OB/GYN Chief Clinical Consultant's Corner

Volume 1, No. 10, November 2003

## News flash.....The Primary Care Forum will be jump started 12/1/03. 

Q. What is the Indian Health Primary Care Forum?

A. It is an e-mail discussion group for topics of interest to the
majority of primary care providers (physicians, advanced practice
nurses, physicians assistants, etc....)

The first topic is ["Cervical Cancer Screening: New guidelines and new
pap technologies"]{.underline} The first discussion will be led by Alan
Waxman, MD.

Subsequent discussions will be quarterly. The discussions will be
captured and available online.

Other quarterly topics so far will be: [Primary care trauma]{.underline}
and [Hormone replacement therapy (HRT): Is there a role for HRT after
the WHI?]{.underline} Let me know about other possible topics

Q. How do I get signed up? How do I get my other service unit staff
signed up?

A. Sign up for the Primary Care listserv by contacting Jason Crim at
[**jason.crim@ihs.gov**](mailto:jason.crim@ihs.gov)

Digest mode is available (all the day's e-mail messages are condensed
into one message)

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}**

From Aberdeen Area, IHS: Characteristics of mothers who have children
with fetal alcohol syndrome

[From your colleagues:]{.underline}

From Sandra Dodge: High School Students in BIA-Funded Schools Tobacco,
Alcohol, and Other Drug Use, CDC is interested in hearing from AI/AN
women, HIV increasing in women, AIDS diagnoses increased 7% among women,
Growing Stronger: Strength Training for Older Adults, Preventing Skin
Cancer

From Jean Howe: Have you ever heard of a low risk VBAC? Minutes from the
2003 Navajo Area Women's Health Provider Meeting

##### From Chuck North and Bob Newcombe: Are liquid prep pap smears the standard of care now?

##### From Rick Olson: Join your Indian Health colleagues in helping the women of Afghanistan

**From Dan Szekely:** Can you use HRT in post menopausal breast cancer
patients? How effective is the clinical breast exam?

**[Hot Topics:]{.underline}**

##### Obstetrics: Helping Pregnant Women Cope With Smoking Cessation

Gynecology: Is colposcopic biopsy overused among women with a
cytological diagnosis of atypical squamous cells of undetermined
significance (ASCUS)?

**Child Health:** A Neonatal Nightmare: The Misread Label,
Cardiovascular risk factors are identifiable in childhood and are
predictive of adulthood, Report compares health of adolescents in the US
to Oother countries

**Chronic Illness and Disease:** New broader diagnostic criteria for
pre-diabetes, National Diabetes Awareness Month \-\-- November 2003,
Rheumatoid Arthritis: Clinical Evidence, Blood cultures for women with
uncomplicated acute pyelonephritis: are they necessary? Treatment of
Tuberculosis: Updated Recommendations

**Other:** Great American Smokeout \-\-- November 20, 2003, November\'s
National American Indian Heritage Month: Health Disparities exist

Features:

##### AFP: Management of Gestational Diabetes Mellitus, Antidepressants for Anxiety Disorder

ACOG: Cervical Insufficiency

Breastfeeding: Guide to Breastfeeding for American Indian and Alaska
Native Families

**Cochrane Library:** Metformin: First choice in anovulation in PCOS,
effective for metabolic syndrome

**Hormone Replacement Update**: Estradiol levels should be monitored and
therapy adjusted

**Information Technology:** New PCC+ Prenatal Flow Sheet

#### MCH Alert: School based vs Hospital based prenatal care for pregnant adolescents, Indicators related to smoking among women and girls

Office of Women's Health, CDC: Updated Mortality Tables Available on the
Healthy Women Web Site; Maternal Behaviors and Experiences Before,
During, and After Pregnancy

Patient Education: Gestational Diabetes Mellitus

#### What's new on the ITU MCH web pages: 

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

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

# 

# [Abstract of the Month]{.underline}

#### From Aberdeen Area, IHS: 

#### Characteristics of mothers who have children with fetal alcohol syndrome 

**BACKGROUND:** Health care providers can more effectively prevent fetal
alcohol syndrome and prenatal alcohol exposure if they know more about
mothers who have children with fetal alcohol syndrome (FAS) or some
characteristics of FAS.

**METHODS:** We conducted two retrospective case-control studies of
Northern Plains Indian children with FAS and some characteristics of FAS
diagnosed from 1981 to 1993 by using the International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), code 760.71.
We compared mothers who had children with FAS or some characteristics of
FAS with mothers who had children that did not have FAS.

