News Flash

-Suzan Murphy, PIMC: New regular columnist - Breastfeeding column

**-Vaginal Birth after Cesarean - New Perinatology Corner Module -- 2
credits**

![](media/image1.png){width="5.998611111111111in"
height="1.3034722222222221in"}

**OB/GYN Chief Clinical Consultant's Corner**

**Volume 4, No. 1, January 2006**

#### Contents: {#contents .Style-Style-Heading-4-+-Arial-14-pt-Underline-+-16-pt}

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

**Link between GDM and Type 2 DM: Can be Broken**

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

#### From your colleagues: page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Carolyn Aoyama {#carolyn-aoyama .Style-Heading-4-+-Arial-14-pt-Underline}

Gestational Diabetes: ACOG / IHS Obstetrics, Neonatal and Gynecologic
Care

####  {#section-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

Vitamin D Levels During Pregnancy Affect Childhood Bone Mass

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

#### Chuck North {#chuck-north .Style-Heading-4-+-Arial-14-pt-Underline}

Chew Your Fowl Carefully

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

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

#### -Maternal weight gain during pregnancy - archived web cast {#maternal-weight-gain-during-pregnancy---archived-web-cast .Style-Heading-4-+-Arial-14-pt-Underline}

-April Conference - AIAN children with educational needs - parents,
advocates

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

**Tom and Edie Welty**

Integrating prevention of mother-to-child HIV transmission into routine
antenatal care

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

##### Obstetrics page 10

-Bed Rest for pregnancy related hypertension: Bed rest should not be
recommended

-Simulation training improves resident performance of a simulated
vaginal breech delivery

-Women Coached To Push During Labor Have Little Advantage Over Women Not
Coached

-Follow-up on Paroxetine change from Class C to Class D

-Sufficient evidence to support implementing first-trimester Down
syndrome risk: NIH

-and more....

**Gynecology page 15**

-Prior Function and Relationship, More Than Hormones, Affect Sexual
Function in Midlife

-HPV-16 vaccine provides high-level protection against CIN for at least
3.5 years

-Have you had trouble clearing up vaginal condyloma or CIN?

-Rectocele xenograft repair: Unsatisfying anatomical cure rate 3 years
postoperatively

-Patient-Administered Analgesic Gas Helpful During Colposcopy

-and more....

**Child Health page 16**

-Cerebral Palsy: An Overview

-Oral Contraceptives and Dysmenorrhea in Adolescents

-Controlling Obesity: School, Work, and Leisure

-Screening and Interventions for Overweight in Children and Adolescents:
USPSTF

**Chronic Illness and Disease: page 18**

-Waking up to Sleep Deprivation

-Medications for Migraine Prophylaxis

-Aromatase inhibitors\--a triumph of translational oncology

-Regular Walking Slows Decline in Patients With Peripheral Arterial
Disease

#### Features: page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

## IVF Therapy for Unexplained Infertility - Cochrane for Clinicians {#ivf-therapy-for-unexplained-infertility---cochrane-for-clinicians .Style-Heading-2-+-14-pt}

American College of Obstetricians and Gynecologists

\"Do Not Use\" Abbreviations

-Vaginal Birth Not Associated With Incontinence Later in Life

-Research Finds 40% of Pregnancy-Related Deaths Potentially Preventable

**Agency for Healthcare Research and Quality**

#### -Younger women more satisfied when a reproductive health specialist is their primary provider {#younger-women-more-satisfied-when-a-reproductive-health-specialist-is-their-primary-provider .Style-Heading-4-+-Arial-14-pt-Underline}

-Uterine artery embolization for uterine fibroids is a low-risk
procedure

#### -More high-quality studies needed to gauge safety of induced labor with prior cesarean deliveries {#more-high-quality-studies-needed-to-gauge-safety-of-induced-labor-with-prior-cesarean-deliveries .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Some State-level policies are associated with women\'s mortality rates for certain diseases {#some-state-level-policies-are-associated-with-womens-mortality-rates-for-certain-diseases .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Clinicians are more likely to counsel youth diagnosed with obesity about diet and exercise {#clinicians-are-more-likely-to-counsel-youth-diagnosed-with-obesity-about-diet-and-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

**Ask a Librarian**

Interested in Maternal and Child Health topics**?**

**Breastfeeding**

-Duration of Lactation and Incidence of Type 2 Diabetes

-Special Editorial: Suzan Murphy, new CCCC columnist

-New studies shows a 15% reduction for the risk of diabetes for every
year of lactation

**CCC Corner Digest**

#### -[Routine screening for protein and glucose at each prenatal visit should be abandoned](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_AOM.cfm) {#routine-screening-for-protein-and-glucose-at-each-prenatal-visit-should-be-abandoned .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[How do you know when you have a false positive HIV test in pregnancy?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#how-do-you-know-when-you-have-a-false-positive-hiv-test-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Paroxetine's pregnancy category changed from C to D](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#ob) {#paroxetines-pregnancy-category-changed-from-c-to-d .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Editorial: Vaccine prevents cervical cancer, Gardasil: Preliminary results 100% effective](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#editorial-vaccine-prevents-cervical-cancer-gardasil-preliminary-results-100-effective .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Handle abnormal Pap smears differently in adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#gyn) {#handle-abnormal-pap-smears-differently-in-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Quick Assessment of Literacy in Primary Care: The Newest Vital Sign](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#chrIll) {#quick-assessment-of-literacy-in-primary-care-the-newest-vital-sign .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Inappropriate use of the terms fetal distress and birth asphyxia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#acog) {#inappropriate-use-of-the-terms-fetal-distress-and-birth-asphyxia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[New studies shows a 15% reduction for the risk of diabetes for every year of lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#breast) {#new-studies-shows-a-15-reduction-for-the-risk-of-diabetes-for-every-year-of-lactation .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[New cigarettes with flavors that appeal to youth](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#alert) {#new-cigarettes-with-flavors-that-appeal-to-youth .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[CC:   I feel really cold and my side hurts, plus I am shaking all over](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#mmtour) {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-over .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[WHI clinical trial revisited: Imprecise methodology disqualifies the study\'s outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#mscape) {#whi-clinical-trial-revisited-imprecise-methodology-disqualifies-the-studys-outcomes .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Post Partum Hemorrhage is the most common cause of maternal mortality worldwide](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives) {#post-partum-hemorrhage-is-the-most-common-cause-of-maternal-mortality-worldwide .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Liability in Triage: Management of EMTALA Regulations and Common Obstetric Risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives) {#liability-in-triage-management-of-emtala-regulations-and-common-obstetric-risks .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[MRSA presents new challenges in treating skin and soft-tissue infections, including in pregnancy...](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#navajo) {#mrsa-presents-new-challenges-in-treating-skin-and-soft-tissue-infections-including-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Many new additions to the Indian Health Guidelines / Patient Education web page](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#many-new-additions-to-the-indian-health-guidelines-patient-education-web-page .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Meconium Happens](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#periPicks) {#meconium-happens .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Cardiology Topics for Primary Care Providers -- February 15, 2006](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#pcf) {#cardiology-topics-for-primary-care-providers-february-15-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[High-Risk HPV Associated with Chlamydia trachomatis with Female Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#std) {#high-risk-hpv-associated-with-chlamydia-trachomatis-with-female-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Type 2 diabetes mortality in women: Same as a \"coronary heart disease equivalent\"](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#stillW) {#type-2-diabetes-mortality-in-women-same-as-a-coronary-heart-disease-equivalent .Style-Heading-4-+-Arial-14-pt-Underline}

\-[21st Annual Midwinter Indian Health OB / PEDS
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#dates)
January 27-29, 2006

**Domestic Violence**

-Sexual Assault Services Delivered by SANES

-The Truth About Rape, CDC

#### -Post-traumatic Stress Disorder - Clinical Evidence Concise {#post-traumatic-stress-disorder---clinical-evidence-concise .Style-Heading-4-+-Arial-14-pt-Underline}

**Elder Care News**

Anticholinergic Drugs for Overactive Bladder - Cochrane for Clinicians

**Family Planning**

-Emergency Contraception Use Not Associated With Risky Sexual Behavior

#### -FDA Safety Changes: ParaGard Copper T 380A  {#fda-safety-changes-paragard-copper-t-380a .Style-Heading-4-+-Arial-14-pt-Underline}

-Hysteroscopic Sterilization May Offer Advantages Over Laparoscopic
Procedure

-Emergency Contraception: AAP Review

Featured Website

Vaginal Birth after Cesarean, New Perinatology Corner Module -- 2
credits

**Frequently asked questions**

What factors effect when we should we start colon cancer screening in
low risk adults?

**Indian Child Health Notes**

-Recommendation for Universal Influenza Immunization in Children Age 6
to 23 Months

-Hepatitis A Vaccine: Nice Success Story - New Recommendations

## -Native American Child Health Advocacy Award -- Call for Nominations

**Information Technology**

-Just out: IHS Information Technology News -- January 2006

-Family Medicine Patients' Use of the Internet for Health Information

International Health

-Association Between Reproductive Health-Related Medical Claims and
Criminal Activity or

-Experience of Abuse among Medicaid-enrolled Adolescent Females

-Reproductive Health Claims and Risk of Abuse among Medicaid-enrolled
Adolescent Females

#### MCH Alert

#### Girl Talk: Choices and Consequences of Underage Drinking

#### Medical Mystery Tour

#### CC: I feel really cold and my side hurts, plus I am shaking all {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

#### WHI Trial Seen Flawed; Alternative Hormone Replacement Regimen Proposed {#whi-trial-seen-flawed-alternative-hormone-replacement-regimen-proposed .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Shoulder Dystocia

-The 'CCC Deliver Through' maneuver for Shoulder Dystocia Prevention

-Hurricane-Related Information for Pregnant and Breastfeeding Women

-System errors in intrapartum electronic fetal monitoring: a case review

**Navajo News**

-Depo-Provera available in a lower dose: limited data to assess 104mg SQ
vs. 150mg IM

#### -Who do you contact in Navajo Area for MCH issues?  {#who-do-you-contact-in-navajo-area-for-mch-issues .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

-Fetal Alcohol Syndrome: Nursing Perspective

#### -Seeking Executive Nurse Leaders  {#seeking-executive-nurse-leaders .Style-Heading-4-+-Arial-14-pt-Underline}

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

Oral Fluid Rapid HIV Antibody Tests Being Investigated: Current
protocols should continue to be followed

**Oklahoma Perspective**

Who do you contact in Oklahoma Area for MCH issues?

Osteoporosis

Exercise, Calcium Supplementation May Improve BMD in Postmenopausal
Women 

Patient Education

-Diabetes and Pregnancy Frequently Asked Questions, CDC

#### -Cognitive Therapy for Depression: What You Should Know {#cognitive-therapy-for-depression-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

-Cerebral Palsy in Children: What You Should Know

-Medicines to Prevent Migraine Headaches

Perinatology Picks

Medicines to Prevent Migraine Headaches

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- February 15, 2006

STD Corner

#### Clinician-Delivered Intervention During Routine Clinical Care Reduces Unprotected Sexual Behavior {#clinician-delivered-intervention-during-routine-clinical-care-reduces-unprotected-sexual-behavior .Style-Heading-4-+-Arial-14-pt-Underline}

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

-High-Normal Fasting Blood Sugar Above 87 mg/dL Could Signal Diabetes
Risk

-Antidepressants Are No Match for Poverty

-Now science allows us all an extra 7lb of fat - at no extra risk

-New Guidelines Available to Raise HDL Cholesterol

-Coffee consumption may reduce breast cancer risk

-and more....

###### Save the Dates: Upcoming events of interest page 44

#### What's new on the ITU MCH web pages page 45

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

#  {#section-5 .Style-Heading-1-+-Underline}

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

**Link between GDM and Type 2 DM can be broken**

Type 2 diabetes frequently results from progressive failure of
pancreatic beta-cell function in the presence of chronic insulin
resistance. We tested whether chronic amelioration of insulin resistance
would preserve pancreatic beta-cell function and delay or prevent the
onset of type 2 diabetes in high-risk Hispanic women.

[Methods:]{.underline} Women with previous gestational diabetes were
randomized to placebo (n = 133) or the insulin-sensitizing drug
troglitazone (400 mg/day; n = 133) administered in double-blind fashion.
Fasting plasma glucose was measured every 3 months, and oral glucose
tolerance tests (OGTTs) were performed annually to detect diabetes.
Intravenous glucose tolerance tests (IVGTTs) were performed at baseline
and 3 months later to identify early metabolic changes associated with
any protection from diabetes. Women who did not develop diabetes during
the trial returned for OGTTs and IVGTTs 8 months after study medications
were stopped.

[Results"]{.underline} During a median follow-up of 30 months on blinded
medication, average annual diabetes incidence rates in the 236 women who
returned for at least one follow-up visit were 12.1 and 5.4% in women
assigned to placebo and troglitazone, respectively (P \< 0.01).

Protection from diabetes in the troglitazone group

1\) was closely related to the degree of reduction in endogenous insulin
requirements 3 months after randomization,

2\) persisted 8 months after study medications were stopped, and

3\) was associated with preservation of beta-cell compensation for
insulin resistance.

[Conclusion]{.underline}:

Treatment with troglitazone delayed or prevented the onset of type 2
diabetes in high-risk Hispanic women. The protective effect was
associated with the preservation of pancreatic beta-cell function and
appeared to be mediated by a reduction in the secretory demands placed
on beta-cells by chronic insulin resistance.

[Buchanan
TA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Buchanan+TA"%5BAuthor%5D),
et al Preservation of pancreatic beta-cell function and prevention of
type 2 diabetes by pharmacological treatment of insulin resistance in
high-risk hispanic women.
[Diabetes.](javascript:AL_get(this, 'jour', 'Diabetes.');) 2002
Sep;51(9):2796-803

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12196473&query_hl]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12196473&query_hl)

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

Buchanan et al is the first RCT to show prevention or delay in the onset
of type 2 diabetes in former gestational diabetes mellitus (GDM)
patients.

Kim et al showed that in gestational diabetes mellitus (GDM) the
cumulative incidence of diabetes ranged to over 70% in studies that
examined women 6 weeks postpartum to 28 years postpartum. Cumulative
incidence of type 2 diabetes increased markedly in the first 5 years
after delivery and appeared to plateau after 10 years. An elevated
fasting glucose level during pregnancy was the risk factor most commonly
associated with future risk of type 2 diabetes. Targeting women with
elevated fasting glucose levels during pregnancy may prove to have the
greatest effect for the effort required. The above RCT by Buchanan et al
that the onset of type 2 DM could be delayed or prevented in women with
a history of GDM.

There is evidence that a number of pharmacologic interventions may be of
value in preventing the development of type 2 diabetes in patients with
impaired glucose tolerance (or prediabetes). Drug therapy with metformin
(a biguanide) or acarbose (an alpha-glucosidase inhibitor) has been
shown to delay or prevent the progression of impaired glucose tolerance
to type 2 diabetes.

The thiazolidinedione troglitazone, which is no longer available, has
also been shown to have a similar effect to other insulin sensitizers.
Current expert opinion is that this is most likely a class effect, and
is not specific to troglitazone only.

Troglitazone was removed from the market due to cases of hepatic
failure.  That is part of the reason for the required LFT monitoring
with pioglitazone and rosiglitazone.  Pioglitazone and rosiglitazone do
not seem to cause hepatic failure as troglitazone did.  Pioglitazone and
rosiglitazone are considered similar to troglitazone and safe.  It was
initially recommended to monitor liver function test (LFT's) at baseline
and every 2 months for the first year of therapy, periodically
thereafter.  The package insert has been relaxed and now recommends
LFT's at baseline and periodically thereafter.

While the particular pharmacological treatment used by Buchanan et al is
no longer available to us, it appears that it was a drug class effect
not limited to that particular agent. On the other hand, diet, exercise
and metformin are widely available.

+-----------+-----------+-----------+-----------+-----------+-----------+
| Study     | P         | N         | Int       | Duration  | Results   |
|           | opulation |           | ervention |           |           |
+-----------+-----------+-----------+-----------+-----------+-----------+
| Da Quing  | IGT       | 577       | Diet      | 6 years   | -42%      |
|           |           |           |           |           |           |
|           |           |           | Exercise  |           |           |
+-----------+-----------+-----------+-----------+-----------+-----------+
| Finnish   | IGT       | 521       | Diet      | 6 years   | -58%      |
| DPS       |           |           |           |           |           |
|           |           |           | Exercise  |           |           |
+-----------+-----------+-----------+-----------+-----------+-----------+
| NIH DPP   | IGT       | 3324      | Diet +    | 3+ years  | -58%      |
|           |           |           | Excers    |           |           |
|           |           |           |           |           | -31%      |
|           |           |           | Metformin |           |           |
+-----------+-----------+-----------+-----------+-----------+-----------+
| TRIPOD    | GDM       | 235       | Tro       | 3 years   | -56%      |
|           |           |           | glitazone |           |           |
+-----------+-----------+-----------+-----------+-----------+-----------+
| Stop --   | IGT       | 1429      | Acarbose  | 3 years   | -21%      |
|           |           |           |           |           |           |
| NIDDM     |           |           |           |           |           |
+-----------+-----------+-----------+-----------+-----------+-----------+

**Background:**

Type 2 diabetes now affects younger individuals more commonly and it is
well known that a significant fraction of those with type 2 diabetes
remain undiagnosed. Current estimates suggest that up to one third of
adults with diabetes in this country remain undiagnosed. Historically,
up to 50% of those with diabetes were diagnosed AFTER complications of
diabetes developed. In the majority of cases these were cardiovascular
complications.

The most important concept to remember about type 2 diabetes is that
insulin resistance and ß-cell function are tightly linked. In the time
period before type 2 diabetes develops (pre-diabetes), insulin
resistance may already be present or may be developing. Insulin
secretion is often increased, but fasting and post-meal blood glucose
levels are normal during much of this period. However, at some point,
those at risk for type 2 diabetes can no longer increase or maintain
insulin secretion at levels that compensate for the insulin resistance.

When insulin secretion can no longer match the demands of cellular
insulin resistance, glucose intolerance develops. In its earliest
phases, mild to moderate glucose intolerance develops after meals.
Ultimately, insulin secretion falls short of insulin demands to such a
degree that even fasting hyperglycemia develops, and once fasting
glucose exceeds 126 mg/dL, diabetes is said to be present However, the
process leading to this disorder has likely been progressing for many
years.

Once diabetes develops, two features of the natural history of diabetes
should be emphasized. First, insulin resistance is very likely a
persistent defect. Second, insulin deficiency is probably progressive,
with declining insulin levels over time often associated with
deterioration in glycemic control. For the clinician, this natural
history suggests that early treatment (and even prevention) of type 2
diabetes, insulin resistance, and ß-cell dysfunction will likely be
needed to best manage the hyperglycemia characteristic of this disease.
In addition, this figure suggests that combination therapy for type 2
diabetes will probably be needed in a significant fraction of patients
to address the dual roles of insulin resistance and insulin deficiency.

In individuals with impaired glucose tolerance or impaired fasting
glucose, the loss of 5%-7% of body weight and an increase in physical
activity are known to reduce the risk of diabetes by more than 50%. In
addition, pharmacologic therapy with either metformin or troglitazone
has been shown to reduce the risk of progression to type 2 diabetes in
those at high risk.

Current recommendations emphasize the importance of identifying and
educating individuals at high risk for diabetes. Screening tests are
advised as part of routine health care, with intervention strategies
strongly emphasizing lifestyle changes, including monitored medical
nutrition and activity programs. At present, drug therapy is not
routinely recommended, although increasing evidence suggests that
targeted treatment of insulin resistance with drugs such as the
glitazones and metformin may prove useful in those for whom lifestyle
changes fail to limit the progression to type 2 diabetes.

Excercise enhances muscle intake of glucose, improves insulin
sensitivity, and improves both fasting and postprandial glucose levels.
Unless the patient exercises every 48-72 hours, however, the benefit is
lost. Cumulative exercise is helpful, and three 10-minute sessions are
almost as beneficial as a single 30-minute session. Some patients may
also find tools such as pedometers helpful for meeting their goal. For
example, taking 10,000 steps per day can be considered the equivalent of
a 5-mile walk.

The thiazolidinediones are used in the insulin-resistant patient. They
have some potential cardiovascular benefits and can improve the
dyslipidemia profile seen in type 2 diabetes. Some early data indicate
they may also have important properties which could aid in diabetes
prevention. These agents are particularly helpful in combination
therapy, and early use with metformin is gaining acceptance. They may be
very helpful in combination with insulin, and even with metformin and
insulin, to obtain near-normal glucose levels.

Women with a previous history of gestational diabetes may also benefit
from TZD therapy, as shown by the TRIPOD study above. This study showed
that women who had gestational diabetes and later took troglitazone had
reduced intimal thickening of the carotid arteries, which is associated
with a reduced risk of cardiovascular disease.

The progressive deterioration of β-cell over time requires that therapy
must be changed in type 2 diabetes. The UKPDS showed that at the time of
diagnosis of diabetes there was only 50% of β-cell function remaining in
people who were diagnosed some 10-11 years after the real onset of their
diabetes. β-Cell function gradually and steadily deteriorated over the
next 6 years of follow-up, which is why initial therapies only work for
a short time.

**Another GDM topic:**

The following data was actually presented to the IHS staff in person at
the last national Women's health and MCH meeting in August 2004 by Lois
Jovanovic

**The Fidgety Fetus Hypothesis**

CONCLUSIONS: The fetus appears to play a role in determining its own
destiny. Increased fetal activity may minimize the impact of
hyperglycemia on subsequent birth weight. The inactive fetus appears to
be at a higher risk for glucose-mediated macrosomia.\
[Zisser
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Zisser+H"%5BAuthor%5D),
[Jovanovic
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jovanovic+L"%5BAuthor%5D),
et al The Fidgety Fetus Hypothesis: Fetal activity is an additional
variable in determining birth weight of offspring of women with
diabetes. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Jan;29(1):63-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16373897&query_hl>

Or

**Meeting and Lecture Notes**

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

**Resources**

U.K. prospective diabetes study 16. Overview of 6 years\' therapy of
type II diabetes: a progressive disease. U.K. Prospective Diabetes Study
Group. *Diabetes* 1995;44(11):1249-58. Erratum in: *Diabetes* 1996
Nov;45(11):1655.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7589820&query_hl>

[Kim C, Newton KM, Knopp
RH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12351492&dopt=Abstract).
Gestational diabetes and the incidence of type 2 diabetes: a systematic
review. Diabetes Care 2002 Oct;25(10):1862-8 (Level III)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12351492&dopt=Abstract>

[Pan
XR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pan+XR"%5BAuthor%5D),
et al Effects of diet and exercise in preventing NIDDM in people with
impaired glucose tolerance. The Da Qing IGT and Diabetes Study.
[Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');)
1997 Apr;20(4):537-44.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9096977&query_h1>

[Uusitupa
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Uusitupa+M"%5BAuthor%5D),
et al The Finnish Diabetes Prevention Study. [Br J
Nutr.](javascript:AL_get(this, 'jour', 'Br J Nutr.');) 2000 Mar;83 Suppl
1:S137-

American Diabetes Association: The prevention or delay of type 2
diabetes. Diabetes Care 2004;27(suppl 1):S47.\
[[http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s47]{.underline}](http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s47)

Rao SS, Disraeli P, McGregor T: Impaired glucose tolerance and impaired
fasting glucose. Am Fam Physician 2004;69:1961-8,1971-2\
[[http://www.aafp.org/afp/20040415/1961.html]{.underline}](http://www.aafp.org/afp/20040415/1961.html)

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

#### Carolyn Aoyama, HQE {#carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Gestational Diabetes: ACOG / IHS Obstetrics, Neonatal and Gynecologic
Care**

I want to make you aware of the Post Graduate Course on Obstetric,
Neonatal and Gynecologic Care which will be offered this year, September
17^th^ through the 21^st^ in Denver, Colorado.  This course will include
content on Gestational Diabetes including how GDM affects the mother's
health during her pregnancy, the health of the fetus and the neonate. 
Please consider attending this interesting course
<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#Sep06>

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

The ACOG / IHS Postgraduate Course represents a unique opportunity for
Indian Health staff who care for AI/AN women and children. There are not
any major subject areas in which a major professional organization, like
ACOG, has devoted so many resources to improving the care of Native
people.

