News Flash(s) Plan now

### **IHS Domestic Violence Prevention / Intentional Injuries April 5-8, 2005**

**17th Annual IHS Research Conference and International**

**Meeting on Inuit and Native American Child Health: April 29-May 1,
2005**

**ACOG / IHS -- Total Women's Health and Neonatal Course: June 19-23,
2005**

New Feature:

CCC Corner Digest - A print friendly digest of the CCC Corner that can
be mailed to you, or

> your colleagues. Just send your address to <nmurphy@scf.cc>

### 

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 3, March 2005

# Contents: {#contents .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### Abstract(s) of the Month: page 3 {#abstracts-of-the-month-page-3 .Style-Heading-4-+-Arial-14-pt-Underline}

**#1 Use 'Opt out' HIV screening methods during pregnancy in Indian
Country**

[**Routine Population-Wide HIV Screening May Be
Cost-Effective**](http://mp.medscape.com/cgi-bin1/DM/y/hmEa0G875W0Dzc0GQ3m0ET)

**Q. What is the Indian Health policy for HIV screening in pregnancy?**

**#2** **Early epidural provided shorter labor and did not increase
cesarean delivery page 5**

#### From your colleagues: page 7 {#from-your-colleagues-page-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Burt Attico: 3 items on Pre-eclampsia from BMJ; Physicians May Be Ignoring Guidelines for Gestational Weight Gain {#burt-attico-3-items-on-pre-eclampsia-from-bmj-physicians-may-be-ignoring-guidelines-for-gestational-weight-gain .Style-Heading-4-+-Arial-14-pt-Underline}

#### Katy Ciacco-Palatianos: Health Literacy Fellowship {#katy-ciacco-palatianos-health-literacy-fellowship .Style-Heading-4-+-Arial-14-pt-Underline}

### **Terry Cullen:** IHS Domestic Violence Prevention / Intentional Injuries Course

#### Sandra Dodge: How many deliveries does a provider need to maintain active privileges? {#sandra-dodge-how-many-deliveries-does-a-provider-need-to-maintain-active-privileges .Style-Heading-4-+-Arial-14-pt-Underline}

#### Mara Fusfield: What are some good resources to develop guidelines from?  {#mara-fusfield-what-are-some-good-resources-to-develop-guidelines-from .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jim Galloway: Women's Health Cardiology Resources Available {#jim-galloway-womens-health-cardiology-resources-available .Style-Heading-4-+-Arial-14-pt-Underline}

**Steve Holve:** What are some of the issues in adoption of an American
Indian child?

March Indian Child Health Notes

**Elaine Locke:** Job Postings on ACOG Career Connection

**Kathleen Masis:** U.S. Surgeon General Releases Advisory on Alcohol
Use in Pregnancy

#### Kate McCarthy: The Public's Health and the Law in the 21^st^ Century: 4^th^ Annual Partnership  {#kate-mccarthy-the-publics-health-and-the-law-in-the-21st-century-4th-annual-partnership .Style-Heading-4-+-Arial-14-pt-Underline}

**Neil Murphy:** Take two Clomid and call me in the morning: A true
story

#### Jane Powers: IHS Child Abuse Project Website has just been updated {#jane-powers-ihs-child-abuse-project-website-has-just-been-updated .Style-Heading-4-+-Arial-14-pt-Underline}

#### Robert Stockburger: Locum tenens availability {#robert-stockburger-locum-tenens-availability .Style-Heading-4-+-Arial-14-pt-Underline}

**Scott Sunde:** What is the significance of the latest NEJM article on
trial of labor after cesarean?

#### Judy Thierry:  {#judy-thierry .Style-Heading-4-+-Arial-14-pt-Underline}

#### -How would you like to be the Czarina of Women's Health in Indian Country? {#how-would-you-like-to-be-the-czarina-of-womens-health-in-indian-country .Style-Heading-4-+-Arial-14-pt-Underline}

-Good FAS web site

-U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy

-Potential Economic Benefits of the National Children\'s Study

-How does your state rank in fitness in Children?

**Judy Whitecrane**: Native American Women\'s Health: Leadership for
Change Conference

#### Hot Topics: {#hot-topics .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics: page 12

-Misoprostol decreases oxytocin use largely due to labor within the
ripening period

-Overweight and obese women with single cephalic term pregnancies have
increased risk

-Fast-Absorbing Sutures Better for Postpartum Perineal Repair

-Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important

#### -[**Perinatal HIV Transmission Now Most Likely to Occur in Utero**](http://mp.medscape.com/cgi-bin1/DM/y/hl4V0G875W0Dzc0GQdM0EH)  {#perinatal-hiv-transmission-now-most-likely-to-occur-in-utero .Style-Heading-4-+-Arial-14-pt-Underline}

-And more

**Gynecology:** **page 15**

-Vaginal pH for Diagnosing Status of Menopause

-Surgical or Medical Treatment for Refractory Menorrhagia?

-Symptom Experiences of Chronically Constipated Women With Pelvic Floor
Disorders

**Child Health:** **page 16**

-Pregnancy, Birth, and Abortion Rates Decline for Teenagers Aged 15-17
Years

-Are children born after assisted reproductive technology at increased
risk for adverse health outcomes?

**Chronic Illness and Disease:** **page 16**

**-Low-dose aspirin can prevent cardiovascular disease in older women**

-Antiplatelet Therapy and Anticoagulation in Patients with Hypertension

-Cardiovascular risk higher among patients with migraine

-Control of Cardiovascular Risk Factors - Diabetic Women Compared to Men

-Insulin Monotherapy vs. Combination Therapy

-And more

#### Features: page 18 {#features-page-18 .Style-Heading-4-+-Arial-14-pt-Underline}

##### AFP

-Does Melatonin Improve Sleep in Asthmatic Women?

ACOG

\- Pregestational diabetes mellitus, ACOG Practice Bulletin No. 60

**AHRQ**

-Follow-up of newborns after hospital discharge: Critical to
preventjaundice and other problems

**Ask a Librarian**

\- Salmonella from Pet Turtles-Again

**Breastfeeding**

-Resurgence of kernicterus attributed primarily to early discharge of
newborns

**CCC Corner Digest**

#### -LEEP Treatment Increases Risk of Preterm Delivery in Future Pregnancies  {#leep-treatment-increases-risk-of-preterm-delivery-in-future-pregnancies .Style-Heading-4-+-Arial-14-pt-Underline}

#### -New OB/GYN Deputy Chief Clinical Consultant IHS {#new-obgyn-deputy-chief-clinical-consultant-ihs .Style-Heading-4-+-Arial-14-pt-Underline}

-Progesterone Treatment Decreases Preterm Birth Rate

-Radio-Frequency Endometrial Ablation for Menorrhagia

#### -Hormonal Contraceptives and Weight Gain {#hormonal-contraceptives-and-weight-gain .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Walk 2000 More Steps a Day and Never Gain Another Pound {#walk-2000-more-steps-a-day-and-never-gain-another-pound .Style-Heading-4-+-Arial-14-pt-Underline}

**Domestic Violence**

-Intimate Partner Violence During Pregnancy

-Homicide is the 2nd leading cause of injury-related deaths among
pregnant and women

-An easy palm-based downloadable domestic violence assessment tool

**Elder Care News**

-Palliative care and hospice training in Anchorage, Alaska - May 10-12,
2005

**Family Planning**

-Women continue to die from unintended pregnancy

-Effects of Contraception on Bone Mineral Density

**Frequently asked questions**

-What is the Indian Health policy for HIV screening in pregnancy?

-Should I prescribe Depo Provera as a long term agent for more than 2
years?

-What preventive therapy is recommended for patients at high risk for
pre-eclampsia?

-My patient is not doing too well with her hormone replacement therapy.
Options?

-What are some of the opportunities to provide care in Indian women's
health?

**Hormone Replacement Update**

-Estrogen with or without progestin should not be prescribed for relief
of incontinence

**Information Technology**

-Computerized order entry system may increase risk of medication errors

-Intranet-based prenatal record improves communication

-UpToDate Version 13.1 Now Available; Includes Pediatrics

-Tribal Connections

-Native Web.org: Resource Database / Health

International Health

-Women, inequality, and the burden of HIV

-Physician Missions With Doctors Without Borders:

-UN Predicts Global Population of 9.1 Billion by 2050

#### MCH Alert

-Task Force presents recommendations for reducing violence

#### Medscape

-Genital Herpes and Pregnancy: Preventing Neonatal Transmission

**Midwives Corner**

\- Emergency OB Drills: The Phoenix Indian Medical Center Experience

-Concern over rising cesarean delivery rate: ACNM approaches Congress

-Alternative Medicines\' Popularity Prompts Concern

#### Office of Women's Health, CDC

-Spread the Word - National Women\'s Health Week, May 8-14, 2005

Osteoporosis

-How best to start good bone health?

-Clinical Rules Don\'t Predict Osteoporosis in Women

Patient Education

-Consumer Health: Indian Health

-What Should I Know About Cholesterol?

-Vertigo-A Type of Dizziness

Primary Care Discussion Forum

-April 1, 2005: Methamphetamine use in Indian

STD Corner

-Women\'s Sexual Health and Sexually Transmitted Diseases -- May 13,
2005

#### -Expedited treatment of sex partners on persistent gonorrhea or chlamydial infection {#expedited-treatment-of-sex-partners-on-persistent-gonorrhea-or-chlamydial-infection .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater, Alaska Diabetes Prevention and Control

#### -Postmenopausal Women and Visceral Fat Loss through Exercise {#postmenopausal-women-and-visceral-fat-loss-through-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

## -Minding the gender gap: The divergence between men\'s and women\'s health research

-Omitting breakfast on insulin sensitivity and fasting lipid:
Deleterious effects

#### -Beginning Exercise Routine Later in Life Still Reduces Heart Disease, Diabetes risk {#beginning-exercise-routine-later-in-life-still-reduces-heart-disease-diabetes-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Blood Pressure, Insulin Sensitivity Linked to Waist Circumference {#blood-pressure-insulin-sensitivity-linked-to-waist-circumference .Style-Heading-4-+-Arial-14-pt-Underline}

#### What's new on the ITU MCH web pages page 28

###### Save the Dates: Upcoming events of interest page 29

**Did you miss something in the last OB/GYN Chief Clinical Consultant
(CCC) Corner?**

#  {#section-1 .Style-Heading-1-+-Underline}

# Abstract(s) of the Month {#abstracts-of-the-month .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**Use 'Opt out' HIV screening methods during pregnancy in Indian
Country**

[**Routine Population-Wide HIV Screening May Be
Cost-Effective**](http://mp.medscape.com/cgi-bin1/DM/y/hmEa0G875W0Dzc0GQ3m0ET)

*Conclusions* In all but the lowest-risk populations, routine, voluntary
screening for HIV once every three to five years is justified on both
clinical and cost-effectiveness grounds. One-time screening in the
general population may also be cost-effective.

Paltiel AD et al Expanded screening for HIV in the United States\--an
analysis of cost-effectiveness. N Engl J Med. 2005 Feb
10;352(6):586-95.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15703423&dopt=Abstract>

and

CONCLUSIONS: The cost-effectiveness of routine HIV screening in health
care settings, even in relatively low-prevalence populations, is similar
to that of commonly accepted interventions, and such programs should be
expanded.

Sanders GD et al. Cost-effectiveness of screening for HIV in the era of
highly active antiretroviral therapy. N Engl J Med. 2005 Feb
10;352(6):570-85.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15703422>

and

Editorial: Bozzette SA. Routine screening for HIV infection\--timely and
cost-effective. N Engl J Med. 2005 Feb 10;352(6):620-1.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15703428&dopt=Abstract>

#### [OB/GYN CCC Editorial comment:]{.underline}

While the articles above discuss the cost effectiveness of future
population based HIV screening in the general population, the use of
universal screening of HIV has already been a reality in pregnancy since
2001. Here are excerpts of the Frequently Asked Question answer that is
on the MCH website.

**Q. What is the Indian Health policy for HIV screening in pregnancy?**

A. Our goal is to maximize our care by using 'opt out' HIV screening.

In Indian Health we follow the PHS, CDC, ACOG, and Institute of Medicine
(see Resources below) recommended 'opt out' system that minimizes
barriers to universal screening for HIV in pregnancy.

'Opt out' screening includes elements of prenatal education for our
patients that universal HIV screening significantly decreases perinatal
HIV transmission. By screening, we may save her infant's life and
improve her own maternal health status. We should further inform all
pregnant patients that they will be screened for HIV, unless the patient
otherwise declines HIV screening.

Initial HIV screening should occur during in the initial prenatal
education and intake process. Subsequent screening should be repeated in
high risk groups and upon admission to labor and delivery, if screening
has not occurred previously. (see Rapid Testing below).

Our goal is the highest attainable health status for our AI/AN patients.
If an Indian Health service facility resides in a state that has
additional screening requirements, then those requirements should be
considered. (see below)

**Q. Does it have to be a separate specific consent in writing during
pregnancy?**

No, staff does not need a specific [separate]{.underline} signed
informed consent for HIV screening in pregnancy, e.g., the written
consent can be part of a 'bundled consent'. This written consent may be
handled differently in pregnancy compared to the non-pregnant state in
some facilities.

From the 2001 Revised CDC guidelines...

\"....Information regarding consent may be presented separately from [or
combined with other consent procedures for health services (e.g., as
part of a package of tests or care for certain conditions).]{.underline}
However, if consent for HIV testing is combined with consent for other
tests or procedures, the inclusion of HIV testing should be specifically
discussed with the client. For a discussion of HIV testing in pregnant
women, consult the guidelines for HIV screening of pregnant
women\"<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019a1.htm>

IHS uses the IOM, ACOG and CDC as best practice benchmarks and Chapter
13 of the IHS Manual does not require an additional separate written IHS
consent for HIV screening in pregnancy.

Those benchmarks call for 'opt out testing'. The basic idea with 'opt
out' testing is to remove barriers to what constitutes life saving
therapy for fetuses, e.g., the 076 Protocol significantly reduces infant
mortality.

