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OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 9, September 2007

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

#### Abstract of the Month page 6 {#abstract-of-the-month-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

Mike Engel

#### The spread of obesity in a large social network over 32 years {#the-spread-of-obesity-in-a-large-social-network-over-32-years .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

2007 National HIV Prevention Conference

**Elaine Locke**

### 2008-09 Packer Fellowships: Deadline Extended

**Shannon Myers**

2008 APN/PA conference is already being planned. Any ideas?

**Chuck North**

Ann Bullock is the new Chief Clinical Consultant for Family Medicine

**Robert Pittman**

Questions about DEA or controlled substance policy

**Ros Singleton**

Immunization errors in Tdap and DTaP vaccine administration: ALERT
-VACCINE UPDATE

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

##### Obstetrics page 10

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

-Oral Antidiabetic Agents in Pregnancy and Lactation: A Paradigm Shift

-Preventive Approach to Cutting Cesarean Delivery Rates Appears Feasible

-No advantage to bulking agent after primary repair of obstetric anal
sphincter injury

-Prepregnancy obesity, overweight raise risk of birth defects

...and more

**Gynecology page 13**

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

-HPV, Vaccines, and Gender: Policy Considerations

-Liquid prep no more accurate than conventional cytology, RCT

-Laparoscopically guided minilaparotomy reduces intraperitoneal spillage

-Quadrivalent HPV Recombinant Vaccine (Gardasil) for the Prevention of
Cervical Cancer

**Child Health page 14**

-Educate parents about new pre-adolescent vaccine recommendations

-Fact sheet focus on adolescent HPV vaccination issues and opportunities

-Tobacco Smoke Exposure During Pregnancy Increases Blood Pressure in
Infants 

-Body composition, physical activity and insulin sensitivity in
adolescents

-Updated AAP Guidelines on Newborn Screening and Tx for Congenital
Hypothyroidism

**Chronic Illness and Disease page 15**

-Exposing the Great Bottled Water Scam

# -Soda consumption linked with metabolic syndrome 

-Antiretroviral Prophylaxis for Occupational Exposure to HIV

-Does Consuming Red Meat Increase Risk of Breast Cancer?

-AHA Releases Statement on Physical Activity Interventions

...and more

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

American College of Obstetricians and Gynecologists

-Prevention of Deep Vein Thrombosis and Pulmonary Embolism

-Sexual Misconduct

-Nalbuphine Hydrochloride Use for Intrapartum Analgesia

-Expert Testimony

-Brand Versus Generic Oral Contraceptives

##### American Family Physician

-Screening and Treatment for Sexually Transmitted Infections in
Pregnancy

-Recommendations for Preconception Care

-Turner Syndrome: Diagnosis and Management

-Varenicline (Chantix) for Smoking Cessation

-CDC Publishes Statement on Cough and Cold Medications in Children

...and more

**Agency for Healthcare Research and Quality**

-Women: Stay Healthy at Any Age, Your Checklist for Health

-Today\'s teen smokers more likely to engage in risky behaviors than
teens in the 1990s

-Inadequate communication of mammogram results may prevent benefits from
screening

-Prophylactic antibiotics are more timely if given in the operating room

-Some diabetes drugs offer important advantages, though similar glucose
control

...and more

**Ask a Librarian**

### Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

**Breastfeeding**

-Progress toward achieving Healthy People 2010 objective for
breastfeeding

-Cup feeding not be recommended over bottle feeding as a supplement to
breastfeeding

-Despite the benefits of early breastfeeding, many women find it
difficult and painful

-New IHS Breast feeding Family Support web page: Have pictures to share?

-What to do when Mom says, "My newborn likes the bottle better."

**CCC Corner Digest**

\-[Within the Hidden Epidemic: STDs and HIV/AIDS Among
AI/AN](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_AOM.cfm)

\-[American Indian / Alaska Native population has the shortest timeline
HIV to
AIDS](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Coll.cfm)

\-[VBAC: Smaller attributable risk than previously
reported](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23ob)

\-[LEEP doubles risk of preterm delivery: Patients need to be
informed](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23gyn)

\-[Physical Activity Alone May Not Reduce Obesity in
Children](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23child)

\-[Teratogenicity of SSRIs\--serious concern or much ado about
little?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23chrIll)

\-[Management of Herpes in Pregnancy: Practice
Bulletin](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23acog)

\-[Scopus ™: A New
Database](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23AskLib)

\-[What to do when: Mom says, "My newborn likes the bottle
better."](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23breast)

\-[IHS-ACF DV Project: Conference CD: Patient Education, Safety
Planning,
etc....](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23dv)

\-[Waiting until the menses to start hormonal contraceptives: Needless
Obstacle](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23fp)

\-[Can oral or sublingual misoprostol be used for postpartum
hemorrhage?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23faq)

\-[Integrated case management software application
release](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23it)

\-[Maternal survival redux: a view from Malawi - Failure of
justice](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23ih)

\-[Who needs liquor stores when parents will
do?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23alert)

\-[Taking a harder line on blood
transfusions](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23headlines)

\-[Nausea and Vomiting in
Pregnancy](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23mmtour)

\-[Hormone Replacement Therapy Linked to Ovarian
Cancer ](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23menopause)

\-[Midwifery's approach to pre-labor SROM supported by professional
organization's
journal](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23MidWives)

\-[The evolution of management of Actinomyces on a Pap
report](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23navajo)

\-[Health Care Without Harm: Nurses Take
Action](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23nurseCorner)

\-[Preconception Health of Women Delivering Live-Born Infants ---
Oklahoma,
2000--2003](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23okie)

\-[Anemia in Pregnancy: The Common to the Unusual -- including IV
therapy](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23periPicks)

\-[Chronic Renal Disease: How is Primary Care
Effected?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23pcf)

\-[Updated Screening for Chlamydial Infection Recommendations,
USPSTF](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23std)

\-[(How) can we prevent type 2
diabetes?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23stillW)

\-[Why do Native American women have the poorest 5-year survival for
breast
cancer?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23wheadlines)

**Domestic Violence**

Sexual assault among American Indian/Alaska Native women

**Elder Care News**

-\'What Older Women Want\' launches new website for doctors and
patients: New Website

-A fall management program improves care and reduces use of physical
restraints

-Certain resident and facility characteristics and medications increase
the risk of fractures

**Family Planning**

#### -Various Implantable Contraceptives Equally Effective in Preventing Pregnancy {#various-implantable-contraceptives-equally-effective-in-preventing-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

-Oral Contraceptives Today: Changes, Challenges, Risks, and Benefits

**Featured Website**

# New Online Training Tool Available for Treatment of Adolescents with HIV

**Frequently asked questions**

Moderate morning sickness only partially responding to doxylamine and
pyridoxine

**Indian Child Health Notes**

-First prophylaxis for infective endocarditis has been written using
evidenced based guidelines. The difference is significant.

-RPMS Immunization Package: Version 8.2 coming this summer

-Substance abuse in Native American communities

**Information Technology**

-Save 750 mega watts/hour per year: It is easy

-iCare Training

International Health

Sex, Soap & Social Change - The Sabido Methodology

Arsenic exposure during pregnancy with fetal loss and infant death in
Bangladesh

#### MCH Alert

-Preconception brochure released

-School based programs decrease rates of violence among adolescents

#### MCH Headlines

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

-Toolkit Supports Efforts in Native Communities to Prevent FAS Disorders

-Sister Study seeks more Native women 

-One size doesn\'t fit all: Helmet Safety Poster

-Get Your Head in the Game

...and more

#### Medical Mystery Tour

#### Nausea and Vomiting in Pregnancy {#nausea-and-vomiting-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -HPV-16/18 Vaccination Should Not Be Used to Treat Prevalent Infections 

-Overactive Bladder in a Menopausal Woman With Complicating Conditions

######### -[Management of Depression and Premenstrual Dysphoria in a Woman Planning Pregnancy](http://mp.medscape.com/cgi-bin1/DM/y/hBVwo0Ou5N60Dzc0Imkv0Gq)

-Management of Premenstrual Dysphoric Disorder Throughout the Ages

\-[Premenstrual Syndrome/Premenstrual Dysphoric Disorder Treatment: Oral
Contraceptives](http://mp.medscape.com/cgi-bin1/DM/y/hBUaW0Ou5N60Dzc0Imkv0G4)

**Menopause Management**

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

-Hormone Therapy Safer in Younger Women? A Best Evidence Review

-Caffeine Reduces Cognitive Decline in Women

-Treatment Options for Insomnia

-NAMS Position Statement on Estrogen and Progestogen in Postmenopausal
Women

...and more

**Midwives Corner**

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

-Skin-to-skin care with the father after cesarean: Effect on crying and
prefeeding behavior

-Midwifery's approach to pre-labor SROM supported by professional
organization's journal

**Navajo News**

Evaluation of the pregnant patient for non-obstetric surgery

**Nurses Corner**

-Nursing education scholarship opportunities

#### -Behavioral and Social Sciences Research: National Assoc. of Clinical Nurse Specialists {#behavioral-and-social-sciences-research-national-assoc.-of-clinical-nurse-specialists .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Companion Animals and Human Health Risk: Animal Bites and Rabies {#companion-animals-and-human-health-risk-animal-bites-and-rabies .Style-Heading-4-+-Arial-14-pt-Underline}

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

-STD Treatment Guidelines - Personal Digital Assistant Version

-Perinatal Group B Streptococcal Disease After Universal Screening
Recommendations

**Oklahoma Perspective**

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

Osteoporosis

-Lifestyle Intervention and BMD in Adolescent Girls

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

-SSRI Use in Older Women Linked to Accelerated Hip Bone Loss

-Effects of the phytoestrogen genistein on bone metabolism in
osteopenia: RCT

Patient Education

-Women\'s Health Booklets

#### -STIs in Pregnancy: Protecting Yourself and Your Baby {#stis-in-pregnancy-protecting-yourself-and-your-baby .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Monitoring Your Blood Pressure at Home {#monitoring-your-blood-pressure-at-home .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Monitoring Your Blood Sugar at Home {#monitoring-your-blood-sugar-at-home .Style-Heading-4-+-Arial-14-pt-Underline}

-Insomnia: What You Should Know

...and more

Perinatology Picks

-Nausea and Vomiting of Pregnancy

-Miscarriage risk from amniocentesis performed for abnormal maternal
serum screening

-Evidence base of predictive markers and therapies (eg, progesterone)
for preterm birth

-Noninherited risk factors and congenital cardiovascular defects: AHA /
AAP statement

-1^st^ trimester US of the nasal bone may improve Down syndrome
screening

...and more

Primary Care Discussion Forum

Chronic Kidney Disease: CKD is Part of Primary Care! Starts September 4,
2007

STD Corner

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

-Sexual Assertiveness among Adolescent Girls: Initiation, Refusal, and
Protective Behaviors

-Sexually Transmitted Infections in Preadolescent Children

#### -Screening for Chlamydial Infection: USPSTF Recommendation Statements {#screening-for-chlamydial-infection-uspstf-recommendation-statements .Style-Heading-4-+-Arial-14-pt-Underline}

# -Home screening for sexually transmitted diseases in high-risk young women: RCT

...and more

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

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

-Regular and Diet Soft Drinks Linked To Increase In Risk Factors For
Heart Disease

#### -Very Low Birth Weight Is Associated With Impaired Glucose {#very-low-birth-weight-is-associated-with-impaired-glucose .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-APN scope of practice: colonoscopy?

-Templates for Protocols and Procedures for Maternity Services 2nd
Edition

###### Save the Dates: Upcoming events of interest page 68

#### What's new on the ITU MCH web pages page 68

New Breastfeeding Family Support webpage, Indian Health

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

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

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

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

Women are more likely to die than men after surgery. A new study
suggests it may be due to blood transfusion-related immunosuppression.
Women tend to have lower hematocrit and hemoglobin than men and
therefore are more likely to receive transfusions during surgery.
Indeed, the study of Michigan Medicare patients found that women
undergoing CABG were 3.4 times as likely to have received blood as men
and generally received more units of blood (11.6 vs. 8.1), after
accounting for factors such as age, race, and coexisting medical
conditions. Patients who received transfused blood were nearly three
times more likely to develop an infection than patients who did not
(14.6 vs. 4.9 percent).

The prevalence of infection increased with the number of units (U)
received during hospitalization from 13.6 percent for 1 to 4 U and 25.3
percent for 5 to 49 U to 30.8 percent for 50 to 99 U and 33.3 percent
for 100 U or more. The risk of mortality attributable to female sex was
13.9 percent, but was no longer significant when adjusted for blood
transfusion. Also, patients who received a transfusion were 5.6 times
more likely to die within 100 days after surgery than those who did not
receive a transfusion.

The risks of transmission of various infectious agents from allogeneic
transfusion (from another individual with compatible blood type) are
generally low. However, the presence of foreign leukocytes in donor
blood may suppress the immune system of the recipient. Patients who have
received nonleukoreduced blood are at increased risk of postoperative
infections and multiorgan failure, explain the Michigan researchers.

The authors note that the United States has not adopted a universal
leukoreduction policy and that by 2003, an estimated 70 percent of the
nation\'s blood supply was leukoreduced. However, their findings were
based on analysis of Medicare files of 9,218 Michigan patients
hospitalized for CABG surgery from July 1, 1997 through September 22,
1998. The study was supported in part by the Agency for Healthcare
Research and Quality (HS11540).

Rogers AM et al Allogeneic blood transfusions explain increased
mortality in women after coronary artery bypass graft surgery December
2006 *American Heart Journal* 152, pp. 1028-1034

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17161047>

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

**Postoperative infection is increased with allogeneic blood during
surgery also**

While most of our patients are not involved with CABG, per se, many of
our inpatients are involved with other surgical procedures, e. g.,
cesarean delivery, vaginal delivery with repairs, or gynecologic
surgery.

The immunosuppressive activity of allogeneic blood has been known since
the studies on renal allograft survival were published in the 1970s.
Increasing attention has been directed towards the impact of the
immunosuppressive effect of allogeneic blood (particularly the leukocyte
component) on postoperative infection, tumor recurrence, and nosocomial
infection in critically ill patients. This phenomenon has been termed
\"transfusion-related immunomodulation\" (TRIM).

**Nosocomial infections**

The evidence that postoperative infection is increased in patients
receiving allogeneic blood during surgery is compelling, though not
absolute, as are the data implicating the leukocyte as the \"culprit\".

In a review of the records of 416 consecutive patients undergoing
coronary artery bypass at one medical center, the 64 patients developing
postoperative pneumonia and/or wound infection received a significantly
higher volume of allogeneic plasma than those not developing infection
(mean ± SE: 957 ± 181 versus 321 ± 40 mL, respectively). However, on
multivariate analysis, which included 25 confounding variables (eg,
repeated surgery, endotracheal intubation, time on bypass pump), the
association between infection and volume of infused allogeneic plasma
was no longer statistically significant.

One study compared the incidence of postoperative infection in 50
patients receiving two or three allogeneic transfusions to that in 34
patients treated with autologous transfusions. Infection was much less
frequent with autologous transfusions (three versus 32 percent).

Another report found that the incidence of postoperative infection was
much lower in patients treated with leukocyte-depleted blood (two versus
23 percent with whole blood). Patients receiving whole blood had
decreased natural killer cell function that may have contributed to the
development of infection.

Several meta-analyses have been performed using slightly different
approaches and have yielded conflicting results. Therefore, it is
premature at this time to recommend routine use of leukocyte- depleted
blood in order to diminish the risk of postoperative infections.

In summary, I am not suggesting that we abandon the successful use of
leukoreduction to prevent complications of blood transfusion. Rather I
submit that we need to be more circumspect each time we consider a
transfusion in our post procedure patients. The risk of post procedure
infection and even mortality need to be considered along with the other
known risks of contamination with infectious agents, e. g., HIV,
hepatitis, etc....when counseling our patients.

**Other resources**

**HLA and ABO sensitization and desensitization in renal
transplantation, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=renltran/6633>

**Leukoreduction to prevent complications of blood transfusion,
UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=transfus/4868>

Taylor RW et al Red blood cell transfusions and nosocomial infections in
critically ill patients. Crit Care Med. 2006 Sep;34(9):2302-8

Michalopoulos A et al Frequency, characteristics, and predictors of
microbiologically documented nosocomial infections after cardiac
surgery. Eur J Cardiothorac Surg. 2006 Apr;29(4):456-60

Shorr AF; Jackson WL Transfusion practice and nosocomial infection:
assessing the evidence. Curr Opin Crit Care. 2005 Oct;11(5):468-72.

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

#### Michael Engel, ANMC {#michael-engel-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

#### The spread of obesity in a large social network over 32 years {#the-spread-of-obesity-in-a-large-social-network-over-32-years-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions. {#conclusions-network-phenomena-appear-to-be-relevant-to-the-biologic-and-behavioral-trait-of-obesity-and-obesity-appears-to-spread-through-social-ties.-these-findings-have-implications-for-clinical-and-public-health-interventions. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Christakis NA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Christakis NA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), [Fowler JH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fowler JH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus). The spread of obesity in a large social network over 32 years. [N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Jul 26;357(4):370-9. {#christakis-na-fowler-jh.-the-spread-of-obesity-in-a-large-social-network-over-32-years.-n-engl-j-med.-2007-jul-263574370-9. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17652652**](http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17652652) {#httpwww.ncbi.nlm.nih.govsitesentrezcmdretrievedbpubmedlist_uids17652652 .Style-Heading-4-+-Arial-14-pt-Underline}

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

Scott Giberson, HQE

**2007 National HIV Prevention Conference**

December 2-5, 2007

Atlanta, Georgia

Center for Disease Control and Prevention

<http://www.2007nhpc.org/conferenceinfo.asp>

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

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

### **2008-09 Packer Fellowships: Deadline Extended**

#### On behalf of the Australian Government Department of Health and Ageing, The Commonwealth Fund invites applications for the 2008-09 Packer Policy Fellowships. The deadline for receipt of applications for the 2008-09 fellowships has been extended to October 1, 2007.  The Packer Policy Fellowships offer a unique opportunity for outstanding, mid-career U.S. professionals\--academics, clinicians, decision makers in managed care and other private health care organizations, federal and state health officials, and journalists\--to spend up to 10 months in Australia conducting research and working with leading Australian health policy experts on issues relevant to both countries. In addition to undertaking original policy research, fellows will participate in seminars and policy briefings, which include meetings with senior officials at the Commonwealth and State levels, Ministerial officers, service providers, academics, and other stakeholders in the public and private sectors. At the end of their tenure, fellows produce a report and present project findings to senior government officials and policy experts at a final reporting seminar.  The Fellowships provide up to \$55,000 (AUD) for six to ten months in Australia. In addition, a supplemental allowance is provided to fellows accompanied by a spouse and/or children.  For the Packer Policy Fellowships brochure and further information on the 2008-09 Packer Policy Fellowships, or to obtain an application, please see [**http://www.commonwealthfund.org/fellowships/**](http://www.commonwealthfund.org/fellowships/) Contact Robin Osborn, The Commonwealth Fund at: telephone: 212-606-3809 or email: [**ro@cmwf.org**](mailto:ro@cmwf.org) {#on-behalf-of-the-australian-government-department-of-health-and-ageing-the-commonwealth-fund-invites-applications-for-the-2008-09-packer-policy-fellowships.-the-deadline-for-receipt-of-applications-for-the-2008-09-fellowships-has-been-extended-to-october-1-2007.-the-packer-policy-fellowships-offer-a-unique-opportunity-for-outstanding-mid-career-u.s.-professionals--academics-clinicians-decision-makers-in-managed-care-and-other-private-health-care-organizations-federal-and-state-health-officials-and-journalists--to-spend-up-to-10-months-in-australia-conducting-research-and-working-with-leading-australian-health-policy-experts-on-issues-relevant-to-both-countries.-in-addition-to-undertaking-original-policy-research-fellows-will-participate-in-seminars-and-policy-briefings-which-include-meetings-with-senior-officials-at-the-commonwealth-and-state-levels-ministerial-officers-service-providers-academics-and-other-stakeholders-in-the-public-and-private-sectors.-at-the-end-of-their-tenure-fellows-produce-a-report-and-present-project-findings-to-senior-government-officials-and-policy-experts-at-a-final-reporting-seminar.-the-fellowships-provide-up-to-55000-aud-for-six-to-ten-months-in-australia.-in-addition-a-supplemental-allowance-is-provided-to-fellows-accompanied-by-a-spouse-andor-children.-for-the-packer-policy-fellowships-brochure-and-further-information-on-the-2008-09-packer-policy-fellowships-or-to-obtain-an-application-please-see-httpwww.commonwealthfund.orgfellowships-contact-robin-osborn-the-commonwealth-fund-at-telephone-212-606-3809-or-email-rocmwf.org .Style-Heading-4-+-Arial-14-pt-Underline}

**Shannon S. Myers, PIMC**

**2008 APN/PA conference is already being planned. Any ideas?**

I would like to thank those of you who attended the IHS APN/PA
conference this year in Scottsdale, Arizona and would like to encourage
participation in 2008. That being said, I have reviewed the comments and
suggestions from attendees and would like to share and get some feedback
please.

This year the conference was held May 21 -- May 25^th^ at the Chaparral
Suites Hotel in Scottsdale, Arizona. Most people liked the venue so that
will remain the same for next year. The timing seems to be the bigger
issue. There were numerous suggestions that we move the conference back
to June due to graduations, end of the school year activities, etc.

Another recurrent suggestion was that there be more workshops. For
example, suturing, casting/splinting, EKG, ACLS, etc. Would you want
these concurrently, in the evenings, late afternoon, at the end of the
conference (perhaps the Saturday?).

Of course there were some who wanted more plenary sessions and there
were others who wanted more concurrent sessions so we will strive to
find the happy medium.

Please remember that this is YOUR conference and we are happy to take
any and all suggestions to make it a better experience and one that is
worthwhile to you.

Please let me know your thoughts regarding June 2008 dates as well as
other suggestions that you might have. We need to block the hotel and
conference rooms within the next few weeks!

Best regards,

Shannon S. Myers FNP-C

Program Director - Native American Breast Care Clinic

APN Representative - IHS NNLC

<Shannon.Myers@ihs.gov>

**Chuck North, HQE**

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

I am pleased to announce the appointment of Dr. Ann Bullock as the new
Chief Clinical Consultant for Family Medicine (CCC-FM).

Dr. Bullock has impressive skills in administration, communication,
teaching, and clinical practice. She has served in a national leadership
capacity with the Diabetes Program and is a well known speaker. Her
understanding and ability to articulate the nature of family medicine
and the underlying theoretical framework of modern clinical practice are
key factors in this appointment.

It is privilege for me as the Acting Chief Medical Officer and as the
CCC-FM for the past 23 years to pass on to Dr. Bullock the lead roll in
coordinating activities that we have developed in family medicine. Dr.
Bullock will continue directing the Advances in Indian Health CME
course, consulting with service units and tribes nationally, and serving
on national committees and work groups. Dr. Bullock previously served as
the first Deputy CCC-FM and is currently the Medical Director for the
Eastern Band of Cherokee.

Dr. Bullock embodies the purpose of the National Council of Chief
Clinical Consultants "...to improve American Indian and Alaska Native
(AI/AN) health and wellness by providing experienced, expert discipline
and specialty medical support and consultation to the Director, IHS,
Tribes, Urban Indian health care programs and others involved in AI/AN
health care."

Please join me in welcoming Dr. Bullock in her new role.

You can learn more about Ann at her CCC website

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-fp.asp>

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

**Ann Bullock new coordinator for the Primary Care Discussion Forum**

Dr. Bullock has also just taken over the reins as coordinator for the
Primary Care Discussion Forum from Neil Murphy, CCC-OBG after 4 years.
The Primary Care Discussion Forum is a highly successful quarterly
discussion forum of hot topics with a national subject matter expert
moderator.

You can directly converse with the moderator, or with any of you
colleagues, on topics of immediate import. The actual discussion, and
the many resources that are developed out of the discussion, are then
captured and posted at the Primary Care Discussion Forum website.

Primary Care Discussion Forum

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm>

Please see the many topics that have been discussed to date.

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm>

**Robert Pittman, HQE**

**Questions about DEA or controlled substance policy**

Do you have questions about DEA or controlled substance policy?  The DEA
Practitioner's Manual and Pharmacist's Manual are excellent resources
for answering these questions.  Theses manuals are available on the DEA
website at <http://www.deadiversion.usdoj.gov/pubs/manuals/index.html>

Please direct questions to <robert.pittman@ihs.gov>

**Rosalyn Singleton, ANMC**

**Immunization errors in Tdap and DTaP vaccine administration: ALERT
-VACCINE UPDATE**

There have been numerous vaccine administration errors involving Tdap
and DTaP vaccines being given at the wrong ages. 

DTaP - is the pediatric vaccine licensed for children \<7 years old.

Tdap  - is the Td booster (Td) with acellular pertussis (ap).  Tdap is
licensed for 11-64 year old persons.  Tdap should not be administered to
children \<11 years old or adults 65 years and older.

Td - is the Td booster - it should only be given to:  

(1) persons 65 years and older,  

\(2\) children aged 7 through 10 years,

(3) pregnant women who require a tetanus booster because it\'s been over
10 years since their last Td, and 

\(4\) people contraindicated for pertussis vaccine. 

Check your vials before giving Tdap, DTaP or Td - make sure that you are
giving the correct vaccine.  

ALSO, please ensure these vaccines are correctly entered in RPMS.

Thank you.

Rosalyn Singleton

<ris2@cdc.gov>

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

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

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

AUTHORS\' CONCLUSIONS: Antiplatelet agents, largely low-dose aspirin,
have moderate benefits when used for prevention of pre-eclampsia and its
consequences. Further information is required to assess which women are
most likely to benefit, when treatment is best started, and at what
dose.

Duley L et al Antiplatelet agents for preventing pre-eclampsia and its
complications. [Cochrane Database Syst Rev.  2007;
(2):CD004659](http://www.medscape.com/medline/publicationbrowser/123?pmid=17443552)

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443552**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443552)

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

**Just cut and paste this into your facility's guidelines**

After 12 weeks GA consider prophylactic low dose ASA 81 mg po every day
to prevent or decrease severe pre-eclampsia and/or IUGR. Indicated if:

-Chronic hypertension

-Past severe preeclampsia

-Renal Disease

-Pre-existing diabetes

**Guidelines for management of hypertensive disorders in pregnancy**

<http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/HYPERT12004.doc>

**Oral Antidiabetic Agents in Pregnancy and Lactation: A Paradigm
Shift**

CONCLUSIONS: Neither glyburide nor metformin has caused developmental
toxicity in humans. Glyburide has been used for the treatment of
gestational diabetes, and metformin has been used in women with PCOS who
eventually became pregnant. Additional trials are needed to better
define the benefits and risks of oral antidiabetic agents in pregnancy.
Metformin, glyburide, and glipizide appear to be compatible with
breast-feeding.

[Feig
DS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Feig DS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Briggs
GG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Briggs GG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Koren
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Koren G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Oral antidiabetic agents in pregnancy and lactation: a paradigm shift?
[Ann
Pharmacother.](javascript:AL_get(this, 'jour', 'Ann Pharmacother.');)
2007 Jul;41(7):1174-80

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17535842>

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

**Glyburide is first line agent, while metformin is awaiting more data**

Studies of glyburide and glipizide have found little or no transfer of
these drugs across the placenta, whereas metformin and rosiglitazone
cross readily. Animal studies have found no evidence to suggest that
glyburide, glipizide, metformin, or rosiglitazone are teratogenic. In
gestational diabetes, glyburide was safe and efficacious; however,
16-19% of women failed to achieve optimal glucose control. No
developmental toxicity in infants was observed when metformin was used
before and throughout pregnancy in women with polycystic ovarian
syndrome (PCOS). Some of the studies involving patients with type 2
diabetes had methodological problems. A randomized controlled trial
using metformin for gestational diabetes in the third trimester is
underway. The human information is inadequate to evaluate the risk of
glipizide or the thiazolidinediones in pregnancy. In breast milk, 3
studies measured nonsignificant amounts of metformin and one study was
unable to detect either glyburide or glipizide.

**Preventive Approach to Cutting Cesarean Delivery Rates Appears
Feasible**

CONCLUSIONS: A preventive approach to reducing cesarean deliveries may
be possible. This study found that practitioners who often used
risk-guided, prostaglandin-assisted labor induction had a lower cesarean
delivery rate without increases in rates of other adverse birth
outcomes. Randomized controlled trials of this method of care are
warranted.

[Nicholson
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nicholson JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Yeager
DL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Yeager DL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Macones
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Macones G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
A preventive approach to obstetric care in a rural hospital: association
between higher rates of preventive labor induction and lower rates of
cesarean delivery. [Ann Fam
Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2007
Jul-Aug;5(4):310-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17664497>

**No advantage to bulking agent after primary repair of obstetric anal
sphincter injury**

RESULTS: Pain scores were similar in the two treatment groups; but
incontinence in the immediate postnatal period was more frequent with
the two preparations compared with lactulose alone (32.86% versus
18.18%, P = 0.03).

