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Maternal Child

Volume 5, No. 9, October 2007

Features

American College of Obstetricians and Gynecologists

Pelvic Organ Prolapse

Summary of Recommendations and Conclusions

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

• The only symptom specific to prolapse is the awareness of a vaginal bulge or protrusion. For all other pelvic symptoms, resolution with prolapse treatment cannot be assumed.
• Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse.
• Cadaveric fascia should not be used as graft material for abdominal sacral colpopexy because of a substantially higher risk of recurrent prolapse than with synthetic mesh.
• Stress-continent women with positive stress test results (prolapse reduced) are at higher risk for developing postoperative stress incontinence after prolapse repair alone compared with women with negative stress test results (prolapse reduced).
• For stress-continent women planning abdominal sacral colpopexy, regardless of the results of preoperative stress testing, the addition of the Burch procedure substantially reduces the likelihood of postoperative stress incontinence without increasing urgency symptoms or obstructed voiding.
• For women with positive prolapse reduction stress test results who are planning vaginal prolapse repair, TVT midurethral sling (rather than suburethral fascial plication) appears to offer better prevention from postoperative stress incontinence.

The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):

• Clinicians should discuss the option of pessary use with all women who have prolapse that warrants treatment based on symptoms. In particular, pessary use should be considered before surgical intervention in women with symptomatic prolapse.
• Alternative operations for uterine preservation in women with prolapse include uterosacral or sacrospinous ligament fixation by the vaginal approach, or sacral hysteropexy by the abdominal approach.
• Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse, particularly enter-ocele.
• Round ligament suspension is not effective in treating uterine or vaginal prolapse.
• Compared with vaginal sacrospinous ligament fixation, abdominal sacral colpopexy has less apical failure and less postoperative dyspareunia and stress incontinence, but is also associated with more complications.
• Transvaginal posterior colporrhaphy is recommended over transanal repair for posterior vaginal prolapse.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• Clinicians should discuss with women the potential risks and benefits in performing a prophylactic antiincontinence procedure at the time of prolapse repair.
• Women with prolapse who are asymptomatic or mildly symptomatic can be observed at regular intervals, unless new bothersome symptoms develop.
• For women who are at high risk for complications with reconstructive procedures and who no longer desire vaginal intercourse, colpocleisis can be offered.
• Cystoscopy should be performed intraoperatively to assess for bladder or ureteral damage after all prolapse or incontinence procedures during which the bladder or ureters may be at risk of injury.

Pelvic Organ Prolapse. ACOG Practice Bulletin No. 85. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:717-29.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766624

Management of Delivery of a Newborn With Meconium-Stained Amniotic Fluid

ABSTRACT: In accordance with the new guidelines from the American Academy of Pediatrics and the American Heart Association, all infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning. If meconium is present and the newborn is depressed, the clinician should intubate the trachea and suction meconium and other aspirated material from beneath the glottis.

Management of Delivery of a Newborn With Meconium-Stained Amniotic Fluid. ACOG Committee Opinion No. 379. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:73 http://www.acog.org/

ACOG Advises Against Cosmetic Vaginal Procedures: Safety and Efficacy Data

ABSTRACT: So-called "vaginal rejuvenation," "designer vaginoplasty," "revirgination," and "G-spot amplification" are vaginal surgical procedures being offered by some practitioners. These procedures are not medically indicated, and the safety and effectiveness of these procedures have not been documented. Clinicians who receive requests from patients for such procedures should discuss with the patient the reason for her request and perform an evaluation for any physical signs or symptoms that may indicate the need for surgical intervention. Women should be informed about the lack of data supporting the efficacy of these procedures and their potential complications, including infection, altered sensation, dyspareunia, adhesions, and scarring.

Vaginal "Rejuvenation" and Cosmetic Vaginal Procedures. ACOG Committee Opinion No. 378. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:737–8

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766626

Research Involving Women

ABSTRACT: All women should be presumed to be eligible for participation in clinical studies. The potential for pregnancy should not automatically exclude a woman from participating in a clinical study, although the use of contraception may be required for participation. Research objectives should not interfere with appropriate clinical management. If a conflict arises between medically appropriate patient care and research objectives, patient care should prevail. Consent of the pregnant woman alone is sufficient for most research. Pregnant women considering participation in a research study should determine the extent to which the father is to be involved in the process of informed consent and the decision.

Research Involving Women. ACOG Committee Opinion No. 377. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:731–6.

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American Family Physician**

Counseling Women About Mammography: Benefits vs. Harms

Clinical Scenario

A healthy 44-year-old woman with no family history of breast cancer has never had a mammogram. Her best friend was recently diagnosed with breast cancer.

Clinical Question

How should physicians counsel women about mammography?

Evidence-Based Answer

Studies of mammography show a 0.1 percent absolute reduction in breast cancer mortality with mammography. This means that if 2,000 women are offered mammography over 10 years, one woman would have her life prolonged, 10 healthy women would be treated unnecessarily for breast cancer, and about 200 women would undergo psychological distress and additional testing because of false-positive results. Women should be informed of the potential benefits and harms of mammography before undergoing the screening test at any age.

Authors' Conclusions: Screening likely reduces breast cancer mortality. Based on all trials, the reduction is 20 percent, but because the effect is lower in the highest-quality trials, a more reasonable estimate is a 15 percent relative risk reduction. Based on the risk level of women in these trials, the absolute risk reduction was 0.05 percent. Screening also leads to overdiagnosis and overtreatment, with an estimated 30 percent increase, or an absolute risk increase of 0.5 percent. This means that for every 2,000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if not screened, will be diagnosed with breast cancer and will be treated unnecessarily. Thus, it is not clear whether screening does more good than harm. Women invited to screening should be fully informed of benefits and harms.

Cochrane for Clinicians. Putting Evidence into Practice http://www.aafp.org/afp/20070901/cochrane.html

Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2006;(4):CD001877.

Guidelines on Screening for Fetal Chromosomal Abnormalities

Conclusion: Maternal age of 35 years should not be used as a cutoff for offering diagnostic testing. The decision to offer screening or invasive testing should not be based on age alone but should take into account patient preferences. The goal is to offer screening tests with high detection rates and low false-positive rates that also provide patients with the diagnostic options they might want to consider, with women being offered integrated or sequential screening earlier in their pregnancies. Other screening options will depend on CVS availability and physician expertise with nuchal translucency measurement.

ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities. Obstet Gynecol. 2007 Jan;109(1):217-27

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AHRQ

Risk of maternal and fetal labor and delivery complications increase as pregnancy progresses beyond 39 weeks of gestation
http://www.ahrq.gov/research/aug07/0807RA8.htm

Midwife practices vary greatly in compensation and employment structures
http://www.ahrq.gov/research/aug07/0807RA9.htm

Pediatricians recognize most overweight or obese children without using proportional weight curves
http://www.ahrq.gov/research/aug07/0807RA4.htm

 The gender of both the child and parent affect a child's participation during visits to the doctor
http://www.ahrq.gov/research/aug07/0807RA5.htm

 Pertussis vaccination in adults can be cost-effective depending on incidence rates
http://www.ahrq.gov/research/aug07/0807RA21.htm

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Ask A Librarian: Diane Cooper, M.S.L.S. / NIH

In Search of a Research Article?

The HSR Library- a branch of the NIH Library Provides Access to Many Online Journals

The HSR Library's online journal collection continues to expand. Select from these options to access one of the titles now available:

• Click on the NIH Library button that appears when searching PubMed®, Scopus™, Web of Science®, and other HSR Library databases.

OR

• Go to the  HSR Library website and select  Online Journals under Quick Links.
• OR
• Search the HSR Library  Online Catalog for a journal title.