The specifics of 'opt out' testing require that the patient be informed
about HIV and its consequences, plus that the patient will be
universally screened unless she specifically opts out, or declines
screening. There is no longer a need to complete the two sided IHS-509,
8/93, HIV Screening form out on each patient.

Most centers that have successfully implemented 'opt out' have done so
by informing the patient in her initial prenatal teaching session about
HIV (and that she will be screened as a course of her routine care)
along with the standard compliment of important prenatal teaching
content.

The rest of this **Frequently Asked Question** is continued at this url
with many other resources:

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/HIVscreen21305.doc>

**2^nd^ Abstract**

**Early epidural provided shorter labor and did not increase cesarean
delivery**

CONCLUSIONS: Neuraxial analgesia in early labor did not increase the
rate of cesarean delivery, and it provided better analgesia and resulted
in a shorter duration of labor than systemic analgesia Cynthia A. Wong,
et al. The Risk of Cesarean Delivery with Neuraxial Analgesia Given
Early versus Late in Labor N Engl J Med. 2005 Feb 17;352(7):655-65.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716559&dopt=Abstract>

and

Camann W. Pain relief during labor. N Engl J Med. 2005 Feb
17;352(7):718-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716567&dopt=Abstract>

#### [OB/GYN CCC Editorial comment:]{.underline}

This was a randomized trial of 750 nulliparous women at term who were in
spontaneous labor or

had spontaneous rupture of the membranes and who had a cervical
dilatation of less than 4.0 cm.

Neuraxial analgesia in early labor did not increase the rate of cesarean
delivery.

As epidural analgesia is both safe and effective, it may deserve a
larger role in the care of AI/AN.

AI/AN birth rates have been steadily declining over the last decade. The
reasons for the

decreasing birth rate are myriad, but include demographic, educational,
and socio-economic

factors among others.

One other factor is that some AI/AN patients choose to deliver outside
the Indian Health system

because epidural or intrathecal analgesia is not available. In many
cases there is a loss of patient

continuity or a loss of the patient and her family to another health
system for future care, as many

times these patients function as the health care gatekeepers for the
extended family. In that latter

process, there is also a loss of alternate funding resources that could
be helpful for the whole

system.

Please also review Dr. Diane Pond's comments below. Dr. Pond is the
Anesthesia Chief Clinical

Consultant for the Indian Health Service.

**[Anesthesia CCC Editorial comment]{.underline} (Diane Pond, MD,
PIMC)**

In the earlier days of epidural analgesia for labor and delivery, it was
common practice to utilize more concentrated doses of local anesthetics.
Infusions consisted of 1/8%, and ¼% bupivicaine with or without
narcotics. At this concentration it was common to see mild-moderate
motor block in addition to sensory blockade. Excessive motor block has
been related to difficulty with the pushing phase of labor. Lack of
ability to effectively push can intuitively lead to an increase in
cesarean rate. Since then further studies with more dilute solutions
have shown effective analgesia can be achieved with minimal motor
blockade. Solutions as dilute as 1/16% with 1-2 mcg of Fentanyl have
been shown to be effective. The phrase "walking epidural" has been
coined to describe the possibilities now available to patients with the
dilute solutions, and intrathecal techniques.

There is also evidence that effective analgesia can actually result in a
shorter duration of labor. The mechanism that has been postulated to
explain this is a reduction in maternal systemic catecholamines. By
reducing the sympathetic system response to a pain challenge, delivery
outcome can actually be improved.

Bottom line: Advantages far outweigh the risks and include:

1.  Safe method

2.  Effective pain relief

3.  Minimize depressive effects on infants

4.  Method provides a rapid means of inducing surgical anesthesia if
    needed in emergent situations.

It is my opinion that relief of pain during childbirth should be a
medically indicated human right.

# From your colleagues: {#from-your-colleagues .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### Burt Attico, Phoenix {#burt-attico-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

#### 3 items on Pre-eclampsia from BMJ {#items-on-pre-eclampsia-from-bmj .Style-Heading-4-+-Arial-14-pt-Underline}

#### A Community Based Clinical Guideline; Systematic Review of Controlled Studies, and an Editorial {#a-community-based-clinical-guideline-systematic-review-of-controlled-studies-and-an-editorial .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Pre-eclampsia Community Guideline (PRECOG), based on recommendations from the National Institute for Clinical Excellence (NICE). The editorialist states that PRECOG is simple, evidence based, and should be used; and an accompanying systematic review of controlled studies summarizes risk factors for preeclampsia. {#the-pre-eclampsia-community-guideline-precog-based-on-recommendations-from-the-national-institute-for-clinical-excellence-nice.-the-editorialist-states-that-precog-is-simple-evidence-based-and-should-be-used-and-an-accompanying-systematic-review-of-controlled-studies-summarizes-risk-factors-for-preeclampsia. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Milne F, Redman et al. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ. 2005 Mar 12;330(7491):576-80. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15760998&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15760998&dopt=Abstract) {#milne-f-redman-et-al.-the-pre-eclampsia-community-guideline-precog-how-to-screen-for-and-detect-onset-of-pre-eclampsia-in-the-community.-bmj.-2005-mar-123307491576-80.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15760998doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-3 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Risk factors for pre-eclampsia at booking: systematic review of controlled studies {#risk-factors-for-pre-eclampsia-at-booking-systematic-review-of-controlled-studies .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: Controlled cohort studies showed that the risk of pre-eclampsia is increased in women with a previous history of pre-eclampsia (relative risk 7.19, 95% confidence interval 5.85 to 8.83) and in those with antiphospholipids antibodies (9.72, 4.34 to 21.75), pre-existing diabetes (3.56, 2.54 to 4.99), multiple (twin) pregnancy (2.93, 2.04 to 4.21), nulliparity (2.91, 1.28 to 6.61), family history (2.90, 1.70 to 4.93), raised blood pressure (diastolic \> or = 80 mm Hg) at booking (1.38, 1.01 to 1.87), raised body mass index before pregnancy (2.47, 1.66 to 3.67) or at booking (1.55, 1.28 to 1.88), or maternal age \> or = 40 (1.96, 1.34 to 2.87, for multiparous women). Individual studies show that risk is also increased with an interval of 10 years or more since a previous pregnancy, autoimmune disease, renal disease, and chronic hypertension. CONCLUSIONS: These factors and the underlying evidence base can be used to assess risk at booking so that a suitable surveillance routine to detect pre-eclampsia can be planned for the rest of the pregnancy. Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005 Mar 12;330(7491):565. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15743856&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15743856&dopt=Abstract) {#results-controlled-cohort-studies-showed-that-the-risk-of-pre-eclampsia-is-increased-in-women-with-a-previous-history-of-pre-eclampsia-relative-risk-7.19-95-confidence-interval-5.85-to-8.83-and-in-those-with-antiphospholipids-antibodies-9.72-4.34-to-21.75-pre-existing-diabetes-3.56-2.54-to-4.99-multiple-twin-pregnancy-2.93-2.04-to-4.21-nulliparity-2.91-1.28-to-6.61-family-history-2.90-1.70-to-4.93-raised-blood-pressure-diastolic-or-80-mm-hg-at-booking-1.38-1.01-to-1.87-raised-body-mass-index-before-pregnancy-2.47-1.66-to-3.67-or-at-booking-1.55-1.28-to-1.88-or-maternal-age-or-40-1.96-1.34-to-2.87-for-multiparous-women.-individual-studies-show-that-risk-is-also-increased-with-an-interval-of-10-years-or-more-since-a-previous-pregnancy-autoimmune-disease-renal-disease-and-chronic-hypertension.-conclusions-these-factors-and-the-underlying-evidence-base-can-be-used-to-assess-risk-at-booking-so-that-a-suitable-surveillance-routine-to-detect-pre-eclampsia-can-be-planned-for-the-rest-of-the-pregnancy.-duckitt-k-harrington-d.-risk-factors-for-pre-eclampsia-at-antenatal-booking-systematic-review-of-controlled-studies.-bmj.-2005-mar-123307491565.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15743856doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

#### and {#and .Style-Heading-4-+-Arial-14-pt-Underline}

#### Editorial - Greer IA. Pre-eclampsia matters. BMJ. 2005 Mar 12;330(7491):549-50. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15760971&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15760971&dopt=Abstract) {#editorial---greer-ia.-pre-eclampsia-matters.-bmj.-2005-mar-123307491549-50.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15760971doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-4 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Physicians May Be Ignoring Guidelines for Gestational Weight Gain {#physicians-may-be-ignoring-guidelines-for-gestational-weight-gain .Style-Heading-4-+-Arial-14-pt-Underline}

#### \"some providers are not aware of the BMI-specific weight gain guidelines and are advising all women to gain within the same range.\" If so, providers and patients both may require more education about BMI-appropriate weight gain in pregnancy. [CONCLUSION:]{.underline} Women\'s beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain. LEVEL OF EVIDENCE: II-2. {#some-providers-are-not-aware-of-the-bmi-specific-weight-gain-guidelines-and-are-advising-all-women-to-gain-within-the-same-range.-if-so-providers-and-patients-both-may-require-more-education-about-bmi-appropriate-weight-gain-in-pregnancy.-conclusion-womens-beliefs-about-the-proper-amount-of-weight-gain-and-provider-recommendations-for-weight-gain-vary-significantly-by-maternal-prepregnancy-bmi.-many-women-report-incorrect-advice-about-gestational-weight-gain-and-women-with-high-or-low-prepregnancy-bmi-are-more-likely-to-have-an-incorrect-target-weight-gain.-new-approaches-to-provider-education-are-needed-to-implement-the-iom-guidelines-for-gestational-weight-gain.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Stotland NE et al. Body Mass Index, Provider Advice, and Target Gestational Weight Gain. Obstet Gynecol. 2005 Mar;105(3):633-638. {#stotland-ne-et-al.-body-mass-index-provider-advice-and-target-gestational-weight-gain.-obstet-gynecol.-2005-mar1053633-638. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738036**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738036) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15738036 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-5 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Katy Ciacco-Palatianos {#katy-ciacco-palatianos .Style-Heading-4-+-Arial-14-pt-Underline}

#### Health Literacy Fellowship {#health-literacy-fellowship .Style-Heading-4-+-Arial-14-pt-Underline}

One year with the potential to extend the award for up to three years.
The Fellow is expected to begin in late spring/summer 2005. Stipend
available**.** Due April 15, 2005
[www.atpm.org](../../../../../../../../%5C%5Cwww.atpm.org)

#### Terry Cullen, Tucson {#terry-cullen-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

### **IHS Domestic Violence Prevention / Intentional Injuries Course**

April 5-8, 2005

Albuquerque, New Mexico

Contact Dr. Larry Berger: [bergerlaw@msn.com](../bergerlaw@msn.com)

This course will focus on practical applications of existing knowledge
to prevent violence / intentional injuries in American Indian/Alaska
Native communities. The primary topic this year (2005) will be
**domestic violence**. There will be a combination of lectures, class
exercises, small group work, and presentations by tribal and IHS staff
who have conducted prevention projects in their communities.

**Who should attend:** Individuals from tribal and IHS programs in
environmental health/injury prevention, behavioral health,
maternal/child health, social work, nursing, medicine, and health
education. **Limit: 25** **participants.**

**Topics:  **

1.  Best practices for intervention and prevention of domestic violence
    in American Indian/Alaska Native (AI/AN) communities;

2.  IHS and tribal initiatives in preventing domestic violence;

3.  Legal aspects of domestic violence in AI/AN communities;

4.  Promoting collaboration and partnerships among individuals, tribal
    agencies, and IHS personnel;

5.  Collecting, interpreting, and using data for violence prevention;

6.  Alcohol/substance abuse and firearms as risk factors;

7.  Resources for prevention, including curricula, technical assistance,
    and funding.

####  {#section-6 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sandra Dodge, Crownpoint {#sandra-dodge-crownpoint .Style-Heading-4-+-Arial-14-pt-Underline}

#### How many deliveries does a provider need to maintain active privileges? {#how-many-deliveries-does-a-provider-need-to-maintain-active-privileges .Style-Heading-4-+-Arial-14-pt-Underline}

Those numbers can be set by the local Medical Staff credentialing
committee

One standard set of numbers that have been used:

Number needed to get initial privileges 30 in the previous 2 years prior
to application

Initial proctoring 5 / year

Maintain current privileges 15 / year

Number needed by facility 120 / year

####  {#section-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Q. How many deliveries does a provider need to maintain active privileges? {#q.-how-many-deliveries-does-a-provider-need-to-maintain-active-privileges .Style-Heading-4-+-Arial-14-pt-Underline}

A. Those numbers should be set by the local Medical Staff. Here are some
examples

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Credent21905.doc>

#### [OB/GYN CCC Editorial comment:]{.underline}

If providers can not maintain those numbers locally each year, then they
should perform a rotation at a facility where they can perform
deliveries.

In facilities with delivery numbers chronically less than 120 / year,
the administration should have an active ongoing program to send their
providers out for delivery rotations. Providers should be allowed
maintain their delivery numbers up as part of their standard job status,
e.g., providers need not have to use annual leave to attend delivery
rotations.