The Postgraduate Course is a thorough 4.5 day primer on all the relevant
topics in the care for AI/AN women and neonates. It is a great resource
for a new staff member new to Indian Health, or a seasoned staff member
who wants a complete update. The Course has been held since the 1980s,
so most of the kinks have been worked out, as witnessed by its
superlative ratings from past attendees.
<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#Sep06>

Each site should consider sending at least one provider and one nurse to
this year's Course. Sign up soon. PS: Limited funding may be available.
Contact Carolyn Aoyama <Carolyn.Aoyama@ihs.gov>

**Burt Attico, Phoenix**

**Vitamin D Levels During Pregnancy Affect Childhood Bone Mass**

Maternal vitamin D insufficiency is common during pregnancy and is
associated with reduced bone-mineral accrual in the offspring during
childhood; this association is mediated partly through the concentration
of umbilical venous calcium. Vitamin D supplementation of pregnant
women, especially during winter months, could lead to long lasting
reductions in the risk of osteoporotic fracture in their offspring.

Javaid MK et al Maternal vitamin D status during pregnancy and childhood
bone mass at age 9 years: a longitudinal study [The
Lancet](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=JournalURL&_cdi=4886&_auth=y&_acct=C000000150&_version=1&_urlVersion=0&_userid=2391895&md5=3ba7c7bbd7d5f10ffebc047bf4bdb389)
2006 Jan [367, Issue
9504](http://ezproxyhhs.nihlibrary.nih.gov:2079/science?_ob=IssueURL&_tockey=%23TOC%234886%232006%23996320495%23614515%23FLA%23&_auth=y&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=2391895&md5=8ab4aa96b427eecc48276cc3fb1f84b9):
36-43

IHS Access <http://hsrl.nihlibrary.nih.gov/> Tribal and Urban Access
<http://nihlibrary.ors.nih.gov/ezproxy/ihs.htm>

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

#### Chuck North, ABQ {#chuck-north-abq .Style-Heading-4-+-Arial-14-pt-Underline}

**Chew Your Fowl Carefully**

A 73-year-old Inuit woman was referred for a barium enema after an
incomplete colonoscopy. A preliminary abdominal radiograph showed that
the appendix was completely full of lead shot, with the contour of the
appendix easily visualized. The natives of northern and western Alaska
hunt waterfowl in the spring and fall and often inadvertently swallow
some of the lead shot embedded in the meat. Although most of the metal
undoubtedly passes through the intestine over time, buckshot in the
appendix is commonly seen in Alaskan natives (but usually not to the
extent pictured here). Decades of ingestion probably resulted in this
....Go to the NIH site and view this NEJM radiograph under 'Online
Journals'

IHS Access <http://hsrl.nihlibrary.nih.gov/>

Tribal and Urban Access <http://nihlibrary.ors.nih.gov/ezproxy/ihs.htm>

[Cox
WM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cox+WM"%5BAuthor%5D),
[Pesola
GR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pesola+GR"%5BAuthor%5D).
Images in clinical medicine. Buckshot ingestion. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Dec
29;353(26)
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16382055&dopt=Abstract>

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

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

#### Maternal weight gain during pregnancy - archived web cast {#maternal-weight-gain-during-pregnancy---archived-web-cast-1 .Style-Heading-4-+-Arial-14-pt-Underline}

\"Obesity and Weight Gain in Pregnancy: Review of the Problem,
Challenges for Research, and an Example from PRAMS\" The Combined
Effects of Pre-Pregnancy Body Mass Index and Weight Gain During
Pregnancy on the Risk of Moderate and Very Preterm Delivery\" Bill
Callaghan, MD
<http://www.uic.edu/sph/cade/mchepi/meetings/nov2005/index.htm>

**April Conference - AIAN children with educational needs - parents,
advocates**

April 11-13, 2006, San Diego, CA

Every year NNAFT PC sponsors the Educating Every Child Institute, which
is designed to meet the needs of Native Children in Special Education.
This is a three-day event for families who have a child with a
disability, Community Friends, Parent Advocates, and all professionals
who serve children with disabilities. This Institute provides full-day
in-depth culturally responsive workshops. The learning strands are
presented by national experts. A Pow Wow is held the second night of the
institute. Also a Community Friends Award Ceremony honoring all our
Community Friends is held during the institute.
[[http://www.nativefamilynetwork.com/]{.underline}](http://www.nativefamilynetwork.com/)

**Tom and Edith Welty, Flagstaff**

**Integrating prevention of mother-to-child HIV transmission into
routine antenatal care**

Here is an article published in JAIDS describing work done by our
colleagues in Cameroon. We will be going to Cameroon again in Feb 2006
for a month to help support the program there.

We trained 690 health workers in PMTCT and counseled 68,635 women, 91.9%
of whom accepted HIV testing. Of 63,094 women tested, 8.7% were
HIV-1-positive. Independent risk factors for HIV-1 infection included
young age at first sexual intercourse, multiple sex partners, and
positive syphilis serology (P \< 0.001 for each). We counseled 98.7% of
positive and negative mothers on a posttest basis. Of 5550 HIV-positive
mothers, we counseled 5433 (97.9%) on single-dose NVP prophylaxis.
Consistent training and programmatic support contributed to rapid up
scaling and high uptake and counseling rates.

[Welty
TK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Welty+TK"%5BAuthor%5D),
[Bulterys
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bulterys+M"%5BAuthor%5D),
[Welty
ER](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Welty+ER"%5BAuthor%5D),
et al Integrating prevention of mother-to-child HIV transmission into
routine antenatal care: the key to program expansion in Cameroon.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16280706&query_hl>

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

According to the report above the Prevention of Mother to Child HIV
Transmission (PMTCT) Program of the Cameroon Baptist Convention Health
Board (CBCHB) owes much of its success to the nurses, midwives and
trained birth attendants who have added HIV/AIDS counseling and testing
to their regular menu of antenatal services offered to pregnant women.
Folding HIV prevention services into existing antenatal care was the key
to rapid expansion of PMTCT programs in Cameroon.

With strong endorsement of the Ministry of Health, CBCHB recently
partnered with Action for West African Region (AWARE), a program
supported by the United States Agency for International Development
(USAID) to launch a PMTCT and reproductive health training center for
the West African region. Based on the EGPAF-funded CBCHB model, the
center in Cameroon trains health care workers from 18 West and Central
African countries to conduct HIV counseling and testing, deliver PMTCT
drug regimens, and conduct follow-up with mothers and their babies. To
date, the CBCHB staff has trained 31 health care workers from 8
countries and plans additional training programs.

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

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

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

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

**Bed Rest for pregnancy related hypertension: Bed rest should not be
recommended**

[Authors\' conclusions:]{.underline} Few randomised trials have
evaluated rest for women with hypertension during pregnancy, and
important information on side-effects and cost implication is missing
from available trials. Although one small trial suggests that some bed
rest may be associated with reduced risk of severe hypertension and
preterm birth, these findings need to be confirmed in larger trials. At
present, there is insufficient evidence to provide clear guidance for
clinical practice. Therefore, bed rest should not be recommended
routinely for hypertension in pregnancy, especially since more women
appear to prefer unrestricted activity, if the choice were given.

Meher S, Abalos E, Carroli G. Bed rest with or without hospitalisation
for hypertension during pregnancy. *The Cochrane Database of Systematic
Reviews* 2005, Issue 4. Art. No.: CD003514.pub2. DOI:
10.1002/14651858.CD003514.pub2

<http://www.update-software.com/cochrane/abstract.htm>

**Simulation training improves resident performance of a simulated
vaginal breech delivery**

CONCLUSION: Simulation training improved resident performance in the
management of a simulated vaginal breech delivery. Performance of a term
breech vaginal delivery is well suited for simulation training, because
it is uncommon and inevitable, and improper technique may result in
significant injury. LEVEL OF EVIDENCE: II-2.

[Deering
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Deering+S"%5BAuthor%5D),
et al Simulation training and resident performance of singleton vaginal
breech delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):86-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394044&dopt=Abstract>

**Women Coached To Push During Labor Have Little Advantage Over Women
Not Coached**

RESULTS: The second stage of labor was abbreviated by approximately 13
minutes in coached women (P = .01). There were no other clinically
significant immediate maternal or neonatal outcomes between the 2
groups. CONCLUSION: Although associated with a slightly shorter second
stage, coached maternal pushing confers no other advantages and
withholding such coaching is not harmful.

[Bloom
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bloom+SL"%5BAuthor%5D),
et al A randomized trial of coached versus uncoached maternal pushing
during the second stage of labor. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):10-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389004&query_hl>

**Follow-up on Paroxetine change from Class C to Class D\***

The following seven articles were published prior to the change from
Class C to Class D, but they offer helpful ideas on non-pharmacologic
therapies and on how to carefully withdrawal antidepressant medications
in pregnancy and lactation.

**Depression during pregnancy**

CONCLUSION: Early detection of depression during pregnancy is critical
because depression can adversely affect birth outcomes and neonatal
health and, if left untreated, can persist after the birth. Untreated
postpartum depression can impair mother-infant attachments and have
cognitive, emotional, and behavioural consequences for children.\
[Ryan
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ryan+D"%5BAuthor%5D),
[Milis
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Milis+L"%5BAuthor%5D),
[Misri
N](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Misri+N"%5BAuthor%5D).
Depression during pregnancy. [Can Fam
Physician.](javascript:AL_get(this, 'jour', 'Can Fam Physician.');) 2005
Aug;51:1087-93.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16121830&query_hl>

**Taking antidepressants during late pregnancy. How should we advise
women?**

QUESTION: In light of recent negative media attention to antidepressant
use during late pregnancy, several of my patients have either
discontinued or are considering discontinuing their antidepressant
medications. How can I best counsel these patients on taking
antidepressants during late pregnancy?

ANSWER: Antidepressant use during the third trimester has been
associated occasionally with a transient neonatal withdrawal-like
syndrome characterized by jitteriness, self-limiting respiratory
difficulties, and problems with feeding. When counseling patients, the
risk of these adverse effects must be weighed against the risks
associated with untreated depression during late pregnancy. Abrupt
discontinuation of psychotropic medications has been associated with
both physical (eg, withdrawal) and psychological (eg, suicidal thoughts)
symptoms.

[Kalra
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kalra+S"%5BAuthor%5D),
et al Taking antidepressants during late pregnancy. How should we advise
women? [Can Fam
Physician.](javascript:AL_get(this, 'jour', 'Can Fam Physician.');) 2005
Aug;51:1077-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16121827&query>

Editorial:

[Stewart
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Stewart+D"%5BAuthor%5D).
Depression during pregnancy. [Can Fam
Physician.](javascript:AL_get(this, 'jour', 'Can Fam Physician.');) 2005
Aug;51:1061-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16121822&query_hl>

**Psychotropic drugs in pregnancy and lactation.**

The management of psychotropic medications during pregnancy and
lactation involves a difficult and complex decision for both patient and
provider, particularly due to the many unknown effects medication may
have on the infant. Available studies concerning use of psychotropic
medications in pregnant and lactating women are limited and there are no
universal guidelines. This article reviews the literature on the use of
psychotropic drugs, including antidepressants, mood stabilizers,
antipsychotics, and benzodiazepines, in pregnant and breast-feeding
women and presents relevant data on teratogenic effects, neonatal
toxicity, perinatal syndromes, and neurobehavioral sequelae.

[Jain
AE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jain+AE"%5BAuthor%5D),
[Lacy
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lacy+T"%5BAuthor%5D).
Psychotropic drugs in pregnancy and lactation. [J Psychiatr
Pract.](javascript:AL_get(this, 'jour', 'J Psychiatr Pract.');) 2005
May;11(3):177-91\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15920391&query_hl>

**Prevalence of suicidality during pregnancy and the postpartum.**

This review examined the available prevalence estimates of suicidality
(suicide deaths, attempts, and ideation including thoughts of self harm)
in pregnancy and the postpartum. Studies that used defined community or
clinic samples were identified through multiple electronic databases and
contacts with primary authors. Definitions of and measurement of suicide
deaths, intentional self-harming behavior, suicide attempts, and
thoughts of death and self-harm were varied and are described with each
study. While suicide deaths and attempts are lower during pregnancy and
the postpartum than in the general population of women, when deaths do
occur, suicides account for up to 20% of postpartum deaths. Self-harm
ideation is more common than attempts or deaths, with thoughts of
self-harm during pregnancy and the postpartum ranging from 5 to 14%. The
risk for suicidality is significantly elevated among depressed women
during the perinatal period, and suicide has been found to be the second
or leading cause of death in this depressed population.

[Lindahl
V](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lindahl+V"%5BAuthor%5D),
et al Prevalence of suicidality during pregnancy and the postpartum.
[Arch Women Ment
Health.](javascript:AL_get(this, 'jour', 'Arch Women Ment Health.');)
2005 Jun;8(2):77-87.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15883651&query_hl>

**Newer antidepressants in pregnancy and rates of major malformations: a
meta-analysis of prospective comparative studies**

CONCLUSIONS: As a group, the newer antidepressants are not associated
with an increased risk of major malformations above the baseline of 1-3%
in the population. Copyright (c) 2005 John Wiley & Sons, Ltd.

[Einarson
TR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Einarson+TR"%5BAuthor%5D),
[Einarson
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Einarson+A"%5BAuthor%5D).
Newer antidepressants in pregnancy and rates of major malformations: a
meta-analysis of prospective comparative studies. [Pharmacoepidemiol
Drug
Saf.](javascript:AL_get(this, 'jour', 'Pharmacoepidemiol Drug Saf.');)
2005 Dec;14(12):823-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15742359&query_hl>

and

[Williams
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Williams+M"%5BAuthor%5D),
[Wooltorton
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wooltorton+E"%5BAuthor%5D).Paroxetine
(Paxil) and congenital malformations.
[CMAJ.](javascript:AL_get(this, 'jour', 'CMAJ.');) 2005 Nov
22;173(11):1320-1.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16272192&query_hl>

**\* December 2005 CCC Corner**

**Paroxetine's pregnancy category changed from C to D**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#ob>

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

#### The CCC Corner would like to thank Chuck North, ABQ, for the above, as he contributed the majority of those resources.

#### While all due caution for the above issues should be exercised, we suggest all to please consider the big picture. See attached abstract below to give part of that larger perspective. Please note the use of SSRIs during pregnancy is not independently associated with increased risk of adverse perinatal outcome, other than need for treatment in neonatal special or intensive care unit. Also see below an article reporting that cognitive therapy works quite well in some patients without medication.

#### SSRIs not associated with risk of adverse perinatal outcome other than need NICU stay

RESULTS: Major malformations were not more common in infants or fetuses
of women with first trimester SSRI purchases (n = 1,398) when compared
with controls with no drug purchases (P = .4). Of infants born to
mothers with SSRI purchases in the 3rd trimester, 15.7% were treated in
special or intensive care unit compared with 11.2% of infants exposed
only during the 1st trimester (P = .009, adjusted odds ratio 1.6, 95%
confidence interval 1.1-2.2). We found no increased risk of preterm
birth (\< 37 weeks), birth 32 weeks of gestation or less, small for
gestational age, or low birth weight in women with purchases in each
trimester or during the 2nd and 3rd trimesters when compared with women
with only 1st trimester purchases

CONCLUSION: Use of SSRIs during pregnancy is not independently
associated with increased risk of adverse perinatal outcome other than
need for treatment in neonatal special or intensive care unit.

[Malm
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Malm+H"%5BAuthor%5D),
[Klaukka
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Klaukka+T"%5BAuthor%5D),
[Neuvonen
PJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Neuvonen+PJ"%5BAuthor%5D)
Risks associated with selective serotonin reuptake inhibitors in
pregnancy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1289-96. LEVEL OF EVIDENCE: II-2

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319254&dopt=Abstract>

**Cognitive Therapy for Depression (see also Patient Education)**

Cognitive therapy is a treatment process that enables patients to
correct false self-beliefs that can lead to negative moods and
behaviors. The fundamental assumption is that a thought precedes a mood;
therefore, learning to substitute healthy thoughts for negative thoughts
will improve a person\'s mood, self-concept, behavior, and physical
state. Studies have shown that cognitive therapy is an effective
treatment for depression and is comparable in effectiveness to
antidepressants and interpersonal or psychodynamic therapy. The
combination of cognitive therapy and antidepressants has been shown to
effectively manage severe or chronic depression. Cognitive therapy also
has proved beneficial in treating patients who have only a partial
response to adequate antidepressant therapy. Good evidence has shown
that cognitive therapy reduces relapse rates in patients with
depression, and some evidence has shown that cognitive therapy is
effective for adolescents with depression. (Am Fam Physician
2006;73:83-6, 93 <http://www.aafp.org/afp/20060101/83.html>

**Sufficient evidence to support implementing first-trimester Down
syndrome risk: NIH**

The participants at the workshop concluded that at this time there is
sufficient evidence to support implementing first-trimester Down
syndrome risk assessment in obstetric practice in the United States,
provided that certain requirements can be met. These requirements
include training and quality control standards for first-trimester
nuchal translucency measurement and laboratory assays, access to
chorionic villus sampling, and appropriate counseling regarding
screening options. [Reddy
UM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Reddy+UM"%5BAuthor%5D),
[Mennuti
MT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mennuti+MT"%5BAuthor%5D).
Incorporating First-Trimester Down Syndrome Studies Into Prenatal
Screening: Executive Summary of the National Institute of Child Health
and Human Development Workshop. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):167-173.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394055&dopt=Abstract>

**Increased nuchal thickness: 1/2 are other than trisomy 21 of the
chromosomally abnormal**

CONCLUSION: In fetuses with increased nuchal translucency, approximately
one half of the chromosomally abnormal group is affected by defects
other than trisomy 21. The distribution of nuchal translucency is
different for each type of chromosomal defect. LEVEL OF EVIDENCE: II-3

[Kagan
KO](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kagan+KO"%5BAuthor%5D),
et al Relation Between Increased Fetal Nuchal Translucency Thickness and
Chromosomal Defects. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):6-10.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394033&dopt=Abstract>

**Editorial**

[Rose
NC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Rose+NC"%5BAuthor%5D).
On the current dilemma of down syndrome screening. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):2-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394031&dopt=Abstract>

**Increased risk of having an instrumental delivery: Epidural --
Cochrane Library**

[Authors\' conclusions:]{.underline} Epidural analgesia appears to be
effective in reducing pain during labour. However, women who use this
form of pain relief are at increased risk of having an instrumental
delivery. Epidural analgesia had no statistically significant impact on
the risk of caesarean section, maternal satisfaction with pain relief
and long-term backache and did not appear to have an immediate effect on
neonatal status as determined by Apgar scores. Further research may be
helpful to evaluate rare but potentially severe adverse effects of
epidural analgesia on women in labour and long-term neonatal outcomes.

Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no
analgesia in labour. *The Cochrane Database of Systematic Reviews* 2005,
Issue 4. Art. No.: CD000331.pub2. DOI: 10.1002/14651858.CD000331.pub2
<http://www.update-software.com/cochrane/abstract.htm>

**Progressive periodontal disease increases the risk for preterm birth
at less than 32 weeks**

CONCLUSION: The OCAP study demonstrates that maternal periodontal
disease increases relative risk for preterm or spontaneous preterm
births. Furthermore, periodontal disease progression during pregnancy
was a predictor of the more severe adverse pregnancy outcome of very
preterm birth, independently of traditional obstetric, periodontal, and
social domain risk factors. LEVEL OF EVIDENCE: II-2.

[Offenbacher
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Offenbacher+S"%5BAuthor%5D),
et al Progressive Periodontal Disease and Risk of Very Preterm Delivery.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2006 Jan;107(1):29-36.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394036&dopt=Abstract>

**Perinatal Complications Increase Risk of Eating Disorders**

CONCLUSIONS: A significantly higher risk of eating disorders was found
for subjects with specific types of obstetric complications. An
impairment in neurodevelopment could be implicated in the pathogenesis
of eating disorders

[Favaro
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Favaro+A"%5BAuthor%5D),
[Tenconi
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Tenconi+E"%5BAuthor%5D),
[Santonastaso
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Santonastaso+P"%5BAuthor%5D).
Perinatal factors and the risk of developing anorexia nervosa and
bulimia nervosa. [Arch Gen
Psychiatry.](javascript:AL_get(this, 'jour', 'Arch Gen Psychiatry.');)
2006 Jan;63(1):82-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389201&query_hl>

**Etiology and prevention of stillbirth**

CONCLUSION: Identification of risk factors for stillbirth assists the
clinician in performing a risk assessment for each patient. Unexplained
stillbirths and stillbirths related to growth restriction are the 2
categories of death that contribute the most to late fetal losses. Late
pregnancy is associated with an increasing risk of stillbirth, and
clinicians should have a low threshold to evaluate fetal growth. The
value of antepartum testing is related to the underlying risk of
stillbirth and, although the strategy of antepartum testing in patients
with increased risk will decrease the risk of late fetal loss, it is of
necessity associated with higher intervention rates

[Fretts
RC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fretts+RC"%5BAuthor%5D).
Etiology and prevention of stillbirth. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Dec;193(6):1923-35.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16325593&query_hl>

### **Acetaminophen overdose in pregnancy.** 

### [Conclusion]{.underline} APAP toxicity in pregnancy is not rare and can result in significant morbidity and mortality in both the mother and the fetus. APAP crosses the placenta and may be metabolized by the fetal liver into active and toxic metabolites. Fetal hepatic necrosis caused by these toxic metabolites may occur from maternal APAP overdose. NAC also crosses the placenta and may bind toxic metabolites in both the mother and the fetus. Limited data based mainly on case reports suggests that NAC may be safely administered during pregnancy and should be initiated early after APAP overdosage. Because the safety profile of oral or intravenous acetylcysteine has not been adequately studied in pregnancy, consideration should be given to obtaining informed consent before administration during pregnancy. Acetaminophen overdose during pregnancy is not an infrequent occurrence, and further investigation is necessary in relation to this field.