If the Library does not subscribe to the journal you need, you may use the Order a Document form to request electronic copies of articles.
Links:

HSR Library http://hsrl.nihlibrary.nih.gov/

Online Journals http://hsrl.nihlibrary.nih.gov/ResearchTools/default.htm?srchType=OnlineJournals

Online Catalog http://hsrl.nihlibrary.nih.gov/ResearchTools/Online+Catalog.htm

Order a Document http://hsrl.nihlibrary.nih.gov/LibraryServices/Order+a+Document.htm

For more information or help using your online library resources, contact me at cooperd@mail.nih.gov

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Breastfeeding - Suzan Murphy, PIMC

A pacifier by any other name….*

Pacifiers have been around for a long time. A painting by Dureer in 1506 shows a baby with a homemade pacifier. Historians describe “sugar -teats” used in the 1800’s as being pieces of cloth tied around about a tablespoon of sugar or pieces of cloth soaked in honey. Today the choices are many – from utilitarian plastic to “orthodontic” to on-line jeweled designer styles with coordinating clips for obvious bling.

Pacifiers have helped many new families survive otherwise sleepless nights and endless car rides. They have been praised, condemned, associated with a variety of health issues, and most recently reduced risk of SIDs. Among the thoughts about pacifiers and how they reduce SIDs risk is that using a sleep/nap time pacifier may prevent a baby from rolling from a safer back to sleep position to the riskier side or tummy sleeping position. Another possibility is that intermittent sleep time sucking may help keep baby in a less risky arousal zone of sleep.

But what impact do pacifiers have on breastfeeding? Numerous studies have been done, most showing that regular use of pacifiers, especially in the early weeks and months, is associated with reduced duration. Speculations for how pacifiers disrupt lactation are that pacifiers:

• Reinforce ineffective sucking habits that reduce milk intake and lead to sore nipples
• Reduce of the baby’s “practice time” needed to strengthen the facial/oral cavity muscles that are necessary for effective nutritive suckling,
• Encourage the loss of the stimulation/instinctual response by the baby to pull the maternal nipple into the mouth. (the pacifier/nipple rubs the roof of the mouth, stimulating the suck, rather than the baby instinctually responding or remembering the need to suck the nipple in)

But not every breastfeeding baby is affected negatively by pacifiers. So, what can a provider tell a new family? Unfortunately there are no absolute answers, although avoiding pacifier use in the first several months is generally safer for supporting successful breastfeeding. Consider these possible scenarios:

1. At a 2 week newborn check, an exclusively breastfed baby is a few ounces below birth weight. Mom states that when the baby nurses it sometimes feels like “chomping at the breast” and the baby wants to linger at nursing, taking 45 minutes or more every couple hours. The baby has 5, maybe 6 diaper changes in 24 hours. They use a pacifier routinely. It will help to:

• Encourage the family to avoid using the pacifier for a while (4 or more weeks if possible). As the baby practices and gets better at nursing, the eating time will get shorter and the baby will go longer in between feeds. The baby will get more calories “practicing” too.
• Watch the baby nurse – apply firm, steady, finger-tip pressure to the bottom of the baby’s chin through several suck cycles – it will help to nudge the baby’s jaw open for a deeper latch and assure that the baby’s bottom lip is “popped” out and that the baby’s tongue is now covering the gum line to more effectively milk the nipple. The baby will get more to eat without hurting mom. Everyone will be happier.
• If short-term supplementation is needed, consider supplementing at the breast. This can be done by filling a syringe with formula or breast milk and attaching a 5 french feeding tube to the syringe. Then slip the end of the tube into the side of the baby’s mouth, as the baby is latched and sucking. Gently tap the syringe plunger to keep the supplement seeping into the feeding. It may be easier to use a smaller syringe and supplement on each side rather than a large, cumbersome syringe on one side. Or - it might be more effective to offer the bulk of the supplement at the end of the feeding, on the 2nd side. Use what is most comfortable for mom.
• It is ok to remind parents that talking to their baby and cuddling can be soothing, for everyone.

1. A family comes in for the one month well baby check. The baby has gained 2 pounds above birth weight. Parents are beyond exhausted. They describe constant nursing (every hour), 14 or more diaper changes in 24 hours, etc. This baby may have an overly abundant need to suck. Careful use of a pacifier might help meet the baby’s extra need to suck and give the parents a chance to sleep.

A little review about the “pacifier or not question” with full term, healthy, breastfeeding newborns:

• Avoid pacifiers until breastfeeding is well established. Establishing breastfeeding takes approximately 6-10 weeks.
• If there are problems with breastfeeding such as poor weight gain, sore nipples, repeat thrush, fretful nursing – pacifiers could be a key part of the problem.
• If the baby is thriving and the family is becoming overwhelmed, occasional use of a clean, safe pacifier could be a reasonable thing.
• If the family is eager to use a pacifier with their newborn, encourage them to watch and avoid pacifier use if there are problems with weight gain, fussy latch or nipple tenderness.

For more information, please consider:

American Academy of Pediatrics Policy Statement, The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. Vol. 116 Nov 5 November 2005, pp. 1245-55.

Murray EK, et al. Hospital Practices that Increase Breastfeeding Duration: Results from a Population-Based Study. Birth, 2007 Sep; 34(3): 202-11.

Scott JA, et al. Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics, 2006 Apr; 117(4): e646-55.

Hauck FR, et al. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics 2005 Nov; 116(5): e716-23, Epub 2005 Oct 10.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16216900

* Dummy - British, New Zealand, Australian term

Binki/binky - US commercial term, 1935

Soother - Canadian, Irish term

Other:

Medications: Information for Pregnant and Breastfeeding Women

As additional research is published, it is increasingly important that women talk with their doctor about the risks and benefits of taking prescription and over-the-counter drugs, vitamins, and dietary or herbal supplements before getting pregnant, during pregnancy, and while breastfeeding. A survey in the U.S. in 1998–99 found that 46% of women in their childbearing years took a prescription medicine during the previous week. So, it is important that we know more about which medications may be harmful during pregnancy and breastfeeding and which are not. http://www.cdc.gov/Features/MedicationUse/

Breastfeeding Trends and Updated National Health Objectives for Exclusive Breastfeeding

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CCC Corner Digest

Nicely laid out hard copy - A compact digest of last month’s CCC Corner

Highlights include

-Women's greater risk of dying after surgery: Transfusion-related immunosuppression

-Ann Bullock is the new Chief Clinical Consultant for Family Medicine

-Low-dose aspirin has benefits when used for prevention of pre-eclampsia

-Human papillomavirus, vaccines and women's health: questions and cautions

-Educate parents about new pre-adolescent vaccine recommendations

-Exposing the Great Bottled Water Scam

-Prevention of Deep Vein Thrombosis and Pulmonary Embolism  Practice Bulletin

-Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

-Various Implantable Contraceptives Equally Effective in Preventing Pregnancy

-Moderate morning sickness only partially responding to doxylamine and pyridoxine

-Don’t use Google, use Blackle instead and save 750 mega watts/hour per year

-Sex, Soap & Social Change - The Sabido Methodology

-Motor vehicle restraint use in American Indian children: Meaningful interventions

-Nausea and Vomiting in Pregnancy

-Study Supports HRT Use for Short Term, but Little Benefit in Older Women

-Group prenatal care reduces preterm births and increases breastfeeding initiation: RCT

-Evaluation of the pregnant patient for non-obstetric surgery

-Nursing education scholarship opportunities

-Decision Rules Useful for Selecting Women for Bone Mineral Density Testing

-Nausea and Vomiting of Pregnancy

-Chronic Renal Disease is Part of Primary Care

-Culture, context, and sexual risk among Northern Plains American Indian Youth

-Within eight years, 75% of adults will be obese or overweight

-APN scope of practice: colonoscopy?

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_08.pdf

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Domestic Violence – Denise Grenier, Rachel Locker

Domestic Violence Awareness Month: October

October is national Domestic Violence Awareness Month (DVAM). This is an annual observance sponsored by the National Coalition Against Domestic Violence. Every October across the country, domestic violence survivors and advocates, health care providers, elected officials, law enforcement and public safety personnel, business leaders, faith-based groups and many others are organizing and participating in domestic violence memorial activities, public education campaigns and community outreach events. If you would like more information about how your facility can participate in DVAM activities, visit www.ncadv.org

Successful public awareness campaigns for Domestic Violence Awareness Month (DVAM) consistently incorporate a unified message, graphic design and theme. By developing a comprehensive, integrated approach for DVAM, your organization can do more to raise awareness and visibility.