####  {#section-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Mara Fusfield, Toppenish, WA {#mara-fusfield-toppenish-wa .Style-Heading-4-+-Arial-14-pt-Underline}

#### What are some good resources to develop guidelines from?  {#what-are-some-good-resources-to-develop-guidelines-from .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-9 .Style-Heading-4-+-Arial-14-pt-Underline}

You may want to go to the latest online **ACOG / IHS Reference Text**

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01.cfm>

You can enter via the various chapter links or go to the index first and
see which chapter you need look things up in

There are also many current Women's Health guidelines and forms already
available here:

**Guidelines: National Comprehensive: by A -Z**

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm>

**Guidelines: by Organ System**

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-organSys.cfm>

**Guidelines: Indian Health Specific, by A -Z**

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm>

**Guidelines: National Clearinghouses or Agencies**

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clearHouse.cfm>

**Useful Forms: by A - Z**

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-forms.cfm>

**Useful Forms: by Organ System**

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-formsOrgSys.cfm>

Other web pages with many resources that may be helpful

**Clinical Information Resources, IHS**

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm>

**MCH -- Indian Health**

<http://www.ihs.gov/MedicalPrograms/MCH/MC.asp>

**Women's Health -- Indian Health**

<http://www.ihs.gov/MedicalPrograms/MCH/Wh.asp>

**Child Health -- Indian Health**

<http://www.ihs.gov/MedicalPrograms/MCH/CH.asp>

**Domestic Violence -- Indian Health**

<http://www.ihs.gov/MedicalPrograms/MCH/W/DV00.cfm>

#### Jim Galloway, Tucson {#jim-galloway-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women's Health Cardiology Resources Available {#womens-health-cardiology-resources-available .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Native American Cardiology Program has several guidelines and resources available for AI/AN. THE IHS CENTER OF EXCELLENCE IN CARDIOLOGY {#the-native-american-cardiology-program-has-several-guidelines-and-resources-available-for-aian.-the-ihs-center-of-excellence-in-cardiology .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/medicalprograms/cardiology/card/sitemap.cfm#CGuidelines**](http://www.ihs.gov/medicalprograms/cardiology/card/sitemap.cfm#CGuidelines) {#httpwww.ihs.govmedicalprogramscardiologycardsitemap.cfmcguidelines .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-10 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Steve Holve, Tuba City  {#steve-holve-tuba-city .Style-Heading-4-+-Arial-14-pt-Underline}

**What are some of the issues in adoption of an American Indian child?**

Adoption of American Indian children is delineated by federal
legislation titled \"The Indian Child Welfare Act\" or ICWA. Adoption of
Indian children cannot take place through state courts but must proceed
through a tribal judicial system.

The purpose of the law is to prevent Indian children being removed
inappropriately from their tribal groups as happened in the past.
Adoption must be offered first within a child\'s family, then the tribal
group and then any federally recognized Indian family. An Indian mother
may not put her child up for adoption outside of ICWA supervision. The
child\'s tribal division of social services has supervisory authority
over any adoption. Many of the larger tribes have an ICWA caseworker.

There is no single entity that oversees adoption of Indian children. The
family in question would need to contact the ICWA worker at each
specific tribe. They could let them know they are interested in
adoption. They would have to show proof of being enrolled in a federally
designated tribe, usually by demonstration of a Certificate of Indian
Blood.

Most tribes have websites with phone contacts.

**March Indian Child Health Notes**

[[http://www.ihs.gov/MedicalPrograms/MCH/C/documents/childHealthNotes0305.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/C/documents/childHealthNotes0305.doc)

####  {#section-11 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Elaine Locke. ACOG {#elaine-locke.-acog .Style-Heading-4-+-Arial-14-pt-Underline}

**Job Postings on ACOG Career Connection**

At no charge, for Indian Facilities Only

#### [**http://www.ihs.gov/MedicalPrograms/MCH/m/documents/ACOGPost3205-2.doc**](http://www.ihs.gov/MedicalPrograms/MCH/m/documents/ACOGPost3205-2.doc) {#httpwww.ihs.govmedicalprogramsmchmdocumentsacogpost3205-2.doc .Style-Heading-4-+-Arial-14-pt-Underline}

**Kathleen Masis, Billings**

**U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy**

Alcohol-related birth defects are completely preventable. A number of
resources are available to assist healthcare and social services
professionals in advising their patients to reduce and refrain from
alcohol in pregnancy.
<http://www.hhs.gov/surgeongeneral/pressreleases/sg02222005.html>

These resources include the National Institute on Alcohol Abuse and
Alcoholism, NIH ([www.niaaa.nih.gov](http://www.niaaa.nih.gov/)), the
Centers for Disease Control and Prevention
([www.cdc.gov/ncbddd/fas/](http://www.cdc.gov/ncbddd/fas/)), and the
Substance Abuse and Mental Health Services Administration
[www.fascenter.samhsa.gov](http://www.fascenter.samhsa.gov/)

####  {#section-12 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Kate McCarthy, CDC {#kate-mccarthy-cdc .Style-Heading-4-+-Arial-14-pt-Underline}

**The Public's Health and the Law in the 21^st^ Century: 4^th^ Annual
Partnership Conference**

June 13-15, 2005 Atlanta, GA CME, CLE and other CEU credits will be
available.

<http://www.phppo.cdc.gov/od/phlp/conference/con2005email_marketing.asp>

####  {#section-13 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Neil Murphy, Anchorage {#neil-murphy-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

**Take two Clomid and call me in the morning: A true story**

OK, well at least the rest of this is true. I recently returned from an
itinerant GYN clinic in a remote Alaskan regional center above the
Arctic Circle. While there, I corresponded by e-mail with a colleague
who retired from a career in Indian Health after 24 years of service and
was currently at the University of New Mexico.

As he signed off his e-mail message, he asked that I give his regards to
the staff at the field hospital, as he had worked in that area nearly 30
years prior.

To my amazement as I performed a chart review on my next patient, I saw
note with his name on it from 1978, 27 years prior. He had prescribed
clomiphene by phone for a patient who desired fertility. As luck would
have it, it seems the Indian Health staff had very effective
reproductive endocrine techniques in those days. The patient conceived
soon thereafter. That clomiphene must have kept working for quite a
while, as the patient went on to have 6 more children. The patient was
very appreciative of her interaction with my colleague, as her ninth
child delivered in 1992, 14 years after that phone call.

**[OB/GYN CCC Editorial comment:]{.underline}**

Indian Health can be a very rewarding career. We have the privilege to
work with wonderful patients. We can develop relationships with our
patients and fellow staff members that last a lifetime. Indian Health is
also a great career for those who want a part time, full time, or locum
tenens position:

**Q. What are some of the opportunities to provide care in Indian
women's health?**

A. Working in Indian Health can be a rewarding health care avenue. See
below

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Recruit21305.doc>

**IHS staff in the news**

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01_news.cfm#News>

**Locum Tenens and Job Opportunities**

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHjobs.asp>

**ACOG Fellows in Service Program**

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOGFellows.cfm>

####  {#section-14 .Style-Heading-4-+-Arial-14-pt-Underline}

**Jane Powers IHS Child Abuse Project**

#### IHS Child Abuse Project Website has just been updated {#ihs-child-abuse-project-website-has-just-been-updated .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Highlight:]{.underline} New upcoming two year session of the course to start May 16-20, 2005, in Salt Lake City. Contact Jane at the program for an application packet. [**Jane.Powers@ihs.gov**](mailto:Jane.Powers@ihs.gov) {#highlight-new-upcoming-two-year-session-of-the-course-to-start-may-16-20-2005-in-salt-lake-city.-contact-jane-at-the-program-for-an-application-packet.-jane.powersihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

#### IHS Child Abuse Project Website [**http://www.ovccap.ihs.gov/cap-course-training.asp**](http://www.ovccap.ihs.gov/cap-course-training.asp) {#ihs-child-abuse-project-website-httpwww.ovccap.ihs.govcap-course-training.asp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-15 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Robert Stockburger {#robert-stockburger .Style-Heading-4-+-Arial-14-pt-Underline}

#### Locum tenens availability {#locum-tenens-availability .Style-Heading-4-+-Arial-14-pt-Underline}

#### Board certified OBGYN wishes to do locums at any IHS facility. 25 years experience. Available on short notice.  Robert Stockburger DO FACOG [**stuttgart822@yahoo.com**](mailto:stuttgart822@yahoo.com)  ph 817-640-0132 {#board-certified-obgyn-wishes-to-do-locums-at-any-ihs-facility.-25-years-experience.-available-on-short-notice.-robert-stockburger-do-facog-stuttgart822yahoo.com-ph-817-640-0132 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Dr. Stockburger was credentialed through the ACOG Fellows in Service Program in 2003 {#dr.-stockburger-was-credentialed-through-the-acog-fellows-in-service-program-in-2003 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-16 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Scott Sunde, Albuquerque {#scott-sunde-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

#### What is the significance of the latest NEJM article on trial of labor after cesarean (TOLAC)? {#what-is-the-significance-of-the-latest-nejm-article-on-trial-of-labor-after-cesarean-tolac .Style-Heading-4-+-Arial-14-pt-Underline}

CONCLUSIONS: A trial of labor after prior cesarean delivery is
associated with a greater perinatal risk than is elective repeated
cesarean delivery without labor, although absolute risks are low. This
information is relevant for counseling women about their choices after a
cesarean section.

#### Landon MB et al Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004 Dec 16;351(25):2581-9 {#landon-mb-et-al-maternal-and-perinatal-outcomes-associated-with-a-trial-of-labor-after-prior-cesarean-delivery.-n-engl-j-med.-2004-dec-16351252581-9 .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15598960&dopt=Abstract>

Editorial

Greene MF. Vaginal birth after cesarean revisited. N Engl J Med. 2004
Dec 16;351(25):2647-9\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15598961&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15598961&dopt=Abstract)

#### [OB/GYN CCC Editorial comment:]{.underline}

**"Risk, like beauty, is in the eye of the beholder"**

This article is significant both what is says, and what it doesn't say.

This is a large observational 4 year prospective at 19 academic
institutions. It showed a small increased risk of hypoxic-ischemic
encephalopathy, endometritis, and blood transfusion among the vaginal
delivery group. As the Editorial points out it would take approximately
588 cesarean deliveries to prevent a single adverse perinatal outcome.

Due to the timing of this study and its observational nature,
approximately ½ of the symptomatic uterine ruptures were involved with
prostaglandin administration, so even the 1/588 risk number may be
overstated a large factor.

As this is not a RCT we can't know with certainty the exact risk, but
this study confirms previous studies that the risk of adverse outcome is
very small.

It is reasonable to use the tenets described at the August 2004 Indian
Women's Health Conference:

-minimize risk by assuring the entire L/D unit functions as a cohesive
team

-perform periodic emergency delivery drills on L/D as a team

-carefully triage TOLAC patients: low, medium, and high risk

-be especially mindful of a lack of timely intrapartum labor progress

See the lecture notes from Michelle Lauria for more details

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#MeetingLecNotes>

See also Midwives Corner below

####  {#section-17 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Judy Thierry, HQE {#judy-thierry-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

#### How would you like to be the Czarina of Women's Health in Indian Country? {#how-would-you-like-to-be-the-czarina-of-womens-health-in-indian-country-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Or do you know someone who does? There are 2 announcements on the web site for this position, one for delegated examining authority and one for merit promotion plan.  See both {#or-do-you-know-someone-who-does-there-are-2-announcements-on-the-web-site-for-this-position-one-for-delegated-examining-authority-and-one-for-merit-promotion-plan.-see-both .Style-Heading-4-+-Arial-14-pt-Underline}

[http://www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/act_job_view.cfm?kw=nurse%20consultant&sl=&dy=%2D11711&st=any&ar=any&sc=any&sort=1&sr=1&jb=18036](http://www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/act_job_view.cfm?kw=nurse consultant&sl=&dy=-11711&st=any&ar=any&sc=any&sort=1&sr=1&jb=18036)

or

[http://www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/act_job_view.cfm?kw=nurse%20consultant&sl=&dy=%2D11711&st=any&ar=any&sc=any&sort=1&sr=1&jb=18038](http://www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/act_job_view.cfm?kw=nurse consultant&sl=&dy=-11711&st=any&ar=any&sc=any&sort=1&sr=1&jb=18038)

or search the Jobs Listing under Nurse Consultant(Women's
Health/Advanced Practice

<http://www.ihs.gov/JobsCareerDevelop/CareerCenter/Vacancy/Index.cfm>

**Good FAS web site**

I like this web site from the approach directed at maternal drinking
behavior and dose, the content itself, how it grabs you right off about
in the first sentence. Canadian data could be extrapolated to US data.
The physiology and effects remain the same. The depth and scope and the
various media allow you to access what I consider a basic and user
friendly resource kit.
[[http://www.faslink.org/]{.underline}](http://www.faslink.org/)

**U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy**

U.S. Surgeon General Richard H. Carmona today warned pregnant women and
women who may become pregnant to abstain from alcohol consumption in
order to eliminate the chance of giving birth to a baby with any of the
harmful effects of the Fetal Alcohol Spectrum Disorders (FASD). FASD is
the full spectrum of birth defects caused by prenatal alcohol exposure.
The spectrum may include mild and subtle changes, such as a slight
learning disability and/or physical abnormality, through full-blown
Fetal Alcohol Syndrome, which can include severe learning disabilities,
growth deficiencies, abnormal facial features, and central nervous
system disorders.

The Year of the Healthy Child,\" visit
[[http://www.surgeongeneral.gov]{.underline}](http://www.surgeongeneral.gov/)

**Potential Economic Benefits of the National Children\'s Study**

[http://nationalchildrensstudy.gov](http://www.nationalchildrensstudy.gov/news/e-updates/e_update_032005.cfm)

**How does your state rank in fitness in Children?**

<http://www.child.com/kids/health_nutrition/fittest_states.jsp?page=9>

#### Judy Whitecrane, Phoenix {#judy-whitecrane-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**Native American Women\'s Health: Leadership for Change Conference**

-   May 19 - 20, 2005

-   Denver, CO

-   Office on Women\'s Health, DHHS

-   [Invitation for Dialogue, Planning, and Commitment to
    Health](http://www.kauffmaninc.com/index.cfm?page=WomensLeadership.cfm)

-   <http://www.kauffmaninc.com/index.cfm?page=WomensLeadership.cfm>

# Hot Topics: {#hot-topics-1 .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### Obstetrics {#obstetrics .Style-Heading-4-+-Arial-14-pt-Underline}

**A single dose of intravaginal misoprostol decreases oxytocin use
compared with intracervical dinoprostone, largely due to labor within
the ripening period.**

CONCLUSION: A single dose of misoprostol administered in the outpatient
setting significantly decreases oxytocin use, largely due to labor
within the ripening period.

LEVEL OF EVIDENCE: II-1. Meyer M, Pflum J, Howard D Outpatient
misoprostol compared with dinoprostone gel for preinduction cervical
ripening: a randomized controlled trial. Obstet Gynecol. 2005
Mar;105(3):466-72.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15738009&dopt=Abstract>

**Overweight and obese women with single cephalic term pregnancies have
a 1.3 to 15.3 times increased risk for pregnancy and delivery
complications than women who are not.**\
CONCLUSION: The rate of complications during pregnancy and delivery
increases with an increasing prepregnancy BMI in women with single
cephalic term pregnancies, particularly in nulliparous women. LEVEL OF
EVIDENCE: III.