**RESULTS:** Compared with control mothers, 43 mothers who had children
with FAS and 35 mothers who had children with some characteristics of
FAS were older, had fewer prenatal visits, more pregnancies, more mental
health problems, and more injuries (both total and alcohol-related).
Although the prevalence of drinking was high in both case and control
mothers, case mothers had more alcohol-related medical problems, drank
heavily, in binges, and daily more often than control mothers.

**CONCLUSIONS**: Women with injuries and mental health problems should
be screened for substance use. Mothers of children with FAS or of some
characteristics of FAS have numerous needs that must be addressed to
prevent future prenatal alcohol exposure.

Kvigne VL, Leonardson GR, Borzelleca J, Brock E, Neff-Smith M, Welty TK.
Characteristics of mothers who have children with fetal alcohol syndrome
or some characteristics of fetal alcohol syndrome. J Am Board Fam Pract.
2003 Jul-Aug;16(4):296-303.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12949030&dopt=Abstract>

## 

## From your colleagues:

###### [From Sandra Dodge, Crownpoint]{.underline}

**High School Students in Bureau of Indian Affairs-Funded Schools
Tobacco, Alcohol, and** Other Drug Use

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5244a3.htm>

**CDC is interested in hearing from AI/AN women: The Futures Initiative
Learn more about** CDC\'s new Strategic Direction Initiative.

<http://www.cdc.gov/futures/default.htm>

**HIV increasing in women**: **AIDS diagnoses increased 7% among women
and decreased 5%** among men

<http://www.cdc.gov/hiv/stats/hasr1402.htm>

**Growing Stronger: Strength Training for Older Adults: Strength
training can help reduce** the signs and symptoms of many chronic
diseases

<http://www.cdc.gov/nccdphp/dnpa/physical/growing_stronger/index.htm>

**Preventing Skin Cancer: Increase protective behaviors Community
interventions to reduce** exposure to ultraviolet light

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5215a1.htm>

##### From Jean Howe, Chinle

###### Have you ever heard of a low risk VBAC? Risk stratification available for the birth provider being 'immediately available'

The Northern New England Perinatal Quality Improvement Network noted
that over the past 3 years, there has been a dramatic decline in the
regional rate of VBAC. Here is their VBAC Project Overview that attempts
to offer women information to make best choices

<http://www.nneob.org/index.php?option=displaypage&Itemid=50&op=page&SubMenu=>

###### Who is Low risk, Medium Risk and High Risk and what interventions apply?

[Low risk:]{.underline} 1 prior cesarean delivery, spontaneous labor, no
augmentation, no repetitive FHR abnormalities, prior successful VBAC.

See other criteria and categories in this document

<http://www.nneob.org/docs/Protocol_NNEOBNet.doc>

###### Consent for Birth After Cesarean Section

<http://www.nneob.org/docs/Consent_NNEOBNet.doc>

###### Patient Education: Birth Choices After a Cesarean Section

<http://www.nneob.org/docs/Ed_NNEOBNet.doc>

Any questions?

Michele R. Lauria, MD. Email:
[**Michele.Lauria@hitchcock.org**](mailto:michele.lauria@hitchcock.org)

Peter Cherouny, MD. Email:
[[Peter.Cherouny@vtmednet.org]{.underline}](mailto:eleanor.capeless@vtmednet.org)

Eleanor Capeless, MD. Email: <Eleanor.Capeless@vtmednet.org>

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

The Indian Health Service benchmark for VBAC is set by ACOG, e.g.,
immediate availability, as defined locally. The Northern New England
Perinatal Quality Improvement Network has raised some excellent
questions about a possible risking system within a structured framework
based on increased patient and provider education.

We will explore this issue more in depth at the 2004 OB/GYN Biennial
meeting. Be sure to block out the dates to that meeting August 4-6, 2004
in Albuquerque.

###### 

###### Minutes from the 2003 Navajo Area Women's Health Provider Meeting

This September 18, 2003 meeting covered many of the current issues and
controversies that we all experience in providing care to Native women
in 2003.

<http://www.ihs.gov/NonMedicalPrograms/nc4/TelConf/areameetingminutes23sept03.doc>

Contact Jean Howe for any questions <jean.howe@his.gov>

##### From Chuck North (Albuquerque) and Bob Newcombe, Alamo

###### Are liquid prep pap smears the standard of care now?

For this answer we abstracted some comments from Alan Waxman, Retired
IHS OB/GYN CCC. Dr. Waxman is currently on the faculty of the University
of New Mexico. Here is a digest of his remarks:

-Thin Prep Paps are not the standard of care in women\'s health. Liquid
preps are a commonly used Pap, however. This is largely because of good
marketing. In addition, most of the literature supports that they will
pick up more dysplasia than the conventional Pap. This includes more
LSIL, as well as HSIL, meaning more colposcopies for LSIL that probably
won\'t prevent any cancers. I know of only one study, in a region of
Costa Rica with a high rate of cervical cancer, where more cancers were
picked up with ThinPrep. This was a largely unscreened population.