[Wilkes
JM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wilkes+JM"%5BAuthor%5D),
Acetaminophen overdose in pregnancy. [South Med
J.](javascript:AL_get(this, 'jour', 'South Med J.');) 2005
Nov;98(11):1118-22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16351032&query_hl>

**Early-Onset and Late-Onset Neonatal Group B Streptococcal Disease -
1996-2004 **

To assess the impact of the guidelines on multistate trends in neonatal
GBS disease incidence, CDC analyzed data from the Active Bacterial Core
surveillance system from 1996-2004. This report summarizes the results
of that analysis, which determined that incidence of GBS disease in
infants aged 0-6 days (i.e., early-onset disease) in 2004 had decreased
by 31% from 2000-2001, the period immediately before universal screening
was implemented. Incidence of GBS disease in infants aged 7-89 days
(i.e., late-onset disease) remained unchanged during the 9-year period
reviewed. Continued monitoring is needed to assess the impact of the
2002 guidelines on early-onset disease and the long-term effect of
widespread intrapartum use of antimicrobial agents on neonatal GBS
disease.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5447a2.htm?s_cid=mm5447a2_e>

**Shoulder dystocia: prevention and management:** **Review article**

Knowledge of the maneuvers used for the alleviation of shoulder dystocia
is relevant not only for obstetric residents and attending house staff
but also for family practitioners, nurses, and nurse midwives. The
performance of shoulder dystocia \"drills\" can be helpful not only to
coordinate a teamwork approach to this obstetric emergency but also to
provide an opportunity to practice the maneuvers. Shoulder dystocia
continues to represent an immense area of clinical interest because it
typically occurs without prediction. All patients in labor should be
considered at risk for the development of shoulder dystocia.

[Gherman
RB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gherman+RB"%5BAuthor%5D).
Shoulder dystocia: prevention and management. [Obstet Gynecol Clin North
Am.](javascript:AL_get(this, 'jour', 'Obstet Gynecol Clin North Am.');)
2005 Jun;32(2):297-305
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15899362&query_h1>

**Mortality decreased in very low birth weight vertex neonates with
cesarean delivery**

A survival advantage was associated with cesarean delivery in the birth
weight analysis up to 1,300 g (P \< .05). This decreased mortality for
VLBW neonates delivered by cesarean persisted after adjusting for other
factors associated with mortality. CONCLUSION: Very low birth weight
vertex neonates are often born by cesarean delivery and have different
maternal risk profiles from non-VLBW vertex neonates born by this route.
Neonatal mortality was decreased in VLBW neonates delivered by cesarean.
Further study is warranted to determine whether this may be a causal
relationship or a marker of quality of care. LEVEL OF EVIDENCE: II-2.

[Lee
HC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lee+HC"%5BAuthor%5D),
[Gould
JB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gould+JB"%5BAuthor%5D).
Survival advantage associated with cesarean delivery in very low birth
weight vertex neonates. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):97-105\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394046&dopt=Abstract>

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

**Prior Function and Relationship, More Than Hormones, Affect Sexual
Function in Midlife**

CONCLUSION(S): Prior function and relationship factors are more
important than hormonal determinants of sexual function of women in
midlife.\
[Dennerstein
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Dennerstein+L"%5BAuthor%5D),
[Lehert
P](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lehert+P"%5BAuthor%5D),
[Burger
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Burger+H"%5BAuthor%5D).
The relative effects of hormones and relationship factors on sexual
function of women through the natural menopausal transition. [Fertil
Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2005
Jul;84(1):174-80.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16009174&query_hl>

**HPV-16 vaccine provides high-level protection against CIN for at least
3.5 years**

CONCLUSION: The vaccine HPV16 L1 VLP provides high-level protection
against persistent HPV16 infection and HPV16-related CIN2-3 for at least
3.5 years after immunization. Administration of L1 VLP vaccines
targeting HPV16 is likely to reduce risk for cervical cancer. LEVEL OF
EVIDENCE: I\
[Mao
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mao+C"%5BAuthor%5D),
et al Efficacy of Human Papillomavirus-16 Vaccine to Prevent Cervical
Intraepithelial Neoplasia: A Randomized Controlled Trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):18-27.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394035&dopt=Abstract>

**Have you had trouble clearing up vaginal condyloma or CIN?**

METHODS: In a phase III unmasked, randomized, multicenter, outpatient
clinical trial, 101 HIV-positive women either received 6 months of
biweekly treatment with vaginal 5-FU cream (2 g) or underwent 6 months
of observation after standard excisional or ablative cervical treatment
for cervical intraepithelial neoplasia (CIN).

CONCLUSION: Adjunctive maintenance intravaginal 5-FU therapy after
standard surgery for high-grade lesions safely and effectively reduced
recurrence of cervical intraepithelial neoplasia in HIV-infected women

[Maiman
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Maiman+M"%5BAuthor%5D)
et al Vaginal 5-fluorouracil for high-grade cervical dysplasia in human
immunodeficiency virus infection: a randomized trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 1999
Dec;94(6):954-61.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10576182&dopt=Abstract>

**Rectocele xenograft repair: Unsatisfying anatomical cure rate 3 years
postoperatively**

CONCLUSION: Rectocele repair using porcine dermal graft was associated
with an unsatisfactory anatomical cure rate and persistent
bowel-emptying difficulties in the majority of patients 3 years
postoperatively. LEVEL OF EVIDENCE: II-3

[Altman
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Altman+D"%5BAuthor%5D),
et al A three-year prospective assessment of rectocele repair using
porcine xenograft. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):59-65.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16394040&dopt=Abstract>

**Patient-Administered Analgesic Gas Helpful During Colposcopy**

CONCLUSION: Satisfaction with outpatient treatment at colposcopy is
generally high. The main effect of isoflurane and desflurane evaluated
in this trial was to reduce pain. It appeared to be effective for women
with clinically significant anxiety and could be offered as an
alternative to general anaesthesia. [Cruickshank
ME](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cruickshank+ME"%5BAuthor%5D),
et al A randomised controlled trial to evaluate the effect of
self-administered analgesia on women\'s experience of outpatient
treatment at colposcopy.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2005
Dec;112(12):1652-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16305570&query_hl>

**Management of Histologic Abnormalities of the Cervix**

The American Society for Colposcopy and Cervical Pathology sponsored a
consensus conference in 2001 to develop evidence-based guidelines for
women with histologic abnormalities of the cervix. The options for
management of cervical intraepithelial neoplasia 1, 2, and 3 are ranked
according to the strength of the recommendation and the quality of the
evidence. Follow-up with repeat cytology at six and 12 months or DNA
testing for high-risk types of human papillomavirus at 12 months is the
preferred management approach for women with cervical intraepithelial
neoplasia 1 and satisfactory initial colposcopy. If results from repeat
cytology are reported as atypical squamous cells of undetermined
significance or greater, or if DNA human papillomavirus testing is
positive for oncogenic types of the virus, repeat colposcopy is
preferred. When the initial colposcopy is unsatisfactory, a diagnostic
excisional procedure is preferred. Follow-up without treatment is
acceptable only in women who are pregnant and adolescents with cervical
intraepithelial neoplasia 1 who had unsatisfactory colposcopy.
Biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 requires
treatment except during pregnancy and in compliant adolescents with
cervical intraepithelial neoplasia 2 and negative endocervical
curettage. When colposcopy is satisfactory, treatment includes ablative
or excisional procedures. A diagnostic excisional procedure is
recommended in women with biopsy-confirmed cervical intraepithelial
neoplasia 2 or 3 and unsatisfactory colposcopy. Am Fam Physician
2006;73:105-12.

<http://www.aafp.org/afp/20060101/105.html>

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

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

**Cerebral Palsy: An Overview (see also Patient Education)**

The presentation of cerebral palsy can be global mental and physical
dysfunction or isolated disturbances in gait, cognition, growth, or
sensation. It is the most common childhood physical disability and
affects 2 to 2.5 children per 1,000 born in the United States. The
differential diagnosis of cerebral palsy includes metabolic and genetic
disorders. The goals of treatment are to improve functionality and
capabilities toward independence. Multispecialty treatment teams should
be developed around the needs of each patient to provide continuously
updated global treatment care plans. Complications of cerebral palsy
include spasticity and contractures; feeding difficulties; drooling;
communication difficulties; osteopenia; osteoporosis; fractures; pain;
and functional gastrointestinal abnormalities contributing to bowel
obstruction, vomiting, and constipation. Valid and reliable assessment
tools to establish baseline functions and monitor developmental gains
have contributed to an increasing body of evidenced-based
recommendations for cerebral palsy. Many of the historical treatments
for this ailment are being challenged, and several new treatment
modalities are available. Adult morbidity and mortality from ischemic
heart disease, cerebrovascular disease, cancer, and trauma are higher in
patients with cerebral palsy than in the general population. Am Fam
Physician 2006;73:91-100, 101-2.
<http://www.aafp.org/afp/20060101/91.html>

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

Oral Contraceptives and Dysmenorrhea in Adolescents: RCT

About 15 percent of adolescent girls report severe menstrual pain.
Although dysmenorrhea is the largest cause of time lost from school or
work in this population, a small percentage seek medical help. Most
adolescents self-treat menstrual pain using nonsteroidal
anti-inflammatory drugs or other nonprescription agents. Oral
contraceptives commonly are used to treat dysmenorrhea in older women,
and their effectiveness is supported by a few low-quality clinical
trials. Davis and colleagues studied the effectiveness of low-dose oral
contraceptives in treating dysmenorrhea in adolescent girls.

The researchers recruited healthy nulliparous girls 19 years or younger
who reported moderate to severe menstrual pain. The severity of
dysmenorrhea was established using a standardized scale validated in
earlier research. Eligible participants had regular menstrual cycles of
21 to 35 days, no gynecologic pathology, and no contraindication to oral
contraceptive use. Participants also were required to be sexually
abstinent or to use condoms for birth control. Parents gave informed
consent for girls younger than 18 years. Baseline assessment included
medical history and physical examination plus the collection of detailed
information about menstruation and related symptoms using tools such as
the Moos Menstrual Distress Questionnaire (MMDQ). Other data included
standardized scales to measure stress and depression. The participants
were randomly assigned to receive oral contraceptive (ethinyl E2 20 mcg
plus 100 mg levonorgestrel) or identical placebo in 28-day blister
packs. Patients were telephoned after each menses for two months and
questioned about pain and medication use. Participants also completed an
exit interview toward the end of the third month of therapy. The primary
outcome was a change in the MMDQ pain subscale score. Secondary outcomes
included reported use of analgesia and ratings of menstrual-related pain
duration, severity, and frequency.

The 38 adolescents assigned to oral contraceptive therapy were
comparable with the 38 assigned to placebo in all significant variables.
At baseline, 58 percent of participants reported severe dysmenorrhea, 55
percent reported associated nausea, and 39 percent reported missing
usual activities at least one day per month because of menstrual pain.
By the third cycle of therapy, the mean MMDQ pain score in the treatment
group had fallen from 11.1 to 3.1. For those assigned to placebo, the
scores fell from 11.8 to 5.8. Analgesic use also fell dramatically in
both groups, from more than 16 pills to six pills per menses. In the
treatment group, the mean analgesic use in the third cycle was 1.3
pills, significantly less than the 3.7 pills reported by the placebo
group. Sixty-one percent of the treatment group reported no medication
use by the third cycle, compared with 36 percent of the placebo group.
The mean pain ratings were significantly lower in oral contraceptive
users than those taking placebo. Measures of the duration and frequency
of pain were lower in the treatment group, but the differences did not
reach statistical significance. No serious adverse effects were reported
or noted during the study. The two discontinuations in the treatment
group were attributed to acne and nausea. One participant in the placebo
group withdrew because of mood changes.

The authors conclude that a low-dose oral contraceptive is more
effective than placebo in managing dysmenorrhea in adolescents. Although
the study is relatively small, they recommend consideration of low-dose
oral contraceptive therapy for adolescents with severe menstrual-related
pain.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15994623&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15994623&query_hl) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15994623query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

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

Controlling Obesity: School, Work, and Leisure

The Centers for Disease Control and Prevention\'s (CDC\'s) Task Force on
Community Preventive Services reviewed school- and worksite-based
strategies for the short-term prevention and control of overweight and
obesity. The full report, \"Public Health Strategies for Preventing and
Controlling Overweight and Obesity in School and Worksite Settings,\"
was published in the October 7, 2005, issue of *Morbidity and Mortality
Weekly Report (MMWR) Recommendations and Reports* and is available
online at <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5410a1.htm>.

The task force found insufficient evidence to make recommendations on
school-based interventions. However, the report suggests interventions
that result in small but positive changes may be useful, such as
programs that combine nutrition and physical activity elements,
allocation of additional time for physical education during the school
day, inclusion of noncompetitive sports such as dance, and reduction of
sedentary activities such as watching television.

For worksite-based strategies, the task force recommends the use of
combined nutrition and physical activity programs, and it suggests that
employers be given evidence on the effectiveness and cost-effectiveness
of worksite interventions to control overweight and obesity.
Cost-effectiveness data can be found on the Community Guide Web site at
<http://www.thecommunityguide.org/obese>.

The task force concluded that much more research is needed to enable the
control and reversal of obesity trends. Topics for potential study
include parental involvement, outcomes of environmental changes such as
making stairs more accessible and providing easy access to nutritious
food, the combination of work and community-based interventions, and
strategies for maintaining initial weight-loss success.

leisure-time inactivity

According to another CDC report, participation in physical activity
outside the workplace has improved in the past decade. The report,
\"Trends in Leisure-Time Physical Inactivity by Age, Sex, and
Race/Ethnicity-United States, 1994-2004,\" was published in the October
7, 2005, issue of *MMWR* and is available online at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a5.htm>.

The report states that the percentage of the U.S. population that
participates in no physical activity outside of regular work decreased
between 1994 and 2004 in every age group. However, more than 30 percent
of adults 70 years or older are inactive, and the CDC recommends that
public health messages focus on raising awareness of opportunities for
physical activity. The report also suggests that community programs be
made more accessible to racial minorities to reduce disparities among
ethnic groups.

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

**Screening and Interventions for Overweight in Children and
Adolescents: Recommendation: USPSTF**

Summary of Recommendation

The USPSTF concludes that the evidence is insufficient to recommend for
or against routine screening for overweight in children and adolescents
as a means to prevent adverse health outcomes. **I recommendation.**

Approximately 15 percent of children and adolescents six to 19 years of
age are overweight and are at risk of diabetes, elevated blood lipids,
increased blood pressure, and their sequelae, as well as slipped capital
femoral epiphysis, steatohepatitis, sleep apnea, and psychosocial
problems. The USPSTF found fair evidence that body mass index (BMI) is a
reasonable measure for identifying children and adolescents who are
overweight or are at risk of becoming overweight. There is fair evidence
that overweight adolescents and children eight years of age and older
are at increased risk for becoming obese adults. The USPSTF found
insufficient evidence for the effectiveness of behavioral counseling or
other preventive interventions with overweight children and adolescents
that can be conducted in primary care settings or to which primary care
physicians can make referrals. There is insufficient evidence to
ascertain the magnitude of the potential harms of screening or
prevention and treatment interventions. The USPSTF was, therefore,
unable to determine the balance between potential benefits and harms for
the routine screening of children and adolescents for overweight.
[http://www.preventiveservices.ahrq.gov](http://www.preventiveservices.ahrq.gov/)

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

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

**Waking up to Sleep Deprivation**

One quarter of the adult population is too sleepy, and sleep deprivation
is the most important underlying cause. Sleep deprivation affects
virtually every aspect of human functioning; it compromises emotional
well-being, impairs physical health, jeopardizes public safety, and even
contributes to mortality.

### [Countermeasures for Daytime Sleepiness]{.underline}

In sleep-deprived individuals, a short nap (\"power nap\") can
temporarily restore daytime alertness. However, the effects of napping
are transient and cannot be relied upon for sustained and dependable
relief from sleepiness. Activities that require a high level of
alertness should not be scheduled at the bimodal peaks in sleepiness
during the 24-hour day. The adherence to proper sleep-hygiene measures
is also important; this includes avoiding alcohol, regularly exercising,
and maximizing exposure to bright light during normal waking hours.
Caffeine, which is commonly consumed by sleepy individuals, is best
avoided within 12 hours of bedtime to diminish sleep fragmentation, yet,
during work hours, it can increase performance and alertness levels.

Although these techniques may help restore daytime alertness, the best
remedy for sleep deprivation is prolonged nocturnal sleep over time,
followed by the maintenance of adequate sleep times. Although the amount
of recovery sleep needed is highly variable from individual to
individual, there is no substitute for sleep.

<http://www.medscape.com/viewarticle/507149?sssdmh=dm1.174905&src=nlpromo>

(see access to Medscape below)

**Medications for Migraine Prophylaxis (see Patient Education)**

Sufficient evidence and consensus exist to recommend propranolol,
timolol, amitriptyline, divalproex, sodium valproate, and topiramate as
first-line agents for migraine prevention. There is fair evidence of
effectiveness with gabapentin and naproxen sodium. Botulinum toxin also
has demonstrated fair effectiveness, but further studies are needed to
define its role in migraine prevention. Limited evidence is available to
support the use of candesartan, lisinopril, atenolol, metoprolol,
nadolol, fluoxetine, magnesium, vitamin B2 (riboflavin), coenzyme Q10,
and hormone therapy in migraine prevention. Data and expert opinion are
mixed regarding some agents, such as verapamil and feverfew; these can
be considered in migraine prevention when other medications cannot be
used. Evidence supports the use of timed-release dihydroergotamine
mesylate, but patients should be monitored closely for adverse effects.
Am Fam Physician 2006;73:72-8, 79-80.
<http://www.aafp.org/afp/20060101/72.html>

**Aromatase inhibitors\--a triumph of translational oncology**

CONCLUSIONS: In postmenopausal women with endocrine-responsive breast
cancer, adjuvant treatment with letrozole, as compared with tamoxifen,
reduced the risk of recurrent disease, especially at distant sites

[Thurlimann
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Thurlimann+B"%5BAuthor%5D),
et al A comparison of letrozole and tamoxifen in postmenopausal women
with early breast cancer. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Dec
29;353(26):2747-57.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16382061&dopt=Abstract>

Editorial\
[Swain
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Swain+SM"%5BAuthor%5D).
Aromatase inhibitors\--a triumph of translational oncology. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Dec
29;353(26):2807-9.\
[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16382068&itool=pubmed_Abstract](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16382068&itool=pubmed_Abstract)

**Regular Walking Slows Decline in Patients With Peripheral Arterial
Disease**

CONCLUSION: Among patients with PAD, self-directed walking exercise
performed at least 3 times weekly is associated with significantly less
functional decline during the subsequent year. Similar trends were
observed in the subset of asymptomatic patients with PAD. These findings
may be particularly important for the numerous patients with PAD who do
not have access to supervised walking exercise programs.\
[McDermott
MM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="McDermott+MM"%5BAuthor%5D),
et al Physical performance in peripheral arterial disease: a slower rate
of decline in patients who walk more. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2006 Jan
3;144(1):10-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389250&query_hl>

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

## American Family Physician {#american-family-physician-1 .Style-Heading-2-+-14-pt}

## IVF Therapy for Unexplained Infertility - Cochrane for Clinicians {#ivf-therapy-for-unexplained-infertility---cochrane-for-clinicians-1 .Style-Heading-2-+-14-pt}

## Clinical Scenario {#clinical-scenario .Style-Heading-2-+-14-pt}

A 32-year-old woman has been trying to conceive for the past 12 months
without success. Medical history, physical examination,
hysterosalpingography, and laboratory testing provide no explanation.

Clinical Question

How does in vitro fertilization (IVF) compare with other available
therapies for unexplained infertility?

Evidence-Based Answer

Although IVF is used routinely for the treatment of unexplained
infertility, there is limited evidence to show that it is more effective
than expectant management, and there is insufficient evidence to
recommend it as an alternative to other therapies such as clomiphene
citrate (Serophene), intrauterine insemination, or gamete intrafallopian
transfer. Risks of IVF include psychological stress, multiple
gestations, operative risks, and ovarian hyperstimulation syndrome.
Another issue is its high cost. More research is needed to clearly
establish the efficacy of IVF compared with other therapies.
<http://www.cochrane.org/cochrane/revabstr/AB003357.htm>

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

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

**\"Do Not Use\" Abbreviations**

ABSTRACT: There are numerous abbreviations used in health care that have
several different meanings. Some of these abbreviations may be mistaken
for other abbreviations, numbers, or symbols, and these mistakes can
have serious consequences. Therefore, the Joint Commission on
Accreditation of Healthcare Organizations has established an \"Official
\'Do Not Use\' List\" of abbreviations as part of its accreditation
standards. It is important for obstetrician--gynecologists to consider
this list when using these and other abbreviations in their practice
settings.