Rode L, Nilas L, Wojdemann K Obesity-related complications in danish
single cephalic term pregnancies. Obstet Gynecol. 2005
Mar;105(3):537-42.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15738021&dopt=Abstract>

**Fast-Absorbing Sutures Better for Postpartum Perineal Repair**

Fast-absorbing polyglactin provides comparable or improved patient
comfort and is rarely associated with late complications in perineal
repair.

Greenberg JA, et al. Randomized comparison of chromic versus
fast-absorbing polyglactin 910 for postpartum perineal repair. Obstet
Gynecol June 2004;103:1308-13.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172869>

**Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important**

CONCLUSION: In contrast to severe systolic hypertension, severe
diastolic hypertension does not develop before stroke in most patients
with severe preeclampsia and eclampsia. A paradigm shift is needed
toward considering antihypertensive therapy for severely preeclamptic
and eclamptic patients when systolic blood pressure reaches or exceeds
155-160 mm Hg. LEVEL OF EVIDENCE: III. Martin JN Stroke and severe
preeclampsia and eclampsia: a paradigm shift focusing on systolic blood
pressure. Obstet Gynecol. 2005 Feb;105(2):246-54.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684147&dopt=Abstract>

**Editorial**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684145&dopt=Abstract>

#### [Perinatal HIV Transmission Now Most Likely to Occur in Utero](http://mp.medscape.com/cgi-bin1/DM/y/hl4V0G875W0Dzc0GQdM0EH)  {#perinatal-hiv-transmission-now-most-likely-to-occur-in-utero-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Although there have been significant declines in perinatal HIV-1 infection over time, there has been an increase in the proportion of infections transmitted in utero. {#conclusion-although-there-have-been-significant-declines-in-perinatal-hiv-1-infection-over-time-there-has-been-an-increase-in-the-proportion-of-infections-transmitted-in-utero. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Magder LS et al Risk factors for in utero and intrapartum transmission of HIV. J Acquir Immune Defic Syndr. 2005 Jan 1;38(1):87-95. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15608531**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15608531) {#magder-ls-et-al-risk-factors-for-in-utero-and-intrapartum-transmission-of-hiv.-j-acquir-immune-defic-syndr.-2005-jan-138187-95.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15608531 .Style-Heading-4-+-Arial-14-pt-Underline}

**Earlier Amniocentesis and Chorionic Villus Sampling**

Compared with CVS, amniocentesis in cytogenetically normal pregnancies
at 13 weeks has an increased risk of talipes equinovarus. This risk
appears to be related to the stage of gestation and the loss of fluid
during and after the procedure. Amniotic fluid loss following
amniocentesis also appears to be related to a slight increase in early
pregnancy loss

Philip J, et al. Late first-trimester invasive prenatal diagnosis:
results of an international randomized trial. Obstet Gynecol June
2004;103:1164-73

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172848>

**How Should Blood Pressure Be Measured During Pregnancy?**

It would be hard to think of a clinical situation where the accurate
tracking of BP is of more critical importance than pregnancy. The
situation in pregnancy is essentially dynamic: BP first falls and then
rises, so the best way of detecting an abnormal pattern that presages
preeclampsia may be to monitor its changes very frequently throughout
the course of pregnancy. Thus the earliest manifestation of preeclampsia
is a failure to decrease, or a premature increase, of BP during the
second trimester.

Ambulatory Blood Pressure monitoring (ABP), which is becoming regarded
as the gold standard for BP measurement, is good at getting detailed
information about BP at one point in time, but it is not suited to
monitoring subtle changes over time. A single ABP recording performed at
this time would be unlikely to detect this altered trajectory, since
there would be no comparison ABP recording from which a change could be
detected. Self monitoring with home BP recordings is better suited to
this task, since it is the best technique for providing multiple
readings recorded at the same time of day over prolonged periods of
time. Self monitoring is also a good technique for avoiding the vagaries
of the human observer. What we need, therefore, are studies using self
monitoring to chart the time course of BP changes in normal pregnancies
and comparing them with the course in women who go on to develop
preeclampsia.

Pickering TG. Reflections in hypertension: how should blood pressure be
measured during pregnancy? J Clin Hypertens (Greenwich). 2005
Jan;7(1):46-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15655388>

and <http://www.medscape.com/viewarticle/497881?src=mp>

#### [OB/GYN CCC Editorial comment:]{.underline}

This review raises an excellent point that we need to be much more
careful about how we measure BP in pregnancy. We may need to consider
multiple ambulatory readings in the near future. Many times our patients
have just corralled her children, done several errands, and rushed up
the stairs, among other things, immediately prior to her BP measurement.
Pending future data on ambulatory BP monitoring, we should use this
method:

[Measuring blood pressure in pregnancy]{.underline}

The diastolic blood pressure is that pressure at which the sound
disappears (Korotkoff phase V)

-To reduce inaccurate readings, an appropriate size cuff should be used
(length 1.5 times upper arm circumference or a cuff with a bladder that
encircles 80% or more of the arm). The blood pressure level should be
taken with the patient in an upright position, after a 10-minute or
longer rest period.

-For patients in the hospital, the blood pressure can be taken with
either the patient sitting up or in the left lateral recumbent position
with the patient\'s arm at the level of the heart.

-The patient should not use tobacco or caffeine for 30 minutes preceding
the measurement -Although validated electronic devices can be used, a
mercury sphygmomanometer is preferred because it is the most accurate
device

GUIDELINES FOR MANAGEMENT OF HYPERTENSIVE DISORDERS IN PREGNANCY

<http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/HYPERT12004.doc>

**Smoking results in a reduction in fetal organ size and function.**

Conclusion: Maternal smoking is associated with an altered placental
appearance on ultrasonography, increased umbilical artery blood flow
resistance and a reduction in longitudinal and intra-abdominal organ
growth. Circulating concentrations of IGF-1 and IGFBP-3 are reduced
along with measures of birth size but not markers of body fat suggesting
smoking results in a reduction in organ size and function.

Pringle PJ, et al The Influence of Cigarette Smoking on Antenatal
Growth, Birth Size and the Insulin-like Growth Factor (IGF) Axis. J Clin
Endocrinol Metab. 2005 Feb 15;\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15713720>

Use of Beta Agonists in Preterm Labor

Clinical Question

Do betamimetics (i.e., beta agonists) improve outcomes for women with
preterm labor?

Evidence-Based Answer

Treatment with betamimetics decreases the number of women with preterm
labor who give birth within 48 hours, but it does not decrease the
number of births within seven days. Limited evidence suggests that
treatment with betamimetics does not decrease perinatal death or
morbidity.

Practice Pointers

Betamimetics commonly are used to decrease uterine contractions in women
with preterm labor. However, they may cause discomfort and
life-threatening adverse effects such as pulmonary edema and
hypokalemia. Anotayanonth and colleagues identified 11 randomized
controlled trials of betamimetics in 1,332 women with preterm labor.

Compared with placebo, the betamimetic ritodrine significantly decreased
the number of women who give birth within 48 hours (23 versus 39
percent; relative risk \[RR\], 0.63; 95 percent confidence interval
\[CI\], 0.53 to 0.75). This corresponds to a number needed to treat of
6.\
It also reduced the risk of delivery within seven days. This benefit did
not persist after the authors performed a sensitivity analysis with a
random-effects model.

Most of the participants were at 32 weeks\' gestation or more. Maternal
adverse effects included chest pain, dyspnea, tachycardia, palpitations,
tremor, headache, hypokalemia, hyperglycemia, nausea and vomiting, and
nasal stuffiness. The RR for cessation of treatment because of adverse
events was 11.3 (95 percent CI, 3.8 to 33.5). There was no difference in
the rate of perinatal and neonatal deaths. Treatment had no effect on
neonatal morbidity such as respiratory distress syndrome, cerebral
palsy, and necrotizing enterocolitis. Two trials comparing ritodrine
with terbutaline in 183 women found that patients who took terbutaline
had a higher incidence of hyperglycemia. There was no difference in
maternal or neonatal outcomes.

Although no improvement in infant outcomes was found in this review,
most of the trials were done before antenatal corticosteroids were used
routinely. Also, most of the trials were done in university hospitals.
More studies must be done to determine if a 48-hour delay in delivery to
allow for patient transfer and a course of corticosteroids improves
outcomes. In the meantime, a short trial of tocolysis for preterm labor
is reasonable if corticosteroids or transfer is indicated.

Anotayanonth S, et al. Betamimetics for inhibiting preterm labour.
Cochrane Database Syst Rev 2004;(4):CD004352.
<http://www.aafp.org/afp/20050301/cochrane.html>

**LEEP and Preterm Births**

There is an increased risk of PROM and preterm delivery, but not overall
preterm deliveries following laser conization or LEEP. Although PROM
leads to preterm deliveries, these were higher in the untreated group
after adjustments compared with the treated group. The authors attribute
this incongruity to the higher rate of iatrogenic preterm deliveries in
the untreated group. The authors suggest careful adherence to CIN
management guidelines, avoidance of unnecessary excisions, and
appropriate counseling of previously treated women when they become
pregnant. Sadler L, et al. Treatment for cervical intraepithelial
neoplasia and risk of preterm delivery. JAMA May 5, 2004;291:2100-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126438>

**Acute MI During Pregnancy, While Rare, Appears to Be on the Rise**

CONCLUSION: Acute MI during pregnancy remains a rare event, with
significant maternal, fetal, and neonatal morbidity and mortality and
maternal mortality limited to the antepartum and intrapartum period.
LEVEL OF EVIDENCE: III.\
Ladner HE, Danielsen B, Gilbert WM. Acute myocardial infarction in
pregnancy and the puerperium: a population-based study. Obstet Gynecol.
2005 Mar;105(3):480-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738011>

**MRI of Acute Abdominal and Pelvic Pain in Pregnant Patients**

CONCLUSION: The intrinsic safety of MRI and its ability to accurately
show abdominal and pelvic disease in pregnant patients make it highly
useful in the evaluation of these patients.

Birchard KR, et al MRI of acute abdominal and pelvic pain in pregnant
patients. AJR Am J Roentgenol. 2005 Feb;184(2):452-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15671363>

**Prevention of Group B Streptococcal Disease in the Newborn**

<http://www.aafp.org/afp/20050301/903.html>

#### Gynecology {#gynecology .Style-Heading-4-+-Arial-14-pt-Underline}

**Vaginal pH for Diagnosing Status of Menopause**

a vaginal pH greater than 4.5 indicates menopause in women who are
without vaginitis and are not receiving estrogen therapy. They add that
vaginal pH is similar to FSH levels in establishing the diagnosis of low
estrogen levels or menopause, and that a vaginal pH of 4.5 or less can
be used to monitor adequate response to estrogen replacement therapy.

Roy S, et al. Vaginal pH is similar to follicle-stimulating hormone for
menopause diagnosis. Am J Obstet Gynecol May 2004;190:1272-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167829>

**Surgical or Medical Treatment for Refractory Menorrhagia?**

Deciding on the optimal treatment strategy for an individual woman with
menorrhagia can be challenging for several reasons. Although the medical
literature is difficult to assess objectively, about one third of
patients are reported to have strong personal preferences for a specific
therapy. The options are much wider than suggested in the Learman
article below.

A review in the BMJ Best Treatments series
([http://www.besttreatments.org](http://www.besttreatments.org/))
concluded that: [Treatments that work are:]{.underline}

Nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid,
hysterectomy (after failure of medical therapy), and endometrial
thinning before hysteroscopic surgery,\"

[Treatment likely to work:]{.underline}

Endometrial destruction (after failure of medical therapy)

[Treatments that need further study]{.underline} include:

Ethamsylate, oral contraceptives, intrauterine progesterones,
gonadotropin-releasing hormone (GnRH), and myomectomy. One of the more
interesting facts found in this review is that women adequately treated
with NSAIDs reported a 25 to 50 percent reduction in bleeding, but in
the above study, only a small proportion of the women assigned to
treatments including NSAIDs actually took them.

Although hysterectomy is the definitive therapy for menorrhagia (and the
leading indication for the more than 600,000 hysterectomies performed in
the United States per year), studies that followed patients for more
than two years after hysterectomy or endometrial ablation found no
significant difference between the groups in satisfaction at longer
follow-up. Women treated by endometrial ablation were calculated to have
a mean reduction in operating time of 23 minutes and returned to work
4.5 weeks sooner than women undergoing hysterectomy.

Learman LA, et al. Hysterectomy versus expanded medical treatment for
abnormal uterine bleeding: clinical outcomes in the medicine or surgery
trial. Obstet Gynecol May 2004;103:824-33.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121552>

**Symptom Experiences of Chronically Constipated Women With Pelvic Floor
Disorders**

IMPLICATIONS FOR PRACTICE: A more thorough assessment of constipation
symptoms in this population is recommended. A combination of
symptom-management strategies may be needed to relieve the multiple
symptoms associated with constipation\
Fuller E, Welch JL, Backer JH, Rawl SM. Symptom experiences of
chronically constipated women with pelvic floor disorders. Clin Nurse
Spec. 2005 Jan-Feb;19(1):34-40;

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684894>

#### Child Health {#child-health .Style-Heading-4-+-Arial-14-pt-Underline}

**Pregnancy and Birth Rates Decline for Teenagers Aged 15--17 Years,
1976-2003**

Since 1990, pregnancy rates have declined substantially for teenagers
aged 15-17 years. From 1990 to 2000, the pregnancy rate decreased 33%,
from 80.3 per 1,000 females to 53.5, a record low. The birth rate
declined 42%, from its peak at 38.6 in 1991 to 22.4 in 2003. The induced
abortion rate peaked in 1983 at 30.7 and decreased by more than half to
14.5 by 2000.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5404a6.htm>

**Are children born after assisted reproductive technology at increased
risk for adverse health outcomes?**

Data from multiple sources indicate that ART is related to several
adverse outcomes in the children conceived; however, more research is
necessary to clarify these risks.

