Overcoming sequelae of childhood sexual abuse with stress management.

The immense stress associated with experiencing and surviving childhood sexual abuse directly influences coping, immune function and overall health. Lifelong overuse of maladaptive coping strategies results in impaired adjustment to stress. The purpose of this research was to re-examine if stress management education would be effective in improving coping skills for this population. Two 4-week series of stress management workshops were completed by 32 adult survivors who completed the ways of coping questionnaire before and after the training. Four categories of coping showed significant change. Stress management education is an effective and cost-efficient approach that gives adult survivors an empowering set of tools for their healing journey.

Chorionic villus sampling: quality control--a continuous improvement model.

OBJECTIVE: Our purpose was to describe Vanderbilt University Medical Center's experience in establishing a chorionic villus sampling program and the importance of quality control along with a continuous improvement model on the first 1000 cases. STUDY DESIGN: A continuous improvement model was established with emphasis on a multidisciplinary team approach and quality assurance process. A computerized data base was used for continuing analysis of complications and for allowing facile access to pertinent information. RESULTS: A continuous improvement model allowed for an improved process and outcome for patients, personnel, and referring health care providers. Follow-up for initial symptoms after chorionic villus sampling was obtained on 98.5% of patients. Pregnancy follow-up, including birth data, was obtained on 93%. CONCLUSION: A continuous improvement mode from the project's onset resulted in an improved process and outcome, information helpful for accessing spontaneous abortion rates and pregnancy outcomes (including the incidence of limb abnormalities and factors associated with abortions) and recommendations for training personnel.

A modified scheme for biophysical profile scoring.

A modified scheme for biophysical profile scoring based exclusively on real-time ultrasonographic examination is proposed and includes expanded scores of fetal movements and fetal breathing and only qualitative assessment of accelerated placental maturation, subjective ultrasonographic impression of oligohydramnios, and decreased fetal tone. This method was compared with the method of Vintzileos et al. in the first phase of this observational study and was found to have good correlation in different score categories. This method was then applied in the second phase of the study to 180 high-risk pregnancies to examine correlation with perinatal outcome variables. The relationship between results of the last total score and perinatal outcome variables shows good predictive values. Results of this preliminary study suggest that real-time ultrasonographic evaluation-based scoring of acute fetal events, namely, movements and breathing alone, may have an important role in perinatal management.

Reassessment of White's classification and Pedersen's prognostically bad signs of diabetic pregnancies in insulin-dependent diabetic pregnancies.

The classification systems developed over 20 years ago by White and Pedersen identified diabetic pregnancies at increased risk for perinatal mortality. To assess whether these same criteria would currently be valid, 199 diabetic pregnancies with deliveries from 1977 to 1983 were reviewed. Perinatal mortality rates for White's Classes B gestational (n = 72), B (n = 27), C (n = 67), and D + F + R (n = 33) were 2.9%, 11.1%, 14.9%, and 21.1%, respectively (p less than 0.05). White's classes were also predictive of pulmonary morbidity (12.5%, 18.5%, 22.4%, and 42.4%, respectively). The presence of one or more of the prognostically bad signs of pregnancy (n = 76) increased the perinatal mortality rate to 17.1% versus 7.3% among insulin-dependent diabetic pregnancies without prognostically bad signs (p less than 0.05). The presence of any prognostically bad signs of pregnancy was also predictive of pulmonary morbidity in general (31.6% versus 16.3%, respectively) and hyaline membrane disease in particular (13.2% versus 4.1%, respectively). Thus with use of modern obstetric management and medical care of the pregnant diabetic patient, both White's classification and Pedersen's prognostically bad signs of pregnancy continue to be predictive of perinatal mortality.

Increased risk of endometritis and wound infection after cesarean section in insulin-dependent diabetic women.

