Obstetrics and gynecology residencies: education in preventive and primary health care for women.

OBJECTIVE: To test the hypothesis that the Residency Review Committee program requirements for obstetrics and gynecology residencies, when properly followed, will result in residents being educated in preventive and primary ambulatory health care for women during their residency training program as specialists in obstetrics and gynecology. METHODS: The 60 requisite residency training competencies identified as essential to educate generalist physicians, and viewed by some educators as a benchmarking standard, each were evaluated to determine whether residents in obstetrics and gynecology are now being educated in each of these areas. The answer was considered affirmative if any of the following pertained: 1) the Residency Review Committee program requirements indicate that the competency "must" or "should" be taught, 2) the Residency Review Committee requests numerical verification related to the competency on the accreditation review application, or 3) by virtue of a specific rotation required by the Residency Review Committee it can be assumed that the resident will be educated in the competency. To make our assessment, we identified and listed the section of the Residency Review Committee for Obstetrics-Gynecology program requirements, which, when properly followed, would result in education in the particular competency. RESULTS: Fifty-seven of the 60 competencies were considered applicable to obstetrician-gynecologists (care of infants, care of children, and infant/child preventive care were not), and residents in obstetrics and gynecology were found to be educated in 54 (95%). CONCLUSION: During their residency training programs as specialists in obstetrics and gynecology, residents are being educated to be able to be providers of preventive and ambulatory primary health care for women.

Placental transfer of milrinone in the nonhuman primate (baboon).

Milrinone is an inotropic agent for short-term intravenous use in the management of congestive heart failure. The purpose of this article is to question the previously reported lack of transplacental transfer of milrinone. Loading and continuous intravenous doses, considered to be therapeutic in humans, were administered to four near-term baboons. Transplacental passage was documented, with a maternal/fetal serum ratio of approximately 4:1 found during the 3 hours of infusion.

A statewide, toll-free telephone service to improve obstetric care.

The University of Oklahoma Health Sciences Center began in 1993 to provide a statewide, toll-free telephone service for pregnancy counseling to primary care physicians. The service was available 24 hours each day, and responses were made by the on-call maternal-fetal medicine specialist. This report summarizes our first full year of operation. Inquiries came from 34 (63%) of the state's 54 counties having physicians who provide obstetric care. One hundred twenty-eight physicians made 523 inquiries (median 3, range 1-15). Information was sought about prenatal genetic disorders, risks from drugs, exposure to infection, environmental hazards, and active obstetric or medical complications. Funds from targeted ultrasounds, genetic amniocenteses, more detailed counselling, and maternal transfers provided support for this expanding educational resource.

Intravenous administration of cocaine stimulates gravid baboon myometrium in the last third of gestation.

OBJECTIVE: The hypothesis for this investigation was that intravenous cocaine results in a dose-dependent increase in myometrial activity of the unanesthetized, chronically instrumented gravid nonhuman primate. STUDY DESIGN: Seven chronically instrumented gravid baboons were individually caged in an environment of 14 hours of light and 10 hours of darkness. Maternal femoral artery and vein catheters and three pairs of myometrial electromyographic wires were surgically placed at 90 to 121 days' gestation (term 180 days). At least 5 days after surgery, bolus intravenous cocaine hydrochloride doses of 0.05, 0.1, 0.3, 0.5, and 1.0 mg/kg maternal body weight were administered according to various schedules. Myometrial activity was analyzed by quantifying the myometrial electromyographic envelope data as the power spectral density window of contraction activity and as the total area under the rectified electromyographic voltage signal (i.e., total electromyographic activity) before and during the experimental period. RESULTS: Myometrial contraction activity increased after the 0.3 mg/kg dose (p < 0.01), the 0.5 mg/kg dose (p < 0.005), and the 1.0 mg/kg dose (p = 0.07) compared with baseline. The total myometrial electromyographic activity also increased as the cocaine dose increased. CONCLUSION: Intravenous cocaine results in increased myometrial contractions in the gravid baboon during the latter third of pregnancy.

Effects of labetalol on uterine blood flow and cardiovascular hemodynamics in the hypertensive gravid baboon.