Schieve LA, et al. Are children born after assisted reproductive
technology at increased risk for adverse health outcomes? Obstet Gynecol
June 2004;103:1154-63.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172847**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172847)

#### Chronic disease and Illness {#chronic-disease-and-illness .Style-Heading-4-+-Arial-14-pt-Underline}

Low-dose aspirin can prevent cardiovascular disease in older women

[Conclusions]{.underline} In this large, primary-prevention trial among
women, aspirin lowered the risk of stroke without affecting the risk of
myocardial infarction or death from cardiovascular causes, leading to a
nonsignificant finding with respect to the primary end point

Ridker PM et al A Randomized Trial of Low-Dose Aspirin in the Primary
Prevention of Cardiovascular Disease in Women. N Engl J Med. 2005 Mar 31
(pre-release March 7, 2005)

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15753114**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15753114)

Antiplatelet Therapy and Anticoagulation in Patients with Hypertension

Cochrane for Clinicians - Putting Evidence into Practice

Clinical Scenario

A new patient tells you that she read in a health magazine that people
with hypertension should take daily aspirin. She asks if you agree.

Clinical Question

Should we prescribe antiplatelet agents or anticoagulants for all
patients with hypertension?

Evidence-Based Answer

Antiplatelet agents should not be used in patients with hypertension and
no previous history of heart attack or stroke. However, these agents are
recommended for use in hypertensive patients who already have vascular
disease. Anticoagulants should not be used for prevention of vascular
events, alone or in combination with acetylsalicylic acid (ASA),\
in patients with elevated blood pressure. Currently, there is not enough
evidence to recommend the use of glycoprotein IIb/IIIa inhibitors,
ticlopidine, or clopidogrel for primary prevention of vascular events.
<http://www.aafp.org/afp/20050301/cochrane.html>

**Cardiovascular risk higher among patients with migraine**

CONCLUSIONS: Migraineurs, particularly with aura, have a higher
cardiovascular risk profile than individuals without migraine.

Scher AI et al. Cardiovascular risk factors and migraine: the GEM
population-based study. Neurology. 2005 Feb 22;64(4):614-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15728281>

**Control of Blood Pressure and Other Cardiovascular Risk Factors at
Different Practice Settings: Outcomes of Care Provided to Diabetic Women
Compared to Men**

Overall there were no gender differences in the percentage of patients
who achieved a goal blood pressure \<130/80 mm Hg or hemoglobin A1c
\<7%. Control of blood pressure and other CVD risk factors in diabetic
patients was largely suboptimal, especially for diabetic women. These
observations underscore the need for better strategies for control of
CVD risk in the diabetic population in general, and women in particular.
McFarlane SI et al Control of blood pressure and other cardiovascular
risk factors at different practice settings: outcomes of care provided
to diabetic women compared to men. J Clin Hypertens (Greenwich). 2005
Feb;7(2):73-80.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15722651>

Insulin Monotherapy vs. Combination Therapy

Clinical Question

Are combinations of insulin and oral agents more effective than insulin
monotherapy in patients with type 2 diabetes mellitus?

Evidence-Based Answer

NPH insulin and metformin taken at bedtime appears to be the most
favorable combination studied, but this conclusion is based on
poor-quality, inconsistent studies that measure disease-oriented
outcomes. There are no data on the effect of these drug combinations on
patient-oriented outcomes.

<http://www.aafp.org/afp/20050301/cochrane.html>

Lung Cancer Screening: Recommendation Statement

U.S. Preventive Services Task Force: D Recommendation

This statement summarizes the current U.S. Preventive Services Task
Force (USPSTF) recommendation on screening for lung cancer and the
supporting scientific evidence, and it updates the 1996 recommendations
contained in the Guide to Clinical Preventive Services, 2d ed.^1^ In
1996, the USPSTF recommended against screening for lung cancer **(\"D\"
recommendation)**. The task force now uses an explicit process in which
the balance of benefits and harms is determined exclusively by the
quality and magnitude of the evidence. As a result, current letter
grades are based on different criteria than those in 1996.

The complete information on which this statement is based, including
evidence tables and references, is available in the summary of the
evidence and in the systematic evidence review on this topic, available
through the USPSTF Web site
([http://www.preventiveservices.ahrq.gov](http://www.preventiveservices.ahrq.gov/))
and through the National Guideline Clearinghouse
([http://www.guideline.gov](http://www.guideline.gov/)).

This recommendation first appeared in Ann Intern Med 2004;140:738-9.

<http://www.aafp.org/afp/20050315/us.html>

**Primary care physicians often miss bipolar disorder**

CONCLUSIONS: In an urban general medicine clinic, a positive screen for
bipolar disorder appears to be common, clinically significant, and
underrecognized. Because of the risks associated with treating bipolar
disorder with antidepressant monotherapy, efforts are needed to educate
primary care physicians about the screening, management, and
pharmacotherapy of bipolar disorders. Das AK, et al. Screening for
bipolar disorder in a primary care practice. 1: JAMA. 2005 Feb
23;293(8):956-63.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15728166>

**Fish Oil Supplements May Be Safer Than Eating Fish**

CONCLUSIONS: Fish oil supplements are more healthful than the
consumption of fish high in organochlorines. Fish oils provide the
benefits of omega-3 fatty acids without the risk of toxicity. In
addition, fish oil supplements have been helpful in a variety of
diseases, including bipolar disorder and depression.

Melanson SF et al Measurement of organochlorines in commercial
over-the-counter fish oil preparations: implications for dietary and
therapeutic recommendations for omega-3 fatty acids and a review of the
literature. Arch Pathol Lab Med. 2005 Jan;129(1):74-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15628911>

**Treatment of Cholesterol Abnormalities (See Patient Education)**

<http://www.aafp.org/afp/20050315/1137.html>

**Oral Analgesics for Acute Nonspecific Pain**

<http://www.aafp.org/afp/20050301/913.html>

**Clostridium difficile-Associated Diarrhea**

<http://www.aafp.org/afp/20050301/921.html>

**Diagnosis and Management of Acute Pyelonephritis in Adults**

<http://www.aafp.org/afp/20050301/933.html>

**Mildly Elevated Liver Transaminase Levels in the Asymptomatic
Patient**

<http://www.aafp.org/afp/20050315/1105.html>

**Treatment of Vertigo (See Patient Education)**

<http://www.aafp.org/afp/20050315/1115.html>

**Urinalysis: A Comprehensive Review**

<http://www.aafp.org/afp/20050315/1153.html>

# Features {#features .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

## American Family Physician\*\* {#american-family-physician .Style-Heading-2-+-14-pt}

###### Patient-Oriented Evidence that Matters (POEMS)\*

Does Melatonin Improve Sleep in Asthmatic Women?

**Clinical Question:** Does melatonin improve sleep in women with
asthma?

###### Bottom Line: Melatonin improves sleep quality in women with asthma, but not in a clinically meaningful way. (Level of Evidence: 2b)

<http://www.aafp.org/afp/20050315/tips/22.html>

**\*POEM Rating system**: <http://www.infopoems.com/levels.html> **POEM
Definition:** <http://www.aafp.org/x19976.xml>

\*\* The AFP sites will sometimes ask for a username and password.
Instead just 'hit; cancel on the pop up password screen, and the page
you are requesting will come up without having to enter a username and
password.

#### ACOG {#acog .Style-Heading-4-+-Arial-14-pt-Underline}

**Pregestational diabetes mellitus.**

**ACOG Practice Bulletin No. 60**

**Summary of Recommendations and Conclusions**

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

-   Suspected fetal macrosomia is not an indication for induction of
    labor because induction does not improve maternal or fetal outcomes.

-   Antepartum fetal monitoring, including fetal movement counting, the
    nonstress test, the biophysical profile, and the contraction stress
    test when performed at appropriate intervals, is a valuable approach
    and can be used to monitor the pregnancies of women with
    pregestational diabetes mellitus.

-   Adequate maternal glucose control should be maintained near
    physiologic levels before conception and throughout pregnancy to
    decrease the likelihood of spontaneous abortion, fetal malformation,
    fetal macrosomia, intrauterine fetal death, and neonatal morbidity.

-   Patients and their families should be taught how to respond quickly
    and appropriately to hypoglycemia.

-   Preconceptional counseling for women with pre-gestational diabetes
    mellitus has been reported to be beneficial and cost-effective and
    should be encouraged.

-   The use of oral agents for control of type 2 diabetes mellitus
    during pregnancy should be limited and individualized until data
    regarding the safety and efficacy of these drugs become available.

-   To prevent traumatic birth injury, cesarean delivery may be
    considered if the estimated fetal weight is greater than 4,500 g in
    women with diabetes.

Pregestational diabetes mellitus. ACOG Practice Bulletin No. 60.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;105:675--85.

**Non-ACOG members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738045>

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb060.cfm>

#### AHRQ {#ahrq .Style-Heading-4-+-Arial-14-pt-Underline}

**First-week followup of newborns after hospital discharge is critical
to prevent severe jaundice and other problems**

<http://www.ahrq.gov/research/jan05/0105RA24.htm#head2>

#### Ask a Librarian: Diane Cooper, M.S.L.S. / NIH {#ask-a-librarian-diane-cooper-m.s.l.s.-nih .Style-Heading-4-+-Arial-14-pt-Underline}

**Salmonella from Pet Turtles-Again**

Although banned by the FDA, pet turtles have emerged as a source of
salmonella disease in children in Wisconsin and Wyoming recently. In
some cases, the turtles were given away with purchases in a souvenir
shop. Apparently the shop owner thought the FDA ban applied only to
selling, but that\'s not a loophole. In another case, the turtle was
sold \"for educational purposes,\" again, not a loophole. Health
departments can issue orders to stop distribution in both cases.
\"Salmonella infections usually (are) mild but can lead to\...septicemia
or meningitis (especially in infants and immunocompromised persons\" the
CDC warns. MMWR March 11, 2005;54:9

##### <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a3.htm>

#### Breastfeeding {#breastfeeding .Style-Heading-4-+-Arial-14-pt-Underline}

Resurgence of kernicterus attributed primarily to early discharge of
newborns

Neonatal Jaundice: Clinical Evidence Concise - BMJ

What are the effects of treatments for unconjugated hyperbilirubinemia
in term and preterm infants?

beneficial

*Exchange Transfusion.* We found no randomized controlled trials (RCTs)
on the effects of exchange transfusion versus no treatment or versus
phototherapy. There is general consensus that exchange transfusion is
effective in reducing serum bilirubin levels and in preventing
neurodevelopmental sequelae. In most of the RCTs comparing other
interventions, exchange transfusion was used successfully to reduce
serum bilirubin levels when those interventions failed to control the
rise of serum bilirubin.

*Phototherapy.* Two RCTs found that conventional phototherapy and
fiberoptic phototherapy reduced neonatal jaundice more effectively than
no treatment. One systematic review (which included quasirandomized and
randomized controlled trials) and one subsequent RCT found that
conventional phototherapy was more effective than fiberoptic
phototherapy, although subgroup analysis in the systematic review found
no significant difference between groups in preterm infants. No trials
included in the review evaluated the impact of either phototherapy
method on parent-infant bonding. One RCT found a greater effect with
double-conventional compared with single-conventional phototherapy, but
another RCT found no significant difference between double-fiberoptic
and single-conventional phototherapy. One systematic review (which
included quasirandomized and randomized controlled trials) found no
significant difference between fiberoptic plus conventional and
conventional phototherapy alone in additional phototherapy, exchange
transfusion, or percentage change in bilirubin after 24 hours, although
it noted a trend favoring the fiberoptic plus conventional group. Most
trials did not report kernicterus as an outcome. We found insufficient
evidence on the adverse effects of phototherapy.

unknown effectiveness

*Albumin Infusion.* We found no RCTs on the effects of albumin infusion
versus no treatment or versus other treatment.

*Home Versus Hospital Phototherapy.* We found no RCTs on the effects of
home phototherapy versus no treatment or versus hospital phototherapy.

Definition

Neonatal jaundice refers to the yellow coloration of the skin and sclera
of newborn infants that results from hyperbilirubinemia.

Incidence/Prevalence

Jaundice is the most common condition requiring medical attention in
newborn infants. About 50 percent of term and 80 percent of preterm
infants develop jaundice in the first week of life.^1^ Jaundice also is
a common cause of readmission to the hospital after early discharge of
newborn infants.^2^ Jaundice usually appears two to four days after
birth and disappears one to two weeks later, usually without the need
for treatment.

Etiology/Risk Factors

In most infants with jaundice, there is no underlying disease and the
jaundice is termed physiologic. Physiologic jaundice occurs when there
is accumulation of unconjugated bilirubin in the skin and mucous
membranes. It typically presents on the second or third day of life and
results from the increased production of bilirubin (caused by increased
circulating red cell mass and a shortened red cell lifespan) and the
decreased excretion of bilirubin (caused by low concentrations of the
hepatocyte binding protein, low activity of glucuronyl transferase, and
increased enterohepatic circulation) that normally occur in newborn
infants. In some infants, unconjugated hyperbilirubinemia may be
associated with breastfeeding (breast milk jaundice), and this typically
occurs after the third day of life. Although the exact cause of breast
milk jaundice is not clear, it is believed to be caused by an
unidentified factor in breast milk. Nonphysiologic causes include blood
group incompatibility (Rhesus or ABO problems), other causes of
hemolysis, sepsis, bruising, and metabolic disorders. Gilbert\'s and
Crigler-Najjar syndromes are rare causes of neonatal jaundice.

Prognosis

In the newborn infant, unconjugated bilirubin can penetrate the
blood-brain barrier and is potentially neurotoxic. Unconjugated
hyperbilirubinemia can, therefore, result in neurodevelopmental sequelae
including the development of kernicterus. Kernicterus is brain damage
arising from the deposition of bilirubin in brain tissue. However, the
exact level of bilirubin that is neurotoxic is unclear, and kernicterus
at autopsy has been reported in infants in the absence of markedly
elevated levels of bilirubin.^3^ Recent reports suggest a resurgence of
kernicterus in countries in which this complication had virtually
disappeared.^4^ This has been attributed primarily to early discharge of
newborns from the hospital.

