7/18/03

OB/GYN Chief Clinical Consultant's Corner

July 18, 2003 Update

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

**Abstract of the Month:** Efficacy and tolerability of low-dose iron
supplements during pregnancy: a randomized controlled trial

From Burt Attico, MD: U.S. Birth Rate Reaches Record Low, Osteoporosis
risk in childhood

From Terry Cullen MD: National HIV/AIDS Clinicians\' Consultation, AHRQ
M/M, USPSTF

From George Gilson, MD: Postpartum hemorrhage and rectal misoprostol,
smallpox vaccine

From Elaine Locke, ACOG: Preventable disparities in AI/ANs MCH health
status persist

From Yolanda Meza, CNM: Do fish oils prolong gestation?

From Kelly Moore,MD: Needs of overweight children, Dyslipidemia in
Children and Adolescents

From Chuck North MD: Policy for chaperons during breast and pelvic
exams?

**Hot Topics:** From Dawn Wyllie, MD, RPMS -- Women's Health Software
Training: Train the Trainer, Aberdeen Area Infant Mortality Study,
Nausea and Vomiting in Early Pregnancy,

Methotrexate Ectopic Protocol, Late Versus Early Testing of HIV, First
trimester ultrasound identifies more cases of Down syndrome than second
trimester, 1990s ELBW infants show deficits at school age, Women
surveyed at gynecology clinics report high rates of abuse,

Increase Access to Care Issues in your Community: Take A Loved One to
the Doctor Day,

Interactive Atlas of Reproductive Health, New Health Promotion / Disease
Prevention IHS web site, Want a way to transfer electronic fetal heart
rate monitoring strips to another facility? Looking for a future
obstetric ultrasound tech?

##### From ACOG: Neural Tube Defects, ACOG Practice Bulletin, July 2003

**Information Technology:** The Clinical Information Resources page just
keeps getting better.

**Hormone Replacement Update:** Evidence implicates combined HRT in
early breast cancer

**International Health:** Health Canada\'s First Nations and Inuit
Health, 3^rd^ stage labor, PPH

#### What's new on the ITU MCH web pages: Program and Resources page has been reorganized

**Patient Education:** Women's Health Matters Resource Database

###### AAFP: Nausea and vomiting in pregnancy, Black Cohosh, Bartholin's cyst, hair loss

###### 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 Carol Treat, Nutritionist, Alaska Native Medical Center)

Makrides M, Crowther CA, Gibson RA, Gibson RS, Skeaff CM. Efficacy and
tolerability of low-dose iron supplements during pregnancy: a randomized
controlled trial. Am J Clin Nutr. 2003 Jul;78(1):145-53.

**BACKGROUND:** Iron deficiency anemia (IDA) is common in pregnant
women, but previous trials aimed at preventing IDA used high-dose iron
supplements that are known to cause gastrointestinal side effects.

**OBJECTIVE:** The objective was to assess the effect on maternal IDA
and iron deficiency (ID, without anemia) of supplementing pregnant women
with a low dosage (20 mg/d) of iron. Effects on iron status were
assessed at the time of delivery and at 6 mo postpartum.
Gastrointestinal side effects were assessed at 24 and 36 wk of
gestation. DESIGN: This was a randomized, double-blind,
placebo-controlled trial of a 20-mg daily iron supplement (ferrous
sulfate) given from 20 wk of gestation until delivery.

**RESULTS:** A total of 430 women were enrolled, and 386 (89.7%)
completed the follow-up to 6 mo postpartum. At delivery, fewer women
from the iron-supplemented group than from the placebo group had IDA
\[6/198, or 3%, compared with 20/185, or 11%; relative risk (RR): 0.28;
95% CI: 0.12, 0.68; P \< 0.005\], and fewer women from the
iron-supplemented group had ID (65/186, or 35%, compared with 102/176,
or 58%; RR: 0.60; 95% CI: 0.48, 0.76; P \< 0.001). There was no
significant difference in gastrointestinal side effects between groups.
At 6 mo postpartum, fewer women from the iron-supplemented group had ID
(31/190, or 16%, compared with 51/177, or 29%; RR: 0.57; 95% CI: 0.38,
0.84; P \< 0.005). The rate of IDA between the groups did not differ
significantly at 6 mo postpartum.