CONCLUSIONS: This study does not support routine prescribing of a
stool-bulking agent in addition to a laxative in the immediate postnatal
period for women who have sustained anal sphincter injury at vaginal
delivery.

Eogan M et al Randomised clinical trial of a laxative alone versus a
laxative and a bulking agent after primary repair of obstetric anal
sphincter injury. [BJOG.  2007;
114(6):736-40](http://www.medscape.com/medline/publicationbrowser/123?pmid=17516966)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17516966>

Prepregnancy obesity, overweight raise risk of birth defects

CONCLUSIONS: To our knowledge, this is the first population-based study
of its scale to examine prepregnancy obesity and a range of structural
birth defects. These results suggest a weak to moderate positive
association of maternal obesity with 7 of 16 categories of birth defects
and a strong inverse association with gastroschisis. The mechanisms
underlying these associations are not yet understood but may be related
to undiagnosed diabetes.

[Waller
DK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Waller DK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Prepregnancy obesity as a risk factor for structural birth
defects. [Arch Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2007 Aug;161(8):745-50

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17679655**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17679655)

Stillbirth: A risk marker for premature mortality among parous women

RESULTS: During the study period, 78 (13.1%) mothers with stillbirths
died, compared with 1,518 (6.2%) women without stillbirth (crude hazard
ratio 2.08, 95% confidence interval \[CI\] 1.65-2.61). The mortality
risk remained significantly increased after adjustments for
sociodemographic variables, maternal diseases at pregnancy, placental
abruption, and preeclampsia (hazard ratio 1.40, 95% CI 1.11-1.77).
Stillbirth was associated with an increased risk of death from coronary
heart disease (adjusted hazard ratio 2.00, 95% CI 1.02-3.93), all
circulatory (adjusted hazard ratio 1.70, 95% CI 1.02-2.84) and renal
(adjusted hazard ratio 4.70, 95% CI 1.47-15.0) causes. Stratifying by
country of origin, an increased risk was evident particularly among
women of North African origin (all-cause mortality, adjusted hazard
ratio 2.47, 95% CI 1.69-3.63).

CONCLUSION: Stillbirth may be a risk marker for premature mortality
among parous women.

Calderon-Margalit R et al Late stillbirths and long-term mortality of
mothers. [Obstet Gynecol.  2007;
109(6):1301-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17540801) 

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17540801**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17540801)

ACOG Releases Guidelines on the Use of SSRIs During Pregnancy

Depression is common among women of reproductive age, and approximately
one in 10 women will have major or minor depression during pregnancy and
the postpartum period. Selective serotonin reuptake inhibitors (SSRIs)
are commonly used to treat depression. Recently, however, there have
been concerns that the use of paroxetine (Paxil) during the first
trimester of pregnancy may increase the risk of congenital cardiac
malformations. Additionally, transient neonatal complications, including
mild respiratory distress, transient tachypnea of the newborn, a weak
cry, and poor tone, have been associated with SSRI use late in
pregnancy. To address this risk, the American College of Obstetricians
and Gynecologists (ACOG) has released a committee opinion on the use of
SSRIs during pregnancy, which was published in the December 2006 issue
of *Obstetrics & Gynecology*.

Although the benefits of paroxetine may outweigh the risks, physicians
should consider whether a patient could have a relapse of depression if
treatment is discontinued. Left untreated, depression could increase the
risk of low weight gain, sexually transmitted diseases, and alcohol and
substance abuse.

Therefore, ACOG recommends that the use of SSRIs and selective
norepinephrine reuptake inhibitors be individualized in pregnant women.
If possible, however, paroxetine should be avoided in patients who are
pregnant or want to become pregnant. If a patient is exposed to
paroxetine in early pregnancy, fetal echocardiography should be
considered.

The committee recommends that treatment decisions involve the expertise
of a mental health professional to assess the benefits. Ideally, this
shared decision making would occur before the patient becomes pregnant.
However, because nearly 50 percent of pregnancies are unplanned,
preconception care for women with depression may not always occur.

When discontinuing paroxetine, patients should follow the instructions
outlined in the prescribing information, because abrupt discontinuation
may lead to withdrawal symptoms.

Treatment with selective serotonin reuptake inhibitors during pregnancy.
ACOG Committee Opinion No. 354. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:1601--3.bstet Gynecol
2006;108:1597--99 Practice Guideline Briefs

<http://www.aafp.org/afp/20070815/practice.html>

Cesarean Delivery Rate Hits All-time High

Nearly one in three live births in the United States in 2005 was a
cesarean delivery, marking the highest U.S. total cesarean rate ever
reported. Since 1996, the total cesarean rate has increased by 46
percent, driven by an increase in the percentage of women having a first
cesarean delivery and a decrease in the percentage of women delivering
vaginally after a previous cesarean delivery. Cesarean rates vary
considerably among states but tend to be lower in the Western mountain
states and upper Midwest, and higher in the Southeast and East.

QuickStats: Percentage of All Live Births by Cesarean Delivery \-\--
National Vital Statistics System, United States, 2005 MMWR April 20,
2007 / 56(15);373

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a8.htm>

**Antibiotics for asymptomatic bacteriuria in pregnancy reduces
pyelonephritis**

AUTHORS\' CONCLUSIONS: Antibiotic treatment is effective in reducing the
risk of pyelonephritis in pregnancy. A reduction in low birthweight is
consistent with current theories about the role of infection in adverse
pregnancy outcomes, but this association should be interpreted with
caution given the poor quality of the included studies.

Smaill F; Vazquez JC Antibiotics for asymptomatic bacteriuria in
pregnancy. [Cochrane Database Syst Rev.  2007;
(2):CD000490](http://www.medscape.com/medline/publicationbrowser/123?pmid=17443502) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443502>

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

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

This will be part of an issue of the CMAJ that will feature other
articles on HPV as well. There is also a larger policy paper available
(19 pages) \-- casting a critical lens on the HPV vaccine \-- now
available on the CWHN website: [www.cmaj.ca](http://www.cmaj.ca/)

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

by A. Lippman PhD, R. Melnychuk PhD, C. Shimmin BJ, and colleagues
(August 1, 2007)

[http://www.cmaj.ca/cgi/rapidpdf/cmaj.070944v1](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.cmaj.ca/cgi/rapidpdf/cmaj.070944v1)

**HPV, Vaccines, and Gender: Policy Considerations**

This paper reflects data available to us as of June 2007. Studies about
HPV vaccines \-- their efficacy, safety, place in women\'s health care
\-- and research on the implications of initiating vaccination programs
continue to evolve. They will be adding new references and links to some
of this work as best we can in the future.\
[http://www.cwhn.ca/resources/cwhn/hpv-brief.html](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.cwhn.ca/resources/cwhn/hpv-brief.html)

**Liquid prep no more accurate than conventional cytology, RCT**

CONCLUSION: Liquid based cytology showed no statistically significant
difference in sensitivity to conventional cytology for detection of
cervical intraepithelial neoplasia of grade 2 or more. More positive
results were found, however, leading to a lower positive predictive
value. A large reduction in unsatisfactory smears was evident

Ronco G et al Accuracy of liquid based versus conventional cytology:
overall results of new technologies for cervical cancer screening:
randomised controlled trial. [BMJ.  2007;
335(7609):28](http://www.medscape.com/medline/publicationbrowser/123?pmid=17517761)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17517761>

**Laparoscopically guided minilaparotomy reduces intraperitoneal
spillage**

CONCLUSION: Laparoscopically guided minilaparotomy, when compared with
laparoscopy, is able to reduce intraperitoneal spillage in patients with
presumably benign large adnexal masses, with minimal increase in patient
short- and long-term discomfort. Because data regarding the importance
of intraperitoneal spillage during surgery for benign and malignant
pathologies, as well as rupture rates during traditional laparotomy, are
scarce, traditional laparotomy still represents the standard treatment.
In women desiring a minimally invasive strategy for large cysts,
laparoscopically guided minilaparotomy should be considered. LEVEL OF
EVIDENCE: I.

[Panici
PB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Panici PB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Laparoscopy compared with laparoscopically guided minilaparotomy
for large adnexal masses: a randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Aug;110(2 Pt 1):241-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17666596&dopt=AbstractPlus>

Quadrivalent HPV Recombinant Vaccine (Gardasil) for the Prevention of
Cervical Cancer

Bottom Line

The HPV vaccine is safe and effective in preventing genital warts and
cervical changes that may lead to cervical cancer, and it is recommended
as part of the vaccination series in females 11 to 12 years of age. It
can be given to females as young as 9 or 10 years of age, and catch-up
vaccination is recommended for those who are 13 to 26 years of age.

STEPS New Drug Reviews
[**http://www.aafp.org/afp/20070815/steps.html**](http://www.aafp.org/afp/20070815/steps.html)

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

**Educate parents about new pre-adolescent vaccine recommendations**

The 2007 Pre-Teen Vaccine Campaign was recently launched to increase
awareness among parents and health professionals of three new vaccine
recommendations for 11- and 12-year-olds. The campaign, launched on
August 1, 2007, by the Centers for Disease Control and Prevention (CDC)
to coincide with National Immunization Month, also encourages parents to
schedule a routine check-up for their children in this age group, as
recommended by the American Academy of Pediatrics, the American Academy
of Family Physicians, and CDC. The campaign provides educational
materials (including posters and flyers in English and in Spanish) about
vaccines to protect children from meningitis, tetanus, diphtheria,
whooping cough, and cervical cancer. It also includes outreach to
mainstream and ethnic media, as well as information on the creation of
partnerships with national and state organizations that reach parents
and health professionals.
[[http://www.cdc.gov/vaccines/spec-grps/preteens-adol/07gallery/default.htm]{.underline}](http://www.cdc.gov/vaccines/spec-grps/preteens-adol/07gallery/default.htm)

**Fact sheet focus on adolescent HPV vaccination issues and
opportunities**

The HVP Vaccine: Background, Coverage & Benefits presents selected
information for state public health leaders and others on the risk
imposed by genital human papillomavirus (HPV) infection and the vaccine
manufactured to protect against it. The fact sheet, produced by the
Association of Maternal and Child Health Programs, provides statistics
on HPV infection and adverse health outcomes, recent research to test
the efficacy of the HPV vaccine, and recommendations for health care
practice. Other topics include (1) HPV vaccine administration and
coverage for costs and (2) controversies surrounding legislation to
mandate the HPV vaccine as a school-entrance requirement. Opportunities
offered by the introduction of the HPV vaccine in addressing the more
comprehensive health needs of adolescents are also discussed.
[[http://www.amchp.org/aboutamchp/publications/HPV.pdf]{.underline}](http://www.amchp.org/aboutamchp/publications/HPV.pdf)

**Tobacco Smoke Exposure During Pregnancy Increases Blood Pressure in
Infants **

Infant offspring of mothers who had smoked during pregnancy had 5.4 mm
Hg (95% CI: 1.2 to 9.7; P=0.01) higher systolic blood pressure levels
than offspring of mothers who were not exposed to tobacco smoke in
pregnancy, taking account of birth weight, infant age, gender,
nutrition, and age of mother. No associations were found between
maternal exposure to tobacco smoke in pregnancy and diastolic blood
pressure. A positive association between maternal exposure to tobacco
smoke and heart rate was largely explained by confounding. It can be
concluded that maternal exposure to tobacco smoke in pregnancy has a
substantial increasing effect on systolic blood pressure in early
infancy.

[Geerts
CC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Geerts CC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Tobacco Smoke Exposure of Pregnant Mothers and Blood Pressure in
Their Newborns. Results from the Wheezing Illnesses Study Leidsche Rijn
Birth Cohort.
[Hypertension.](javascript:AL_get(this, 'jour', 'Hypertension.');) 2007
Jul 30

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17664395>

**Body composition, physical activity and insulin sensitivity in
adolescents**

The study shows that in a community sample of African American
adolescents, both adiposity \[percentage of total body fat\] and lack of
PEPA \[play-equivalent physical activity\] are independent statistical
determinants of low insulin sensitivity and high insulin secretion, both
of which have been identified as precursors of type 2 diabetes..

The authors found that

\* The models with BMI z score and time spent in PEPA as the sole
determinants of insulin sensitivity explained 21% of the variance in
insulin sensitivity and 18% of the variance in insulin secretion. Models
in which BMI z score was replaced by other measures of adiposity (BMI,
percentage of total body fat, or percentage of abdominal fat) provided
an almost identical fit.

\* When PEPA was replaced by mean daily activity counts (to evaluate the
importance of cumulative activity rather than intensity), insulin
sensitivity was no longer significantly correlated with activity but
only with BMI z score. Insulin secretion, on the other hand, was
correlated with mean daily activity counts and BMI z score.

\* Neither PEPA nor BMI z score was a significant independent
determinant of DI.

In our study, both adiposity and level of physical activity were
significant, independent determinants of insulin sensitivity and
secretion, such that a high degree of adiposity and a small proportion
of time spent in PEPA were associated with low insulin sensitivity and
high insulin secretion.

Snitker S, Le KY, Hager E, et al. 2007. Association of physical activity
and body composition with insulin sensitivity in a community sample of
adolescents. Archives of Pediatrics & Adolescent Medicine
161(7):677-683.
[[http://archpedi.ama-assn.org/cgi/content/abstract/161/7/677?etoc]{.underline}](http://archpedi.ama-assn.org/cgi/content/abstract/161/7/677?etoc)

Updated AAP Guidelines on Newborn Screening and Tx for Congenital
Hypothyroidism

Unrecognized congenital hypothyroidism leads to mental retardation.
Newborn screening and thyroid therapy started within 2 weeks of age can
normalize cognitive development. The primary thyroid-stimulating hormone
screening has become standard in many parts of the world. However,
newborn thyroid screening is not yet universal in some countries.
Initial dosage of 10 to 15 µg/kg levothyroxine is recommended. The goals
of thyroid hormone therapy should be to maintain frequent evaluations of
total thyroxine or free thyroxine in the upper half of the reference
range during the first 3 years of life and to normalize the serum
thyroid-stimulating hormone concentration to ensure optimal thyroid
hormone dosage and compliance.

Improvements in screening and therapy have led to improved developmental
outcomes in adults with congenital hypothyroidism who are now in their
20s and 30s. Thyroid hormone regimens used today are more aggressive in
targeting early correction of thyroid-stimulating hormone than were
those used 20 or even 10 years ago. Thus, newborn infants with
congenital hypothyroidism today may have an even better intellectual and
neurologic prognosis. Efforts are ongoing to establish the optimal
therapy that leads to maximum potential for normal development for
infants with congenital hypothyroidism.

Remaining controversy centers on infants whose abnormality in neonatal
thyroid function is transient or mild and on optimal care of very low
birth weight or preterm infants. Of note, thyroid-stimulating hormone is
not elevated in central hypothyroidism. An algorithm is proposed for
diagnosis and management.

Physicians must not relinquish their clinical judgment and experience in
the face of normal newborn thyroid test results. Hypothyroidism can be
acquired after the newborn screening. When clinical symptoms and signs
suggest hypothyroidism, regardless of newborn screening results, serum
free thyroxine and thyroid-stimulating hormone determinations should be
performed

Newborn Screening for Congenital Hypothyroidism: Recommended Guidelines

Pediatrics 91: 1203-1209.
<http://pediatrics.aappublications.org/cgi/content/abstract/117/6/2290>

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

**Exposing the Great Bottled Water Scam**

This Newsletter issue tackles our first environmental health topic:
Americans' addiction to bottled water, and it's ramifications for the
environment. I think you will be as shocked as I was when you learn more
about the size and speed of growth of this social phenomenon. It's hard
to believe we are drinking more bottled water than milk, coffee or beer;
only carbonated soft drinks are more popular!

[http://consortiumlibrary.org/hsis/about/newsletters/Jul07.pdf](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://consortiumlibrary.org/hsis/about/newsletters/Jul07.pdf)

# Soda consumption linked with metabolic syndrome 

CONCLUSIONS: In middle-aged adults, soft drink consumption is associated
with a higher prevalence and incidence of multiple metabolic risk
factors.

[Dhingra
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dhingra R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Soft drink consumption and risk of developing cardiometabolic risk
factors and the metabolic syndrome in middle-aged adults in the
community.
[Circulation.](javascript:AL_get(this, 'jour', 'Circulation.');) 2007
Jul 31;116(5):480-8.

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17646581**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17646581)

Antiretroviral Prophylaxis for Occupational Exposure to HIV

Clinical Question: Cochrane for Clinicians

Should health care workers with occupational exposure to human
immunodeficiency virus (HIV) receive postexposure antiretroviral
prophylaxis?

Evidence-Based Answer

There are no controlled trials of postexposure prophylaxis for persons
with occupational exposure to body fluids potentially infected with HIV.
Based on one case-control study, individually selected antiretroviral
therapy, initiated soon after exposure, is recommended. Treatment should
continue for four weeks or until the source body fluid tests HIV
negative.

Practice Pointers

The Centers for Disease Control and Prevention (CDC) defines
occupational HIV exposure as a percutaneous injury (e.g., a needlestick,
cut from a sharp object) or contact of mucous membranes or nonintact
skin (e.g., skin that is chapped, abraded, or affected by dermatitis)
with blood, tissue, or other body fluids that are potentially infected
with HIV.1 Potentially infectious fluids include cerebrospinal,
synovial, pleural, peritoneal, pericardial, and amniotic fluids. Feces,
nasal secretions, saliva, sputum, sweat, tears, urine, and vomit are not
considered infectious unless visibly bloody. The risk of HIV
transmission is approximately 0.3 percent after percutaneous exposure to
infected blood and 0.9 percent after mucous membrane exposure. The risk
of transmission varies with the type of exposure and infected fluid.1

The authors of this Cochrane review searched the literature from 1985 to
May 2005. They found no controlled trials of postexposure prophylaxis,
but found one case-control study. Participants were health care workers
with occupational, percutaneous exposure to HIV-infected blood. Patients
in the case group had HIV seroconversion temporally associated with the
exposure and no other reported concurrent exposure to HIV. Participants
in the control group remained seronegative six months after exposure.

An increased risk of HIV transmission was associated with deep injury,
visible blood on the device, procedures involving a needle placed in the
source patient\'s blood vessel, and terminal illness in the source
patient. Zidovudine (Retrovir) use after exposure was associated with a
lower risk of HIV transmission. Most patients took at least 1,000 mg of
zidovudine per day starting within four hours of exposure.

Of 58 health care workers who received postexposure prophylaxis, 71
percent had adverse effects, including nausea (24 percent), fatigue (22
percent), emotional distress (13 percent), and headache (9 percent).
Although patients who received a three-drug regimen reported more
adverse effects, the drop-out rate in these patients was similar to that
in patients who received fewer drugs.

The CDC recommends postexposure prophylaxis for health care workers who
have occupational exposure to blood infected with HIV, and it recommends
considering prophylaxis for health care workers with percutaneous
injuries from sources with unknown HIV status who have risk factors or
who are from settings where HIV exposure is likely.1 Prophylaxis should
be initiated as soon as possible, ideally within hours, not days, of
exposure. Therapy should continue for four weeks or until the source
blood tests HIV negative. Selection of prophylactic medication should be
determined in consultation with an expert in antiretroviral therapy and
HIV transmission.1

Young TN, Arens FJ, Kennedy GE, Laurie JW, Rutherford G. Antiretroviral
post-exposure prophylaxis (PEP) for occupational HIV exposure. Cochrane
Database Syst Rev 2007;(1):CD002835.

If expert consultation is not immediately possible, more information on
prophylactic regimens is available at
[**http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm)
and
[**http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html**](http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html)

**Does Consuming Red Meat Increase Risk of Breast Cancer?**

Results: Of the 90,659 participants, 1,021 were diagnosed with invasive
premenopausal breast carcinoma. Although a high intake of red meat was
weakly associated with an overall increased risk of breast cancer, there
was a strong association between the intake of red meat and the risk of
hormone-receptor-positive breast cancer. Consuming red meat was not
associated with an increased risk of hormone-receptor-negative breast
cancer. Compared with participants who ate three or fewer servings of
red meat per week, women who had four to five servings per week had a
relative risk of breast cancer of 1.14. Those who consumed more than 1.5
servings per day had a relative risk of 1.97.

Conclusion: Red meat intake was associated with a higher risk of
hormone-receptor-positive breast cancer in premenopausal women.
Moreover, a higher consumption of red meat during the study increased
the risk of invasive hormone-receptor-positive breast cancer. Because
few breast cancer risk factors are modifiable, the authors add that
these findings have potential health implications in preventing breast
cancer.

Cho E, et al. Red meat intake and risk of breast cancer among
premenopausal women. Arch Intern Med November 13, 2006;166:2253-9.
<http://www.aafp.org/afp/20070801/tips/3.html>

**AHA Releases Statement on Physical Activity Interventions**

Sedentary behavior is a common but preventable cause of death, and an
inverse linear relationship exists between all-cause mortality and
volume of physical activity. Further, regular physical activity
decreases the risk of type 2 diabetes, osteoporosis, obesity,
cardiovascular disease, breast cancer, depression, colon cancer, and
falls in older adults. Because of these numerous health benefits,
various public health guidelines have been published on the recommended
volume and intensity of physical activity. Therefore, the American Heart
Association (AHA) has released a summary statement on physical activity
interventions, which appears in the December 12, 2006, issue of
*Circulation*.

The AHA\'s aim was to provide an overview of the population-wide impact
of physical activity interventions. Along with the U.S. Surgeon General,
the Centers for Disease Control and Prevention, and the American College
of Sports Medicine, the AHA recommends at least 30 minutes a day of at
least moderate-intensity physical activity on most, and preferably all,
days of the week. However, despite the known benefits of physical
activity, only 32 percent of adults and 66 percent of children and
adolescents actively pursue leisure-time physical activity. It is
imperative that interventions be designed to promote the adoption and
maintenance of active lifestyles in large numbers of the population.

In older adults, behaviorally oriented approaches have shown short-term
effectiveness, but long-term maintenance is not as strong. However, even
brief interventions (three to 10 minutes) in health care settings have
been shown to increase physical activity in patients over a short-term
follow-up. Written prescriptions as well as verbal advice may also
enhance the effectiveness of interventions. However, interventions that
include behavioral strategies (e.g., goal setting, self-monitoring,
feedback, problem solving) and supervised exercise are more effective
than advice alone.

Adults spend most of their time at work, so the workplace has been
examined as a setting for physical activity interventions. Although the
evidence supporting workplace interventions is mixed, stronger evidence
suggests that individually tailored behavior-change programs sent
through e-mail or the Internet are effective. Incentives for positive
behavior that do not undermine work productivity also may be considered.

Interventions delivered through the television, the telephone, the
Internet, or in print have produced short-term behavioral change among
adults, and they may be effective in the longer term. Creating new
opportunities for physical activity for recreational and transportation
purposes (e.g., improving sidewalks, creating bike trails) may also
prove to be valuable.

Research on physical activity interventions has grown, but employing
these transdisciplinary efforts will be important for promoting physical
activity among children and adults. The AHA notes that, to be
successful, these efforts must be collaborative in theory development,
hypothesis generation, study design, implementation, and analysis

<http://circ.ahajournals.org/cgi/content/full/114/24/2739>

Western diet linked to colon cancer recurrence

CONCLUSIONS: Higher intake of a Western dietary pattern may be
associated with a higher risk of recurrence and mortality among patients
with stage III colon cancer treated with surgery and adjuvant
chemotherapy. Further studies are needed to delineate which components
of such a diet show the strongest association.

[Meyerhardt
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Meyerhardt JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Association of dietary patterns with cancer recurrence and
survival in patients with stage III colon cancer.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2007 Aug
15;298(7):754-64

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17699009**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17699009)

**Herbal and Dietary Supplements for Treatment of Anxiety Disorders**

Use of complementary and alternative medicine has increased over the
past decade. A variety of studies have suggested that this use is
greater in persons with symptoms or diagnoses of anxiety and depression.
Data support the effectiveness of some popular herbal remedies and
dietary supplements; in some of these products, particularly kava, the
potential for benefit seems greater than that for harm with short-term
use in patients with mild to moderate anxiety. Inositol has been found
to have modest effects in patients with panic disorder or
obsessive-compulsive disorder. Physicians should not encourage the use
of St. John\'s wort, valerian, Sympathyl, or passionflower for the
treatment of anxiety based on small or inconsistent effects in small
studies. Although the evidence varies depending on the supplement and
the anxiety disorder, physicians can collaborate with patients in
developing dietary supplement strategies that minimize risks and
maximize benefits. Am Fam Physician 2007;76:549-56.

<http://www.aafp.org/afp/20070815/549.html>

**Fibromyalgia**

Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with
generalized tender points. It is a multisystem disease characterized by
sleep disturbance, fatigue, headache, morning stiffness, paresthesias,
and anxiety. Nearly 2 percent of the general population in the United
States suffers from fibromyalgia, with females of middle age being at
increased risk. The diagnosis is primarily based on the presence of
widespread pain for a period of at least three months and the presence
of 11 tender points among 18 specific anatomic sites. There are certain
comorbid conditions that overlap with, and also may be confused with,
fibromyalgia. Recently there has been improved recognition and
understanding of fibromyalgia. Although there are no guidelines for
treatment, there is evidence that a multidimensional approach with
patient education, cognitive behavior therapy, exercise, physical
therapy, and pharmacologic therapy can be effective. Am Fam Physician
2007;76:247-54.

<http://www.aafp.org/afp/20070715/247.html>

**Home Monitoring of Glucose and Blood Pressure (see Patient
Education)**

Home monitoring of blood glucose and blood pressure levels can provide
patients and physicians with valuable information in the management of
diabetes mellitus and hypertension. Home monitoring allows patients to
play an active role in their care and may improve treatment adherence
and clinical outcomes. Glucose meters currently on the market produce
results within 15 percent of serum blood glucose readings and offer a
variety of features. Although the data are somewhat conflicting, home
glucose monitoring has been associated with improved glycemic control
and reduced long-term complications from diabetes. These effects are
more pronounced in patients who take insulin. Home blood pressure values
predict target organ damage and cardiovascular outcomes better than
values obtained in the office. Home blood pressure measurements are also
effective at detecting borderline hypertension and monitoring the
effectiveness of antihypertensive drugs. Validated arm cuffs are the
preferred blood pressure devices for home use. Information from home
monitoring should always be used in conjunction with that from regular
office visits and other data to make appropriate therapeutic decisions.
Am Fam Physician 2007;76:255-60, 261, 262.

<http://www.aafp.org/afp/20070715/255.html>

**Cytochrome P450 Metabolism on Drug Response, Interactions, and Adverse
Effects**

Cytochrome P450 enzymes are essential for the metabolism of many
medications. Although this class has more than 50 enzymes, six of them
metabolize 90 percent of drugs, with the two most significant enzymes
being CYP3A4 and CYP2D6. Genetic variability (polymorphism) in these
enzymes may influence a patient\'s response to commonly prescribed drug
classes, including beta blockers and antidepressants. Cytochrome P450
enzymes can be inhibited or induced by drugs, resulting in clinically
significant drug-drug interactions that can cause unanticipated adverse
reactions or therapeutic failures. Interactions with warfarin,
antidepressants, antiepileptic drugs, and statins often involve the
cytochrome P450 enzymes. Knowledge of the most important drugs
metabolized by cytochrome P450 enzymes, as well as the most potent
inhibiting and inducing drugs, can help minimize the possibility of
adverse drug reactions and interactions. Although genotype tests can
determine if a patient has a specific enzyme polymorphism, it has not
been determined if routine use of these tests will improve outcomes. Am
Fam Physician 2007;76:391-6

<http://www.aafp.org/afp/20070801/391.html>

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

#### ACOG, American College of Obstetricians and Gynecologists {#acog-american-college-of-obstetricians-and-gynecologists .Style-Heading-4-+-Arial-14-pt-Underline}

**Prevention of Deep Vein Thrombosis and Pulmonary Embolism**

Summary of Conclusions and Recommendations

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

-   Alternatives for thromboprophylaxis for moderate-risk patients
    include the following:

    1.  Graduated compression stockings placed before initiation of
        surgery and continued until the patient is fully ambulatory

    2.  Pneumatic compression devices placed before the initiation of
        surgery and continued until the patient is fully ambulatory

    3.  Unfractionated heparin (5,000 units) administered subcutaneously
        2 hours before surgery and every 12 hours after surgery until
        discharge

    4.  Low molecular weight heparin (dalteparin 2,500 antifactor-Xa
        units, or enoxaparin 40 mg) administered subcutaneously, 12
        hours before surgery and once a day postoperatively until
        discharge

```{=html}
<!-- -->
```
-   Alternatives for prophylaxis for high-risk patients undergoing
    gynecologic surgery include the following:

    1.  Pneumatic compression devices placed before surgery and
        continued until hospital discharge

    2.  Unfractionated heparin (5,000 units) administered subcutaneously
        2 hours before surgery and every 8 hours postoperatively and
        continued until discharge

    3.  Low molecular weight heparin (dalteparin 5,000 antifactor-Xa
        units or enoxaparin 40 mg) administered subcutaneously, 12 hours
        before surgery and once daily postoperatively until discharge

The following recommendations are based on limited scientific evidence
(Level C).