+---------------------------+-------------------------------+----------+
| **Table 1.** Official     |                               |          |
| \"Do Not Use\" List\*     |                               |          |
+---------------------------+-------------------------------+----------+
| **Do Not Use**            | **Potential Problem**         | **Use    |
|                           |                               | I        |
|                           |                               | nstead** |
+---------------------------+-------------------------------+----------+
| U (unit)                  | Mistaken for \"0\" (zero),\   | Write    |
|                           | the number \"4\" (four), or   | \"unit\" |
|                           | \"cc\"                        |          |
+---------------------------+-------------------------------+----------+
| IU (International Unit)   | Mistaken for IV               | Write    |
|                           | (intravenous)\                | \"Inter  |
|                           | or the number 10 (ten)        | national |
|                           |                               | Unit\"   |
+---------------------------+-------------------------------+----------+
| Q.D., QD, q.d., qd        | Mistaken for each other       | Write    |
| (daily)                   |                               | \        |
|                           |                               | "daily\" |
+---------------------------+-------------------------------+----------+
| Q.O.D., QOD, q.o.d., qod\ | Period after the Q mistaken\  | Write    |
| (every other day)         | for \"I\" and the \"O\"       | \"every  |
|                           | mistaken for \"I\"            | other    |
|                           |                               | day\"    |
+---------------------------+-------------------------------+----------+
| Trailing zero (X.0 mg)^†^ | Decimal point is missed       | Write X  |
|                           |                               | mg       |
+---------------------------+-------------------------------+----------+
| Lack of leading zero (.X  |                               | Write    |
| mg)                       |                               | 0.X mg   |
+---------------------------+-------------------------------+----------+
| MS                        | Can mean morphine sulfate\    | Write    |
|                           | or magnesium sulfate          | \"       |
|                           |                               | morphine |
|                           |                               | s        |
|                           |                               | ulfate\" |
+---------------------------+-------------------------------+----------+
| MSO~4~ and MgSO~4~        | Confused for one another      | Write    |
|                           |                               | \"m      |
|                           |                               | agnesium |
|                           |                               | s        |
|                           |                               | ulfate\" |
+---------------------------+-------------------------------+----------+
| \*Applies to all orders   |                               |          |
| and all                   |                               |          |
| medication-related        |                               |          |
| documentation that is     |                               |          |
| handwritten (including    |                               |          |
| free-text computer entry) |                               |          |
| or on preprinted forms.   |                               |          |
|                           |                               |          |
| ^†^A \"trailing zero\"    |                               |          |
| may be used only where    |                               |          |
| required to demonstrate   |                               |          |
| the level of precision of |                               |          |
| the value being reported, |                               |          |
| such as for laboratory    |                               |          |
| results, imaging studies  |                               |          |
| that report size of       |                               |          |
| lesions, or catheter/tube |                               |          |
| sizes. It may not be used |                               |          |
| in medication orders or   |                               |          |
| other medication-related  |                               |          |
| documentation.            |                               |          |
|                           |                               |          |
| Joint Commission on       |                               |          |
| Accreditation of          |                               |          |
| Healthcare Organizations. |                               |          |
| Official \"do not use\"   |                               |          |
| list. Available at:       |                               |          |
| [http://www.jcah          |                               |          |
| o.org/accredited+organiza |                               |          |
| tions/laboratory+services |                               |          |
| /npsg/06_dnu_list.pdf](ht |                               |          |
| tp://www.acog.org/cgi-shl |                               |          |
| /leaving.pl?http://www.jc |                               |          |
| aho.org/accredited+organi |                               |          |
| zations/laboratory+servic |                               |          |
| es/npsg/06_dnu_list.pdf). |                               |          |
| Retrieved September 8,    |                               |          |
| 2005.                     |                               |          |
+---------------------------+-------------------------------+----------+

\"Do not use\" abbreviations. ACOG Committee Opinion No. 327. American
College of Obstetricians and Gynecol-ogists. Obstet Gynecol
2006;107:213--4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16394065&query_hl>

**Vaginal Birth Not Associated With Incontinence Later in Life**

Contrary to the belief held by some, vaginal birth does not appear to be
associated with incontinence later in life, a new study has found. The
study, published in the [December issue of Obstetrics &
Gynecology](http://www.acog.org/from_home/publications/green_journal/2005/v106n6p1253.pdf),
found that incontinence was more strongly related with family history.
<http://www.acog.org/from_home/publications/press_releases/nr11-30-05-1.cfm>

**Research Finds 40% of Pregnancy-Related Deaths Potentially
Preventable**

The overall maternal mortality rate in the US is not as low as it could
be, according to a review of pregnancy-related deaths published in the
[December issue of Obstetrics &
Gynecology](http://www.acog.org/from_home/publications/green_journal/2005/v106n6p1228.pdf).
The review found that 40% of all pregnancy-related deaths in North
Carolina from 1995-1999 were potentially preventable. Worldwide,
complications of pregnancy are a major source of mortality among women.
Although the US saw a 99% reduction in maternal death during the 20th
century, 29 developed nations still have lower maternal mortality rates

<http://www.acog.org/from_home/publications/press_releases/nr11-30-05-2.cfm>

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

#### Younger women are more satisfied with their health care when a reproductive health specialist is their primary provider {#younger-women-are-more-satisfied-with-their-health-care-when-a-reproductive-health-specialist-is-their-primary-provider .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ahrq.gov/research/nov05/1105RA7.htm]{.underline}](http://www.ahrq.gov/research/nov05/1105RA7.htm) {#httpwww.ahrq.govresearchnov051105ra7.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Uterine artery embolization for uterine fibroids is a low-risk procedure {#uterine-artery-embolization-for-uterine-fibroids-is-a-low-risk-procedure .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ahrq.gov/research/nov05/1105RA8.htm]{.underline}](http://www.ahrq.gov/research/nov05/1105RA8.htm) {#httpwww.ahrq.govresearchnov051105ra8.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### More high-quality studies are needed to gauge the safety of induced labor in women who have had prior cesarean deliveries {#more-high-quality-studies-are-needed-to-gauge-the-safety-of-induced-labor-in-women-who-have-had-prior-cesarean-deliveries .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ahrq.gov/research/nov05/1105RA9.htm]{.underline}](http://www.ahrq.gov/research/nov05/1105RA9.htm) {#httpwww.ahrq.govresearchnov051105ra9.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Some State-level policies are associated with women\'s mortality rates for certain diseases {#some-state-level-policies-are-associated-with-womens-mortality-rates-for-certain-diseases-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ahrq.gov/research/nov05/1105RA10.htm]{.underline}](http://www.ahrq.gov/research/nov05/1105RA10.htm) {#httpwww.ahrq.govresearchnov051105ra10.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Clinicians are more likely to counsel youth diagnosed with obesity about diet and exercise {#clinicians-are-more-likely-to-counsel-youth-diagnosed-with-obesity-about-diet-and-exercise-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ahrq.gov/research/nov05/1105RA13.htm]{.underline}](http://www.ahrq.gov/research/nov05/1105RA13.htm) {#httpwww.ahrq.govresearchnov051105ra13.htm .Style-Heading-4-+-Arial-14-pt-Underline}

#### 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}

**Interested in Maternal and Child Health topics?**

Maternal and Child Health Journal provides a forum to advance the
scientific and professional knowledge base of the maternal and child
health (MCH) field. This bimonthly provides peer-reviewed papers
addressing the following areas of MCH practice, policy, and research:

MCH epidemiology, demography, and health status assessment Innovative
MCH service initiatives Implementation of MCH programs MCH policy
analysis and advocacy MCH professional development.

Exploring the full spectrum of the MCH field, Maternal and Child Health
Journal is an important tool for practitioners in public health,
obstetrics, gynecology, prenatal medicine, pediatrics, and neonatology.

Sponsors include the Association of Maternal and Child Health Programs
(AMCHP), the Association of Teachers of Maternal and Child Health
(ATMCH), and CityMatCH.

You have online Access to this journal through the HSR Library
websites\*. In the Search box under Online Journals on the left side of
the main webpage type \"Maternal\". A list of journals with \"maternal\"
will appear. Click on Maternal and Child Health Journal to go to the
available online issues. If you need help with any online resources call
me at 301.594.2449 or email me at <cooperd@mail.nih.gov>

\*IHS Access <http://hsrl.nihlibrary.nih.gov/>

\*Tribal and Urban Access
<http://nihlibrary.ors.nih.gov/ezproxy/ihs.htm>

##### 

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

**Duration of Lactation and Incidence of Type 2 Diabetes**

**Special Editorial: Suzan Murphy, new CCCC columnist**

The following are comments on the December CCC Corner Breastfeeding
posting:

**"New studies shows a 15% reduction for the risk of diabetes for every
year of lactation"**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#breast>

There are growing lists of research about the positive benefits
of lactation for both the mom and baby. For our families where type 2
diabetes is a common, chronic threat and reality, a new tool
- like breastfeeding - is a welcome addition to the diabetes
prevention/care \"tool kit.\" Studies in AI/AN and Native Canadian
communities have linked breastfeeding with less risk of type 2 diabetes
(Pettitt et al, 1997; Young et al, 2002) for offspring. Now studies
support an even more profound maternal benefit for reducing diabetes
risk (Stuebe AM et al, 2005)\*. Breastfeeding could be the
\"immunization\" that means less diabetes for future generations.

 

The CDC report, *Maternal Morbidity in American Indian and Alaska Native
Women, 2002-2004*, by Bacak SJ et al, states the prevalence of
gestational diabetes is 7.8% - an alarming number that hints at the
spiraling increases ahead for our communities.  The presence of diabetes
during pregnancy dramatically increases the risk of diabetes for the
offspring and the mother. Breastfeeding could reduce risk for both.
Providing families/communities/tribal agencies with information about
these benefits and ways to support the practice of breastfeeding will
allow more families to breastfeed. 

 

For ideas about ways to support breastfeeding, please watch for the new
IHS MCH Breastfeeding page. If a video/DVD would help, call
1-877-868-9473 for a 12 minute professionally done \"Close to the Heart,
Breastfeeding Our Children, Honoring Our Values. It is free and can be
duplicated. Posters are also available at this number. 

For free written materials, consider ordering \"The Easy Guide To
Breastfeeding for American Indians and Alaska Native Families\" (url
below) Scroll down to pregnancy, it is the last item in the category.
100 can be ordered on line. If you need more, use the comment section to
explain the need.  Thanks to IHS Head Start, there is a generous supply.

 

\*Although there will be likely be more research about the mechanism for
how this works, there are several possibilities, including enhanced
maternal insulin sensitivity (Kjos SL et al, 1993; Tigas et al, 2002). 
Stay tuned.

**Resources**

#### The Easy Guide To Breastfeeding for American Indians and Alaska Native Families {#the-easy-guide-to-breastfeeding-for-american-indians-and-alaska-native-families .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/diabetes/resources/rde/index.cfm?module=catalog**](http://www.ihs.gov/MedicalPrograms/diabetes/resources/rde/index.cfm?module=catalog)  {#httpwww.ihs.govmedicalprogramsdiabetesresourcesrdeindex.cfmmodulecatalog .Style-Heading-4-+-Arial-14-pt-Underline}

Bacak SJ, Thierry J, Tucker M, Paisano E *Maternal Morbidity in American
Indian and Alaska Native Women, 2002-2004*

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MatMorb9205.doc>

[Kjos
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kjos+SL"%5BAuthor%5D),
et al The effect of lactation on glucose and lipid metabolism in women
with recent gestational diabetes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 1993
Sep;82(3):451-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8355952&query_hl=11>

[Pettitt
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pettitt+DJ"%5BAuthor%5D),
et al Breastfeeding and incidence of non-insulin-dependent diabetes
mellitus in Pima Indians.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 1997 Jul
19;350(9072):166-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9250183&query_hl=m>

Stuebe AM et al. Duration of Lactation and Incidence of Type 2 Diabetes
JAMA. 2005;294:2601-2610
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16304074&query_hl=1>

[Tigas
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Tigas+S"%5BAuthor%5D),
et al Metabolic adaptation to feeding and fasting during lactation in
humans. [J Clin Endocrinol
Metab.](javascript:AL_get(this, 'jour', 'J Clin Endocrinol Metab.');)
2002 Jan;87(1):302-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11788664&query_hl=13>

[Young
TK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Young+TK"%5BAuthor%5D)
et al Type 2 diabetes mellitus in children: prenatal and early infancy
risk factors among native canadians.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12090830&query_hl=6>

####  {#section-19 .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 - A compact digest of last month's CCC Corner {#nicely-laid-out-hard-copy---a-compact-digest-of-last-months-ccc-corner .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -[Routine screening for protein and glucose at each prenatal visit should be abandoned](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_AOM.cfm) {#routine-screening-for-protein-and-glucose-at-each-prenatal-visit-should-be-abandoned-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[How do you know when you have a false positive HIV test in pregnancy?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#how-do-you-know-when-you-have-a-false-positive-hiv-test-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Paroxetine's pregnancy category changed from C to D](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#ob) {#paroxetines-pregnancy-category-changed-from-c-to-d-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Editorial: Vaccine prevents cervical cancer, Gardasil: Preliminary results 100% effective](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#editorial-vaccine-prevents-cervical-cancer-gardasil-preliminary-results-100-effective-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Handle abnormal Pap smears differently in adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#gyn) {#handle-abnormal-pap-smears-differently-in-adolescents-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Quick Assessment of Literacy in Primary Care: The Newest Vital Sign](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#chrIll) {#quick-assessment-of-literacy-in-primary-care-the-newest-vital-sign-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Inappropriate use of the terms fetal distress and birth asphyxia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#acog) {#inappropriate-use-of-the-terms-fetal-distress-and-birth-asphyxia-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[New studies shows a 15% reduction for the risk of diabetes for every year of lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#breast) {#new-studies-shows-a-15-reduction-for-the-risk-of-diabetes-for-every-year-of-lactation-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[New cigarettes with flavors that appeal to youth](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#alert) {#new-cigarettes-with-flavors-that-appeal-to-youth-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[CC:   I feel really cold and my side hurts, plus I am shaking all over](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#mmtour) {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-over-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[WHI clinical trial revisited: Imprecise methodology disqualifies the study\'s outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#mscape) {#whi-clinical-trial-revisited-imprecise-methodology-disqualifies-the-studys-outcomes-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Post Partum Hemorrhage is the most common cause of maternal mortality worldwide](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives) {#post-partum-hemorrhage-is-the-most-common-cause-of-maternal-mortality-worldwide-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Liability in Triage: Management of EMTALA Regulations and Common Obstetric Risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives) {#liability-in-triage-management-of-emtala-regulations-and-common-obstetric-risks-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[MRSA presents new challenges in treating skin and soft-tissue infections, including in pregnancy...](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#navajo) {#mrsa-presents-new-challenges-in-treating-skin-and-soft-tissue-infections-including-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Many new additions to the Indian Health Guidelines / Patient Education web page](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#many-new-additions-to-the-indian-health-guidelines-patient-education-web-page-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Meconium Happens](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#periPicks) {#meconium-happens-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Cardiology Topics for Primary Care Providers -- February 15, 2006](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#pcf) {#cardiology-topics-for-primary-care-providers-february-15-2006-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[High-Risk HPV Associated with Chlamydia trachomatis with Female Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#std) {#high-risk-hpv-associated-with-chlamydia-trachomatis-with-female-adolescents-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Type 2 diabetes mortality in women: Same as a \"coronary heart disease equivalent\"](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#stillW) {#type-2-diabetes-mortality-in-women-same-as-a-coronary-heart-disease-equivalent-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[21st Annual Midwinter Indian Health OB / PEDS Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#dates) January 27-29, 2006 [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05DecOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05DecOL.pdf) {#st-annual-midwinter-indian-health-ob-peds-conference-january-27-29-2006-httpwww.ihs.govmedicalprogramsmchmdocuments05decol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-20 .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-21 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Sexual Assault Services Delivered by SANES**

### [Conclusion]{.underline} The empirical documentation and description of SANE practices is an important step toward evaluating the effectiveness of specialized sexual assault services. Future research should compare acute post-assault services delivered by SANEs and non-SANEs in order to examine the extent to which SANE practices help mitigate potential negative health outcomes of sexual assault. Research evaluating the effectiveness of SANE practices could help refine and expand SANE services and contribute to developing evidence-based best practices for sexual assault in an urgent care setting. The ultimate goal is to provide services that best meet the medical, legal, and psychosocial needs of sexual assault survivors.

Lana Stermac, PhD; Hester Dunlap, MEd; Deidre Bainbridge, Sexual Assault
Services Delivered by SANES J Foren Nurs.  2005;1(3):124-128.  
<http://www.medscape.com/viewarticle/515881_6>

**The Truth About Rape, CDC**

[http://www.cdc.gov/ncipc/dvp/The%20Truth%20About%20Rape%20Final.pdf](http://www.cdc.gov/ncipc/dvp/The Truth About Rape Final.pdf)

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

#### Post-traumatic Stress Disorder - Clinical Evidence Concise {#post-traumatic-stress-disorder---clinical-evidence-concise-1 .Style-Heading-4-+-Arial-14-pt-Underline}

What are the effects of preventive intervention?

likely to be beneficial

**Multiple-session CBT in People with Acute Stress Disorder (Reduced
PTSD Compared with Supportive Counseling).** Two small randomized
controlled trials (RCTs) in people with acute stress disorder after a
traumatic event (e.g., motor vehicle crash, nonsexual assault) found
that five sessions of cognitive behavior therapy (CBT) reduced the
proportion of people with post-traumatic stress disorder (PTSD) after
six months compared with supportive counseling.

unlikely to be beneficial

**Single-session Individual Debriefing.** One systematic review of RCTs
in people who had been exposed to a traumatic event in the previous
month found no significant difference between a single session of
individual psychological debriefing and no debriefing in the rate of
PTSD at three to six months. The review found that individual
psychological debriefing increased the rate of PTSD compared with no
debriefing at 13 months.

**Supportive Counseling.** Two RCTs in people with acute stress disorder
after a traumatic event (e.g., motor vehicle crash, nonsexual assault)
found that supportive counseling was less effective than five sessions
of CBT in reducing the proportion of people with PTSD after six months.

unknown effectiveness

**Single-session Group Debriefing.** One systematic review identified no
RCTs comparing single-session group debriefing with no debriefing. One
RCT found that early group debriefing (within 10 hours of the traumatic
event) reduced PTSD compared with delayed group debriefing (after 48
hours) at two weeks.

**Multiple-session CBT in All People Exposed to a Traumatic Event.** One
RCT found that four sessions of CBT reduced post-traumatic stress
symptoms at 13 months in people with psychological distress following
physical injury compared with no psychological intervention. However, it
found no significant difference in the proportion of people meeting the
*Diagnostic and Statistical Manual of Mental Disorders,* 4th ed.
(DSM-IV) criteria for PTSD. Another RCT in bus drivers who had been
attacked in the previous five months found that CBT improved measures of
anxiety and intrusive symptoms at six months compared with standard
care. However, it found no significant difference in measures of
depression or avoidance symptoms. One RCT provided insufficient evidence
to assess CBT plus education techniques in preventing PTSD in motor
vehicle crash survivors. Another small RCT provided insufficient
evidence to compare memory structuring with supportive listening in
motor vehicle crash survivors.

**Multiple-session Collaborative Trauma Support.** Two RCTs provided
insufficient evidence to assess multiple-session collaborative trauma
support interventions involving emotional, social, and practical support
in people exposed to a traumatic event in the previous 24 hours to one
week.

**Multiple-session Education.** No systematic review or RCTs assessing
the effects of multiple-session education alone were found. One RCT
provided insufficient evidence to assess education techniques plus CBT
in preventing PTSD in motor vehicle crash survivors.

**Hydrocortisone.** One small RCT involving people in intensive care
with septic shock provided insufficient evidence to assess
hydrocortisone in preventing PTSD.

**Propranolol.** One small RCT provided insufficient evidence to assess
propranolol in preventing PTSD in people with early symptoms of PTSD
after a traumatic event.

**Temazepam.** One small RCT provided insufficient evidence to assess
temazepam in preventing PTSD in people with acute stress disorder or
early symptoms of PTSD after a motor vehicle crash, industrial accident,
or nonsexual assault.

What are the effects of treatment?

beneficial

**CBT.** One systematic review found that CBT reduced rates of PTSD
compared with no treatment, stress management, supportive psychotherapy,
psychodynamic psychotherapy, supportive counseling, or hypnotherapy. The
review found no significant difference in rates of PTSD between CBT and
eye movement desensitization and reprocessing.

**Eye Movement Desensitization and Reprocessing.** One systematic review
found that eye movement desensitization and reprocessing improved
symptoms compared with no treatment or usual treatment. The review found
no significant difference in rates of PTSD between eye movement
desensitization and reprocessing and stress management or CBT.

likely to be beneficial

**Fluoxetine.** One systematic review found that fluoxetine reduced
symptoms of PTSD compared with placebo at three months.

**Paroxetine.** One systematic review found that paroxetine improved
symptoms compared with placebo at three months in people with PTSD.

**Sertraline.** One systematic review found that sertraline improved
symptoms of PTSD at three to seven months compared with placebo.

unlikely to be beneficial

**Venlafaxine.** One large RCT identified by a systematic review found
no significant difference in symptom severity at 12 weeks between
venlafaxine and placebo in people with PTSD.

unknown effectiveness

**Affect Management.** One RCT provided insufficient evidence about the
effects of affect management in improving symptoms in people with PTSD.

**Drama Therapy.** We found no systematic review or RCT investigating
the effects of drama therapy in improving symptoms of PTSD.

**Group Therapy.** RCTs identified by a systematic review provided
insufficient evidence about the effects of group therapy in improving
symptoms of PTSD.

**Hypnotherapy.** One RCT identified by a systematic review provided
insufficient evidence about the effects of hypnotherapy in improving
symptoms of PTSD.

**Inpatient Treatment Programs.** We found no systematic review or RCT
investigating the effects of inpatient treatment programs in improving
symptoms of PTSD.

**Internet-based Psychotherapy.** One RCT provided insufficient evidence
about the effects of Internet-based psychotherapy in improving symptoms
of PTSD.

**Psychodynamic Psychotherapy.** One RCT identified by a systematic
review provided insufficient evidence about the effects of psychodynamic
psychotherapy in improving symptoms of PTSD.

**Supportive Psychotherapy.** One RCT provided insufficient evidence
about the effects of supportive psychotherapy in improving symptoms in
people with PTSD.

**Mirtazapine.** One RCT identified by a systematic review provided
insufficient evidence about the effects of mirtazapine in improving
symptoms of PTSD.

**Nefazodone.** We found insufficient evidence about the effects of
nefazodone in improving symptoms of PTSD.

**Tricyclic Antidepressants.** RCTs identified by a systematic review
provided insufficient evidence to assess imipramine or amitriptyline in
people with PTSD.

**Phenelzine.** One RCT identified by a systematic review provided
insufficient evidence about the effects of phenelzine in improving
symptoms of PTSD.

**Brofaromine.** One RCT identified by a systematic review provided
insufficient evidence about the effects of brofaromine in improving
symptoms of PTSD.

**Carbamazepine.** We found no systematic review or RCT of carbamazepine
in people with PTSD.

**Risperidone.** One RCT identified by a systematic review provided
insufficient evidence about the effects of risperidone in improving the
symptoms of PTSD.

**Benzodiazepines.** One systematic review identified no RCT of
sufficient quality that assessed benzodiazepines in people with PTSD.

**Propranolol.** We found no systematic review or RCT that assessed
propranolol in people with PTSD.

**Olanzapine.** One systematic review identified no good quality RCTs
that assessed olanzapine in people with PTSD.

Definition

PTSD can occur after any major traumatic event. Symptoms include
upsetting thoughts and nightmares about the traumatic event, avoidance
behavior, numbing of general responsiveness, increased irritability, and
hypervigilance. To fulfill the DSM-IV criteria for PTSD, an individual
must have been exposed to a traumatic event; have at least one
reexperiencing, three avoidance, and two hyperarousal phenomena; have
had the symptoms for at least one month; and the symptoms must cause
clinically important distress or reduced day-to-day functioning. People
with subsyndrome PTSD meet the criteria for PTSD except one of the
reexperiencing, avoidance, or hyperarousal phenomena. Acute stress
disorder occurs within the first month after a major traumatic event and
requires the presence of symptoms for at least two days. It is similar
to PTSD, but dissociative symptoms are required to make the diagnosis.
Treatments for PTSD may have similar effects, regardless of the
traumatic event that precipitated PTSD. However, caution should be
applied when generalizing among types of trauma.

Incidence

One large cross-sectional study in the United States found that one in
10 women (10 percent) and one in 20 men (5 percent) experience PTSD at
some stage in their lives.

Etiology

Risk factors for PTSD include major trauma (e.g., rape), a history of
psychiatric disorders, acute distress and depression after the trauma,
lack of social support, and personality factors.

Prognosis

One large cross-sectional study in the United States found that more
than one third of people with previous PTSD continued to satisfy the
criteria for PTSD six years after initial diagnosis.^2^ However,
cross-sectional studies provide weak evidence about prognosis. A
Publication of BMJ Publishing Group

#### [**http://www.aafp.org/afp/20060101/bmj.html**](http://www.aafp.org/afp/20060101/bmj.html) {#httpwww.aafp.orgafp20060101bmj.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

Anticholinergic Drugs for Overactive Bladder - Cochrane for Clinicians

Clinical Question

Which anticholinergic drug regimen is most effective for overactive
bladder?