-Reflex HPV is very convenient. It should not be done for LSIL, however.

(see the ASCCP consensus guidelines)
<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp#ASCCP>

-Unlike ASC-US, 84% of women with LSIL are high risk HPV positive, so
HPV is useless in triaging them to colposcopy or routine follow-up. With
reflex HPV, you do liquid Paps on 100% of your patients and ask for HPV
only on the 5% or so with ASC-US. At least one study has shown that it
is cost effective on a population basis. It is the preferred way of
managing ASC-US, if you\'re already using ThinPrep.

-There are two other factors to consider. First, cost. How many Paps do
you do? How much more will you spend for the ThinPrep? Can you afford
it? If a service unit population is small, the difference in cost over
conventional Paps may not matter. Second, if you have a lot

of women who don\'t get Paps but every 4 or 5 years, a more sensitive
Pap may be important.

-Even without using ThinPrep, if you want to follow your ASC-US patients
with HPV you can use the ThinPrep medium or you can use the Digene STM.
If you\'re using HPV from the ThinPrep medium to triage an ASC-US on
conventional Pap, then don\'t let them charge you for another Pap. It
won\'t make any difference in your care.

[Bottom line.]{.underline} While they are not standard of care, liquid
preps have some advantages and disadvantages. While in most studies they
pick up more SIL than conventional Paps, it is still far from 100%
sensitive. Computer modeling has suggested that you will do more
colposcopies finding LSIL, which is not premalignant, as well as finding
a few more HSILs that are. Reflex HPV is very attractive for the 4-5%
with ASC-US. If you can afford it, go for it.

On the other hand, there are the increased costs of each pap smear, plus
the extra colposcopies needed. There is no clear evidence the increased
costs improve patient clinical outcomes in a screened population.

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

Yes, liquid preps have some advantages and disadvantages. Another
valuable benchmark, in addition to Dr. Waxman's comments, is this
**[Level A Recommendation]{.underline}** from the ACOG Practice
Bulletin:

"Evidence-based data indicate both liquid-based and conventional methods
of cervical cytology are acceptable for screening."

For the ACOG Summary of Recommendations, OB/GYN CCC Corner, August 2003

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner81703C.doc>

An abstract of the Practice Bulletin for non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12907124&dopt=Abstract>

Full text Practice Bulletin for ACOG Members

<http://www.acog.com/publications/educational_bulletins/pb045.cfm>

Liquid preps do present a technically more satisfying slide to look at,
but that comes at a higher price tag. On balance they are an equivalent
preparations in terms of clinical outcome, though.

One could argue that there is a small group of patients for which a
liquid prep might be most helpful. That would the 4-5% with a true
ASC-US, because they would benefit from reflex HPV testing.
Unfortunately one can\'t tell prospectively which patients will have
ASC-US.

The corollary is using the more expensive preparation on the other 96%
of your patients for which reflex testing offers no benefit. ACOG and
ASCCP have noted that it is clinically equivalent to repeat a convention
pap in 6 months for the ASC-US patient.

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp#ASCCP>

Other factors to consider are the patient's emotional costs for the
increased colposcopy referrals versus the advantages of reflex testing
in ASC-US patients.

This topic will be part of the Primary Care Forum discussion on Cervical
Cancer Screening, which will take place next month on the IHS Primary
Care listserv. Let me know if you are interested in hearing more about
the Discussion Forum <nmurphy@anmc.org>

Here are some other items that we have on our MCH web site on this
topic:

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner81703C.doc>

<http://www.ihs.gov/medicalprograms/mch/m/mchdownloads/ccccorner21003.doc>

<http://www.ihs.gov/medicalprograms/mch/m/mchdownloads/ccccorner21003.htm>

<http://www.ihs.gov/medicalprograms/mch/m/faqdnlds/faqthinprepwaxman.doc>

##### From Rick Olson, HQE

###### Join your Indian Health colleagues in helping the women of Afghanistan: Urgent need for TDY for IHS OB/GYNs, FPs, and CNMs in Kabul, Afghanistan

This item was referred to the OB/GYN CCC Corner by Rick Olson by Brian
McCarthy below:

The Secretary of HHS, Tommy Thompson, is inviting you to participate in
HHS Secretarial Initiative at the Rabia-Balkhi Women\'s Hospital (RBH)
in Kabul, Afghanistan. The project\'s

primary goal is to establish a high quality OB/GYN residency program at
RBH while serving as a leading institution for the training of MCH
health care providers for Afghanistan.