Frequency of message is crucial to success; in fact, some public relations experts contend that a message needs to be seen or heard at least seven times to be remembered. Varying the ways to deliver the message is important because individuals receive messages in different ways. For example, some people don’t read newspapers but do watch television, while others only listen to radio. So the more ways a message is conveyed, the better chance it will reach people. A comprehensive public awareness campaign delivers messages numerous times in numerous ways.

The most important part of choosing campaign components is to think about your audience. What components will work will depend completely on the audience you want to reach. It is important for your organization, or DVAM committee, to consider the target audience and the best ways to reach them. For example, teens may not see print ads in daily newspapers but do use some pages on of the web more frequently than some adults.

Possible components of a DVAM public awareness campaign include, but are not limited to:

Materials/Collateral

Collateral materials are anything that is paper based and can include: posters; palm cards; brochures; handbooks; fliers; bookmarks; calendars; fact sheets; postcards; and more. While the web has become a new and important way to reach many audiences, there is still a place for materials/collateral in public awareness efforts. Given the cost of design and printing, it is important to ensure that the materials you develop will reach your audience and that they deliver a clear message.

Merchandise

Merchandise is goods and products your organization gives away or sells. Most merchandise should display your message and/or contact information. The primary reason to give out merchandise is to promote your organization and contact information. Merchandise is also a good organizing tool because it provides your staff with something fun to leave with folks when they are out in the community.

Merchandise should be chosen based on the audience, and selected to have staying power. For example, a refrigerator magnet may have a longer life than a Frisbee. DVAM merchandise may include: purple ribbons (stick-on, pin-on, stickers, etc.); key chains; mouse pads; iPod holders; cell phone holders or other technology accessories; magnets; pens or pencils; t-shirts, hats or other apparel; and coffee mugs, cups, cup holders or other beverage accessories.

Advertising

Advertising is an important component of integrated public awareness campaigns because it allows organizations to reach new audiences. It can widen the circle to the larger community. Again, it is important to research what type of advertising would be most effective with your target audience. Types of advertising include:

• Outdoor advertising includes billboards, bus, subway, bus shelters, taxi cabs and other mass transit avenues. It is very effective for certain audiences. Most localities have a business that is responsible for selling outdoor advertising, and many will give nonprofit organizations a reduced rate.
• Broadcast advertising includes television and radio ads, which can be effective in reaching a target audience. Television ads can be expensive to produce and air, but don’t rule out trying to connect with an advertising agency that can develop spots pro bono, or a station that can produce and air them.
• Print ads can be effective in reaching certain audiences. Some newspapers will donate ad space free to nonprofit organizations.

Media

Media should always be an important component of your public awareness campaign and DVAM efforts. The next issue of Speaking Up will include media tips and sample materials.

Web

Keep in mind that your website, and those of allies, can be critical to your DVAM efforts. At a minimum, it should offer information on DVAM, how people can become involved, and activities happening during the month.

Don’t Put All Your Eggs in One Basket

Varying the avenues through which you convey messages is critical. In addition to the methods described above, there are ways to reach people through grassroots activism such as distributing materials and merchandise in the community. Grassroots efforts help ensure message saturation throughout a town, city, state, or region.

Volume 13 Issue 12 Family Violence Prevention Fund (on-line journal)

http://www.endabuse.org/

Health Cares About Domestic Violence Day: October 10, 2007

Health Cares About Domestic Violence Day (HCADV Day) is a nationally recognized awareness-raising day that takes place annually on the second Wednesday of October. Sponsored by the Family Violence Prevention Fund, HCADV Day aims to reach members of the healthcare community and educate them about the critical importance of assessing for domestic violence, as well as the long term health implications of domestic violence and lifetime exposure to violence.

Medical studies link long term effects of domestic violence and abuse with a myriad of health problems including smoking, diabetes, obesity, eating disorders and substance abuse. However, while doctors and nurses routinely screen for high blood pressure and high cholesterol, too few screen for domestic violence. This year we hope to support you in your efforts to prioritize routine assessment and intervention for domestic violence as part of a preventative healthcare strategy.

There are many ways that you can provide leadership in your community on HCADV Day and the Family Violence Prevention Fund is committed to helping you craft activities that best meet your interests, resources and time availability. Examples of past participation include hanging posters in waiting rooms that advertise local resource numbers, writing a newsletter article or an op-ed for a local paper, and inviting a speaker to conduct a brown bag lunch on domestic violence for staff.

You can learn more about HCADV Day, and obtain an organizing packet by visiting http://www.endabuse.org/hcadvd/

Health care providers are in a unique position to identify and assist victims of domestic violence. If you would like more information about how to improve the response of your facility to domestic violence visit www.endabuse.org/health

Sample hospital and clinic domestic violence policies and procedures and guidelines for providers can be found on the IHS Maternal and Child Health Domestic Violence website at

http://www.ihs.gov/MedicalPrograms/MCH/V/index.cfm

If you are a victim of domestic violence, call the National Domestic Violence Hotline at 1-800-799-SAFE (7233); 1-800-787-3224 (TTY).

Victim Advocates And Tribal Law Enforcement
October 17-18, 2007
Tucson, Arizona

Domestic Violence Expert Witness Institute
This 2 day, tuition free course provides hands-on, experiential  training on how to qualify as an expert witness on domestic violence  in tribal, state, and federal courts. Learn from some of Indian  Country's leading judges, attorneys, law enforcement officers, and  victim advocates how to prepare for trial, qualify as an expert  witness on domestic violence, and provide effective, persuasive  testimony.

Participants will have the opportunity to simulate taking the stand  and providing domestic violence expert witness testimony in small,  interactive breakout groups facilitated by legal, advocacy, and law  enforcement experts.
This is an advanced level professional course to assist experienced  victim advocates and law enforcement officers in qualifying and providing effective testimony as expert witnesses on domestic  violence against Native women. Registration is free. You can register  on-line at www.swclap.org   The deadline for registration is very soon. Preference is given to OVW grantees working with Native women.

Location of shelters and other assistance programs impacts the incidence of violence against homeless women

http://www.ahrq.gov/research/aug07/0807RA7.htm

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Elder Care News

Daily Back Pain May Have Adverse Health Effects in Elderly Women 

CONCLUSION: Daily back pain is associated with reduced quality of life, mobility and longevity and increased risk of coronary heart events. The adverse health effects of chronic back pain deserve greater recognition.

Zhu K, et al Association of back pain frequency with mortality, coronary heart events, mobility, and quality of life in elderly women. Spine. 2007 Aug 15;32(18):2012-8

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17700450

Estrogens May Modify Course of Parkinson's Disease in Women

CONCLUSIONS: Our results suggest that, in women, the development of symptomatic Parkinson's disease (PD). may be delayed by higher physiological striatal dopamine levels, possibly due to the activity of oestrogens. This could explain the epidemiological observations of a lower incidence and higher age at onset in women. Women also presented more often with tremor which, in turn, is associated with milder motor deterioration and striatal degeneration. Taken together, these findings suggest a more benign phenotype in women with PD.

Haaxma CA, et al Gender differences in Parkinson's disease. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):819-24 .

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17098842

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Family Planning

Advance Provision for Emergency Oral Contraception

Clinical Question

Does providing women with emergency oral contraception in advance for use as needed change pregnancy rates, frequency and timing of contraceptive use, risk of sexually transmitted infections, or sexual behavior?

Evidence-Based Answer

Providing oral emergency contraceptives in advance to fertile women for use after unprotected sexual intercourse (i.e., advance provision) does not affect pregnancy rates, condom use, sexually transmitted infection rates, or type of contraception used. Advance provision more than doubles the odds that a woman will use emergency contraception once and more than quadruples the odds that she will use it two or more times. It also reduces the time from sexual intercourse to emergency contraceptive use by about 15 hours.