OBJECTIVE: The purpose of this study was to investigate the effects of labetalol on uterine blood flow and cardiovascular parameters in acutely instrumented, hypertensive gravid baboons. STUDY DESIGN: During the latter half of pregnancy six gravid baboons were acutely instrumented, with ultrasonic flow probes placed on ipsilateral, external iliac, and uterine arteries and a flow-directed pulmonary artery catheter in the pulmonary artery. After a stable arterial pressure baseline was obtained, norepinephrine was infused to increase mean arterial pressure by at least 20%. A 20-minute hypertensive steady state was obtained. Labetalol at 0.5 and 1.0 mg/kg was randomly infused, followed by a 2.0 mg/kg dose, each over 1 minute. A 20-minute recovery period followed every labetalol infusion, allowing the hypertensive steady state to reestablish. External iliac and uterine blood flow measurements were continuously recorded during the baseline and experimental trials. Mean arterial blood pressure, heart rate, pulmonary artery and capillary wedge pressure, central venous pressure, and cardiac output were obtained at 5, 10, and 15 minutes during each steady state and after each labetalol infusion. RESULTS: Labetalol at all dosages significantly reduced the mean arterial pressure and the systemic vascular resistance at 1.0 and 2.0 mg/kg. External iliac blood flow was not consistently significantly reduced; however, uterine blood flow was significantly reduced after the 1.0 and 2.0 mg/kg labetalol dosages (p < 0.05). Although uterine vascular resistance tended to increase after the 1.0 and 2.0 mg/kg doses, statistical significance was not achieved. CONCLUSION: Low-dose labetalol (0.5 mg/kg) significantly reduces the pharmacologic hypertensive gravid baboon's mean arterial blood pressure without adversely affecting uterine blood flow.

Different patterns of myometrial activity and 24-h rhythms in myometrial contractility in the gravid baboon during the second half of pregnancy.

Two clearly distinct epochs of myometrial contractility were observed in 13 pregnant baboons when recorded either as intraamniotic pressure (IAP) or myometrial electromyogram (EMG). Contractures, epochs lasting longer than 3 min, were the characteristic form of myometrial activity throughout pregnancy. Contractures generated only small increases in IAP. Short-lived contractions, generating larger increases in IAP, were characteristic of labor and delivery. Power spectral analysis of IAP and myometrial EMG activity proved to be an effective means whereby periods when the myometrium was in the contractures or contractions mode could be easily distinguished. Concomitantly recorded maternal intraabdominal temperature showed significant 24-h variations. When myometrial activity switched from low-amplitude, long-lasting regular contractures of pregnancy to contractions, the switch always occurred around the onset of darkness. Five baboons went into spontaneous labor, 3 prematurely and 2 at term. In these animals the switch from contractures to contractions occurred for several nights before delivery. The recurrence and timing of the switch from contractures to contractions for several nights before delivery were similar to the pattern we and others have observed in the pregnant rhesus monkey. The presence of 24-h periodicity in the patterns of specific types of myometrial activity in another nonhuman primate lends support to the view that similar 24-h patterns of myometrial activity may occur in pregnant women.

Effect of intravenous cocaine on uterine blood flow in the gravid baboon.

Cocaine abuse during pregnancy is associated with adverse perinatal outcome, believed to be a result of potent vasoconstrictive effects that cocaine has on the maternal cardiovascular system. The direct effect of cocaine on the pregnant, nonhuman primates' uterine vasculature in vivo has not been examined. We investigated the effects of intravenous cocaine on maternal arterial blood pressure, uterine blood flow, and uterine vascular resistance in four unanesthetized, chronically instrumented pregnant baboons. Baboons were instrumented during the latter half of pregnancy, placing an ultrasonic flow probe around one uterine artery and catheters in the maternal inferior vena cava and aorta. Bolus intravenous cocaine hydrochloride doses of 0.05 mg/kg, 0.1 mg/kg, and 0.3 mg/kg by maternal weight were infused 30 minutes apart at least 5 days after surgical instrumentation. The maternal blood pressure rose 7.3% and 12.0% after the 0.1 mg/kg and 0.3 mg/kg cocaine infusions, respectively, and the uterine blood flow fell in a dose-dependent fashion 13.1% and 22.7%. Plasma norepinephrine levels rose in response to the 0.3 mg/kg cocaine infusion. These studies show that low doses of cocaine significantly reduce uterine blood flow in the pregnant baboon in a dose-dependent manner by increasing uterine vascular resistance.

