News flash: Almost getting too late to sign up

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

-   June 13-17, 2004 **with separate NRP Course on first morning
    session, 6/13/04**

-   Denver, CO See Save the Dates, below

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 4, April, 2004

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

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

## Singleton Vaginal Breech Delivery at Term: Still a Safe Option page 2

[From your colleagues:]{.underline} page 3

###### From Barbara Fine: 2004 National Women\'s Health Week celebration, May 9-15, 2004

**From Bruce Finke:** Evidence Based Elder Periodic Exam: Osteoporosis

**From George Gilson:** Thyroid Disorders in Pregnancy: New Perinatology
Corner Module

**From Bill Green:** Indian Health - Special Interest Group Discussion
Forum Now Available online\
**From Steve Holve:** IHS Child Health Notes: New service from Pediatric
CCC

From Ursula Knoki-Wilson: Keeping the sacred in childbirth practices

From Deborah Lessmeier: Patient at 4-6 weeks gestation with a varicella
like rash?

**From Janet Mehring:** Teenage pregnancy prevention: Any resources
available?

From Judy Thierry: School based care; Distance Learning Certificate in
MCH Epidemiology: Fellowships; Online Alcohol Screening; Funds for HIV
and Prevention Services Into Reproductive Health and Community Settings;
Do you live in a state with a primary seat belt law?

**From Judy Ungerleider:** Value of the total protein to creatinine
ratio in pre-eclampsia?

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

**Obstetrics:** **page 7**

Visual dipstick urinalysis at the 1+ (30 mg/dL) threshold not reliable;
Safety of Vaginal Birth After Cesarean; Subdural hemorrhages not
uncommon in full-term infants; Mediolateral episiotomy: worse pelvic
floor function, incontinence, and prolapse; Vegetarian diet in pregnancy
raises risk of false-positive Down syndrome screen; Use of ginger in
early pregnancy will reduce their symptoms; Parental attitudes about a
pregnancy predict birth weight in a low-income population; Predictors of
Cesarean Delivery for the Second Twin in Vaginal Delivery of the First
Twin; Can Biophysical Profiles in Labor Predict C-Section? Normal
Control in Pregnant Women with Hypothyroidism; Benefits of Incomplete
Courses of Antenatal Corticosteroids; Effects of Automobile Crashes
Occurring During Pregnancy;

## Gynecology: page 9

## Single 1.5 mg levonorgestrel dose can substitute two 0.75 mg doses 12 h apart; Emergency Contraception Resources: Not-2-Late.com; Progestin only pills; Women often choose surgery after extended drug treatment of menorrhagia; 2 Randomized Trials on Menorrhagia Compare Medical Therapy With Hysterectomy; Managing Ovarian Cysts in Postmenopausal Women; High-Grade Squamous Intraepithelial Lesions: Abbreviating Post treatment Surveillance; 3 year screening is cost effective versus annual screening over 30 years; **Effect of Oral Contraceptives on Functional Ovarian Cysts; Metabolic Abnormalities in Bulimia Nervosa**; Can Women Self-Screen for Cervical Abnormalities? Diagnosing and Managing Endometriosis; Effects of Oral Contraceptive Use in Older Smokers; Extending the Interval between Pap Smears; Vaginal Delivery Affects Pelvic Organ Support

**Child Health:** **page 11**

Ending an Anti-tobacco Youth Campaign on Adolescent Susceptibility to
Smoking

New Community Pediatrics Web Site Launched; FAS \"Better Safe than
Sorry; CATCH / Medical Home National Conference

**Chronic Illness and Disease:** **page 12**

Virtual colonoscopy sensitivity is low; Cigarette smoking, awareness of
diabetes, binge drinking, drinking / driving and others; Smoking ban
linked to drop in heart attacks; Type 2 diabetes linked to cognitive
decline in women; Long-Term Sequelae of Breast Cancer Treatment;
Exercise Testing as a Predictor of Mortality in Women; Asthma
Surveillance and Epidemiology; Abortions do not raise breast cancer risk

[Features:]{.underline} page 13

###### AFP: **COCHRANE FOR CLINICIANS:** What Is the Best Collection Device for Screening Cervical Smears? Shoulder Dystocia Chapter updated

ACOG: Nausea and Vomiting of Pregnancy; ACOG supports universal care:
Cover the Uninsured

**AHRQ:** Rural studies examine telecolposcopy for women with abnormal
Pap smears

**Breastfeeding:** Breastfeeding Track at Biennial OB/GYN meeting in
August 2004

**Domestic Violence:** Domestic Violence Track at Biennial OB/YN meeting
in August 2004; Take a Leadership Role in Combating Sexual Violence in
US: Funding available

**Elder Care News:** Prevention in Native Women: IHS Biennial meeting in
August 2004

**Frequently asked questions:** Can misoprostol be used in an outpatient
setting? Can we use Lispro in pregnancy? What is the clinical
significance of endometrial cells found on Pap smears? Am I eligible for
care at this Indian Health facility?

**Hormone Replacement Update**: Nonhormonal alternatives for the
treatment of hot flashes; Use of Ultra-Low-Dose Estrogen to Prevent Bone
Loss; Transdermal Estrogen and Venous Thromboembolism; Breast Cancer
Risk Related to Type of Hormone Therapy

**Information Technology:** 2004 Technology Conference

**International Health:** Suicides in young people in rural southern
India -- relevance to AI/AN youth

**MCH Alert:** Effectiveness of school-based suicide-prevention program
evaluated

**Medscape:** Bisphosphonates in Osteoporosis: Emerging Science
Endometriosis and Infertility Opioid Analgesia: Practical Treatment of
the Patient with Chronic Pain:

**Office of Women's Health, CDC:** First and only rapid HIV test
approved for use with oral fluid

**Osteoporosis**: Evidence Based Periodic Exam in the Elderly Native
Americans Osteoporosis in American Indian / Alaska Native Women, 2004
Early Discontinuation of Osteoporosis Treatment

**Patient Education:** Eating Disorders; Anorexia Nervosa; Sports and
Women Athletes: The Female Athlete Triad

**Primary Care Discussion Forum:** Adolescent Risk Behavior - 5/1/04;
Adult Asthma - 8/1/04

**What's new on the ITU MCH web pages: page 18**

New Perinatology Corner Module - Free CEU /CME available **-** Thyroid
Disorders in Pregnancy:

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

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

# 

# [Abstract of the Month]{.underline}

## Singleton Vaginal Breech Delivery at Term: Still a Safe Option 

[OBJECTIVE]{.underline}: To examine the obstetric and perinatal outcome
of pregnancies with singleton breech presentation at term when selection
for vaginal delivery was based on clear prelabor and intrapartum
criteria.