Evidence-Based Answer

Tolterodine (Detrol) is as effective as immediate-release oxybutynin
(Ditropan) and causes less dry mouth. A dose of 1 mg tolterodine twice
daily is as effective as higher dosages of tolterodine. Extended-release
preparations have less risk of dry mouth but are more expensive.

Practice Pointers

Overactive bladder syndrome is characterized by the sensation of urgency
to urinate, sometimes with involuntary leakage (urge incontinence), with
no metabolic, mechanic or neurologic cause. Most patients also have
frequency and nocturia. It is thought to be caused by an overactive
detrusor muscle surrounding the bladder. Overactive bladder syndrome can
cause significant discomfort and is more common in older persons.

Options for treatment include nonpharmacologic approaches such as
adjusting urine output to 1 to 1.5 L daily, urge-suppression training,
bladder retraining, and prompted voiding. Drug treatments include
oxybutynin, tolterodine, propantheline (Pro-banthine), dicyclomine
(Bentyl), and tricyclic antidepressants.^1^

In a 2002 Cochrane review,^2^ Hay-Smith and colleagues determined that,
compared with placebo, anticholinergic medications produce a
statistically significant improvement in symptoms. To determine which
anticholinergic medication regimen is most effective, Hay-Smith and
colleagues searched for randomized controlled trials that compared
anticholinergic drugs in adults with overactive bladder symptoms.

The two most studied drugs were oxybutynin and tolterodine. In studies
comparing the abilities of tolterodine and oxybutynin in reducing
leakage episodes and micturitions, the two drugs were similar in effect.
However, patients receiving tolterodine were less likely to withdraw
because of adverse events (7 versus 12 percent, respectively) and had
one half to one third the risk of dry mouth. In addition, 1 mg of
tolterodine twice daily was as effective as the more standard dosage of
2 mg twice daily and caused fewer adverse effects. Limited data showed
extended-release preparations were equally as effective as
immediate-release preparations with fewer adverse effects.

Tolterodine and oxybutynin are available in the following forms:
tolterodine immediate-release, 1- and 2-mg capsules; tolterodine
extended-release, 2- and 4-mg capsules; oxybutynin immediate-release,
5-mg tablets and 5-mg (5-mL) syrup; oxybutynin extended-release, 5-mg
tablets and a transdermal patch that delivers 3.9 mg daily.

<http://www.aafp.org/afp/20060101/cochrane.html>

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

#### Emergency Contraception Use Not Associated With Risky Sexual Behavior  {#emergency-contraception-use-not-associated-with-risky-sexual-behavior .Style-Heading-4-+-Arial-14-pt-Underline}

#### Critics of emergency contraception (EC) have raised concerns that making it easily accessible could result in women having more unprotected sex, unintended pregnancies, and sexually transmitted infections. A new study, presented this week at the American Public Health Association annual meeting, suggests those concerns are unfounded:  {#critics-of-emergency-contraception-ec-have-raised-concerns-that-making-it-easily-accessible-could-result-in-women-having-more-unprotected-sex-unintended-pregnancies-and-sexually-transmitted-infections.-a-new-study-presented-this-week-at-the-american-public-health-association-annual-meeting-suggests-those-concerns-are-unfounded .Style-Heading-4-+-Arial-14-pt-Underline}

#### This data suggests the opposite to be true. The women we followed used EC for exactly what it\'s intended to be used for --- only in an atypical emergency situation in which they had unprotected sex and did not want to become pregnant. {#this-data-suggests-the-opposite-to-be-true.-the-women-we-followed-used-ec-for-exactly-what-its-intended-to-be-used-for-only-in-an-atypical-emergency-situation-in-which-they-had-unprotected-sex-and-did-not-want-to-become-pregnant. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The results of this study are consistent with the findings of 7 published studies specifically designed to test the hypothesis that easier access to EC promotes risk-taking. All of these studies showed that easier access did not result in more unprotected sex and did not reduce the use of regular contraceptive methods. {#the-results-of-this-study-are-consistent-with-the-findings-of-7-published-studies-specifically-designed-to-test-the-hypothesis-that-easier-access-to-ec-promotes-risk-taking.-all-of-these-studies-showed-that-easier-access-did-not-result-in-more-unprotected-sex-and-did-not-reduce-the-use-of-regular-contraceptive-methods. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The public could be better served by moving beyond the \"what-ifs\" and focusing on the available research data. The same sort of concerns were discussed when general contraception was introduced. The fact is that EC is really underused at this point. Half of all unintended pregnancies in the United States could be averted if EC was readily available and used. {#the-public-could-be-better-served-by-moving-beyond-the-what-ifs-and-focusing-on-the-available-research-data.-the-same-sort-of-concerns-were-discussed-when-general-contraception-was-introduced.-the-fact-is-that-ec-is-really-underused-at-this-point.-half-of-all-unintended-pregnancies-in-the-united-states-could-be-averted-if-ec-was-readily-available-and-used. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Toni Felice, PhD. APHA 133rd Annual Meeting: Abstract 102917. Presented Dec. 12, 2005 [**http://www.apha.org/meetings/**](http://www.apha.org/meetings/) {#toni-felice-phd.-apha-133rd-annual-meeting-abstract-102917.-presented-dec.-12-2005-httpwww.apha.orgmeetings .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-24 .Style-Heading-4-+-Arial-14-pt-Underline}

#### APHA 133rd Annual Meeting Coverage: Medscape {#apha-133rd-annual-meeting-coverage-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/4838**](http://www.medscape.com/viewprogram/4838) {#httpwww.medscape.comviewprogram4838 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Women\'s Sexual Health -From Adolescence to Postmenopause Resource Center: Medscape {#womens-sexual-health--from-adolescence-to-postmenopause-resource-center-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/pages/editorial/resourcecenters/public/wsh/rc-wsh.ov**](http://www.medscape.com/pages/editorial/resourcecenters/public/wsh/rc-wsh.ov) {#httpwww.medscape.compageseditorialresourcecenterspublicwshrc-wsh.ov .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### FDA Safety Changes: ParaGard Copper T 380A  {#fda-safety-changes-paragard-copper-t-380a-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The U.S. Food and Drug Administration (FDA) approved in September safety labeling revisions for a nonhormonal intrauterine device (IUD) to advise of new contraindications associated with its use. The agency also warned of the risks associated with pregnancies that occur while the device is in place, the risk for pelvic inflammatory disease associated with its use, and various other adverse events. {#the-u.s.-food-and-drug-administration-fda-approved-in-september-safety-labeling-revisions-for-a-nonhormonal-intrauterine-device-iud-to-advise-of-new-contraindications-associated-with-its-use.-the-agency-also-warned-of-the-risks-associated-with-pregnancies-that-occur-while-the-device-is-in-place-the-risk-for-pelvic-inflammatory-disease-associated-with-its-use-and-various-other-adverse-events. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The nonhormonal copper IUD is indicated for contraceptive use for up to 10 years in women aged 16 years and older. Previous restrictions on its use recently were removed to reflect findings that the risk for pelvic infection is more closely linked to sexual behavior rather than choice of contraceptive. {#the-nonhormonal-copper-iud-is-indicated-for-contraceptive-use-for-up-to-10-years-in-women-aged-16-years-and-older.-previous-restrictions-on-its-use-recently-were-removed-to-reflect-findings-that-the-risk-for-pelvic-infection-is-more-closely-linked-to-sexual-behavior-rather-than-choice-of-contraceptive. .Style-Heading-4-+-Arial-14-pt-Underline}

#### As a result, the IUD may now be used by nulliparous women and those not in a mutually monogamous relationship, although presence of a stable relationship is encouraged to decrease the risk for STDs and HIV infection. Use of the device is also allowed in women with a history of STDs or PID who do not have acute PID or engage in sexual behavior that increase their risk for developing PID. [**http://www.fda.gov**](http://www.medscape.com/px/trk.svr?exturl=http://www.fda.gov/medwatch/safety/2005/sep05.htm) {#as-a-result-the-iud-may-now-be-used-by-nulliparous-women-and-those-not-in-a-mutually-monogamous-relationship-although-presence-of-a-stable-relationship-is-encouraged-to-decrease-the-risk-for-stds-and-hiv-infection.-use-of-the-device-is-also-allowed-in-women-with-a-history-of-stds-or-pid-who-do-not-have-acute-pid-or-engage-in-sexual-behavior-that-increase-their-risk-for-developing-pid.-httpwww.fda.gov .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.fda.gov/medwatch/safety/2005/sep05.htm**](http://www.medscape.com/px/trk.svr?exturl=http://www.fda.gov/medwatch/safety/2005/sep05.htm) {#httpwww.fda.govmedwatchsafety2005sep05.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Hysteroscopic Sterilization May Offer Advantages Over Laparoscopic
Procedure**

#### CONCLUSIONS: This study provides evidence that ESSURE can be performed in the majority of women and, when successful, is associated with a greater overall patient satisfaction rate than laparoscopic sterilisation. Women also spend less time in hospital, have better tolerance of the procedure and describe less severe post-operative pain. However, the devices cannot be bilaterally placed in all cases and some women do not tolerate the procedure awake. {#conclusions-this-study-provides-evidence-that-essure-can-be-performed-in-the-majority-of-women-and-when-successful-is-associated-with-a-greater-overall-patient-satisfaction-rate-than-laparoscopic-sterilisation.-women-also-spend-less-time-in-hospital-have-better-tolerance-of-the-procedure-and-describe-less-severe-post-operative-pain.-however-the-devices-cannot-be-bilaterally-placed-in-all-cases-and-some-women-do-not-tolerate-the-procedure-awake. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Duffy S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Duffy+S"%5BAuthor%5D), et al Female sterilisation: a cohort controlled comparative study of ESSURE versus laparoscopic sterilisation. [BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2005 Nov;112(11):1522-8. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16225573&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16225573&query_hl) {#duffy-s-et-al-female-sterilisation-a-cohort-controlled-comparative-study-of-essure-versus-laparoscopic-sterilisation.-bjog.-2005-nov112111522-8.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16225573query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

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

Emergency Contraception: AAP Review

In a statement published in the October 2005 issue of *Pediatrics*, the
American Academy of Pediatrics (AAP) recommends that education and
counseling about emergency contraception be incorporated into the annual
preventive visits of adolescent patients when issues of sexuality are
addressed. Physicians also should provide community-specific guidance on
access and availability of emergency contraception and consider writing
an advance prescription.

The full policy statement, \"Emergency Contraception,\" is available
online at <http://www.pediatrics.org/cgi/content/full/116/4/1026>.

Emergency contraception is approximately 80 percent effective for
preventing pregnancy when the first dose is taken within 72 hours of
sexual intercourse. Two medications have been approved by the U.S. Food
and Drug Administration (FDA) for use as emergency contraception-a
combination estrogen/progestin pill (Preven) and a progestin-only
formulation (Plan B). In addition, the off-label use of combination oral
contraceptives at higher dosages (e.g., two doses taken 12 hours apart,
each containing at least 100 mcg of ethinyl estradiol and at least 0.50
mg of levonorgestrel) has been declared safe and effective by the FDA
Reproductive Health Advisory Committee.

Emergency contraception is indicated when unprotected or inadequately
protected sex has taken place within the previous 72 to 120 hours
(although the FDA approves the use only within 72 hours). The AAP states
that progestin-only emergency contraception may be prescribed over the
telephone, but an office visit should be scheduled for 10 to 14 days
after use to exclude pregnancy and to provide contraceptive advice and
screening for sexually transmitted diseases.

The AAP report suggests that an antiemetic agent taken one hour before
estrogen-containing medication may decrease the risk and severity of
nausea. The progestin-only method is better tolerated and may be more
effective than combination methods. Because of the short duration of
use, combination emergency contraception may be offered to patients with
chronic conditions in whom estrogen-containing oral contraceptives are
contraindicated. There are no contraindications for the use of
progestin-only emergency contraception. Almost all patients menstruate
within three weeks of taking emergency contraception; patients who have
not menstruated within three weeks should be tested for pregnancy.

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

**Featured Website David Gahn, IHS Women's Health Web Site Content
Coordinator**

**Vaginal Birth after Cesarean**

**New Perinatology Corner Module -- 2 credits**

This is a new edition of our previous module of the same name. The main
changes include a new risk factor grading system, plus how to apply that
information to clinical practice.
[[http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm)

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

**What factors effect when we should we start colon cancer screening in
low risk adults?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ColonScr10205.doc>

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

**January 2006**

\- The cost of peditric influenza hospitalizations

\- CDC review of pediatric influenza deaths in 2003-2004

\- Hepatitis A vaccine shows greatest benefits for Native Americans

\- Coordinated primary care in rural areas

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/IHSchildnotesJan2006.doc>

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

**Just out: IHS Information Technology News -- January 2006**

Contact Theresa Cullen for 551KB pdf document <Theresa.Cullen@IHS.GOV>

**Family Medicine Patients' Use of the Internet for Health Information**

A total of 74% of those with access had used the Internet to find health
information for themselves or family members. Disease-specific
information was most frequently sought, followed by medication
information, and then information about nutrition and exercise. Patients
determine website accuracy by the endorsement of the site by a
government agency or a professional organization, their own perception
of reliability of the website source, and the understandability of the
information.

Almost 90% attempted to verify the information they obtained. A majority
had discussed website information with their physicians. The physicians
(n = 92) underestimate the proportion of their patients who used the
Internet for health information. A total of 36% of physicians said at
least one patient per week brought in Internet health information, and
63% said they had suggested a specific website to their patients.

Physicians need critical appraisal skills to determine whether
information found by a patient is relevant to that patient's condition
and is based on the best available evidence. In addition, physicians
directing patients to websites for health information must be confident
that the site is maintained and updated by a reliable and credible
source.

Kendra L. Schwartz KL, et al Family Medicine Patients' Use of the
Internet for Health Information: A MetroNet Study. *The Journal of the
American Board of Family Medicine* 19:39-45 (2006)

<http://www.jabfp.org/cgi/content/abstract/19/1/39>

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

**The Association Between Reproductive Health-Related Medical Claims and
Criminal Activity or the Experience of Abuse among Medicaid-enrolled
Adolescent Females**

[[http://www.epi.alaska.gov/bulletins/docs/rr2006_01.pdf]{.underline}](http://www.epi.alaska.gov/bulletins/docs/rr2006_01.pdf)

**Summary Report:  Reproductive Health Claims and Risk of Abuse among
Medicaid-enrolled Adolescent Females**

[[http://www.epi.alaska.gov/bulletins/docs/b2006_01.pdf]{.underline}](http://www.epi.alaska.gov/bulletins/docs/b2006_01.pdf)

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

**Girl Talk: Choices and Consequences of Underage Drinking**

Girl Talk: Choices and Consequences of Underage Drinking is intended to
increase knowledge about the prevalence of underage drinking among girls
and to improve dialogue among mothers and their adolescent daughters.
The initiative, developed by the Century Council in partnership with the
Society for Women's Health Research and the Montgomery County Maryland
Alcohol Beverage Control Board, utilizes data from surveys of daughters
(ages 13-15, 16-18, and 19-20) and their mothers, including data on the
health consequences of most concern to the girls and on their advice to
mothers about discussing underage drinking. Components of the initiative
include

\*A Web site for mothers and daughters with additional information on
how to have a conversation about underage drinking, and links to
national and local resources related to underage drinking.

\* Booklets for mothers discussing how to begin and sustain the
conversation and how to have an impact. The booklets also explain the
facts about alcohol and address related issues such as peer pressure and
creative ways to say \"no\" to alcohol.

\* A blog (available in January 2006), hosted by the Society for Women's
Health Research, for mothers and daughters to discuss their experiences
and connect with others on this issue.

\* A media partnership with The N, a nighttime network for adolescents,
to include sponsorship of programs that feature underage drinking
themes.

\* An endorsement by the U.S. Women's National Soccer Team Players
Association through personal appearances at functions and schools, in
print and online media, and via public service announcements and other
integrated marketing initiatives. Through its official fan club alone,
The Ponytail Posse, the association has the potential to reach millions
of girls around the world.

[http://www.girlsanddrinking.org](http://www.girlsanddrinking.org/)

#### Medical Mystery Tour {#medical-mystery-tour-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CC: I feel really cold and my side hurts, plus I am shaking all {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Let us recap from last month {#let-us-recap-from-last-month .Style-Heading-4-+-Arial-14-pt-Underline}

#### A 21 year old G2 P1001presented complaining of nausea, vomiting, shaking chills, and contractions every 2 minutes.  {#a-21-year-old-g2-p1001presented-complaining-of-nausea-vomiting-shaking-chills-and-contractions-every-2-minutes. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-31 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The patient was 37 3/7 weeks EGA by a 32 week ultrasound. Her prenatal history was not significant, but then again she had only 3 total prenatal visits. {#the-patient-was-37-37-weeks-ega-by-a-32-week-ultrasound.-her-prenatal-history-was-not-significant-but-then-again-she-had-only-3-total-prenatal-visits. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-32 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Her initial urinalysis showed WBC 10-30 hpf, positive leukocyte esterase, bacteria 1+, 3 + ketones, epithethial cells 1-5 hpf, trace protein, nitrite negative, and negative casts. {#her-initial-urinalysis-showed-wbc-10-30-hpf-positive-leukocyte-esterase-bacteria-1-3-ketones-epithethial-cells-1-5-hpf-trace-protein-nitrite-negative-and-negative-casts. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-33 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The patient was admitted with a diagnosis of pyelonephritis and treated with Ceftriaxone 1 gm intravenously. Later that day the laboratory reported a preliminary blood culture result with gram positive cocci in clusters. Gentamicin 140 mg IV and vancomycin 500 mg IV were added to the antibiotic regime.  {#the-patient-was-admitted-with-a-diagnosis-of-pyelonephritis-and-treated-with-ceftriaxone-1-gm-intravenously.-later-that-day-the-laboratory-reported-a-preliminary-blood-culture-result-with-gram-positive-cocci-in-clusters.-gentamicin-140-mg-iv-and-vancomycin-500-mg-iv-were-added-to-the-antibiotic-regime. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-34 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The patient was subsequently transferred to a tertiary care facility approximately 500 miles away by air ambulance. Upon arrival the patient was afebrile, but had shaking chills. The patient had developed exquisite right flank pain. The physical examination was otherwise essentially unchanged. The cervix was 1 cm dilated, thick, and -- 3 station {#the-patient-was-subsequently-transferred-to-a-tertiary-care-facility-approximately-500-miles-away-by-air-ambulance.-upon-arrival-the-patient-was-afebrile-but-had-shaking-chills.-the-patient-had-developed-exquisite-right-flank-pain.-the-physical-examination-was-otherwise-essentially-unchanged.-the-cervix-was-1-cm-dilated-thick-and-3-station .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-35 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The referring facility subsequently reported the preliminary positive blood culture as gram negative rods. The patient's gentamicin was changed to 100 mg q 8 hours IV and the vancomycin was stopped. The pyelonephritis patient was suspected of urosepsis. Five hours after admission the patient's white blood cell count increased to 26,100 cells /microL and the patient continued to have right flank and right lower quadrant pain. The right flank pain now required intermittent intravenous morphine.  {#the-referring-facility-subsequently-reported-the-preliminary-positive-blood-culture-as-gram-negative-rods.-the-patients-gentamicin-was-changed-to-100-mg-q-8-hours-iv-and-the-vancomycin-was-stopped.-the-pyelonephritis-patient-was-suspected-of-urosepsis.-five-hours-after-admission-the-patients-white-blood-cell-count-increased-to-26100-cells-microl-and-the-patient-continued-to-have-right-flank-and-right-lower-quadrant-pain.-the-right-flank-pain-now-required-intermittent-intravenous-morphine. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-36 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The General Surgery team concurred that the patient had pyelonephritis with a suspected perinephric abscess. They suggested adding vancomycin back to the regimen because of the preliminary positive blood culture at the referring facility had suggested gram positive cocci in clusters and was still unidentified. There was a significant prevalence of methicillin resistant Staphylococcus aureus infection in the patient's home region. The General Surgery Service agreed with obtaining a renal ultrasound in the morning. {#the-general-surgery-team-concurred-that-the-patient-had-pyelonephritis-with-a-suspected-perinephric-abscess.-they-suggested-adding-vancomycin-back-to-the-regimen-because-of-the-preliminary-positive-blood-culture-at-the-referring-facility-had-suggested-gram-positive-cocci-in-clusters-and-was-still-unidentified.-there-was-a-significant-prevalence-of-methicillin-resistant-staphylococcus-aureus-infection-in-the-patients-home-region.-the-general-surgery-service-agreed-with-obtaining-a-renal-ultrasound-in-the-morning. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-37 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Is there anything else would you like to do now for this patient diagnosed with urosepsis at 37 weeks EGA? {#is-there-anything-else-would-you-like-to-do-now-for-this-patient-diagnosed-with-urosepsis-at-37-weeks-ega .Style-Heading-4-+-Arial-14-pt-Underline}

#### The rest of the story..... {#the-rest-of-the-story.. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The General Surgery Service signed off the case after the renal ultrasound was reported as normal. Two days later the patient continued to have right flank and lower quadrant pain with a WBC of 22.9 K. The General Surgery Service was re-consulted and their suggested RUQ and RLQ ultrasounds were both negative, though there was a term fetus in the pelvis. {#the-general-surgery-service-signed-off-the-case-after-the-renal-ultrasound-was-reported-as-normal.-two-days-later-the-patient-continued-to-have-right-flank-and-lower-quadrant-pain-with-a-wbc-of-22.9-k.-the-general-surgery-service-was-re-consulted-and-their-suggested-ruq-and-rlq-ultrasounds-were-both-negative-though-there-was-a-term-fetus-in-the-pelvis. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-38 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In the meantime, the blood culture was reported pan sensitive E. coli. In view of the continued symptoms, the General Surgery team suggested primary cesarean delivery and exploratory laparotomy / appendectomy (whether it was inflamed or not) versus vaginal delivery and computerized tomography after delivery. After discussion of the risks and benefits, a misoprostol cervical ripening was begun. The previous antibiotics were discontinued and the patient was started on ampicillin sulbactam 3 g q 6 IV.  {#in-the-meantime-the-blood-culture-was-reported-pan-sensitive-e.-coli.-in-view-of-the-continued-symptoms-the-general-surgery-team-suggested-primary-cesarean-delivery-and-exploratory-laparotomy-appendectomy-whether-it-was-inflamed-or-not-versus-vaginal-delivery-and-computerized-tomography-after-delivery.-after-discussion-of-the-risks-and-benefits-a-misoprostol-cervical-ripening-was-begun.-the-previous-antibiotics-were-discontinued-and-the-patient-was-started-on-ampicillin-sulbactam-3-g-q-6-iv. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

#### After the misoprostol 50 ug was placed vaginally, a prior blood culture returned with a second organism, a slender, elongated Gram negative rods, consistent with Bacteroides fragilis.  {#after-the-misoprostol-50-ug-was-placed-vaginally-a-prior-blood-culture-returned-with-a-second-organism-a-slender-elongated-gram-negative-rods-consistent-with-bacteroides-fragilis. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

#### If there wasn't enough complicating the last few days of this patient's pregnancy, her midwife noted an unusual presenting structure. This was later confirmed to be a face presentation in right mentum transverse. In a rare stroke of good luck that week, the patient subsequently rotated her fetus to mentum anterior and delivered a normal infant in a double set up delivery suite later that evening. {#if-there-wasnt-enough-complicating-the-last-few-days-of-this-patients-pregnancy-her-midwife-noted-an-unusual-presenting-structure.-this-was-later-confirmed-to-be-a-face-presentation-in-right-mentum-transverse.-in-a-rare-stroke-of-good-luck-that-week-the-patient-subsequently-rotated-her-fetus-to-mentum-anterior-and-delivered-a-normal-infant-in-a-double-set-up-delivery-suite-later-that-evening. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Post partum, the patient's WBC decreased 9.8K, but she continued with the same right sided pain. Computerized tomogram with contrast revealed a phlegmon surrounding a dilated appendix and appendicolith.  {#post-partum-the-patients-wbc-decreased-9.8k-but-she-continued-with-the-same-right-sided-pain.-computerized-tomogram-with-contrast-revealed-a-phlegmon-surrounding-a-dilated-appendix-and-appendicolith. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

####  Approximately 12 hours postpartum, the patient underwent an exploratory laparotomy. The General Surgery team discovered a hardened retrocecal appendix which was completely avulsed at the base. The avulsion occurred either with the gentle attempts to visualize the appendix, or having already separated from the cecum. There was also a large appendicolith inferior to this. There was spillage of purulent material, but no bowel contents. An attempt was made to find where the base of the appendix came off the cecum. Two possible areas were treated with a 1-0 endoloops. The surgical incision was left open initially, but received a loose closure on postoperative day 2. The patient subsequently had an unremarkable postpartum course and was discharged on post partum day 3. The patient called back 2 weeks later and thanked the night shift L/D staff members for their care. {#approximately-12-hours-postpartum-the-patient-underwent-an-exploratory-laparotomy.-the-general-surgery-team-discovered-a-hardened-retrocecal-appendix-which-was-completely-avulsed-at-the-base.-the-avulsion-occurred-either-with-the-gentle-attempts-to-visualize-the-appendix-or-having-already-separated-from-the-cecum.-there-was-also-a-large-appendicolith-inferior-to-this.-there-was-spillage-of-purulent-material-but-no-bowel-contents.-an-attempt-was-made-to-find-where-the-base-of-the-appendix-came-off-the-cecum.-two-possible-areas-were-treated-with-a-1-0-endoloops.-the-surgical-incision-was-left-open-initially-but-received-a-loose-closure-on-postoperative-day-2.-the-patient-subsequently-had-an-unremarkable-postpartum-course-and-was-discharged-on-post-partum-day-3.-the-patient-called-back-2-weeks-later-and-thanked-the-night-shift-ld-staff-members-for-their-care. .Style-Heading-4-+-Arial-14-pt-Underline}

#### OB/GYN CCC Editorial comment:

In retrospect, the initial urinalysis with WBC 10-30 hpf, was somewhat
misleading, but consistent with an inflammatory process adjacent to the
ureter and bladder. Microscopic hematuria and pyuria are found in up to
one-third of patients with acute appendicitis.