Practice Pointers

To increase the availability and use of emergency contraception, the American College of Obstetricians and Gynecologists recommends one 1.5-mg dose of levonorgestrel (Plan B) or two 0.75-mg doses taken 12 to 24 hours apart for women who have had unprotected or inadequately protected sexual intercourse.1 This practice guideline supports advance provision. The American Academy of Pediatrics has a similar policy.2 The American Academy of Family Physicians does not specifically address advance provision.3 Although combined contraceptive pills and mifepristone (Mifeprex) can be used for emergency contraception, levonorgestrel is better tolerated, is more effective, and is approved by the U.S. Food and Drug Administration for over-the-counter distribution.

This Cochrane review included randomized controlled trials comparing advance provision with standard access to emergency contraception. The review included eight trials (6,389 total participants); five of the trials were conducted in the United States. Two studies had the power to show a difference in pregnancy rates. Control groups received general contraceptive counseling, information about emergency contraceptives, and/or access to emergency contraception on request. Most of the trials provided one to three courses of levonorgestrel and followed patients for three to 12 months.No study found a difference in pregnancy rates. Women who had advanced access to emergency contraception were about 2.5 times more likely to use it once and over four times more likely to use it two or more times. These women were also more likely to take the contraception an average of about 15 hours sooner after sexual intercourse than those in the control groups. The three studies that measured rates of sexually transmitted infections did not find a difference between groups. The five studies that reported on contraception use did not find differences between groups in the type or frequency of contraception use, including condom use. The six studies that compared frequency of unprotected sexual intercourse did not find a difference between groups. No adverse events were reported in any of the studies.

Although most women took the first contraceptive pill as directed, in one study, 17 percent of women who received advanced access took the second pill incorrectly. Therefore, single-dose regimens may be preferable. Providing women with advanced access to emergency contraception appears to be safe but does not reduce pregnancy rates on a population level. However, individual women might benefit because advance provision increases the speed and frequency of contraceptive use. Cochrane Briefs

Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007;(2):CD005497

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Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator

State trends on uninsured children

Child health coverage publication with state level trends for SCHIP and uninsured http://covertheuninsured.org/pdf/americasfuture.pdf

I would like you to particularly note these 3 key tables:SCHIP and the uninsured child Judith.Thierry@ihs.gov

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Frequently asked questions

What's the first course of action for this couple that's trying to conceive?

When assessing a couple who comes to the clinician complaining of inability to conceive after 1 year, which of the following statements best describes the first course of action?
-The female partner should be administered an ovulation stimulator to help promote conception

-A careful medical history of both partners should be taken to assess fertility risk factors

-The male partner should undergo tests to evaluate ejaculatory function and semen quality

-Both partners should provide blood samples to test for hormone levels

Go here to find out

http://www.medscape.com/viewarticle/559055_7

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Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant

October 2007 – Highlights

• Less is more: bracing is better than casting for fibular fractures
• Super-hero related injuries in children
• Influenza vaccination doses and schedules
• What does global eradication of the guinea worm have to do with the IHS?

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1007.doc

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Information Technology

Changes in workflow and tasks need to be assessed when introducing bar code medication administration into nurses' work

Bar code medication administration (BCMA) technology is being implemented slowly in hospitals across the United States. The BCMA technology consists of a medication network server and handheld devices that connect to medication administration record data through a wireless radio frequency link.

The software system enables users to document the administration of medications at the bedside or other points of care in real time. When hospitals introduce a new technology like BCMA, they should study how the technology will change nurses' workflow and tasks as well as the safe administration of medications, according to a new study.

A human factors engineer and a pharmacist observed use of BCMA technology during medication administrations to identify work system factors that affected nurses' use of and interaction with the technology when they administered medications. Nurses varied in the order in which they performed steps of the medication administration process, with a total of 18 different sequences identified.

Some of these sequences were contrary to hospital policy and the original design of the medication administration process. In addition, they could be considered workarounds or potentially unsafe acts, notes Pascale Carayon, Ph.D., of the University of Wisconsin-Madison. Interruptions and patient factors typically were precursors to medication errors and workarounds. For example, in 32 percent of observations, nurses were interrupted by the needs of patients and their families, nurses were interrupted by another provider or the nurse initiated an exchange with another provider, or interruptions were caused by equipment, technology, or medications.

Patient factors like unique patient populations (children, the disabled, or the critically ill) or contact isolation requirements also affected medication administration. These factors may not have been taken into consideration during the development of BCMA technology, note the researchers. Their study was supported by the Agency for Healthcare Research and Quality (HS14253).

Evaluation of nurse interaction with bar code medication administration technology in the work environment, by Dr. Carayon, Tosha B. Wetterneck, M.D., Ann Schoofs Hundt, Ph.D., and others, in the March 2007 Journal of Patient Safety 3(1), pp. 34-42.

http://www.ahrq.gov/research/aug07/0807RA18.htm

The Commonwealth Fund/Harvard University Fellowship in Minority Health Policy

Supported by The Commonwealth Fund, administered by the Minority Faculty Development Program at Harvard Medical School, this innovative fellowship is designed to prepare physicians, particularly minority physicians, for leadership roles in formulating and implementing public health policy and practice on a national, state, or community level.  Five one-year, degree-granting fellowships will be awarded per year.  Fellows will complete academic work leading to a Master of Public Health (MPH) degree at the Harvard School of Public Health, and, through additional program activities, gain experience in and understanding of major health issues facing minority, disadvantaged, and underserved populations. CFHUF also offers a Master of Public Administration (MPA) degree at John F. Kennedy School of Government to physicians possessing an MPH. It is expected that CFHUF will support the development of a cadre of leaders in minority health, well-trained academically and professionally in public health, health policy, health management, and clinical medicine, as well as actively committed to careers in public service.

 As Director of CFHUF, I seek your assistance in informing potential candidates of this opportunity to gain exposure to and understanding of major health issues facing minority and disadvantaged populations.  For application materials, information, and other training opportunities, please contact the CFHUF Program Coordinator by telephone at (617) 432-2922; by fax at 617-432-3834; or by e-mail at mfdp_cfhuf@hms.harvard.edu

Sincerely,    

Joan Y. Reede, M.D., M.P.H., M.S.

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International Health Update: Claire Wendland, Madison, WI

Prevention of Mother-to-Child HIV Transmission: An Innovative Program in Cameroon

For over twenty years, the Cameroon Baptist Convention Health Board (CBCHB) has set up and maintained primary health centers in the more isolated villages of rural Cameroon. Literate women selected by village leaders are trained as birth attendants who provide basic antenatal care, attend low-risk deliveries, and triage high-risk women to facilities with more resources. (At least in theory – many women don’t have adequate transportation to get to those facilities.) In a recent article in the Journal of Midwifery and Women’s Health, Benjamin Wanyu and colleagues describe the initiation of a program in which those birth attendants were also trained in services designed to reduce the prevention of mother-to-child HIV transmission. Trained birth attendants are now able to provide group pretest counseling, voluntary HIV testing (using rapid oral tests -- the only lab test of any kind currently available in these health centers), individual posttest counseling and single-dose nevirapine administration for mothers and newborns.

In the program's first three years, the birth attendants in twenty village health centers tested over 2300 women. Of the 82 women (3.5%) with positive tests, 42 were delivered by the birth attendants, and of those 88% of mothers and 85% of newborns received single-dose nevirapine prophylaxis.

The program encountered several problems. It has proved difficult to maintain adequate supplies of HIV test kits, a problem made worse by the short shelf-life of the oral kits. (In fact, program administrators are shifting to a blood test, which is more stable for storage and also -- because it is donated -- is cheaper for the program.) Maintaining regular stocks of nevirapine in these geographically isolated clinics has also proved to be problematic, and the syrup is particularly difficult as it too has a short shelf life. Because the oral tests have a reasonably high false-positive rate, the program's protocol dictates a second test to be done by a nurse supervisor who would visit monthly for this purpose. Transportation for both nurse supervisors and patients was an obstacle to this plan, especially during the rainy season when the roads and trails are in terrible condition, and over a third of the women with an initial positive test never had the second test done. The most serious problem the program encountered was the stigma associated with HIV/AIDS. This stigma is so great that 11 families moved out of their communities after the first positive test, and program coordinators also reported problems with domestic violence related to positive test results. Despite these drawbacks, the program had many significant successes. An astonishing 99% of women counseled accepted the tests, which is much higher than rates seen elsewhere and may be related to the respected position of these birth attendant counselors in their communities. In addition, the treatment rates for both mothers and infants are better than those seen in the larger hospitals running similar programs. Best of all, only about 15% of infants had positive HIV tests at 15 months of age, comparable to what has been seen with nevirapine-based trials in urban settings.