Join David Gahn, Tahlequah OB/GYN, and Scott Deasy, OB/GYN, formerly of
Tuba City, now volunteering with Project Hope who are currently in
Kabul.

Please contact Brian McCarthy for details at <bjm1@cdc.gov> or
770-488-5229

**[From Dan Szekely, ANMC]{.underline}**

**Can you use HRT in post menopausal breast cancer patients?**

Here is a review by Dan Mishell, MD, from the National Menopause Society
Newsletter

###### [**http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#Postmen**](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#Postmen)

###### 

###### How effective is the clinical breast exam?

There is a lack of evidence for benefit to a prolonged breast exam with
Mammacare - no improvement in mortality, but extra tests and biopsies
when lumps are found. It was left to each provider to determine what
exam to do, without providing extra time for extended exam of unproven
benefit. We will work with radiology to drop the requirement for breast
exam prior to mammogram. 'Not there yet. Excellent references are
attached.

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp#Breast>

**[Hot Topics:]{.underline}**

**[Obstetrics]{.underline}**

###### Helping Pregnant Women Cope With Smoking Cessation

Learn a 3-step approach to helping pregnant women stop smoking

<http://www.medscape.com/viewarticle/462980>

######## 

######## NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access using your personal username and password you create.

**[Gynecology]{.underline}**

Is colposcopic biopsy overused among women with a cytological diagnosis
of atypical squamous cells of undetermined significance (ASCUS)?

CONCLUSIONS: In stratified analyses, we found that high income was
positively associated with odds of colposcopic biopsy in all strata of
health coverage and that among those in the highest income category,
private insurance remained an indicator of colposcopic biopsy use. Our
findings raise the possibility that among women with ASCUS, there is an
overuse of colposcopic biopsy by high-income and privately insured women
who are likely to be at low risk of cervical malignancies.\
Lousuebsakul V, Knutsen SM, Singh PN, Gram IT. Is colposcopic biopsy
overused among women with a cytological diagnosis of atypical squamous
cells of undetermined significance (ASCUS)? J Womens Health (Larchmt).
2003 Jul-Aug;12(6):553-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=13678510&dopt=Abstract>

**[Child Health]{.underline}**

###### A Neonatal Nightmare: The Misread Label

AHRQ Morbidity and Mortality: Pediatrics

<http://www.webmm.ahrq.gov/cases.aspx?ic=39>

**Cardiovascular risk factors are identifiable in childhood and are
predictive of adulthood** risk for coronary artery disease (CAD)

Study found that carotid IMT \[intima-media thickness\] in asymptomatic
healthy young adults is associated with traditional cardiovascular risk
factors measured since childhood. Cardiovascular risk factors (such as
IMT) are identifiable in childhood and are predictive of adulthood risk
for coronary artery disease (CAD) but that most studies of IMT have been
performed in middle-aged and elderly populations.

Li S, Chen W, Srinivasan SR, et al. 2003. Childhood cardiovascular risk
factors and carotid vascular changes in adulthood: The Bogalusa Heart
Study. JAMA, The Journal of the American Medical Association
290(17):2271-2276.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14600185&dopt=Abstract>

###### REPORT COMPARES HEALTH OF ADOLESCENTS IN THE US TO OTHER COUNTRIES

U.S. Teens in Our World: Understanding the Health of U.S. Youth in
Comparison to Youth in Other Countries investigates areas where U.S.
adolescents\' health or health-related behaviors have emerged as
significantly different from those of adolescents in other countries.
Available from the HRSA Information Center at
[http://www.ask.hrsa.gov](http://www.ask.hrsa.gov/) (Document code:
MCH00094).

**[Chronic disease and Illness]{.underline}**

###### New broader diagnostic criteria for pre-diabetes

The new guidelines, published in the November issue of *Diabetes Care,*
lower the acceptable level of fasting plasma glucose from 110 milligrams
a deciliter to 100 mg/dl, according to ADA figures. That means anyone
with a level over 100 and under 126 --- the cutoff point for a diagnosis
of diabetes --- is defined as having impaired fasting glucose and will
now be considered pre-diabetic. The ADA screening guidelines define
people at risk as:

-Age of 45

-Overweight or obese

-Family history of type 2 diabetes, first degree relatives

-High-risk minority groups, including African-Americans,
Hispanic-Americans, **Native Americans** and Asian-Americans.\
-**Women who have had gestational diabetes**

People with those characteristics should be tested with a test that
includes a fasting plasma glucose, preferably a 75 oral glucose
tolerance test (FBS and 2 hour post load glucose)

The Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus Follow-up Report on the Diagnosis of Diabetes Mellitus.
Diabetes Care. 2003 Nov;26(11):3160-3167.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14578255&dopt=Abstract>

Full text

<http://care.diabetesjournals.org/cgi/content/full/26/11/3160>

**National Diabetes Awareness Month \-\-- November 2003**\
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5244a1.htm>

**Rheumatoid Arthritis: Clinical Evidence Concise, published by the BMJ
Publishing Group**

<http://www.aafp.org/afp/20031101/british.html>

###### Blood cultures for women with uncomplicated acute pyelonephritis: are they necessary?

To assess the utility of blood cultures in the management of
uncomplicated pyelonephritis in women, we prospectively collected data
from 583 cases. Discordant cases were defined as those for which the
pathogens isolated from urine and from blood were different. We found
that 97.6% of cases were nondiscordant. Clinical and microbiological
evolution of infection did not differ between the 2 groups, and no
changes of antibiotic therapy were required on the basis of blood
culture results. Blood culture may not be routinely required for the
evaluation of uncomplicated pyelonephritis in women.

Velasco M, Martinez JA, Moreno-Martinez A, Horcajada JP, Ruiz J,
Barranco M, Almela M, Vila J, Mensa J. Blood cultures for women with
uncomplicated acute pyelonephritis: are they necessary? Clin Infect Dis.
2003 Oct 15;37(8):1127-30.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14523779&dopt=Abstract>

Treatment of Tuberculosis: Practice Guidelines - Updated Recommendations

from the ATS, CDC, and IDSA

<http://www.aafp.org/afp/20031101/practice.html>

##### Other Hot topics:

###### November\'s National American Indian Heritage Month: Health Disparities exist

One of the health outcomes coming out of this history is that the median
age of death for our Indian population is 60, compared to 76 for Whites.
The median age of death for Indian males in Oregon is 55.
[www.healthoregon.org/cdsummary/1997/ohd4606.pdf](http://www.healthoregon.org/cdsummary/1997/ohd4606.pdf)
Office of Multicultural Health

**Great American Smokeout \-\-- November 20, 2003**\
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5245a8.htm>

##### Features

## American Family Physician

###### Management of Gestational Diabetes Mellitus

This article uses objective data to help guide clinical decision-making,
acknowledging when recommendations are based on expert opinion. See also
Patient Education below

<http://www.aafp.org/afp/20031101/1767.html>

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

Free online CEU /CME is also available on this topic through the
Perinatology Corner at:

Screening and Diagnosis: Diabetes in Pregnancy

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP01.asp#top>

Management, delivery, and postpartum: Diabetes in Pregnancy

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP21.asp#top>

###### Cochrane for Clinicians: Antidepressants for Generalized Anxiety Disorder (GAD)

The available evidence suggests that antidepressants are superior to
placebo in treating GAD. There is evidence from one trial suggesting
that paroxetine and imipramine have similar efficacy and tolerability.
There also is evidence from placebo-controlled trials suggesting that
these drugs are well tolerated by patients with GAD. Further trials of
antidepressants for GAD will help to demonstrate which antidepressants
should be used in which patients.

<http://www.aafp.org/afp/20031101/cochrane.html>

##### ACOG

###### Cervical Insufficiency: ACOG Practice Bulletin No. 48

**Summary of Recommendations**

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

Serial assessments in low-risk women to screen for cervical
insufficiency are of low yield and should not be done routinely.

Serial ultrasound examinations should be considered in a patient with
historical risk factors for cervical insufficiency and should be
initiated between 16 and 20 weeks of gestation or later.

An elective cerclage can be considered in a patient with a history of 3
or more unexplained midtrimester pregnancy losses or preterm deliveries.

Women exposed to DES in utero may be evaluated for cervical
insufficiency using the same clinical criteria as nonexposed
individuals.

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

The evaluation of a patient with cervical shortening or funneling should
include a comprehensive ultrasonographic assessment of the fetus to rule
out anomalies, as well as physical and laboratory assessments to rule
out labor and chorioamnionitis.

Given the advances in neonatal care and the potential maternal and fetal
morbidity associated with cerclage, surgical correction of cervical
insufficiency should be limited to pregnancies before fetal viability
has been achieved.

Cervical insufficiency. ACOG Practice Bulletin No. 48. The American
College of Obstetricians and Gynecologists. Obstet Gynecol
2003;102:1091--9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi>

For ACOG members

<http://www.acog.com/publications/educational_bulletins/pb048.cfm>

[Breastfeeding]{.underline}

An Easy Guide to Breastfeeding for American Indian and Alaska Native
Families takes the reader through the "four directions" of benefits,
risks associated with not breastfeeding, "how to get started,"
continuation upon returning to work, and frequently asked questions.
<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/PatEd.cfm>

You can place larger orders for the Guide at 800 994 9662, 9-6 Eastern
Time

They have a high call volume, so you may need to keep trying.