[METHODS]{.underline}: The outcomes of all pregnancies with a breech
presentation after 37 weeks of gestation were retrospectively reviewed
from January 1997 to June 2000. Criteria for prelabor cesarean or trial
of vaginal breech delivery included type of breech, estimated fetal
weight (more than 3,800 g), maternal preference, and gestation more than
41 weeks. An intrapartum protocol excluded induction and oxytocin
augmentation of labor, combined with a low threshold for cesarean
delivery for dystocic labor; an experienced obstetrician was in
attendance during labor and delivery.

[RESULTS:]{.underline} Of 641 women, 343 (54%) underwent prelabor
cesarean, and 298 (46%) had a trial of vaginal delivery, of whom 146
(49%) delivered vaginally. Significantly fewer nulliparas (58 of 158,
37%) than multiparas (88 of 140, 63%; P \<.001) achieved vaginal
delivery after trial of labor. Significantly more infants weighing more
than 3,800 g were selected for prelabor (87 of 343, 25%) and intrapartum
(31 of 152, 20%) cesarean than delivered vaginally (15 of 146, 10%). Two
neonates (0.7%) had Apgar scores of less than 7 at 5 minutes; both were
neurologically normal at 6 weeks. There were no nonanomalous perinatal
deaths and no cases of significant trauma or neurological dysfunction; 3
infants delivered vaginally died due to lethal anomalies.
[CONCLUSION]{.underline}: Safe vaginal breech delivery at term can be
achieved with strict selection criteria, adherence to a careful
intrapartum protocol, and with an experienced obstetrician in
attendance. Our protocol effectively selects larger infants for cesarean
delivery. LEVEL OF EVIDENCE: II-2

May Alarab, et al *Obstetrics & Gynecology* 2004;103:407-412

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990399&dopt=Abstract>

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

\# 1 In comparison to the 2000 Hannah et al multicenter randomized
controlled trial, the current Alarab study was done retrospectively in a
homogeneous group of patients with well-trained providers. The Alarab
study suggests that in a carefully selected group of patients, while
using a more limited selection process, that vaginal delivery can be
safe for the fetus and mother.

This is an area of controversy. In the meantime, providers should
carefully re-examine their own current competence at breech vaginal
delivery before they consider re-instituting selected breech vaginal
delivery into their armamentarium.

Hannah et al

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11052579&dopt=Abstract>

\# 2 To that end, Dr. John Queenan offers some thoughtful advice for
teaching infrequently used skills. We have to learn from other
infrequent but inevitable complications, such as cardiac arrest. We
promote, indeed even mandate, the teaching of cardiopulmonary
resuscitation (CPR), even though it is rarely needed. When the need for
CPR arises, it can be performed almost reflexively. It appears that the
time has come for those in charge of the curricula and standards of
educating medical personnel to heed the change in trend. We need to
address this issue before problems occur as a result of inadequate
training. Teaching films, hands-on sessions, and mannequins have great
value for training these skills, as shown by the experience with CPR
education.

'Teaching Infrequently Used Skills: Vaginal Breech Delivery' *Obstetrics
& Gynecology* 2004;103:405-406

[www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990398&dopt=Abstract](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990398&dopt=Abstract)
njm

## 

## From your colleagues:

**[From Barbara Fine, HQE]{.underline}**

###### 2004 National Women\'s Health Week celebration, May 9-15, 2004

Many resources to help with local activities

<http://www.4woman.gov/whw/2004/>

###### Learn more about National Women\'s Check-Up Day: May 10, 2004

<http://www.4woman.gov/whw/2004/Join-the-fun/check-up-day.html>

**[From Bruce Finke, IHS Elder Care Initiative]{.underline}**

**Evidence Based Elder Periodic Exam: Osteoporosis**

Dr. Finke moderated the Primary Care Discussion Forum on the Evidence
Based Elder Periodic Exam Discussion. I want to thank Bruce Finke for
all his effort and to all of those of you for your good points and
references. The full Discussion is captured here

[[www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ExamElderDiscussion41004.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ExamElderDiscussion41004.doc)

The Summary is here, or see Osteoporosis, below

[[www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ElderSummary41004.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ElderSummary41004.doc)

**[From George Gilson, Anchorage]{.underline}**

**Thyroid Disorders in Pregnancy: New Perinatology Corner Module
available**

A. N. is a 34 y/o G3P2 at 19 weeks gestation with known hypothyroidism
who is taking levothyroxine 0.2 mg daily. She has no complaints.
Physical examination is unremarkable. Her initial thyroid functions are
reported as follows:

TSH: 17.2 mIU/mL (nl: 0.46-4.68)

Free T4: 0.70 ng/dL (nl: 0.78-2.19)

Should you take any action? What would be most appropriate?

S. N. is a 27 y/o G5P3 at 10 weeks gestation that is complaining of
severe nausea and vomiting. She is sent to you for consultation by an
outlying facility. Physical examination is unremarkable. Liver
functions, electrolytes, and thyroid functions are drawn and are
reported as follows: TSH: 0.01 mIU/mL (nl: 0.46-4.68), Free T4: 2.01
ng/dL (nl: 0.78-2.19), ALT/AST: within normal limits, Electrolyte panel:
within normal limits except K = 3.1 mEq/L

Should you take any action? What would be most appropriate?

S. N. returns post partum:

The patient returns to see you postpartum referred for a tubal
sterilization procedure. You repeat her thyroid functions and they
return as follows:

TSH: 5.18 mIU/mL (nl: 0.46-4.68), Free T4: 0.53 ng/dL (nl: 0.78-2.19)

Should you take any action? What would be most appropriate?

Want the answers to these questions?
<http://www.ihs.gov/MedicalPrograms/MCH/M/THYR01.cfm>

Free CEU /CME available

**[From Bill Green, Albuquerque]{.underline}**

**Indian Health - Special Interest Group Discussion Forum Now Available
online**\
The AAP Indian Health Special Interest Group (SIG-IH) Discussion
Summaries are now on the IHS MCH page for you to read and use
<http://www.ihs.gov/MedicalPrograms/MCH/C/CHprogram.asp#aapdisc>

Topics include: Childhood Asthma, Injury Prevention, ADHD, and Oral
Health so far

**[From Steve Holve, Tuba City]{.underline}**

**IHS Child Health Notes: New service from Pediatric CCC**

A great new service has just been started up for those of you who care
for Native young people. Steve Holve, the IHS Pediatric CCC, has started
a monthly online newsletter, IHS Child Health Notes. It will be
distributed on the various listserv(s) monthly. The IHS Child Health

Notes are archived on the IHS Child Health website here

[[www.ihs.gov/MedicalPrograms/MCH/C/ChPedNotes.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/C/ChPedNotes.cfm)

**[From Ursula Knoki-Wilson, Chinle]{.underline}**

**KEEPING THE SACRED IN CHILDBIRTH PRACTICES**

# Integrating Navajo Cultural Aspects into Obstetric Care (PowerPoint 4.5 MB). Ursula M. Knoki-Wilson CNM. This is a large file to download. You may want to contact Ursula for a copy.