Many of you will be pleased to know that there is an Indian Health Service connection with this excellent program. The program’s associate directors, who were also instrumental in obtaining the grant that funded it, are long-time I.H.S. veterans Drs. Tom and Edie Welty.

Wanyu B, Diom E, Mitchell P et al. 2007 Birth attendants Trained in "Prevention of Mother-to-Child HIV Transmission" Provide Care in Rural Cameroon, Africa. J Midwifery Womens Health 2007; 52(4):334-341.

OB/GYN CCC Editorial comment

Edie and Tom retired from IHS after 26 years (23 with IHS and 3 with CDC) in 1997. They began to work as volunteers with the Cameroon Baptist Convention Health Board in 1998 and go there about 6 weeks a year to support their program. They wrote a grant to Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) in 2000, which was one of eight programs funded and EGPAF has renewed it annually since then. The AIDS Program is quite comprehensive (summary available upon request).

“It is very gratifying for us to see how much they have accomplished with minimal resources. Everyone has been affected by HIV and is motivated to do as much as possible to prevent and treat it.” Tom and Edie Welty

Other

Visual inspection with acetic acid: Effective method to prevent cervical cancer

BACKGROUND: Cervical cancer is the most common cancer among women in developing countries. We assessed the effect of screening using visual inspection with 4% acetic acid (VIA) on cervical cancer incidence and mortality in a cluster randomised controlled trial in India.

INTERPRETATION: VIA screening, in the presence of good training and sustained quality assurance, is an effective method to prevent cervical cancer in developing countries

Sankaranarayanan R et al Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet.  2007; 370(9585):398-406

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17679017

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MCH Alert

Infant Mortality Awareness Month Toolkit

The National Healthy Start Association's (NHSA's) Infant Mortality Awareness Month Toolkit is designed to increase national awareness of the factors that contribute to infant mortality in the United States and to urge community leaders to get involved in efforts to reduce infant mortality rates. The toolkit was produced by NHSA with support from the Annie E. Casey Foundation following the introduction of a Congressional resolution to observe September as Infant Mortality Awareness Month.

Contents include promotional materials, suggested fundraising and advocacy activities, statistical resources, and public relations and marketing tips. The toolkit is intended for use by Healthy Start programs and others to help raise awareness of infant mortality throughout the country and to gain community support for activities to reduce infant mortality. http://www.healthystartassoc.org/tkguide.html

New Edition of Child Health USA Released

Child Health USA 2006 reports on the health status and service needs for the target population of Title V funding: infants, children, adolescents, children with special health care needs, and women of childbearing age. The book, published by the Health Resources and Services Administration's Maternal and Child Health Bureau, comprises secondary data for more than 50 health status and health care indicators, provides both graphical and textual summaries of relevant data, and addresses long-term trends where applicable and feasible. The first section, Population Characteristics, presents statistics on factors (including poverty, education, and child care) that influence children's well-being. The second section, Health Status, contains vital statistics and health behavior information for the maternal and child health population. Health Services Financing and Utilization, the third section, includes data on health care financing and newly implemented health policies. The final sections, State Data and City Data, contain information on selected indicators at state and city levels. http://www.mchb.hrsa.gov/chusa_06/pages/pdf/c06.pdf

MCH Library expands availability and access to historical documents

The Maternal and Child Health (MCH) Library Web site now includes over 300 historical documents published by the U.S. Children's Bureau between 1912 and 1969, the earliest years of the federal agency. The documents have been made available electronically on the library's Web site with support from the Health Resources and Services Administration's Maternal and Child Health Bureau. Many of the documents are being made available online for the first time and are accessible only from the MCH Library.

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MCH Headlines: Judy Thierry HQE

AI / AN researchers on perinatal depression requesting names of interested individuals

Researchers that could knowledgeably present the American Indian/Alaska Native perspective related to parental depression (maternal, paternal, or both); as well as other issues that may place children at risk for developing depression and/or behavioral disorders--such as substance abuse and intimate partner violence are being sought.

Institute of Medicine IOM is also interested in learning about any promising community-based interventions that address these issues for our populations.  Institute of Medicine is interested in identifying speakers for future committee meetings.

Submit names and contact info to me or have people contact me directly

Thanks so very much.

Judy

Judith.Thierry@ihs.gov

Protecting America’s Future

The 4-page issue brief produced by the State Health Access Data Assistance Center (SHADAC) at the University Of Minnesota School Of Public Health presents the impact of reclassification of health insurance coverage for Indian Health Service (IHS) in select states on uninsured rates. The Current Population Survey (CPS) is a commonly used data source for health insurance rate estimates.  In 1998 with consultation between the BIA and the Census Bureau the definition of insurance coverage for respondents who report IHS-only to that of “uninsured” was made. The impact of this change in seven states with five percent or more of the population self-reporting their race/ethnicity as American Indian and Alaska Native (AIAN) either alone or in combination with another race/ethnicity is discussed. The methodology used two-year pooled averages before and after the definition/reclassification change.   A statistically significant increase (p<0.01%) of uninsured was noted for all states except Arizona.  Impact on position in state uninsured rankings worsened.  Effect size nationally however showed no influence.  Of note: during this period OMB standards for reporting racial categories changed from a one of four categories to multiple race categories.  

The authors go on to point out that while the IHS is not defined as a comprehensive health insurance it provides access to a level of services, and services that vary across tribes.  In the seven state analysis over one-half of the uninsured AIAN population reported IHS as their sole source of health care.  

The 2005 SHADAC Issue Brief describes an important milestone in the definitional change of AIAN coverage, that being the IHS-only uninsured classification, and its measured impact on seven of the most AIAN populous states. The change was statistically significant for six of the seven states in this analysis.  These data impact administrative, fiscal and patient care resources. Obvious and not so obvious costs of bearing the load of care for sizeable uninsured populations (range of 24.2% to 43.2%) bear’s further analysis.  Age-specific stratification within states if described could provide understanding of actions to take for coverage of potential eligible groups such as children.  http://www.shadac.umn.edu/img/assets/18528/IssueBrief11.pdf

Alliance for a Healthier Generation Webinar

How to Register for a Webinar Session:

• All webinar sessions are free, you simply need to have access to a phone and computer to participate

Please email us at webinars@HealthierGeneration.org with the following information:

• your name
• email address
• school/organization name
• specify which session (including time) you would like to attend 

We will confirm your participation via email, as well as provide you with directions on how to call-in and log-in for the training

Alliance for a Healthier Generation A Partnership between the William J. Clinton Foundation and the American Heart Association T: ( 646) 775-9155  55 W. 125th Street New York, NY 10027 www.HealthierGeneration.org8 The Healthy Schools Program: Making Schools Healthier Places to Learn, Work, Eat, and Play.

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Medical Mystery Tour

Endometriosis: Where is the real truth?

Here are some questions to ponder.

