Cost effectiveness of bedside fetal fibronectin testing varies according to treatment algorithm.

OBJECTIVE: To determine the cost effectiveness of implementing fetal fibronectin testing in women with threatened preterm labor. METHODS: We developed a cost analysis model based upon our institution's experience with threatened preterm labor. Model estimates related to fetal fibronectin were obtained from the literature. The model considered hospital admission and assay cost. RESULTS: Approximately 2000 women deliver annually at our tertiary care facility. In the prior 11 months, 340 (19%) presented for threatened preterm labor with 45 (13%) admissions. In a group of individuals with threatened preterm labor and < 3 cm cervical dilatation, approximately 25% can be expected to have a positive fetal fibronectin test. If fetal fibronectin testing were used to influence the decision of admission, 93 (25%) would have a positive test over a 12-month period, potentially increasing admissions by 94%. At a cost of $225 per test, our institution's antepartum admission cost of $1919, a prevalence of threatened preterm labor of 19% and admission rate of 13%, fetal fibronectin testing applied prior to the decision to admit would result in a total cost of $262 583 with 373 assays performed, and 93 admissions. If only those who would have been admitted based on traditional criteria are considered, > 25% should have a positive fetal fibronectin test. If we assume a positive rate of 70%, fetal fibronectin testing employed after the decision to admit would result in a total cost of $75 963, with 48 assays performed and 34 admissions. Without using the assay, total costs are $92 950 for 48 admissions. CONCLUSION: This cost analysis suggests that fetal fibronectin testing on all patients presenting with threatened preterm labor significantly increases the cost, while fetal fibronectin testing after the decision to admit may reduce the cost.

Hand-held computer operating system program for collection of resident experience data.

OBJECTIVE: To describe a system for recording resident experience involving hand-held computers with the Palm Operating System (3 Com, Inc., Santa Clara, CA). PROGRAM DESCRIPTION: Hand-held personal computers (PCs) are popular, easy to use, inexpensive, portable, and can share data among other operating systems. Residents in our program carry individual hand-held database computers to record Residency Review Committee (RRC) reportable patient encounters. Each resident's data is transferred to a single central relational database compatible with Microsoft Access (Microsoft Corporation, Redmond, WA). Patient data entry and subsequent transfer to a central database is accomplished with commercially available software that requires minimal computer expertise to implement and maintain. The central database can then be used for statistical analysis or to create required RRC resident experience reports. As a result, the data collection and transfer process takes less time for residents and program director alike, than paper-based or central computer-based systems. CONCLUSION: The system of collecting resident encounter data using hand-held computers with the Palm Operating System is easy to use, relatively inexpensive, accurate, and secure. The user-friendly system provides prompt, complete, and accurate data, enhancing the education of residents while facilitating the job of the program director.

Videoteleconferencing for administration of a multisite obstetrics and gynecology core clerkship.

Recent changes and trends in health care delivery have required medical schools to use multiple sites to obtain adequate patient exposure for their students. Decentralization of clinical undergraduate medical education may lead to a lack of continuity in curricula, evaluation, and feedback. We describe the use of interactive videoteleconferencing as a tool to link and improve a multi-site undergraduate core clerkship in obstetrics and gynecology. The Uniformed Services University of the Health Sciences, Bethesda, Maryland, currently utilizes five geographically separate sites for its 6-week core clerkship in obstetrics and gynecology. The site coordinators, clerkship director, and administrative personnel from the parent institution meet approximately 3 weeks after the completion of each core clerkship for live, real-time, and interactive broadcast to complete student evaluations, review curricula, and discuss problems with current students and other pertinent educational issues. Videoteleconferencing provides a mechanism to ensure consistency in curriculum and student evaluations and provides administrative support to distant sites. Furthermore, it enables site coordinators to keep the clerkship director abreast of students and clerkship issues.

Effect of meconium on the hemoglobin-oxygen association curve.