# [**http://www.ihs.gov/MedicalPrograms/MCH/M/MCHabout.asp#Cult**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHabout.asp#Cult)

**[From Deborah Lessmeier, Juneau]{.underline}**

**What should I do about a patient at 4-6 weeks gestation with a
varicella like rash?**

As luck would have it only 5% of pregnant women who had no history of
varicella are susceptible, using fluorescent antibody to
varicella-zoster virus (VZV) membrane antigen to measure antibody
status.

On the other hand, to evaluate those 5%, the diagnosis of varicella is
usually made clinically. VZV may be cultured from vesicular fluid, but
this is a cumbersome process. Serologic tests may help document acute
infection in confusing cases or indicate immunity. IgM antibody may be
detected as soon as three days after VZV symptoms appear, and IgG may be
detected as early as seven days after varicella symptoms. Multiple
antibody detection assays are available including fluorescent
anti-membrane antibody (FAMA), latex agglutination (LA), enzyme-linked
immunosorbent assay (ELISA), and complement fixation tests.

Depending on your lab's turn around time, serologic testing is often not
initially helpful. As acyclovir has not been shown to be helpful to
treat the fetus in utero, its use is confined to decrease the severity
of the maternal disease by 1-2 days, if initiated within the first 24
hours of rash onset. Treatment with acyclovir from 25 to 72 hours after
the appearance of the rash had no effect on the course of the illness.

There is no role for VARIVAX, a live attenuated vaccine, in pregnancy
and once active varicella is diagnosed in the mother, V.Z.I.G. is of no
proven benefit.

Congenital varicella has an incidence of 2% and often confined to two
scenarios: 1.) congenital varicella syndrome cases occur in infants
whose mothers were infected between 8 and 20 weeks of gestation 2.)
neonates born to mothers who are exposed to VZV or have clinical disease
manifestations within two weeks of delivery are at the greatest risk for
infection. Neonatal varicella is a serious illness associated with up to
a 25 percent mortality rate. Nosocomial acquisition of VZV has been
reported.

Prenatal diagnosis of fetal varicella infection is possible.
Ultrasonography can detect limb abnormalities in affected fetuses. In
other studies, fetal blood has been obtained via percutaneous blood
sampling for VZV antibody or DNA on blood or amniotic fluid. Although
serologic methods can identify VZV infection early in fetal development,
they cannot predict sequelae from VZV infection.

The mother should be carefully monitored for the development of
varicella pneumonia. Varicella pneumonia in pregnancy is a medical
emergency. The mortality rate in untreated pregnant women is in excess
of 40 percent. Varicella pneumonia is seen in up to 20 percent of adult
chickenpox cases. Retrospective studies suggest that varicella pneumonia
may be more severe, although not more frequent, in pregnant compared to
nonpregnant women.

For the rest of the story please see these resources.

**Perinatology Corner Module: Chickenpox (varicella) in pregnancy (Free
CME/CEU)**

[[http://www.ihs.gov/MedicalPrograms/MCH/M/VC01.cfm]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/VC01.cfm)

**Varicella-zoster virus infection in pregnancy: UpToDate**

[[http://www.uptodateonline.com/application/topic.asp?r=/application/topic.asp&file=viral_in/4765&app=utdol]{.underline}](http://www.uptodateonline.com/application/topic.asp?r=/application/topic.asp&file=viral_in/4765&app=utdol)

**Treatment and prevention of chickenpox: UpToDate**

[[http://www.uptodateonline.com/application/topic.asp?file=viral_in/11333]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=viral_in/11333)

**Exposure algorithm**

<http://www.uptodateonline.com/application/image.asp?file=id_pix/rx_varic.gif>

**Acyclovir: UpToDate**

[[http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/7496&drug=true]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=drug_a_k/7496&drug=true)

**[From Janet Mehring, Anchorage]{.underline}**

**Teenage pregnancy prevention**

What resources are available to manage and/or prevent teenage pregnancy
in the Indian Health system? Here are some examples from Alaska

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/AlaskaTeenPregnancy31404.doc>

Phoenix / Sells / and several other resources

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/OtherResTeenagePreg32704.doc>

Do you know of any other success programs to decrease teenage pregnancy
in Indian Country?

Contact Janet Mehring <janetruth196@email.uophx.edu> or Neil Murphy
<nmurphy@anmc.org>

**[From Judy Thierry, HQE]{.underline}**

**School based care**

<http://www.ihs.gov/NonmedicalPrograms/NC4/TelConf/Documents/Minutes31704.doc>

**Teen Clinic Super bill page 1**

<http://www.ihs.gov/NonmedicalPrograms/NC4/TelConf/Documents/TeenClinicSuperbillpage111.doc>

**Teen Clinic Super bill page 2**

<http://www.ihs.gov/NonmedicalPrograms/NC4/TelConf/Documents/Teenclinicsuperbillpage211.doc>

From the MCH Teleconference Minutes March 17, 2004

**Distance Learning Certificate in MCH Epidemiology: Fellowships**

The Rollins School of Public Health at Emory University announces the
availability of fellowships for employees of MCH agencies to do graduate
training via distance learning. Persons may apply either for a 27 month
mid Career MPH Program or a 12-month, 18 credit hour Program.

<http://www.sph.emory.edu/academic/MCHEPI/> or email
<slandsk@sph.emory.edu>

**Online Alcohol Screening**\
How much is too much? At AlcoholScreening.org, individuals can take a
confidential, informative self-test to assess their drinking patterns
and receive personalized feedback. AlcoholScreening.org would be an
appropriate resource to link to as sidebar in news stories covering
alcohol and health issues. AlcoholScreening.org also offers free flash
banner graphics, pre-made print ads, door hangers, and the alcohol
screening syndication tool. The syndication tool is a way of seamlessly
integrating all the content of alcoholscreening.org into a 3^rd^ party
site.
[www.AlcoholScreening.org/promote](http://www.alcoholscreening.org/promote)

Funds for HIV and Prevention Services Into Reproductive Health and
Community Settings

CDC announces support HIV and other prevention services in reproductive
health and community settings to reach beyond their current efforts to
prevent STD and HIV transmission, and unintended and teen
pregnancies. Technical Information Management Section at (770) 488-2700.

