Examination of the adolescent patient.

Adolescent patients need knowledge and motivation to practice a healthy lifestyle. The provider of adolescent health care is uniquely qualified to provide factual health information and practical advice. Enlisting parental support for confidential adolescent health services usually is not problematic when parents and health care providers share common goals and responsibility. The health care provider must develop rapport to foster high-risk health behavior disclosure and must promote health messages that are stronger than those received from peers, television, movies, and magazines. Adolescents who elect to abstain from sexual activity need as much support as sexually active patients. Depression, substance abuse, and eating disorders must be recognized and treated. Preventative health care services for adolescents can be optimized when office staff understand the special needs of these young women. The physician's concerns regarding the health of adolescent patients will be welcomed by patients, their parents, and the community.

Obstetrical outcome in the very young adolescent.

PURPOSE AND METHODS: To determine the obstetrical outcome in adolescent pregnancies younger than 15 years of age. A retrospective multivariant analysis from January 1, 1985 to November 2, 1990 was undertaken. Comparison of all data sets were structured to analyze groups of patients < 15 years of age (group I) or 15 years of age (group II) at the time of delivery. RESULTS: No significant difference was observed between groups for mode of delivery, incidence of low birth weight delivery, or rates of preeclampsia. Group I was less likely to obtain adequate prenatal care. The development of preeclampsia and low birth weight delivery was positively correlated with late entry into prenatal care. Rates of preeclampsia for both groups exceed normal levels for this patient population. CONCLUSIONS: Efforts to promote utilization of the health care system are of paramount importance in the very young adolescent age group.

Medical practices of past graduates from one obstetric/gynecologic training program.

BACKGROUND: We sought to assess the practice patterns of former obstetric-gynecologic residents and to solicit their opinions regarding their educational experience and its clinical relevance to primary care. METHOD: In response to a Residency Review Committee mandate regarding past residents, a questionnaire was sent to all graduates from our residency program over a 17-year period (1979 to 1995). RESULTS: Of the 90 subjects who received the survey, 86 responded. Their ages ranged from 29 years to 49 years; 79 were married and 7 were single. Of the 75 in clinical practice, 71 practiced both obstetrics and gynecology and 13 had subspecialized. Most of the respondents (77/80) practiced in the mid-South. Of all graduates, 93% routinely provided primary care. In rating 20 major resident education categories, respondents gave high grades to training in surgically related areas. Only 4% rated their experience as fair or poor in the operative categories. CONCLUSION: Our graduates indicate satisfaction with their training, and their practices include primary care.

The effect of levenogesterol (Norplant) contraception on coagulation as measured by antithrombin-III levels.

PURPOSE: To determine the effect of contraception given immediately postpartum on coagulation as measured by antithrombin III. STUDY DESIGN: In this prospective study, parturients (n = 85) self selected three means of postpartum contraception: levenorgesterol implants, oral contraceptives, or a barrier method. RESULTS: Baseline coagulation was assessed by antithrombin-III levels in each of the 85 women within 48 hours of delivery (100.35 +/- 1.61%) and at one (109.1 +/- 1.89%) and six (105.51 +/- 1.71%) weeks postpartum. There was a rise in antithrombin-III after delivery but there were no significant differences between the groups. CONCLUSION: The levenorgesterol implant system did not cause a decrease in antithrombin-III in normal parturients.

PIP: The effect of postpartum Norplant implant use on coagulation factors was investigated in a prospective study conducted in Mississippi, US. 85 postpartum women were given a choice of 3 contraceptive methods: levonorgestrel implants (n = 25), oral contraceptives (n = 38), or a barrier method (n = 22). Antithrombin-III (AT-III) levels were measured on the day of discharge from the hospital after delivery, 7 days after delivery, and 6 weeks after delivery. There was no significant difference between groups in the initial AT-III level (mean, 100.35 +or- 1.61%). At the end of the first postpartum week, AT-III levels rose significantly to 109.1 +or- 1.89%, but again, there were no significant differences according to contraceptive method. By the 6-week follow-up, AT-III levels had stabilized at a mean of 105.51 +or- 1.71%, with no significant between-group differences. AT-III levels in pill users declined more markedly between the first and sixth postpartum weeks than those in the 2 other groups. These findings indicate that subdermal implant use does not affect coagulation, and these devices can be inserted safely during the postpartum period.

Order of rotation in third-year clerkships. Influence on academic performance.

OBJECTIVE: To determine if student performance during the third-year clerkship is influenced by the order of departmental rotation. STUDY DESIGN: In this retrospective, descriptive study, the National Board of Medical Examiners (NBME) scores, departmental examination grade (DE) and final block grade (FG) were stratified into six segments based on the order of block time in obstetrics-gynecology, pediatrics, psychiatry, internal medicine, surgery and family medicine. Consistency was validated by comparing these performance criteria from 1988 to 1992. RESULTS: When all six clerkships were assessed by year, there was no uniform trend of improved performance over time. In the obstetrics-gynecology block, however, NBME scores and FGs were highest for students assigned to the fifth and sixth rotation as compared to the first two groups (P < .02). No such trend was noted with the departmental written examination. In surgery, DE and FG were always lower in the first rotation (P = .0001). Psychiatry DE scores were significantly higher on the second or third blocks as compared to the fifth and sixth rotation positions (P < .001). Students had a higher FG in pediatrics when the sixth position was compared to the second block (P = .02), but the DE grades and NBME scores were not altered by rotational schema. In family medicine and internal medicine, no effect of rotation was noted. CONCLUSION: Third-year clerks tended to have higher NBME scores and FGs in obstetrics-gynecology if they selected this rotation later in the academic year. Surgery DEs and FGs were lowest if selected first in the academic year. There was no similar trend in other nonsurgical specialties. These data suggest that prior clinical rotations positively influence student performance in obstetrics-gynecology.

