Obstetric anesthesia: a national survey.

To assess obstetric anesthesia in the United States, and to determine why more anesthesia personnel are not involved in this subspecialty, a questionnaire was sent to the heads of obstetric and anesthesia services in 1,200 hospitals. Both obstetric and anesthesia respondents agreed on several characteristics of obstetric anesthesia that inhibit more participation by anesthesia personnel. Among others, they identified that: the unpredictability of labor and delivery makes scheduling difficult; obstetricians tend to dictate type and timing of anesthesia; the risk of malpractice claims is increased for obstetric anesthesia; and, finally, larger obstetric services would make it more practical to provide anesthesia services. Regarding availability of personnel and procedures, obstetric units with less than 500 deliveries per year were considerably more under-staffed than the larger units in most areas studied. When general anesthesia was used for cesarean section in these units, it was provided by, or given under the direction of, an anesthesiologist only 44% of the time, whereas in the hospitals with more than 1,500 deliveries per year, an anesthesiologist was present 86% of the time. Likewise, in the small units, personnel classified as "others" were responsible for newborn resuscitation in 24% and 43% of instances after cesarean section and vaginal delivery, respectively. In the hospitals with more than 1,500 deliveries, comparable figures were 4% and 2%, respectively.

Focal vulvitis: a characteristic syndrome and cause of dyspareunia. Features, natural history, and management.

Based on the study of 67 affected women during a period of 15 years, we report the clinical features and natural history of focal vulvitis, a unique syndrome characterized by severe and persistent superficial dyspareunia and the presence of one to 11 (median three) minute, exquisitely tender areas of focal inflammation or ulceration on the mucosa of the vestibule. Three fourths of all lesions occur around the Bartholin gland ducts or between them posteriorly. Histopathologic study of tissues from seven patients has not shown a characteristic pattern of inflammation and fails to confirm a reported association between these lesions and the minor vestibular glands. These histologic studies and an in-depth clinical and epidemiologic investigation in nine patients, including microbiologic studies to identify infection by herpes simplex virus. Neisseria gonorrhoeae, Staphylococcus aureus, beta-hemolytic streptococci, Chlamydia trachomatis, mycoplasmas, Candida sp., trichomonads, or Mycobacterium sp., have not established an infectious etiology for this syndrome or evidence that it represents an unusual form of an autoimmune disease or Behcet's syndrome. Treatment with topical antimicrobial or corticosteroid creams, antibiotics given systemically, or cryotherapy has not been of demonstrable benefit. Approximately one half of patients eventually experience spontaneous remission but many appear to remain symptomatic indefinitely. Surgical excision of the hymenal ring and contiguous mucosa of the vestibule has brought relief and permitted resumption of sexual activity in seven of eight treated patients. While promising, operation should be reserved for patients who have experienced unremitting dyspareunia associated with the characteristic focal inflammatory lesions for at least 6 months.

Evaluation of intra-amniotic administration of 120 gm of urea with 5 mg of prostaglandin F2 alpha for midtrimester termination of pregnancy between 20 and 24 weeks' gestation.

The occasional finding of signs of life in fetuses delivered following intra-amniotic administration of 80 gm of urea and 5 mg of prostaglandin F2 alpha suggested that the dose of 80 gm of urea was inadequate beyond the nineteenth week. Protocol modifications were made, and the metabolic effects of intra-amniotic administration of 120 gm of urea used beyond the nineteenth week were compared to those of the 80 gm dose of urea used in patients prior to the twentieth week. The 120 gm urea dose was well tolerated. The peak blood urea nitrogen (at 4 hours after instillation) was higher with 120 gm of urea (36.4 mg/dl) than with 80 gm of urea (24.6 mg/dl) (p less than 0.05). Small decreases in the platelet count (14% of control) and serum fibrinogen (11%), sodium (2%), potassium (7%), and carbon dioxide (11%) levels and a 5% increase in peak serum osmolality were found. Following the change in protocol, fetal heart activity has been absent at 3 hours after instillation in all cases less than 24 weeks from the last menstrual period.

Outpatient therapy: success and failure with dysplasia and carcinoma in situ.

Between 1971 and 1980, 385 patients with colposcopic biopsy-proved cervical intraepithelial neoplasia were treated by either the colposcopist or the referring physician by means of cryosurgery, electrocautery, or biopsy excision. All were observed for a minimum of 1 year, 220 between 1 and 2 years, 50 between 3 and 4 years, and 23 for 4 or more years. Therapy failed in 29 in the first year ("failures" proved by tissue examination). The failure rate among the 35 patients with carcinoma in situ was 20%, a rate significantly higher than that seen in 108 patients with severe dysplasia (7 or 6.5%) or in mild and moderate dysplasia (4.4% and 8.5%, respectively). There were 10 "recurrences" seen among those observed for more than 1 year after treatment. In eight instances the histologic severity of the recurrence was more severe than that of the original lesion. The comparative efficacy of cryosurgery and electrocautery and the success and failure rates for the colposcopists and other therapists who had not viewed the lesions prior to therapy are examined.

Resident training goals in obstetrics and gynecology for the 1980's. Presidential address.

Residency training goals and manpower needs in the 1980's and beyond should bear a consistent relationship. Projections for supply and demand for obstetrics and gynecology and for those medical specialties with overlapping responsibilities, though fraught with uncertainties, suggest that currently approved training programs in obstetrics and gynecology will meet clinical manpower needs for 1990. The role of the obstetrician-gynecologist in the primary care of women will be increasingly shared with others and the trend in urban areas for task delegation seems likely to increase. The popular and pervasive emphasis on primary care carries with it the serious risk that the present shortage of qualified investigators may not be corrected in the next decade. This could seriously hamper our efforts to recruit new faculty and maintain quality in our training programs.