**CONCLUSION:** Supplementing the diet of women with 20 mg Fe/d from
week 20 of pregnancy until delivery is an effective strategy for
preventing IDA and ID without side effects.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12816784&dopt=Abstract>

## OB/GYN CCC Editorial comment

Some maternity providers routinely supplement their patients with as
much as 3 FeSO4 tablets a day from the onset of known clinical
pregnancy. This randomized controlled (Level I) study shows that iron
supplementation can wait until mid second trimester, and be given in
much smaller doses. Given in this manner iron will not cause those side
effects that are commonly associated with iron supplementation given
earlier in pregnancy or with higher doses. njm

#### [From Burt Attico, MD]{.underline}

**U.S. Birth Rate Reaches Record Low\
**Births to Teens Continue 12-Year Decline; Cesarean Deliveries Reach
All-Time High

#### [**http://www.cdc.gov/nchs/releases/03news/lowbirth.htm**](http://www.cdc.gov/nchs/releases/03news/lowbirth.htm)

#### 

**Osteoporosis risk may start in childhood or earlier**

\>\> Professor Cyrus Cooper reported\> that small newborn babies, would
also be small at one year old, \> have low bone mass at the age of 25,
and go on to have possible bone \> trauma at the age of 70 and hip
fracture at 80. This effect may be due to adverse conditions, such as \>
undernourishment, while in the womb. Prof Cooper believes this may have
\> an effect on bone growth and could contribute to the risk of \>
osteoporosis in adult life. Questions? Contact <nbattico@pol.net>

#### [From Terry Cullen MD]{.underline}

Do you and your patients feel inundated with information about
prevention and screening tests?

A pamphlet from the AHRQ-sponsored U.S. Preventive Services Task Force,
\"Women: Stay Healthy at Any Age: Checklist for Your Next Checkup\"
tells you exactly what you need to know about the most important
screening tests.

<http://www.ahrq.gov/ppip/healthywom.htm>

Feeling No Pain: [Following hysterectomy, a PCA pump is mistakenly
continued in a woman suffering an adverse reaction to morphine, noticed
only when her respiratory status set off an
alarm.](../cases.aspx%3Fic=23)...... (from AHRQ WebM/M)

<http://webmm.ahrq.gov/cases.aspx?ic=23>

National HIV/AIDS Clinicians\' Consultation Center:

-National HIV/Telephone Consultation Service (Warmline) or the National

# -Clinician\'s Post-Exposure Prophylaxis Hotline (PEPline)

# [**http://www.ucsf.edu/hivcntr/**](http://www.ucsf.edu/hivcntr/)

# [From George Gilson, MD]{.underline}

# Postpartum Hemorrhage and rectal misoprostol

"Several providers have discussed with me the use of rectal misoprostol
for the treatment of PPH. Some feel it has become the drug of choice for
this situation. I\'d like to disagree (!) and present some of the
evidence of which I\'m aware.

While rectal misoprostol is an inexpensive and readily available agent,
the evidence for its use for the *treatment* of PPH comprises several
case reports, totaling all of 14 patients, as far as I\'ve been able to
ascertain. It certainly has a use in the *prevention* of PPH (active
management of the third stage of labor), especially in developing
countries, and good evidence exists, although it appears to be slightly
inferior to oxytocin for that indication.

The most recent green journal had the paper we\'d been waiting for on
the pharmacokinetics of rectal misoprostol. They are actually identical
to those of vaginally administered misoprostol. Levels begin to rise by
30 minutes, peak at 60 minutes, and are sustained for at least 4 hours.
This makes it a great agent for the prevention of delayed PPH, but not
very helpful for the treatment of acute hemorrhage, where you need
something that will work immediately. I believe the supposed benefit you
are seeing represents the effect of the other agents you have given and
the ongoing massage you are doing, and are not the result of the drug.

# I would not count on it when you have much more rapid acting, and effective, agents available."

# [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12738159&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12738159&dopt=Abstract)

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

# 515,00 women die worldwide of complications of childbirth. Hemorrhage is the single most important cause of maternal death worldwide. One quarter of those deaths are due t hemorrhage. Active management of the third stage of labor will significantly reduce the incidence of PPH with uterotonic drugs, early cord clamping, and controlled cord tension. In the ITU system we should rely on those injectable rapid acting agents that are readily available, e.g, oxytocin. 