Here is a sample <http://www.4woman.gov/Breastfeeding/EasyGuide.NA.pdf>

Perhaps a better approach is reach them by e-mail through their web site

Just go to this page, fill in your info, and put your request in the
Message Body section

<http://www.4woman.gov/search/contact.cfm>

If you have problems with that link, you can reach the above page
through the Contact Us page under 'Contact Us electronically'

<http://www.4woman.gov/about/phoneinfo.htm>

The Contact Us link is at the bottom of their main page

[**http://www.4woman.gov**](http://www.4woman.gov/)

[Cochrane Database]{.underline}

Metformin: First choice in anovulation in PCOS, plus effective for
metabolic syndrome

**BACKGROUND:** Polycystic ovary syndrome (PCOS) is characterised by
anovulation, hyperandrogenaemia and Insulin resistance.
Hyperinsulinaemia is known to be associated with an increase in
cardiovascular risk and the development of diabetes mellitus. If insulin
sensitising agents such as metformin are effective in treating features
of PCOS, then they could have wider health benefits than just treating
the symptoms of the syndrome.

**OBJECTIVES:** To assess the effectiveness of insulin sensitising drugs
in improving clinical and biochemical features of PCOS.

**SEARCH STRATEGY**: We searched the Cochrane Menstrual Disorders &
Subfertility Group trials register (December 2002), the Cochrane Central
Register of Controlled Trials (Cochrane Library, Issue 4, 2002), MEDLINE
(January 1966 to December 2002), and EMBASE (January 1985 to December
2002).

**SELECTION CRITERIA:** Randomised controlled trials which investigated
the effect of insulin sensitising drugs compared with either placebo or
no treatment, or compared with an ovulation induction agent.

**DATA COLLECTION AND ANALYSIS:** Performed by two reviewers, one
blinded to information that could have identified the authors, publisher
or results of each study. Fifteen trials were included for analysis, 13
of them using metformin and involving 543 participants. MAIN
**RESULTS:** Meta-analysis showed that metformin is effective in
achieving ovulation in women with PCOS with odds ratios of 3.88 (CI 2.25
to 6.69) for metformin versus placebo and 4.41 (CI 2.37 to 8.22) for
metformin and clomifene versus clomifene alone. An analysis of pregnancy
rates suggests a significant treatment effect for metformin and
clomifene (OR 4.40, CI 1.96 to 9.85). Metformin has a significant effect
in reducing fasting insulin levels (WMD -5.37, CI -8.11 to -2.63), blood
pressure and low-density lipoprotein cholesterol (LDL). There was no
evidence of effect on body mass index or waist:hip ratio. Metformin was
associated with a significantly higher incidence of nausea, vomiting and
other gastrointestinal disturbance, but no serious adverse effects were
reported.

**REVIEWER\'S CONCLUSIONS**: Metformin is an effective treatment for
anovulation in women with PCOS. Its choice as a first line agent seems
justified, and there is some evidence of benefit on parameters of the
metabolic syndrome. Ovulation rates are higher when combined with
clomifene (76% versus 46% when used alone), but there is no evidence to
indicate whether there is an increased multiple pregnancy rate with this
combination. There is no data regarding its safety in long-term use in
young women. It should be used as an adjuvant to general lifestyle
improvements, and not as a replacement for increased exercise and
improved diet.

Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs (metformin,
troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for
polycystic ovary syndrome. Cochrane Database Syst Rev. 2003;(3)

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12917943&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12917943&dopt=Abstract)

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

The Cochrane Database reports on meta-analysis of randomized controlled
trials. The IHS has purchased an institutional subscription of the
Cochrane Database which is available on the Clinical Information
Resources page at:

[**http://www.ihs.gov/MedicalPrograms/CIR/index.asp**](http://www.ihs.gov/MedicalPrograms/CIR/index.asp)

Cochrane Database

[**http://www.ihs.gov/MedicalPrograms/CIR/cir-cochrine-library-gateway.asp**](http://www.ihs.gov/MedicalPrograms/CIR/cir-cochrine-library-gateway.asp)

If you have any questions on how to use the Cochrane Database, please
contact me

[**nmurphy@anmc.org**](mailto:Nmurphy@anmc.org)

In the meantime, this study represents a major step forward to confirm
the utility of insulin sensitizing agents for anovulation in Polycystic
Ovarian Syndrome (PCOS). As PCOS may be present in as much as 7% of the
adult female population, this may benefit a large number of our
patients. In addition, insulin sensitizing agents may be beneficial in
modifying some of the variables in the metabolic syndrome of glucose
intolerance and lipid abnormalities. Metformin should be started at a
low dose, and increased slowly to minimize gastrointestinal side
effects.