Care of the woman who has been raped.

There is an escalating epidemic of rape in the United States. All victims have psychological injury, and over half sustain physical injury in the assault. The response of health care professionals to these women demands sensitivity and expertise. A focused history and well-documented physical examination are crucial. Consistency among the history and physical findings, objective findings of recent trauma, and evidence of recent sexual activity are critical. Compliance with forensic protocols ensures that this information will be available for criminal proceedings. Long-term follow-up care and psychological support are necessary for the woman to make the transition from victim to survivor.

PIP: This review discusses the care of postmenarchal women raped by men in the US. A woman who is a victim of sexual assault suffers psychological injury in addition to physical harm. Thus, the response of health care professionals to these women demands sensitivity and expertise. The first step involves a medical evaluation of the patient. Informed consent must be obtained before the physical and forensic examination of an assault victim. A focused history and well-documented physical examination are crucial since it serves as a guide in the medico-legal examination. In addition, consistency among the history and physical findings, objective findings of recent trauma, and evidence of recent sexual activity are critical. Compliance with forensic protocols ensures that this information will be available in criminal proceedings. Moreover, long-term follow-up care and psychological support are necessary for women to make the transition from victim to survivor.

Sexual assault.

Sexual assault continues to represent the most rapidly growing violent crime in America. Vital legal reforms are underway, but statistics prove a persistent rise in rape incidence with poor conviction rates. This knowledge, along with the vast multitude of emotional sequelae of rape and self-perceived inferior legal status of women, results in a high percentage of unreported cases. It is imperative that health care providers understand the horrific nature of sexual assault in order to provide appropriate care. All medical care personnel involved in the care of potential rape victims should be briefed in historic and modern legalities of sexual assault. Specific training in emergent and chronic care, both physical and mental, in conjunction with an understanding of rape legislation is vital if health care professionals are to appropriately care for victims of rape.

Extraovarian Brenner tumor.

Extraovarian Brenner tumors are exceedingly rare. Only four cases of extragonadal tumors have been reported in women, and three cases in men. We describe an extraovarian Brenner tumor discovered incidentally in the broad ligament at vaginal hysterectomy.

Treatment of unruptured ectopic pregnancy with methotrexate.

Medical treatment is appropriate for patients with an unruptured tubal pregnancy who wish to preserve fertility or have medical problems associated with increased risk of anesthesia. Patients with persistent trophoblast after conservative surgery should be treated with methotrexate rather than undergo a repeat surgery. All nine of our patients with ectopic pregnancies who were treated with MTX were cured with one course of therapy. Little toxicity was observed and subsequent reproductive performance after medical treatment was comparable to that reported in the literature. Direct injection of MTX into an ectopic pregnancy under sonographic control provided an option for treatment which required little anesthesia, reduced the amount of drug and allowed the treatment of a gestation which would otherwise not be considered a candidate for the 3 dose intramuscular injection protocol (see Table 3).

Gonadotropin-releasing hormone agonist (leuprolide acetate) induced ovarian hyperstimulation syndrome in a woman undergoing intermittent hemodialysis.

Moderate ovarian hyperstimulation syndrome occurred after LA was administered to control menorrhagia in an anephric woman who required hemodialysis. We postulate that women who require dialysis may be at special risk for the development of this syndrome.

Pregnancy after successful vaginoplasty and cervical stenting for partial atresia of the cervix.

We previously reported surgical correction of vaginal agenesis and partial cervical atresia in an 11-year-old girl with amenorrhea and a pelvic mass. This patient, the subject of this report, conceived 7 years later and delivered at term. An abdominal cerclage was placed at 12 weeks' gestation to protect the cervix, and delivery was by cesarean.

Stripping membranes at term: can it safely reduce the incidence of post-term pregnancies?

Membrane stripping has been used clinically for many years but has not been well studied. An investigation was undertaken to determine whether weekly membrane stripping beginning at 38 weeks could safely reduce post-term pregnancies. One hundred eighty patients with firm gestational dates were randomized to either a treatment or control group. Control subjects received a gentle cervicovaginal examination each week to assess Bishop scores, whereas the treatment group also underwent weekly stripping of membranes. Women who received treatment had earlier delivery (mean +/- SEM 8.60 +/- 0.74 versus 15.14 +/- 0.83 days; P less than .0001) and fewer post-term deliveries than those in the control group (three versus 14; P less than .004). The reduction of post-term pregnancies was most notable in nulliparous women with unfavorable Bishop scores. Complications were similar in both groups. Membrane stripping was safe and was associated with earlier delivery and a decreased incidence of post-term gestation.