# 

# In the case of PPH, Methergine should be your first choice after oxytocin, if the patient is not hypertensive. The second tier of uterotonic agents that would be used for treatment of PPH may be chosen by the patient's clinical course and their side effect profile. Hemabate can produce dramatic uterotonic results, but is also accompanied copious diarrhea. Rectal misoprostol has less side effects, but has a delayed onset of action. 

# The Advanced Life Support in Obstetrics Course (ALSO) offers an excellent step-wise approach for treatment of hemorrhage. I recommend the ALSO Course for all providers who provide maternity care.

I have also provided several online resources for guidelines and
background of the active management of the 3^rd^ stage of labor and the
treatment of PPH in the International Health section\* below. njm

# Smallpox vaccine in pregnancy: Per CDC recommendation\... the husband should not be vaccinated while she is pregnant. He may be vaccinated while she is breastfeeding but needs to wash his hands and keep the vaccination site covered when he is with the baby. It doesn\'t say anything about the age of the baby, but after 6 weeks sounds reasonable to me.

<http://www.bt.cdc.gov/agent/smallpox/vaccination/vaccination-program-qa.asp>

<http://www.bt.cdc.gov/agent/smallpox/index.asp>

**[From Elaine Locke, ACOG]{.underline}**

**CONCLUSIONS:** Preventable disparities between AI/ANs and Whites in
maternal and infant health status persist.

**Perinatal and infant health among rural and urban American
Indians/Alaska Natives.** Am J Public Health. 2002 Sep;92(9):1491-7.

Baldwin LM, Grossman DC, Casey S, Hollow W, Sugarman JR, Freeman WL,
Hart LG.

# [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12197982&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12197982&dopt=Abstract)

# [From Yolanda Meza,CNM]{.underline}

I read an article in Contemporary OB/GYN many years ago about the affect
of diet in relations to premature birth. It appeared that in countries
where women have fish as their main part of their diet, like in the
Philipines, there are less premature births. I have not been able to
find the research on this. Could you find this research?

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

Yolanda's impression was correct. Fish oil intake early in pregnancy
significantly reduced preterm delivery and lengthened gestation by 6-7
days. Please view these data within the context of the overall preterm
labor management schema presented by ACOG in their May Practice
Bulletin.

See May CCC Corner

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner52403.doc>

Or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12738177&dopt=Abstract>

Here are the results of a PubMed search performed this month on fish
oils and PTL njm

Two randomized trials showing longer gestation and less preterm delivery

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12636950&dopt=Abstract>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10740336&dopt=Abstract>

Case control study with altered essential fatty acid intake or
metabolism in preterm delivery

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9125620&dopt=Abstract>

Case control study with 50-year follow-up showing longer gestation

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2265175&dopt=Abstract>

Prospective cohort study showing longer gestation

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11859044&dopt=Abstract>

Review pro-fish oil showing longer gestation

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11395920&dopt=Abstract>

Sheep study showing longer gestation

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10026118&dopt=Abstract>

Case control study showing no effect

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9033242&dopt=Abstract>

Letter to the Editor

# [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12666637&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12666637&dopt=Abstract)

# [From Kelly Moore, MD]{.underline}

Here is a great resource for professionals and parents who are
addressing the needs of overweight children. From the University of
California\...

<http://anrcatalog.ucdavis.edu/merchant.ihtml?pid=5523&lastcatid=349&step=4>

New ADA Consensus Statement: Management of Dyslipidemia in Children and
Adolescents with Diabetes including how frequently lipid levels should
be monitored, how elevated levels should be treated, and what additional
research is needed.

<http://americandiabetesassn.org/GoNow/a16366a80467a139386537a11>

##### From Chuck North MD

We are working on a policy for pelvic chaperons. I have come to learn
that our female clinicians generally do pelvics and colpos unassisted,
i.e. with no chaperone. They think it will disrupt their routine and be
a burden on the nursing staff to have a chaperone during pelvics. What
is the usual and customary practice? Should we make an exception for
female colposcopists and other female clinician pelvic exams?

