Hypertensive Disorders of Pregnancy.

Elevated blood pressure in pregnancy may represent chronic hypertension (occurring before 20 weeks' gestation or persisting longer than 12 weeks after delivery), gestational hypertension (occurring after 20 weeks' gestation), preeclampsia, or preeclampsia superimposed on chronic hypertension. Preeclampsia is defined as hypertension and either proteinuria or thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Proteinuria is not essential for the diagnosis and does not correlate with outcomes. Severe features of preeclampsia include a systolic blood pressure of at least 160 mm Hg or a diastolic blood pressure of at least 110 mm Hg, platelet count less than 100 × 103 per µL, liver transaminase levels two times the upper limit of normal, a doubling of the serum creatinine level or level greater than 1.1 mg per dL, severe persistent right upper-quadrant pain, pulmonary edema, or new-onset cerebral or visual disturbances. Preeclampsia without severe features can be managed with twice-weekly blood pressure monitoring, antenatal testing for fetal well-being and disease progression, and delivery by 37 weeks' gestation. Preeclampsia with any severe feature requires immediate stabilization and inpatient treatment with magnesium sulfate, antihypertensive drugs, corticosteroids for fetal lung maturity if less than 34 weeks' gestation, and delivery plans. Preeclampsia can worsen or initially present after delivery. Women with hypertensive disorders should be monitored as inpatients or closely at home for 72 hours postpartum.

Management of Spontaneous Vaginal Delivery.

Most of the nearly 4 million births in the United States annually are normal spontaneous vaginal deliveries. In the first stage of labor, normal birth outcomes can be improved by encouraging the patient to walk and stay in upright positions, waiting until at least 6 cm dilation to diagnose active stage arrest, providing continuous labor support, using intermittent auscultation in low-risk deliveries, and following the Centers for Disease Control and Prevention guidelines for group B streptococcus prophylaxis. Most women with a low transverse uterine incision are candidates for a trial of labor after cesarean delivery and should be counseled accordingly. Pain management during labor includes complementary modalities and systemic opioids, epidural anesthesia, and pudendal block. Outcomes in the second stage of labor can be improved by using warm perineal compresses, allowing women more time to push before intervening, and offering labor support. Delayed pushing increases the length of the second stage of labor and does not affect the rate of spontaneous vaginal delivery. A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, or the baby may be delivered using a somersault maneuver in which the cord is left nuchal and the distance from the cord to placenta minimized by pushing the head toward the maternal thigh. After delivery, skin-to-skin contact with the mother is recommended. Beyond 35 weeks' gestation, there is no benefit to bulb suctioning the nose and mouth. Postpartum maternal and neonatal outcomes can be improved through delayed cord clamping, active management to prevent postpartum hemorrhage, careful examination for external anal sphincter injuries, and use of absorbable synthetic suture for second-degree perineal laceration repair. Practices that will not improve outcomes and may result in negative outcomes include discontinuation of epidurals late in labor and routine episiotomy.

The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries.

OBJECTIVE: To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries. METHODS: Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania. RESULTS: In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased. In Guatemala, sustained reductions in overall maternal mortality and mortality from postpartum hemorrhage (PPH) were recorded after ALSO implementation. In Honduras, there was a significant decrease in episiotomy rates, and increases in active management of the third stage of labor (AMTSL), vacuum-assisted delivery, and reported comfort managing obstetric emergencies. In Tanzania, the frequency of PPH and severe PPH decreased after training, while management improved. CONCLUSION: In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training.

Low primary cesarean rate and high VBAC rate with good outcomes in an Amish birthing center.

PURPOSE: Recent national guidelines encourage a trial of labor after cesarean (TOLAC) as a means of increasing vaginal births after cesarean (VBACs) and decreasing the high US cesarean birth rate and its consequences (2010 National Institute of Health Consensus Statement and American College of Obstetricians and Gynecologists revised guideline). A birthing center serving Amish women in Southwestern Wisconsin offered an opportunity to look at the effects of local culture and practices that support vaginal birth and TOLAC. This study describes childbirth and perinatal outcomes during a 17-year period in LaFarge, Wisconsin. METHODS: We undertook a retrospective analysis of the records of all women admitted to the birth center in labor. Main outcome measures include rates of cesarean deliveries, TOLAC and VBAC deliveries, and perinatal outcomes for 927 deliveries between 1993 and 2010. RESULTS: The cesarean rate was 4% (35 of 927), the TOLAC rate was 100%, and the VBAC rate was 95% (88 of 92). There were no cases of uterine rupture and no maternal deaths. The neonatal death rate of 5.4 of 1,000 was comparable to that of Wisconsin (4.6 of 1,000) and the United States (4.5 of 1,000). CONCLUSIONS: Both the culture of the population served and a number of factors relating to the management of labor at the birthing center have affected the rates of cesarean delivery and TOLAC. The results of the LaFarge Amish study support a low-technology approach to delivery where good outcomes are achieved with low cesarean and high VBAC rates.