A method to limit working hours and reduce sleep deprivation in an obstetrics and gynecology residency program.

We adopted a system in which a team of residents works at night and all other residents work during the day. This system allows us to limit resident work time to 75 hours a week. Residents never work more than 24 hours in a 36-hour period, and usually no more than 13 hours in a 24-hour period. All residents have 1 day off each week and at least one weekend in three off. We did not have to obtain additional residents or ancillary personnel, and residents have the same exposure to operative cases as they did under the old system. The system can work with as few as 12 residents. Sleep deprivation is reduced, resident morale is improved, and resident learning, as reflected by in-training examinations, appears to be enhanced.

Conceptional age, menstrual age, and ultrasound age: a second-trimester comparison of pregnancies of known conception date with pregnancies dated from the last menstrual period.

Ultrasound dating-curve analysis was performed for the biparietal diameter, mean head diameter, and mean trunk diameter in individual singletons, twins, and triplets from in vitro fertilization (IVF) pregnancies and pregnancies with ultrasonographic determination of ovulation. Linear growth was found for all parameters prior to 28 weeks' conceptional age. No differences were observed among singletons, twins, or triplets. Using linear equations, no significant difference was found in systematic errors between pregnancies with a known date of conception and pregnancies dated from the last menstrual period (LMP). Pregnancies with reliable LMPs had only a slight and nonsignificant increase in random errors when compared with pregnancies from IVF. Current polynomial dating equations produced considerable systematic and random errors as well as errors related to fetal growth. Acceptable results were obtained with a new linear equation based on two examinations. We conclude that gestational age based on good menstrual records supported by a pelvic examination in the first trimester may be more reliable than even the best ultrasound method for dating.

Format of an obstetrics and gynecology journal club and four years' experience.

Departmental journal clubs have experienced varied degrees of success and longevity. Although a high degree of enthusiasm is difficult to maintain, clear objectives are key factors that encourage active participation. In this report we present a journal club format that has demonstrated popularity and 4 years of longevity. On the basis of this experience, we believe a journal club forum offers medical students and residents the optimal opportunity to learn an approach to critical reading of medical reports. In addition, they gain understanding of experimental design and research protocols and ultimately acquire knowledge of the current medical literature.

Effects of amrinone and dopamine on uterine blood flow and vascular responses in the gravid baboon.

Amrinone is a bipyridine derivative with positive inotropic and vasodilator properties. We investigated its effects on uterine and iliac artery blood flow, blood pressure, and heart rate in 10 acutely instrumented gravid baboons. Amrinone was compared with dopamine, infused systemically or regionally via the common iliac artery. When given intravenously at a constant rate of 40 micrograms/kg/min, amrinone produced a slight increase in iliac artery blood flow but did not significantly alter mean arterial pressure, heart rate, or uterine artery blood flow. Dopamine at an intravenous dose of 40 micrograms/kg/min produced a mean (+/- SD) 49.2% +/- 18.7% increase in mean arterial pressure (p less than 0.01) and a 84.2% +/- 56.1% increase in uterine vascular resistance (p less than 0.01), but caused no changes in heart rate, uterine artery blood flow, or iliac artery blood flow. Regional infusion of amrinone at the rate of 25 micrograms/kg/min produced a significant increase in iliac artery blood flow (p less than 0.01) without changing uterine artery blood flow, heart rate, or mean arterial pressure. Regional infusion of dopamine at concentrations of 2.5 to 25 micrograms/kg/min produced decreases in flow (p less than 0.01) and increases in resistance (p less than 0.01) in the uterine and iliac vascular beds. We conclude that amrinone dilates the vascular bed of the external iliac artery, but has no remarkable effect on the uterine vascular bed. Dopamine increases uterine vascular resistance and may impair uteroplacental perfusion.