From **ACOG's Ethics in Gynecology: Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations**

\"....The request by either a patient or a physician to have a chaperon
present during a physical examination should be accommodated
irrespective of the physician\'s gender. . Local practices and
expectations differ with regard to the use of chaperons, but the
presence of a third person in the examination room can confer benefits
for both patient and physician, regardless of the gender of the chaperon
....."

<https://www.acog.com/from_home/publications/ethics/ethics89.cfm>

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

Please open the ACOG link above and do take a look at it.

We all should follow the benchmark advice given to us by ACOG. The
Indian Health, Tribal, or Urban Native facilities standard of care
should be to have another person present during examination of the
breast or genital area. Chapter 13 of the IHS Manual is being revised at
this time to reflect that 'best practices' suggestion from ACOG.

Let me know if you are having any problem implementing this practice at
your facility. njm

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

#### From Dawn Wyllie, MD

#### RPMS -- Women's Health Software Training: Train the Trainer

August 13, 2003 -- 8:30 a.m. -- 4:00 p.m.

August 14, 2003 -- 8:30 a.m. -- 12:00 noon

Nashville, TN, No Registration Fee Required

### Call  866-4niwhrc or 918-456-6094

### **RPMS -- Women's Health Software Training: Train the Trainer**

August 20, 2003 -- 8:30 a.m. -- 4:00 p.m.

August 21, 2003 -- 8:30 a.m. -- 12:00 noon

Bemidji, MN, No Registration Fee Required

Call  866-4niwhrc or 918-456-6094

**Aberdeen Area Infant Mortality Study (AAIMS):** Leslie Randall, RN,
MPH, Hannah Kinney,MD\
Archive of the May 7, 2003 audio and Powerpoint presentation

<http://www.uic.edu/sph/cade/mchepi/meetings/may2003/index.htm>

#### Nausea and Vomiting in Early Pregnancy 

#### Evidence Based Medicine, Clinical Evidence Concise, BMJ Publishing Group 

<http://www.aafp.org/afp/20030701/british.html>

####### Methotrexate Ectopic Protocol

Family Practice Notebook

<http://www.fpnotebook.com/OB118.htm>

###### Late Versus Early Testing of HIV-16 Sites, United States, 2000-2003

Reducing the incidence of both new infections and HIV-associated
morbidity and mortality will require earlier testing and improved access
to prevention and care services for persons infected with HIV.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5225a2.htm>

**First trimester ultrasound identifies more cases of Down syndrome**
**than second trimester** maternal serum screening and is more cost
effective

<http://www.ahrq.gov/research/may03/head3>

**1990s ELBW infants show deficits at school age**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12824207&dopt=Abstract>

###### Women surveyed at gynecology clinics report high rates of abuse

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12826432&dopt=Abstract>

### **Increase Access to Care Issues in your Community: Take A Loved One to the Doctor Day**

<http://www.healthgap.omhrc.gov/dr22003.htm>

**Interactive Atlas of Reproductive Health**

August  Wednesday, August 6  ,2003, 2:00-3:00 pm EST  Maternal and Child
Health Epidemiology Program (MCH EPI) 

<http://www.phppo.cdc.gov/phtn/calendar.asp#Webcasts>

**New Health Promotion / Disease Prevention IHS web site**

Physical Activity and Exercise section provides information on promoting
physical activity in the workplace, creating access to community places
for physical activity with minimal expenditure, a program to encourage
use of stairs instead of elevators and links to US government fitness
recommendations. <http://www.ihs.gov/HPDP/>

###### Want a way to transfer electronic fetal heart rate monitoring strips to another facility?

<http://www.analogic.com/fetalmonitor/>

**Looking for a future obstetric ultrasound tech?**

This ultrasound student at Keiser College in Ft. Lauderdale, Florida
will be graduating from the program in August and was wondering if you
were looking for an OB tech to do ultrasounds.  The student is also
interested in any programs that are willing to help pay back student
loans

Contact <FREEKNASTEE11@aol.com>

##### From ACOG

**Neural Tube Defects**

ACOG Practice Bulletin NUMBER 44, JULY 2003

**Summary of Recommendations**

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

-   Periconceptional folic acid supplementation is recommended because
    it has been shown to reduce the occurrence and recurrence of NTDs.