Patients with pyelonephritis patients will often continue to spike
temperatures, while they otherwise improve other symptoms, though this
patient's fever curve became increasing atypical for pyelonephritis.
Lastly, though the lab result returned after the clinical decision was
made to begin cervical ripening and post partum CT scan, the second
positive blood culture with a different organism suggested a
polymicrobial septic process.

Escherichia coli is the major causative pathogen in both uncomplicated
upper and lower urinary tract infection, being present in approximately
70 to 95 percent of cases. Staphylococcus saprophyticus is found in 5 to
20 percent of cases of cystitis or even higher in some studies. It can
also cause pyelonephritis. Occasionally other Enterobacteriaceae such as
Proteus mirabilis and Klebsiella species or enterococci are isolated
from the urine of patients with acute pyelonephritis.

A renal abscess is an uncommon infection of the urinary tract. It can
develop by one of two general mechanisms: hematogenous spread, which
usually results in a cortical abscess; and ascending infection from the
bladder, which primarily involves the medulla in most cases. In this
patient's case the renal ultrasound was negative.

**Appendicitis in Pregnancy**

Acute appendicitis is the most common general surgical problem
encountered during pregnancy, occurring equally in all trimesters.
Estimates of its incidence have ranged from 0.1 to 0.06 percent of
deliveries.

The clinical features depend upon the stage of pregnancy, which may make
diagnosis more difficult than in nonpregnant women. Because the location
of the appendix migrates upward with the enlarging uterus, the location
of pain or tenderness is variable. Other physiologic changes that occur
during pregnancy may also cause confusion. As an example, the normal
white blood cell count ranges from 6000 to 16000 cell/mm3 in the first
and second trimesters, and may rise to 20,000 to 30,000 cells/mm3 in
labor. Another difficulty arises in the reluctance to expose pregnant
women to radiation needed for diagnostic imaging.

These problems were underscored by the variable conclusions reached in a
number of series of appendicitis in pregnancy. As an example, in three
series with a total of 181 patients with suspected appendicitis, the
pattern of presenting complaints, laboratory and physical examination
were unhelpful for establishing the diagnosis. In contrast, a third
report comparing clinical features in 28 pregnant women with
appendicitis to matched nonpregnant controls found no significant
differences in clinical presentation.

Ultrasonography is safe and (as in nonpregnant women) may be helpful for
diagnosis. In a series of 45 patients, for example, the sensitivity,
specificity, and accuracy were estimated to be 100, 96, and 98 percent,
respectively. The gravid uterus prevented adequate sonographic
examination of the appendix in only three women, each of whom was near
term.

Considering the above studies, and clinical experience, the diagnosis of
appendicitis should be considered in pregnant women complaining of new
abdominal pain. The decision to proceed to laparotomy should be based
upon the clinical and sonographic features and clinical judgment. The
greatest risk is delayed intervention, which increases the risk of
perforation. In two retrospective reviews, perforation occurred in 14 to
43 percent of patients. All of these patients had symptoms for longer
than 24 hours. In another series that included 333 patients, fetal loss
was much more frequent in patients in whom the appendix had perforated
(36 versus 1.5 percent, respectively). Given the diagnostic difficulties
and significant risk of fetal mortality with perforation, a higher
negative laparotomy rate (20 to 35 percent) compared to nonpregnant
women has generally been considered to be acceptable.

Maternal morbidity following appendectomy is low except in patients in
whom the appendix has perforated. In contrast, pregnancy related
complications are frequent, particularly when surgery was performed in
the first or second trimester. This was illustrated in a series of 56
women who underwent appendectomy in various trimesters. Spontaneous
abortion was observed in 4 of 12 patients (33 percent) who underwent
appendectomy in the first trimester while 4 of 28 (14 percent) patients
operated on in the second trimester delivered prematurely. No pregnancy
complications were observed in women who underwent appendectomy in the
third trimester.

Although an appendectomy is usually performed through a transverse
incision over the point of maximal tenderness, a midline vertical
incision is preferred by some surgeons since it permits adequate
exposure of the abdomen for diagnosis and treatment of surgical
conditions that mimic appendicitis. It also can be used for a cesarean
delivery, if subsequently required for the usual obstetric indications.
Dehiscence during vaginal delivery should not be a concern when the
fascia has been appropriately re-approximated.

There have been several reports on the use of laparoscopic appendectomy
in pregnancy suggesting that such procedures can be performed
successfully during all trimesters and with few complications. However,
considerable skill is required to perform such procedures in the
presence of an enlarged uterus. Although promising, further studies are
needed to better document the safety and efficiency of this approach.
The long-term prognosis for women who underwent appendectomy is good.
Such women do not appear to be at increased risk for infertility or
other complications.

#### Resources: {#resources .Style-Heading-4-+-Arial-14-pt-Underline}

#### Appendicitis in adults, UpToDate {#appendicitis-in-adults-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/application/topic.asp?file=gi_dis/20863&type=A&selectedTitle=1\~28**](http://www.uptodateonline.com/application/topic.asp?file=gi_dis/20863&type=A&selectedTitle=1~28) {#httpwww.uptodateonline.comapplicationtopic.aspfilegi_dis20863typeaselectedtitle128 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Acute pyelonephritis: Microbiology and pathogenesis, UpToDate {#acute-pyelonephritis-microbiology-and-pathogenesis-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/application/topic.asp?file=uti_infe/2148&type=A&selectedTitle=1\~30**](http://www.uptodateonline.com/application/topic.asp?file=uti_infe/2148&type=A&selectedTitle=1~30) {#httpwww.uptodateonline.comapplicationtopic.aspfileuti_infe2148typeaselectedtitle130 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Renal and perinephric abscess, UpToDate {#renal-and-perinephric-abscess-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/application/topic.asp?file=uti_infe/4973&type=A&selectedTitle=1\~6**](http://www.uptodateonline.com/application/topic.asp?file=uti_infe/4973&type=A&selectedTitle=1~6) {#httpwww.uptodateonline.comapplicationtopic.aspfileuti_infe4973typeaselectedtitle16 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

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

######### 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.

**Menopause Management**

#### WHI Trial Seen Flawed; Alternative Hormone Replacement Regimen Proposed {#whi-trial-seen-flawed-alternative-hormone-replacement-regimen-proposed-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Two aspects of the design contributed to the adverse events:  {#two-aspects-of-the-design-contributed-to-the-adverse-events .Style-Heading-4-+-Arial-14-pt-Underline}

#### \[1\] The decision to administer continuous combined conjugated equine estrogen (CEE)/medroxyprogesterone acetate (MPA) or E alone as a standard regimen to a population with little previous hormonal treatment, ranging in age from 50-79 years, who, because of their age, were predisposed to coronary and cerebral atherosclerosis.  {#the-decision-to-administer-continuous-combined-conjugated-equine-estrogen-ceemedroxyprogesterone-acetate-mpa-or-e-alone-as-a-standard-regimen-to-a-population-with-little-previous-hormonal-treatment-ranging-in-age-from-50-79-years-who-because-of-their-age-were-predisposed-to-coronary-and-cerebral-atherosclerosis. .Style-Heading-4-+-Arial-14-pt-Underline}

#### \[2\] Selection of an untested regimen of continuous combined CEE plus MPA, which we hypothesize, negated the protective effect of E on the cardiovascular and cerebrovascular systems. Multiple observational studies that preceded the WHI study concluded that the use of E alone and E plus cyclic (not daily) progestin combination treatments initiated in early menopause had beneficial effects. The therapeutic regimens resulted in prevention of atherosclerosis and reductions in coronary artery disease mortality.  {#selection-of-an-untested-regimen-of-continuous-combined-cee-plus-mpa-which-we-hypothesize-negated-the-protective-effect-of-e-on-the-cardiovascular-and-cerebrovascular-systems.-multiple-observational-studies-that-preceded-the-whi-study-concluded-that-the-use-of-e-alone-and-e-plus-cyclic-not-daily-progestin-combination-treatments-initiated-in-early-menopause-had-beneficial-effects.-the-therapeutic-regimens-resulted-in-prevention-of-atherosclerosis-and-reductions-in-coronary-artery-disease-mortality. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Conclusion]{.underline} The WHI hormonal replacement study had major design flaws that led to adverse conclusions about the positive effects of hormone therapy. An alternative hormonal regimen is proposed that, on the basis of data supporting its beneficial cardiovascular effects, when initiated appropriately in a population of younger, more recently menopausal women, has promise to yield a more favorable risk/benefit outcome. It is imperative that a large scale study evaluating forms of hormone therapy other than continuous combined estrogen plus progestin be undertaken to evaluate their risks and benefits. {#conclusion-the-whi-hormonal-replacement-study-had-major-design-flaws-that-led-to-adverse-conclusions-about-the-positive-effects-of-hormone-therapy.-an-alternative-hormonal-regimen-is-proposed-that-on-the-basis-of-data-supporting-its-beneficial-cardiovascular-effects-when-initiated-appropriately-in-a-population-of-younger-more-recently-menopausal-women-has-promise-to-yield-a-more-favorable-riskbenefit-outcome.-it-is-imperative-that-a-large-scale-study-evaluating-forms-of-hormone-therapy-other-than-continuous-combined-estrogen-plus-progestin-be-undertaken-to-evaluate-their-risks-and-benefits. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Klaiber EL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Klaiber+EL"%5BAuthor%5D) et al A critique of the Women\'s Health Initiative hormone therapy study. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2005 Dec;84(6):1589-601 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16359951&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16359951&query_hl)  {#klaiber-el-et-al-a-critique-of-the-womens-health-initiative-hormone-therapy-study.-fertil-steril.-2005-dec8461589-601-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16359951query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Shoulder Dystocia**

Shoulder dystocia though a relatively rare complication of vaginal
birth, 0.6-1.4%, yet is one of the most dire of obstetric emergencies.
 Though associated with certain risk factors shoulder dystocia is
largely unpredictable in its occurrence and preventability.  

Shoulder dystocia is described as either the impaction of the anterior
shoulder behind the symphysis pubis, or as the impaction of the
posterior shoulder behind the sacral promontory. Resulting neonatal
morbidities such as permanent brachial plexus injuries and /or mental
impairment are one of the leading causes of malpractice litigation.
 This month's Midwives' Corner reviews shoulder dystocia from a variety
of perspectives:

**HELPS shoulder dystocia simulator training program**

In a recent personal communication with Susan DeJoy, Director of the
Midiwfery Service at Baystate Medical Center in Springfield Mass, we
discussed the history and the origin of the HELPS shoulder dystocia
simulator training program. 

We (Dept Ob/GYN at Baystate Medical Center) developed and implemented a
shoulder dystocia simulation training program in the spring of 2002,
entitled HELPS (\'call for Help, cut Episiotomy if needed, Legs back,
Posterior arm, Suprapubic pressure).  Modeled after other simulations
commonly used in health care for rare emergencies (CPR, NNR, ALSO), the
training included both theory/didactic and skills practice portions.
Emphasis was placed on teamwork, skills development, understanding other
team members\' roles, patient communication skills and risk reduction.
All birth attendants - physicians, midwives, residents and nurses - were
required to attend, and the Ob/Gyn Department Chair added certification
in HELPS training to requirements for credentialing. 

The training program was 1-2 hrs in length:  a short (\<30min) overview
of essential skills and maneuvers for each member of the team, who was
in charge during an event, who needed to respond when help was called
for (more on this later).  Then the majority of time was spent
practicing shoulder dystocia management with \'Noelle\', a manikin
specially designed to teach birth skills.  Participants were divided up
into teams

\- provider, nurse, resident - and had to go through a predetermined set
of steps to manage the problem.  Just like what you do in CPR
certification.  Everyone was then checked out and rec\'d a certificate
of completion.  If you are a credentialed provider here, that
certificate needed to be submitted to the Medical Staff office for
re-credentialing. Once you have initial certification, you get
recertified every 2 years by watching the CDROM and completing a
posttest.  A certificate is printed at the end of the posttest which,
again, must go to medical staff office for re-credentialing.  The med
staff office has verification of SD training as another checkbox on
there forms, along with license verification, etc.

We discovered several systems issues as we implemented the training.
First was, when/how to call for help to get the right people to come to
the right place.  We had an existing \'code white\' stat page to gather
a team in the OR to do a stat section, so we piggy-backed onto that:
calling a code white to an LDRP room instead of the OR now means
shoulder dystocia, and the code white team\'s beepers go off and the
code white is announced overhead (\'Code White, Rm 1809\').  The team
that arrives is the charge nurse, the pod coordinator (another RN on the
unit), the OR tech, the house attending, the anesthesia attending and
the 3rd and 4th year residents.  We also discovered that it was
important that the L&D secretaries knew what this was all about, as they
could get lab slips ready for cord gases, etc, could call NICU team
down, could get baby bands ready in case of fast transfer to NICU, etc.

**'Couple of other insights: **

How to do suprapubic pressure correctly.

Many providers did not know that the FIRST thing you do is move the
baby\'s shoulders to the oblique diameter; that going after the
posterior shoulder was less traumatic than Wood\'s maneuver; and that
episiotomy was not essential. 

"Breaking the bed" issue

CNMs generally do not break beds for delivery, but that the doc who
comes in to help you always breaks the bed and is somewhat incapacitated
when they find the bed not broken. We also had to come to consensus on
this. Talking this out, really helped.  The docs now understand they
might find the bed intact, and if that is a problem, they just say
\'Break the bed!\' and it will happen fast.  Teaching alternative
maneuvers to Wood\'s maneuver also helped.

The midwives understand that when you call for emergency help, you
facilitate what your consultant needs without hesitation or discussion. 
Having the code white team arrive helps all of this, as there are enough
people to do what ever is needed quickly.

The program is available through Veritech
[[www.veritechmedia.com]{.underline}](http://www.veritechmedia.com/) or
<ShoulderDystocia@veritechmedia.com>

**Other Resources**

Two relevant articles are also offered for your review.  They review
etiology, risk factors, management and prevention as well as offer
suggestions for appropriate documentation to aide the provider and limit
litigation due to negligence.

[Jevitt
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jevitt+CM"%5BAuthor%5D).
Shoulder dystocia: etiology, common risk factors, and management. [J
Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):485-97.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260363&query_hl>

CONCLUSION In a laboratory model of initial maneuvers for shoulder
dystocia, anterior Rubin\'s maneuver requires the least traction for
delivery and produces the least amount of brachial plexus tension.

[Gurewitsch
ED](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gurewitsch+ED"%5BAuthor%5D),
et al Comparing McRoberts\' and Rubin\'s maneuvers for initial
management of shoulder dystocia: an objective evaluation.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672018&query_hl>

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

If shoulder dystocia is a concern, some clinicians have empirically
advocated immediately proceeding to delivery of the fetal shoulders to
maintain the forward momentum of the fetus. (See 'CCC Deliver Through'
maneuver for Shoulder Dystocia Prevention below) Others support a short
delay in delivery of the shoulders, arguing that the endogenous
rotational mechanics of the second stage may spontaneously alleviate the
obstruction.

**Clinical Pearl:**

**The 'CCC Deliver Through' maneuver** **for Shoulder Dystocia
Prevention**

One maneuver to completely avoid shoulder dsystocia is to continue the
expulsive momentum and deliver the presenting part on through to the
visualization of the anterior shoulder without stopping for suctioning
the oropharynx, fetal mouth, or nares, and/or to reduce a nuchal cord.

**What does the 'CCC Deliver Through' maneuver entail?**

If you have any suspicion that the patient may be at risk for shoulder
dystocia, then consider the following:

Pre-'CCC Deliver Through' maneuver

First, try to gauge the expulsion of the head for the initial peak of a
contraction, e.g., not at the end of third Valsalva maneuver in a 60-90
second contraction in an exhausted parturient.

If a regional anesthetic has been utilized, then also make sure that the
anesthetic is at a nadir on motor function.

And now 'CCC Deliver Through' maneuver

As soon as the head presents itself in the cardinal movements from
extension, restitution and onto external rotation, the provider should
continue that momentum with gentle posterior traction toward the rectum
on the fetal parietal bones until you clearly see delivery of the fetal
anterior shoulder emerging from beneath the symphysis. Alternately one
hand can be over the face and the other hand on the occiput to continue
the momentum.

At this time ask the mother to pant while you suction the infant as
needed, or reduce any obstructing elements of the umbilical cord. Then
ask the patient to continue to bear down gently and deliver the
posterior shoulder and body.

Please note: This is unlike what some classic obstetrics texts recommend
for the normal course of delivery of the fetal head. The main difference
is that you do not halt the momentum after restitution or external
rotation to suction the oropharynx. Also you do not halt the momentum to
reduce a nuchal cord unless it is critically tight. Both suctioning and
movement of the cord can be completed after delivery of the anterior
shoulder.

After delivery of the anterior shoulder, then continue as you would
normally, e.g., ask the mother to pant while you suction the oropharynx
or manipulate the cord, then direct the fetal body anteriorly until the
posterior shoulder passes the perineum to accomplish complete delivery.
Please protect the perineum as you complete the delivery process after
delivery of the anterior shoulder.

**Pelvic Geometry**

Once the head is out of the vagina, the head restitutes and the neck
untwists. After a few moments, external rotation takes place as the
shoulders move from the oblique to the anteroposterior diameter of the
pelvis. One possible advantage is if the 'CCC Deliver Though' maneuver
is done quickly enough, the accoucheur may deliver the anterior shoulder
before the shoulders reach the full anteroposterior diameter of the
pelvis that they achieve when external rotation occurs.

**Caveat**

While this maneuver seems to work 100% of the time in our less than
random sample, we should be skeptical of anything that seems to work so
well.

A random sample of \~10 providers on L/D had heard of it, and many did
it when the suspected a risk of shoulder dystocia was an imminent risk.
In fact it was so common that no one had a separate name for it....it
was an unnamed automatic reflex. In addition, it seems to be used more
commonly as the incidence of heavy parturients increases.

Would the 'CCC Deliver Through' maneuver increase perineal trauma?

Or....?the old way has got to be the best way for the perineum. My
experience with many, many deliveries the old way includes a few hundred
2^nd^ degree lacerations (?10%) with the rare 3-4^th^ degree laceration
during delivery of the head or the posterior shoulder Yet, lacerations
occurring during the delivery of the anterior shoulder, per se would be
very rare..... for a ratio of \~ 0-1 / 1000+.

As the 'CCC Deliver Through' maneuver simply suggests that once the head
is delivered....just do not stop to suction the oropharynx, or reduce
the cord till you have the anterior shoulder out, and then do everything
else the same.... the impact on perineal lacerations is probably closer
to nil.

A better argument against this maneuver is that its effect is it is
unstudied, e.g., perhaps just by the fact that one could perform the
'CCC Deliver Through' maneuver at all meant that the shoulder dystocia
was not going to occur anyway....or that the development of the true
shoulder dystocia geometry would not allow one to deliver through to the
anterior shoulder regardless.

On the other hand, it may be more like the insurance business....if you
have an expensive flood policy....then you'll never even see a heavy
drizzle.

**Resources**

Shoulder Dystocia ACOG Practice Bulletin Number 40, November 2002.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2002 Nov;100(5 Pt 1):1045-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12434783&query_hl>

[Gherman
RB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gherman+RB"%5BAuthor%5D).
Shoulder dystocia: prevention and management. [Obstet Gynecol Clin North
Am.](javascript:AL_get(this, 'jour', 'Obstet Gynecol Clin North Am.');)
2005 Jun;32(2):297-305\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15899362&query_hl]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15899362&query_hl)

**Other Midwives' Corner items: Jenny Glifort, CNM**

**Hurricane-Related Information for Pregnant and Breastfeeding Women**

Natural disasters like Hurricanes Katrina and Rita are devastating for
anyone affected.  But pregnant and breastfeeding women may have special
concerns about the effects of certain hurricane-related exposures (such
as infections, medications, mold, chemicals, and stress) on their unborn
or breastfed child. 

For this reason, CDC has contracted with the Organization of Teratology
Information Specialists
([www.otispregnancy.org](blocked::http://www.otispregnancy.org/)), a
national organization that takes telephone calls from women and health
care professionals who need information about the effects of
exposures on pregnancy and breastfeeding. This service is available free
of charge by calling **1-866-626-OTIS** or **1-866-626-6847** toll-free
between the hours of 8:00 AM and 6:00 PM Central Time.