1.) Endometriosis virtually always progresses in severity without treatment

True False

2.) Postoperative medical therapy has been shown to produce significant benefit in reducing pain in women who have treated for endometriosis laparscopically

True False

3.) Appoximately 40% of women with endometriosis and pain will derive symptomatic benefit from treatment with placebo

True False

4.) Surgical modalities, such as electrocautery, laser, or harmonic scalpel appear to be equally effective in treating endometriosis

True False

5.) Surgical aspiration is the preferred treatment method for women with ovarian endometrioma

True False

6.) Treatment with a GnRH analog for 6 months is associated with an increased fracture risk in women with endometriosis

True False

7.) Interstitial cystitis coexists with endometriosis in approximately 10 percent of cases

True False

8.) The extent of endometriosis does not parallel the extent of improvement after surgical therapy, e. g., minimal disease – most benefit; greatest amount of disease – least response

True False

Extra credit

Promising therapies for endometriosis include:

-Aromatase inhibitors

-RU-486

-Levonorgestrel containing IUDs

-Antiangiogenic cancer therapy

-None the above

-All of the above

We’ll thoroughly discuss the answers next month, but you can preview the answers at the bottom of this webpage

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Medscape*

Hereditary Link to PMDD Identified
http://www.medscape.com/resource/pmdd?src=rcupdate#1

The Reproductive Phenotype in Polycystic Ovary Syndrome
http://www.medscape.com/viewprogram/7768?src=nlcmealert

Passive Smoking Increases Risk for Sleep Disturbance During Pregnancy
http://mp.medscape.com/cgi-bin1/DM/y/hBXc20Ou5N60Dzc0IvZY0Es

Management of Valvular Heart Disease in Pregnancy
http://www.medscape.com/viewarticle/561354?src=mp

Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth

OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b

Clinical Discussion Board Index, Medscape

Hundreds of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b

Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default

*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.

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Menopause Management

Estrogen Protects Women’s Brains Prior to Menopause

CONCLUSIONS: Both unilateral and bilateral oophorectomy preceding the onset of menopause are associated with an increased risk of cognitive impairment or dementia. The effect is age-dependent and suggests a critical age window for neuroprotection.

Rocca WA et al Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology. 2007 Aug 29

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17761551

Atrophic Vaginitis and Estrogen Treatment - Medscape CME
http://www.medscape.com/viewarticle/560167

Cholesterol-Related Compound Can Block Estrogen From Helping To Prevent Heart Disease in Some Women

A molecule related to cholesterol can block the hormone estrogen from performing functions in blood vessels that keep them healthy and protected against heart disease

Umetani M et al 27-Hydroxycholesterol is an endogenous SERM that inhibits the cardiovascular effects of estrogen

Nature Medicine Published online: 16 September 2007

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Midwives Corner - Lisa Allee, CNM

Nurse Midwife Week October 7-13, 2007

National Midwifery Week, October 7-13, 2007, is a wonderful occasion celebrating midwifery and midwives' commitment to being "With Women, for a Lifetime." Whether you are a midwife, a new parent or grandparent, or you're just seeking information about midwifery, this week will be filled with educational opportunities. Please hug all the midwives you see, after you help them work for equitable reimbursement, that is. http://www.midwife.org/index.cfm?id=312

Piercing the veil: the marginalization of midwives in the United States

This paper investigates the marginalization of certified nurse-midwives (CNMs) in the US. This marginalization occurs despite ample evidence demonstrating that a midwifery model delivers high-quality cost-effective care. Currently midwives attend only 7% of births, compared to 50-75% of births in other developed countries. Given the escalating costs of health care and relatively poor maternal and child health indicators in comparison with other developed countries, these findings are disturbing. This paper investigates this paradox through a qualitative case study of two prestigious but declining midwifery services in a large US city. Fifty-two multi-sited in-depth interviews were conducted along with an analysis of relevant archival sources. It was found that institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. These findings illuminate the larger political-economic forces that shape the marginalization of midwifery in the US.

Goodman S. Piercing the veil: the marginalization of midwives in the United States. Soc Sci Med. 2007 Aug;65(3):610-21.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17475381

Impact of written information on women's use of postpartum services

RESULTS: Satisfaction with care during the postpartum period was 57.2% in the intervention and 38.9% in the control arm (p<0.001). Some 85% of women in the intervention arm had a postpartum visit compared to 55% in the control arm (p<0.001). CONCLUSION: In the context of high female literacy, the intervention is effective and requires few resources.

Kabakian-Khasholian T; Campbell OM Impact of written information on women's use of postpartum services: a randomised controlled trial. Acta Obstet Gynecol Scand.   2007; 86(7):793-8.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17611823

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Navajo News, John Balintona, Shiprock

Evaluation of the pregnant patient for non-obstetric surgery: Part Two

Editorial Note:

This is Part Two of a two Part series on Evaluation of the Pregnant Patient for Non-obstetric Surgery. Part One discussed the Epidemiology and Maternal Adaptation in Pregnancy and is available here http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo

Part Two

Laboratory Data and Imaging Studies

The maternal blood volume increases markedly throughout pregnancy with levels 40 to 50 percent above nonpregnant levels when at term. This increased volume is a result of both an increase in plasma, as well as, erythrocytes with a slightly higher increase in plasma volume. Therefore, despite the increased erythropoesis, normal pregnancies result in a slight decrease in both hemoglobin concentration and hematocrit. A hemoglobin concentration below 11.0 g/dl should be considered abnormal in a term pregnancy resulting typically from iron deficiency and not hypervolemia of pregnancy. The blood leukocyte count can vary widely during pregnancy, quoted by experts as typically between 5, 000 – 12, 000/ml with a normal range of 14, 000 to 16,000 shortly after delivery. Many obstetric providers have observed the “leukocytosis of pregnancy”, but must take into account other signs and symptoms of infection when interpreting this lab value. Gestational thrombocytopenia of pregnancy is a known phenomenon. The platelet level is usually greater than 70, 000, and after a thorough evaluation and dismissal of other conditions and lack of signs of abnormal bleeding an obstetric provider may elect to continue to observe these pregnant patients. Although there is no firm recommendation for platelet transfusion in relation to pending nonobstetric surgery, it may be reasonable to use a threshold of greater than 50, 000 platelets for platelet transfusion. The levels of several blood coagulation factors are increased during pregnancy, e.g. fibrinogen, factor VII, VIII, IX, and X all of which are important components in producing clot. The natural inhibitors of coagulation including ATIII, protein C and S have been shown to be unchanged quantitatively with protein S activity being shown to decrease. The clotting time of pregnant patients when compared to their nonpregnant counterparts shows no significant change. The overall effect of these changes in coagulation factors predisposes toward a hypercoagulable state and this can have implications for those who undergo surgery. The prolonged immobilization coupled with the aforementioned physiologic changes may predispose some patients to the development of thrombosis and therefore proper prophylaxis should be initiated.

Basic chemistry studies are included in the evaluation of any surgical patient. Pregnancy is shown to confer a decrease in serum sodium and potassium, but the literature does not give a firm range of normal values during pregnancy. In the absence of signs and symptoms of hyponatremia or hypokalemia, intervention is not indicated. Due to the respiratory alkalosis of normal pregnancy the serum bicarbonate level subsequently decreases from about 26 to 22 mmol/L, but this should not be interpreted as acidosis in most cases. Due to the increase of glomerular filtration rate during pregnancy, serum levels of creatinine and urea normally decrease as a consequence. Some of the laboratory tests that are commonly used to evaluate hepatic function are appreciably different in pregnancy. Total alkaline phosphatase levels almost double during pregnancy where serum albumin levels show a decrease to an average of 3.0 g/L. Despite these changes, there is no distinct change in liver morphology or function in normal pregnant women.

A finding of glucosuria during pregnancy is not necessarily abnormal. An increase in glomerular filtration may account for the majority of glucosuria, but again this finding should be taken in context especially when evaluating the patient for presumed gestational diabetes or related diabetic condition. Proteinuria is normally not evident during pregnancy, however some suggest that levels up to around 115 mg/day, which translates to “trace” on a urine dipstick test, may be considered normal. A pregnant patient who presents with hematuria, if not resulting from contamination, is compatible with the diagnosis of urinary tract disease, i.e. infection, urolithiasis, etc. Evidence of nitrites in the urine is diagnostic for urinary tract infection in both pregnant and nonpregnant individuals. The presence of leukocyte esterase, representing white blood cells in the urine may be indicative of infection but not in all cases.