OBJECTIVE: Our purpose was to determine the effect of meconium-stained amniotic fluid on the hemoglobin-oxygen association curve of maternal whole blood. METHODS: Whole blood was obtained from term gravidas in active labor. Hemoglobin-oxygen association curves were generated for blood incubated with meconium vs. controls. Oxygen association curves were determined at pH 7.4 and 37 degrees C utilizing an automated device consisting of a spectrophotometer cuvette fitted with a magnetic stirrer, gas exchange line, and a Clark oxygen electrode. The samples were deoxygenated with nitrogen and association curves recorded while reoxygenating. Data was analyzed with Sigma Plot and Sigma Stat software. Analysis included log transformation, linear regression, and paired t-test. RESULTS: Twenty-eight hemoglobin oxygen association curves were generated. In all 14 pairs, meconium shifted the hemoglobin-oxygen association curve to the right. Partial pressures of oxygen required for various degrees of hemoglobin saturation were higher in meconium-exposed samples; P50 (30.1+/-0.6 vs. 27.8+/-0.4 mmHg, P < 0.01); P75 (46.9+/-0.6 vs. 43.1+/-0.5 mmHg, P < .001); P90 (69.2+/-1 vs. 63.3+/-1 mmHg, P < 0.01). CONCLUSIONS: Meconium-stained amniotic fluid causes a statistically significant, but clinically small, right shift in the hemoglobin-oxygen association curve.

Effect of residency program merger on undergraduate medical student education in obstetrics and gynecology.

OBJECTIVE: To evaluate the effect of residency program merger on third-year medical student clerkships using student evaluations of their experiences and standardized subject examination scores. METHODS: End-of-clerkship ratings from student evaluations and National Board of Medical Examiners standardized subject examination scores in obstetrics and gynecology were used from clerkship sites where three separate military residency programs in obstetrics and gynecology recently merged into two new programs. Mean student evaluation scores and subject examination scores for the year preceding and the year following the merger were compared. RESULTS: The mean differences in medical student evaluation scores before and after merger of the residency programs were 0.1 (Mann-Whitney rank sum, P = .1), -0.1 (Mann-Whitney rank sum, P = .8), and 0.2 (Mann-Whitney rank sum, P = .3). The mean differences for subject examination scores before and after merger of the residency programs were -3.5 (95% confidence interval [CI] -33.2, 26.2; paired t test), -30.1 (95% CI -58.9, -1.4; paired t test), and -35.3 (95% CI -74.8, 4.3; paired t test). CONCLUSION: Merger of residency programs in obstetrics and gynecology does not appear to have a deleterious effect on medical students' satisfaction with the clerkship or their performance on standardized subject examinations at our institution.

Development and use of military-unique standardized gynecology patients in military undergraduate medical education.

Performance-based testing using standardized patients is becoming increasingly popular as a means to assess the clinical competence of medical students. Medical students entering postgraduate training in military treatment facilities have the additional responsibility of military readiness. The increasing number of women in the active armed forces and the diverse missions encountered by the military today necessitate inclusion of military-unique standardized gynecologic patients and scenarios into curricula. We developed a military-unique standardized gynecology patient and scenario and an objective structured clinical examination to evaluate medical students' skills in data gathering and synthesis, development of differential diagnoses, problem solving, and working through military-unique issues of the patient scenario. Integration of an objective structured clinical examination of military-unique gynecology standardized patient scenarios into the obstetrics and gynecology curriculum at the Uniformed Services University of the Health Sciences can lead to successful assessment of student clinical skills and provide a means of ongoing military readiness training.

A survey of military residencies regarding 4th-year medical school clerkships.

OBJECTIVE: To determine the value of 4th-year medical student clerkships assessed by military obstetric and gynecologic program directors and residents. METHODS: A questionnaire was sent to all Department of Defense obstetric and gynecologic residency program directors and residents. All of the program directors and 124 of 194 (64%) residents responded, reporting the value of 4th-year medical student clerkships for students entering their programs. Descriptive statistics are reported. RESULTS: Primary care clerkships were valued most highly by program directors who valued obstetric and gynecologic clerkships at their program sites or audition electives higher than those done at other sites. Residents most highly valued obstetric and gynecologic and intensive care clerkships. Most surgical subspecialties were believed to be of minimal or no value. CONCLUSION: For students entering their programs, military program directors placed the highest value on primary care clerkships. Program directors also highly valued obstetric and gynecologic clerkships at their programs, whereas residents considered obstetric and gynecologic and intensive care clerkships to be most helpful.