Cesarean delivery.

Cesarean delivery rates rose from 20 to 33% of births in the United States from 2006-2009 without an accompanying improvement in neonatal outcomes. The cesarean rate may be safely decreased by increasing vaginal birth after cesarean, encouraging external cephalic version for breech presentation, maintaining operative vaginal delivery skills, and applying stricter criteria for operative intervention in labor dystocia. A variety of cesarean operative techniques are supported by randomized controlled trials. Optimal maternity care outcomes depend on sound medical decision-making, appropriate operative technique and skills, and effective communication between maternity care team members.

The effect of prenatal support on birth outcomes in an urban midwestern county.

OBJECTIVES: In Dane County, Wisconsin, the black-white infant mortality gap started decreasing from 2000 and was eliminated from 2004 to 2007. Unfortunately, it has reappeared since 2008. This paper examines risk factors and levels of prenatal care to identify key contributors to the dramatic decline and recent increase in black infant mortality and extremely premature birth rates. METHODS: This retrospective cohort study analyzed approximately 100,000 Dane County birth, fetal, and infant death records from 1990 to 2007. Levels of prenatal care received were categorized as "less-than-standard," "standard routine" or "intensive." US Census data analysis identified demographic and socioeconomic changes. Infant mortality rates and extremely premature ( < or = 28 weeks gestation) birth rates were main outcome measures. Contributions to improved outcomes were measured by calculating relative risk, risk difference and population attributable fraction (PAF). Mean income and food stamp use by race were analyzed as indicators of general socioeconomic changes suspected to be responsible for worsening outcomes since 2008. RESULTS: Risk of extremely premature delivery for black women receiving standard routine care and intensive care decreased from 1990-2000 to 2001-2007 by 77.8% (95% CI = 49.9-90.1%) and 57.3% (95% CI = 27.6-74.8%) respectively. Women receiving less-than-standard care showed no significant improvement over time. Racial gaps in mean income and food stamp use narrowed 2002-2007 and widened since 2008. CONCLUSIONS: Prenatal support played an important role in improving black birth outcomes and eliminating the Dane County black-white infant mortality gap. Increasing socioeconomic disparities with worsening US economy since 2008 likely contributed to the gap's reappearance.

Venous thromboembolism during pregnancy.

Venous thromboembolism is the leading cause of maternal death in the United States. Pregnancy is a risk factor for deep venous thrombosis, and risk is further increased with a personal or family history of thrombosis or thrombophilia. Screening for thrombophilia is not recommended for the general population; however, testing for inherited or acquired thrombophilic conditions is recommended when personal or family history suggests increased risk. Factor V Leiden and prothrombin G20210A mutation are the most common inherited thrombophilias, and antiphospholipid antibody syndrome is the most important acquired defect. Clinical symptoms of deep venous thrombosis may be subtle and difficult to distinguish from gestational edema. Venous compression (Doppler) ultrasonography is the diagnostic test of choice. Pulmonary embolism typically presents postpartum with dyspnea and tachypnea. Multidetector-row (spiral) computed tomography is the test of choice for pulmonary embolism. Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy.

Prenatal ultrasound: a tale of two cities.

At the beginning of the 21st century, community-based physicians have a technology which is safe, noninvasive and relatively inexpensive. It allows immediate access to visual data inside the body for the evaluation of health and disease. Prenatal ultrasound is vital for the efficient provision of preventive care even in community health centers, where physicians may not be the delivering physicians. To assess the frequency of this diagnostic technology, a longitudinal study of 36 months tabulated prenatal ultrasound scans performed in two community-based offices providing generalist healthcare from 2001 through 2003. Between the two offices, 68,938 patients were seen, 679 deliveries were attended and 1,286 medically indicated prenatal ultrasound examinations were performed. Prenatal ultrasound scans--compared to other common office procedures, such as electrocardiograms, chest radiographs, circumcisions, blood sugar checks, Papanicolaous and colposcopies--emerged as one of the most frequently preformed diagnostic tests in the office. Based on these results, medical educators preparing generalist physicians for community medicine may want to consider some training in prenatal ultrasound. Future research can confirm the generalizability of the findings of this pilot study in two urban health centers.