Plasma fibronectin levels in normal pregnancy and pre-eclampsia: a preliminary report.

Fibronectin, a major component of the extracellular matrix and basement membranes throughout the body, is thought to maintain the integrity of both the reticulo-endothelial system and microvasculature. In this study, plasma fibronectin levels were assayed by nephelometry in nine pre-eclamptic gravid women, nine normotensive gravid women and ten non-gravid women. The mean plasma fibronectin level (+/-S.E.M.) in pre-eclamptic gravidas (1687 +/- 101 micrograms/ml) is significantly higher than that of either normotensive gravidae (1129 +/- 99 micrograms/ml) or non-gravid women (897 +/- 60 micrograms/ml). Although the mechanism for elevated levels of plasma fibronectin in patients with pre-eclampsia is not clear, it may serve as an early biochemical marker for this disorder.

The fetal-pelvic index as an indicator of fetal-pelvic disproportion: a preliminary report.

The objective of this study was to develop a standardized method of identifying fetal-pelvic disproportion by comparing fetal head and abdomen circumferences with the respective maternal pelvic inlet and midpelvis circumferences. Fetal ultrasound and maternal x-ray pelvimetry measurements were performed on 75 term pregnant women with indications for a trial of labor. By means of individually measured fetal and maternal pelvic diameters, circumferences of the fetal head, fetal abdomen, maternal pelvic inlet, and maternal midpelvis were computed. Based on four circumference differences between the fetus and maternal pelvis (fetal head--maternal pelvic inlet, fetal head--maternal midpelvis, fetal abdomen--maternal pelvic inlet, and fetal abdomen--maternal midpelvis), a fetal pelvic index number was derived from the sum of the two most positive values. Of the 27 patients requiring cesarean sections for failure to progress in labor, all but four had positive fetal pelvic index values (sensitivity = 85%). Of the 48 patients who were delivered vaginally, all but four had negative fetal pelvic index values (specificity = 92%).

Anesthesia for outpatient female sterilization.

PIP: This issue of the Bulletin deals with the principles of anesthesia for outpatient female sterilization with emphasis on techniques for laparoscopy and minilaparotomy. General anesthesia techniques provide analgesia, amnesia, and muscle relaxation and are particularly useful for managing the anxious patient. Disadvantages include increased expense, need for specialized equipment, and highly trained personnel, and delayed recovery. Complications, though relatively rare, can be life-threatening and include aspiration of stomach contents, hypoxia, hypercarbia, hypotension, hypertension, cardiac arrhythmias, cardiorespiratory arrest, and death. There is no single preferred technique of general anesthesia, athough most anesthetists employ methods that allow rapid recovery of faculties, enabling the patient to be discharged soon after surgery. To accomplish this end, light anesthesia with sodium thiopental induction and nitrous oxide maintenance is often used. Short duration muscle relaxation with an agent such as succinylcholine supplements this technique. Other techniques include light anesthesia with inhalational anesthetic agents and the use of intravenous ketamine. Local anesthesia augmented by systemic and/or inhalational analgesia is supplanting general anesthesia techniques for laparoscopy in many locales. This approach is also particularly well-suited for minilaparotomy in developing countries, where it has achieved its greatest popularity. The local technique carries with it reduced morbidity and mortality but may not entirely relieve discomfort. The primary danger of local anesthesia is respiratory depression due to excessive narcosis and sedation. The operator must be alert to the action of the drugs and should always use the minimal effective dose. Although toxicity due to overdosage with local anesthetic drugs is occasionally experienced, allergic reactions to the amide-linkage drugs such as lidocaine or bupivacaine are exceedingly rare. For outpatient laparoscopy or minilaparotomy, local anesthesia with proper preoperative counselling and premedication should provide adequate relief of pain and is the method of choice, unless the patient cannot be examined awake or is totally uncooperative. The decision to utilize either general or local anesthesia should be made by the patient after thorough counselling by the surgical team. In many cases, the circumstances of the surgical environment will dictate the choice, but patient comfort and safety should always be the goal.^ieng

Bacterial endocarditis in pregnancy.