Imaging techniques such as plain film, computerized tomography (CT), magnetic resonance imaging, and ultrasound are utilized in the evaluation of patients despite their pregnancy status. While the majority of diagnostic procedures are associated with little or no known significant fetal risks, obtaining certain imaging tests in a known pregnant patient may be difficult due to the reluctance from the nonobstetric provider. One must remember that certain conditions, e.g. life-threatening emergencies and trauma, may necessitate imaging modalities. Furthermore, according to the American College of Radiology (ACR), no single diagnostic procedure results in a radiation dose significant enough to threaten the well being of the developing embryo and fetus. The obstetric provider, however, must be cognizant of the accepted threshold for ionizing radiation (< 5 rad) as well as the estimated gestational age, organogenesis occurring between 8 and 15 weeks gestation, when recommending imaging studies. Abdominal shielding is also a reasonable recommendation when it is indicated. The American College of Obstetricians and Gynecologists (ACOG) has published guidelines reviewing the effects of imaging during pregnancy and are summarized as follows:

1. Women should be counseled the x-ray exposure from a single diagnostic procedure does not result in harmful fetal effects. Specifically dose less than 5 rad.
2. Concern about possible effects of high-dose ionizing radiation should not prevent medically indicated procedures from being performed. One should consider imaging procedure not associated with ionizing radiation.
3. Ultrasonography and magnetic resonance imaging are not associated with known adverse effects. First trimester use of MRI is still considered controversial.
4. Consultation with a radiologist may be helpful in calculating total fetal dose when multiple studies are indicated
5. The use of radioactive isotopes of iodine is contraindicated for therapeutic use during pregnancy.

Anesthetic and Operative Considerations

Most obstetric authorities would contend that the risk of an adverse pregnancy outcome is not increased after undergoing most technically uncomplicated or anesthetic procedures. The risk of spontaneous abortion or premature labor may be increased, however, when the surgical condition or procedure is associated with complications. The most prudent recommendation that one can offer is that consideration for nonobstetric surgical intervention in a pregnant patient should be individualized.

The American Society of Anesthesiologists (ASA) has published guidelines regarding the practice of obstetric anesthesia, but these are implicitly stated to not apply to nonobstetric surgical intervention during pregnancy. After a careful review of the ASA guidelines, one may be able to extrapolate certain recommendations that are probably useful for the pregnant woman. Each patient, pregnant or nonpregnant, deserves some type of preanesthetic evaluation to include an appropriate history and physical exam. Preoperative labs can be individualized. Solid food intake should be avoided for at least 6 hours in patients undergoing elective surgery and timely administration of aspiration prophylaxis should be considered.

The administration of prophylactic antibiotics may be individualized and ACOG practice bulletins #47 (Prophylactic Antibiotics in Labor and Delivery) and #74 (Antibiotic Prophylaxis in Gynecologic Procedures) provide guidelines for its use.

ACOG practice bulletin #9 (Antenatal Fetal Surveillance) does state that all indications for antepartum testing must be considered somewhat relative, but in general antepartum fetal surveillance has been employed in pregnancies in which the risk of fetal demise is increased. There is insufficient literature to demonstrate that perianesthetic recording of fetal heart rate prevents fetal or neonatal complications. In spite of its unproven value, antepartum fetal surveillance is widely integrated into clinical practice in the developed world. The obstetric provider should take into account several factors such as gestational age, continuation of medical/surgical condition, etc when making recommendations for perioperative antepartum fetal surveillance.

Obstetric providers have an enormous opportunity and responsibility for ensuring the best possible maternal and fetal outcome for nonobstetric surgical procedures. Knowledge of physiologic and laboratory changes, as well as, advice on perioperative management should be well communicated between the obstetric provider and other members of the health care team. This review highlights some of the aspects of care that should be conveyed and provides a general rational approach to management. In the coming issues, more in depth review of specific conditions, such as appendicitis, biliary gallstone disease, urolithiasis, adnexal masses in pregnancy, and trauma in pregnancy will be presented…stay tuned!

References:

1. Williams Obstetrics. 22nd Edition. 2005. Chapter 42. General Considerations and Maternal Evaluation
2. American College of Obstetrics and Gynecologists. 2004. Committee Opinion # 299. Guidelines for Diagnostic Imaging During Pregnancy
3. American Society of Anesthesiologists. 2006. Practice Guidelines for Obstetric Anesthesia

Part One in this series is available here

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo

Questions? Contact John Balintona John.Balintona@ihs.gov

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Nurses Corner - Kendra Carter

Memories, As a Public Health Nurse on the Navajo

Marie A. Swigert, RN MS is one of those nurses who have managed to be a staff nurse in the hospital prior to becoming the Director of Community Health Nursing for the State of Colorado. Along the way she stopped at Northern Navajo Medical Center.

She graduated nursing in 1957 from the University of Connecticut and earned her Master of Science in nursing in 1967 from University of Colorado in Boulder. She became a nurse to earn her blue and red cape however what she got was the white dress and white shoes and her cap. The year she graduated they discontinued the cape. She still has the white dress and she presented me with her cap during my graduation from nursing school in 2002. She has been a source of inspiration for me as well as for others along our way to become nurses.

Here are her stories about Maternal Child Health in the Indian Health Services……

I worked on the Navajo in the middle ‘70s. I was attached to the public health section of the Shiprock Service Unit (IHS employee) as Nursing Director/Supervisor. We had approximately 5-6 nurses, either RNs, LPNs who were assigned as public health, school, and clinic nurses. Also included were our driver-interpreters and CHNs (community health aides), our office also worked closely with the environmental health team who were located in same office, as well as the nutritionist and her nutrition aides.

Our office was on the first floor of the apartment building adjacent to the old hospital. All of the nursing staff and other health teams worked closely together. One of my strongest memories is that of our off site MCH clinics held in the small communities which constituted the Shiprock Service Unit that covered the Four Corners area of Colorado, New Mexico, Arizona, and Utah.

In the morning of the MCH clinics we would collect our supplies and materials. Our driver/interpreter telling us ‘we’re going to late’. Off we head for Sanostee or one of the other small communities with our crew, our nurses, nutritionist, nurse-midwives and whomever. Arriving, we would open the clinic building, air it out and let our first families. Many had been waiting for us to open.

The Public Health nurses would do the child health portion of the clinic, the nurse midwife the maternal portion, the nutritionist and her staff the food aspect. All of us shared in the nutrition part as we partook of the food prepared by them. They always made enough for the mothers, children, staff, and whoever else was there.

The PHNs did the well baby checks, assessments of “sick kids” and occasionally grandmas too.

Ear infections were the bane of our assessments. I remember one time, having told one young mom that propping the baby’s bottle was not healthy and increased ear infections. I told her “you don’t prop the bottle when feeding you sheep, you can’t do it with your baby.” She agreed, somewhat reluctantly. The next visit, there she was in the lobby at Sanostee. As I approached her she yelled out, “I didn’t prop the bottle, I really didn’t.” Sure enough, the baby’s ear infection was much improved.

We had protocols which allowed us to treat ear infections so long as we appointed them back to our clinic or the Shiprock clinic. Our protocols included immunizations, treatment for impetigo and other minor infections. Any infection treatment, we reviewed with the doctors prior to the next local clinic. Our community clinics were held monthly, located in communities such as Toadlene, Tees Nos Pos, Checkerboard and others.

The families valued our clinics; I remember one instance when a grandmother carried her grandson over to our clinic. It had rained the night before the roads were muddy. The bottom of her shirt and shoes were covered with mud. Her grandson had been vomiting and had diarrhea all night, she said. He was a sick little fellow. So, we cleaned him up as best we could, told Grandma that he needed to be seen in Shiprock: “you take him’ she asked, ‘yes we take him’. Much to the displeasure of the driver, I said I would sit in the front seat of the car, as I had more room. The youngster’s clothes were soiled and a bit smelly. Once in Shiprock, the child was admitted and Grandma came in that evening to see him. I think most everyone knew ‘I was the PHN that brought the feverish but smelly child in and I got smelly too as his clothes were wet.

