.

Forty-three percent of women experiencing a pregnancy during a residency education program report medical complications. Analysis of questionnaires from 1197 respondents to a survey of 2000 female physicians indicates that the actual rate of medical and obstetric complications is no different from that in the general population except for the incidence of pregnancy-induced hypertension (12%). Although the incidence was similar for the three specialties studied (obstetrics-gynecology, psychiatry, and surgery), it is higher than that reported in the general population (5%). This may reflect an older maternal age.