A similar publication is available here:

Lord JM, Flight IH, Norman RJ. Metformin in polycystic ovary syndrome:
systematic review and meta-analysis. BMJ. 2003 Oct 25;327(7421):951-3.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14576245&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14576245&dopt=Abstract)

**[Hormone Replacement Update]{.underline}**

**Estradiol (E2) levels should be monitored and hormone replacement
therapy adjusted** accordingly.

**CONCLUSIONS:** First, there is substantial variability in E(2)
concentrations achieved with conventional oral and patch HRT. Second,
various factors that are statistically significant predictors of
response categories have been identified. Third, race/ethnic group plays
a role in the response to HRT. Finally, the demonstration of variable
responses to HRT and the application of the categorization paradigm
presented will be useful in resolving the controversy about the risks
and benefits of conventional HRT.

Gavaler JS. Thoughts on individualizing hormone replacement therapy
based on the postmenopausal health disparities study data. J Womens
Health (Larchmt). 2003 Oct;12(8):757-68.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14588126&dopt=Abstract>

# [Information Technology]{.underline}

###### New PCC+ Prenatal Flow Sheet

There is a new template of a PCC+ form that allows for previous
information (fundal height, BP, etc...) to be automatically populated
onto your prenatal flow sheet. Take a look.
<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#Forms>

E-mail for questions [nmurphy@anmc.org](mailto:Nmurphy@anmc.org)

Many other PCC+ forms are also available, e.g., GYN, Colpo, etc....

Take a look

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

# [International Health Update]{.underline}

## Join your Indian Health colleagues in helping the women of Afghanistan

See discussion above from Rick Olson

Please contact Brian McCarthy for details at <bjm1@cdc.gov> or
770-488-5229

## MCH Alert

SCHOOL-BASED VS. HOSPITAL-BASED PRENATAL CARE FOR PREGNANT ADOLESCENTS

Teenagers who received prenatal care in a school-based CAPP
\[comprehensive adolescent pregnancy program\] were significantly less
likely to deliver a low birth weight infant compared with teenagers
receiving care at a hospital-based CAPP.

###### Barnet B, Duggan AK, Devoe M. 2003. Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: Effect of access and comprehensive care. Journal of Adolescent Health 33(5):349-358.

###### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14596956&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14596956&dopt=Abstract)

###### 

###### INDICATORS RELATED TO SMOKING AMONG WOMEN AND GIRLS

Women and Smoking: A National State-by-State Report Card is a national
and state-by-state evaluation of both smoking-related health status data
and health policies. The report, produced by the National Women\'s Law
Center and Oregon Health and Science University, addresses smoking as
part of a comprehensive assessment of women\'s overall health.. The
report provides information for policymakers, researchers, and others on
the nation\'s progress (or lack thereof) in reaching key benchmarks
related to women\'s health. The report is available at
<http://www.nwlc.org/pdf/Women&SmokingReportCard2003.pdf>.

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

**Updated Mortality Tables Available on the Healthy Women Web Site**\
Updated mortality tables are now available on the Healthy Women web site
with data from 1997-2000.

<http://www.cdc.gov/nchs/healthywomen.htm>

Maternal Behaviors and Experiences Before, During, and After Pregnancy:

Pregnancy Risk Assessment Monitoring System (PRAMS), 2000

<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5211a1.htm>

Appendix

<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5211a2.htm>

**[Patient Information]{.underline}**

###### Gestational Diabetes Mellitus, American Family Physician

<http://www.aafp.org/afp/20031101/1775ph.html>

##### What's new on the ITU MCH web pages?

###### Postmenopausal Hormone Therapy and Breast Cancer

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#Postmen>

###### Stop Chlamydia! Project Home page

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

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/WN08.asp#top>

### **[Save the dates]{.underline}**

**Ninth Annual Maternal and Child Health Epidemiology Conference**\
December 10-12, 2003, Tempe, AZ

Accepting abstracts <http://www.cdc.gov/nccdphp/drh/index.htm>

**19^th^ Annual Midwinter Conference for providers caring for Native
women and children**

Jan 30 -- Feb 1, 2004.