The Navajo people and their land are fascinating; I don’t practice nursing anymore, but do return as a reading and math tutor at the public schools in Mexican Hat and Monument Valley. As one Navajo, told me ‘you get our sand in your shoes, you return.’ It’s true...

Submitted by Marie A Swigert and LTJG Kendra A. Carter RN BSN USPHS

Kendra.Carter@ihs.gov

CCC Editorial Comment:

Once you get our sand in your shoes, you return

Marie A. Swigert, RN MS is one of those nurses who started as a staff nurse in the hospital prior to becoming the Director of Community Health Nursing for the State of Colorado. Along the way she stopped at Northern Navajo Medical Center. The Nurses Corner by Kendra Carter has Marie’s stories about MCH within the IHS.

An elder Navajo said ‘once you get our sand in your shoes, you return’. If you know other veteran Indian Health colleagues like Marie Swigert, the CCC Corner would love to share their stories. Those who don’t know history were bound to repeat it.

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Office of Women's Health, CDC

Common Questions about HPV and Cervical Cancer: For Women Who Have HPV

This sheet answers 15 questions about HPV and cervical cancer, including how to prevent infection, testing, talking to a partner about HPV, and the HPV vaccine.

http://www.cdc.gov/std/HPV/common-questions.htm

Prevalence of HPV* Infection† Among Sexually Active Females

Aged 14--59 Years, by Age Group --- National Health and Nutrition Examination Survey, United States, 2003—2004, QuickStats

* Human papillomavirus.

† Determined by DNA extraction from self-collected cervicovaginal swabs.

§ 95% confidence interval.

Among sexually active females (i.e., 57% of females aged 14--19 years and 97% of those aged 20--59 years), the prevalence of HPV infection was highest for those in the youngest age groups (i.e., approximately 40% in those aged 14--19 years and 50% in those aged 20--24 years). Prevalence declined substantially after age 24 years.

SOURCES: National Health and Nutrition Examination Survey, 2003--2004. Available at http://www.cdc.gov/nchs/about/major/nhanes/nhanes2003-2004/nhanes03_04.htm

Dunne EF, Unger ER, Sternberg M, et al. Prevalence of HPV infection among females in the United States. JAMA 2007;297:813--9.

Pre-Teen Vaccine Campaign

The Pre-teen Vaccine Campaign launched on August 1, 2007. Through extensive audience research, CDC has created posters and flyers, in English and Spanish to educate parents and providers about the three pre-teen vaccines and the 11 and 12 year old medical check-up. Use the links to visit the “flyers” and “posters” gallery pages to download materials. You can also request a DVD if you plan to professionally print any of these materials.

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Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center

Preconception Health of Women Delivering Live-Born Infants — Oklahoma, 2000–2003

The U.S. Public Health Service recommends that all women of childbearing age consume >400 µg of folic acid daily through either supplementation or fortified foods. CDC recommends offering, as a component of maternity care, one pre-pregnancy visit to a health care provider for women planning pregnancy to enable women to receive risk assessment, health education, and specific interventions to address identified risks before conception. Analysis of data collected from women in Oklahoma during 2000–2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS) indicated that 21.5 percent of women with a recent live birth were not aware of folic acid benefits before they became pregnant, 73.5 percent did not consume multivitamins at least four times per week during the month before pregnancy, and 84.8 percent did not receive preconception counseling from a health-care provider. Although pre-pregnancy awareness of the benefits of taking vitamins with folic acid in the prevention of some birth defects was high among Oklahoma women with a recent live birth, actual consumption of multivitamins during the month before pregnancy was low. Promoting preconception health of women is a key public health strategy in the United States to decrease morbidity and mortality associated with negative maternal and infant outcomes. Increased folic acid consumption before conception and during the first trimester of pregnancy can reduce the incidence of neural tube defects by 50–70 percent.

Surveillance of Preconception Health Indicators Among Women Delivering Live-Born Infants --- Oklahoma, 2000—2003 MMWR June 29, 2007 / 56(25);631-634

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a3.htm

Editorial comment: Greggory Woitte – Hastings Indian Medical Center

Preconception Counseling

I am sure that most of your patients are similar to mine in that your first visit with them is after they have become pregnant. They show up at the clinic for a confirmatory pregnancy test, to schedule their first prenatal visit and to get started on prenatal vitamins (or as I am frequently seeing to start Flintstones vitamins). However, as I am sure you are aware, by the time the patient reaches our doorstep, we have missed a very important part of the pregnancy that we may have had some dramatic affect upon.

Between 2000 and 2003, the state of Oklahoma developed and administered a preconception survey. (See above) They found that 84.8% of women did not have any preconception counseling by a provider. 21.5% of women did not know about the benefits of preconception folic acid and equally disturbing was that 73.5% did not take vitamins before trying to become pregnant.

In accordance with the ACOG Committee Opinion No. 313, patients who are in the reproductive ages should be questioned about the possibility of becoming pregnant, especially if they are not on contraception. Women should be encouraged to formulate a reproductive health plan. We, as practitioners of Women’s Health, should be encouraging women to take steps to get as healthy as possible at every visit. This is especially important in women of reproductive ages where we have the opportunity to provide education regarding the benefits to the fetus, as well as to identify patients at high risk for adverse pregnancy outcomes.

We also need to remind our colleagues from other disciplines of medicine to ask their patients about potentially becoming pregnant and refer those who may be in need of pre-conceptional counseling or those in need of contraceptive counseling.

ACOG Committee Opinion Number 313. The importance of preconception care in the continuum of women's health care. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2005 Sep;106(3):665-6 .

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16135611

Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/nccdphp/

Office of Communication (770) 488-5131

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Osteoporosis

Fracture Outcomes in Women Discontinuing Alendronate

Conclusion: Women who continued alendronate treatment after the initial five years had higher hip and spine BMD, lower bone remodeling, and a lower rate of clinical vertebral fractures; there was no difference in nonvertebral fractures. The authors conclude that, unless patients are at high risk of clinical vertebral fracture, those who have taken alendronate for five years can discontinue the drug for up to five years without a significant increase in fracture risk.

Black DM, et al. Effects of continuing or stopping alendronate after 5 years of treatment. The Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA December 27, 2006;296:2927-38.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17190893

Childhood, Teen Restriction of Dairy Foods Lowers Spinal Bone Mineral Content

CONCLUSIONS: These results suggest that, starting as early as 10 years of age, self-imposed restriction of dairy foods because of perceived milk intolerance is associated with lower spinal bone mineral content values. The long-term influence of these behaviors may contribute to later risk for osteoporosis.

Matlik L et al Perceived milk intolerance is related to bone mineral content in 10- to 13-year-old female adolescents. Pediatrics. 2007 Sep;120(3):e669-77.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766507

Pharmacologic Treatment of Osteopenia Not Usually Indicated

Background: Osteoporosis is arbitrarily defined as a bone mineral density (BMD) that is 2.5 standard deviations (SDs) or more below the mean in younger women, as measured at the femoral neck. Osteopenia is defined as a BMD that is 1 SD or more below the younger women’s mean. Using these cutoffs, it is estimated that 17 percent of U.S. women 50 years and older will be diagnosed with osteoporosis and 50 percent of white U.S. women who are postmenopausal will be identified as having osteopenia. Because there is only fair correlation in BMD measurements at different sites, the convention is to use the lowest score from measurements taken at the femoral neck, total hip, or lumbar spine. However, this practice increases the number of women diagnosed with osteopenia without providing additional predictive information about fracture risk, and therefore is no more useful than the femoral neck measurement alone.

Fracture risk increases with age and lower BMD; however, white race, female sex, previous fractures, stroke, and deconditioning or weakness also increase fracture risk. Alcohol consumption of one or two drinks daily may decrease the risk, but consumption of greater amounts increases it. Other modifiable risk factors include smoking and poor visual acuity. Although low weight is associated with fracture risk, it is not a meaningful risk factor when the BMD has been measured because weight is merely a marker for BMD. Women with a history of fractures or radiographically confirmed fractures have a fourfold risk of fracture, and pharmacologic tr