-   Alternatives for prophylaxis for highest-risk patients include the
    following:

    1.  Combination prophylaxis (such as the combination of pneumatic
        compression and either low-dose unfractionated heparin or low
        molecular weight heparin)

    2.  Consideration of continuing low molecular weight heparin
        prophylaxis as an outpatient for up to 28 days postoperatively

```{=html}
<!-- -->
```
-   If administration of low molecular weight heparin 12 hours before
    surgery is impractical, initial dosing should commence 6--12 hours
    postoperatively.

-   Low-risk patients who are undergoing gynecologic surgery do not
    require specific prophylaxis other than early ambulation.

-   Until more evidence is accumulated, patients undergoing laparoscopic
    surgery should be stratified by risk category (and provided
    prophylaxis) similar to patients undergoing laparotomy.

Prevention of Deep Vein Thrombosis and Pulmonary Embolism. ACOG Practice
Bulletin No. 84. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2007; 110:429-40.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666620>

**Sexual Misconduct**

ABSTRACT: The physician-patient relationship is damaged when there is
either confusion regarding professional roles and behavior or clear lack
of integrity that allows sexual exploitation and harm. Sexual contact or
a romantic relationship between a physician and a current patient is
always unethical, and sexual contact or a romantic relationship between
a physician and a former patient also may be unethical. The request by
either a patient or a physician to have a chaperone present during a
physical examination should be accommodated regardless of the
physician\'s sex. If a chaperone is present during the physical
examination, the physician should provide a separate opportunity for
private conversation. Physicians aware of instances of sexual misconduct
have an obligation to report such situations to appropriate authorities.

Sexual Misconduct. ACOG Committee Opinion No. 373. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:441-4

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666621>

**Nalbuphine Hydrochloride Use for Intrapartum Analgesia**

ABSTRACT: Nalbuphine hydrochloride (formerly marketed as Nubain) is a
synthetic opioid agonist-- antagonist analgesic commonly used for
intrapartum analgesia. Concerns for fetal safety have been raised by one
pharmaceutical company that no longer manufactures this agent
([www.fda.gov/medwatch/safety/2005/aug_PI/Nubain_PI.pdf](http://www.acog.org/cgi-shl/leaving.pl?http://www.fda.gov/medwatch/safety/2005/aug_PI/Nubain_PI.pdf)).
To date there are insufficient data to support these concerns or to
recommend any change in the administration of this medication for
analgesia in labor.

Nalbuphine Hydrochloride Use for Intrapartum Analgesia. ACOG Committee
Opinion No. 376. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2007; 110:449.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666624>

**Expert Testimony**

ABSTRACT: It is the duty of obstetricians and gynecologists who testify
as expert witnesses on behalf of defendants, the government, or
plaintiffs to do so solely in accordance with their judgment on the
merits of the case. Obstetrician--gynecologists must limit testimony to
their sphere of medical expertise and must be prepared adequately. They
must make a clear distinction between medical malpractice and medical
maloccurrence. The acceptance of fees that are greatly disproportionate
to those customary for professional services can be construed as
influencing testimony given by the witness, and it is unethical to
accept compensation that is contingent on the outcome of litigation.

Expert Testimony. ACOG Committee Opinion No. 374. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:445--6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666622>

**Brand Versus Generic Oral Contraceptives**

ABSTRACT:The U.S. Food and Drug Administration considers generic and
brand name oral contraceptive (OC) products clinically equivalent and
interchangeable. The American College of Obstetricians and Gynecologists
supports patient or clinician requests for branded OCs or continuation
of the same generic or branded OCs if the request is based on clinical
experience or concerns regarding packaging or compliance, or if the
branded product is considered a better choice for that individual
patient.

Brand Versus Generic Oral Contraceptives. ACOG Committee Opinion No.
375. American College of Obstetricians and Gynecologists. Obstet Gynecol
2007; 110:447--8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666623>

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

**Screening and Treatment for Sexually Transmitted Infections in
Pregnancy**

Many sexually transmitted infections are associated with adverse
pregnancy outcomes. The Centers for Disease Control and Prevention
recommends screening all pregnant women for human immunodeficiency virus
infection as early as possible. Treatment with highly active
antiretroviral therapy can reduce transmission to the fetus. Chlamydia
screening is recommended for all women at the onset of prenatal care,
and again in the third trimester for women who are younger than 25 years
or at increased risk. Azithromycin has been shown to be safe in pregnant
women and is recommended as the treatment of choice for chlamydia during
pregnancy. Screening for gonorrhea is recommended in early pregnancy for
those who are at risk or who live in a high-prevalence area, and again
in the third trimester for patients who continue to be at risk. The
recommended treatment for gonorrhea is ceftriaxone 125 mg
intramuscularly or cefixime 400 mg orally. Hepatitis B surface antigen
and serology for syphilis should be checked at the first prenatal visit.
Benzathine penicillin G remains the treatment for syphilis. Screening
for genital herpes simplex virus infection is by history and examination
for lesions, with diagnosis of new cases by culture or polymerase chain
reaction assay from active lesions. Routine serology is not recommended
for screening. The oral antivirals acyclovir and valacyclovir can be
used in pregnancy. Suppressive therapy from 36 weeks\' gestation reduces
viral shedding at the time of delivery in patients at risk of active
lesions. Screening for trichomoniasis or bacterial vaginosis is not
recommended for asymptomatic women because current evidence indicates
that treatment does not improve pregnancy outcomes. Am Fam Physician
2007;76:265-70, 272.

<http://www.aafp.org/afp/20070715/265.html> **(see Patient Education)**

**Recommendations for Preconception Care**

Every woman of reproductive age who is capable of becoming pregnant is a
candidate for preconception care, regardless of whether she is planning
to conceive. Preconception care is aimed at identifying and modifying
biomedical, behavioral, and social risks through preventive and
management interventions. Key components include risk assessment, health
promotion, and medical and psychosocial interventions. Patients should
formulate a reproductive life plan that outlines personal goals about
becoming pregnant based on the patient\'s values and resources.
Preconception care can be provided in the primary care setting and
through activities linked to schools, workplaces, and the community. Am
Fam Physician 2007;76:397-400

<http://www.aafp.org/afp/20070801/397.html>

**Turner Syndrome: Diagnosis and Management**

Turner syndrome occurs in one out of every 2,500 to 3,000 live female
births. The syndrome is characterized by the partial or complete absence
of one X chromosome (45,X karyotype). Patients with Turner syndrome are
at risk of congenital heart defects (e.g., coarctation of aorta,
bicuspid aortic valve) and may have progressive aortic root dilatation
or dissection. These patients also are at risk of congenital lymphedema,
renal malformation, sensorineural hearing loss, osteoporosis, obesity,
diabetes, and atherogenic lipid profile. Patients usually have normal
intelligence but may have problems with nonverbal, social, and
psychomotor skills. Physical manifestations may be subtle but can
include misshapen ears, a webbed neck, a broad chest with widely spaced
nipples, and cubitus valgus. A Turner syndrome diagnosis should be
considered in girls with short stature or primary amenorrhea. Patients
are treated for short stature in early childhood with growth hormone
therapy, and supplemental estrogen is initiated by adolescence for
pubertal development and prevention of osteoporosis. Almost all women
with Turner syndrome are infertile, although some conceive with assisted
reproduction. Am Fam Physician 2007;76:405-10
<http://www.aafp.org/afp/20070801/405.html>

Varenicline (Chantix) for Smoking Cessation

Varenicline (Chantix) is a selective alpha4-beta2 neuronal nicotinic
acetylcholine receptor partial agonist approved as an aid to smoking
cessation therapy. This receptor is believed to play a significant role
in reinforcing the effects of nicotine and in maintaining smoking
behaviors. The agonist effect of varenicline at the nicotinic receptor
is approximately half that of nicotine, which may lessen craving and
withdrawal without inducing dependence. In theory, stimulation of the
nicotinic receptor by a partial agonist could provide enough stimulation
to reduce craving and withdrawal while competitively blocking the
binding of smoked nicotine.1,2 Varenicline represents a new approach to
smoking cessation by mitigating some of the satisfying and reinforcing
aspects of smoking.

Safety

Studies of more than 4,500 patients have established a favorable safety
profile for varenicline, and there have been no reports of abuse or
serious safety issues. Because varenicline is excreted by the kidney,
the manufacturer recommends reducing the dosage in patients with
impaired renal function. There are currently no known drug interactions,
and the safety of varenicline used in combination with other smoking
cessation therapies has not been established. Because smoking may alter
the metabolism of some medications (e.g., warfarin \[Coumadin\],
theophylline), dosing adjustments of other drugs the patient is
receiving may need to be made upon smoking cessation.2 Varenicline is
U.S. Food and Drug Administration pregnancy category C.

Tolerability

The most common adverse effect associated with varenicline is nausea,
which occurs in about 30 percent of patients taking the maintenance
dose. Although the nausea is not typically severe, it may persist for
the duration of treatment in a small number of persons. Other common
adverse effects that occur in more than 10 percent of patients include
headache, insomnia, abnormal dreams, and flatulence. The rate of
discontinuation because of side effects was 12 percent for patients
receiving varenicline compared with 10 percent for patients receiving
placebo.2

Effectiveness

Varenicline has been compared with placebo in five studies3-7 and with
sustained-release bupropion (Wellbutrin SR) in three studies of healthy
persons highly motivated to quit smoking.5-7 On average, patients had
been smokers for 20 to 25 years and reported smoking approximately one
pack per day. Most patients (approximately 90 percent) had tried to quit
at least once.3-7 Based on these studies, about 20 percent of patients
taking varenicline will be continuously abstinent from smoking one year
after treatment compared with less than 10 percent of patients taking
placebo. In other words, for approximately every nine patients treated
with varenicline instead of placebo, one additional patient will remain
abstinent for one year.3-7

Varenicline treatment seems to be as effective or more effective than
treatment with sustained-release bupropion. Two studies found that
treatment with varenicline had similar results to treatment with
bupropion,5,7 and one study found better abstinence rates with
varenicline at one year compared with bupropion (23.0 versus 14.6
percent, respectively).6

Varenicline has not been compared with nicotine replacement therapy or
for use in combination with other smoking cessation therapies. Also,
varenicline has not been studied in patients who use tobacco products
other than cigarettes or in patients who have significant
cardiopulmonary disease or psychological disorders.

Price

A one-month supply of varenicline will cost approximately \$120 for the
maintenance dose. This is more than the cost of generic
sustained-release bupropion (\$116) but less than the cost of Wellbutrin
SR (\$150). Patients who smoke one pack per day will spend an average of
\$130 per month on cigarettes.8

Simplicity

Varenicline is taken with a full glass of water twice daily after a
meal. The initial dose is 0.5 mg once daily starting one week before the
quit date and increased to 0.5 mg twice daily after three days. At the
start of the second week, the dose is increased to 1 mg twice daily and
continued for 12 weeks. If a patient relapses during the 12 weeks of
therapy or after therapy is completed, he or she should be encouraged to
make another attempt to quit once contributing factors have been
identified and addressed. Patients unable to tolerate the side effects
at the maintenance dose should have the dose lowered temporarily or
permanently. Patients with pronounced renal dysfunction (creatinine
clearance less than 30 mL per minute \[0.5 mL per second\]) should take
half the usual dose.2

Bottom Line

For every nine highly-motivated patients who use varenicline instead of
placebo, one will not be smoking one year later. Although the cost of
therapy is a limitation (total cost is approximately \$360 for a
three-month course), the easy dosage titration, lack of drug
interactions, and favorable side-effect profile make varenicline an
appealing alternative to sustained-release bupropion for smoking
cessation

[**http://www.aafp.org/afp/20070715/steps.html**](http://www.aafp.org/afp/20070715/steps.html)

**CDC Publishes Statement on Cough and Cold Medications in Children**

Cough and cold medications that contain expectorants, antihistamines,
nasal decongestants, and cough suppressants are commonly used to treat
symptoms of upper respiratory infection in children younger than two
years. However, in 2004 and 2005 an estimated 1,519 children younger
than two years were treated in U.S. emergency departments for adverse
events associated with use of cough and cold medications. Although the
U.S. Food and Drug Administration (FDA) has approved the use of cough
and cold medications for children two years and older, no FDA-approved
dosing recommendations exist for children younger than two years.
Therefore, the Centers for Disease Control and Prevention (CDC) has
released a statement on the risks of cough and cold medications in
children younger than two years. The statement appears in the January
12, 2007, issue of *Morbidity and Mortality Weekly Report*.

Evidence of the effectiveness of cough and cold medications in children
younger than two years is limited. Systematic reviews of controlled
trials involving these medications conclude that they are no more
effective than placebo in reducing symptoms of upper respiratory tract
infection. Additionally, cough suppressants containing codeine
(Robitussin AC) and dextromethorphan (Delsym) have not been proven
effective, and their use could lead to potential adverse events in
children younger than two years.

Health care professionals should advise parents against administering
cough and cold medications to children younger than two years because of
the risk of toxicity and the lack of dosing recommendations. As an
alternative to pseudoephedrine (Sudafed) and other nasal decongestants,
physicians should recommend clearing the child\'s nasal congestion with
a rubber suction bulb or using saline nose drops or a cool-mist
humidifier to soften secretions.

Health care professionals also should be aware of the risks of serious
illness or fatal overdose in children younger than two years who have
been given cough and cold medications. To avoid overdose, physicians
should prescribe these medications with extreme caution and should
inquire about additional over-the-counter medications the child is being
given. Additionally, physicians should be certain that parents
understand the importance of administering these medications only as
directed and are aware of the risk of an overdose if the child is given
additional medications with the same ingredients.

<http://www.aafp.org/afp/20070715/practice.html>

Common Problems in Endurance Athletes

Endurance athletes alternate periods of intensive physical training with
periods of rest and recovery to improve performance. An imbalance caused
by overly intensive training and inadequate recovery leads to a
breakdown in tissue reparative mechanisms and eventually to overuse
injuries. Tendon overuse injury is degenerative rather than
inflammatory. Tendinopathy is often slow to resolve and responds
inconsistently to anti-inflammatory agents. Common overuse injuries in
runners and other endurance athletes include patellofemoral pain
syndrome, iliotibial band friction syndrome, medial tibial stress
syndrome, Achilles tendinopathy, plantar fasciitis, and lower extremity
stress fractures. These injuries are treated with relative rest, usually
accompanied by a rehabilitative exercise program. Cyclists may benefit
from evaluation on their bicycles and subsequent adjustment of seat
height, cycling position, or pedal system. Endurance athletes also are
susceptible to exercise-associated medical conditions, including
exercise-induced asthma, exercise-associated collapse, and overtraining
syndrome. These conditions are treatable or preventable with appropriate
medical intervention. Dilutional hyponatremia is increasingly
encountered in athletes participating in marathons and triathlons. This
condition is related to overhydration with hypotonic fluids and may be
preventable with guidance on appropriate fluid intake during
competition. Am Fam Physician 2007;76:237-44

[**http://www.aafp.org/afp/20070715/237.html**](http://www.aafp.org/afp/20070715/237.html)

#### AHRQ, Agency for Healthcare Research and Quality  {#ahrq-agency-for-healthcare-research-and-quality .Style-Heading-4-+-Arial-14-pt-Underline}

**Women: Stay Healthy at Any Age, Your Checklist for Health**

The Agency for Healthcare Research and Quality (AHRQ) now has available
2 evidence-based checklists designed to help men and women understand
which medical checkup tests they need to stay healthy at any age. Each
list uses the US Preventive Services Task Force (USPSTF) recommendations
to inform patients about screening tests, preventive medicine, and other
healthy lifestyle behaviors.

You can download these checklists for distribution to your patients, by
clicking on:

Women: Stay Healthy at Any Age, Your Checklist for Health

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

Men: Stay Healthy at Any Age: Your Checklist for Health

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

 

**Today\'s teen smokers are more likely to engage in risky behaviors
than teens who smoked in the early nineties**

[http://www.ahrq.gov/research/jul07/0707RA3.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jul07/0707RA3.htm)

 

**Inadequate communication of mammogram results may prevent women from
fully benefiting from screening**

[http://www.ahrq.gov/research/jul07/0707RA6.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jul07/0707RA6.htm)

**Prophylactic antibiotics given to prevent surgical site infections are
more timely if given in the operating room**

[http://www.ahrq.gov/research/jun07/0607RA12.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun07/0607RA12.htm)

  

**While most diabetes drugs provide similar glucose control, some offer
important advantages**

[http://www.ahrq.gov/research/jul07/0707RA1.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jul07/0707RA1.htm)

**Mandatory limits on medical resident work hours may constrain hospital
house staff and affect patient outcomes and resource use**

[http://www.ahrq.gov/research/jul07/0707RA18.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jul07/0707RA18.htm)

 

**Incentives combined with peer counseling are a cost-effective way to
get adolescents to adhere to a tuberculosis control program**

[http://www.ahrq.gov/research/jun07/0607RA8.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun07/0607RA8.htm)

 

**Better outpatient care processes can improve the quality of life for
patients with chronic disease**

[http://www.ahrq.gov/research/jun07/0607RA11.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun07/0607RA11.htm)

 

**Risk factors can help predict which patients with hospital-acquired
urinary tract infections will develop blood infections**

[http://www.ahrq.gov/research/jun07/0607RA16.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun07/0607RA16.htm)

 

**Rate of childbirth-related hospital stays decreases for girls under
age 18**

[http://www.ahrq.gov/research/jun07/0607RA20.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun07/0607RA20.htm)

#### 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}

### **Prevent Fetal Alcohol Spectrum Disorders: A Toolkit**

A toolkit to help Native communities protect their children from the
harm caused by drinking alcohol during pregnancy is now available from
the Substance Abuse and Mental Health Services Administration.\
\
*The American Indian/Alaska Native/Native Hawaiian Resource Kit* is
designed to help mothers-to-be and their friends, relatives, health
professionals, and leaders understand and prevent fetal alcohol spectrum
disorders. FASD describes the range of effects that can occur in an
individual whose mother drank alcohol during pregnancy. These effects
may include physical, mental, behavioral, and/or learning disabilities
with possible lifelong implications.\
\
Each year, at least 40,000 babies are born with an FASD in the United
States, and Native communities have some of the highest rates. This new
resource will support prevention and treatment efforts in American
Indian, Alaska Native and Native Hawaiian communities.\
\
The kit, which was developed and reviewed by representatives from Native
communities and FASD experts, includes the following:

-   Current data and statistics on FASD

-   Fact sheets and brochures for women, men, youth and communities on
    how to prevent FASD and how to find help

-   Strategies for FASD education and prevention

-   Posters that can be copied and shared

-   *FASD\--The Basics*, a slide presentation for people with no prior
    knowledge of or experience with FASD

-   A CD with an electronic version of the entire resource kit

*The American Indian/Alaska Native/Native Hawaiian Resource Kit* is
available on the Web at
<http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702>.

Copies may be obtained free of charge by calling SAMHSA's Health
Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request
inventory number SMA07-4264.

#####  {#section-4}

#### Breastfeeding Suzan Murphy, PIMC {#breastfeeding-suzan-murphy-pimc .Style-Heading-4-+-Arial-14-pt-Underline}

**Progress toward achieving Healthy People 2010 objective for
breastfeeding**

Further research is needed to identify successful programs and policies
to support exclusive breastfeeding, especially among subgroups with the
lowest rates. Healthy People 2010 objectives for breastfeeding
initiation and duration were updated in 2007 to include two new
objectives on exclusive breastfeeding: (1) to increase the proportion of
mothers who exclusively breastfeed their infants through age 3 months to
60% and (2) to increase the proportion of mothers who exclusively
breastfeed their infants through age 6 months to 25%.

The authors found that

\* Among infants born in 2000, breastfeeding rates for the early
postpartum period, 6 months, and 12 months were 70.9%, 34.2%, and 15.7%,
respectively. For infants born in 2004, these rates had consistently
increased to 73.8%, 41.5%, and 20.9%, respectively.

\* Based on the revised questions, rates for exclusive breastfeeding
through ages 3 and 6 months were 30.5% and 11.3%, respectively, among
infants born in 2004.

\* Disparities were observed in rates of exclusive breastfeeding among
infants born in 2004. Rates of exclusive breastfeeding through age 3
months were lowest among black infants (19.8%) and among infants of
mothers ages 19 and younger (16.8%), those who had a high school
education or less than a high school education (22.9% and 23.9%,
respectively), those who were unmarried (18.8%), those who resided in
rural areas (23.9%), and those who had an income-to-poverty ratio of
less than 100% (23.9%).

Scanlon KS, Grummer-Strawn L, Shealy KR, et al. 2007. Breastfeeding
trends and updated national health objectives for exclusive
breastfeeding: United States, birth years 2000-2004. MMWR Weekly
56(30):760-763
[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a2.htm?s_cid=mm5630a2_e]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a2.htm?s_cid=mm5630a2_e)

**Cup feeding not be recommended over bottle feeding as a supplement to
breastfeeding**

AUTHORS\' CONCLUSIONS: Cup feeding cannot be recommended over bottle
feeding as a supplement to breastfeeding because it confers no
significant benefit in maintaining breastfeeding beyond hospital
discharge and carries the unacceptable consequence of a longer stay in
hospital.

[Flint
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Flint A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Cup feeding versus other forms of supplemental enteral feeding for
newborn infants unable to fully breastfeed. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Apr 18;(2):CD005092

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443570>

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

**Despite the benefits of early breastfeeding, many women find it
unexpectedly difficult and painful**
<http://www.ahrq.gov/research/may07/0507RA18.htm>

**New IHS Breast feeding Family Support web page: Have pictures to
share?**

When family and friends support breastfeeding,\
it makes the challenges easier.\
Your encouragement will touch a lifetime.

Tell mom that she is doing great.\
Let dad know that his patience is beautiful.\
Let the new family how proud you are of them.\
Praise grandparents/aunts/uncles/cousins/friends\
for their wonderful care and wisdom.

#### Give the new family a boost: 

-   Tackle some household chores

-   Bring a meal over

-   Change some diapers

-   Make the trip to the grocery store

-   Give the baby a bath

-   Take the new siblings to the park

-   Read a book or watch TV with the new siblings

-   Keep mom resting, bring the baby to her

If you have pictures to share, please email them to
[[suzan.murphy@ihs.gov]{.underline}](mailto:suzan.murphy@ihs.gov)

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

**What to do when Mom says, "My newborn likes the bottle better."**

Why does it happen?

In a normal, healthy newborn, bottle preference is usually from overuse
of a bottle and/or pacifier. However, it is helpful to rule out unusual
newborn issues that can effect sucking like a short frenulum or thrush.

What is the cause?

Formula or breast milk comes out of the bottle quickly, just a little
tug. Also, the plastic nipple can rub the roof of the mouth, stimulating
the suck. It is not much work for the baby - and there is no waiting for
let down. It is easy. Breastfeeding takes more work. Often, but not
always, a baby will begin to favor the bottle and avoid breastfeeding.
Unfortunately, it is hard to know which baby will be influenced by
frequent bottles/pacifiers.

In the first couple weeks, there is probably still time for the mom's
supply to bounce back. To get mom and baby back to breastfeeding:

Assure the mom that her baby is getting enough:

Have her count diaper changes - if her baby has least 6 in 24 hours, her
baby is probably has an adequate intake.

Check her baby's weight gain -- ½ oz -- 1 oz per day, 3.5 - 7 oz per
week is normal

Tell the mom to breastfeed about 2 hours -- 8 to 12 times in 24 hours.
The baby's suck muscles and mom's milk supply will get up to speed
together and the frequency will slow down within a couple days.

Discourage the "pump and feed" method -- it has a near 100% burn out
rate.

Tell the mom to praise her baby for sucking well. The baby knows mom's
happier voice and will respond appropriately.

Recommend less use of the bottle. If the bottle can be weaned down to
once or twice a day, the mom's milk supply will probably be protected.
Less is best in the first 4-6 weeks.

Suggest that the pacifier be avoided -- and saved for difficult times
like car trips with screaming a baby or challenging moments.

If it looks like it really is a supply issue, or the "bounce back" is
not happening, consider medication. Clinical studies indicate that
metoclopromide can increase milk supply in difficult situations. For
more information, refer to Thomas Hales' text, Medications and Mother's
Milk or sources like the San Diego Breastfeeding Coalition web page,
<http://www.breastfeeding.org/articles/reglan.html>.

If the baby won't latch, refer the mom to WIC or a Lactation Consultant.
It is OK to call us for over-the-phone-ideas at 1- 877-868-9473. It is
toll-free - best times are 7 am -- 10 pm, Mountain Standard Time.

What about extra fluids?

Clinical studies have not agreed with the common practice of encouraging
fluids to increase milk supply. Unfortunately the studies were small,
each with less than 30 participants, and did not correct for climate
issues -- such as excessive heat/cold, or the typical amount of outdoor
exposure the mother experienced. So while encouraging water is a healthy
practice, excessive fluids are not necessary. A reasonable
recommendation is to keep water nearby and drink to thirst.

Please note: If it is believed that a specific (safe) beverage will
help, it probably will. Confidence is a powerful tool with parenting,
especially breastfeeding.

**References**

Dusdieker LB et al. Prolonged maternal fluid supplementation in
breast-feeding. Pediatrics,

1990 Nov;86(5):737-40.

Morse JM et al. The effect of maternal fluid intake on breast milk
supply: a pilot study.

Canadian Journal of Public Health, 1992 May-Jun;83(3):213-6.

####  {#section-6 .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}

\-[Within the Hidden Epidemic: STDs and HIV/AIDS Among
AI/AN](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_AOM.cfm)

\-[American Indian / Alaska Native population has the shortest timeline
HIV to
AIDS](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Coll.cfm)

\-[VBAC: Smaller attributable risk than previously
reported](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23ob)

\-[LEEP doubles risk of preterm delivery: Patients need to be
informed](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23gyn)

\-[Physical Activity Alone May Not Reduce Obesity in
Children](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23child)

\-[Teratogenicity of SSRIs\--serious concern or much ado about
little?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23chrIll)

\-[Management of Herpes in Pregnancy: Practice
Bulletin](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23acog)

\-[Scopus ™: A New
Database](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23AskLib)

\-[What to do when: Mom says, "My newborn likes the bottle
better."](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23breast)

\-[IHS-ACF DV Project: Conference CD: Patient Education, Safety
Planning,
etc....](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23dv)

\-[Waiting until the menses to start hormonal contraceptives: Needless
Obstacle](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23fp)

\-[Can oral or sublingual misoprostol be used for postpartum
hemorrhage?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23faq)

\-[Integrated case management software application
release](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23it)

\-[Maternal survival redux: a view from Malawi - Failure of
justice](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23ih)

\-[Who needs liquor stores when parents will
do?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23alert)

\-[Taking a harder line on blood
transfusions](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23headlines)

\-[Nausea and Vomiting in
Pregnancy](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23mmtour)

\-[Hormone Replacement Therapy Linked to Ovarian
Cancer ](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23menopause)

\-[Midwifery's approach to pre-labor SROM supported by professional
organization's
journal](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23MidWives)

\-[The evolution of management of Actinomyces on a Pap
report](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23navajo)

\-[Health Care Without Harm: Nurses Take
Action](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23nurseCorner)

\-[Preconception Health of Women Delivering Live-Born Infants ---
Oklahoma,
2000--2003](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23okie)

\-[Anemia in Pregnancy: The Common to the Unusual -- including IV
therapy](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23periPicks)

\-[Chronic Renal Disease: How is Primary Care
Effected?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23pcf)

\-[Updated Screening for Chlamydial Infection Recommendations,
USPSTF](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23std)

\-[(How) can we prevent type 2
diabetes?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23stillW)

\-[Why do Native American women have the poorest 5-year survival for
breast
cancer?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23wheadlines)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_07.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_07.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v5_07.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-7 .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-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Domestic Violence Denise Grenier, Tucson / Rachel Locker, Warm Springs {#domestic-violence-denise-grenier-tucson-rachel-locker-warm-springs .Style-Heading-4-+-Arial-14-pt-Underline}

**Sexual assault among American Indian/Alaska Native women**

Colleagues:

The URL below will take you to the page on the National Public Radio
website featuring their story on sexual assault that they featured last
night on their news show "All Things Considered".  

Contact
[[Carolyn.Aoyama@ihs.gov]{.underline}](mailto:Carolyn.Aoyama@ihs.gov)

<http://www.npr.org/templates/story/story.php?storyId=12203114>

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

**\'What Older Women Want\' launches new website for doctors and
patients: New Website**

Urinary incontinence, memory loss and exercise top the list of older
women\'s unmet health needs and concerns

A Canadian study of older women\'s health needs and concerns published
in the Canadian Medical Association Journal and reported widely in the
media, has sparked a new website directed at both patients and health
practitioners: [[www.wowhealth.ca]{.underline}](../www.wowhealth.ca)

Known widely as \'WOW\' or the \'What Older Women Want\' study,
conducted by Drs. Cara Tannenbaum, Nancy Mayo and Francine Ducharme, the
study asked 5000 older women across Canada which of their health needs
they felt were not being met or addressed adequately by their health
practitioners.