<http://www.cdc.gov/health/funding.htm>

**Do you live in a state with a primary seat belt law?**

A primary or standard enforcement safety belt law allows law enforcement
to enforce a violation of a safety belt law after observing a belt use
infraction alone. For the states with a secondary law the safety belt
infraction can only be enforced in the presence of another violation
such as speeding, and DUI.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5312a2.htm> 

<http://www.nsc.org/public/impactseatbeltonflmedicaid.pdf>

**[From Judy Ungerleider, Tuba City]{.underline}**

**What is the value of the total protein to creatinine ratio in
pre-eclampsia?**

We have been using the T P/Cr ratio for a number of years. The T P/Cr
ratio is a quick adjunct to help establish the diagnosis of
pre-eclampsia. Just like the standard protein dipstick, the T P/Cr ratio
is also dependent on getting a relatively clean specimen for accuracy.

On the other hand the T P/Cr ratio has not been as well correlated with
the severity of the disease yet, so the T P/Cr ratio is only useful
until the T P/Cr ratio is greater than 0.2. It also has very little
value as a serial measurement, e.g., once it positive, the T P/Cr ratio
is positive, period.

The UpToDate link below states that the T P/Cr ratio can be used to
evaluate the progression of the disease, but this is based on very
limited data.

After the T P/Cr ratio positive, then other means need to be used for
severity, e.g., 24 hour urine or other clinical findings. This is
especially important since we have all re-started giving antenatal
aspirin again for a history of previous severe pre-eclampsia.

In other words, if we are going to commit a patient to aspirin therapy
from 13 weeks EGA till her delivery, among other significant
interventions, then we need to use established criteria for severe
pre-eclampsia, which is still \> 5 gm on 24 hour specimen.

Some good resources

Recently revised ANMC Hypertension in Pregnancy Guidelines
[[http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/HYPERT12004.doc]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/HYPERT12004.doc)

**[UpToDate]{.underline}**

Clinical features and prognosis of pre-eclampsia (see Urine protein to
creatinine ratio)

[[http://www.uptodateonline.com/application/topic.asp?file=pregcomp/4788]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=pregcomp/4788)

Measurement of urinary protein excretion

[[http://www.uptodateonline.com/application/topic.asp?file=glomrdis/5359]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=glomrdis/5359)

Screening for and management of pre-eclampsia

[[http://www.uptodateonline.com/application/topic.asp?file=pregcomp/7800&type=A&selectedTitle=3\~46]{.underline}](http://www.uptodateonline.com/application/topic.asp?file=pregcomp/7800&type=A&selectedTitle=3~46)

or try these free online CME modules for the MCH website

Hypertensive Complications of Pregnancy, Part 1: Mild Pre-Eclampsia

<http://www.ihs.gov/MedicalPrograms/MCH/M/HP01.cfm>

Hypertensive Complications of Pregnancy, Part 2: Severe Pre-Eclampsia

<http://www.ihs.gov/MedicalPrograms/MCH/M/HP02.cfm>

Part 3: Gestational Hypertension and Chronic Hypertension in Pregnancy

<http://www.ihs.gov/MedicalPrograms/MCH/M/HP03.cfm>

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

**[Obstetrics]{.underline}**

## Visual dipstick urinalysis at the 1+ (30 mg/dL) threshold not reliable: Systematic review CONCLUSION: The accuracy of dipstick urinalysis with a 1+ threshold in the prediction of significant proteinuria is poor and therefore of limited usefulness to the clinician. Accuracy may be improved at higher thresholds (greater than 1+ proteinuria), but available data are sparse and of poor methodological quality. Therefore, it is not possible to make meaningful inferences about accuracy at higher urine dipstick thresholds. There is an urgent need for research in this area of common obstetric practice. Waugh JJ, Clark TJ, Divakaran TG, Khan KS, Kilby MD. Accuracy of urinalysis dipstick techniques in predicting significant proteinuria in pregnancy. Obstet Gynecol. 2004 Apr;103(4):769-77. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051572&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051572&dopt=Abstract)

##  Safety of Vaginal Birth After Cesarean: A Systematic Review 

Safety in childbirth for women with prior cesarean is a major public
health concern. Methodological deficiencies in the literature evaluating
the relative safety of vaginal birth after cesarean compared with repeat
cesarean delivery are striking. The identification of high-risk and
low-risk groups of women and settings for morbidity remains a key
research priority. Level III

Jeanne-Marie Guise et al *Obstetrics & Gynecology* 2004;103:420-429

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990401&dopt=Abstract>

**Subdural hemorrhages not uncommon in full-term infants**

[INTERPRETATION:]{.underline} Presence of unilateral and bilateral
subdural hemorrhage is not necessarily indicative of excessive birth
trauma. Whitby EH, Griffiths PD, Rutter S, Smith MF, Sprigg A, Ohadike
P, Davies NP, Rigby AS, Paley MN. Frequency and natural history of
subdural hemorrhages in babies and relation to obstetric factors.
Lancet. 2004 Mar 13;363(9412):846-51.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15031028>

**Mediolateral episiotomy: worse pelvic floor function, incontinence,
and prolapse**

[CONCLUSION]{.underline}: Mediolateral episiotomy does not protect
against urinary and anal incontinence and genital prolapse and is
associated with a lower pelvic floor muscle strength compared with
spontaneous perineal lacerations and with more dyspareunia and perineal
pain. LEVEL OF EVIDENCE: II-2 Sartore A, De Seta F, Maso G, Pregazzi R,
Grimaldi E, Guaschino S. The effects of mediolateral episiotomy on
pelvic floor function after vaginal delivery. Obstet Gynecol. 2004
Apr;103(4):669-73.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051557&dopt=Abstract>

**Vegetarian diet in pregnancy raises risk of false-positive Down
syndrome screen**

CONCLUSION: The current data showed that the midtrimester maternal serum
free beta-human chorionic gonadotropin levels increased in vegetarian
pregnancies and led to an elevated false-positive rate in screening for
Down syndrome compared with pregnant women with regular diet and
resulted in unnecessary invasive procedures. It is necessary to
establish vegetarian pregnancy alpha-fetoprotein and beta-human
chorionic gonadotropin reference levels to correct increased
false-positive screening results. Cheng PJ, Chu DC, Chueh HY, See LC,
Chang HC, Weng DR. Elevated maternal midtrimester serum free beta-human
chorionic gonadotropin levels in vegetarian pregnancies that cause
increased false-positive Down syndrome screening results. Am J Obstet
Gynecol. 2004 Feb;190(2):442-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14981387>

**Use of ginger in early pregnancy will reduce their symptoms**

[CONCLUSION:]{.underline} For women looking for relief from their
nausea, dry retching, and vomiting, the use of ginger in early pregnancy
will reduce their symptoms to an equivalent extent as vitamin B6. LEVEL
OF EVIDENCE: I

Smith C, Crowther C, Willson K, Hotham N, McMillian V. A randomized
controlled trial of ginger to treat nausea and vomiting in pregnancy.
Obstet Gynecol. 2004 Apr;103(4):639-45.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051552&dopt=Abstract>

**Parental attitudes about a pregnancy predict birth weight in a
low-income population**

Maternal report of greater partner happiness about a pregnancy is
associated with birth weight and appears to define low- and high-risk
subgroups for low birth weight in a low-income population. Further study
in larger samples is needed to confirm our findings and to assess
whether maternal report of greater partner happiness is itself a
modifiable factor or is a marker for other factors that might be
modified with targeted interventions.