To determine if diabetic women have an increased risk for post-cesarean section endometritis and/or wound infection, all insulin-requiring diabetic women who were delivered by cesarean section between 1977 and 1981 were compared with a group of nondiabetic patients delivered by cesarean section. Patients were divided into low-risk or high-risk groups on the basis of labor and ruptured membranes. Compared with control subjects, diabetic patients were at significantly greater risk for postoperative infectious morbidity. Among diabetic patients, risk for postoperative infections was independent of White's classification of diabetes and gestational age at delivery. The increased rate of infection among the diabetic patients suggests that prophylactic antibiotics might be efficacious for insulin-requiring diabetic patients undergoing cesarean section.

Antepartum fetal monitoring in insulin-dependent diabetic pregnancies.

In order to minimize unexplained stillbirths in insulin-dependent diabetic pregnancies, fetal well-being was assessed by antepartum monitoring while development of pulmonary maturity was awaited. Antepartum monitoring consisted of outpatient nonstress tests beginning at 32 weeks' gestation. Fetuses with nonreactive nonstress tests were further evaluated by contraction stress tests and were delivered if tests were positive. With use of this system there were no unexplained stillbirths during management of 119 insulin-dependent diabetic pregnancies. Of 14 infants delivered because of positive contraction stress tests, six were found to have major disorders; the other eight had no major residual neonatal morbidity. Thus this system of antepartum fetal surveillance: eliminated unexplained stillbirths, identified a subgroup of insulin-dependent diabetic pregnancies with a high rate of major fetal abnormalities, and allowed for identification and subsequent timely delivery of the other distressed fetuses that were at a high risk of neonatal morbidity and/or mortality, such that potential long-term adverse outcomes were avoided.

Continuing neonatal morbidity in infants of women with class A diabetes.

Despite having implemented rigorous glucose control for women with gestational diabetes early in the third trimester, we found excessive morbidity among the neonates of these women. To accurately assess the risk of newborn complications, we did a five-year review (1977 to 1981) of infants of class A diabetic mothers to determine the incidence and scope of morbidity in these infants. Fifty-one infants of class A mothers were identified (group 1) and randomly matched with 102 infants of nondiabetic mothers (group 2). The distribution of morbidity between the two groups was as follows: hypoglycemia 9/51 (18%) vs 0/102 (P less than .001); birth injuries 4/51 (8%) vs 1/102 (2%) (P less than .05); pulmonary edema 3/51 (6%) vs 0/102 (P less than .05); respiratory distress 4/51 (8%) vs 7/102 (7%) (NS); macrosomia 18/51 (35%) vs 23/102 (23%) (NS); and hyperbilirubinemia 3/51 (6%) vs 8/102 (8%) (NS). There were two fetal deaths and three infants with major congenital anomalies among the diabetic pregnancies compared to none from the nondiabetic pregnancies. Compared to insulin-dependent diabetes, class A diabetes is accompanied by relatively mild metabolic disturbances in the mother. On the other hand, the infant of a mother with class A diabetes appears to be at risk for serious and life-threatening complications, both before and after birth. These results raise the question of whether earlier identification, subsequent meticulous diabetic management, and altered timing of delivery might reduce the complications experienced by these infants.

The nonstress test: an evaluation of 1,000 patients.

In November, 1978, the fetal heart rate nonstress test (NST) was instituted as the primary screening procedure for the evaluation of fetal well-being at Vanderbilt University Hospital. The results of the first 1,000 patients tested are presented. The stillborn rate within 8 days of a reactive NST was 6.4 per 1,000, with the stillbiths occurring either in patients with diabetes mellitus or with intrauterine growth retardation (IUGR). A review of other series in which both the total indications for nonstressed testing and the risk groups in which stillbirths occurred within 7 days of an NST reveals that patients with diabetes mellitus (p less than 0.025) and patients with IUGR (p less than 0.01) are at greater risk for stillbirth within 7 days of an NST. Weekly nonstress testing, effective in preventing stillbirths in most risk groups, is not adequate in patients with diabetes mellitus or IUGR.