Their answers surprised many in healthcare provision, since the key
topics the women highlighted were not concerned so much with critical
care concerns or disease treatment, but primary care and disease
prevention.

Among the top unmet concerns Canadian senior women mentioned were:
screening and treating urinary incontinence; counselling about memory
loss (or perceived memory loss); and exercise strategies to address
falls and functional decline.

\"Women were very satisfied with the care they were receiving to treat
their blood pressure and prevent heart attacks and stroke, but
emphasized gaps in care surrounding more \'taboo\' issues, such as
discussing urine or memory loss,\" says Dr. Tannenbaum, a Geriatrician
at the Institut universitaire de gériatre de Montréal, and lead author
of the WOW study.

\"It may be that women are uncomfortable talking about these issues with
their physicians because it is embasrassing, because they believe it is
a part of normal aging or because they are unaware that treatments
exist.\"

In order to address this gap in primary health provision and give older
women what they want, Dr. Tannenbaum teamed up with the Canadian
Women\'s Health Network and the Centre de recherche de l\'Institut
universitaire de gériatrie de Montréal to create the WOW website.

The website contains a portal for health consumers that provides health
information on the three unmet health needs of older Canadian women:

urinary incontinence, memory loss and exercise. The information is
clear, straight-forward and easy-to-read, with engaging illustrations
and diagrams. The focus is on prevention, with tips on diet, lifestyle
changes and exercise; treatment options are also provided.

But the onus is not left only up to older women to seek and address
their own health needs. The WOW website also has a portal for health
practitioners, outlining the kinds of questions that practitioners
should be asking their older female patients routinely, and the ways in
which they can provide prevention and improvement strategies to their
patients for urinary incontinence, memory loss, as well as the
particular exercise needs of older women.

\"When asked, clinicians admitted that they often do not pursue these
issues because there is rarely enough time during the medical visit and
they often get the impression that their patients are reluctant to talk
about it,\" states Dr. Tannenbaum. \"That is why it is so important that
we get the message out that something like urinary incontinence can be
effectively treated in up to 75% of patients with simple behavioural
techniques, and that clinicians should routinely screen for it.\"

.

\"The goal with the WOW website was to find an effective means to
translate the research we have done on older women\'s health concerns
into tangible results. We want women to be able to articulate their
needs and clinicians to learn what questions they ought to be asking,\"
Dr.

Tannenbaum adds.

The WOW website is the essential first step to make sure that older
women\'s unmet health needs and concerns are present in health care
provision, and communicated in ways that both senior women and their
health practitioners can understand.

For full study details on the What Older Women Want study, visit:

[[www.wowhealth.ca/pdf/wowCMAJ.pdf]{.underline}](../www.wowhealth.ca/pdf/wowCMAJ.pdf)

[Tannenbaum
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tannenbaum C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Mayo
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mayo N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Ducharme
F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ducharme F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Older women\'s health priorities and perceptions of care delivery:
results of the WOW health survey.
[CMAJ.](javascript:AL_get(this, 'jour', 'CMAJ.');) 2005 Jul
19;173(2):153-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16027431>

**A fall management program in nursing homes improves care and reduces
use of physical restraints**

[http://www.ahrq.gov/research/jun07/0607RA10.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun07/0607RA10.htm)

**Certain resident and facility characteristics and medications increase
the risk of fractures among nursing home residents**

[http://www.ahrq.gov/research/jul07/0707RA7.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jul07/0707RA7.htm)

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

#### Various Implantable Contraceptives Equally Effective in Preventing Pregnancy {#various-implantable-contraceptives-equally-effective-in-preventing-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Implanon, Norplant and Jadelle are highly effective contraceptive methods. No significant differences were found in contraceptive effectiveness or continuation. The most common side-effect with all implants was unpredictable vaginal bleeding. Time taken for removal of Implanon and Jadelle was less than that for Norplant.Although this systematic review was unable to provide a definitive answer on relative effectiveness, tolerability and acceptability of contraceptive implants in comparison to other contraceptive methods, it has raised issues around the conduct of contraceptive research. {#conclusions-implanon-norplant-and-jadelle-are-highly-effective-contraceptive-methods.-no-significant-differences-were-found-in-contraceptive-effectiveness-or-continuation.-the-most-common-side-effect-with-all-implants-was-unpredictable-vaginal-bleeding.-time-taken-for-removal-of-implanon-and-jadelle-was-less-than-that-for-norplant.although-this-systematic-review-was-unable-to-provide-a-definitive-answer-on-relative-effectiveness-tolerability-and-acceptability-of-contraceptive-implants-in-comparison-to-other-contraceptive-methods-it-has-raised-issues-around-the-conduct-of-contraceptive-research. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Power J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Power J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), [French R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="French R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), [Cowan F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cowan F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus). Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy. {#power-j-french-r-cowan-f.-subdermal-implantable-contraceptives-versus-other-forms-of-reversible-contraceptives-or-other-implants-as-effective-methods-of-preventing-pregnancy. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Cochrane Database Syst Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');) 2007 Jul 18;(3):CD001326 {#cochrane-database-syst-rev.-2007-jul-183cd001326 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636668**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636668) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17636668 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Oral Contraceptives Today: Changes, Challenges, Risks, and Benefits: Medscape CME {#oral-contraceptives-today-changes-challenges-risks-and-benefits-medscape-cme .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/7384?src=mp**](http://www.medscape.com/viewprogram/7384?src=mp) {#httpwww.medscape.comviewprogram7384srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

# New Online Training Tool Available for Treatment of Adolescents with HIV

A new online training program developed for health
care providers entitled Treating Adolescents with HIV: Tools for
Building Skills in Cultural Competence, Clinical Care, and Support will
be launched Monday, July 23. Continuing education credits are available
for participating in this training which can be accessed at
[www.hivcareforyouth.org](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.hivcareforyouth.org)

 

This project is supported by the Department of Health and Human
Services\' Health Resources and Services Administration\'s [HIV/AIDS
Bureau](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://hab.hrsa.gov/). The
series begins, and is framed, by an introductory module covering best
practices in adolescent care and the impact of the AIDS epidemic on
minority youth. The four additional modules in this series: Psychosocial
Issues, Antiretroviral Treatment and Adherence, Transitioning Care, and
Prevention with Positives address core issues in HIV care for
adolescents. The expert authors and editors come from diverse clinical
settings around the country, and present course information from the
perspective of a culturally aware care provider. Throughout the course,
practical tools are provided to assist with \"operationalizing\"
culturally sensitive best practices in the clinic setting.

<http://hab.hrsa.gov/>

From Lori de Ravello <Lori.deRavello@ihs.gov>

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

**Moderate morning sickness only partially responding to doxylamine and
pyridoxine**

**QUESTION** One of my patients suffers from a moderate-to-severe form
of morning sickness. She responded only partially to doxylamine and
pyridoxine, and I wish to try adding another medication. What should my
priority be?

**ANSWER**\
An algorithm used by Motherisk to manage thousands of patients takes a
hierarchical approach to this condition. This approach is evidence based
with regard to fetal safety as well as efficacy. (Go to 'algorithm used
by Motherisk' and scroll down page to see algorithm, link below)

Nausea and vomiting of pregnancy (NVP) affects an estimated 80% of all
pregnant women, making it the most common medical condition during
pregnancy. In most cases, symptoms are worse in the morning; severity
usually peaks by 8 to 12 weeks\' gestation. Some women are affected
throughout the day, and the condition sometimes continues beyond the
first trimester and even until the birth.

Hyperemesis gravidarum is the most severe form of morning sickness,
affecting 0.05% to 1% of pregnant women. Hyperemesis gravidarum is
characterized by dehydration and electrolyte imbalance, and might
require hospitalization. Nausea and vomiting of pregnancy has serious
detrimental effects on the lives of women, even those with a milder
presentation. Termination of otherwise wanted pregnancies among women
suffering from severe and prolonged NVP has been reported.

**Inappropriate treatment common**\
Ample evidence indicates that most women with NVP do not receive
appropriate pharmacologic or nonpharmacologic treatment for the
condition. In 1996, the Motherisk Program in Toronto, Ont, initiated the
NVP Healthline (1-800-436-8477) to counsel and support women and health
professionals in managing NVP. Members of Motherisk systematically
review available data on treatment in an attempt to obtain the best
available evidence on efficacy and safety. Callers and clinic patients
are advised on both pharmacologic and nonpharmacologic management.

This paper provides clinicians with a simple evidence-based algorithm on
the efficacy and safety of treatments for NVP.

**Rationale**\
In planning and evaluating management of NVP, fetal safety is clearly
the primary concern, followed by efficacy. This order of priorities
dictates that, in general, older medications, for which there are more
data on fetal safety, are preferred over newer, perhaps more effective,
drugs for which there are as yet fewer data on safety.

**Methods**

The algorithm is based on a recent systematic review of the literature
on safety and efficacy of management of NVP conducted by members of the
Motherisk Team. The course of NVP ranges in severity, length, and
response to treatment. We addressed treatment of NVP in a decision tree
(Figure 1, at link below) It begins with pharmacologic management of
relatively mild cases and progresses to treatment of patients who cannot
tolerate oral treatment or are dehydrated, or both. At any stage of the
algorithm, physicians can add or, when there is improvement, withdraw
treatment. The systematic review included meta-analyses whenever the
data permitted.

The quality of the evidence on fetal safety and maternal efficacy
varies. There is large and convincing evidence on the safety and
efficacy of doxylamine and pyridoxine (Diclectin). Evidence on the
safety of other H1 blockers is as strong, but evidence of efficacy is
less strong. Many studies on the efficacy of phenothiazines offer
convincing evidence, but the number of studies on safety is much smaller
(birth defects are generally rare). Evidence on the safety and efficacy
of ondansetron and metoclopramide is preliminary.

The hierarchy presented in the algorithm is based on the strength of
evidence for fetal safety, and only treatments shown to be efficacious
were included. It has been used by the Motherisk Program for treating a
large number of patients.

Levichek Z et al Nausea and vomiting of pregnancy: Evidence-based
treatment algorithm Canadian Family Physician 2002;48:267-8,277.

<http://www.motherisk.org/prof/updatesDetail.jsp?content_id=348>

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

**September 2007**

-First time that prophylaxis for infective endocarditis has been written
using evidenced based guidelines. The difference is significant.

-RPMS Immunization Package: Version 8.2 coming this summer

-Substance abuse in Native American communities. It is no secret that
substance abuse poses a serious threat to the health of children, youth,
families, and communities all across the nation.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN907.doc>

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

**Save 750 mega watts/hour per year: It is easy**

If Google had a black screen, taking in account the huge number of page
views, according to calculations, 750 mega watts/hour per year would be
saved.\
\
In response, Google created a black version of its search engine, called
Blackle, with the exact same functions as the white version, but with
lower energy consumption:  <http://www.blackle.com/>

**iCare Training**

The IHS Office of Information Technology is pleased to continue offering
WebEx training for the new iCare (Population Management) software
application. You will be able to participate in the training from the
comfort of your office or conference room and will not be required to
travel to obtain this training.

iCare is a tool with multiple uses for a wide variety of providers that
presents diverse RPMS data through an easy to use graphical user
interface (GUI).

There are two types of training offered:

1.  iCare Technical Overview

2.  iCare -- Nuts and Bolts

The target audience is [any]{.underline} provider who cares for patients
(e.g. physicians, mid-level providers, nurses, case managers, public
health personnel, pharmacists etc.)

**[NOTE:]{.underline}** **You must register for these classes.** They
are NOT limited to participants in a particular Area; they are open to
all, however, space is limited so be sure to register right away. Below
are the agendas and date/times for both classes. It is recommended that
you attend them sequentially.

[Each session is limited to 30 participants.]{.underline}  [Therefore,
if there is a group of people who would like to attend at your facility,
our recommendation is that you attend as a group and have only one
person register for the session.]{.underline}  For the group, you will
need a conference room, conference phone, computer and projector. 
Please ensure someone at your facility is responsible for taking care of
these arrangements.

Please note this is a live, internet-based training, not a recorded
session, and people will be able to ask questions and actively
participate in the class.

**[NOTE:  All training times shown above are for the Pacific Daylight
Time zone.  Please ensure you adjust the time for your particular time
zone.]{.underline}**

**[Training Schedule]{.underline}**

1.  **[iCare -- Nuts and Bolts]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Set Up and Background (Server) Processes

-   Establishing and Changing User Preferences

-   Panel Creation

-   Panel Modification

-   Flags

-   Diagnostic Tags

-   National Performance Measures

-   Patient Record

-   Question and Answer Session

**[Session                          Date and Time                Reg
Password]{.underline}**

iCare Nuts and Bolts Mon 07/16/2007 12:00-14:00 PDT coyote

Tue 07/31/2007 11:00-13:00 PDT coyote

Thur 08/23/2007 09:00-11:00 PDT coyote

Mon 08/27/2007 13:30-15:30 PDT coyote

Fri 09/14/2007 10:30-12:30 PDT coyote

2.  **[The Practical Use of iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Scenarios

-   Tips

-   Using the Performance Measure views to improve outcomes

-   Questions and Answers

**[Session                         Date and
Time                              Reg Password]{.underline}**

The Practical Use of iCare Wed 07/18/2007 09:00-10:30 PDT coyote

Thur 08/02/2007 09:30-11:00 PDT coyote

Fri 08/24/2007 10:00-11:30 PDT coyote

Thur 08/30/2007 12:00-13:30 PDT coyote

Wed 09/19/2007 11:00-12:30 PCT coyote

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

1.  Click this link:<https://ihs-training.webex.com/>

```{=html}
<!-- -->
```
1.  At the Search For box, type in \"iCare\" (do not type in the
    quotation marks) and click the Go button.  **NOTE:  If you do not
    see the Search For box, ensure the Training Center tab is selected
    at the top of the WebEx window, immediately under "webex."**

2.  All of the scheduled sessions will then be displayed in the window
    below.  Choose the one you want to attend and click "Registration"
    in the Status column.

3.  Enter the Registration password that is shown above that corresponds
    to the class you want to attend.

4.  Click the OK button.

5.  Complete the registration form.

6.  Click the Register button.

7.  A Registration confirmation is displayed that contains all of the
    information for the training session, including the link for the
    session and the password to enter when you are ready to attend the
    session.  Click the OK button to finish.

**[Setup (Software Install) Information:]{.underline}**

You must have the WebEx software installed on your computer prior to
attending the WebEx session.  **[You should setup the software at least
a day before the training session.]{.underline}**  You should not need
anyone such as the Site Manager to install it for you.  Below are the
instructions.

1.  Click this link:

> <https://ihs-training.webex.com/ihs-training/mywebex/default.php?Rnd0969=0.20680128403018566>

1.  On the left side of the window, click Set Up.

2.  Immediately under Set Up you will see two options:  Training
    Manager, Preferences.

3.  Click Training Manager.

4.  A message is displaying giving you information about the setup
    process. Click the Set Up button.

5.  After the software is installed, click the OK button.

**[Attending the Session:]{.underline}**

When you are ready to attend the session, connect to the WebEx session
first using the information contained in your registration confirmation
e-mail and then connect to the conference line.  The dial information
for the conference line is shown below and is also included in your
registration confirmation message.

Phone Number:  (877) 781-4791

Passcode:         135963#

Questions? Contact Cynthia Gebremariam at <Cynthia.Gebremariam@ihs.gov>

#### International Health Update Claire Wendland, Madison, WI {#international-health-update-claire-wendland-madison-wi .Style-Heading-4-+-Arial-14-pt-Underline}

**Sex, Soap & Social Change - The Sabido Methodology**

As anyone who's gotten seriously hooked on a TV drama knows, viewers can
start thinking of fictional characters as real, even as friends. Health
educators worldwide take advantage of this response by using serial
dramas -- soap operas -- to reach diverse audiences with behavior-change
messages through what has come to be called the "Sabido method." Miguel
Sabido, a Mexican TV executive in the 1970s, built on the social
learning theory of Albert Bandura to produce telenovelas encouraging
Mexican couples to use contraception. Sabido's key insight was that
television characters could be role models, allowing viewers to learn
vicariously from the troubles and successes of others. To work, the
shows had to be entertaining, and the audience had to become attached to
the characters.

Acompaname, "Come Along," was Sabido's first serial drama to address
health. It spared viewers none of the drama for which soaps are famous:
infidelities, amnesia, unwanted pregnancies. Among the suffering
heroines and evil villains, however, was Martha, the "transitional
character" with whom the audience was meant to identify -- a fallible
but likeable protagonist who envied her sister's small and happy family,
and feared sharing the fate of her mother, burdened with too many
children and not enough resources. As Martha and her husband tentatively
began to use family planning, many of the members of her audience did
too. Sales of over-the-counter contraceptives rose nearly twenty-five
percent the first year the show was on the air, and there is evidence
suggesting that Acompaname and Sabido's next four telenovelas were
important factors in the 34% drop in Mexico's population growth rate
over the next few years.

Fine-tuning the shows through audience research is an important part of
their design. Wila Kasta (an Aymara-language radio show in Bolivia
focused on HIV/AIDS and condom use) initially made the mistake of
putting prevention messages in the mouth of a Western-trained doctor
character. Though handsome, musical, and powerful, he was a far less
popular character than anticipated. The show fared better, and the
audience paid greater attention, when the same messages came through a
grandmother midwife.

The formula for producing such dramas was exported by the mid-1980s, and
serial dramas intended to create social change have hit the airwaves in
a hundred countries, from Ethiopia (where the radio drama Yeken Kignit,
"Journey of Life," is credited with tripling HIV-testing rates among
listeners) to India (where the musical soap Tinka Tinka Sukh, "Happiness
Lies in Small Pleasures," convinced at least one village to abolish the
dowry system) to Burma (where the military junta has made listening to a
shortwave drama on health and civil engagement a treasonous offence).
They have addressed topics from literacy to agricultural techniques to
women's rights to condom use. In the twenty-first century, the urgent
need to interrupt the HIV epidemic has spawned even more shows.

Do they work? It is very difficult to distinguish correlation from
causation, and to some extent the jury is still out. After all, people
who own a television or radio may also be better off, more comfortable
with Western lifestyles, and already more likely to use a condom or get
an HIV test than those who don't. What little evidence there is,
however, suggests an effect greater than that seen in more traditional
public health campaigns. Perhaps it's time to try the Sabido method in
the US?

-   Readers looking for more can find an overview in Global Health Watch
    at <http://www.globalhealth.org/reports/> -- click on "Sex, Soap &
    Social Change - The Sabido Methodology."

-   The best available summary of evidence on these programs' efficacy
    is an open-access article from
    [http://her.oxfordjournals.org](http://her.oxfordjournals.org/) --
    Bertrand JT, O'Reilly K et al. Systematic review of the
    effectiveness of mass communication programs to change
    HIV/AIDS-related behaviors in developing countries. Health Education
    Research 21(4):567-597, 2006.

-   Interested in making a serial drama for your own community? You can
    download a step-by-step guide free from the United Nations
    Population Fund at
    <http://www.unfpa.org/upload/lib_pub_file/538_filename_training_guide.pdf>

**Other**

**Association of arsenic exposure during pregnancy with fetal loss and
infant death: a cohort study in Bangladesh.**

The authors evaluated the effect of arsenic exposure on fetal and infant
survival in a cohort of 29,134 pregnancies identified by the health and
demographic surveillance system in Matlab, Bangladesh, in 1991-2000.
Arsenic exposure, reflected by drinking water history and analysis of
arsenic concentrations in tube-well water used by women during
pregnancy, was assessed in a separate survey conducted in 2002-2003.
Data on vital events, including pregnancy outcome and infant mortality,
were collected by monthly surveillance at the household level. The risk
of fetal loss and infant death in relation to arsenic exposure was
estimated by a Cox proportional hazards model. Drinking tube-well water
with more than 50 microg of arsenic per liter during pregnancy
significantly increased the risks of fetal loss (relative risk = 1.14,
95% confidence interval: 1.04, 1.25) and infant death (relative risk =
1.17, 95% confidence interval: 1.03, 1.32). There was a significant dose
response of arsenic exposure to risk of infant death (p = 0.02). Women
of reproductive age should urgently be prioritized for mitigation
activities where drinking water is contaminated by arsenic.

Rahman A et al Association of arsenic exposure during pregnancy with
fetal loss and infant death: a cohort study in Bangladesh. [Am J
Epidemiol.  2007;
165(12):1389-96](http://www.medscape.com/medline/publicationbrowser/123?pmid=17351293) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17351293>

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

**Preconception brochure released**

A Woman\'s Guide to Preventing or Planning Pregnancy provides
information on pregnancy and pregnancy-prevention program services in
California, as well as tips for staying healthy before and during
pregnancy. The brochure, developed by the Center for the Health
Professions\' Network for Multicultural Health, builds on the project
undertaken by LEAD (LEADing Organizational Change: Advancing Quality
Through Culturally Responsive Care) program Cohort 1, Contra Costa
Health Services, and its focus on community outreach. The services of
two specific programs are highlighted: (1) Family PACT, a state- and
federally funded program to provide comprehensive family planning
services to individuals with eligible incomes and (2) Presumptive
Eligibility for Pregnant Women, a Medi-Cal program to provide immediate,
temporary coverage for prenatal care pending a formal Medi-Cal
application. The brochure may be downloaded and customized by inserting
specific information on the back, center panel.
[[http://futurehealth.ucsf.edu/TheNetwork/LinkClick.aspx?link=WomansGuide_English.pdf&mid=2181]{.underline}](http://futurehealth.ucsf.edu/TheNetwork/LinkClick.aspx?link=WomansGuide_English.pdf&mid=2181)

**School based programs decrease rates of violence among adolescents**

\"On the basis of this evidence, the Task Force on Community Preventive
Services recommends the implementation of universal, school-based
programs to prevent violent behavior,\" state the authors of a report
published in a supplement to the August 2007 issue of the American
Journal of Preventive Medicine. Violence is widespread and causes
considerable morbidity and mortality in the United States. Research has
shown that childhood violence is predictive of later violent pathways.

The report summarizes the findings of a systematic review of the effects
of universal, school-based programs intended to prevent violent
behavior. Information on interpreting and using the recommendation are
provided.
[[http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0126-0]{.underline}](http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0126-0)

The other systematic reviews of the effectiveness of selected
population-based interventions designed to reduce or prevent violence by
and against children and adolescents are available from the Guide to
Community Preventive Service at
[[http://www.thecommunityguide.org/violence/default.htm]{.underline}](http://www.thecommunityguide.org/violence/default.htm)

**MCH Headlines Judy Thierry HQE**

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

[Results:]{.underline} Of 775 children age 1-8 years, 29 percent were
properly restrained, 30 percent were incorrectly restrained, and 41
percent were completely unrestrained in the vehicle. The strongest
associations with proper child restraint use, rather than no restraint
use, were seat eligibility (Odds Ratio \[OR\] for infant seat vs booster
seat: 25.1; OR for child seat vs booster seat: 8.7), driver seat belt
use (OR: 6.5), and driver relationship to the child (OR for parents vs
non-parents: 3.9). Being subject to a state seat belt law was associated
with both proper (OR: 4.4) and incorrect restraint use (OR: 6.6), rather
than no restraint use, compared to children riding in areas with no law.
Being subject to a tribal seat belt law was also associated with
incorrect restraint use (OR: 2.4), rather than no restraint use,
compared to children riding in areas with no law. The three factors that
were differently associated with proper and incorrect restraint use were
the child's seat eligibility (OR for infant seat vs booster seat:15.7;
OR for child seat vs booster seat: 7.5),seating position (OR for
rear-outboard seated vs front seated: 1.9), and whether or not the child
was riding with his or her own parent (OR for parents vs
non-parents:2.9).

[Conclusions]{.underline}: AI/AN children are at risk for incorrect and
non-use of motor vehicle restraints. Understanding barriers and
facilitators to the use of child passenger restraint systems in tribal
communities can guide prevention efforts for American Indian communities
across the United States. Such interventions might include strategies to
get all occupants (adults and children) to use proper restraints;
stressing importance of regular use, even for short trips; increase
availability of proper seats for all vehicles that children ride in
regularly; include training on proper use, not only for parents, but all
regular caregivers.

Nicole Smith, MPH

MCH Biostatistician

Northwest Portland Area Indian Health Board

<nsmith@npaihb.org>

**Toolkit Supports Efforts in Native Communities to Prevent FAS
Disorders**

The American Indian/Alaska Native/Native Hawaiian Resource Kit is
available on the Web at
[**http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702**](http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702).

Copies may be obtained free of charge by calling SAMHSA's (working
hours) Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727).
Request inventory number SMA07-4264.

For related publications and information, visit <http://www.samhsa.gov/>
and the FASD Native Initiative Web site at
<http://fasdcenter.samhsa.gov/nativeinitiative/indexhtmlorflash.cfm>

**Sister Study seeks more Native women **

The study must have 50,000 women participate; and in order to ensure
accurate research results representative of the entire U.S. and Puerto
Rican population, organizers hope to have at least 750 American Indian
participants. As of August, 565 Native women were enrolled in the study.
\'\'Breast cancer is the second leading cause of cancer death among
Native women, and their five-year survival rate is lower than that of
white women,\'\' said Sara Williams, the Sister Study\'s recruitment
coordinator in charge of Native recruitment.\
\
Previous breast cancer research has been limited to mostly white women,
Williams said, and scientists are hoping to learn a great deal from the
study. The participants must be between the ages of 35 and 74, must
never have had cancer and must have a sister who was diagnosed with
breast cancer.\
\
Because there is so little known about the environmental causes of
breast cancer, many women are compelled to join the study to try and
help future families. The study was officially launched in 2004 after a
few years of planning. Organizers have worked diligently to spread the
word of the study, publicizing their intent and creating a user-friendly
Web site. Reaching Indian country can be more difficult. \'\'We want the
cohort to really be diverse and not have everyone in the study be white
and middle-aged and work at a desk job,\'\' Williams said. Native women
who sign up must be residents of the United States; however, they do not
need to give their tribal affiliation.\
\
\'\'Because this is not a study comprised of only Native women, it was
never the intention to study any differences in breast cancer risk at a
tribal level,\'\' Williams said. \'\'There will only be broad analyses
done among all Native women generally, regardless of tribal affiliation.
Still, so much is going to be learned at this level.\'\'\
\
The Sister Study is a long-term research project. When participants sign
up, they\'ll be asked to take part in two hour-long phone interviews in
which they\'ll give detailed information about their medical history,
environment and lifestyle. Then, the individual will set up an in-home
appointment with a female examiner, who will draw blood and take a
urine, house dust and toenail sample.\
\
The participants will receive a kit in the mail that has all the
information and questionnaires organized in tabbed form. After the
initial period, the women will then be contacted every year for 10 years
to provide updated information, such as any changes to their health.\
\
\'\'You don\'t have to take any medicine, you don\'t have to go
anywhere,\'\' Williams stressed. \'\'You never even have to leave your
house \... I think the most important message now is that you just have
to step up to the plate and realize that this is really important to do
for future generations of women.\'\' Women are not paid for their
participation and their motivation to join comes from their desire to
contribute to scientific research.\
\
The study is being conducted by the U.S. Department of Health and Human
Services through their National Institute of Environmental Health
Sciences; and because it is a federally funded program, there isn\'t an
open-ended budget. \'\'I wish we could say, \'Join this program and
we\'ll give you \$500!\' Williams said. \'\'We are at the mercy of
people\'s good will. To me, it\'s almost like a social justice issue.
We\'re really working hard to encourage these women to enroll because we
know so little \[about Native breast cancer\].\'\'

To learn more about the study, visit
<http://www.sisterstudy.org/English/index1.htm> 

To sign up, call toll-free (877) 4SISTER.**  **

**One size doesn\'t fit all: Helmet Safety Poster**

Three page poster with chart and narrative matches' helmet with activity
from CPSC\'s Neighborhood Safety Network

The Neighborhood Safety Network has a very special poster to share with
you this month.  In March of this year, the Raffaelli family of San
Mateo, Calif., tragically lost their son Casey, 20, after he fell from
his skateboard.  Casey's parents and uncle have courageously partnered
with CPSC to share a powerful safety message about the unquestionable
importance of wearing a helmet when out on a bicycle, skateboard,
scooter, etc.  The visual and written message from the Raffaellis should
motivate everyone to "strap a helmet on -- it could save your life!"    

To honor Casey and to help create a safer community where you live, we
ask that you download this poster
([www.cpsc.gov/nsn/helmets.pdf](http://www.cpsc.gov/nsn/helmets.pdf))
and share it with friends, family and neighbors.