Keeley RD, et al Parental attitudes about a pregnancy predict birth
weight in a low-income population. Ann Fam Med. 2004 Mar-Apr;2(2):145-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15083855>

**Predictors of Cesarean Delivery for the Second Twin in Vaginal
Delivery of the First Twin**

In the general population, the cesarean delivery rate for the second
twin after vaginal delivery of the first twin is approximately 9.5%.
With the presence of breech and other malpresentations, the need for
emergent cesarean delivery of the second twin after vaginal delivery of
the first twin is increased by 4-fold. LEVEL OF EVIDENCE: II-2

Shi Wu Wen et al *Obstetrics & Gynecology* 2004;103:413-419

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990400&dopt=Abstract>

**Can Biophysical Profiles in Labor Predict C-Section?**

Kim SY, et al. Is the intrapartum biophysical profile useful? Obstet
Gynecol September 2003;102:471-6.
<http://www.aafp.org/afp/20040315/tips/19.html>

**Normal Control in Pregnant Women with Hypothyroidism**

Blazer S, et al. Maternal hypothyroidism may affect fetal growth and
neonatal thyroid function. Obstet Gynecol August 2003;102:232-41.
<http://www.aafp.org/afp/20040301/tips/23.html>

**Benefits of Incomplete Courses of Antenatal Corticosteroids**

Elimian A, et al. Antenatal corticosteroids: are incomplete courses
beneficial? Obstet Gynecol August 2003;102: 352-5.
<http://www.aafp.org/afp/20040301/tips/30.html>

**Effects of Automobile Crashes Occurring During Pregnancy**

Hyde LK, et al. Effect of motor vehicle crashes on adverse fetal
outcomes. Obstet Gynecol August 2003;102;279-86.
<http://www.aafp.org/afp/20040301/tips/31.html>

**[Gynecology]{.underline}**

**Gynecology in Native Women: IHS Biennial meeting has an
Internationally known faculty**

The Biennial Women's Health meeting is August 4-6, 2004 in Albuquerque.
The theme is 'Prevention in Native Women' but it will include many
others topics, as well. If your facility

cares for Native Women of any age, then you should attend if you are a
physician, Advanced Practice Nurse, Physician Assistant, or nurse. There
will be an internationally known faculty. It works best if your facility
sends a team of 1-3 clinical or opinion leaders. Info here

[[www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004)

**Single 1.5 mg levonorgestrel dose can substitute two 0.75 mg doses 12
h apart.**\
WHO multicentre randomized trial. von Hertzen H, et al Lancet. 2002 Dec
7;360(9348):1803-10.

## [**http://wwwdev.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon**](http://wwwdev.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon)

## 

**Other Emergency Contraception Resources**

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon>

**Not-2-Late.com**

<http://ec.princeton.edu/>

**Progestin only pills**

<http://ec.princeton.edu/info/ecminip.html>

**Women often choose surgery after extended drug treatment of
menorrhagia:**

## 2 Randomized Trials on Menorrhagia Compare Medical Therapy With Hysterectomy

## CONCLUSIONS: Among women with abnormal uterine bleeding and dissatisfaction with medroxyprogesterone, hysterectomy was superior to expanded medical treatment for improving health-related quality-of-life after 6 months. With longer follow-up, half the women randomized to medicine elected to undergo hysterectomy, with similar and lasting quality-of-life improvements; those who continued medical treatment also reported some improvements.

Kuppermann M, Varner RE, Summitt RL Jr, Learman LA, Ireland C,
Vittinghoff E, Stewart AL, Lin F, Richter HE, Showstack J, Hulley SB,
Washington AE; Ms Research Group. Effect of hysterectomy vs. medical
treatment on health-related quality of life and sexual functioning: the
medicine or surgery (Ms) randomized trial. JAMA. 2004 Mar
24;291(12):1447-55\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15039411>

[CONCLUSIONS:]{.underline} By providing improvement in HRQL at
relatively low cost, the LNG-IUS may offer a wider availability of
choices for the patient and may decrease costs due to interventions
involving surgery.

Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivela A,
Kujansuu E, Vuorma S, Yliskoski M, Paavonen J. Clinical outcomes and
costs with the levonorgestrel-releasing intrauterine system or
hysterectomy for treatment of menorrhagia: randomized trial 5-year
follow-up. JAMA. 2004 Mar 24;291(12):1456-63.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15039412>

[JAMA Editorial:]{.underline} JAMA 2004;291:1503-1504.

Results of the two studies suggest that women whose response to
first-line treatment is unsatisfactory \"can be counseled that further
conservative therapy carries approximately a 50% likelihood of
ultimately leading to hysterectomy,\" Drs. Roy M Pitkin and James R.
Scott wrote.

Total costs averaged \$2817 per subject in the LNG-IUS group and \$4660
in the hysterectomy group. By improving quality of life at relatively
low cost, \"the LNG-IUS may offer a wider availability of choices for
the patient and may decrease costs due to interventions involving
surgery.\"

But does this mean that surgery should be performed early to spare
patients ongoing symptoms, or that persisting with medical therapy
offers good odds of avoiding a major operation? Trials with longer
follow-up will be needed to determine the answers.

**Managing Ovarian Cysts in Postmenopausal Women**

## In postmenopausal women, most ovarian cysts smaller than 50 mm in diameter are benign and can be managed safely by regular monitoring of cyst size and serum CA 125 level.