#### [**http://www.aafp.org/afp/20050301/bmj.html**](http://www.aafp.org/afp/20050301/bmj.html) {#httpwww.aafp.orgafp20050301bmj.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-18 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CCC Corner Digest {#ccc-corner-digest .Style-Heading-4-+-Arial-14-pt-Underline}

#### Nicely laid out hard copy of a compact digest of last month's CCC Corner {#nicely-laid-out-hard-copy-of-a-compact-digest-of-last-months-ccc-corner .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Highlights include:]{.underline} {#highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

#### LEEP Treatment Increases Risk of Preterm Delivery in Future Pregnancies  {#leep-treatment-increases-risk-of-preterm-delivery-in-future-pregnancies-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Announcing the new OB/GYN Deputy Chief Clinical Consultant IHS {#announcing-the-new-obgyn-deputy-chief-clinical-consultant-ihs .Style-Heading-4-+-Arial-14-pt-Underline}

#### It makes it easy for moms to remember: 2 days, 2 weeks, and 2 months {#it-makes-it-easy-for-moms-to-remember-2-days-2-weeks-and-2-months .Style-Heading-4-+-Arial-14-pt-Underline}

Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important

Progesterone Treatment Decreases Preterm Birth Rate

Sexual Function After Hysterectomy

Screening for Ovarian Cancer: Not Recommended

Gender bias in child growth evaluations may miss disease in girls

Chronic disease antecedents arise in utero and infancy: The Barker
Hypothesis

Radio-Frequency Endometrial Ablation for Menorrhagia

Esterified Estrogen and Venous Thrombotic Risk

Infant Mortality: Bad News, Good News

#### Hormonal Contraceptives and Weight Gain {#hormonal-contraceptives-and-weight-gain-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Men have often been overlooked for routine chlamydia screening

#### Walk 2000 More Steps a Day and Never Gain Another Pound {#walk-2000-more-steps-a-day-and-never-gain-another-pound-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/050307_OL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/050307_OL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments050307_ol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-19 .Style-Heading-4-+-Arial-14-pt-Underline}

#### If you want a copy of the CCC Digest mailed to you each month, please contact [**nmurphy@scf.cc**](mailto:nmurphy@scf.cc) {#if-you-want-a-copy-of-the-ccc-digest-mailed-to-you-each-month-please-contact-nmurphyscf.cc .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-20 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Domestic Violence {#domestic-violence .Style-Heading-4-+-Arial-14-pt-Underline}

**Intimate Partner Violence During Pregnancy APRIL 2005 MCH EPI GRAND
ROUNDS**\
PRESENTER: Kenneth D. Rosenberg, MD, MPH

WHEN: Wednesday, April 6, 2005 at 2:00-3:00 pm EDT

WEBCAST REQUIREMENTS: To join the webcast, you must register at least a
day ahead of time at
[[http://www.uic.edu/sph/cade/mchepi/]{.underline}](http://www.uic.edu/sph/cade/mchepi/)

**Homicide is the 2nd leading cause of injury-related deaths among
pregnant and women**

\"For every 100,000 live births in the United States during 1991 through
1999, there were at least 2 women who died as a result of homicide
during pregnancy or within 1 year after pregnancy,\"

Chang J, Berg CJ, Saltzman LE, et al. 2005. Homicide: A leading cause of
injury deaths among pregnant and postpartum women in the United States,
1991-1999. American Journal of Public Health 95(3):471-477.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15727979>

**An easy palm-based downloadable domestic violence assessment tool**

In an effort to reach health practitioners and health professional
students who rely on palm-based electronic tools for quick reference,
the Family Violence Prevention Fund, in collaboration with Denise
Bilbao, MD and Leigh Kimberg, MD, recently created a new assessment tool
for domestic violence. Complete with tips on how to conduct inquiry,
assessment, intervention, documentation, and follow-up for domestic
violence, along with facts and web links, this palm ready tool is
available in two formats, for either the iSilo or Documents to Go text
readers. <http://endabuse.org/health/ipv/>

#### Elder Care News {#elder-care-news .Style-Heading-4-+-Arial-14-pt-Underline}

**Palliative care and hospice training in Anchorage, Alaska - May 10-12,
2005**

We have funds to support travel, per diem, and registration for three
persons from each Area.  This can be in the form of an interdisciplinary
team or individuals from different sites.  They can be tribal or IHS.
This is an interdisciplinary training, targeted toward physicians, NPs,
PAs, nurses, pharmacists, and behavioral health clinicians.

Federal travelers will be asked to generate their own travel orders and
arrangements and the costs will reimbursed directly from HQE.

Nonfederal travelers will have their travel arrangements made by ANTHC,
the conference contractor and reimbursement will be made by ANTHC to the
traveler. 

There is room for as many additional individuals from each Area as you
can send, with travel, per diem and registration costs (\$300) borne by
the Area, SU, or Tribe.  The registration cost is significantly less
than what it is actually costing for the conference and also includes a
toolkit including state-of-the art reference materials.

As in the past, we are asking that the CMO from each Area \"nominate\"
the team that will be supported from the Area.  CDs and DONs are asked
to send their nominations to their Area CMO.

Please send Dr. Finke the names and contact information for all
individuals traveling through the Area, indicating those \"nominated\"
for complete cost coverage and those additional folks whose programs
will be covering the costs.  We will register all of them directly.  If
there are additional funds available, we can, perhaps, help defray the
cost of additional trainees.

**The absolute deadline for nominations is Friday, April 1**

Contact <Bruce.Finke@ihs.gov> or
<http://www.ihs.gov/MedicalPrograms/ElderCare/Index.asp>

#### Family Planning {#family-planning .Style-Heading-4-+-Arial-14-pt-Underline}

**Women continue to die from unintended pregnancy**

...despite all that is known about them, nearly half of U.S. pregnancies
continue to be unintended, women continue to die from unintended
pregnancy, and adverse consequences of unintended pregnancy can be felt
throughout families, communities, and the larger society

Gardner J, Miller L. 2005. Promoting the safety and use of hormonal
contraceptives. Journal of Women\'s Health 14(1):53-60

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15692278>

**Effects of Contraception on Bone Mineral Density**

Women using depot medroxyprogesterone acetate contraception lost
approximately 3 percent in bone mineral density per year. Because this
form of contraception is intended for long-term use, they call for
additional studies to determine if the loss continues linearly and to
identify strategies to counteract the effect. Berenson AB, et al.
Effects of hormonal contraception on bone mineral density after 24
months of use. Obstet Gynecol May 2004;103:899-906.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121563>

**[OB/GYN CCC Editorial comment:]{.underline}**

Please see the January CCC Corner commentary on caution in use of DMPA
for greater than 2 years after the FDA Black Box Warning.

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0105_AOM.cfm>

#### Frequently asked questions {#frequently-asked-questions .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. What is the Indian Health policy for HIV screening in pregnancy?**

A. Our goal is to maximize our care by using 'opt out' HIV screening.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/HIVscreen21305.doc>

**Q. Should I prescribe Depo Provera as a long term agent for more than
2 years?**

A. There is concern about bone loss if used \> 2 yrs. Here are some
alternative strategies

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Depo21205.doc>

**Q. What preventive therapy is recommended for patients at high risk
for pre-eclampsia?**

A. Low dose aspirin is recommended for selected high risk patients.
Calcium is less certain.

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/AspirPreec21405.doc>

**Q. My patient is not doing too well with her hormone replacement
therapy. Options?**

A. There are many options: pharmacologic, behavioral, dietary, and
cultural.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/HRT21405.doc>

**Q. What are the best staffing ratios for my clinic and / or my
hospital?**

A. The best ratios provide effective care with dignity for your
patients. See below

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Staffing21205.doc>

**Q. What are some of the opportunities to provide care in Indian
women's health?**

A. Working in Indian Health can be a rewarding health care avenue. See
below

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Recruit21305.doc>

**Q. Is Depo Provera associated with weight gain or diabetes in American
Indians and Alaska Natives?**

A. Use of depot medroxyprogesterone acetate (DMPA) has commonly been
associated with weight gain, but not as much as you may expect.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DepoWeight22805.doc>

#### Hormone Replacement Update {#hormone-replacement-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Estrogen with or without progestin should not be prescribed for relief
of incontinence**

CONCLUSIONS: Conjugated equine estrogen alone and CEE + MPA increased
the risk of UI among continent women and worsened the characteristics of
UI among symptomatic women after 1 year. Conjugated equine estrogen with
or without progestin should not be prescribed for the prevention or
relief of UI. Hendrix SL et al. Effects of estrogen with and without
progestin on urinary incontinence. JAMA. 2005 Feb 23;293(8):935-48.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15728164&dopt=Abstract>

#### Information Technology {#information-technology .Style-Heading-4-+-Arial-14-pt-Underline}

**Computerized order entry system may increase risk of medication
errors**

[CONCLUSIONS:]{.underline} In this study, we found that a leading CPOE
system often facilitated medication error risks, with many reported to
occur frequently. As CPOE systems are implemented, clinicians and
hospitals must attend to errors that these systems cause in addition to
errors that they prevent. Koppel R et al. Role of computerized physician
order entry systems in facilitating medication errors. JAMA. 2005 Mar
9;293(10):1197-203.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15755942>

and

[CONCLUSIONS]{.underline}: Many CDSSs improve practitioner performance.
To date, the effects on patient outcomes remain understudied and, when
studied, inconsistent

Garg AX et al Effects of computerized clinical decision support systems
on practitioner performance and patient outcomes: a systematic review.
JAMA. 2005 Mar 9;293(10):1223-38.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15755945>

and

**Editorial:** Wears RL, Berg M. Computer technology and clinical work:
still waiting for Godot. JAMA. 2005 Mar 9;293(10):1261-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15755949>

**The use of an intranet-based prenatal record improves communication
among the outpatient office, the antepartum testing unit, and the labor
floor.**

CONCLUSION: The use of a paperless, hospital intranet-based prenatal
chart significantly improves communication among providers. LEVEL OF
EVIDENCE: II-3.\
Bernstein PS, Farinelli C, Merkatz IR. Using an electronic medical
record to improve communication within a prenatal care network. Obstet
Gynecol. 2005 Mar;105(3):607-12.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15738032&dopt=Abstract>

**UpToDate Version 13.1 Now Available; Includes Pediatrics**

Since our last release, our editors have updated more than 40% of our
topic reviews with new information. We encourage you to check out the
**\"What\'s New\"** section in the **\"Table of Contents\"** to access
the updates considered to be of particular interest by our editors.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**Tribal Connections**

The website is an important outreach tool to the American Indian/Alaska
Native (AI/AN) communities and for promoting [National Library of
Medicine (NLM)](http://www.nlm.nih.gov/) online resources like
MedlinePlus. What we have begun in our new phase is to provide editorial
content in the form of news articles and features about health and
wellness issues. <http://www.tribalconnections.org/>

**Native Web.org: Resource Database / Health**

<http://www.nativeweb.org/resources/health/>

#### International Health Update {#international-health-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Women, inequality, and the burden of HIV**

Driving through KwaZulu-Natal, South Africa, one is struck by the lush
farmland and beautiful coast. Beyond this panorama, however, lie rural
communities such as Umbumbulu, with its unemployment rate of 60 percent
and rampant violence, where 40 percent of women seeking prenatal care
are positive for the human immunodeficiency virus (HIV). Thandi Dlamini
(not her real name) grew up in a crowded four-room house in Umbumbulu
with 13 family members. As the youngest girl, she was charged with
cooking, cleaning, and caring for her elders. At 19 years of age, she
met her first boyfriend. From the perspective of...*.*

Ojikutu BO, Stone VE. Women, inequality, and the burden of HIV. N Engl J
Med. 2005 Feb 17;352(7):649-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716557&dopt=Abstract>

**Physician Missions With Doctors Without Borders: A Newsmaker Interview
With Christophe Fournier, MD**
<http://www.medscape.com/viewarticle/497076?src=nlpromo>

**UN Predicts Global Population of 9.1 Billion by 2050**

<http://www.medscape.com/viewarticle/500236?src=mp>

#### MCH Alert {#mch-alert-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Task Force presents recommendations for reducing violence**

Given that violence, particularly violence by and against juveniles, is
widespread and causes considerable morbidity and mortality in the United
States, the findings and recommendations in this report should be
relevant to most communities. Task Force on Community Preventive
Services. 2005. Recommendations to reduce violence through early
childhood home visitation, therapeutic foster care, and firearm laws.
American Journal of Preventive Medicine 28(2S1):6-10

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15698745>

#### Medscape\* {#medscape-1 .Style-Heading-4-+-Arial-14-pt-Underline}

######### Genital Herpes and Pregnancy: Preventing Neonatal Transmission (Archived Web Conference) [**http://www.medscape.com/viewprogram/3772?src=mp**](http://www.medscape.com/viewprogram/3772?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**](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.

#### Midwives Corner: Marsha Tahquechi, CNM, GIMC {#midwives-corner-marsha-tahquechi-cnm-gimc .Style-Heading-4-+-Arial-14-pt-Underline}

**Emergency OB Drills: The Phoenix Indian Medical Center Experience**

After attending the American Native Women's Health & Maternity Care
Conference in Albuquerque last August, the Phoenix Indian Medical Center
Midwifery Services created an Emergency OB Drill team, which includes
CNMs and RNs from the obstetrical services. The team has been holding
emergency OB drills in the areas of emergency cesarean section and
post-partum hemorrhage, with future plans to add eclamptic events and
shoulder dystocia. The drills have been quite successful with
participation from the OB/GYN providers, CNMs, RNs, and most ancillary
services, such as, anesthesia, laboratory, radiology, and respiratory
therapy. They have been instrumental in discovering areas to improved
and well received by staff.

#### [OB/GYN CCC Editorial comment:]{.underline}

## Thanks very much to Tami McBride, RNC; Karen Carey, CNM of PIMC for that posting

This is exactly what we all need to continue to do to keep up our skills
as a team.