-   For low-risk women, folic acid supplementation of 400 µg per day
    currently is recommended because nutritional sources alone are
    insufficient. Higher levels of supplementation should not be
    achieved by taking excess multivitamins because of the risk of
    vitamin A toxicity.

-   For women at high risk of NTDs or who have had a previous pregnancy
    with an NTD, folic acid supplementation of 4 mg per day is
    recommended.

-   Maternal serum alpha-fetoprotein evaluation is an effective
    screening test for NTDs and should be offered to all pregnant women.

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

-   Women with elevated serum AFP levels should have a specialized
    ultrasound examination to further assess the risk of NTDs.

-   The fetus with an NTD should be delivered at a facility that has
    personnel capable of handling all aspects of neonatal complications.

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

-   The ideal dose for folic acid supplementation has not been
    appropriately evaluated in prospective clinical studies. A 400 µg
    supplement currently is recommended for women capable of becoming
    pregnant.

-   The route of delivery for the fetus with an NTD should be
    individualized because data are lacking that any one route provides
    a superior outcome.

# [Electronic Medical Records and Information Technology]{.underline}

The Clinical Information Resources page just keeps getting better.

What is the Clinical Information Resources (CIR) page? The CIR is a
website available on the [www.ihs.gov](http://www.ihs.gov/) that
functions as a virtual online library. You can quickly look up clinical
questions, get abstracts, or order full text articles.

Clinical Information Resources main page

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

Answering Clinical Questions (UpToDate, Cochrane, Micromedex-has good
teratology sites)

<http://www.ihs.gov/MedicalPrograms/CIR/cir-answering-clinical-questions.asp>

Need to get some full text articles or other resources? Try the Parklawn
Library

<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link_gov=http://library.psc.gov/library/services.htm>

What Journals are available to me online?

<http://www.ihs.gov/MedicalPrograms/CIR/cir-online-journals.asp>

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

###### 

###### Evidence implicates combined HRT in early, aggressive breast cancer 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12824206&dopt=Abstract>

###### Phytoestrogen supplements not useful for menopause symptoms

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12851275&dopt=Abstract>

###### Estrogen may play a role in etiology of GERD

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12837713&dopt=Abstract>

# [International Health Update]{.underline}

**From Health Canada\'s First Nations and Inuit Health Branch**

I received an E-mail from Lyse Côté Bolaños from the Health Canada\'s
First Nations and Inuit Health Branch, Ottawa, Ontario, Canada. Lyse
wanted to establish contact with any nurses or providers who care for
AI/AN women that may have common issues.

Please contact Lyse at <Lyse_Cote_Bolanos@hc-sc.gc.ca>

or at

\(613\) 957-3396 Fax: (613) 946-4625

Here are some of the Programs the Health Canada\'s First Nations and
Inuit Health Branch currently are involved in:

FAS Program details, Community Projects, funding, and publications

<http://www.hc-sc.gc.ca/fnihb/cp/fas_fae/index.htm>

First Nations and Inuit Health Branch website

<http://www.hc-sc.gc.ca/fnihb/>

National Aboriginal Health Organization

# [**http://www.naho.ca/**](http://www.naho.ca/)

The Importance of Culture to Aboriginal Health and Health Care

<http://www.hc-sc.gc.ca/iacb-dgiac/arad-draa/english/rmdd/bulletin/page20>

The Aboriginal Healing Foundation addresses the issue of Residential
Schools and the legacy of abuse. <http://www.ahf.ca/>

Aboriginal Peoples Television Network

<http://www.aptn.ca/>

###### Active management of 3rd stage of labor and postpartum hemorrhage management (PPH)

\*See the discussion of the active management of the 3^rd^ stage of
labor and PPH above

Outlook: Preventing PPH

<http://www.reproline.jhu.edu/english/2mnh/2articles/otlkpph.pdf>

3^rd^ stage of labor: Family Practice Notebook

<http://www.fpnotebook.com/OB109.htm>

3^rd^ stage of labor: ReproLine MCH

<http://www.reproline.jhu.edu/english/2mnh/2ppts/3rdstage/>

3^rd^ stage of labor: US Agency for International Development

<http://www.mnh.jhpiego.org/best/pphactmng.asp>

PPH treatment: Family Practice Notebook

<http://www.fpnotebook.com/OB14.htm>

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

Want some PCC+ forms, Where is Chapter 13? Other MCH program material?