## [**http://www.aafp.org/afp/20040401/tips/25.html**](http://www.aafp.org/afp/20040401/tips/25.html)

## High-Grade Squamous Intraepithelial Lesions: Abbreviating Post treatment Surveillance 

A clinically and financially optimal surveillance schedule for women
treated for high-grade dysplasia with loop excision would be to obtain
Pap tests every 6 months for 1 year and then return to annual screening.
Lengthening the surveillance intervals could be beneficial to patients,
while decreasing healthcare costs, without compromising the ability to
detect and treat recurrent disease. LEVEL OF EVIDENCE: II-2

Elizabeth N. Skinner et al *Obstetrics & Gynecology* 2004;103:488-492

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990411&dopt=Abstract>

**3 year screening is cost effective versus annual screening over 30
years**

CONCLUSIONS: For women aged 30 years and more, every 2- or 3-year
screening strategy that uses either HPV DNA testing in combination with
cytology for primary screening or cytology with reflex HPV DNA testing
for equivocal results will provide a greater reduction in cancer and be
less costly than annual conventional cytology. Goldie SJ, Kim JJ, Wright
TC. Cost-effectiveness of human papillomavirus DNA testing for cervical
cancer screening in women aged 30 years or more. Obstet Gynecol. 2004
Apr;103(4):619-31.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051550&dopt=Abstract>

**Effect of Oral Contraceptives on Functional Ovarian Cysts**

Holt VL, et al. Oral contraceptives, tubal sterilization, and functional
ovarian cyst risk. Obstet Gynecol August 2003; 102:252-8.
<http://www.aafp.org/afp/20040315/tips/20.html>

**Metabolic Abnormalities in Bulimia Nervosa**

Mehler PS. Bulimia nervosa. N Engl J Med August 28, 2003;349:875-81*.*

<http://www.aafp.org/afp/20040315/tips/22.html>

**Can Women Self-Screen for Cervical Abnormalities?**

Garcia F, et al. Cross-sectional study of patient- and
physician-collected cervical cytology and human papillomavirus. Obstet
Gynecol August 2003;102:226-72.

<http://www.aafp.org/afp/20040301/tips/24.html>

**Diagnosing and Managing Endometriosis**

Winkel CA. Evaluation and management of women with endometriosis. Obstet
Gynecol August 2003;102:397-408
<http://www.aafp.org/afp/20040301/tips/25.html>

**Effects of Oral Contraceptive Use in Older Smokers**

Vessey M, et al. Mortality in relation to oral contraceptive use and
cigarette smoking. Lancet July 19, 2003;362:185-91.
<http://www.aafp.org/afp/20040301/tips/26.html>

**Extending the Interval Between Pap Smears**

Sawaya GF, et al. Risk of cervical cancer associated with extending the
interval between cervical-cancer screenings. N Engl J Med October 16,
2003;349:1501-9.

<http://www.aafp.org/afp/20040301/tips/27.html>

**Vaginal Delivery Affects Pelvic Organ Support**

Dietz HP, Bennett MJ. The effect of childbirth on pelvic organ mobility.
Obstet Gynecol August 2003;102:223-8.
<http://www.aafp.org/afp/20040301/tips/28.html>

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

**Adolescent Health, School based care, and contraception : IHS Women's
Health Biennial meeting. Steve Holve, Donna Perry, Susie John, and many
others**

The Biennial Women's Health meeting is August 4-6, 2004 in Albuquerque.
The theme is 'Prevention in Native Women' but it will include many
others topics, as well. If your facility

cares for Native Women of any age, then you should attend if you are a
physician, Advanced Practice Nurse, Physician Assistant, or nurse. There
will be an internationally known faculty. It works best if your facility
sends a team of 1-3 clinical or opinion leaders. Info here

[[www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004)

**Ending an Antitobacco Youth Campaign on Adolescent Susceptibility to
Smoking**

Tobacco use remains the leading preventable cause of death in the United
States and efforts to prevent smoking initiation among youths can have a
profound impact on public health. While cutbacks in state programs were
occurring, the tobacco industry spent \$11.2 billion in 2001 (the most
recent year for which data are available), or \$39 per person in the
United States, on advertising and promotion expenditures. These tobacco
industry expenditures were 17% higher than the previous year and nearly
double the amount spent on marketing in 1997, the year before MSA. The
decline in campaign awareness and increase in adolescent susceptibility
in suggest that antitobacco funding cuts could reverse the recent
declines in youth tobacco use.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5314a1.htm>

**New Community Pediatrics Web Site Launched**

The AAP new and improved Community Pediatrics Web Site can now be found
at <http://www.aap.org/commpeds/> You will find a host of new features
including, a U.S. map with links to state specific community pediatric
resources by programs (e.g., Breastfeeding, Medical Home, CATCH). The
Web Site also features easy-to-access links to funding opportunities,
medical home and community-based initiative tools and resources, and
access to the DOCP searchable grant/project database. This database
enables you to search for information on current and previous grant
projects funded through AAP programs. In addition, you will find links
to all Community Pediatrics programs.

**FAS \"Better Safe than Sorry**

The curriculum has recently been cleared by DHHS.  The hardcopy
materials and Power Point is available on-line.  We have recently
distributed CD-Rom versions of the curricula and will continue to do so
at subsequent teacher meetings.  Carolina Biological Supply Company will
be printing and releasing the full curriculum kits late in the summer
for next school year, free to teachers, along with discounted lab kits
for the hands-on experiment. You can view the available materials at
<http://www.niaaa.nih.gov/publications/Science/main.htm>

**CATCH/Medical Home National Conference**

Exciting opportunity to showcase your community-based project at the
Community Access to Child Health (CATCH) and Medical Home Conference
July 16-17, 2004, in Chicago, IL. Requests for Proposal (RFP) for a
Poster Exhibit are currently being accepted. Submit ASAP.

Please see the conference flyer for additional information. Registration
information and the full Conference Brochure can now be found at:
[[http://www.aap.org/catch/nationalconf.html]{.underline}](http://www.aap.org/catch/nationalconf.html)

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

**Virtual colonoscopy sensitivity is low**

[CONCLUSIONS]{.underline}: Computed tomographic colonography by these
methods is not yet ready for widespread clinical application. Techniques
and training need to be improved.