**System errors in intrapartum electronic fetal monitoring: a case
review**

Intrapartum electronic fetal monitoring (EFM) interpretation and
management continue to be a common issue in litigation involving adverse
outcomes in term pregnancies. This article uses a case study approach to
illustrate system errors related to intrapartum EFM. Common system
errors related to use of intrapartum EFM include knowledge deficits,
communication failures, and fear of conflict. Strategies for reducing
error and the promotion of a patient safety approach to risk management
in EFM are discussed, with an emphasis on the importance of a true team
approach to EFM education, interpretation, and management.

### [Conclusion]{.underline}

Lack of knowledge, fear of conflict, and poor communication are three
areas that contribute to error in obstetrics and especially in EFM
interpretation and management. There are many other error-producing
conditions, such as fatigue and excessive workload, which need to be
addressed in the interest of patient safety. As advocates for women and
families, CMs and CNMs must be willing to look at errors systematically,
without blame, and with an eye toward reducing error and making patient
safety a primary concern. In the area of EFM, this includes not only
proper patient selection, but ensuring that all clinicians using EFM
share an adequate knowledge base and an environment that encourages open
communication and a true team approach to care.

[Miller
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Miller+LA"%5BAuthor%5D)
System errors in intrapartum electronic fetal monitoring: a case review.
[J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):507-16.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260365&query_hl>

**Navajo News Jean Howe, Chinle**

**Depo-Provera available in a lower dose: limited data to assess 104mg
SQ vs. 150mg IM**

After the recent dramatic shifts in available information about the
contraceptive patch, it is with some trepidation that I again address a
hormonal contraceptive topic. But similar shifting sands of popularity
and concern affect Depo-Provera and warrant ongoing attention.

Depo-Provera (depot medroxyprogesterone acetate or DMPA given 150 mg IM
every 12 weeks) was first approved for use in the United States by the
FDA in 1992. This approval came after many years of widespread
international use and DMPA quickly became popular in the U.S. as well.
One issue that has limited its popularity is the weight gain often
associated with DMPA use. The manufacturer product information states
that, from an average initial body weight of 136 pounds, women gained an
average of 5.4 pounds with one year of use, 8.1 pounds with 2 years of
use, 13.8 pounds with 4 years of use, and 16.5 pounds with 6 years of
use. A study done at Shiprock by Espey, et al, compared 172 women who
used DMPA for one or two years with 134 women who used a
non-progestin-based method or no method. The women using DMPA gained an
average of 6 pounds more than the comparison group with one year of use
and 11 pounds more with 2 years of use, thus suggesting that the weight
gain issues may be even more significant with DMPA for Navajo women.
DMPA use may thus indirectly increase the risk of diabetes and other
health problems associated with obesity.

A more recent concern about DMPA is that the bone loss associated with
long-term use may not completely resolve after DMPA is discontinued.
These concerns have resulted in the addition of a "black box" warning
recommending that use be limited to two years unless other forms of
birth control are inadequate. Strategies to address these concerns are
outlined in the January 2005 CCC Corner. The two year restriction
remains controversial. In June 2005 the World Health Organization issued
a statement on Hormonal Contraception and Bone Health recommending that:

> -There should be no restriction on the use of DMPA, including no
> restriction on duration of use, among women aged 18 to 45 who are
> otherwise eligible to use the method.
>
> -Among adolescents (menarche to \<18) and women over 45, the
> advantages of using DMPA generally outweigh the theoretical safety
> concerns regarding fracture risk. Since data are insufficient to
> determine if this is the case with long-term use among these age
> groups, the overall risks and benefits for continuing use of the
> method should be reconsidered over time with the individual user.

Despite concerns about weight gain and bone health, DMPA remains a
preferred contraceptive for many Navajo women. Thus any improvement in
the side effect profile would be important. In December 2004 the FDA
approved marketing of a lower dose formulation of DMPA, marketed under
the name "depo-subQ provera 104" (DMPA-SC). It contains 30.7% less
medroxyprogesterone acetate and is administered subcutaneously into the
anterior thigh or abdominal wall. The product information describes
three clinical trials where the weight gain averaged 3.5 pounds in the
first year of use. A smaller comparison trial showed similar weight gain
to DMPA-IM (7.5 vs. 7.6 pounds). The "black box" warning about bone loss
is identical although this issue does not seem to have been studied yet
in DMPA-SC. The subcutaneous formulation is believed to provide slower
absorption with a lower early peak in dose and a lower total dose
delivered; whether this will be shown to result in a lower side effect
profile is not yet known. The SC and IM formulations are different and
cannot be used interchangeably. One of the most interesting features of
DMPA-SC is that patient self-administration may be possible; this would
be a potential benefit to the many patients who find it difficult to
keep clinic appointments every 12 weeks. In March 2005, DMPA-SC was
approved by the FDA for the treatment of endometriosis pain.

Alas, a lower dose does not mean a lower cost. Local pricing inquiries
revealed the following:

Depo-Provera 150mg IM prefilled syringe: \$32.34

Depo-Provera 104mg SQ prefilled syringe: \$48.85

This compares to an average cost locally of \$4 to \$29 for 12 weeks of
OCPs, \$66 for 12 weeks of Ortho-Evra patches, \$262 for a Mirena IUD,
or \$40 for a Paraguard IUD. Whether the 50% increase in price for a 31%
decrease in dose is a worthwhile investment will depend on additional
studies of weight gain, bone density, and other issues. It may be
especially valued by some women who are willing to self-administer
DMPA-SC and find it burdensome to come to clinic every 12 weeks.

**Resources**

Provider information for DMPA-IM:

<http://www.pfizer.com/pfizer/download/uspi_depo_provera_contraceptive.pdf>

Provider information form DMPA-SC:

<http://www.pfizer.com/pfizer/download/uspi_depo_subq_provera.pdf>

Espey E, Steinhart J, Ogburn T, Qualls C. "Depo-Provera associated with
weight gain in Navajo Women". *Contraception*. 2000. 62:55-58.

[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11102587&itool=iconabstr&query](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11102587&itool=iconabstr&query)

World Health Organization. "WHO Statement on Hormonal Contraception and
Bone Health". July 2005.
<http://www.who.int/reproductive-health/family_planning/docs/hormonal_contraception_bone_health.pdf>

Jain J, Dutton C, Nicosia A, Wajszczuk C, Bode FR, Mishell DR.
"Pharmacokinetics, ovulation suppression and return to ovulation
following a lower dose subcutaneous formulation of Depo-Provera".
*Contraception*. 2004. 70:11-18.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15208047&query>

Jain J, Jakimiuk AJ, Bode FR, Ross D, and Kaunitz AM. "Contraceptive
efficacy and safety of DMPA-SC". *Contraception.* 2004 70:269-275.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15451329&query>

Lakha F, Henderson C, Glasier A. "The acceptability of
self-administration of subcutaneous Depo-Provera". *Contraception*.
2005. 72:14-18.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15964286&query>

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Who do you contact in Navajo Area for MCH issues?  {#who-do-you-contact-in-navajo-area-for-mch-issues-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Jean Howe is the OB/GYN Deputy Chief Clinical Consultant (CCC). Jean
participates in many of the [national functions of the
CCC.](http://www.ihs.gov/NonMedicalPrograms/nc4/obgyn.cfm) Originally
from Vermont and trained at the University of Colorado, Dr. Howe has
been an OB/GYN at Chinle Hospital for 7 years. She also currently serves
as the Navajo Area OB/GYN consultant and will complete an MPH program
this May. Her areas of interest include preventive services,
contraception, and diabetes in pregnancy.
<http://www.ihs.gov/NonMedicalPrograms/nc4/obgyn_dccc.cfm>

and

#### Diana Hu, MD is the Acting MCH Consultant/Chief Clinical Consultant in Pediatrics Navajo Area Indian Health Service [**http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC14.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC14.cfm) {#diana-hu-md-is-the-acting-mch-consultantchief-clinical-consultant-in-pediatrics-navajo-area-indian-health-service-httpwww.ihs.govmedicalprogramsmchmmchc14.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

**Fetal Alcohol Syndrome: Nursing Perspective**

Nursing Spectrum, the country\'s largest nursing continuing education
program, has published a course on FASD in its December 5, 2005
magazine.  The continuing education program can be accessed through
their website at the link below

The segment was written by Patti Lucarelli, RN, MSN, who is a pediatric
nurse practitioner and the child care health consultant coordinator at
Child Care Resources in Neptune, NJ.  Patti chairs the Prevention
Committee of The Arc of NJ.

Dorothy (Dody) W. Angelini, RN, MSN, the Director of Continuing
Education for Provider-Directed Events at Nursing Spectrum, was of great
assistance in getting the segment published.  Dody is a member of the NJ
Governor\'s Council on the Prevention of Mental Retardation and
Developmental Disabilities, the advisory board that oversees the work of
Debbie Cohen's office.

<http://www2.nursingspectrum.com/CE/Self-Study_modules/syllabus.html?ID=638>

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Seeking Executive Nurse Leaders  {#seeking-executive-nurse-leaders-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Robert Wood Johnson Executive Nurse Fellows Program is seeking applicants for an advanced leadership program for nurses in senior executive roles in health services, public health and nursing education who aspire to help lead and shape the U.S. health care system. Up to 20 three-year fellowships will be awarded in 2006. Apply until Feb. 1, 2006 [[http://www.enfp-info.org/]{.underline}](http://www.enfp-info.org/) {#the-robert-wood-johnson-executive-nurse-fellows-program-is-seeking-applicants-for-an-advanced-leadership-program-for-nurses-in-senior-executive-roles-in-health-services-public-health-and-nursing-education-who-aspire-to-help-lead-and-shape-the-u.s.-health-care-system.-up-to-20-three-year-fellowships-will-be-awarded-in-2006.-apply-until-feb.-1-2006-httpwww.enfp-info.org .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-50 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Oral Fluid Rapid HIV Antibody Tests Being Investigated: Current protocols should continue to be followed {#oral-fluid-rapid-hiv-antibody-tests-being-investigated-current-protocols-should-continue-to-be-followed .Style-Heading-4-+-Arial-14-pt-Underline}

#### Supplemental Testing for Confirmation of Reactive Oral Fluid Rapid HIV Antibody Tests. In late 2005, HIV testing programs in multiple U.S. cities experienced apparent clusters of false-positive rapid HIV test results using oral fluid (but not whole blood) specimens. Counselors at these programs have expressed concern regarding the specificity and positive predictive value of the oral fluid rapid HIV test. CDC is actively working with FDA, state and local health officials, and the product manufacturer to investigate these reports, assess the test\'s current performance, and consider whether changes in testing protocols should be recommended or any other actions taken. In the meantime, current protocols for confirmation of reactive rapid HIV test results should continue to be followed. {#supplemental-testing-for-confirmation-of-reactive-oral-fluid-rapid-hiv-antibody-tests.-in-late-2005-hiv-testing-programs-in-multiple-u.s.-cities-experienced-apparent-clusters-of-false-positive-rapid-hiv-test-results-using-oral-fluid-but-not-whole-blood-specimens.-counselors-at-these-programs-have-expressed-concern-regarding-the-specificity-and-positive-predictive-value-of-the-oral-fluid-rapid-hiv-test.-cdc-is-actively-working-with-fda-state-and-local-health-officials-and-the-product-manufacturer-to-investigate-these-reports-assess-the-tests-current-performance-and-consider-whether-changes-in-testing-protocols-should-be-recommended-or-any-other-actions-taken.-in-the-meantime-current-protocols-for-confirmation-of-reactive-rapid-hiv-test-results-should-continue-to-be-followed. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm54d1216a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm54d1216a1.htm) {#httpwww.cdc.govmmwrpreviewmmwrhtmlmm54d1216a1.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-51 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Fertility, Family Planning, and Reproductive Health of US Women  {#fertility-family-planning-and-reproductive-health-of-us-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### This report presents national estimates of fertility, family planning, and reproductive health indicators among females 15-44 years of age in the United States in 2002 from the National Survey of Family Growth. Women's reproductive experiences vary significantly, and often sharply, by demographic characteristics such as education, income, and Hispanic origin and race. {#this-report-presents-national-estimates-of-fertility-family-planning-and-reproductive-health-indicators-among-females-15-44-years-of-age-in-the-united-states-in-2002-from-the-national-survey-of-family-growth.-womens-reproductive-experiences-vary-significantly-and-often-sharply-by-demographic-characteristics-such-as-education-income-and-hispanic-origin-and-race. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/nchs/products/pubs/pubd/series/sr23/pre-1/sr23_25.htm**](http://www.cdc.gov/nchs/products/pubs/pubd/series/sr23/pre-1/sr23_25.htm) {#httpwww.cdc.govnchsproductspubspubdseriessr23pre-1sr23_25.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-52 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Oklahoma Perspective Greggory Woitte -- Hastings Indian Medical Center {#oklahoma-perspective-greggory-woitte-hastings-indian-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

#### Who do you contact in Oklahoma Area for MCH issues?  {#who-do-you-contact-in-oklahoma-area-for-mch-issues .Style-Heading-4-+-Arial-14-pt-Underline}

#### Two contacts are Dr. George Chiarchiaro in the Area Office and Greggory Woitte at Tahlequah. {#two-contacts-are-dr.-george-chiarchiaro-in-the-area-office-and-greggory-woitte-at-tahlequah. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Dr. George Chiarchiaro is the MCH Coordinator and has a helpful website with many resources [[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top) {#dr.-george-chiarchiaro-is-the-mch-coordinator-and-has-a-helpful-website-with-many-resources-httpwww.ihs.govmedicalprogramsmchmmchc07.cfmtop .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Greggory Woitte at Tahlequah is available at [[Greggory.Woitte@mail.ihs.gov]{.underline}](mailto:Greggory.Woitte@mail.ihs.gov) {#greggory-woitte-at-tahlequah-is-available-at-greggory.woittemail.ihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Exercise, Calcium Supplementation May Improve BMD in Postmenopausal
Women **

The significant, positive, association between BMD change and exercise
frequency supports the long-term usefulness of strength training
exercise for the prevention of osteoporosis in postmenopausal women,
especially HT users. The positive relationship of CI to change in BMD
among postmenopausal women not using HT has clinical implications in
light of recent evidence of an increased health risk associated with HT.

#### [Cussler EC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cussler+EC"%5BAuthor%5D), et al Exercise frequency and calcium intake predict 4-year bone changes in postmenopausal women. [Osteoporos Int.](javascript:AL_get(this, 'jour', 'Osteoporos Int.');) 2005 Dec;16(12):2129-41 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16283062&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16283062&query_hl) {#cussler-ec-et-al-exercise-frequency-and-calcium-intake-predict-4-year-bone-changes-in-postmenopausal-women.-osteoporos-int.-2005-dec16122129-41-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16283062query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-53 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Diabetes and Pregnancy Frequently Asked Questions, CDC**

<http://www.cdc.gov/ncbddd/bd/diabetespregnancyfaqs.htm>

####  {#section-54 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cognitive Therapy for Depression: What You Should Know {#cognitive-therapy-for-depression-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060101/90ph.html**](http://www.aafp.org/afp/20060101/90ph.html) {#httpwww.aafp.orgafp2006010190ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-55 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cerebral Palsy in Children: What You Should Know {#cerebral-palsy-in-children-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060101/101ph.html**](http://www.aafp.org/afp/20060101/101ph.html) {#httpwww.aafp.orgafp20060101101ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-56 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medicines to Prevent Migraine Headaches {#medicines-to-prevent-migraine-headaches .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060101/79ph.html**](http://www.aafp.org/afp/20060101/79ph.html) {#httpwww.aafp.orgafp2006010179ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-57 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Should Pregnant Women Be Tested for Herpes Susceptibility? {#should-pregnant-women-be-tested-for-herpes-susceptibility .Style-Heading-4-+-Arial-14-pt-Underline}

#### Along with genital warts and Chlamydia infections, herpes virus (HSV) infection is one of the most prevalent sexually transmitted infections. Both HSV-1 (oral) and HSV-2 (genital) herpes can cause neonatal disease. The distinctions between primary and recurrent infections are often blurred, and asymptomatic HSV shedding remains the most common scenario. While neonatal transmission is low (about 1%) with secondary infection, because HSV is so common, the total number of HSV infections in infants born to women with recurrent disease remains significant. Likewise, up to 80% of infected neonates are currently born to asymptomatic women. Men and women both commonly identify "jock itch" or "yeast infection", not HSV, as the cause of the symptoms they may have.  {#along-with-genital-warts-and-chlamydia-infections-herpes-virus-hsv-infection-is-one-of-the-most-prevalent-sexually-transmitted-infections.-both-hsv-1-oral-and-hsv-2-genital-herpes-can-cause-neonatal-disease.-the-distinctions-between-primary-and-recurrent-infections-are-often-blurred-and-asymptomatic-hsv-shedding-remains-the-most-common-scenario.-while-neonatal-transmission-is-low-about-1-with-secondary-infection-because-hsv-is-so-common-the-total-number-of-hsv-infections-in-infants-born-to-women-with-recurrent-disease-remains-significant.-likewise-up-to-80-of-infected-neonates-are-currently-born-to-asymptomatic-women.-men-and-women-both-commonly-identify-jock-itch-or-yeast-infection-not-hsv-as-the-cause-of-the-symptoms-they-may-have. .Style-Heading-4-+-Arial-14-pt-Underline}

#### While history is an unreliable way to identify those at risk, laboratory evaluation is also problematic. While viral culture remains the "gold standard", its sensitivity depends on the stage of the episode (vesicle, ulcer, crusted) and whether the lesion is primary or recurrent, and the results are not available for up to 7-10 days. PCR may be helpful to confirm the diagnosis, but at present it is expensive and not clinically used. Serologic testing with first generation assays remains neither sensitive nor specific for differentiating HSV-1 or HSV-2 because of cross reactivity. Likewise, IgM and IgG determinations are notoriously unreliable for differentiating new from recurrent infection with this virus. Recently however, newer type-specific glycoprotein-G based enzyme-linked immunosorbent assays (EIA) and immunoblot tests have been approved by the FDA. While these tests have much improved sensitivity and specificity, it remains controversial whether or not screening with these second generation tests is cost-effective, and is not currently recommended by ACOG.  {#while-history-is-an-unreliable-way-to-identify-those-at-risk-laboratory-evaluation-is-also-problematic.-while-viral-culture-remains-the-gold-standard-its-sensitivity-depends-on-the-stage-of-the-episode-vesicle-ulcer-crusted-and-whether-the-lesion-is-primary-or-recurrent-and-the-results-are-not-available-for-up-to-7-10-days.-pcr-may-be-helpful-to-confirm-the-diagnosis-but-at-present-it-is-expensive-and-not-clinically-used.-serologic-testing-with-first-generation-assays-remains-neither-sensitive-nor-specific-for-differentiating-hsv-1-or-hsv-2-because-of-cross-reactivity.-likewise-igm-and-igg-determinations-are-notoriously-unreliable-for-differentiating-new-from-recurrent-infection-with-this-virus.-recently-however-newer-type-specific-glycoprotein-g-based-enzyme-linked-immunosorbent-assays-eia-and-immunoblot-tests-have-been-approved-by-the-fda.-while-these-tests-have-much-improved-sensitivity-and-specificity-it-remains-controversial-whether-or-not-screening-with-these-second-generation-tests-is-cost-effective-and-is-not-currently-recommended-by-acog. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The study from the University of Washington reported below adds another piece of evidence to this debate. It again demonstrated that clinical risk factor profiles could not be relied upon to replace or direct serologic testing to identify women who would become infected. The main risk factors here were a new (\<1 year) partner, and a partner with oral HSV. The long-ranging implications of the study are that women and their partners who could be identified by serologic testing as at risk of acquiring HSV-2 could be counseled to avoid oral sex, use condoms, or be abstinent in late pregnancy. They might also be candidates for viral suppressive therapy.  {#the-study-from-the-university-of-washington-reported-below-adds-another-piece-of-evidence-to-this-debate.-it-again-demonstrated-that-clinical-risk-factor-profiles-could-not-be-relied-upon-to-replace-or-direct-serologic-testing-to-identify-women-who-would-become-infected.-the-main-risk-factors-here-were-a-new-1-year-partner-and-a-partner-with-oral-hsv.-the-long-ranging-implications-of-the-study-are-that-women-and-their-partners-who-could-be-identified-by-serologic-testing-as-at-risk-of-acquiring-hsv-2-could-be-counseled-to-avoid-oral-sex-use-condoms-or-be-abstinent-in-late-pregnancy.-they-might-also-be-candidates-for-viral-suppressive-therapy. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Several studies have now shown that, in women with a history of HSV, acyclovir or valacyclovir prophylaxis in the late third trimester was effective in reducing clinical HSV recurrences, cesarean deliveries for active HSV, as well as asymptomatic HSV shedding. Numerous studies have documented the safety of acyclovir and its congeners for use in pregnancy. While this also appears to be a cost-effective intervention, it has only been partially addressed to by our parent organizations, although it seems to be widely implemented clinically. Whether or not this strategy could be applied more effectively if more women were identified serologically, remains to be seen. As with other evolving areas of clinical interest in obstetrics, stay tuned for on-going developments!  {#several-studies-have-now-shown-that-in-women-with-a-history-of-hsv-acyclovir-or-valacyclovir-prophylaxis-in-the-late-third-trimester-was-effective-in-reducing-clinical-hsv-recurrences-cesarean-deliveries-for-active-hsv-as-well-as-asymptomatic-hsv-shedding.-numerous-studies-have-documented-the-safety-of-acyclovir-and-its-congeners-for-use-in-pregnancy.-while-this-also-appears-to-be-a-cost-effective-intervention-it-has-only-been-partially-addressed-to-by-our-parent-organizations-although-it-seems-to-be-widely-implemented-clinically.-whether-or-not-this-strategy-could-be-applied-more-effectively-if-more-women-were-identified-serologically-remains-to-be-seen.-as-with-other-evolving-areas-of-clinical-interest-in-obstetrics-stay-tuned-for-on-going-developments .Style-Heading-4-+-Arial-14-pt-Underline}

#### HSV acquisition rates are high in pregnancy  {#hsv-acquisition-rates-are-high-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: HSV acquisition rates in pregnancy are high in discordant couples, especially for HSV-2. Interventions that address risk factors for HSV acquisition should be studied in pregnancy. Clinical profiles cannot replace serologic screening to identify susceptible women with serologically discordant partners. {#conclusion-hsv-acquisition-rates-in-pregnancy-are-high-in-discordant-couples-especially-for-hsv-2.-interventions-that-address-risk-factors-for-hsv-acquisition-should-be-studied-in-pregnancy.-clinical-profiles-cannot-replace-serologic-screening-to-identify-susceptible-women-with-serologically-discordant-partners. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Gardella C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gardella+C"%5BAuthor%5D), et al Risk factors for herpes simplex virus transmission to pregnant women: a couples study. [Am J Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005 Dec;193(6):1891-9. {#gardella-c-et-al-risk-factors-for-herpes-simplex-virus-transmission-to-pregnant-women-a-couples-study.-am-j-obstet-gynecol.-2005-dec19361891-9. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16325589&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16325589&query_hl) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16325589query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-58 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [OB/GYN CCC Editorial comment:]{.underline} {#obgyn-ccc-editorial-comment-6 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women with one or more genital HSV recurrences during pregnancy appear to benefit from suppression (acyclovir 400 mg three times daily) given at 36 weeks of gestation through delivery. The following table is from the American College of Obstetricians and Gynecologists Practice Bulletin. Furthermore, although study data are lacking, we also recommend suppressive therapy starting at 36 weeks for all women with a prior history of recurrent genital herpes. Weekly genital cultures or PCR testing during late gestation are not recommended. They are expensive and not predictive of a poor outcome {#women-with-one-or-more-genital-hsv-recurrences-during-pregnancy-appear-to-benefit-from-suppression-acyclovir-400-mg-three-times-daily-given-at-36-weeks-of-gestation-through-delivery.-the-following-table-is-from-the-american-college-of-obstetricians-and-gynecologists-practice-bulletin.-furthermore-although-study-data-are-lacking-we-also-recommend-suppressive-therapy-starting-at-36-weeks-for-all-women-with-a-prior-history-of-recurrent-genital-herpes.-weekly-genital-cultures-or-pcr-testing-during-late-gestation-are-not-recommended.-they-are-expensive-and-not-predictive-of-a-poor-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### Antiviral Treatment for Herpes Simplex Virus {#antiviral-treatment-for-herpes-simplex-virus .Style-Heading-4-+-Arial-14-pt-Underline}

  ---------------- -------------------------- ----------------- -----------------
  **Indication**   **Valacyclovir**           **Acyclovir**     **Famciclovir**

  First clinical   1,000 mg twice a day for   200 mg five times 250 mg three
  episode          7--14 days                 a day or 400 mg   times a day for
                                              three times a day 7--14 days
                                              for 7--14 days    

  Recurrent        500 mg twice a day for 5   200 mg five times 125 mg twice a
  episodes         days                       a day or 400 mg   day for 5 days
                                              three times a day 
                                              for 5 days        

  Daily            500 mg once a day (\<=     400 mg twice a    250 mg twice a
  suppressive      recurrences per year) or   day               day
  therapy          1,000 mg once a day or 250                   
                   mg twice a day (\>9                          
                   recurrences per year)                        
  ---------------- -------------------------- ----------------- -----------------

Baker DA. Antiviral therapy for genital herpes in nonpregnant and
pregnant women. Int J Fertil 1998;43:243­248

**ACOG Practice Bulletin. Management of Herpes in Pregnancy.** Number 8
October 1999. Clinical management guidelines for
obstetrician-gynecologists.