See the previous comments on TOLAC in From Your Colleagues: Scott Sunde

## Here are other resources

Michele Lauria, M.D.: Emergency Delivery Simulations: How to Develop
Teamwork (PPT 728k)

[[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt)

or for all the lecture notes and slides

[[http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#MeetingLecNotes]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#MeetingLecNotes)

**Other Midwive Corner items:**

**Concern over rising cesarean delivery rate: ACNM approaches Congress**

The American College of Nurse Midwives in February sent a letter to
Congress expressing concern over the rising cesarean delivery rate (27%
in 2003) and the declining VBAC rate (10.6% in 2003) in this country.
They have asked Congress to explore these issues from a public health
perspective. <http://www.midwife.org/press/display.cfm?id=461>

**Ice Massage for the Reduction of Labor Pain**

Two recent studies have explored the use of ice message for the
reduction of pain in early labor. This technique may be added to the
armamentarium of providers for some patients seeking pain relief in
early labor.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14526344]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14526344)

**Alternative Medicines\' Popularity Prompts Concern**

Use of Alternative and Complementary Remedies on the Rise - Midwives and
Ob-Gyn providers are not strangers to the use of traditional and
alternative medicine in native populations. The Center for Complementary
and Alternative Medicine at NIH released a survey in May 2004
demonstrating the widespread use of CAM's across the nation. The need
for careful screening of ob-gyn patients in the use of CAM's at entry
into care is essential in safely and effectively treating patients. The
\"WHO Guidelines: Developing Information on Proper Use of Traditional,
Complementary and Alternative Medicine\" can be found online at
[[www.who.int/medicines/library/trm/consumer.pdf]{.underline}](http://www.who.int/medicines/library/trm/consumer.pdf)
Other resources

[http://nccam.nih.gov]{.underline}
<http://www.medscape.com/viewarticle/484309?src=search>

#### Office of Women's Health, CDC {#office-of-womens-health-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Spread the Word - National Women\'s Health Week, May 8-14, 2005**

Whether you are an individual, organization, health professional, or
other, you can participate. Host an event, spread the word or do what
you can to help women get the health screenings or information they need
<http://www.4woman.gov/whw/>

#### Osteoporosis {#osteoporosis .Style-Heading-4-+-Arial-14-pt-Underline}

**How best to start good bone health?**

CONCLUSION: Scant evidence supports nutrition guidelines focused
specifically on increasing milk or other dairy product intake for
promoting child and adolescent bone mineralization.

Lanou AJ, Berkow SE, Barnard ND. Calcium, dairy products, and bone
health in children and young adults: a reevaluation of the evidence.
Pediatrics. 2005 Mar;115(3):736-43.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15741380>

[Commentary]{.underline}\
Greer FR Bone Health: It\'s More Than Calcium Intake Pediatrics. 2005
Mar;115(3):792-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15741386>

**Clinical Rules Don\'t Predict Osteoporosis in Women**

CONCLUSIONS: Our results suggest that these clinical prediction rules do
not perform well as a general screening method to identify
postmenopausal women who are more likely to have osteoporosis; however,
the Osteoporosis Risk Assessment Instrument and Simple Calculated
Osteoporosis Risk Estimation may be useful in identifying some women who
need not undergo testing, especially younger postmenopausal women.

Mauck KF et al. Use of clinical prediction rules in detecting
osteoporosis in a population-based sample of postmenopausal women. Arch
Intern Med. 2005 Mar 14;165(5):530-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15767529&dopt=Abstract>

#### Patient Information {#patient-information .Style-Heading-4-+-Arial-14-pt-Underline}

**Consumer Health: Indian Health**

[[http://www.ihs.gov/MedicalPrograms/consumer-health/]{.underline}](http://www.ihs.gov/MedicalPrograms/consumer-health/)

**What Should I Know About Cholesterol?**

<http://www.aafp.org/afp/20050315/1147ph.html>

**Vertigo-A Type of Dizziness**

<http://www.aafp.org/afp/20050315/1129ph.html>

#### Primary Care Discussion Forum {#primary-care-discussion-forum .Style-Heading-4-+-Arial-14-pt-Underline}

**April 1, 2005: Methamphetamine use in Indian Country**

Moderator: Steve Holve

-How common is Methamphetamine use in your area?

-Should all mothers be screened at delivery for Methamphetamine use or
only if medically indicated?

-What resources are available in your community if a pregnant mother is
found to be using Methamphetamine?

-What resources are available for teenagers and adults who are
Methamphetamine users?

-What programs have shown success in treating Methamphetamine addiction?

### How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1>

Questions on how to subscribe, contact <nmurphy@scf.cc> directly

**STD Corner - Laura** **Shelby, STD Director, IHS**

**Women\'s Sexual Health and Sexually Transmitted Diseases -- Advances
in the Field **

May 13, 2005 San Francisco

Current advances in the intersecting fields of women's sexual health and
STDs. The conference proposes a sexual health agenda for the 21st
century. 7.25 CMEs; 8.7 CEUs

\(916\) 443-0218 or <Alex@RDLent.com>

[www.rdlent.com](http://www.rdlent.com/) or
<http://www.rdlent.com/index.cfm?fuseaction=agenda&cid=61>

####  {#section-22 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Other: {#other .Style-Heading-4-+-Arial-14-pt-Underline}

#### Expedited treatment of sex partners on persistent gonorrhea or chlamydial infection {#expedited-treatment-of-sex-partners-on-persistent-gonorrhea-or-chlamydial-infection-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Providing medication for the sexual partners of patients with gonorrhea or chlamydial infection without requiring the partners\' prior medical evaluation significantly reduced persistent or recurrent infections among participants {#providing-medication-for-the-sexual-partners-of-patients-with-gonorrhea-or-chlamydial-infection-without-requiring-the-partners-prior-medical-evaluation-significantly-reduced-persistent-or-recurrent-infections-among-participants .Style-Heading-4-+-Arial-14-pt-Underline}

#### Golden MR, Whittington WLH, Handsfield HH, et al. 2005. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. The New England Journal of Medicine, 352(7):676-685. {#golden-mr-whittington-wlh-handsfield-hh-et-al.-2005.-effect-of-expedited-treatment-of-sex-partners-on-recurrent-or-persistent-gonorrhea-or-chlamydial-infection.-the-new-england-journal-of-medicine-3527676-685. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15716561**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15716561) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15716561 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-23 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Barbara Stillwater, Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### Postmenopausal Women and Visceral Fat Loss through Exercise {#postmenopausal-women-and-visceral-fat-loss-through-exercise-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women with diabetes cannot rely on diet alone to get rid of the stomach bulge {#women-with-diabetes-cannot-rely-on-diet-alone-to-get-rid-of-the-stomach-bulge .Style-Heading-4-+-Arial-14-pt-Underline}

#### When a woman with type 2 diabetes wants to lose her belly, exercise is her best friend. Even if she diets perfectly, eating all the right foods in ideal amounts, her waistline may not budge unless she works out. Exercise is required to lose excess fat deep in the abdomen, says a new study. Diet alone did not reduce visceral fat. Only exercise alone or exercise plus dieting reduced visceral fat. The researchers say their study demonstrates the importance of exercise in reducing visceral fat in the treatment of women with type 2 diabetes. {#when-a-woman-with-type-2-diabetes-wants-to-lose-her-belly-exercise-is-her-best-friend.-even-if-she-diets-perfectly-eating-all-the-right-foods-in-ideal-amounts-her-waistline-may-not-budge-unless-she-works-out.-exercise-is-required-to-lose-excess-fat-deep-in-the-abdomen-says-a-new-study.-diet-alone-did-not-reduce-visceral-fat.-only-exercise-alone-or-exercise-plus-dieting-reduced-visceral-fat.-the-researchers-say-their-study-demonstrates-the-importance-of-exercise-in-reducing-visceral-fat-in-the-treatment-of-women-with-type-2-diabetes. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [In conclusion,]{.underline} modest weight loss, through either D or D+E, resulted in similar improvements in total abdominal fat, SAT, and glycemic status in postmenopausal women with type 2 diabetes; however, the addition of exercise to diet is necessary for VAT loss. These data demonstrate the importance of exercise in the treatment of women with type 2 diabetes. Giannopoulou I, et al. Excercise is required for visceral fat loss in postmenopausal women with type 2 diabetes. J Clin Endocrinol Metab. 2005 Mar;90(3):1511-8 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15598677**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15598677) {#in-conclusion-modest-weight-loss-through-either-d-or-de-resulted-in-similar-improvements-in-total-abdominal-fat-sat-and-glycemic-status-in-postmenopausal-women-with-type-2-diabetes-however-the-addition-of-exercise-to-diet-is-necessary-for-vat-loss.-these-data-demonstrate-the-importance-of-exercise-in-the-treatment-of-women-with-type-2-diabetes.-giannopoulou-i-et-al.-excercise-is-required-for-visceral-fat-loss-in-postmenopausal-women-with-type-2-diabetes.-j-clin-endocrinol-metab.-2005-mar9031511-8-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15598677 .Style-Heading-4-+-Arial-14-pt-Underline}

## 

## Minding the gender gap: The divergence between men\'s and women\'s health research

### Men and women are different \-- in ways beyond anatomy. A push to explore the chasm that separates research could give primary care more insight into the variations.

#### The NIH didn\'t require that women be included in clinical trials until 1993. {#the-nih-didnt-require-that-women-be-included-in-clinical-trials-until-1993. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here is just one example of the downstream result of these trends: {#here-is-just-one-example-of-the-downstream-result-of-these-trends .Style-Heading-4-+-Arial-14-pt-Underline}

### **Women\'s hearts at risk**

Women are still less likely than men to receive recommendations from
their physicians for preventive therapies such as cholesterol-lowering
drugs, aspirin therapy and cardiac rehabilitation to protect them from
heart disease and death, according to a new study.

#### Mieres JH et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005 Feb 8;111(5):682-96 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15687114**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15687114) {#mieres-jh-et-al.-role-of-noninvasive-testing-in-the-clinical-evaluation-of-women-with-suspected-coronary-artery-disease-consensus-statement-from-the-cardiac-imaging-committee-council-on-clinical-cardiology-and-the-cardiovascular-imaging-and-intervention-committee-council-on-cardiovascular-radiology-and-intervention-american-heart-association.-circulation.-2005-feb-81115682-96-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15687114 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-25 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Omitting breakfast on insulin sensitivity and fasting lipid: Deleterious effects [Conclusion:]{.underline} Omitting breakfast impairs fasting lipids and postprandial insulin sensitivity and could lead to weight gain if the observed higher energy intake was sustained {#omitting-breakfast-on-insulin-sensitivity-and-fasting-lipid-deleterious-effects-conclusion-omitting-breakfast-impairs-fasting-lipids-and-postprandial-insulin-sensitivity-and-could-lead-to-weight-gain-if-the-observed-higher-energy-intake-was-sustained .Style-Heading-4-+-Arial-14-pt-Underline}

#### Farshchi HR et al Deleterious effects of omitting breakfast on insulin sensitivity and fasting lipid profiles in healthy lean women. Am J Clin Nutr. 2005 Feb;81(2):388-96 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699226**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699226) {#farshchi-hr-et-al-deleterious-effects-of-omitting-breakfast-on-insulin-sensitivity-and-fasting-lipid-profiles-in-healthy-lean-women.-am-j-clin-nutr.-2005-feb812388-96-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15699226 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-26 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Waist circumference cutoffs for identifying cardiovascular disease risk factors {#waist-circumference-cutoffs-for-identifying-cardiovascular-disease-risk-factors .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusions: WC is a better indicator of CVD risk than is BMI in the 3 race-ethnicity groups studied. The proposed WC cutoffs are more sensitive than are BMI cutoffs in predicting CVD risk. {#conclusions-wc-is-a-better-indicator-of-cvd-risk-than-is-bmi-in-the-3-race-ethnicity-groups-studied.-the-proposed-wc-cutoffs-are-more-sensitive-than-are-bmi-cutoffs-in-predicting-cvd-risk. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Zhu S et al Race-ethnicity-specific waist circumference cutoffs for identifying cardiovascular disease risk factors. Am J Clin Nutr. 2005 Feb;81(2):409-15. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699228**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699228) {#zhu-s-et-al-race-ethnicity-specific-waist-circumference-cutoffs-for-identifying-cardiovascular-disease-risk-factors.-am-j-clin-nutr.-2005-feb812409-15.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15699228 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-27 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Beginning Exercise Routine Later in Life Still Reduces Heart Disease, Diabetes risk {#beginning-exercise-routine-later-in-life-still-reduces-heart-disease-diabetes-risk-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Higher fitness achieved over 10 years of regular exercise training in older adults was associated with reduced development of metabolic risk factors for cardiovascular disease, fewer exercise-induced cardiac abnormalities, and reduced comorbidity. {#conclusions-higher-fitness-achieved-over-10-years-of-regular-exercise-training-in-older-adults-was-associated-with-reduced-development-of-metabolic-risk-factors-for-cardiovascular-disease-fewer-exercise-induced-cardiac-abnormalities-and-reduced-comorbidity. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Petrella RJ, et al Can adoption of regular exercise later in life prevent metabolic risk for cardiovascular disease? : Diabetes Care. 2005 Mar;28(3):694-701  {#petrella-rj-et-al-can-adoption-of-regular-exercise-later-in-life-prevent-metabolic-risk-for-cardiovascular-disease-diabetes-care.-2005-mar283694-701 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15735210&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15735210&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids15735210doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-28 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Blood Pressure, Insulin Sensitivity Linked to Waist Circumference {#blood-pressure-insulin-sensitivity-linked-to-waist-circumference-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### These results suggest that the documented association between obesity, fasting insulin, insulin sensitivity, and blood pressure is largely explained by concomitant variation in WC. {#these-results-suggest-that-the-documented-association-between-obesity-fasting-insulin-insulin-sensitivity-and-blood-pressure-is-largely-explained-by-concomitant-variation-in-wc. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Poirier P, et al Impact of waist circumference on the relationship between blood pressure and insulin: the Quebec Health Survey. Hypertension 2005;45:347-348,363-367. {#poirier-p-et-al-impact-of-waist-circumference-on-the-relationship-between-blood-pressure-and-insulin-the-quebec-health-survey.-hypertension-200545347-348363-367. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15668356**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15668356) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15668356 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Commentary: Dr. Ele Ferrannini, University of Pisa School of Medicine, Pisa, Italy {#commentary-dr.-ele-ferrannini-university-of-pisa-school-of-medicine-pisa-italy .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hypertension 2005;45:347-348 {#hypertension-200545347-348 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-29 .Style-Heading-4-+-Arial-14-pt-Underline}