Cotton PB et al Computed tomographic colonography (virtual colonoscopy):
a multicenter comparison with standard colonoscopy for detection of
colorectal neoplasia. JAMA. 2004 Apr 14;291(14):1713-9\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15082698>

**Cigarette smoking, awareness of diabetes, binge drinking, drinking /
driving and others**

Health Behaviors of American Indians and Alaska Natives, 1997-2000

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHsubst.asp#healthb>

**Smoking ban linked to drop in heart attacks**

\"The observations \... suggest that smoke-free laws not only protect
people from the long-term dangers of second-hand smoke but also that
they may be associated with a rapid decrease in heart attacks,\"

Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for
myocardial infarction associated with public smoking ban: before and
after study. BMJ. 2004 Apr 5\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15066887>

**Type 2 diabetes linked to cognitive decline in women**

CONCLUSIONS: Women with type 2 diabetes had increased odds of poor
cognitive function and substantial cognitive decline. Use of oral
hypoglycemic therapy, however, may ameliorate risk.\
Logroscino G, Kang JH, Grodstein F. Prospective study of type 2 diabetes
and cognitive decline in women aged 70-81 years. BMJ. 2004 Mar
6;328(7439):548.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14980984>

**Long-Term Sequelae of Breast Cancer Treatment**

Long-term sequelae of breast cancer diagnosis and treatment: data from a
20-year follow-up of breast cancer survivors.
<http://www.aafp.org/afp/20040401/tips/23.html>

**Exercise Testing as a Predictor of Mortality in Women**

Exercise capacity and HRR are strong, graded, and independent predictors
of cardiovascular and all-cause mortality, while ST-segment depression
is not. Treadmill testing has a potential role for further risk
stratification in asymptomatic women with low or intermediate Framingham
risk scores. One limitation of the study is that it is unclear to what
extent the treadmill testing represents a modifiable risk factor.
<http://www.aafp.org/afp/20040401/tips/24.html>

**\"Asthma Surveillance and Epidemiology\"** **Wednesday, May 5, 2004 at
2:00-3:00\
**WEBCAST Leslie Boss,MPH,PhD, *CDC*, Sarah Lyon-Callo,MA,MS, *Michigan
Department of Community Health*, Patricia Miskell, *Connecticut
Department of Public Health*\
Meeting address: <http://www.uic.edu/sph/cade/mchepi/>    

**Abortions do not raise breast cancer risk**

INTERPRETATION: Pregnancies that end as a spontaneous or induced
abortion do not increase a woman\'s risk of developing breast cancer.
Collectively, the studies of breast cancer with retrospective recording
of induced abortion yielded misleading results, possibly because women
who had developed breast cancer were, on average, more likely than other
women to disclose previous induced abortions. Beral V, Bull D, Doll R,
Peto R, Reeves G; Collaborative Group on Hormonal Factors in Breast
Cancer. Breast cancer and abortion: collaborative reanalysis of data
from 53 epidemiological studies, including 83?000 women with breast
cancer from 16 countries. Lancet. 2004 Mar 27;363(9414):1007-16.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051280>

##### Features

## American Family Physician

###### COCHRANE FOR CLINICIANS:

**What Is the Best Collection Device for Screening Cervical Smears?**

[Reviewers\' Conclusions.]{.underline} Extended-tip spatulas of various
designs appear to be better for collecting endocervical cells than the
commonly used Ayre spatula. The most effective combination appears to be
the endocervical brush with an extended-tip spatula. The rate of
detection of endocervical cells appears to be a valid and convenient
surrogate for the ability to detect dyskaryosis and for adequate smear
rates. The ability of the extended-tip spatula with the endocervical
brush compared with the extended-tip spatula alone to detect disease
must be evaluated in a trial.
<http://www.aafp.org/afp/20040401/cochrane.html>

##### Advanced Life Support in Obstetrics (ALSO) Series

##### Shoulder Dystocia Chapter updated

Shoulder dystocia can be one of the most frightening emergencies in the
delivery room. Although many factors have been associated with shoulder
dystocia, most cases occur with no warning. Calm and effective
management of this emergency is possible with recognition of the
impaction and institution of specified maneuvers, such as the McRoberts
maneuver, suprapubic pressure, internal rotation, or removal of the
posterior arm, to relieve the impacted shoulder and allow for
spontaneous delivery of the infant. The \"HELPERR\" mnemonic from the
Advanced Life Support in Obstetrics course can be a useful tool for
addressing this emergency. Although no ideal manipulation or treatment
exists, all maneuvers in the HELPERR mnemonic aid physicians in
completing one of three actions: enlarging the maternal pelvis through
cephalad rotation of the symphysis and flattening of the sacrum;
collapsing the fetal shoulder width; or altering the orientation of the
longitudinal axis of the fetus to the plane of the obstruction. In rare
cases in which these interventions are unsuccessful, additional
management options, such as intentional clavicle fracture,
symphysiotomy, and the Zavanelli maneuver, are described. (Am Fam
Physician 2004;69:1707-14. Copyright© 2004 American Academy of Family
Physicians.)

<http://www.aafp.org/afp/20040401/1707.html>

##### ACOG

**Nausea and Vomiting of Pregnancy, ACOG Practice Bulletin No. 52.**

**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 B~6~ or
    vitamin B~6~ 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 H~1~ 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

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051578>

**Nausea and vomiting in pregnancy will also be covered at the IHS
Biennial Women's Health meeting by Sharon Phelan, University of New
Mexico**

The Biennial Women's Health meeting is August 4-6, 2004 in Albuquerque.
The theme is 'Prevention in Native Women' but it will include many
others topics, as well. If your facility

cares for Native Women of any age, then you should attend if you are a
physician, Advanced Practice Nurse, Physician Assistant, or nurse. There
will be an internationally known faculty. It works best if your facility
sends a team of 1-3 clinical or opinion leaders. Info here

[[www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004)

**ACOG supports universal health care: Cover the Uninsured Week is May
10-16\
**Of the nearly 44 million uninsured Americans, almost half are women.
These women are less likely than insured women to receive preventive
care or early intervention, and are more likely to lack access to needed
medications. An uninsured woman is less likely to receive an annual Pap
test, mammogram, or clinical breast exam, meaning her cervical cancer or
breast cancer may go unnoticed and untreated. She may not seek out a
doctor when she has chest pains or abnormal bleeding or cramping.
Thirteen percent of all pregnant women are uninsured, and an uninsured
pregnant woman may not seek prenatal care early or often enough.