Delaying surgery for thyroid cancer in pregnancy. A case report.

BACKGROUND: Management of thyroid cancer in pregnancy is controversial, as evidenced by disagreement in recommendations cited in leading obstetrics textbooks. Most thyroid carcinomas are well differentiated and pursue an indolent course. Many physicians recommend delay in surgical therapy until after delivery because of operative morbidity. CASE: A 27-year-old primigravida was found to have a solitary thyroid nodule at her initial obstetrics appointment. Fine needle aspiration was consistent with papillary carcinoma. Although detected at 8 weeks' estimated gestational age (EGA), the decision was made to defer surgical therapy until postpartum. The patient was referred to a tertiary care facility at 24 weeks' EGA secondary to rapid growth of the nodule. Surgery performed at that time revealed invasive disease. CONCLUSION: Review of the literature suggests that delay in definitive therapy stems from early reports of fetal loss related to surgery, but contemporary data suggest that the risk of fetal loss related to surgery is minimal.

Development and use of military-unique standardized gynecology patients for military residents in obstetrics and gynecology training programs.

Focused military curricula and readiness training are often inadequate for military resident physicians. We developed a standardized gynecologic military-unique patient scenario and examination to assess obstetrics and gynecology residents' clinical and operational problem-solving abilities. Integration of military-unique gynecologic standardized patients, clinical scenarios, and objective structured clinical examinations into obstetrics and gynecology curricula is a novel approach for realistic medical readiness training for resident physicians. This tool can become a cornerstone in the ongoing development of needed military-unique curricula.

Delayed diagnosis of bowel infarction secondary to maternal midgut volvulus at term.

BACKGROUND: Intestinal volvulus is responsible for 25% of acute bowel obstructions in pregnant women but only 3-5% in nonpregnant patients. Pregnancy may hinder early diagnosis. CASE: A woman in early labor subsequently developed hypotension and a nonreassuring fetal heart rate tracing. Emergency cesarean was performed and a live infant was born. At surgery, the patient was noted to have ascites, necrotic bowel, and a congenital gut malrotation with a complete midgut volvulus. Several congenital peritoneal bands were lysed, the volvulus was reduced, and 184 cm of small bowel were resected. CONCLUSION: This patient represents a case of midgut volvulus with bowel infarction and necrosis secondary to congenital malrotation of the gut.

Oxytocin labor stimulation of twin gestations: effective and efficient.

OBJECTIVE: To test the hypothesis that oxytocin labor stimulation of twin gestations is similar to that of singletons regarding dosage, time, complications, and ability to achieve vaginal delivery. METHODS: This retrospective investigation included 124 gravidas receiving oxytocin for augmentation or induction of labor. Sixty-two women with twin gestations were matched by parity, cervical dilation at initiation of oxytocin, gestational age, oxytocin dosage regimen, and indications for oxytocin to controls with singleton pregnancies. Outcome variables included maximum dosage of oxytocin, incidence of hyperstimulation and fetal heart rate (FHR) abnormalities, time from oxytocin to delivery, cesarean deliveries, and maternal and neonatal outcomes. Statistical analysis was done using McNemar test, paired t test, and Wilcoxon signed-rank test for paired samples. RESULTS: Women with twin pregnancies and those with singletons responded similarly regarding maximum oxytocin dosage (21 +/- 1.5 and 18 +/- 2.4 mU/minute, respectively, P = .1), time from oxytocin to delivery (7.0 +/- 0.8 and 6.7 +/- 0.6 hours, respectively, P = .88), and successful vaginal delivery (90% and 90%, respectively). Oxytocin stimulation of twins resulted in fewer interruptions of the infusion for FHR abnormalities (5% compared with 26%, odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16, 0.47) and hyperstimulation (6% compared with 18%, OR 0.19, 95% CI 0.36, 0.99). CONCLUSION: Twin gestation has no adverse impact on the effectiveness or efficiency of oxytocin labor stimulation. Twin pregnancy seems to be associated with fewer side effects.

Physical and sexual abuse in a middle-class obstetric population.