#### VHA Health Foundation 2005 Call for Proposals The VHA Health Foundation is challenging health care providers across the country to submit their best, most innovative programs for funding consideration. The Foundation will award grants ranging from \$100,000 to \$250,000 to support promising initiatives at the local level that represent a novel and/or significantly better approach to solving a problem or need related to health and/or health care. This program encourages creativity, innovation and the adoption and/or adaptation of new ideas and practices in the health care industry  [**www.vhahf.org**](http://www.magnetmail.net/ls.cfm?r=12268528&sid=440580&m=83127&u=AHA_HFSF_1&s=http://www.vhahf.org/). {#vha-health-foundation-2005-call-for-proposals-the-vha-health-foundation-is-challenging-health-care-providers-across-the-country-to-submit-their-best-most-innovative-programs-for-funding-consideration.-the-foundation-will-award-grants-ranging-from-100000-to-250000-to-support-promising-initiatives-at-the-local-level-that-represent-a-novel-andor-significantly-better-approach-to-solving-a-problem-or-need-related-to-health-andor-health-care.-this-program-encourages-creativity-innovation-and-the-adoption-andor-adaptation-of-new-ideas-and-practices-in-the-health-care-industry-www.vhahf.org. .Style-Heading-4-+-Arial-14-pt-Underline}

#### **The Letter of Intent deadline: April 18, 2005** **Full proposal:  May 13, 2005** {#the-letter-of-intent-deadline-april-18-2005-full-proposal-may-13-2005 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-30 .Style-Heading-4-+-Arial-14-pt-Underline}

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**Obesity: Surgical Treatment? Primary Care Forum Discussion Summary**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SumObe22805.doc>

**Obesity: Surgical Treatment? Primary Care Forum Discussion - Full**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ObesDisc31305.doc>

#### Q. How many deliveries does a provider need to maintain active privileges? {#q.-how-many-deliveries-does-a-provider-need-to-maintain-active-privileges-1 .Style-Heading-4-+-Arial-14-pt-Underline}

A. Those numbers should be set by the local Medical Staff. Here are some
examples

<http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Credent21905.doc>

There are several upcoming **Conferences**

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#top>

and **Online CME/CEU resources**, etc....

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm>

and the latest **Perinatology Corners** (free online CME from IHS) are
at

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHpericrnr.asp>

...or just take a look at the **What's New** page

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top>

# Save the dates {#save-the-dates .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

### **IHS Domestic Violence Prevention / Intentional Injuries Course**

-   April 5-8, 2005

-   Albuquerque, New Mexico

-   Contact Dr. Larry Berger: [bergerlaw@msn.com](../bergerlaw@msn.com)

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#apr2005>

**17th Annual IHS Research Conference: International Meeting on Inuit
and Native American Child Health: Innovations in clinical care and
research**

> April 29-May 1, 2005, Seattle, WA

<http://www.aap.org/nach/InternationalMeeting.htm>

**3rd Western MCH Epidemiology**

-   May 12-13, 2005

-   Portland, OR

-   <http://sphcm.washington.edu/mchepi2005/>

**American College of Obstetricians and Gynecologists Annual Clinical
Meeting**

-   May 7-11, 2005

-   San Francisco , California

-   53rd Annual ACOG ACM <http://www.acog.org/ACM2005/>

**Advances in Indian Health**

-   May 11-13, 2005

-   Albuquerque, NM

-   2004 Brochure (2005 pending)

-   [http://hsc.unm.edu/cme/2004%20Web%20Info/AIH2004/AIHIndex.shtml](http://hsc.unm.edu/cme/2004 Web Info/AIH2004/AIHIndex.shtml)

-   Contact <CNorth@abq.ihs.gov>

**Prevention of Cardiovascular Disease & Diabetes Among** **AI / AN**

-   May 16 - 19, 2005

-   Denver, CO

-   Co-sponsored by IHS, Joslin, ADA, NIH

-   <http://professionaled.joslin.org/CourseListing/CourseDesc.asp?intCourseTypeId=4&intCourseID=1269&strFullInd=Y>

**Native American Women's Health: Leadership for Change Conference**

-   May 19 -20, 2005

-   Denver, CO

-   Office on Women's Health, DHHS

-   Invitation for Dialogue, Planning, and Commitment to Health

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May05>

**2005 U.S. Public Health Conference/Global Health Summit**

-   June 5-9, 2005

-   Philadelphia, PA, Development of the Report on Global Health

-   40^th^ Annual U.S. Public Health Professional Conference, June 6-9,
    2005

-   [www.coausphsconference.org](../../../../../../../../exchweb/bin/redir.asp%3FURL=http://www.coausphsconference.org/)

**I.H.S. / A.C.O.G. Postgraduate Course: Obstetric, Neonatal, and
Gynecologic Care**

-   June 19 - 23, 2005

-   Denver, CO

-   Contact [Yvonne Malloy](mailto:YMalloy@acog.org) <YMalloy@acog.org>
    202-863-2580

-   Save the date info
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc>

-   2005 Brochure

```{=html}
<!-- -->
```
-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/Brochure2005EL.doc>

-   June 19th at 8:00 am: NEONATAL RESUSCITATION PROGRAM

```{=html}
<!-- -->
```
-   NRP Class size limited. Sign up now
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc>

```{=html}
<!-- -->
```
-   Meeting Website
    <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June05>

**National Summit on Preconception Care**

-   JUNE 21-22, 2005

-   Atlanta, Georgia

-   Catalyst for national recommendations for preconception care, CDC

-   <http://www.signup4.net/Public/ap.aspx?EID=NATI14E>

# Did you miss something in the last OB/GYN Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-obgyn-chief-clinical-consultant-corner .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### The February 2005 OB/GYN CCC Corner is available at: {#the-february-2005-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0205.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0205.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0205.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month: page 3 {#abstract-of-the-month-page-3 .Style-Heading-4-+-Arial-14-pt-Underline}

LEEP Treatment Increases Risk of Preterm Delivery in Future Pregnancies

#### From your colleagues: page 4 {#from-your-colleagues-page-4 .Style-Heading-4-+-Arial-14-pt-Underline}

Elaine Locke: Free Job Postings for Indian Facilities on ACOG Career
Connection

**Sandra Haldane:** Web portal linking all HHS.gov sites to breast
cancer information

-Women and Medication Safety: Special Journal Issue Is Available Online

#### Steve Holve: How common is Methamphetamine use in your area? Feb '05 ICHN available {#steve-holve-how-common-is-methamphetamine-use-in-your-area-feb-05-ichn-available .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jean Howe: Announcing the new Deputy Chief Clinical Consultant {#jean-howe-announcing-the-new-deputy-chief-clinical-consultant .Style-Heading-4-+-Arial-14-pt-Underline}

**Yolanda Meza:** Routine suctioning of meconium-stained before delivery
of the shoulders?

Suzan Murphy: Methamphetamine abuse and breastfeeding

**Chuck North:** Patients with more than one medical condition: How can
guidelines help?

-Single digit need to treat (NNT) obesity are remarkable statistics -
should spur us on

#### Lori de Ravello: Contraceptive Methods Among Women: Quickstats {#lori-de-ravello-contraceptive-methods-among-women-quickstats .Style-Heading-4-+-Arial-14-pt-Underline}

**Judy Thierry:** Discourage use of infant car seats as long term sleep
environments

-Training for Nursery Room Nurses on Back to Sleep

-Tony Dekker, M.D. New Addiction Medicine Chief Clinical Consultant
(CCC)

-The Chief Clinical consultants - are available for your consultation

-What is the definition of 'preventable or avoidable maternal death?

**Judy Whitecrane:** It makes it easy for moms to remember: 2 days, 2
weeks, and 2 months

#### Hot Topics:  {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics: page 10

-Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important

-Progesterone Treatment Decreases Preterm Birth Rate

-Ripening of the Cervix and Risk for Later Preterm Birth

-Ginger May Relieve Nausea During Early Pregnancy

-Effect of Episiotomy on Pelvic Floor Weakness

**Gynecology: page 12**

-Sexual Function After Hysterectomy

-Screening for Ovarian Cancer: Recommendation Statement

#### -Limitations of Screening Tests for Asymptomatic Chlamydia {#limitations-of-screening-tests-for-asymptomatic-chlamydia .Style-Heading-4-+-Arial-14-pt-Underline}

-Abnormal Uterine Bleeding: Surgical or Medical Therapy?

-Endometriosis and Subfertility: Is the Relationship Resolved?

**Child Health: page 13**

-Gender bias in child growth evaluations may miss disease in girls

-Recommended Childhood and Adolescent Immunization Schedule, United
States, 2005

-Protective effects of firearm storage practices for children

-Dramatic decline in varicella related mortality: Impact of vaccine

-Oral health is looking to better capture the topical fluoride
applications

**Chronic Illness and Disease: page 14**

-Quality of Care May Decline as Physicians Age

-Chronic disease antecedents arise in utero and infancy

-JAMA Editorialist recommends the \"low fad\" approach

-Diabetes Mellitus in Women: Adolescence Through Pregnancy and Menopause

-Irritable Bowel Syndrome: Clinical Evidence Concise - BMJ

#### Features: page 17 {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Radio-Frequency Endometrial Ablation for Menorrhagia

-Esterified Estrogen and Venous Thrombotic Risk

-Physical Therapy and Stress Urinary Incontinence

-Lactobacillus Does Not Prevent Post-Antibiotic Vaginitis

-Antidepressants and Smoking Cessation

ACOG

Coping With the Stress of Medical Professional Liability Litigation

**AHRQ**

**-**Computerized Order Entry Leads to Unwanted Testing- Web M + M -
Clinical Ethics

-Women who have given birth only via cesarean are less likely than those
with vaginal -deliveries to report stress incontinence

**Ask a Librarian**

-Infant Mortality: Bad News, Good News

**Breastfeeding**

**-**American Academy of Pediatrics Revised policy on Breastfeeding

**CCC Corner Digest**

#### -A compact digest of last month's CCC Corner - Highlights include:  {#a-compact-digest-of-last-months-ccc-corner---highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

#### Depo Provera and bone loss {#depo-provera-and-bone-loss .Style-Heading-4-+-Arial-14-pt-Underline}

#### Oral rehydration solution -- reverse transfer of technology {#oral-rehydration-solution-reverse-transfer-of-technology .Style-Heading-4-+-Arial-14-pt-Underline}

#### What maneuver is in best in shoulder dystocia? {#what-maneuver-is-in-best-in-shoulder-dystocia .Style-Heading-4-+-Arial-14-pt-Underline}

#### Midwives serving in Indian Country {#midwives-serving-in-indian-country .Style-Heading-4-+-Arial-14-pt-Underline}

#### Marriage may be good for you {#marriage-may-be-good-for-you .Style-Heading-4-+-Arial-14-pt-Underline}

#### Consumer Reports evaluates condoms, and 16 other contraceptive methods {#consumer-reports-evaluates-condoms-and-16-other-contraceptive-methods .Style-Heading-4-+-Arial-14-pt-Underline}

#### Bariatric surgery may be a viable treatment option in severe obesity, etc...  {#bariatric-surgery-may-be-a-viable-treatment-option-in-severe-obesity-etc .Style-Heading-4-+-Arial-14-pt-Underline}

**Domestic Violence**

-Intimate Partner Violence During Pregnancy APRIL 2005 MCH EPI GRAND
ROUNDS

-Primary Care Discussion Forum: Domestic Violence in AI/AN - Just
finished

-Assaults during pregnancy: both immediate and long-term adverse
neonatal outcomes

**Elder Care News**

-Caring for elders at home: what is the best bath strategy?

-Cultural Diversity at the End of Life: Issues and Guidelines

-Management of Hypertension in Older Persons

-White House Conference on Aging

**Family Planning**

-Do combination hormonal contraceptives cause weight gain?

-Availability and Use of Publicly Funded Family Planning Clinics

**Frequently asked questions**

What is the Indian Health policy on use of chaperones?

How does one manage possible exposure to hand foot and mouth disease in
pregnancy?

The 'quad' second trimester screening test is expensive. Is it worth it?

.How can you predict if a placenta previa will persist based on US at
15-24 weeks?

**Hormone Replacement Update**

Benefits and Risks of Estrogen in Postmenopausal Women

**Information Technology**

Free CME from Harvard to 60 of our providers

International Health

Institute for OneWorld Health \-- A Not-for-Profit Pharmaceutical
Company

#### MCH Alert

-Entire supplement on sleep in children: Cultural impacts

#### Medscape

**Midwives Corner**

#### Office of Women's Health, CDC

-Cesarean Rate Highest Ever

Osteoporosis

-"Uncertain Role" of Biochemical Markers Use in Osteoporosis Therapy

-Fracture Protection Lost Five Years After Stopping Hormone Replacement
Therapy

-Impact of Intense Exercise on Early Osteopenia in Women

Patient Education

-Painful Menstrual Periods

-Urinary Tract Infections

-Pelvic Floor Muscle Exercises

-Microscopic Hematuria

-Heart Palpitations

Primary Care Discussion Forum

-April 1, 2005: Methamphetamine use in Indian Country

STD Corner

-Men have often been overlooked for routine chlamydia screening

#### Barbara Stillwater, Alaska Diabetes Prevention and Control

-Walk 2000 More Steps a Day and Never Gain Another Pound

-Fit And Fat Not Good Enough

-15-Year Study Shows Link Between Fast Food, Obesity and Insulin
Resistance

-How Well Do Adults Follow Prescriptions for insulin?

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@scf.cc>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp>

3/20/05njm