**Get Your Head in the Game**

Concussion Tool Kit for Youth Sports Coaches, Parents, and Athletes

A concussion is a brain injury caused by a bump or blow to the head that
can change the way your brain normally works. Even what seems to be a
mild bump or blow to the head can be serious. As many as 3.8 million
sports- and recreation-related concussions are estimated to occur in the
United States each year.

To help ensure the health and safety of young athletes, the Centers for
Disease Control and Prevention (CDC), in collaboration with 26 leading
organizations, developed the new \"Heads Up: Concussion in Youth
Sports\" tool kit for youth sports coaches, parents, and athletes. The
tool kit offers important information on preventing, recognizing, and
responding to a concussion---a type of traumatic brain injury---to
coaches, parents, and athletes involved in youth sports.

 

CDC wants to equip coaches, parents, and young athletes across the
country with the \"[Heads Up: Concussion in Youth
Sports](http://www.cdc.gov/concussioninyouthsports/)\" tool kit, which
contains a:

 

> §         Fact sheet for coaches, parents, and athletes on concussion;
>
> §         Clipboard with concussion facts for coaches;
>
> §         Magnet with concussion facts for coaches and parents;
>
> §         Poster with concussion facts for coaches and sports
> administrators; and
>
> §         Quiz for coaches, athletes, and parents to test their
> concussion knowledge.

 

The \"Heads Up: Concussion in Youth Sports\" tool kit can be ordered or
downloaded free-of-charge at:
<http://www.cdc.gov/ConcussionInYouthSports>

 

To view the MMWR on sports- and recreation-related traumatic brain
injury: <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a2.htm>

**Usage of Booster Seats (NSUBS) are now posted online on the NHTSA
website**

The study is NHTSA's first formal foray into the development of a
reliable scientific estimate of booster seat use in the U.S. Three
"Research Notes" analyzing and describing the NSUBS results are posted
at [www.nhtsa.gov](http://www.nhtsa.gov/)

These are:

[Booster Seat Use in
2006](http://www.nhtsa.gov/portal/nhtsa_static_file_downloader.jsp?file=/staticfiles/DOT/NHTSA/NCSA/Content/RNotes/2007/810796.pdf)

[Child Restraint Use in 2006 \-- Demographic
Results](http://www.nhtsa.gov/portal/nhtsa_static_file_downloader.jsp?file=/staticfiles/DOT/NHTSA/NCSA/Content/RNotes/2007/810797.pdf)

[Child Restraint Use in 2006 \-- Use of Correct Restraint
Types](http://www.nhtsa.gov/portal/nhtsa_static_file_downloader.jsp?file=/staticfiles/DOT/NHTSA/NCSA/Content/RNotes/2007/810798.pdf)

A fourth Research Note ("Preliminary Data Indicate That Booster Seat
Laws Increase Child Safety Seat Use") has been published in conjunction
with the NSUBS findings. That link is:

[Preliminary Data Indicate That Booster Seat Laws Increase Child Safety
Seat
Use](http://www.nhtsa.gov/portal/nhtsa_static_file_downloader.jsp?file=/staticfiles/DOT/NHTSA/Communication & Consumer Information/Traffic Tech Publications/Associated Files/tt331.pdf)

The NSUBS' primary purpose is to estimate booster seat use among 4- to
7-year-olds, but it also collects very rich information on the restraint
use of all children under age 13, and on race/ethnicity results on
restraint use among all ages. In particular, the NSUBS provides the best
data to date on the premature graduation of children age 0-12 to
restraint types that are inappropriate for their height or weight.

The survey was conducted by NHTSA's National Center for Statistics and
Analysis (NCSA) in July 2006, and the second year survey is in the field
this month.

Although clear progress in increasing booster seat use is evident \--
thanks to a host of developments and interventions conducted by many
people over many years \-- much work remains to be done to more fully
protect booster-aged/-sized child passengers.

**FASD Online Course**\
Online Course: (2004) FASD 4-Digit Diagnostic Code - individual-start,
self-paced, fully online program. The course includes readings,
exercises, quizzes and video segments of an actual FAS Diagnostic
Evaluation. This 20-hour course is designed for completion in 4 weeks.
Students may complete the course in less time or may take up to 8 weeks.
Students may start the course on any date.  \$100 COURSE FEE. RECOMMEND
REVIEW OF THE INTRO VIDEO -- LINK BELOW.  \
\
FAS is a permanent birth defect syndrome caused by maternal consumption
of alcohol during pregnancy. FASD is the leading known cause of mental
retardation and developmental disabilities and is entirely preventable.
Learn an interdisciplinary clinical approach to diagnosing FASD using
the (2004) 4-Digit Diagnostic Code. The 4-Digit Code has been practiced
by interdisciplinary diagnostic teams across the U.S. and Canada since
1997 with documented high performance. This online course includes case
studies, animations, practice sessions and self-assessment.\
\
The Online Course is now open for registration.\
Earn 2 Continuing Education Units.\
The Course was developed by Susan J. Astley, Ph.D. and the University of
Washington FAS DPN Clinical Team. This course was developed in
partnership with UW Extension, Distance Learning Division.\
 

Click here to view an introductory video of the Online Course.**  **
<http://depts.washington.edu/fasdpn/htmls/online-train.htm>** \
**\
The video requires Windows Media Player software to view. If you are
using a computer with Microsoft\'s Windows operating system, you may
already have this software loaded in your computer. If you do not have
this software, or the version you have is outdated, a free copy of the
software can be downloaded from Microsoft.

Let me know if you are interested in taking this online course.

<Judith.Thierry@ihs.gov>

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

#### Nausea and Vomiting in Pregnancy {#nausea-and-vomiting-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

As you recall from last month, we presented 3 case scenarios and then
asked 3 questions. Here are the questions. The correct answers and
explanations are given below.

**Editorial Note**

This month's Perinatology Picks CCC Corner submission (below) offers
background on Nausea and Vomiting of Pregnancy for these 3 questions.
This background is based on the Perinatology Corner CME module on Nausea
and Vomiting of Pregnancy

After you peruse this material and answer the questions, you should go
to the link directly below, take the Posttest and receive free CME
credit. <http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm>

The module itself has many other available references and links to
hundreds of other resources.

**Case 1**

MTB is a 24 y/o G1P0 at 10 weeks by her dates who presents to her first
prenatal visit complaining of morning sickness. Her symptoms are not
incapacitating, but she would like to feel better. She has tried various
herbal teas without much relief. Your most useful recommendation at this
initial visit would be:

a.  reassurance, small frequent intake, pyridoxine (vitamin B-6)

b.  prescribe a cholinomimetic agent (e.g., metoclopramide)

c.  prescribe a 5-HT-3 receptor inhibitor (e.g., ondansetron)

d.  clear liquid diet and bismuth subsalicylate (Pepto-Bismol)

**Case 2**

HB is a 30 y/o G3P2 at 9 weeks by her dates who presents for her first
prenatal visit complaining of nausea with vomiting that lasts pretty
much all day, but she is able to keep some food down. She says this has
occurred with each of her pregnancies, but this time it is especially
troublesome. She has had a small amount of spotting but no cramping. She
appears to be well hydrated. Your initial work up at this time should
include:

a.  complete metabolic panel, thyroid functions, amylase and lipase

b.  electrolytes, alanine aminotransferase, pelvic ultrasound

c.  upper abdominal ultrasound, H.pylori antigen testing, stool guiac
    testing

d.  no laboratory studies are indicated at this time

**Case 3**

EP is a 19 y/o G1P0 at 11 weeks by her dates who presents to the
emergency department complaining of severe nausea and vomiting. She is
wretching, appears ill, and is only able to produce a small amount of
concentrated urine that is strongly positive for ketones. Your initial
management should include:

a.  oral hydration, mental health consult

b.  intravenous hydration, admit for parenteral alimentation

c.  intravenous hydration, nasogastric tube, H2-blocker drip

d.  intravenous hydration, parenteral anti-emetics

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

**Case 1**

#### Correct answer: a Ms B is a primigravida at 10 weeks who has mild pregnancy associated nausea. It should begin to resolve by 12 weeks as serum HCG levels taper. In the meantime, reassurance that this is a normal pregnancy symptom is appropriate. Dietary modification in the form of small, frequent, usually dry, not fatty, meals is often helpful. Pyridoxine, which is vitamin B6, is the pharmacotherapy that most often is helpful for mild cases such as that described here, and usually has no side effects. If pyridoxine is not helpful for her, she may supplement it with over the counter doxylamine (the ingredient in mild sleep aids such as \'Sominex\'). This combination was formerly marketed as \'Bendectin ®\', which is no longer available, but which is definitely not a teratogen. It may also be supplemented with a phenothiazine or an antihistamine anti-emetic for more severe symptoms, but she should know that these are usually quite sedating. If these interventions are not helpful, metoclopramide or a 5-HT-3 receptor inhibitor, such as ondansetron, can be added, but mild symptoms, such as described, usually will not require these more costly drugs, at least initially. Oral hydration is important, but fasting is not helpful. Bismuth subsalicylate is often helpful for nausea in non-pregnant individuals, but the high dose of salicylate is not recommended during pregnancy, and may also cause constipation. {#correct-answer-a-ms-b-is-a-primigravida-at-10-weeks-who-has-mild-pregnancy-associated-nausea.-it-should-begin-to-resolve-by-12-weeks-as-serum-hcg-levels-taper.-in-the-meantime-reassurance-that-this-is-a-normal-pregnancy-symptom-is-appropriate.-dietary-modification-in-the-form-of-small-frequent-usually-dry-not-fatty-meals-is-often-helpful.-pyridoxine-which-is-vitamin-b6-is-the-pharmacotherapy-that-most-often-is-helpful-for-mild-cases-such-as-that-described-here-and-usually-has-no-side-effects.-if-pyridoxine-is-not-helpful-for-her-she-may-supplement-it-with-over-the-counter-doxylamine-the-ingredient-in-mild-sleep-aids-such-as-sominex.-this-combination-was-formerly-marketed-as-bendectin-which-is-no-longer-available-but-which-is-definitely-not-a-teratogen.-it-may-also-be-supplemented-with-a-phenothiazine-or-an-antihistamine-anti-emetic-for-more-severe-symptoms-but-she-should-know-that-these-are-usually-quite-sedating.-if-these-interventions-are-not-helpful-metoclopramide-or-a-5-ht-3-receptor-inhibitor-such-as-ondansetron-can-be-added-but-mild-symptoms-such-as-described-usually-will-not-require-these-more-costly-drugs-at-least-initially.-oral-hydration-is-important-but-fasting-is-not-helpful.-bismuth-subsalicylate-is-often-helpful-for-nausea-in-non-pregnant-individuals-but-the-high-dose-of-salicylate-is-not-recommended-during-pregnancy-and-may-also-cause-constipation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Case 2**

#### Correct answer: b Ms H is a multiparous woman at 9 weeks with symptoms which are quite distressing, but she is able to accomplish some oral intake and does not appear to be dehydrated. When we aren\'t able to offer a great deal therapeutically, we often \'go overboard\' diagnostically! Such \'mega work ups\' for a problem that the patient knows is recurrent each pregnancy is usually not cost-effective. A simple basic workup is helpful however, and might include electrolytes (hypokalemia is the most common abnormality encountered) and a screen for hepatitis. The alanine aminotransferase (ALT, formerly known as SGPT or the serum glutamic pyruvate transaminase) is usually the most sensitive. If it is abnormal, you can investigate further from there. There is usually a history to suggest other gastrointestinal problems (colicy RUQ pain radiating to the shoulder for gallbladder disease, epigastric pain and pyrosis for peptic ulcer disease, a history of ethanol ingestion, etc.). If your initial therapy proves unhelpful and the symptoms become worse or evolve, then more of a GI work up may certainly be indicated later. While nausea and vomiting is not a common symptom of hyperthyroidism, it has somehow become routine to order thyroid functions on these women. If you have read a former \'Perinate\'s Corner\' on thyroid disease in pregnancy, you will recall that these women, who typically have high human chorionic gonadotrophin (HCG) levels, will frequently have an assay for TSH that often returns very low, suggesting hyperthyroidism. This may occur in up to 20% of pregnant women in whom the newer third generation, ultrasensitive TSH assays are obtained. These women may even have a mildly elevated free T4, but they will be clinically euthyroid, without tremor, tachycardia, hyperreflexia, or the other signs of hyperthyroidism. Both these biochemical abnormalities will resolve by 18 weeks and anti-thyroid medications should not be started. (They will not help the nausea and vomiting either!) They may cause the fetus, who is totally dependent on its mother\'s thyroxine until its own gland becomes functional at about 18 weeks, to become hypothyroid, with the accompanying later intellectual deficits. \'Primum non nocere\' (first do no harm)! {#correct-answer-b-ms-h-is-a-multiparous-woman-at-9-weeks-with-symptoms-which-are-quite-distressing-but-she-is-able-to-accomplish-some-oral-intake-and-does-not-appear-to-be-dehydrated.-when-we-arent-able-to-offer-a-great-deal-therapeutically-we-often-go-overboard-diagnostically-such-mega-work-ups-for-a-problem-that-the-patient-knows-is-recurrent-each-pregnancy-is-usually-not-cost-effective.-a-simple-basic-workup-is-helpful-however-and-might-include-electrolytes-hypokalemia-is-the-most-common-abnormality-encountered-and-a-screen-for-hepatitis.-the-alanine-aminotransferase-alt-formerly-known-as-sgpt-or-the-serum-glutamic-pyruvate-transaminase-is-usually-the-most-sensitive.-if-it-is-abnormal-you-can-investigate-further-from-there.-there-is-usually-a-history-to-suggest-other-gastrointestinal-problems-colicy-ruq-pain-radiating-to-the-shoulder-for-gallbladder-disease-epigastric-pain-and-pyrosis-for-peptic-ulcer-disease-a-history-of-ethanol-ingestion-etc..-if-your-initial-therapy-proves-unhelpful-and-the-symptoms-become-worse-or-evolve-then-more-of-a-gi-work-up-may-certainly-be-indicated-later.-while-nausea-and-vomiting-is-not-a-common-symptom-of-hyperthyroidism-it-has-somehow-become-routine-to-order-thyroid-functions-on-these-women.-if-you-have-read-a-former-perinates-corner-on-thyroid-disease-in-pregnancy-you-will-recall-that-these-women-who-typically-have-high-human-chorionic-gonadotrophin-hcg-levels-will-frequently-have-an-assay-for-tsh-that-often-returns-very-low-suggesting-hyperthyroidism.-this-may-occur-in-up-to-20-of-pregnant-women-in-whom-the-newer-third-generation-ultrasensitive-tsh-assays-are-obtained.-these-women-may-even-have-a-mildly-elevated-free-t4-but-they-will-be-clinically-euthyroid-without-tremor-tachycardia-hyperreflexia-or-the-other-signs-of-hyperthyroidism.-both-these-biochemical-abnormalities-will-resolve-by-18-weeks-and-anti-thyroid-medications-should-not-be-started.-they-will-not-help-the-nausea-and-vomiting-either-they-may-cause-the-fetus-who-is-totally-dependent-on-its-mothers-thyroxine-until-its-own-gland-becomes-functional-at-about-18-weeks-to-become-hypothyroid-with-the-accompanying-later-intellectual-deficits.-primum-non-nocere-first-do-no-harm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Case 2**

#### Correct answer: d Ms P is a 19 y/o primigravida at 11 weeks with symptoms probably severe enough to be characterized as hyperemesis gravidarum. She is clinically dehydrated and may well need to be admitted. She certainly needs an IV for hydration as she is unlikely to tolerate PO. Despite a common belief that this disorder is largely \'psychological\', there is no evidence that these women have any higher incidence of mental health issues than other pregnant women who do not have such severe symptoms. This patient will almost certainly need parenteral anti-emetics. Either a phenothiazine or an antihistamine type may be very helpful here. Severe symptoms such as these may also benefit from IV metoclopramide and/or dolasetron or ondansetron. These classes of drugs are usually very effective, but the 5-HT-3 receptor inhibitors are quite costly, usually upwards of \$50 a dose, so they should be reserved for women who are unresponsive to other forms of therapy. Nasogastric suction and therapy aimed at reducing gastric acidity are usually not helpful for this disorder. Further work up may well be indicated in patients such as this who have severe and recurrent symptoms that are not amenable to therapy. Specific therapy can then be tailored to any pathology that may be uncovered. Parenteral nutrition was formerly used in hyperemesis patients who were unable to maintain oral intake, but, as noted above, they have fallen out of favor because of the associated complications. {#correct-answer-d-ms-p-is-a-19-yo-primigravida-at-11-weeks-with-symptoms-probably-severe-enough-to-be-characterized-as-hyperemesis-gravidarum.-she-is-clinically-dehydrated-and-may-well-need-to-be-admitted.-she-certainly-needs-an-iv-for-hydration-as-she-is-unlikely-to-tolerate-po.-despite-a-common-belief-that-this-disorder-is-largely-psychological-there-is-no-evidence-that-these-women-have-any-higher-incidence-of-mental-health-issues-than-other-pregnant-women-who-do-not-have-such-severe-symptoms.-this-patient-will-almost-certainly-need-parenteral-anti-emetics.-either-a-phenothiazine-or-an-antihistamine-type-may-be-very-helpful-here.-severe-symptoms-such-as-these-may-also-benefit-from-iv-metoclopramide-andor-dolasetron-or-ondansetron.-these-classes-of-drugs-are-usually-very-effective-but-the-5-ht-3-receptor-inhibitors-are-quite-costly-usually-upwards-of-50-a-dose-so-they-should-be-reserved-for-women-who-are-unresponsive-to-other-forms-of-therapy.-nasogastric-suction-and-therapy-aimed-at-reducing-gastric-acidity-are-usually-not-helpful-for-this-disorder.-further-work-up-may-well-be-indicated-in-patients-such-as-this-who-have-severe-and-recurrent-symptoms-that-are-not-amenable-to-therapy.-specific-therapy-can-then-be-tailored-to-any-pathology-that-may-be-uncovered.-parenteral-nutrition-was-formerly-used-in-hyperemesis-patients-who-were-unable-to-maintain-oral-intake-but-as-noted-above-they-have-fallen-out-of-favor-because-of-the-associated-complications. .Style-Heading-4-+-Arial-14-pt-Underline}

After you absorb (sic) the material above and the Background in the
Perinatology Picks below, you should go to the link directly below, take
the Posttest and receive the free CME credit.
<http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm>

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

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

######### HPV-16/18 Vaccination Should Not Be Used to Treat Prevalent Infections 

######### [**http://www.medscape.com/viewarticle/561418?src=mp**](http://www.medscape.com/viewarticle/561418?src=mp)

**Interactive Case: Overactive Bladder in a Menopausal Woman With
Complicating Conditions**

<http://www.medscape.com/viewprogram/5780?sssdmh=dm1.286131&src=0_mp_cmenl_0#2>

######### [Management of Depression and Premenstrual Dysphoria in a Woman Planning Pregnancy](http://mp.medscape.com/cgi-bin1/DM/y/hBVwo0Ou5N60Dzc0Imkv0Gq)

<http://www.medscape.com/resource/pmdd?sssdmh=dm1.294520&src=rcupdate>

#########  {#section-15}

**Management of Premenstrual Dysphoric Disorder Throughout the Ages: A
Series of Interactive Cases**

<http://www.medscape.com/viewarticle/558957?sssdmh=dm1.288228&src=0_tp_nl_0>

[**Premenstrual Syndrome/Premenstrual Dysphoric Disorder: Treatment With
Oral
Contraceptives**](http://mp.medscape.com/cgi-bin1/DM/y/hBUaW0Ou5N60Dzc0Imkv0G4)

<http://www.medscape.com/resource/pmdd?sssdmh=dm1.289582&src=rcupdate#1>

######### 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)

#########  {#section-16}

######### 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**

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

CONCLUSIONS: Hormone replacement therapy increases cardiovascular and
thromboembolic risk when started many years after the menopause. The
results are consistent with the findings of the women\'s health
initiative study and secondary prevention studies. Research is needed to
assess the long term risks and benefits of starting hormone replacement
therapy near the menopause, when the effect may be different.

[Vickers
MR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Vickers MR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Main morbidities recorded in the women\'s international study of
long duration oestrogen after menopause (WISDOM): a randomised
controlled trial of hormone replacement therapy in postmenopausal women.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2007 Aug
4;335(7613):239.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17626056>

**Hormone Therapy Safer in Younger Women? A Best Evidence Review**

CONCLUSIONS: Women who initiated hormone therapy closer to menopause
tended to have reduced CHD risk compared with the increase in CHD risk
among women more distant from menopause, but this trend test did not
meet our criterion for statistical significance. A similar
nonsignificant trend was observed for total mortality but the risk of
stroke was elevated regardless of years since menopause. These data
should be considered in regard to the short-term treatment of menopausal
symptoms. TRIAL REGISTRATION: clinicaltrials.gov Identifier:
NCT00000611.

[Rossouw
JE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rossouw JE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Postmenopausal hormone therapy and risk of cardiovascular disease
by age and years since menopause.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2007 Apr
4;297(13):1465-77

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17405972>

**Caffeine Reduces Cognitive Decline in Women**

CONCLUSIONS: The psychostimulant properties of caffeine appear to reduce
cognitive decline in women without dementia, especially at higher ages.
Although no impact is observed on dementia incidence, further studies
are required to ascertain whether caffeine may nonetheless be of
potential use in prolonging the period of mild cognitive impairment in
women prior to a diagnosis of dementia.

[Ritchie
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ritchie K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al The neuroprotective effects of caffeine: a prospective population
study (the Three City Study).
[Neurology.](javascript:AL_get(this, 'jour', 'Neurology.');) 2007 Aug
7;69(6):536-45

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17679672>

**Treatment Options for Insomnia (see Patient Education)**

The frequency of sleep disruption and the degree to which insomnia
significantly affects daytime function determine the need for evaluation
and treatment. Physicians may initiate treatment of insomnia at an
initial visit; for patients with a clear acute stressor such as grief,
no further evaluation may be indicated. However, if insomnia is severe
or long-lasting, a thorough evaluation to uncover coexisting medical,
neurologic, or psychiatric illness is warranted. Treatment should begin
with nonpharmacologic therapy, addressing sleep hygiene issues and
exercise. There is good evidence supporting the effectiveness of
cognitive behavior therapy. Exercise improves sleep as effectively as
benzodiazepines in some studies and, given its other health benefits, is
recommended for patients with insomnia. Hypnotics generally should be
prescribed for short periods only, with the frequency and duration of
use customized to each patient\'s circumstances. Routine use of
over-the-counter drugs containing antihistamines should be discouraged.
Alcohol has the potential for abuse and should not be used as a sleep
aid. Opiates are valuable in pain-associated insomnia. Benzodiazepines
are most useful for short-term treatment; however, long-term use may
lead to adverse effects and withdrawal phenomena. The better safety
profile of the newer-generation nonbenzodiazepines (i.e., zolpidem,
zaleplon, eszopiclone, and ramelteon) makes them better first-line
choices for long-term treatment of chronic insomnia. Am Fam Physician
2007;76:517-26, 527-8

<http://www.aafp.org/afp/20070815/517.html>

**NAMS Releases Updated Position Statement on the Use of Estrogen and
Progestogen in Perimenopausal and Postmenopausal Women**

There are risks and benefits associated with the use of estrogen therapy
(ET) and combined estrogen-progestogen therapy (EPT) in perimenopausal
and postmenopausal women. For this reason, the North American Menopause
Society (NAMS) evaluated the latest evidence and created the following
recommendations and guidelines to update its 2004 position statement.

Recommendations

PRETREATMENT

Before initiation of treatment, a thorough history should be obtained
and a complete physical **examination performed, including mammography
in accordance with national guidelines.**

VASOMOTOR SYMPTOMS

All ET and EPT products are approved for use in treating vasomotor
symptoms, such as night sweats or hot flashes. Treatment of these
symptoms is the main reason for systemic ET and EPT **use.**

VAGINAL SYMPTOMS

Nearly all systemic and vaginal ET and EPT products are approved for the
treatment of symptoms of vulvar and vaginal atrophy (e.g., dryness,
dyspareunia); however, local vaginal ET is typically recommended only
when needed solely for this purpose.

PROGESTOGEN INDICATION AND REGIMEN

In women with intact uteruses, unopposed ET can increase the risk of
endometrial cancer; progestogen is primarily used for protection against
this. Physicians should provide continuous-combined EPT or
continuous-sequential EPT for women with intact uteruses who are taking
ET. EPT should not be prescribed for postmenopausal women without
uteruses who are taking systemic estrogen.

Progestogen may have adverse effects in some women who take EPT. There
is insufficient evidence to recommend alternative options, such as
off-label use of long-cycle progestogen, vaginal administration, the use
of the levonorgestrel-releasing intrauterine system (Mirena), or the use
of **low-dose estrogen without progestogen.**

CORONARY HEART DISEASE

ET and EPT are not recommended for use as coronary protection in women.
One arm of the Women\'s Health Initiative (WHI) study showed a
significant association between time since start of EPT and coronary
heart disease (CHD) risk, with an increased risk in the first year and a
decreased risk in later years. It is important to note that the WHI
study population did not include enough younger, symptomatic, newly
postmenopausal women to determine if there are similar CHD risk patterns
in that population.

Observational data have shown a pattern of reduced CHD events in women
who started hormone therapy within the first 10 years of menopause, and
a pattern of greater CHD risk if therapy was started more than 10 years
after the start of menopause. The risk of early CHD is lower in the
younger cohort of newly postmenopausal women compared with the older
women studied in the WHI trial.

VENOUS THROMBOEMBOLISM

Studies have shown that women have a significantly increased risk of
venous thromboembolism if they are using systemic ET and EPT. This risk
appears within the first two years after starting therapy, but it
decreases over time. In the WHI study, excess risk was low overall and
lower still in women younger than 60 years who were randomized to ET and
EPT. There were few data available regarding differences in venous
thromboembolism risk in transdermal 17 beta-estradiol (Estrace) and oral
therapies.

STROKE

ET and EPT both seem to increase ischemic stroke risk in postmenopausal
women. Although some large trials have shown no increased risk, the ET
arm of the WHI study had eight additional strokes per 10,000 women, and
the EPT arm had 12. For this reason, it is recommended that ET and EPT
should not be used for primary or secondary prevention of stroke, and
they should not be prescribed to women who are already at increased
risk.

DIABETES

Randomized controlled trials (RCTs) have shown that ET and EPT lower the
risk of new-onset diabetes. Women taking EPT in the WHI study had a 0.61
percent annual incidence of diabetes requiring treatment compared with
0.76 percent in women taking placebo (number needed to treat to prevent
one case of diabetes = 670 per year of EPT). Women receiving ET in the
WHI study had a similarly small reduction. EPT is not recommended for
preventing diabetes in postmenopausal women.

BREAST CANCER

EPT use beyond five years is associated with increased breast cancer
risk. Evidence shows that ET alone has little or no impact; however,
some limited observational data have suggested that if ET lasts longer
than 15 years, risk may increase. There are few data showing any change
in breast cancer mortality with ET or EPT. Both therapies increase
breast cell proliferation, breast pain, and mammographic density, and
EPT can obstruct the diagnostic reading of mammograms.

OSTEOPOROSIS

Evidence has shown that ET and EPT reduce osteoporotic fracture risk in
postmenopausal women; many of these products are approved for this use.

DEPRESSION

Studies have shown an increased risk of onset of major depression in
perimenopausal versus premenopausal women without a history of
depression, and an increased risk of major and minor depression in early
postmenopause versus premenopause. Effectiveness of ET as an
antidepressant in perimenopausal women has been demonstrated in two
RCTs, whereas one RCT did not demonstrate effectiveness in older
postmenopausal women. There is insufficient evidence to recommend using
ET or EPT to treat depression.

PREMATURE MENOPAUSE OR OVARIAN FAILURE

Premature menopause and ovarian failure are linked to a lower risk of
breast cancer, early osteoporosis, and CHD; it is unknown if ET or EPT
affect morbidity and mortality rates from these conditions. It also is
unknown if the risk/benefit ratio may be favorable for younger women who
start ET or EPT at an earlier age.

RISK/BENEFIT RATIO

ET and EPT use should be consistent with treatment goals, benefits, and
risks. It also should take into account factors such as the cause of
menopause; time since menopause; symptoms; and other issues that could
affect quality of life or risk of cardiovascular disease, stroke, venous
thrombosis, or other conditions.

LOWER DOSES

Studies have shown similar relief of vasomotor or vulvovaginal symptoms
and maintenance of bone mineral density with lower-dose ET or EPT (e.g.,
0.3 mg of oral conjugated estrogen daily, 0.25 to 0.50 mcg of oral
micronized 17 beta-estradiol) compared with standard doses. These lower
doses appear to better tolerated and have a better risk/benefit ratio;
however, lower doses have not been evaluated in long-term studies.