To evaluate the prevalence of a history of physical and sexual abuse in pregnant, economically stable, middle-class women with access to comprehensive health care, we issued self-report questionnaires to prenatal orientation classes at Wilford Hall Medical Center from October 19, 1992, to March 15, 1993. After identifying women who had been physically or sexually abused, we identified the assailant, the number of occurrences, and injuries resulting from the abuse. Of the 563 women who responded, 100 (18%) reported previous physical or sexual abuse. Seven women (1%) stated that they were physically abused during the pregnancy. Women were more likely to be physically than sexually abused by a spouse or lover (46% versus 13%). To identify women who have a history of abuse and to address their needs, practitioners should incorporate taking a history of physical and sexual abuse during the routine new obstetric visit.

The pharmacokinetics of oxytocin as they apply to labor induction.

OBJECTIVE: Our purpose was to determine the relationship among plasma oxytocin levels, metabolic clearance rate of oxytocin, and uterine activity in gravid women undergoing labor induction. STUDY DESIGN: Ten women receiving oxytocin for labor induction and agreeing to participate had blood sampled before initiation of oxytocin and at different levels of uterine pressure. Samples were analyzed with 200 microliter extracts from 1 ml of plasma with an oxytocin radioimmunoassay. The intraassay coefficient of variation was < 3%. Sensitivity of the assay was 1.5 pg/ml. Pharmacokinetic parameters including plasma levels and metabolic clearance rates were calculated. Data were analyzed with the paired t test and linear and logistic regression. RESULTS: Mean oxytocin levels and metabolic clearance rates were 26.6 pg/ml and 7.97 ml/min. There was no correlation between changes in oxytocin level and metabolic clearance rate. Increases in infusion rates were correlated with increases in oxytocin levels (r = 0.71, p < 0.001). Cervical dilatation and uterine contraction pressures did not correlate with oxytocin levels. CONCLUSION: Peripheral plasma levels of oxytocin may not accurately reflect uterine activity or progress in labor. Plasma levels of oxytocin may merely reflect the rate of oxytocin infusion.

The impact of sexual abuse on job attrition in military recruits.

OBJECTIVE: To determine whether recruits entering the U.S. Air Force with a history of sexual abuse had a higher attrition rate from basic military training (BMT). METHODS: Retrospective, case-control study involving 28,918 recruits entering BMT from October 1, 1991, to September 30, 1992. Self-report questionnaires were given to all recruits on the second day of BMT. We compared recruits revealing a history of sexual abuse to all other recruits at the end of BMT and at the end of the next fiscal year. RESULTS: We found that victims of sexual abuse had a higher attrition rate from BMT than non-victims (10.6 versus 4.1%, p < 0.0001). Four and one-tenth percent of all recruits (1,289) reported a history of sexual abuse, and fewer male than female recruits reported a history of sexual abuse (1.5 versus 15.1%, p < 0.0001). However, after BMT there were no differences in any job performance indicators between victims and non-victims. CONCLUSION: We conclude that recruits with a history of sexual abuse had a higher attrition rate from BMT than those without a history of abuse; however, those recruits who did complete BMT were as successful as those who did not report a similar history of abuse.

Cerebellar hemangioblastoma complicating pregnancy. A case report.

BACKGROUND: Cerebellar hemangioblastomas are unusual benign neoplasms that may go undetected for years. When associated with pregnancy, however, these tumors may undergo rapid expression and promote progression of symptomatology. CASE: A 28-year-old woman with ataxia and left-sided weakness was diagnosed with cerebellar hemangioblastoma in the second trimester of pregnancy following repeated hospital admissions for nausea and vomiting. Surgical removal was uneventful, and she delivered vaginally at term. CONCLUSION: Cerebellar hemangioblastomas, although rare, should be considered in the differential diagnosis of persistent nausea and vomiting when accompanied by an abnormal neurologic examination.

Physical and sexual abuse. A middle-class concern?