The Program and Resources page has been reorganized. Take a look

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.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/WN07.asp#top>

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

**\> The Women's Health Matters Resource Database is a searchable
bilingual \> database of** women's health resources for consumers and
health \> professionals alike. It provides women with information about
where to \> find women's health resources to support their health-care
\> decision-making.

<http://www.womenshealthmatters.ca/resources/>

#### 

## American Academy of Family Physicians 

Black Cohosh : The herbal medicine black cohosh is effective in the
short-term treatment of menopausal symptoms.

<http://lyris.aafp.org/t/21913/5913807/255/0/>

Nausea and vomiting of pregnancy

Nausea and vomiting of pregnancy is generally a mild, self-limited
condition that may be controlled with conservative measures. A small
percentage of pregnant women have hyperemesis gravidarum, which can have
negative implications for maternal and fetal health.

<http://www.aafp.org/afp/20030701/121.html>

Management of Bartholin\'s Duct Cyst and Gland Abscess\
Bartholin\'s duct cyst or gland abscess usually can be managed with Word
catheter placement, which frequently can be performed in the office.
Marsupialization is an alternative treatment for Bartholin\'s duct cyst;
however, it should not be performed if a gland is abscessed.

<http://www.aafp.org/afp/20030701/135.html>

Common hair loss disorders

<http://www.aafp.org/afp/20030701/107ph.html>

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

#### RPMS -- Women's Health Software Training: Train the Trainer

August 13, 2003 -- 8:30 a.m. -- 4:00 p.m.

August 14, 2003 -- 8:30 a.m. -- 12:00 noon

Nashville, TN, No Registration Fee Required

### Call  866-4niwhrc or 918-456-6094

### **RPMS -- Women's Health Software Training: Train the Trainer**

August 20, 2003 -- 8:30 a.m. -- 4:00 p.m.

August 21, 2003 -- 8:30 a.m. -- 12:00 noon

Bemidji, MN, No Registration Fee Required

Call  866-4niwhrc or 918-456-6094

#### Comprehensive Colposcopy: ASCCP

August 7-10, 2003 Seattle, Washington, 26 credits

<http://www.asccp.org/pdfs/comprehensive/seattle/7687_Seattle.pdf>

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

-   September 7-11, 2003

-   Denver, CO

-   Contact Barbara Fine at 301 443 1840

-   2003 brochure now available

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

#### Comprehensive Colposcopy: ASCCP

October 16-19, 2003 Nashville, Tennessee, 26 credits

<http://www.asccp.org/pdfs/comprehensive/nashville/7689_Nashville.pdf>

**Ninth Annual Maternal and Child Health Epidemiology Conference**\
December 2003, Accepting abstracts, Location to be announced, Date to be
announced.

<http://www.cdc.gov/nccdphp/drh/MCHEpi/02_mchepi.htm>

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

Tentative dates: 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>

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

The **June 2003 OB/GYN CCC Corner**

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner61903.doc>

covered:

**Abstract of the Month:** A Native American Community with a 7%
Cesarean Delivery Rate: Does Case Mix, Ethnicity, or Labor Management
Explain the Low Rate?

**Hot Topics:**

RPMS -- Women's Health Software Training: Train the Trainer; Juvenile
Justice in Indian Country Video conference; Effect of a clinical
practice improvement intervention on Chlamydial screening among
adolescent girls; Web based Epidemiology in the IHS: Track Chlamydia
(and get CME); Over-the-Counter Medications in Pregnancy; Evaluation and
Treatment of Women with Hirsutism; Motivational Intervention to Reduce
Alcohol-Exposed Pregnancies

**AAP Alert:** Breast feeding and early childhood -Vitamin D suggested

**From Chuck North MD:** Preventive services, Cervical cytology, HPV
testing

**Electronic Medical Records:** From Terry Cullen MD, From Burt Attico,
MD

**International Health:** How Sexual Assault and fistulas ruins women's
lives

**Hormone Replacement Update:** Effect of HRT on cognitive function: WHI

#### What's new on the ITU MCH web pages: New Domestic Violence main page

**Patient Education:** NATIVE CIRCLE, Endometrial cancer, Pap smears,
Ovarian cysts

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)