NONORAL THERAPY

The risk/benefit ratio of nonoral EPT or ET administration is unknown.
Differences between oral and nonoral administration are related to the
role of first-pass hepatic effect, hormone concentrations in the blood
by the given administration option, and biologic activity of active
ingredients. Some evidence exists regarding an association between 17
beta-estradiol and a lower risk of deep venous thrombosis compared with
oral ET.

LONG-TERM THERAPY IN SYMPTOMATIC WOMEN

Although RCTs in symptomatic perimenopausal women have not been
performed, results of the WHI suggest that physicians should use caution
in prescribing long-term therapy for these patients.

Extended use of ET or EPT in women who are aware of the risks and
benefits and are under physician supervision is acceptable under certain
circumstances: (1) the patient feels that the benefit of relief from
menopause outweighs the risk of extended use; (2) the patient has
moderate or severe menopausal symptoms and is at high risk of
osteoporotic fracture; or (3) the patient has reduced bone mass and
wants to prevent future bone loss, and alternative therapies are
inappropriate (e.g., cause adverse effects, have unknown outcomes).

SYMPTOM RECURRENCE

If ET or EPT is discontinued, symptoms have a 50 percent chance of
returning. Decisions about whether or not to continue therapy should be
based on symptom severity and the current risk/benefit ratio.

QUALITY OF LIFE

Because ET and EPT improve menopausal symptoms, there typically is an
associated increase in health-related quality of life. However, there is
disagreement about whether this is true in asymptomatic women as well.
Validated instruments should be incorporated into future studies to help
determine the effects of ET and EPT on quality of life.

CLASS VS. PRODUCT EFFECT

RCTs are the only way to determine the different outcomes of various
therapies. It is not possible to extrapolate the results of one study to
another. However, if data specific to a certain agent are lacking,
results from one trial can be generalized to other agents within the
same family if they are given in equivalent dosages.

BIOIDENTICAL HORMONES

Safety concerns about ET and EPT products have prompted an increase in
the use of alternative dose forms (e.g., gels, suppositories) that are
not commercially available. Because there are no safety or effectiveness
data for these forms, a generalized risk/benefit ratio based on
commercially available products can be used instead. However, it is
recommended that these alternative dose forms be used cautiously in case
of possible lack of quality or purity or batch-to-batch ingredient
inconsistencies.

Discussion

NAMS found insufficient or inconsistent evidence regarding several major
factors of ET and EPT. There was disagreement over the best way to
discontinue therapy, such as whether it should be abruptly discontinued
or gradually tapered off. There also was insufficient evidence to
determine if continuous-combined EPT has a different effect than
continuous ET with continuous-sequential EPT. Lastly, there was
conflicting evidence regarding signs that some continuous progestogen
doses could be linked to adverse breast cancer or cardiovascular
outcomes.

NAMS recognizes that each woman\'s willingness to accept risks
associated with ET or EPT varies, and that disease outcomes are
dependent on age and time since start of menopause. It cannot be assumed
that the risks and benefits of ET and EPT apply to all ages and therapy
durations. It is important to understand that even if ET and EPT are not
being used, there is still a risk of developing all diseases under
consideration in this statement, an idea that is demonstrated in the
rates of disease seen in the RCT placebo groups. NAMS concludes that
there are still many areas needing further research (e.g., timing of
starting therapy, comparison of different formulations, long-term risks
and benefits) with regard to ET and EPT in perimenopausal and
postmenopausal women.

<http://www.menopausejournal.com/pt/re/menopause/home.htm;jsessionid=GLcWXZGbHkQsvYx7HQKLnJv3G1j2bWWFSnGG7LLxfm5G8jC10ZVc!-362743511!181195628!8091!-1>

or

<http://www.aafp.org/afp/20070715/practice.html>

**Atrophic Vaginitis and Estrogen Treatment: Medscape CME**

<http://www.medscape.com/viewprogram/7489?sssdmh=dm1.291271&src=nlcmealert>

Hormone Therapy Safer in Younger Women? A Best Evidence Review

[**http://www.medscape.com/viewprogram/7404?src=mp**](http://www.medscape.com/viewprogram/7404?src=mp)

Vitamin E Does Not Protect Cognitive Function

**Results:** At the end of the trial, the total study population was
5,845, and the mean follow-up time was 9.6 years. The vitamin E and
placebo groups had similar characteristics except for a higher level of
education in the placebo group. Cognitive function scores at the start
of the study were similar for the placebo and treatment groups. There
was no difference between the groups with regard to cognitive change
over time.

**Conclusions:** Vitamin E supplementation does not offer cognitive
benefits in healthy older women. Although the study did not address the
use of vitamin E at younger ages, it showed that vitamin E
supplementation of 10 years or less did not offer neuroprotection.

Kang JH, et al. A randomized trial of vitamin E supplementation and
cognitive function in women. Arch Intern Med December 11/25,
2006;166:2462-8.

<http://www.aafp.org/afp/20070815/tips/6.html>

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

**Midwives Corner**, **Lisa Allee, CNM, Chinle**

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

CONCLUSION: Group prenatal care resulted in equal or improved perinatal
outcomes at no added cost. CLINICAL TRIAL REGISTRATION:
ClinicalTrials.gov, www.clinicaltrials.gov, NCT00271960 LEVEL OF
EVIDENCE: I.

[Ickovics
JR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ickovics JR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Group prenatal care and perinatal outcomes: a randomized
controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Aug;110(2 Pt 1):330-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17666608&dopt=AbstractPlus>

**Skin-to-skin care with the father after cesarean birth and its effect
on newborn crying and prefeeding behavior**

CONCLUSIONS: The infants in the skin-to-skin group were comforted, that
is, they stopped crying, became calmer, and reached a drowsy state
earlier than the infants in the cot group. The father can facilitate the
development of the infant\'s prefeeding behavior in this important
period of the newborn infant\'s life and should thus be regarded as the
primary caregiver for the infant during the separation of mother and
baby.

Erlandsson K; et al Skin-to-skin care with the father after cesarean
birth and its effect on newborn crying and prefeeding behavior. [Birth.
 2007;
34(2):105-14](http://www.medscape.com/medline/publicationbrowser/123?pmid=17542814) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17542814>

**Midwifery's approach to pre-labor SROM supported by professional
organization's journal**

Morwitz and Jordan present a review of the literature on pre-labor
rupture of membranes at term. Most significantly, they point out some of
the flaws in the TERMPROM study by Hannah et al. The biggest problem was
that there was no control of the number of vaginal exams, which have
been shown to be directly correlated with increased risk of infection by
Hannah et al. and others. Speculation has been made that if the number
of vaginal exams had been limited in the study pool the results may have
been different. Another problem has to do with GBS-positive management
being very different and inconsistent during the study time period as
compared to today. The authors' concluding statements support the
time-honored midwifery practice of having options in the management of
pre-labor SROM tailored to the individual patient and setting and the
integral role played by the woman herself in the decision making
process.

'Two practices supported by current research findings should be
incorporated into midwifery care of women with term PROM. The first is
to strictly limit vaginal examinations. There is considerable evidence
documenting the increased risk of perinatal infection related to digital
vaginal examination, yet little change has occurred in this aspect of
practice. Despite ACOG's recommendation that vaginal examination should
be deferred during the initial evaluation, doing a "baseline vaginal
exam" is common practice. Requiring vaginal examinations at set
intervals to prove labor progression is another entrenched habit. A
speculum examination to determine initial cervical status is sufficient
in most cases, and digital examinations should be done only when the
information is needed to make management decisions. The second practice
is to consistently provide information about the options of expectant
management and immediate induction to women with term PROM, and to
involve them in the decision-making process. This is congruent with
midwifery hallmarks and philosophy of care. In addition, it is
explicitly supported by Cochrane reviewers and the TERMPROM researchers.

In an editorial accompanying the publication of the term PROM study,
Duff stated his view that the practice of expectant management should be
abandoned. An unquestioning acceptance of this view is not justified
based on available evidence. Women should be fully informed on the risks
and benefits of induction and expectant management, and offered both
options. Midwives should strive to remain champions of a care approach
that involves women in decision making and supports the value of
nonintervention.'

Marowitz, A; Jordan, R Midwifery management of prelabor rupture of
membranes at term. J Midwifery Womens Health. 2007 May-Jun;52(3):199-206

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17467586>

**[Editorial Comment by Lisa Allee, CNM:]{.underline}**

I couldn't have said it better myself. But I will add my two cents, too.
I think the ACOG statement that induction should be started immediately
upon SROM is over interventionist, not evidence based, and disrespectful
of the inherent wisdom and intelligence of women's bodies and minds. I
encourage midwives to feel supported by our professional organization's
journal in continuing evidence-based approaches to pre-labor SROM by
offering options of induction or awaiting spontaneous labor. AND most
importantly keep your fingers out of there!!! (Really folks, the vaginal
exam does not make much difference --her cervix is what is and her labor
goes as it goes no matter if we check the cervix or not AND there are
other ways to tell how her labor is progressing---tune in and labor
sit.)

[Hannah
ME](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hannah ME"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Induction of labor compared with expectant management for prelabor
rupture of the membranes at term. TERMPROM Study Group. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 1996 Apr
18;334(16):1005-10
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8598837>

[Duff
P](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Duff P"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Premature rupture of the membranes at term. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 1996 Apr
18;334(16):1053-4

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8598845>

**Navajo News John Balintona, Shiprock**

Evaluation of the pregnant patient for non-obstetric surgery

This is Part one of a two Part series on evaluation of the pregnant
patient for non-obstetric surgery.

Nonobstetric surgical conditions that occur during pregnancy require
communication between obstetric providers specialists. One large
retrospective study cited the incidence of nonobstetric surgical
intervention as occurring in roughly 0.75% of pregnancies. The anatomic
and physiologic changes that occur during pregnancy can be profound and
the obstetric provider should be familiar with the effects that surgical
illness can have on pregnant patients. Furthermore, the obstetric
provider can be called on to direct the evaluation of a pregnant patient
who may require a surgical procedure. The purpose of this paper is to
review generalizations for care and offer a rational approach for
management. Pre-operative evaluation with specific focus on physiologic
changes in the cardiovascular, pulmonary, gastrointestinal, and renal
systems will be addressed. Other topics that will be reviewed include
laboratory data, imaging techniques, anesthetic and surveillance
considerations.

# Maternal Adaptation in Pregnancy

At term, the pregnant uterus can reach a capacity of 500 to 1000 times
the capacity of a nonpregnant uterus. The sheer size of this organ may
complicate the evaluation of a patient. After the 12th week of
pregnancy, the uterus typically has grown out of the pelvis and can be
considered an abdominal organ. As the pregnancy progresses and the
uterus enlarges, the intestines are displaced laterally and superiorly.
This fact is specifically important when evaluating a patient for
suspected appendicitis as McBurney's Point is directed toward the right
upper quadrant. The growth of the uterus can also be a cause for
abdominal pain. Tension is exerted upon the broad and round ligaments
that subsequently can be manifested as pain in certain patients.

The large pregnant uterus is known to compress the venous system in the
lower half of the body, which can reduce cardiac filling and cardiac
output. Placing the patient in the left lateral recumbent position can
alleviate this effect. It has been reported that uteroplacental blood
flow ranges from 450 to 650 ml/min is term pregnancies. Placental
perfusion by maternal blood is dependent in turn upon blood flow to the
uterus through the uterine and ovarian arteries; therefore hypoperfusion
before, during, and after surgical procedures must be properly
addressed.

The resting pulse increases on average 10 to 15 beats per minute during
pregnancy. Sinus tachycardia, however, is not considered normal during
pregnancy and should be evaluated. The cardiac output of a pregnant
patient at rest is markedly increased, in part this is due to increase
in maternal weight and increase in basal metabolic rate. Arterial blood
pressure in a pregnant individual tends to decreases to a nadir during
mid-pregnancy and rises thereafter, however, hypertension in an
otherwise non-hypertensive pregnant patient does deserve an evaluation.
It is reported that normal pregnancy induces no characteristic change in
an ECG other than a slight left axis deviation. The heart is displaced
in the thorax to the left and upward due to the elevation of the
diaphragm. This in turn leads to an increase in the size of the cardiac
silhouette on chest x-ray.

During pregnancy, the diaphragm rises appreciably and the subcostal
angle widens, both of which can be seen on plain chest x-ray. This
physiologic change affects certain aspects of pulmonary function in
these patients, but overall pulmonary function is not impaired during
pregnancy. It is known that the tidal volume, minute ventilatory volume
and minute oxygen uptake increase as pregnancy advances. It is believed
that the increased tidal volume is responsible for the increased
perception of breathing in these patients, which may be interpreted as
dyspnea. Evaluation of the cardiovascular and pulmonary systems under
this circumstance tends to be within normal limits. Normal pregnancy is
associated with little change in the respiratory rate, therefore,
tachypnea does deserve further evaluation. The lung sounds of a pregnant
patient should be similar to a nonpregnant individual and any finding on
auscultation should be addressed.

As previously noted, during normal pregnancy the uterus displaces the
stomach and intestines. This physiologic change, along with hormonal
factors, contributes to the delayed gastric emptying and intestinal
transit times in pregnant patients. This condition is especially
significant during cases requiring general anesthesia where
regurgitation and aspiration is a risk. Pregnancy can induce a focal
highly vascular swelling of the gums, known as epulis of pregnancy.
Patients with this condition often complain of bleeding when brushing
their teeth. An exam of the oral cavity by a qualified provider should
rule out most other causes of bleeding gums. This condition usually
regresses spontaneously after delivery and pregnancy is not known to
promote tooth decay. Hemorrhoids are also common during pregnancy that
is caused in large part to constipation and elevated pressure in veins
below the level of the enlarged uterus. This condition may regress after
delivery and therefore many general surgeons may defer definitive
treatment until the postpartum period. Bloody stool or blood from the
rectum may be associated with the aforementioned hemorrhoids, but other
more serious conditions may exist or result and therefore at a minimum a
rectal exam should be performed on these individuals.

The urinary system undergoes a remarkable number of changes during
normal pregnancy that need to be recognized when evaluating the pregnant
patient. There is a normal dilation of pelves, calyces, and ureters,
which can be shown during ultrasound and IVP. Typically this phenomenon
is more evident on the right. In absence of other clinical findings,
this should not automatically be interpreted as obstructive uropathy.

Renal length can increase about 1 cm during pregnancy and decrease after
delivery should not necessarily be interpreted as parenchymal loss.

Stay tuned for next month's Navajo Corner for the conclusion which will
include discussion of

# Laboratory Data and Imaging Studies and Anesthetic and Operative Considerations

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

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

**Nurses Corner, Sandra Haldane, HQE**

**Nursing education scholarship opportunities**

I want to alert you to the HRSA web site below where you can get
information on nursing education scholarship opportunities.  Questions
<Carolyn.Aoyama@ihs.gov>

<http://www.hrsa.gov/help/healthprofessions.htm>

#### Behavioral and Social Sciences Research: National Assoc. of Clinical Nurse Specialists {#behavioral-and-social-sciences-research-national-assoc.-of-clinical-nurse-specialists-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### EBBP.org is the beta version of a web-based training resource funded by NIH\'s Office of Behavioral and Social Sciences Research.  The site is being developed to provide information and tools to promote evidence-based behavioral practice (EBBP).    We are interested in your opinions about the appearance, content, organization, and overall quality of the website. The evaluation survey will take approximately 5 minutes to complete. In appreciation for your time, survey participants may enter a drawing to win one of three \$100 gift cards to Amazon.com.  To view the website and complete the evaluation survey, please click here: [**http://www.ebbp.org**](http://www.ebbp.org/)  Bonnie Spring, Ph.D., ABPP Telephone:  312-908-2293 FAX:  312-908-9588 e-mail:  [**bspring@northwestern.edu**](mailto:bspring@northwestern.edu) {#ebbp.org-is-the-beta-version-of-a-web-based-training-resource-funded-by-nihs-office-of-behavioral-and-social-sciences-research.-the-site-is-being-developed-to-provide-information-and-tools-to-promote-evidence-based-behavioral-practice-ebbp.-we-are-interested-in-your-opinions-about-the-appearance-content-organization-and-overall-quality-of-the-website.-the-evaluation-survey-will-take-approximately-5-minutes-to-complete.-in-appreciation-for-your-time-survey-participants-may-enter-a-drawing-to-win-one-of-three-100-gift-cards-to-amazon.com.-to-view-the-website-and-complete-the-evaluation-survey-please-click-here-httpwww.ebbp.org-bonnie-spring-ph.d.-abpp-telephone-312-908-2293-fax-312-908-9588-e-mail-bspringnorthwestern.edu .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Companion Animals and Human Health Risk: Animal Bites and Rabies {#companion-animals-and-human-health-risk-animal-bites-and-rabies-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Topics in Advanced Practice Nursing](http://www.medscape.com/nursingejournal): Medscape {#topics-in-advanced-practice-nursing-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/7550?src=mp**](http://www.medscape.com/viewprogram/7550?src=mp) {#httpwww.medscape.comviewprogram7550srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-20 .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}

**STD Treatment Guidelines - Personal Digital Assistant Version**

This point-of-care tool includes the complete 2006 STD Treatment
Guidelines. The recommendations for each category have been moved to the
top of the screen for efficiency, and the table of contents has been
prioritized according to the needs of clinicians.

<http://www.cdc.gov/std/treatment/PDA/default.htm>

**Perinatal Group B Streptococcal Disease After Universal Screening
Recommendations**

This report indicates that annual incidence of early onset Group B
streptococcus (GBS) disease (i.e., in infants aged 0-6 days) was 33%
lower during 2003-2005 than during 2000-2001. However, although
incidence among white infants decreased steadily during 2003-2005,
incidence increased 70% among black infants. Incidence of GBS disease
among infants aged 7-89 days (i.e., late-onset disease) and pregnant
women remained stable after revised universal screening guidelines were
issued. Continued surveillance is needed to monitor the impact of the
guidelines on perinatal GBS disease and trends in racial disparities and
to guide interventions to reduce disparities.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5628a1.htm>

####  {#section-21 .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}

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

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

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

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

#### [Editorial comment:]{.underline} Greggory Woitte -- Hastings Indian Medical Center

**Preconception Counseling**

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

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

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

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

ACOG Committee Opinion Number 313. The importance of preconception care
in the continuum of women\'s health care. [American College of
Obstetricians and
Gynecologists](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="American College of Obstetricians and Gynecologists"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2005 Sep;106(3):665-6.

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

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

Office of Communication (770) 488-5131

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

Lifestyle Intervention and BMD in Adolescent Girls

**Results:** Of 228 girls, 113 were randomized to the intervention
group. The intervention group had significantly higher BMD at the spine
and trochanter regions at one year compared with the control group; they
maintained this increase during year 2. The intervention group also had
biomarkers for bone turnover that were more consistent with an increase
in bone building. Compared with the control group, the intervention
group had greater consumption of calcium and fruits and vegetables in
both years and vitamin D consumption in the first year. There were no
differences between the two groups with regard to soda consumption or
exercise rates.

**Conclusions:** The authors conclude that increasing BMD in adolescent
girls can be accomplished through a comprehensive health care-based
lifestyle intervention. They note that this study is the first
nonschool-based intervention that emphasized self-directed behavior
changes.

DeBar LL, et al. YOUTH: a health plan-based lifestyle intervention
increases bone mineral density in adolescent girls. Arch Pediatr Adolesc
Med December 2006;160:1269-76.

<http://www.aafp.org/afp/20070815/tips/4.html>

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

CONCLUSION: In a complementary way with previous studies in older women,
where decision rules were valuable to identify the majority of women
likely to have osteoporosis, our data indicate that in younger
postmenopausal women, decision rules are useful as a screening method to
rule out the presence of osteoporosis and the need for BMD scanning

[Martínez-Aguilà
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Martínez-Aguilà D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Decision rules for selecting women for bone mineral density
testing: application in postmenopausal women referred to a bone
densitometry unit. [J
Rheumatol.](javascript:AL_get(this, 'jour', 'J Rheumatol.');) 2007
Jun;34(6):1307-12

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17552058>

**SSRI Use in Older Women Linked to Accelerated Hip Bone Loss**

CONCLUSION: Use of SSRIs but not TCAs is associated with an increased
rate of bone loss at the hip in this cohort of older women.

[Diem
SJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Diem SJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Use of antidepressants and rates of hip bone loss in older women:
the study of osteoporotic fractures. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 Jun
25;167(12):1240-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17592096>

**Effects of the phytoestrogen genistein on bone metabolism in
osteopenic postmenopausal women: a randomized trial**

CONCLUSION: Twenty-four months of treatment with genistein has positive
effects on BMD in osteopenic postmenopausal women

Marini H et al osteopenic postmenopausal women: a randomized trial. [Ann
Intern Med.  2007;
146(12):839-47](http://www.medscape.com/medline/publicationbrowser/123?pmid=17577003)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17577003>

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

**Women\'s Health Booklets**

Colleagues:

Below are URLs that will take you to a Medicare site offering patient
education materials on women's health topics.  For example, one booklet
explains the mammogram and provides information about breast health. (24
pages), another answers to commonly asked questions from older women
about Pap tests, HPV, and the Medicare benefit for Pap test screening.
(2 pages), includes information women need to know about heart disease.
(2 pages).  There is a charge for these booklets. Link to other CMS
women's health publications.

[http://www.medicare.gov/Publications/Search/Results.asp?PubName=women&PubCat=All%7CAll+Publications&Type=NameCat&Language=English&pagelist=Home&dest=NAV%7CHome%7CSearch%7CResults%7CSearchCriteria&comingFrom=13&version=default&browser=IE%7C6%7CWinXP&go2.x=14&go2.y=8](http://www.medicare.gov/Publications/Search/Results.asp?PubName=women&PubCat=All|All+Publications&Type=NameCat&Language=English&pagelist=Home&dest=NAV|Home|Search|Results|SearchCriteria&comingFrom=13&version=default&browser=IE|6|WinXP&go2.x=14&go2.y=8)

Contact
[[Carolyn.Aoyama@ihs.gov]{.underline}](mailto:Carolyn.Aoyama@ihs.gov)

Site to order other CMS publications
<http://pubordering.cms.hhs.gov/mailinglist/>

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

#### STIs in Pregnancy: Protecting Yourself and Your Baby {#stis-in-pregnancy-protecting-yourself-and-your-baby-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070715/272ph.html**](http://www.aafp.org/afp/20070715/272ph.html) {#httpwww.aafp.orgafp20070715272ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Monitoring Your Blood Pressure at Home {#monitoring-your-blood-pressure-at-home-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070715/261ph.html**](http://www.aafp.org/afp/20070715/261ph.html) {#httpwww.aafp.orgafp20070715261ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Monitoring Your Blood Sugar at Home {#monitoring-your-blood-sugar-at-home-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070715/262ph.html**](http://www.aafp.org/afp/20070715/262ph.html) {#httpwww.aafp.orgafp20070715262ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Insomnia: What You Should Know {#insomnia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070815/527ph.html**](http://www.aafp.org/afp/20070815/527ph.html) {#httpwww.aafp.orgafp20070815527ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Preventing Another Stroke: What You Should Know {#preventing-another-stroke-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070801/389ph.html**](http://www.aafp.org/afp/20070801/389ph.html) {#httpwww.aafp.orgafp20070801389ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-27 .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}

**Nausea and Vomiting of Pregnancy**

**Editorial Note**

This month's Perinatology Picks submission offers background on Nausea
and Vomiting of Pregnancy for the 3 questions posed in last month's
Medical Mystery Tour. This background is based on the Perinatology
Corner CME module on Nausea and Vomiting of Pregnancy

After you peruse this material, you should go to the link directly
below, take the Posttest and receive free CME credit.
<http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm>

**Background**

Over 75 per cent of pregnant women experience some degree of nausea and
vomiting during pregnancy. Up to 2 per cent of pregnancies are
complicated by the severe syndrome referred to as hyperemesis
gravidarum, which frequently prompts hospital admission for control of
symptoms and the accompanying biochemical abnormalities.

A treatment algorithm for this spectrum of symptoms, based on the
available evidence, will be suggested for mild nausea and vomiting and
for severe nausea and vomiting (hyperemesis gravidarum) One clinical
definition is persistent vomiting, with weight loss exceeding 5 percent
of pre-pregnancy body weight, and ketonuria.

**Clinical Features**

There are several classic features of hyperemesis gravidarum. It
presents early in the first trimester of pregnancy, usually in the
fourth to tenth week of gestation, with intractable vomiting. Many
patients have weight loss exceeding 5 percent of their body weight.
Abdominal pain is infrequent.

Patients may present with ketosis and electrolyte derangements such as
hypokalemia and metabolic alkalosis. There is often an increase in
hematocrit, indicating hemoconcentration due to plasma volume depletion.
The degree of hemoconcentration may be underestimated unless the decline
in hematocrit seen in normal pregnancies is considered. Abnormal liver
enzymes may also be present.

**Risk factors**

Studies of the risk factors for hyperemesis gravidarum have been small,
and results not always definitive. Advanced maternal age (age \>35) and
cigarette smoking (perhaps due to the effect of nicotine may be
protective. An association with gestational trophoblastic disease has
been well-described.

Non-pregnant women who experience nausea and vomiting after estrogen
exposure, from motion sickness, with migraine, or with exposure to
certain tastes (supertasters) are more likely to have pregnancy-related
nausea and vomiting. In contrast, anosmic women appear to be at low risk
for this disorder.

**Case Scenario**

Mrs. B is a 24 y/o G1P0 at 10 weeks by her dates who presents to her
first prenatal visit complaining of morning sickness. Her symptoms are
not incapacitating, but she would like to feel better. She has tried
various herbal teas without much relief.

Your most useful recommendation at this initial visit would be?

Try the following in a stepwise or cumulative fashion:

a.  Advise the patient to temporarily discontinue her prenatal vitamins
    with iron if she feels they are upsetting her stomach.

b.  Make dietary adjustments (small, frequent, low fat meals, etc.).

c.  Avoidance of triggers

d.  Try alternative therapies such as ginger, chamomile, or peppermint
    teas. (Acupressure at the wrist P6 locus has not been shown to be
    superior to placebo in the available aggregate data.)

e.  Prescribe pyridoxine (vitamin B6) 25 mg po tid.

f.  Add the H1-receptor blocker doxylamine 12.5 mg po tid if needed.

g.  Anti-emetic for p.r.n. use if intermittent more severe symptoms.

> Prescribe a phenothiazine: promethazine 12.5-25 mg po/pr
>
> Prescribe an antihistamine: hydroxyzine 12.5-25 mg po

If symptoms persists despite the above methods, consider adding:

a.  metoclopramide 5-10 mg po tid,

> a cholinomimetic agent
>
> (manufacturer's nonrandomized study demonstrated 78 % efficacy)

b.  if relief is not obtained, consider the 5-HT-3 receptor inhibitor,
    dolasetron 25-100 mg po tid. (expensive, over 80 % effective in only
    randomized controlled trial)

(None of the above medications have been associated with an increased
risk of fetal malformations.)

**Initial Work-up: History**

**Case Scenario**

Mrs. H is a 30 y/o G3P2 at 9 weeks by her dates who presents for her
first prenatal visit complaining of nausea with vomiting that lasts
pretty much all day, but she is able to keep some food down. She says
this has occurred with each of her pregnancies, but this time it is
especially troublesome. She has had a small amount of spotting but no
cramping. She appears to be well hydrated.

Your initial work up at this time should include?

Hyperemesis is generally a diagnosis of exclusion, based on its
occurrence in pregnancy before 10 weeks of gestation and likely gradual
resolution

A simple basic workup is helpful and might include:

History: Anything to suggest:

Gastrointestinal problems?

-gastroenteritis, hepatitis, pancreatitis, cholelithiasis, ulcer

-colicy RUQ pain radiating to the shoulder for gallbladder disease,
epigastric pain and pyrosis for peptic ulcer disease, a history of
ethanol ingestion, etc....

Metabolic problems?

-diabetes, porphyria

Neurologic disease?

-migraine, tumor, vestibular lesions

Pregnancy related?

(typically in the latter half of pregnancy)

-Preeclampsia

-HELLP syndrome (Hemolysis, Elevated Liver function tests, Low
Platelets)\
-Acute fatty liver of pregnancy

Other

Drug toxicity, genitourinary tract disorders, and psychological problems

Nausea and vomiting that develop after 10 weeks of gestation are not
likely due to hyperemesis gravidarum.

Associated symptoms suggesting other etiologies discussed above include
abdominal pain, fever, headache, goiter, abnormal; neurologic findings,
or hypertension.

**Initial Work-up: Physical exam and lab**

Hyperemesis gravidarum is a clinical diagnosis, without uniform
criteria. As discussed above, one clinical definition is persistent
vomiting, with weight loss exceeding 5 percent of pre-pregnancy body
weight, and ketonuria.

Nausea and vomiting that develop after 10 weeks of gestation are not
likely due to hyperemesis gravidarum. Associated symptoms suggesting
other etiologies include abdominal pain and headache. See physical
findings and lab abnormalities below.