Non-ACOG members ([Int J Gynaecol
Obstet.](javascript:AL_get(this, 'jour', 'Int J Gynaecol Obstet.');)
2000 Feb;68(2):165-73)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10717827&query_hl>

**ACOG members**

<http://www.acog.org/publications/educational_bulletins/pb008.cfm>

**UpToDate**

**Genital herpes simplex virus infection and pregnancy**

<http://www.uptodateonline.com/application/topic.asp?file=viral_in/7178&type=A&selectedTitle=3~23>

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

**Cardiology Topics for Primary Care Providers -- February 15, 2006**

Moderator: Jim Galloway, MD

Director, Native American Cardiology Program

**Here are some of the topics to be discussed**

-Role of CRP in cardiac evaluation

-Should we all take statins? or get out of our chairs, work out, lose
weight, diet and get fitness religion?

-Lipid screening guidelines in non-smoking non-diabetic Native Americans

-Newer cardiac imaging techniques (MRI, CT angio) over traditional
catheterization procedures.  

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

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

**STD Corner - Lori de Ravello, National IHS STD Program**

#### Clinician-Delivered Intervention During Routine Clinical Care Reduces Unprotected Sexual Behavior {#clinician-delivered-intervention-during-routine-clinical-care-reduces-unprotected-sexual-behavior-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: A clinician-delivered HIV prevention intervention targeting HIV-infected patients resulted in reductions in unprotected sex. Interventions of this kind should be {#conclusions-a-clinician-delivered-hiv-prevention-intervention-targeting-hiv-infected-patients-resulted-in-reductions-in-unprotected-sex.-interventions-of-this-kind-should-be .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Fisher JD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fisher+JD"%5BAuthor%5D), et al Clinician-Delivered Intervention During Routine Clinical Care Reduces Unprotected Sexual Behavior Among HIV-Infected Patients. [J Acquir Immune Defic Syndr.](javascript:AL_get(this, 'jour', 'J Acquir Immune Defic Syndr.');) 2006 Jan 1;41(1):44-52. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16340472&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16340472&query_hl) {#fisher-jd-et-al-clinician-delivered-intervention-during-routine-clinical-care-reduces-unprotected-sexual-behavior-among-hiv-infected-patients.-j-acquir-immune-defic-syndr.-2006-jan-141144-52.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16340472query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-59 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Famciclovir for the Management of Genital Herpes Simplex {#famciclovir-for-the-management-of-genital-herpes-simplex .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: In immunocompetent adults with recurrent genital herpes, a 5-day course of famciclovir at a dosage of 125 mg, 250 mg, or 500 mg twice per day was significantly more effective than was placebo in reducing the duration of viral shedding and symptoms and in accelerating lesion healing. These results support the use of treatment with famciclovir at a dosage of 125 mg for 5 days as an effective, well-tolerated treatment for episodes of recurrent genital herpes. [Sacks SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sacks+SL"%5BAuthor%5D) et al Clinic-initiated, twice-daily oral famciclovir for treatment of recurrent genital herpes: a randomized, double-blind, controlled trial. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16163627&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16163627&query_hl) {#conclusions-in-immunocompetent-adults-with-recurrent-genital-herpes-a-5-day-course-of-famciclovir-at-a-dosage-of-125-mg-250-mg-or-500-mg-twice-per-day-was-significantly-more-effective-than-was-placebo-in-reducing-the-duration-of-viral-shedding-and-symptoms-and-in-accelerating-lesion-healing.-these-results-support-the-use-of-treatment-with-famciclovir-at-a-dosage-of-125-mg-for-5-days-as-an-effective-well-tolerated-treatment-for-episodes-of-recurrent-genital-herpes.-sacks-sl-et-al-clinic-initiated-twice-daily-oral-famciclovir-for-treatment-of-recurrent-genital-herpes-a-randomized-double-blind-controlled-trial.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16163627query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-60 .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}

**High-Normal Fasting Blood Sugar Above 87 mg/dL Could Signal Diabetes
Risk**

CONCLUSIONS: Higher fasting plasma glucose levels within the
normoglycemic range constitute an independent risk factor for type 2
diabetes among young men, and such levels may help, along with body-mass
index and triglyceride levels, to identify apparently healthy men at
increased risk for diabetes [Tirosh
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Tirosh+A"%5BAuthor%5D),
et al Normal fasting plasma glucose levels and type 2 diabetes in young
men. [N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');)
2005 Oct 6;353(14):1454-62.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16207847&query_hl>

**Antidepressants Are No Match for Poverty**

In a study that compared the outcome of a depression therapy with a
combination of pharmacologic and physical treatment, poverty was a
marker for poor outcome, according to a team of Harvard researchers.
Depressed patients who were classified as middle income were almost
twice as likely to respond to treatment as were those who lived in poor
neighborhoods

CONCLUSION: Residence in a low-income census tract is associated with a
less favorable course of depression among older adults receiving a
combination of pharmacologic and psychosocial treatment. [Cohen
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cohen+A"%5BAuthor%5D),
et al Social inequalities in response to antidepressant treatment in
older adults. [Arch Gen
Psychiatry.](javascript:AL_get(this, 'jour', 'Arch Gen Psychiatry.');)
2006 Jan;63(1):50-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389196&query_hl>

**Now science allows us all an extra 7lb of fat - at no extra risk**

The following analysis does not support the idea that reducing weight,
per se, would result in any large mortality risk reduction for most of
the population. This does not downplay the importance of the health
risks involved. While there are ongoing debates about the effects of
weight loss programs, exercise programs, and surgical interventions on
mortality and health outcomes, there is little doubt that most people
could benefit from moderation in diet and increased exercise.

RESULTS: The mortality risk among \"normal\" weight men (i.e., those in
the BMI range of 20 to 25 kg/m(2)) was as high as that among men in the
mild obesity category (BMIs of 30-35 kg/m(2)), with a minimum risk
observed at a BMI of approximately 26 kg/m(2). Among women, the
mortality risk was smallest at approximately 23 to 24 kg/m(2), with the
risk increasing steadily with BMIs above 27 kg/m(2). In each
specification, the slope of the line was small and volatile through the
BMI range of 20 to 35 kg/m(2), suggesting negligible risk differences
with minor differences in weight for much of the population CONCLUSIONS:
Traditional BMI categories do not conform well to the complexities of
the BMI-mortality relationship. In concurrence with conclusions from
previous literature, I found that the current definitions of obesity and
overweight are imprecise predictors of mortality risk. [Gronniger
JT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gronniger+JT"%5BAuthor%5D)
A semiparametric analysis of the relationship of body mass index to
mortality. [Am J Public
Health.](javascript:AL_get(this, 'jour', 'Am J Public Health.');) 2006
Jan;96(1):173-8.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16131644&dopt=Abstract>

**New Guidelines Available to Raise HDL Cholesterol**\
Cardiologists and other experts at Johns Hopkins University have issued
interim guidelines for physicians on how best to treat low levels of HDL
cholesterol and help keep arteries clear from LDL buildup. Researchers
reported that existing strategies to prevent heart disease have not
addressed the best means to raise HDL cholesterol and instead have
focused heavily on lowering LDL cholesterol. We have reached a turning
point in the prevention of coronary heart disease, from an emphasis
during the last 15 years on lowering LDL cholesterol levels to an
emphasis in the next decade on raising levels of HDL cholesterol.

Ashen MD, Blumenthal RR. Low HDL cholesterol levels. New Engl J Med.
2005; 353:1252-1260

<http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16177251&dopt=Abstract>

**Coffee consumption may reduce breast cancer risk**

CONCLUSION: No linear association between caffeine consumption and
incident hypertension was found. Even though habitual coffee consumption
was not associated with an increased risk of hypertension, consumption
of sugared or diet cola was associated with it. Further research to
elucidate the role of cola beverages in hypertension is warranted.

[Winkelmayer
WC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Winkelmayer+WC"%5BAuthor%5D)
et al Habitual caffeine intake and the risk of hypertension in women.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2005 Nov
9;294(18):2330-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16278361&query_hl>

**Health, United States: Annual report on trends in health statistics -
NCHS**

This report consists of two main sections: A chart book containing text
and figures that illustrates major trends in the health of Americans;
and a trend tables section that contains 156 detailed data tables. The
two main components are supplemented by an executive summary, a
highlights section, an extensive appendix and reference section, and an
index. <http://www.cdc.gov/nchs/hus.htm>

**Theory at a Glance: A Guide for Health Care Promotion**

NCI: Application to Health Promotion and Health (Second Edition) Great
for grant writing when you need a theoretical model
<http://www.nci.nih.gov/theory/pdf>

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

**Sudden Infant Death Syndrome (SIDS), Sudden Unexplained Death in
Childhood (SUDC)**

-   February 23-26, 2006

-   Philadelphia, Pennsylvania

-   [[http://www.cjsids.com/]{.underline}](http://www.cjsids.com/)

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

**Native Peoples of North America HIV/AIDS Conference**

-   May 3--6, 2006

-   Anchorage, Alaska

-   Embracing Our Traditions, Values, and Teachings
    [www.embracingourtraditions.org](http://www.embracingourtraditions.org/)

-   [National Institutes of Health (NIH),
    DHHS](http://www.embracingourtraditions.org/conf_info.htm)
    <http://www.ou.edu/rec/pdf/Native_Fact_Sheet.pdf>

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

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

-   May 6-10, 2006

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

-   Last year's brochure link below (2005 Brochure) (PDF 145k)

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/FinalACOGBrochure.pdf>

-   NEONATAL RESUSCITATION PROGRAM available

# 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%)}

**Vaginal Birth after Cesarean**

**New Perinatology Corner Module -- 2 credits**

This is a new edition of our previous module of the same name. The main
changes include a new risk factor grading system, plus how to apply that
information to clinical practice.
[[http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm)

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>

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

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn1205.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month: page 4 {#abstract-of-the-month-page-4-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Routine screening for protein and glucose at each prenatal visit
should be abandoned**

#### From your colleagues: page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

#### Breast cancer in Native American women treated at an urban-based Indian health center {#breast-cancer-in-native-american-women-treated-at-an-urban-based-indian-health-center .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico:

Asian Descent: Diabetic Women Have High Rates of Adverse Pregnancy
Outcomes

Bonnie Bishop-Stark

How do you know when you have a false positive HIV test in pregnancy?

Terry Cullen

Northwest Portland Area Indian Health Board recruiting new EpiCenter
Director

Lani Desaulniers

5th International Workshop-Conference on Gestational Diabetes

Kate Landis

HPV and Cervical Cancer: Update on Prevention Strategies, is now
available on DVD

Leslie Randall

#### PHN visits, maternal EtoH use, and layers of clothing are important risk factors for SIDS among Northern Plains Indians {#phn-visits-maternal-etoh-use-and-layers-of-clothing-are-important-risk-factors-for-sids-among-northern-plains-indians .Style-Heading-4-+-Arial-14-pt-Underline}

Ty Reidhead

Updated and revised IHS Clinical Guidelines, IHS Clinical Forms, Patient
Education sites

Judy Thierry

-What a great library resource! ...and it is available to *ALL* ITU
staff for free

-Do you want to increase your funding for the care of children?

-MCH tribal epidemiology on WIC data

-Sudden Infant Death Syndrome (SIDS), Sudden Unexplained Death in
Childhood (SUDC)

-Upcoming Theme: Health Care Systems -- The Key to Complete Women's
Health Care

...and more

**Myra Tucker**

An invitation to Submit Manuscripts to the Maternal and Child Health
Journal

**Alan Waxman**

Vaccine prevents cervical cancer, Gardasil: Preliminary results 100%
effective

**Judy Whitecrane**

Teen Birth Rate Continues to Decline, but Slowly

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

##### Obstetrics: page 12

Paroxetine's pregnancy category changed from C to D

Do you work with a low HIV prevalence population? Here is a strategy to
keep it that way

Evidence-based surgery for cesarean delivery

Umbilical cord blood is a proven source of hematopoietic stem cells: You
can bank on it

#### Women with a prior cesarean should be offered VBAC, esp. with prior vaginal delivery  {#women-with-a-prior-cesarean-should-be-offered-vbac-esp.-with-prior-vaginal-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

...and more

**Gynecology: page 20**

#### -Urinary incontinence: Familial association stronger than that of vaginal delivery {#urinary-incontinence-familial-association-stronger-than-that-of-vaginal-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

-Handle abnormal Pap smears differently in adolescents

-Simplifying the Diagnosis of Bacterial Vaginosis

-Certain factors predict chronic pelvic pain after pelvic inflammatory
disease

#### -Uterine artery embolization: Low complication rate, reduced length stay {#uterine-artery-embolization-low-complication-rate-reduced-length-stay .Style-Heading-4-+-Arial-14-pt-Underline}

...and more

**Child Health: page 22**

-Two RCTs show promising results with hypothermia for neonatal
encephalopathy

-Guidelines for Identifying and Referring Persons with Fetal Alcohol
Syndrome

-National Conference on Juvenile Issues

-AAP Report on Assessment of Sexual Abuse in Children

-Heads Up: Concussion in High School Sports

...and more

**Chronic Illness and Disease: page 25**

-Quick Assessment of Literacy in Primary Care: The Newest Vital Sign

-Stroke preventive treatments are well understood and widely available:
Why isn't it used?

-USPHS Releases Updated Guidelines for Management of Occupational
Exposure to HIV

-Moderate Exercise Improves Breast Cancer Outcomes

-Management of Active Tuberculosis

...and more

#### Features: page 27 {#features-page-27 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Duration of Therapy for Women with Uncomplicated UTI: Cochrane Briefs

-Metformin Increases Fertility in Patients with PCOS

American College of Obstetricians and Gynecologists

-Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin

-Inappropriate use of the terms fetal distress and birth asphyxia

-Vaginal Birth Not Associated With Incontinence Later in Life

-Update on Carrier Screening for Cystic Fibrosis: Committee Opinion

**Agency for Healthcare Research and Quality**

-Two American Indian tribes with different rates of smoking, but
similarly high life traumas

-Shortage of radiologists and certified mammography technologists in
U.S. communities

**Ask a Librarian**

Obesity Before Pregnancy Linked to Childhood Weight Problems

**Breastfeeding**

-New studies shows a 15% reduction for the risk of diabetes for every
year of lactation

-Infant feeding choice collection tool

-Women in the US Need More Breastfeeding Support

**CCC Corner Digest**

\-[Evidence does not justify routine use: Magnesium sulfate
prophylaxis - mild
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_AOM.cfm)

\-[Medical Staff Credentialing and Privileging Guide, 3rd Edition: Now
available](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Coll.cfm)

\-[Two handy 'Best Practice' checklists now available: DM or HTN in
pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#ob)

\-[Have you ever had problems with a stenotic cervix? Here's an easy
solution](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#gyn)

\-[Advanced skills practitioner not needed at uncomplicated elective
cesarean
delivery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#child)

\-[Beyond Red Lake - The persistent crisis in American Indian Health
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#chrIll)

\-[Low Testosterone Not Linked with Female Sexual
Dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#afp)

\-[USPSTF Releases Updated Guide to Clinical Preventive
Services](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#ahrq)

\-[Exciting news: All clinicians involved with Indian Health are now
invited: Tribal, urban,
etc..](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#AskLib)

\-[We need your expertise: Breast Feeding Best Practices in Indian
Country](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#breast)

\-[FDA Updates Labeling for Ortho Evra Contraceptive
Patch](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#fp)

\-[DMPA bone mass loss is
reversible](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#fp)

\-[The HCG curve has been redefined. How about
ultrasound?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#mmtour)

\-[Bioidentical Hormones: No scientific evidence to support claims of
increased
efficacy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#mscape)

\-[Trends in umbilical cord care: Scientific Evidence for
Practice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#MidWives)

\-[Once a day gentamicin dosing intrapartum may provide better coverage
for the
fetus ](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#navajo)

\-[Stressful workplaces and unfair bosses can raise cardiac
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#nurseCorner)

\-[Shoulder
dystocia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#okie)

\-[Many new additions to the Indian Health Guidelines / Patient
Education web
page](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm)

\-[Estrogen supplementation may be protective of BMD in adolescents who
use
DMPA](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#oste)

\-[Medical Management of Early Pregnancy Failure -- Use
Misoprostol](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#periPicks)

\-[Daily suppressive therapy is recommended for HSV-2 seropositive
individuals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#std)

\-[Just an additional 3200 steps a day, not 10,000 shows fitness
gains](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#stillW)

**Domestic Violence**

-"Dating & Violence Should Never Be a Couple" Preventing Teen Dating
Violence

-Funding for Legal Services to Victims of DV, Sexual Assault, Stalking &
Dating Violence

-Project about Adult Native American and Alaska Native Women and Sexual
Assault

**Elder Care News**

-Women with DM had about 25% higher prevalence of incontinence

-Treatment of Constipation in Older Adults

-Older Patients with Caregivers and Assistance for Activities of Daily
Living: 1998 and 2000

**Family Planning**

-Women who attend a postpartum visit 3x more likely to use postpartum
contraception

-Ortho Evra Contraceptive Patch Linked to Increased Estrogen Exposure

**Featured Website**

The Indian Health Women's Health pages are getting a facelift and needs
input

**Frequently asked questions**

Should we perform a routine urine screen at each prenatal visit?

**Indian Child Health Notes**

-Antibiotics: Everyone says there overused in America: strep throat
infections, otitis media

-Dr Singelton: Prevnar vaccine may increase of non vaccine serotypes of
Strep pneumoniae

-Dr.Esposito: MVA rates in AI/ANs and increased risk of retinopathy of
prematurity in AI/AN

**Information Technology**

National Release Notice - Clinical Reporting System, Version 6.0

International Health

Cross-Cultural Medicine

#### MCH Alert

New cigarettes with flavors that appeal to youth

#### Medical Mystery Tour

#### I feel really cold and my side hurts, plus I am shaking all over {#i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-over .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-WHI clinical trial revisit: imprecise methodology disqualifies the
study\'s outcomes

#### -WHI response to Ostrzenski and Ostrzenska {#whi-response-to-ostrzenski-and-ostrzenska .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Mechanisms of Premature Menopause {#mechanisms-of-premature-menopause .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Liability in Triage: Management of EMTALA Regulations and Common
Obstetric Risks

-Post Partum Hemorrhage is the most common cause of maternal mortality
worldwide

-Motherhood a \"rite of passage\" for some teens

-A trial should focus on women at low risk for failed trial or uterine
rupture and should not be

limited to a restrictive evaluation of short-term complications

-Midwifery Measures in Stage Two: Reduction of Genital Tract Trauma at
Birth

**Navajo News**

MRSA presents new challenges in treating soft-tissue infections,
including in pregnancy

**Nurses Corner**

#### Seeking Executive Nurse Leaders  {#seeking-executive-nurse-leaders-2 .Style-Heading-4-+-Arial-14-pt-Underline}

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

Cigarette Smoking in the United States, 2004

**Oklahoma Perspective**

-Who do you contact in Oklahoma for MCH issues?

Osteoporosis

Screening and treatment for osteoporosis low among patients taking
glucocorticoids

Patient Education

-FDA Patient Education page- paroxetine changed for Class C to Class D

-The Eagle's Nest: Safe (online) place for youth to learn more about
living healthy with DM

#### -Constipation: What You Should Know {#constipation-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Taking Care of Yourself After Having a Baby {#taking-care-of-yourself-after-having-a-baby .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Tuberculosis: What You Should Know {#tuberculosis-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Meconium Happens

#### -Since the amnio is immature today, should we re-tap in a week or just deliver then? {#since-the-amnio-is-immature-today-should-we-re-tap-in-a-week-or-just-deliver-then .Style-Heading-4-+-Arial-14-pt-Underline}

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- February 15, 2006

STD Corner

## -High-Risk HPV Associated with Chlamydia trachomatis with Female Adolescents 

#### -Financial support for I/T/U staff to attend STD/HIV training in FY2006 {#financial-support-for-itu-staff-to-attend-stdhiv-training-in-fy2006 .Style-Heading-4-+-Arial-14-pt-Underline}

-Screening for HIV: Recommendation Statement USPSTF

-HIV-Prevention Research in Minority Communities Program Accepting
Applications

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

-Type 2 diabetes mortality in women: Same as a \"coronary heart disease
equivalent\"

-Homocysteine: Risk factor for the development of diabetes in women with
previous GDM

-Protein and Unsaturated Fats Lowers BP, Improves Lipids, and May Reduce
CVD

-Glycemic Index online

###### Save the Dates: Upcoming events of interest page 46

#### What's new on the ITU MCH web pages page 47

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>

1/11/06 njm