This study evaluated the prevalence of physical and/or sexual abuse in a population of employed, middle-class women who all have access to health care. Questionnaires were given to all patients who came to the ambulatory gynecology clinic at Wilford Hall Medical Center from October 19, 1992, to November 13, 1992. Questions were asked to ascertain the number of women who had experienced at least one episode of forced sexual contact or physical abuse. Other questions allowed identification of the relationship of the assailant to the respondent, number of occurrences and injuries resulting from the abuse. Of the 531 women who responded, 72 reported a history of only physical abuse, and 37 reported a history of only sexual abuse. Forty women reported that they were both physically and sexually abused. The typical victim of abuse was younger (32.6 vs. 39.8 years old, P < .001) and was more likely to work outside the home (63.1% vs. 47.9%, P < .005). Women were significantly more likely to be battered by a husband or lover than to be sexually assaulted by an intimate partner (75% vs. 16%, P < .001). Women who were both physically and sexually abused were injured more often than women who were only physically or sexually abused (60% vs. 28%, P < .01, and 60% vs. 24%, P < .01, respectively). Victims abused by an intimate partner were more likely to be abused on more than one occasion. All women should be asked about a recent history of abuse so that individuals identified can be counseled appropriately and attempts can be made to intervene to prevent further episodes of abuse.

Trial of labor: a disciplined approach to labor management resulting in a high rate of vaginal delivery.

A disciplined approach to labor management has resulted in a low cesarean rate (9%) in our population. We wondered if this management scheme was applicable and safe applied to women with previous cesareans. Women with a previous cesarean delivering in a 5-year period were included. Labor management included encouragement of trial of labor, labor stimulation with oxytocin when indicated, epidural analgesia only after entering the active phase, and continuous monitoring. Demographic, labor and delivery, and neonatal data were electronically stored and analysis performed using SPSS release 4.1 for VAX/VMS. Statistical analysis was performed using chi-square and Fisher's exact test where appropriate. Multiple logistic regression was performed to control for potentially confounding variables. A previous cesarean had been performed in 713 (11%) gravidas who met the inclusion criteria. Vaginal delivery was attempted in 588 (82%) and 517 (88%) achieved vaginal birth. Older women (14 versus 1 versus 8%, p = 0.04), of higher parity (63 versus 35 versus 17%, p = 0.0001), requiring preterm delivery (14 versus 8 versus 4%) were more likely to have an elective repeat cesarean than a successful or failed trial of labor. Pregnancies requiring oxytocin (90 versus 53%, p = 0.02), receiving epidural analgesia (62 versus 49%, p = 0.05), developing chorioamnionitis (20 versus 4%, p < 0.0001) were more likely to fail a trial of labor. Four uterine ruptures occurred and only one patient was receiving oxytocin. There were no differences in umbilical artery blood acidemia among elective repeat cesarean sections and successful or failed trial of labor.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of indomethacin tocolysis on maternal coagulation status.

OBJECTIVE: To investigate the effect of indomethacin tocolysis on maternal coagulation. METHODS: Twenty gravidas at 24-32 weeks' gestation were treated for preterm labor with 50 mg indomethacin orally, followed by 25 mg every 6 hours for 3 days. Bleeding time, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were measured before and 48 hours after initiation of therapy. Statistical analysis was performed by paired t test and Fisher exact test. RESULTS: The typical participant was 22 years old, nulliparous, and 26.2 weeks' gestational age at enrollment. The mean bleeding time was 4.5 minutes before therapy and 8.8 minutes after therapy (P < .0001, mean difference 4.3 minutes, 95% confidence interval 2.9-5.8). Nineteen of the 20 subjects experienced an increase in bleeding time and 13 had abnormal bleeding times. No clinically significant changes in PT or aPTT were noted. The mean period from treatment to delivery was 60.2 days. No cases of neonatal intraventricular hemorrhage or maternal postpartum hemorrhage were noted. CONCLUSION: Oral indomethacin treatment for tocolysis has no impact on PT and aPTT; however, profound acute changes in maternal bleeding time occur.

The economic advantages of measured change in health care: an example from obstetrics.

To evaluate the economic effects of an increased oxytocin dosage for labor stimulation at a large urban hospital, a cost analysis of a before and after cohort, analytic clinical trial was performed. Delivery outcomes for two different oxytocin dosages were evaluated from the perspective of provider and consumer costs attributable to the oxytocin regimen. The high-dose oxytocin regimen resulted in an estimated provider and consumer cost savings of approximately $350,000 per year. We conclude that a small change in health care, such as an increased infusion rate of a single drug, can have economic advantages.