Physical Exam:

-measurement of weight, orthostatic blood pressures

-fever

-hypertension

-goiter

-abnormal neurologic findings

Lab:

Thyroid function testing

See What about thyroid disease in pregnancy?

Unine

-Ketones

Electrolytes

(hypokalemia is the most common abnormality encountered)

Screen for hepatitis

Serum aminotransferase elevation is usually lower in hyperemesis than in
viral hepatitis. Similarly, serum amylase levels are usually elevated to
a lesser degree than in patients with acute pancreatitis and are of
salivary rather than pancreatic

Alanine aminotransferase

(ALT, formerly known as SGPT or the serum glutamic pyruvate
transaminase)

-usually the most sensitive.

-if it is abnormal, then you can investigate further from there.

If your initial therapy proves unhelpful and the symptoms become worse
or evolve, then more of a GI work up may certainly be indicated later.

Ultrasound

An ultrasound examination is performed to exclude molar pregnancy and
multiple gestation, both of which are associated with hyperemesis.

**What about thyroid disease in pregnancy?**

While nausea and vomiting is not a common symptom of hyperthyroidism, it
has somehow become routine to order thyroid functions on these women.

signs of hyperthyroidism.

If you have read the Perinatologist Corner on Thyroid Disease in
Pregnancy, you will recall that these women, who typically have high
human chorionic gonadotrophin (HCG) levels, will frequently have an
assay for TSH that often returns very low, suggesting hyperthyroidism.
This may occur in up to 20% of pregnant women in whom the newer third
generation, ultrasensitive TSH assays are obtained. These women may even
have a mildly elevated free T4, but they will be clinically euthyroid,
without tremor, tachycardia, hyperreflexia, or the other signs of
hyperthyroidism.

Both these biochemical abnormalities will resolve by 18 weeks and
anti-thyroid medications should not be started. (They will not help the
nausea and vomiting either!) They may cause the fetus, who is totally
dependent on its mother's thyroxine until its own gland becomes
functional at about 18 weeks, to become hypothyroid, with the
accompanying later intellectual deficits.

Features that distinguish the transient hyperthyroidism of hyperemesis
gravidarum from hyperthyroidism of other causes (which in a pregnant
woman is most likely to be due to Graves\' disease) are the vomiting,
absence of goiter and ophthalmopathy, and absence of the common symptoms
and signs of hyperthyroidism (heat intolerance, muscle weakness,
tremor). In addition, serum free T4 concentrations are only minimally
elevated and serum T3 concentrations are not elevated in women with
hyperemesis gravidarum, whereas both are usually unequivocally elevated
in pregnant women with true hyperthyroidism. Treatment of
hyperthyroidism should not be undertaken without clear evidence of a
primary thyroid disorder (eg, goiter, elevated free thyroid hormone or
elevated TSH receptor antibody levels).

"Primum non nocere" (first do no harm)!

**Hyperemesis gravidarum: What is helpful ?**

**Case Scenario**

Mrs P is a 19 y/o G1P0 at 11 weeks by her dates who presents to the
emergency department complaining of severe nausea and vomiting. She is
wretching, appears ill, and is only able to produce a small amount of
concentrated urine that is strongly positive for ketones.

Your initial management should include?

Severe Nausea and Vomiting of Pregnancy (Hyperemesis gravidarum)

The diagnosis of hyperemesis gravidarum is applied to the most severely
affected patients, approximately 0.5 to 2 percent of pregnancies.

Hyperemesis gravidarum is intractable vomiting, not responsive to the
above outpatient treatments. It is associated with dehydration, 4+
ketonuria, and/or electrolyte derangements, such that hospitalization
for intravenous hydration is required.

1.  Admit.

2.  NPO; advance to sips and chips as tolerated.

3.  IV hydration, with electrolyte replacement as indicated.

4.  Rule out other causes (cholecystitis/pancreatitis, pyelonephritis,
    hepatitis, hyperthyroidism, etc.....)

5.  Many patients with hyperemesis will demonstrate biochemical evidence
    of a hyperthyroid state, but this is usually secondary to their high
    HCG levels. Treatment with anti-thyroid medications is usually not
    indicated, does not relieve nausea and vomiting, and may cause the
    patient, and the fetus, to become hypothyroid if continued beyond 18
    weeks gestation.

6.  IV multivitamin replacement (especially thiamine 100 mg per liter,
    to prevent a Wernicke's encephalopathy-like picture) if symptoms
    very severe and protracted.

7.  Any of the following parenteral anti-emetics:

    a.  dimenhydrinate 50 mg in 50 mL NS q4-6h IV over 20 minutes

    b.  metoclopramide 5-10 mg q8h IV

    c.  promethazine 12.5-25 mg q4h IV

    d.  dolasetron 4-8 mg over 15 minutes q12h IV

When the patient tolerates adequate oral intake, she may be considered
for outpatient management. She may be sent home on the pharmacologic
interventions recommended above for "Moderate Nausea and Vomiting of
Pregnancy".

**Algorithm**

Here is another helpful approach from Levichek Z et al 2002

**QUESTION** One of my patients suffers from a moderate-to-severe form
of morning sickness. She responded only partially to doxylamine and
pyridoxine, and I wish to try adding another medication. What should my
priority be?

**ANSWER**\
An algorithm used by Motherisk to manage thousands of patients takes a
hierarchical approach to this condition. This approach is evidence based
with regard to fetal safety as well as efficacy. (Go to 'algorithm used
by Motherisk' and scroll down page to see algorithm)

(This link is available in the CME module)

**Hyperemesis gravidarum: What is NOT helpful**

Interventions considered not helpful for the treatment of hyperemesis:

1.Total parenteral nutrition has been associated with life-threatening
complications. These complications are usually secondary to central
intravenous access complications. This form of therapy may have more
hazards to the patient than the underlying disorder, and is not
recommended.

Short-term peripheral parenteral nutrition (through a "PICC-Line") may
be appropriate for selected cases.

2\. Parenteral steroids (e.g., methylprednisolone) have not been
consistently shown to be helpful in the aggregate meta-analysis data,
and are no longer recommended for inpatient treatment of hyperemesis.

Most obstetricians avoid chronic administration of corticosteroids in
pregnant women, when possible, because prolonged use appears to increase
the risk of preterm premature rupture of membranes (PPROM). There may
also be a slightly increased risk of oral clefts when the drugs are
administered before 10 weeks of gestation. Data on the efficacy of this
therapy largely derives from case reports; most randomized controlled
trials using corticosteroids for treatment of hyperemesis failed to show
a significant decrease in nausea and vomiting or number of hospital
admissions.

3\. There is little evidence that psychotherapy is helpful for
hyperemesis, but the social situation of some patients may make
short-term counseling a helpful adjunctive treatment modality.

**Are these medications harmful to my fetus**?

The agents below are Pregnancy Class A -- C. (see Table, below). None of
the above medications have been associated with an increased risk of
fetal malformations. See Drug Safety below

+-------------+-------------+-------------+------------+--------------+
| **Agent**   | **Drug      | **Dose**    | *          | **Rx**       |
|             | Class**     |             | *Pregnancy |              |
|             |             |             | Class**    |              |
+-------------+-------------+-------------+------------+--------------+
| **P         | Vitamin     | 25 mg po    | A          | **Oral:** 25 |
| yridoxine** |             |             |            | mg po tid    |
|             |             |             |            |              |
| **(Vitamin  |             |             |            |              |
| B6)**       |             |             |            |              |
+-------------+-------------+-------------+------------+--------------+
| **D         | An          | 12.5 mg po  | A          | **Oral:**    |
| oxylamine** | tihistamine |             |            | 12.5 mg po   |
|             |             |             |            | tid          |
|             | (H-1        |             |            |              |
|             | Blocker)    |             |            |              |
+-------------+-------------+-------------+------------+--------------+
| **Fructose, | Antiemetic  | 15-30 mL    | A          | **Oral:**    |
| dextrose,   |             |             |            | 15-30 mL on  |
| and         |             |             |            | arising;     |
| orth        |             |             |            | repeat every |
| ophosphoric |             |             |            | 3 hours or   |
| acid**      |             |             |            | when nausea  |
|             |             |             |            | threatens    |
+-------------+-------------+-------------+------------+--------------+
| **D         | An          | Doxylamine  | A          | **Oral:**    |
| oxylamine** | tihistamine | succinate   |            | Two delayed  |
|             |             | 10 mg po    |            | release      |
| **/         | (H-1        |             |            | tablets (a   |
| p           | Blocker)    | /           |            | total of     |
| yridoxine** |             | pyridoxine  |            | doxylamine   |
|             | Vitamin     | hy          |            | 20 mg and    |
| Available   |             | drochloride |            | pyridoxine   |
| in Canada,  |             | 10 mg po    |            | 20 mg) at    |
| **not**     |             |             |            | bedtime.     |
| available   |             |             |            |              |
| in U.S.     |             |             |            | In severe    |
|             |             |             |            | cases or in  |
|             |             |             |            | cases with   |
|             |             |             |            | nau          |
|             |             |             |            | sea/vomiting |
|             |             |             |            | during the   |
|             |             |             |            | day, dosage  |
|             |             |             |            | may be       |
|             |             |             |            | increased by |
|             |             |             |            | 1 tablet in  |
|             |             |             |            | the morning  |
|             |             |             |            | and/or       |
|             |             |             |            | afternoon.   |
+-------------+-------------+-------------+------------+--------------+
| **Pro       | Ant         | 12.5-25 mg  | C          | **Oral,      |
| methazine** | ihistamine\ | po          |            | I.M., I.V.,  |
|             | Ph          |             |            | rectal:**    |
|             | enothiazine |             |            |              |
|             | Derivative\ |             |            | 12.5-25 mg   |
|             | Sedative    |             |            | every 4-6    |
|             |             |             |            | hours as     |
|             |             |             |            | needed       |
+-------------+-------------+-------------+------------+--------------+
| **Hy        | An          | 12.5-25 mg  | C          | **Oral:**    |
| droxyzine** | tihistamine | po          |            | 12.5-100     |
|             |             |             |            | mg/dose      |
|             |             |             |            | every 4-6    |
|             |             |             |            | hours as     |
|             |             |             |            | needed       |
+-------------+-------------+-------------+------------+--------------+
| **Dimen     | An          | 50-100 mg   | B          | **Oral**:    |
| hydrinate** | tihistamine |             |            | 50-100 mg    |
|             |             | 50 mg IV    |            | every 4-6    |
|             |             |             |            | hours, not   |
|             |             |             |            | to exceed    |
|             |             |             |            | 400 mg/day   |
|             |             |             |            |              |
|             |             |             |            | **I.V.**     |
|             |             |             |            |              |
|             |             |             |            | 50 mg in 50  |
|             |             |             |            | mL NS q4-6h  |
|             |             |             |            | IV over 20   |
|             |             |             |            | minutes      |
+-------------+-------------+-------------+------------+--------------+
| **Metoc     | Cho         | 5-10 mg po  | B          | **[Oral:]{.  |
| lopramide** | linomimetic |             |            | underline}** |
|             |             |             |            | 10-15        |
|             |             |             |            | mg/dose up   |
|             |             |             |            | to 4         |
|             |             |             |            | times/day 30 |
|             |             |             |            | minutes      |
|             |             |             |            | before meals |
|             |             |             |            | or food and  |
|             |             |             |            | at bedtime.  |
|             |             |             |            | Single doses |
|             |             |             |            | of 20 mg are |
|             |             |             |            | occasionally |
|             |             |             |            | needed for   |
|             |             |             |            | provoking    |
|             |             |             |            | situations   |
|             |             |             |            |              |
|             |             |             |            | **I.V.:**    |
|             |             |             |            |              |
|             |             |             |            | 5-10 mg q8h  |
|             |             |             |            | IV           |
|             |             |             |            |              |
|             |             |             |            | (5-10 mg/kg) |
+-------------+-------------+-------------+------------+--------------+
| **D         | Selective   | 25-100 mg   | B          | **Oral:**    |
| olasetron** | 5-HT3       | po          |            | 25-200 mg    |
|             | Receptor    |             |            | single dose  |
|             | Antagonist  | 4-8 mg IV   |            |              |
|             |             |             |            | **I.V.:**\   |
|             |             |             |            |  4-8 mg over |
|             |             |             |            | 15 minutes   |
|             |             |             |            | q12h IV      |
|             |             |             |            |              |
|             |             |             |            | (0.6-5 mg/kg |
|             |             |             |            | as a single  |
|             |             |             |            | dose\        |
|             |             |             |            |     50 mg    |
|             |             |             |            | 1-2 minute   |
|             |             |             |            | bolus\       |
|             |             |             |            |     2.4-3    |
|             |             |             |            | mg/kg        |
|             |             |             |            | 20-minute    |
|             |             |             |            | infusion)    |
+-------------+-------------+-------------+------------+--------------+

**Drug Safety**

A number of reports have demonstrated that antiemetic drug therapy is
effective and does not increase the incidence of congenital anomalies.
Some examples are illustrated below:

  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} The safety of antihistamines was
affirmed in a meta-analysis that examined the association between
antihistamine use and major malformations. This review of 24 controlled
studies including over 200,000 first trimester exposures found that
H1-receptor blockers actually had a protective effect (odds ratio 0.76,
95 percent CI 0.60 to 0.94). Pooled analysis also demonstrated efficacy
of this class of drugs (RR 0.34, 95 percent CI 0.27 to 0.43).\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} The most common anticholinergic drug
used for treatment of nausea is dicyclomine which had been a component
of Bendectin until it was removed because of lack of efficacy. A
meta-analysis of studies on outcome of pregnancies exposed to Bendectin
reported no increase in the incidence of birth defects. Pooled analysis
demonstrated efficacy of Bendectin (RR 0.53, 95 percent CI 0.41 to
0.68). In addition, data from a Swedish registry on women who took
promethazine or meclizine in the first trimester did not show an
increase in the rate of birth defects.\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Evidence from systematic review (n =
2948 exposed patients) showed that dopamine antagonists (eg,
phenothiazines, droperidol, metoclopramide) were not teratogenic (RR
1.03, 95 percent CI 0.88 to 1.22)\]. The best studied drugs in this
class are the phenothiazines, which appeared effective (RR 0.31, 95
percent CI 0.24 to 0.42).\
\
  ![](media/image2.png){width="6.25e-2in"
height="7.152777777777777e-2in"} Ondansetron is the most widely used HT3
antagonist. Animal data are reassuring as to safety in pregnancy, but
human data on safety or efficacy are sparse.

**What about natural products and lifestyle changes?**

The first steps in managing nausea and vomiting in pregnancy should be
diet and lifestyle changes.

Avoidance of triggers

The cornerstone of nonpharmacologic therapy of hyperemesis gravidarum is
avoidance of environmental triggers. Examples of some triggers include:
stuffy rooms, odors (eg, perfume, chemicals, food, smoke), heat,
humidity, noise, and visual or physical motion (eg, flickering lights,
driving). Brushing teeth after eating, quickly changing position, and
not getting enough rest may also aggravate symptoms. Supplements
containing iron should be avoided until symptoms resolve.

Diet

Advise your patient to make dietary adjustments, e.g., small, frequent,
low fat meals, etc....

Dietary management generally consists of frequent high carbohydrate, low
fat, small meals. Dietary manipulations, such as eliminating foods high
in fat or spicy foods or eating salty or high protein snacks/meals
appear to help some women. Fluids are better tolerated if cold, clear,
and carbonated or sour (eg, ginger ale, lemonade) and if taken in small
amounts between meals.

Aromatic therapies involving lemon (lemonade), mint (tea), or orange
have also been described as useful. Women with hyperemesis should eat
before or as soon as they feel hungry in order to avoid an empty stomach
that may aggravate nausea.

Herbal or Natural alternatives

Other patients may want to pursue herbal or natural alternatives. These
agents are unregulated products, hence one can never be certain what
dose, potency, or contaminants are actually present in these
preparations. Caution should be exercised when using any unregulated
products like those listed below.

Here are some examples

+-----------+--------------+-------------+-------------+--------------+
| **Name**  | **Category** | **Plant     | **Dose**    | **Comments** |
|           |              | Part**      |             |              |
+-----------+--------------+-------------+-------------+--------------+
| *         | Herb         | Root        | **Oral:**   | Ginger has   |
| *Ginger** |              |             | 250 mg 3 -4 | been used    |
|           |              |             | times/day   | extensively  |
| **        |              |             | with food,  | as both a    |
| (Zingiber |              |             | s           | culinary     |
| offi      |              |             | tandardized | herb and an  |
| cinale)** |              |             | to contain  | agent in     |
|           |              |             | 4% volatile | traditional  |
|           |              |             | oils or 5%  | medicine. In |
|           |              |             | total       | the US, it   |
|           |              |             | pungent     | has been     |
|           |              |             | compounds   | popularized  |
|           |              |             | (most       | for motion   |
|           |              |             | prominently | sickness,    |
|           |              |             | 6-gingerol  | dyspepsia,   |
|           |              |             | and         | and nausea.  |
|           |              |             | 6-shogaol)  | Its lack of  |
|           |              |             | per dose    | sedative     |
|           |              |             |             | effects may  |
|           |              |             |             | be an        |
|           |              |             |             | advantage    |
|           |              |             |             | over other   |
|           |              |             |             | antiemetic   |
|           |              |             |             | agents.      |
|           |              |             |             |              |
|           |              |             |             | Ginger is    |
|           |              |             |             | beneficial   |
|           |              |             |             | as an        |
|           |              |             |             | antiemetic,  |
|           |              |             |             | for both     |
|           |              |             |             | nausea and   |
|           |              |             |             | vomiting, in |
|           |              |             |             | women        |
|           |              |             |             | ![](         |
|           |              |             |             | media/image3 |
|           |              |             |             | .png){width= |
|           |              |             |             | "8.333333333 |
|           |              |             |             | 333333e-2in" |
|           |              |             |             | height="9.   |
|           |              |             |             | 236111111111 |
|           |              |             |             | 112e-2in"}17 |
|           |              |             |             | weeks        |
|           |              |             |             | gestation.   |
|           |              |             |             | In one       |
|           |              |             |             | study,       |
|           |              |             |             | subjects     |
|           |              |             |             | took ginger  |
|           |              |             |             | at doses up  |
|           |              |             |             | to 1 g daily |
|           |              |             |             | for a        |
|           |              |             |             | maximum of 4 |
|           |              |             |             | days.        |
|           |              |             |             | Follow-up    |
|           |              |             |             | and          |
|           |              |             |             | assessment   |
|           |              |             |             | took place   |
|           |              |             |             | for 7 days   |
|           |              |             |             | following    |
|           |              |             |             | the          |
|           |              |             |             | treatment    |
|           |              |             |             | period. No   |
|           |              |             |             | side effects |
|           |              |             |             | were         |
|           |              |             |             | reported     |
|           |              |             |             | during this  |
|           |              |             |             | study and    |
|           |              |             |             | evaluation   |
|           |              |             |             | period       |
+-----------+--------------+-------------+-------------+--------------+
| **German  | Herb         | Flower      | **Oral:**   | Chamomile    |
| ch        |              |             | 400-1600    | has been     |
| amomile** |              |             | mg/day in   | used for     |
|           |              |             | divided     | centuries as |
|           |              |             | doses,      | a mild       |
|           |              |             | s           | sedative and |
|           |              |             | tandardized | anxiolytic.  |
|           |              |             | to contain  | In contrast  |
|           |              |             | 1.2%        | to many      |
|           |              |             | apigenin    | anxiolytic   |
|           |              |             | and 0.5%    | agents, it   |
|           |              |             | essential   | does not     |
|           |              |             | oil per     | generally    |
|           |              |             | dose        | cause        |
|           |              |             |             | drowsiness   |
|           |              |             | **Tea:** 1  | or motor     |
|           |              |             | heaping     | impairment.  |
|           |              |             | teaspoonful | Chamomile    |
|           |              |             | of dried    | also has     |
|           |              |             | flowers in  | spasmolytic  |
|           |              |             | hot water;  | and          |
|           |              |             | steep for   | anti-        |
|           |              |             | 10 minutes, | inflammatory |
|           |              |             | drink up to | properties   |
|           |              |             | 3 times/day | which may    |
|           |              |             |             | contribute   |
|           |              |             |             | to its       |
|           |              |             |             | apparent     |
|           |              |             |             | value in     |
|           |              |             |             | relieving a  |
|           |              |             |             | number of    |
|           |              |             |             | gast         |
|           |              |             |             | rointestinal |
|           |              |             |             | complaints.  |
+-----------+--------------+-------------+-------------+--------------+
| **Pep     | Herb         | Leaf, oil   | **Oral:**   | Peppermint   |
| permint** |              |             | One tablet  | oil is used  |
|           |              |             | (enteric    | for          |
| **(Mentha |              |             | coated),    | digestive    |
| pi        |              |             | 2-3         | complaints   |
| perita)** |              |             | times/day,  | as a         |
|           |              |             | containing  | carminative  |
|           |              |             | 0.2 mL oil  | and          |
|           |              |             | per tablet\ | spasmolytic. |
|           |              |             |   Note: The | It is also   |
|           |              |             | oil should  | used in      |
|           |              |             | contain:    | Irritable    |
|           |              |             |             | Bowel        |
|           |              |             |   ![](me    | Syndrome     |
|           |              |             | dia/image2. | (IBS).       |
|           |              |             | png){width= |              |
|           |              |             | "6.25e-2in" |              |
|           |              |             | height="    |              |
|           |              |             | 7.152777777 |              |
|           |              |             | 777777e-2in |              |
|           |              |             | "} ![](medi |              |
|           |              |             | a/image4.pn |              |
|           |              |             | g){width="8 |              |
|           |              |             | .3333333333 |              |
|           |              |             | 33333e-2in" |              |
|           |              |             | hei         |              |
|           |              |             | ght="9.2361 |              |
|           |              |             | 11111111112 |              |
|           |              |             | e-2in"}4.5% |              |
|           |              |             | w/v and     |              |
|           |              |             | ![](medi    |              |
|           |              |             | a/image3.pn |              |
|           |              |             | g){width="8 |              |
|           |              |             | .3333333333 |              |
|           |              |             | 33333e-2in" |              |
|           |              |             | he          |              |
|           |              |             | ight="9.236 |              |
|           |              |             | 11111111111 |              |
|           |              |             | 2e-2in"}10% |              |
|           |              |             | w/w of      |              |
|           |              |             | esters      |              |
|           |              |             | calculated  |              |
|           |              |             | as menthyl  |              |
|           |              |             | acetate\    |              |
|           |              |             |  ![](me     |              |
|           |              |             | dia/image2. |              |
|           |              |             | png){width= |              |
|           |              |             | "6.25e-2in" |              |
|           |              |             | height="    |              |
|           |              |             | 7.152777777 |              |
|           |              |             | 777777e-2in |              |
|           |              |             | "} ![](medi |              |
|           |              |             | a/image4.pn |              |
|           |              |             | g){width="8 |              |
|           |              |             | .3333333333 |              |
|           |              |             | 33333e-2in" |              |
|           |              |             | he          |              |
|           |              |             | ight="9.236 |              |
|           |              |             | 11111111111 |              |
|           |              |             | 2e-2in"}44% |              |
|           |              |             | w/v of free |              |
|           |              |             | alcohols    |              |
|           |              |             | calculated  |              |
|           |              |             | as menthol\ |              |
|           |              |             |   ![](me    |              |
|           |              |             | dia/image2. |              |
|           |              |             | png){width= |              |
|           |              |             | "6.25e-2in" |              |
|           |              |             | height="    |              |
|           |              |             | 7.152777777 |              |
|           |              |             | 777777e-2in |              |
|           |              |             | "} ![](medi |              |
|           |              |             | a/image4.pn |              |
|           |              |             | g){width="8 |              |
|           |              |             | .3333333333 |              |
|           |              |             | 33333e-2in" |              |
|           |              |             | he          |              |
|           |              |             | ight="9.236 |              |
|           |              |             | 11111111111 |              |
|           |              |             | 2e-2in"}15% |              |
|           |              |             | w/v and     |              |
|           |              |             | ![](medi    |              |
|           |              |             | a/image3.pn |              |
|           |              |             | g){width="8 |              |
|           |              |             | .3333333333 |              |
|           |              |             | 33333e-2in" |              |
|           |              |             | he          |              |
|           |              |             | ight="9.236 |              |
|           |              |             | 11111111111 |              |
|           |              |             | 2e-2in"}32% |              |
|           |              |             | w/v ketones |              |
|           |              |             | calculated  |              |
|           |              |             | as menthone |              |
+-----------+--------------+-------------+-------------+--------------+

**What about 'alternative' therapies?**

Other options are P6 acupuncture or acupressure wristbands and powdered
ginger (1 gram daily). (See Herbal or 'Natural' alternatives)

Although acupuncture has been shown to be useful when compared to no
treatment, there appears to be a strong placebo effect. A Cochrane type
review did not find P6 acupuncture or acupressor to be clearly
effective.

Although ginger has been shown to be more effective than placebo and
equivalent to vitamin B6 (pyridoxine), its safety in pregnancy has not
been firmly established.

Hypnosis has been reported to be helpful in selected patients. It has
been suggested that hypnotized women with severe nausea and vomiting of
pregnancy are more easily influenced by suggestion than controls, and at
least one controlled study supports this hypothesis. In a limited number
of studies, all lacking controls, hypnosis has been shown to decrease
vomiting in patients undergoing chemotherapy and those with hyperemesis
gravidarum.

Psychotherapy can also be a useful adjunctive therapy, if other
psychological sources of anxiety are identified and can be ameliorated.
There is little evidence for a therapeutic effect of traditional
psychotherapy in hyperemesis gravidarum. No controlled trials have
evaluated behavioral therapy in nausea and vomiting of pregnancy, but
there are data to indicate that delayed and anticipatory nausea and
vomiting after chemotherapy is diminished by systematic desensitization
and relaxation therapy.

**ACOG Resources**

Nausea and Vomiting of Pregnancy

ACOG Practice Bulletin #52 April 2004

Summary of Recommendations

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

-   Taking a multivitamin at the time of conception may decrease the
    severity of nausea and vomiting of pregnancy.

-   Treatment of nausea and vomiting of pregnancy with vitamin B6 or
    vitamin B6 plus doxylamine is safe and effective and should be
    considered first-line pharmacotherapy.

-   In patients with hyperemesis gravidarum who also have suppressed
    thyroid-stimulating hormone levels, treatment of hyperthyroidism
    should not be undertaken without evidence of intrinsic thyroid
    disease (including goiter and/or thyroid autoantibodies).

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

-   Treatment of nausea and vomiting of pregnancy with ginger has shown
    beneficial effects and can be considered as a nonpharmacologic
    option.

-   In refractory cases of nausea and vomiting of pregnancy, the
    following medications have been shown to be safe and efficacious in
    pregnancy: antihistamine H1 receptor blockers, phenothiazines, and
    benzamides.

-   Early treatment of nausea and vomiting of pregnancy is recommended
    to prevent progression to hyperemesis gravidarum.

-   Treatment of severe nausea and vomiting of pregnancy or hyperemesis
    gravidarum with methylprednisolone may be efficacious in refractory
    cases; however, the risk profile of methylprednisolone suggests it
    should be a treatment of last resort.

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

-   Intravenous hydration should be used for the patient who cannot
    tolerate oral liquids for a prolonged period or if clinical signs of
    dehydration are present. Correction of ketosis and vitamin
    deficiency should be strongly considered. Dextrose and vitamins,
    especially thiamine, should be included in the therapy when
    prolonged vomiting is present.

-   Enteral or parenteral nutrition should be initiated for any patient
    who cannot maintain her weight because of vomiting.

Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 52.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2004;103:803--15

Again, after you peruse this material, you should go to the link
directly below, take the Posttest and receive free CME credit.
<http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm>

**Other**

**Miscarriage risk from amniocentesis performed for abnormal maternal
serum screening**

RESULTS: The miscarriage rate with amniocentesis, 0.46% (69/15,005), was
no different than without, 0.53% (90/17,045), P = .38. There was no
difference in maternal age, serum biochemical factors, gestational age
at miscarriage (21.1 weeks for both groups), or days until miscarriage
(23 after amniocentesis and 20.4 without). Log-rank test revealed no
difference for gestational age at miscarriage (P = .61) or number of
days until miscarriage (P = .40). CONCLUSION: The rate and timing of
miscarriage was similar with or without amniocentesis in California
women with abnormal maternal serum screening.