Bacterial endocarditis in pregnancy is uncommon but serious. A case is presented of subacute bacterial endocarditis with severe aortic and mitral valvular insufficiency and with associated multiple systemic and cerebral emboli. Therapy consisted of cesarean section at 33 weeks' gestation followed by aortic and mitral valve replacement; there was no maternal or fetal mortality. The English literature on infective endocarditis complicating pregnancy is reviewed.

Value of serial sonography in the in utero detection of duodenal atresia.

Duodenal atresia can be fatal unless promptly diagnosed and treated surgically. Death occurs in the newborn secondary to emesis, aspiration, and electrolyte imbalance. Serial ultrasound scans were obtained for 2 patients, but duodenal atresia was not detected until 29 and 32 weeks' gestation, respectively. With prior knowledge of an infant with Down syndrome and duodenal atresia, management of fetal distress with subsequent operative delivery can be altered. Early prenatal diagnosis by ultrasonography and subsequent amniocentesis plays an important role in the antenatal and postpartum counseling and management of these patients and neonates.

Sterilization-attributable deaths in bangladesh.

From January 1, 1979, to March 31, 1980, 20 sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. The leading cause of death from tubectomy was anesthesia overdose and from vasectomy, scrotal infection. Overall. The sterilization-attributable death-to-case rate was 21.3 deaths/100,000 procedures. The health impact of contraceptive sterilization is highly favorable: for each 100,000 tubectomies performed, the cost in lives (19) is offset by approximately 1015 maternal deaths averted.

PIP: Over the January 1, 1979 to March 31, 1980 period sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. These deaths were identified primarily through government records of compensation to families of deceased sterilization patients. This list was augmented by deaths reported from clinics of the Bangladesh Association for Voluntary Sterilization, detected through a prospective study of sterilization in Bangladesh, and identified by interviews with government family planning officials. A sterilization-associated death was defined as the death of a patient from any cause occurring within 42 days of tubal ligation or vasectomy. Death-to-case rates for vasectomy and tubal ligation were calculated for each month with 95% confidence intervals based on the Poisson distribution. 31 sterilization-associated deaths were identified over the study period. 28 of these were sterilization attributable and 3 were not. The mean age of the 21 women was 30.6 years, and their mean parity was 4.8. The mean age of the 7 vasectomy patients was 37.0 years. Abdominal Pomeroy method of tubal ligation was the only female sterilization technique used. 2 temporal clusters of sterilization attributable deaths occurred during the study. The 1st was a cluster of 5 deaths from tubal ligation performed in June 1979. 3 of these operations took place on June 5, 1979 but in different facilities. 1 factor common to each of these operations was the unseasonably hot weather. The 2nd temporal cluster consisted of 3 deaths after vasectomy in July 1979. 2 men from the same village died from scrotal infections after vasectomy on July 19, 1979 by the same surgeon at a single clinic. A similar death occurred earlier the same month. Another patient of the same surgeon and clinic associated with the deaths after operation on July 19 died from scrotal infection in January 1980. 3 vasectomy deaths related to 1 surgeon in a single remote facility suggests a breach of sterile technique. This could not be confirmed as this clinic physician could not be interviewed. The death-to-case rate for all procedures combined was 21.3 deaths/100,000 procedures, with the rate for vasectomy 1.6 times higher than that for tubal ligation. Anesthesia overdosage was the leading cause of death attributed to tubal ligation with tetanus (24%), intraperitoneal hemorrhage (14%), and infection other than tetanus (5%) as other leading causes. 2 patients (10%) died from pulmonary embolism after tubal ligation; 1 (5%) died from each of the following: anaphylaxis from anti-tetanus serum, heat stroke, small bowel obstruction, and aspiration of vomitus. All 7 men died from scrotal infections after vasectomy. Improvement in anesthesia management and sterile technique can lower the death-to-case rate for contraceptive sterilization in 2 Divisions of Bangladesh.