2004 brochure = pending

See Conference Archives in February 2003 for information on last year's
conference

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

**3rd National Sexual Violence Prevention Conference, CDC **

May 25 - 28, 2004 

Los Angeles, California 

 <http://www.cdc.gov/ncipc/2004nsvpc.htm> 

#### National IHS PA / APN Annual Meeting

June 7-11, 2004

Scottsdale, Arizona

[**http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004**](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004)

Contact Judy Whitecrane for questions <judy.whitecrane@mail.ihs.gov>

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

-   June 13-17, 2004 **Please, note this date change!**

-   Denver, CO

-   Contact Barbara Fine at 301 443 1840

-   2003 brochure below. 2004 brochure will be available soon

<http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/ACOGpostgradBroch-2002.doc>

**2004 Biennial OB/GYN meeting Please, note this date change!**

August 4-6, 2004

Albuquerque, New Mexico

Location and brochure to follow

Contact Neil Murphy for questions <nmurphy@anmc.org>

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

Did you miss something in the last OB/GYN Chief Clinical Consultant
Corner?

The **October 2003 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner101803.doc>

**[Abstract of the Month]{.underline}:**

Prophylactic Antibiotics in Labor and Delivery, ACOG Practice Bulletin

[From your colleagues:]{.underline}

From Hope Baluh: Wrong Site Surgery

#### From James Bresette: Possible Additional Resources for AI/AN Women\'s Health

From Tom Creelman: Information about intrathecal analgesia after reading
Leeman et al

From Terry Cullen: Domestic Violence Awareness Month, Health Promotion
and Disease Prevention, Asthma, Best Practices, VA Clinical Practice
Guidelines: Uncomplicated pregnancy guidelines and Home page

From Sandra Dodge: Cigarette Smoking Among Adults \-\-- United States,
2001, CDC

##### From James Galloway: [**Diabetic Dyslipidemia, ADA**](http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/ADACardioReview_3.pdf)

From Ursula Knoki-Wilson: Two West Nile virus human cases confirmed in
the Navajo Nation

# From Larry Leeman: Effective repair of obstetric perineal lacerations requires a knowledge of perineal anatomy and surgical technique

From Elaine Locke: Tribal benefits counseling program: expanding health
care opportunities for tribal members.

From Kelly Moore: FAS on NBC television program Law & Order: Special
Victims Unit.

##### From Chuck North: Routine prenatal urine screening for preeclampsia?

From Judy Thierry: The Stop Chlamydia! Project Home Page

**[Hot Topics:]{.underline}**

##### Obstetrics: Rapid HIV Test, Antenatal screening with fetal echocardiography: when and how, Legislation for Cord Blood Bank Network Reminiscent of Early Organ Transplant 

**Gynecology:** Colposcopy and Women's Value judgements: Funding is
available, Effectiveness of Strategies for Preventing Violence:
Firearms, Continuous combination oral contraceptive pills to eliminate
withdrawal bleeding: a randomized trial, Premenstrual dysphoric disorder
(PMDD)

**Child Health:** [**www.4girls.gov**](http://www.4girls.gov/), State
Policies in Brief: Sexuality Education presents information on sex
education policies, Prevention and Treatment of Type 2 Diabetes Mellitus
in Children With Special Emphasis on American Indian and Alaska Native
Children, Sudden Infant Death Syndrome, Infant Mortality Statistics from
the 2001 Period Linked Birth/Infant Death

**Chronic Illness and Disease:** October is Breast Cancer Awareness
Month, Prevalence of Diabetes and Impaired Fasting Glucose in
Adults-United States, Overweight or obese individuals in the US do not
believe that they are at serious risk of developing type 2 diabetes
mellitus

[Features:]{.underline}

##### AFP: Common skin conditions in women

## ACOG: Benefits and Risks of Sterilization, ACOG disagrees with WHI on osteoporosis prophylaxis

**AHRQ:** Lengthening postpartum hospital stays, Later admission in
labor and collaborative care increase spontaneous vaginal delivery

ACOG: Benefits and Risks of Sterilization

Breastfeeding: Educational programs were the most effective single
intervention

**Hormone Replacement Update**: ACOG disagrees with WHI on osteoporosis
prophylaxis, Red clover and soy both contain phytoestrogens

**Information Technology:** Comparison of telecolposcopy systems,

International Health: Outcomes, safety, and resource utilization in a
collaborative care birth center

# MCH Alert: Toolkit helps increase knowledge and awareness of emergency contraception, Effectiveness of early home visitation programs in preventing violence, Impact of health centers on reducing health disparities

**Office of Women's Health, CDC:** Preventing Male Perpetration of
Sexual Violence

Patient Education: Alternatives to Hysterectomy, Public health campaign
launched to promote appropriate use of antibiotics

#### What's new on the ITU MCH web pages: 

**Save the Dates:** Upcoming events of interest

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@anmc.org>

or 907 729 3154 (with voicemail) 11/17/03