A molar pregnancy detected by following beta-human chorionic gonadotropin levels after a first trimester loss.

This case report summarizes the sequence of events that led to the detection of a molar pregnancy missed by ultrasound and initial pathology examinations. This patient illustrates that following serial quantitative beta-human chorionic gonadotropin (B-hCG) levels after spontaneous, therapeutic, and elective abortions will help detect potentially life-threatening molar and ectopic pregnancies. Further research is needed to determine the optimal frequency of B-hCG testing. For now, maternity care providers can follow the American College of Obstetrics and Gynecology recommendation that abnormal bleeding for more than 6 weeks after any pregnancy should be evaluated with B-hCG testing. Earlier testing may be considered.

The Advanced Life Support in Obstetrics (ALSO) program: fourteen years of progress.

BACKGROUND: The Advanced Life Support in Obstetrics (ALSO) program is a highly structured, evidence-based, two-day course designed to provide healthcare professionals with the knowledge and skills to manage the emergency conditions that can occur during childbirth. OBJECTIVES: To document the number of ALSO-trained clinicians and instructors in the United States and internationally and to promote ALSO training among prehospital and disaster medicine professionals. METHODS: Records maintained by the American Academy of Family Physicians (AAFP) for each country where ALSO is taught were reviewed for: (1) the years and locations of the ALSO courses; (2) the number of ALSO-trained caregivers; and (3) the number of ALSO instructors. RESULTS: Between 1991 and 2005, 54,071 ALSO-trained caregivers and 2,251 instructors have completed provider and instructor ALSO courses in 25 countries. Of these, 17,755 caregivers and 1,220 instructors are from outside the United States. CONCLUSION: The ALSO program is a popular, multi-disciplinary course for preparing maternity caregivers to manage obstetric emergencies. Limited evidence suggests it can be effective and efficient in enhancing the knowledge and skills of prehospital and disaster medicine clinicians. Hong Kong provides a model in which emergency physicians have taken the lead in promoting the ALSO course. As the ALSO program expands, additional research is needed to assess its impact on educational and health outcomes.

Colposcopy: an evidence-based update.

Colposcopy is a diagnostic procedure, most commonly used in the diagnosis of cervical intraepithelial neoplasia and lower genital tract carcinoma. In this article, evidence-based management strategies are updated with discussion of the 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines. Practice management issues include methods to improve cervical cancer screening rates, coding and billing, and telemedicine. Textbooks, CD-ROMs, and courses are listed for new learners and experienced providers who want to update and sharpen their skills.

Family medicine in Cuba: community-oriented primary care and complementary and alternative medicine.

Family physicians in Cuba and the United States operate within very different health systems. Cuba's health system is notable for achieving developed country health outcomes despite a developing country economy. The authors of this study traveled to Cuba and reviewed the literature to investigate which practices of Cuban family physicians might be applicable for US family physicians wishing to learn from the Cuban experience. We found that community-oriented primary care (COPC) and complementary and alternative medicine (CAM) are well developed within the Cuban medical system. Because COPC and CAM are already recommended by US family medicine professional bodies, US family physicians may want to learn from the Cuban experience and perhaps incorporate elements into their individual practices.

Advanced life support in obstetrics in Ecuador: teaching the teachers.

The advanced life support in obstetrics (ALSO) course is designed to help maternity care providers prepare for obstetrical emergencies. A team of 12 US physicians and a medical interpreter recently taught the ALSO course in Ecuador, with the goal of addressing Ecuador's high maternal and infant mortality rates. To have a greater impact, a teach-the-teacher model was used so that Ecuadorian physicians can now hold their own ALSO courses. In the process of implementing the courses, valuable lessons were learned which can be applied to future ALSO courses in developing countries and in the United States.

Teaching prenatal ultrasound to family medicine residents.

Prenatal ultrasound is a powerful diagnostic tool, but there has been little research on how to teach ultrasound to family physicians. The available evidence supports teaching through didactics followed by supervised scanning. Didactic topics include physics and machine usage, indications, fetal biometry, anatomic survey, practice management, ethical issues, and resources. Supervised scanning reinforces the didactic components of training. A "hand-on-hand" supervised scanning technique is recommended for the transmission of psychomotor skills in these sessions. Curricula for teaching ultrasound should include information on which residents will be taught prenatal ultrasound, who will teach them, how to create time for learning ultrasound skills, and how to test for competency. The literature suggests that competency can be achieved within 25-50 supervised scans. Measures of competency include examination and qualitative analysis of scanning. Competency-based testing needs further development because no uniform standards have been established.