Towner D et al Miscarriage risk from amniocentesis performed for
abnormal maternal serum screening. [Am J Obstet Gynecol.  2007;
196(6):608.e1-5;](http://www.medscape.com/medline/publicationbrowser/123?pmid=17547917)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17547917>

**Evidence base of predictive markers and therapies (eg, progesterone)
for preterm birth**

Rates of preterm birth have continued to rise despite intensive research
efforts over the last several decades. A woman who has a spontaneous
preterm birth is at high risk for a subsequent preterm birth. Studies
have identified clinical, sonographic, and biochemical markers that help
to identify the women at highest risk. Determining cervical length and
measuring cervicovaginal fibronectin have been proposed as useful tools
for evaluating women at risk of preterm birth and may identify those who
might benefit from a timely course of antenatal corticosteroids, but
effective interventions to prevent preterm birth remain elusive. In the
prevention of recurrent spontaneous preterm birth, recent trials have
confirmed the use of progesterone beginning in the second trimester as
an effective intervention. Optimal management of women with a history of
spontaneous preterm birth includes a thorough review of the obstetric,
medical, and social history, with attention to potentially reversible
causes of preterm birth (eg, smoking cessation, acute infections,
strenuous activities), accurate ultrasound dating, consideration of
progesterone therapy beginning at 16-20 weeks of gestation, and close
surveillance during the pregnancy for evolving findings. Results from
the ongoing trials of cerclage as an interventional therapy and omega-3
fatty acid supplementation as a preventive therapy will provide
additional knowledge for the optimal management of these high-risk
women.

[Spong
CY](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Spong CY"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Prediction and prevention of recurrent spontaneous preterm birth.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Aug;110(2 Pt 1):405-15

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17666618&dopt=AbstractPlus>

**Noninherited risk factors and congenital cardiovascular defects:
current knowledge: a scientific statement from the American Heart
Association Council on Cardiovascular Disease in the Young: endorsed by
the American Academy of Pediatrics.**

Prevention of congenital cardiovascular defects has been hampered by a
lack of information about modifiable risk factors for abnormalities in
cardiac development. Over the past decade, there have been major
breakthroughs in the understanding of inherited causes of congenital
heart disease, including the identification of specific genetic
abnormalities for some types of malformations. Although relatively less
information has been available on noninherited modifiable factors that
may have an adverse effect on the fetal heart, there is a growing body
of epidemiological literature on this topic. This statement summarizes
the currently available literature on potential fetal exposures that
might alter risk for cardiovascular defects. Information is summarized
for periconceptional multivitamin or folic acid intake, which may reduce
the risk of cardiac disease in the fetus, and for additional types of
potential exposures that may increase the risk, including maternal
illnesses, maternal therapeutic and nontherapeutic drug exposures,
environmental exposures, and paternal exposures. Information is
highlighted regarding definitive risk factors such as maternal rubella;
phenylketonuria; pregestational diabetes; exposure to thalidomide,
vitamin A cogeners, or retinoids; and indomethacin tocolysis. Caveats
regarding interpretation of possible exposure-outcome relationships from
case-control studies are given because this type of study has provided
most of the available information. Guidelines for prospective parents
that could reduce the likelihood that their child will have a major
cardiac malformation are given. Issues related to pregnancy monitoring
are discussed. Knowledge gaps and future sources of new information on
risk factors are described.

Jenkins KJ et al. Noninherited risk factors and congenital
cardiovascular defects: current knowledge: a scientific statement from
the American Heart Association Council on Cardiovascular Disease in the
Young: endorsed by the American Academy of Pediatrics. [Circulation.
 2007;
115(23):2995-3014](http://www.medscape.com/medline/publicationbrowser/123?pmid=17519397)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17519397>

**1^st^ trimester US of the nasal bone may improve Down syndrome
screening**

Increasingly, women are choosing first-trimester risk assessment for
Down syndrome and other aneuploid conditions. Recent studies have
suggested that adding ultrasound assessment of the nasal bone to nuchal
translucency thickness and maternal serum analytes in the first
trimester will improve performance. This report assesses the current
literature and discusses practical issues that must be addressed before
widespread implementation of nasal bone screening in the United States

[Rosen
T](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rosen T"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al First-trimester ultrasound assessment of the nasal bone to screen
for aneuploidy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Aug;110(2 Pt 1):399-404

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17666617&dopt=AbstractPlus>

**A meta-analysis on the influence of inflammatory bowel disease on
pregnancy**

CONCLUSION: The study has shown a higher incidence of adverse pregnancy
outcomes in patients with IBD. Further studies are required to clarify
which women are at higher risk, as this was not determined in the
present study. This has an effect on the management of patients with IBD
during pregnancy, who should be treated as a potentially high-risk
group.

Cornish J et al A meta-analysis on the influence of inflammatory bowel
disease on pregnancy [Gut.  2007;
56(6):830-](http://www.medscape.com/medline/publicationbrowser/123?pmid=17185356)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17185356>

**A comprehensive analysis of adverse obstetric and pediatric
complications in women with asthma**

CONCLUSIONS: We found some increased risks in women with asthma that
need to be considered in the future; however, our results indicate that
women with asthma have similar reproductive risks compared with women
without asthma in the general population for most of the range of
outcomes studied

Tata LJ et al A comprehensive analysis of adverse obstetric and
pediatric complications in women with asthma. [Am J Respir Crit Care
Med.  2007;
175(10):991-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17272783)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17272783>

#### Primary Care Discussion Forum Ann Bullock, Cherokee, NC {#primary-care-discussion-forum-ann-bullock-cherokee-nc .Style-Heading-4-+-Arial-14-pt-Underline}

**Chronic Kidney Disease: CKD is Part of Primary Care**!

Moderator: Andrew Narva, MD

September 4, 2007

-   What is the burden of CKD in AI/AN?

-   How should CKD patients be identified and followed?

-   What should we be doing for CKD patients in the primary setting?

-   When should patients be referred?

### 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=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

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

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

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

American Indian adolescents have two to four times the rate of sexually
transmitted diseases (STDs) compared to whites nationally, they shoulder
twice the proportion of AIDS compared to their national counterparts,
and they have a 25% higher level of teen births. Yet little is known
about the contemporary expectations, pressures, and norms that influence
American Indian youth or how those might be shaped by today\'s lived
cultural experiences, which frustrates attempts to mitigate the apparent
disparity in sexual health. This paper used data from focus groups,
in-depth interviews, and surveys with American Indian adolescents and
young male and female adults from a Northern Plains tribe to
contextualize sexual risk (and avoidance). Placing the findings within
an adapted indigenist stress-coping framework, we found that youth faced
intense pressures for early sex, often associated with substance use.
Condoms were not associated with stigma, yet few seemed to value their
importance for disease prevention. Youth encountered few economic or
social recriminations for a teen birth. As such, cultural influences are
important to American Indian sexual health and could be a key part of
prevention strategies.

Kaufman CE et al Culture, context, and sexual risk among Northern Plains
American Indian Youth Social Science & Medicine. 64(10):2152-64, 2007
May

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17379373>

 

**Perceptions of Sexual Assertiveness among Adolescent Girls:
Initiation, Refusal, and Use of Protective Behaviors**

Conclusions:  Most of these girls perceived themselves as sexually
assertive. Given that sexual experience, not relationship factors, were
related to perceptions of sexual assertiveness, the design of counseling
messages should incorporate sexual experience. These messages should
find effective ways to help girls both to communicate their sexual
desires and to enhance their ability to protect themselves.

Auslander BA et al Perceptions of Sexual Assertiveness among Adolescent
Girls: Initiation, Refusal, and Use of Protective Behaviors Journal Of
Pediatric And Adolescent Gynecology, Volume 20, Issue 3, Pages 157-162
(June 2007)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17561183>

**Sexually Transmitted Infections in Preadolescent Children**

Pediatric nurse practitioners may be called on to conduct an assessment
for sexual abuse of a young child. Depending on the type of sexual
contact, a decision may have to be made to obtain cultures for sexually
transmitted infections (STIs). Recognizing the symptoms of STIs in
preadolescent children, along with having knowledge of the modes of
transmission, diagnostics, and treatment, are part of the clinical
decision. The impact of STI in preadolescent children has physical and
emotional consequences for the child and family, along with legal
consequences for an accused perpetrator. Knowledge about types of sexual
contact that necessitate STI cultures, incubation periods, and
symptomatology is essential. Accurate techniques and appropriate
selection of culture materials are necessary. Proper positioning of the
child for obtaining cultures can decrease the potential for discomfort
during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex
virus, human papillomavirus virus, syphilis, Trichomonas vaginalis,
hepatitis B, and HIV are reviewed.  

Lewin LC. Sexually Transmitted Infections in Preadolescent Children
Journal of Pediatric Health Care, Volume 21, Issue 3, May-June 2007,
Pages 153-161

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17478304>

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

#### Screening for Chlamydial Infection: USPSTF Recommendation Statements {#screening-for-chlamydial-infection-uspstf-recommendation-statements-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The USPSTF recommends screening for chlamydial infection for all sexually active nonpregnant young women age 24 years or younger and older nonpregnant women who are at increased risk. This is a grade A recommendation.  {#the-uspstf-recommends-screening-for-chlamydial-infection-for-all-sexually-active-nonpregnant-young-women-age-24-years-or-younger-and-older-nonpregnant-women-who-are-at-increased-risk.-this-is-a-grade-a-recommendation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 years or younger and for older pregnant women who are at increased risk.  {#the-uspstf-recommends-screening-for-chlamydial-infection-for-all-pregnant-women-age-24-years-or-younger-and-for-older-pregnant-women-who-are-at-increased-risk. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a grade B recommendation.  {#this-is-a-grade-b-recommendation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The USPSTF recommends against routinely screening for chlamydial infection for women age 25 years or older, regardless of whether they are pregnant, if they are not at increased risk. {#the-uspstf-recommends-against-routinely-screening-for-chlamydial-infection-for-women-age-25-years-or-older-regardless-of-whether-they-are-pregnant-if-they-are-not-at-increased-risk. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a grade C recommendation.  {#this-is-a-grade-c-recommendation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men.  {#the-uspstf-concludes-that-the-current-evidence-is-insufficient-to-assess-the-balance-of-benefits-and-harms-of-screening-for-chlamydial-infection-for-men. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is an I statement. {#this-is-an-i-statement. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiars.pdf**](http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiars.pdf) {#httpwww.ahrq.govclinicuspstf07chlamydiachlamydiars.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

# Home screening for sexually transmitted diseases in high-risk young women: RCT

Results: Of 197 women in the intervention group, 140 (71%) returned at
least one home test and 25 of 249 (10%) home tests were positive. Women
who received home screening tests completed significantly more STD tests
overall (1.94 vs 1.41 tests per woman-year, p\<0.001) and more STD tests
in the absence of symptoms (1.18 vs 0.75 tests per woman-year,
p\<0.001). More women in the intervention group completed at least one
test when asymptomatic (162 (82.2%) vs 117 (61.3%), p\<0.001). The
intervention was most effective among women recruited outside medical
clinics. There was no significant difference in the overall rate of STDs
detected.

Conclusions: Home screening significantly increased the utilisation of
chlamydia and gonorrhoea testing in this sample of high-risk young
women, and thus represents a feasible strategy to facilitate STD testing
in young women.

# Cook R et al Home screening for sexually transmitted diseases in high-risk young women: randomised controlled trial Sexually Transmitted Infections July  2007; Vol 83: p.  286-291. 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17301105>

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

**Defining Virginity and Abstinence: Adolescents\' Interpretations of
Sexual Behaviors**\
The authors of the current study set out to examine adolescent
conceptualizations of virginity and abstinence. They further sought to
learn whether differences in youths\' definitions of these terms varied
by age, gender, ethnicity, and sexual experience.\
\
The researchers conducted a series of logistic regressions to study
whether gender, age, ethnicity, and sexual experience predicted whether
an individual was still a virgin after taking part in genital touching,
oral sex, anal sex or vaginal sex.\
\
The results indicated that youths\' concept of loss of virginity was
linked primarily with vaginal and anal intercourse, while a greater
proportion of respondents attributed a loss of abstinence to other
behaviors, such as genital touching and oral sex. Sexual experience was
the strongest predictor of how the adolescents defined virginity and
abstinence.\
\
The fact that significant differences in youths\' definitions of
abstinence and virginity existed \"suggests that additional attention is
needed to ensure a common understanding of these terms to achieve
successful sexual education and prevention programs,\" the authors
concluded.

Bersamin M et al Defining Virginity and Abstinence: Adolescents\'
Interpretations of Sexual Behaviors Journal of Adolescent Health Vol.
41; No. 2: P. 182-188    (08..07)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17659223>

####  {#section-33 .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}

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

An astonishing doubling in American obesity took place in the two
decades after the nation\'s bicentennial, epidemiologists reported.

By 2015, 75% of adults will be overweight or obese, and 41% will be
obese. In conclusion, obesity has increased at an alarming rate in the
United States over the past three decades. The associations of obesity
with gender, age, ethnicity, and socioeconomic status are complex and
dynamic. Related population-based programs and policies are needed.

Wang Y, et al. The Obesity Epidemic in the United States \-- Gender,
Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A
Systematic Review and Meta-Regression Analysis [Epidemiol
Rev.](javascript:AL_get(this, 'jour', 'Epidemiol Rev.');) 2007;29:6-28.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17510091**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17510091) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17510091 .Style-Heading-4-+-Arial-14-pt-Underline}

**Regular and Diet Soft Drinks Linked To Increase In Risk Factors For
Heart Disease**

#### Drinking more than one soft drink daily --- whether it's regular or diet --- may be associated with an increase in the risk factors for heart disease {#drinking-more-than-one-soft-drink-daily-whether-its-regular-or-diet-may-be-associated-with-an-increase-in-the-risk-factors-for-heart-disease .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: In middle-aged adults, soft drink consumption is associated with a higher prevalence and incidence of multiple metabolic risk factors. {#conclusions-in-middle-aged-adults-soft-drink-consumption-is-associated-with-a-higher-prevalence-and-incidence-of-multiple-metabolic-risk-factors. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Dhingra R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dhingra R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. {#dhingra-r-et-al-soft-drink-consumption-and-risk-of-developing-cardiometabolic-risk-factors-and-the-metabolic-syndrome-in-middle-aged-adults-in-the-community. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17646581**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17646581) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17646581 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Very Low Birth Weight Is Associated With Impaired Glucose {#very-low-birth-weight-is-associated-with-impaired-glucose-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Young adults with very low birth weight had significantly higher indexes
of glucose intolerance and insulin resistance, and higher blood
pressure, compared with those born at term. These differences, however,
were not attributable to body size or composition, or fat

distribution. The authors suggested that persons with very low birth
weight might be more vulnerable to type 2 diabetes and cardiovascular
disease later in life, and young adults with very low birth weight might
benefit from targeted preventive interventions.

Hovi P et al. Glucose regulation in young adults with very low birth
weight. N Engl J Med. 2007;356:2053-2063.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17507704>

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

#### Women's Health Headlines, Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**APN scope of practice: colonoscopy?**

Study Finds Colonoscopy Most Effective Method of Colon Cancer Screening
(especially for women!) Colon cancer is the third leading cause of
cancer deaths for AI/AN women and the second leading cause of cancer
deaths for AI/AN men.  Given the prevalence of colon cancer among AI/AN
people, one would assume that colonoscopy would be available at the
majority of IHS hospitals.   This is not the case.   Consideration is
being given to training interested APNs in colonoscopy. 

I have heard from two APNs who include colonoscopy within their scope of
practice; one practicing in a Tribal facility and one in a federal
facility. If you are interested in broadening your scope of practice to
include colonoscopy, please email me.  If there is sufficient interest
in colonoscopy, I will convene an advisory group to consider this change
in scope and the necessary training.  Contact
[[Carolyn.Aoyama@ihs.gov]{.underline}](mailto:Carolyn.Aoyama@ihs.gov)

[Schoenfeld
P](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Schoenfeld P"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Colonoscopic screening of average-risk women for colorectal
neoplasia. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 May
19;352(20):2061-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15901859>

**Templates for Protocols and Procedures for Maternity Services 2nd
Edition**

The Association of Women's Health, Obstetric and Neonatal Nurses
(AWHONN) has developed a reference entitled, "Templates for Protocols
and Procedures for Maternity Services".  The reference (hard copy and
disc) can be used to update intrapartum, postpartum, and newborn
protocols and procedures, plus discharge instructions and sample
orders. 

I have scanned in a few pages of this reference to give you an idea of
content.   The Division of Nursing at Headquarters will supply any IHS
facility with a copy. 

Contact
[[Carolyn.Aoyama@ihs.gov]{.underline}](mailto:Carolyn.Aoyama@ihs.gov)

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

**3rd Annual American Indian and Alaska Native Long Term Care
Conference**

-   September 5-6, 2007

-   Albuquerque, New Mexico

-   Visit
    [http://www.aianlongtermcare.org](http://www.aianlongtermcare.org/)

-   Contact <Bruce.Finke@ihs.gov>

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

-   September 16 -- 19, 2007

-   Denver, CO

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

**Second National Summit on Preconception Health and Health Care**

-   October 29-31 2007

-   Oakland, CA

-   CDC and March of Dimes

-   <http://www.marchofdimes.com/california/4947_24789.asp>

**2007 National HIV Prevention Conference**

-   December 2-5, 2007

-   Atlanta, Georgia

-   Center for Disease Control and Prevention

-   <http://www.2007nhpc.org/conferenceinfo.asp>

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

**New Breastfeeding Family Support webpage, Indian Health**

<http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.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-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### The August 2007 OB/GYN CCC Corner is available at: {#the-august-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0807.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 6 {#abstract-of-the-month-page-6-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Within the Hidden Epidemic: STDs** **and HIV/AIDS Among AI/AN**

#### From your colleagues page 8 {#from-your-colleagues-page-8-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Scott Giberson**

# -Rapid HIV testing in emergency departments

-Treating Antiretroviral-Experienced Patients: Case-based CME Program\
-Stop the Silence

**James Holsinger Jr, Surgeon General Nominee**

Physician professionalism for a new century

**Favian Kennedy**

-How long does it take Nicotine to reach your brain after inhaling ?

-Northern Plains Tobacco Prevention Project: Spring Newsletter available
online

**Roberta Ward, Anchorage**

All you need to know about food safety during pregnancy, FDA

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

##### Obstetrics page 10

-VBAC: Labor induction outcome dependent on history of vaginal delivery
and cervix

-New Recommendation for Varicella Vaccine: Prenatal Assessment and
Postpartum Vaccination

-Postpartum Labial Adhesions

-Administration of cefazolin prior to skin incision is superior to
cefazolin at cord clamping

-Simulation-based, hands-on training can identify recurring errors in
emergencies

and others....

**Gynecology page 14**

-LEEP doubles risk of preterm delivery: Patients need to be informed

-Treatment of bleeding irregularities induced by progestin only
contraceptives: Effective

-Clinic management of early pregnancy failure: Safe, cost-effective

-Short-term superiority of effectiveness of transobturator tape reported

-Women in their 50s: fecal incontinence not associated with parity or
mode of delivery

and others....

**Child Health page 17**

-Physical Activity Alone May Not Reduce Obesity in Children

-Obese Young Adults Face High Diabetes Risk

-Increased risk of autism: associated with parental age and obstetric
conditions

-Physician Prompting Improves Asthma Preventive Care

-Child adiposity at 3 years: New recommendations for gestational weight
gain required?

and others....

**Chronic Illness and Disease page 18**

-Teratogenicity of SSRIs\--serious concern or much ado about little?

-American Native Suicide

-Depression: Deadlier in the Spring

-Rosiglitazone: seeking a balanced perspective

-How much does exercise help in weight loss?

and others....

#### Features page 21 {#features-page-21 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Management of Herpes in Pregnancy

-Management of Adnexal Masses

-Sterilization of Women, Including Those With Mental Disabilities

-The Role of Cystourethroscopy in the Generalist Obstetrician
Gynecologist Practice

-Adoption

and others....

##### American Family Physician

-Screening for Breast Cancer: Current Recommendations and Future
Directions

-ACS Recommendations on MRI and Mammography for Breast Cancer Screening

-Ginger: An Overview

-CDC Changes Treatment Guidelines for Gonorrhea

-Headache (Chronic Tension-Type)

and others....

**Agency for Healthcare Research and Quality**

-Use of high-risk medications by pregnant women is not uncommon

-GI complaints in young women of low to normal weight may indicate
eating disorders

-Contribution of mammography and therapy to reducing breast cancer
deaths from 1975 to 2000

-PEDS with more knowledge of identifying and managing child abuse more
likely to identify abuse

-Oncologists communicate differently with breast cancer patients: age,
race, education, income

and others....

**Ask a Librarian**

*Scopus*™: A New Database

**Breastfeeding**

-My newborn likes the bottle better: What to do when

-New IHS Breast feeding Family Support web page: Have pictures to share?

-Cup feeding not be recommended over bottle feeding as a supplement to
breastfeeding

-Despite the benefits of early breastfeeding, many women find it
unexpectedly difficult and painful

**CCC Corner Digest**

-A new management category: 'First Trimester GDM'

-Control over schedule: Most important predictor of staff work-life
balance / burnout

-Placental problems with previous caesarean delivery: Abruptio, previa

-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable

-Guidelines for School-Based STD Screening in Indian Country

-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery

-Seeking and Giving Consultation

-Long-Term Breastfeeding among Native American Women

-The failure to protect Indigenous women from sexual violence in the USA

-Reasons for unprotected intercourse

-What are the Unnecessary Tests?

-Improve HIV screening in pregnancy? Preliminary GPRA Related Results

-Social context of maternal deaths and morbidity

-Improve the system - Improve the care: Underpinnings

-Which Indian Health facilities lead the U.S. in national benchmarks?

-Earlier hormone therapy closer to menopause tended to have reduced CHD
risk

-Adjustable Urethral Slings: Hope for Patients with Complex Incontinence

-Personal Digital Assistants: Practical Advice for Nurses in 2007

-Placental cultures and histology poor predictors of infectious amniotic
fluid

-Electronic Health Record (EHR) Implementation: Worth the effort?

-Fluoroquinolones No Longer Recommended for Gonococcal Infections

-High rate of DM among indigenous people ?not due to thrifty gene

-Women's Early Drinking Problems More Likely to Escape Diagnosis

**Domestic Violence**

-IHS-ACF DV Project: Conference CD

-Family Violence Prevention Funds Screen to End Abuse Video

-Perceptions of Adult Patients' History of Child Abuse

-Study finds connection between teenage violence and domestic violence

-SANE: Is there a center near you?

and others....

**Elder Care News**

-Reporting Medical Conditions That May Affect Driving Competency: AAN
Guidelines

-Elderly patients with low health literacy receive little tangible
support for their health care needs

**Family Planning**

#### -Waiting until the menses to start hormonal contraceptives: Needless Obstacle  {#waiting-until-the-menses-to-start-hormonal-contraceptives-needless-obstacle .Style-Heading-4-+-Arial-14-pt-Underline}

-One In Four with Unplanned Pregnancy Experience Gaps In BCM Or Do Not
Use A Method

#### -Little variation in the frequency of reported symptoms among oral contraceptive pills {#little-variation-in-the-frequency-of-reported-symptoms-among-oral-contraceptive-pills .Style-Heading-4-+-Arial-14-pt-Underline}

#### -FDA Approves Contraceptive for Continuous Use {#fda-approves-contraceptive-for-continuous-use .Style-Heading-4-+-Arial-14-pt-Underline}

-Implanon and bone mineral density

and others....

**Featured Website**

-Contraception Online

-Last Special Issue on Methamphetamine in Indian Country: Now online

-Wrong link for National Sexual Violence Resource Center

**Frequently asked questions**

-Can oral or sublingual misoprostol be used for postpartum hemorrhage?

-How should you greet your patients?

-How can I better counsel my patient to adhere to therapy?

-Should patients use sweat lodges during pregnancy?

-What is recommended about peyote use in pregnancy

**Indian Child Health Notes**

-Lactose intolerance in infants, children, and adolescents.

-Influenza activity, 2006-7

-Inhalant abuse

-Fatal Injuries Among Children by Race and Ethnicity

**Information Technology**

-Integrated case management software application release

-iCare Training

International Health

-Maternal survival redux: a view from Malawi - Failure of justice

-Malarial drugs in early pregnancy

-Malaria Preventive Therapy Useful for Pregnant Women Despite Resistance

-Multivitamins should be considered for all pregnant women in developing
countries

#### MCH Alert

-Who needs liquor stores when parents will do?

-Home visiting associated with decreased infant death

-Resident fathers' prenatal behaviors, pregnancy intentions and
involvement with infants

-Office based motivational interviewing to prevent overweight in
children

-Association between confidential services and parent adolescent
**communiciation**

and others....

#### MCH Headlines

-Taking a harder line on blood transfusions

-Are you interested in the bigger picture of Indian Health care? Join a
listserv

-Do you know your state\'s teen-driving-laws?

-Program for At-Risk Infants and Mothers Recognized

-Adolescent Pregnancy Prevention Knowledge Path

and others....

#### Medical Mystery Tour

#### Nausea and Vomiting in Pregnancy {#nausea-and-vomiting-in-pregnancy-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -Public Health Impact of HPV Vaccination: Aligning Policy With Science

######### -Premenstrual Dysphoric Disorder: A New Treatment Paradigm

-Hormone Therapy Safer in Younger Women? A Best Evidence Review

**Menopause Management**

-Hormone Replacement Therapy Linked to Ovarian Cancer 

-Menopause Linked to Elevated Fasting Plasma Glucose Levels in
Nondiabetic Women

-Exercise Plus Isoflavones May Improve Body Composition in
Postmenopausal Women

-Relation of Cortisol Levels and BMD Among Premenopausal Women With
Depression 

-New Guidelines Issued for Treatment of Vaginal Atrophy: NAMS

and others....

**Midwives Corner**

-Midwifery's approach to pre-labor SROM supported by professional
organization's journal

-Let it pulse---the cord that is

-Upright position during the first stage of labor did not contribute
towards a shorten labor

-Cesarean rate can be reduced by health workers in analyzing and
modifying their practice

-Midwives' perspectives improves risk assessment in early pregnancy

and others....

**Navajo News**

The evolution of management of Actinomyces on a Pap report

**Nurses Corner**

#### -Health Care Without Harm: Nurses Take Action {#health-care-without-harm-nurses-take-action .Style-Heading-4-+-Arial-14-pt-Underline}

#### -A Complementary Approach to Pain Management {#a-complementary-approach-to-pain-management .Style-Heading-4-+-Arial-14-pt-Underline}

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

-One Test. Two Lives Campaign

-Human Papillomavirus: HPV Information for Clinicians

**Oklahoma Perspective**

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

Osteoporosis

-Dietary calcium is better than supplements at protecting bone health

-Calcium, Vitamin D supplements may help prevent weight gain in
postmenopausal women

-Down to the Bone: Issues in the Maintenance and Evaluation of Bone
Health: CME

Patient Education

#### Heavy Periods (Menorrhagia) {#heavy-periods-menorrhagia .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Anemia in Pregnancy Briefly: The Common to the Unusual -- including IV
therapy

-Contingent sequential screening is the most cost-effective form of Down
syndrome

-Aspirin during pregnancy could reduce risk of pre-eclampsia

-Abnormal Doppler is the best predictor of adverse perinatal outcome in
IUGR

-Changes in prepregnancy BMI between the first and second pregnancies
and risk of LGA

and others....

Primary Care Discussion Forum

Chronic Renal Disease: How is Primary Care Effected? Andy Narva,
September 1^st^

STD Corner

-Updated Screening for Chlamydial Infection Recommendations, USPSTF

#### -Sexually active women benefit from HPV vaccine {#sexually-active-women-benefit-from-hpv-vaccine .Style-Heading-4-+-Arial-14-pt-Underline}

#### -HPV vaccine against human papillomavirus to prevent anogenital diseases {#hpv-vaccine-against-human-papillomavirus-to-prevent-anogenital-diseases .Style-Heading-4-+-Arial-14-pt-Underline}

-Vulvar Vaccinia Infection After Sexual Contact with a Military Smallpox
Vaccinee

#### -A Series on Adolescence Sexual Activity {#a-series-on-adolescence-sexual-activity .Style-Heading-4-+-Arial-14-pt-Underline}

and others....

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

-(How) can we prevent type 2 diabetes?

-Prenatal Omega 3 Fatty Acid Consumption Improves Infant Problem Solving

-More Women than Men Having Mid-Life Stroke

#### -Diabetes Reduces Life Expectancy by 8 Years {#diabetes-reduces-life-expectancy-by-8-years .Style-Heading-4-+-Arial-14-pt-Underline}

#### -GDM represents a significant risk factor for future DM development regardless of ethnicity {#gdm-represents-a-significant-risk-factor-for-future-dm-development-regardless-of-ethnicity .Style-Heading-4-+-Arial-14-pt-Underline}

and others....

**Women's Health Headlines**

-Why do Native American women have the poorest 5-year survival rate for
breast cancer?

-Motivational Interviewing training and Promoting Motivational
Incentives: NIDA

-Aiming Higher: Results from a State Scorecard on Health System
Performance

-Women\'s emotional health and wellness materials

-Native American Rehabilitation Association: Children, Youth & Family
Services Director

###### Save the Dates: Upcoming events of interest page 74

#### What's new on the ITU MCH web pages page 74

-Should patients use sweat lodges during pregnancy?

-New Breast feeding Family Support web page: Have pictures to share?

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/F/MCHdiscuss.cfm>

8/22/07njm