<http://www.acog.com/from_home/publications/press_releases/coverUninsuredWeek.cfm>

##### AHRQ: From Elaine Locke ACOG Committee on American Indian Affairs

**Rural studies examine telecolposcopy for women with abnormal Pap
smears:**

satisfaction with and cost-effectiveness

[[http://www.ahrq.gov/research/feb04/0204RA7.htm#head2]{.underline}](http://www.ahrq.gov/research/feb04/0204RA7.htm#head2)

##### Breastfeeding

**Breastfeeding Track at Biennial OB/GYN meeting in August 2004:
Multiple sessions**

**Suzan Murphy, Eve Espey, Jenny Chee, Maria Lennon, and other
presenters**

The Biennial Women's Health meeting is August 4-6, 2004 in Albuquerque.
The theme is 'Prevention in Native Women' but it will include many
others topics, as well. If your facility

cares for Native Women of any age, then you should attend if you are a
physician, Advanced Practice Nurse, Physician Assistant, or nurse. There
will be an internationally known faculty. It works best if your facility
sends a team of 1-3 clinical or opinion leaders. Info here

[[www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004)

**[Domestic Violence]{.underline}**

**Domestic Violence Track at Biennial OB/YN meeting in August 2004:
Multiple sessions**

**Rachel Locker, Donald Clark, Bonnie Duran and other presenters**

The Biennial Women's Health meeting is August 4-6, 2004 in Albuquerque.
The theme is 'Prevention in Native Women' but it will include many
others topics, as well. If your facility

cares for Native Women of any age, then you should attend if you are a
physician, Advanced Practice Nurse, Physician Assistant, or nurse. There
will be an internationally known faculty. It works best if your facility
sends a team of 1-3 clinical or opinion leaders. Info here

[[www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004)

**Take a Leadership Role in Combating Sexual Violence in US: Funding
available**

State sexual assault coalitions receiving sexual assault coalition grant
funds through the Violence Against Women Act. Funding: \$700,000 for one
cooperative agreement.   

Applications are available at
[[www.cdc.gov/od/pgo/forminfo.htm]{.underline}](../www.cdc.gov/od/pgo/forminfo.htm)

**[Elder Care News]{.underline}**

**Prevention in Native Women: IHS Biennial meeting has an
Internationally known faculty**

**Bruce Finke, James Galloway and many others**

The Biennial Women's Health meeting is August 4-6, 2004 in Albuquerque.
The theme is 'Prevention in Native Women' but it will include many
others topics, as well. If your facility

cares for Native Women of any age, then you should attend if you are a
physician, Advanced Practice Nurse, Physician Assistant, or nurse. There
will be an internationally known faculty. It works best if your facility
sends a team of 1-3 clinical or opinion leaders. Info here

[[www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004)

**[Frequently asked questions]{.underline}**

**Can misoprostol be used in an outpatient setting?**

Q. What is the cost effectiveness for the use of cytotec or any other
induction agents?

A. Misoprostol is more cost-effective than the comparable commercial
agents.
<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/OutptMiso32704.doc>

**Q. Can we use Lispro in pregnancy?**

A. Yes, we can use lispro in pregnancy
<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/Lispro31304.doc>

**Q. What is the clinical significance of endometrial cells found on Pap
smears?**

A. It is only significant in women 40 years of age and then an
endometrial biopsy should be performed.
<http://www.ihs.gov/MedicalPrograms/MCH/M/Faqdnlds/EndometrialCellPap31404.doc>

**Am I eligible for care at this Indian Health facility?**

Q. What medical services are available to American Indians and Alaska
Natives, including eligibility, and services to members of federally
recognized Indian tribes who may live near an Indian Health Service
facility but are not enrolled in the tribe where the services are
provided?

A. There are many requirements to qualify for those potential services

<http://www.ihs.gov/GeneralWeb/HelpCenter/CustomerServices/FAQ_index.asp>
and

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/Eligibility31404.doc>

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

**Nonhormonal alternatives for the treatment of hot flashes.**

Clonidine, venlafaxine, paroxetine, fluoxetine, and gabapentin are
nonhormonal agents that have demonstrated efficacy in small controlled
and uncontrolled trials in reducing hot flashes and should be considered
in patients unwilling or unable to take hormonal therapies

Sicat BL, Brokaw DK.. Nonhormonal alternatives for the treatment of hot
flashes. Pharmacotherapy. 2004 Jan;24(1):79-93.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14740790>

**Use of Ultra-Low-Dose Estrogen to Prevent Bone Loss**

Prestwood KM, et al. Ultra low-dose micronized 17b-estradiol and bone
density and bone metabolism in older women. JAMA August 27,
2003;290:1042-8 <http://www.aafp.org/afp/20040315/tips/21.html>

**Transdermal Estrogen and Venous Thromboembolism**

Scarabin PY, et al. Differential association of oral and transdermal
estrogen-replacement therapy with venous thromboembolism risk. Lancet
August 9, 2003;362:428-32.

<http://www.aafp.org/afp/20040315/tips/23.html>

**Breast Cancer Risk Related to Type of Hormone Therapy**

Million Women Study collaborators. Breast cancer and hormone-replacement
therapy in the Million Women Study. Lancet August 9, 2003;362:419-27.
<http://www.aafp.org/afp/20040315/tips/24.html>

# [Information Technology]{.underline}

**2004 Technology Conference**

DIR is planning to host the 2004 Technology Conference the week of
August 23^rd^, 2004 in Scottsdale, Az. Contact Terry Cullen for
questions <Theresa.Cullen@IHS.GOV>

# [International Health Update]{.underline}

**Suicides in young people in rural southern India -- relevance to AI/AN
youth**

Suicide rates among young people in southern India are much higher than
anywhere in the world, especially for women. Rates in other parts of
India may be just as high, but appear lower due to underreporting of
suicides. Some AI/AN groups have the next highest rates of suicide in
youth. A system of surveillance is well established and the verbal
autopsy method has been validated. These very high rates of suicide need
urgent intervention.

Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, Minz S,
Abraham VJ, Bose A.

Suicides in young people in rural southern India. Lancet. 2004 Apr
3;363(9415):1117-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15064031>

#### [MCH Alert]{.underline}

**Effectiveness of school-based suicide-prevention program evaluated**

This is the first school-based suicide prevention program for which a
reduction in self-reported suicide attempts has been documented with a
randomized experimental design.

Aseltine RH, DeMartino R. 2004. An outcome evaluation of the SOS suicide
prevention program. American Journal of Public Health 94(3):446-451

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14998812>

#### [Medscape\*]{.underline}

######### Bisphosphonates in Osteoporosis: Emerging Science: CME

######### [**http://www.medscape.com/viewprogram/2998?mpid=26141**](http://www.medscape.com/viewprogram/2998?mpid=26141)

**Endometriosis and Infertility: CME**

<http://www.medscape.com/viewprogram/2947?mpid=26141>

**Opioid Analgesia: Practical Treatment of the Patient With Chronic
Pain: CME**

<http://www.medscape.com/viewprogram/2942?mpid=26141>

######### Ask the Experts topics in Women\'s Health and OB/GYN Index, by specialty, Medscape

######### [**http://www.medscape.com/pages/editorial/public/ate/index-womenshealth**](http://www.medscape.com/pages/editorial/public/ate/index-womenshealth)

######### 

######### OB GYN & Women\'s Health 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@@.eeab9d1>

**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.

**[Office of Women's Health, CDC]{.underline}**

**First and only rapid HIV test approved for use with oral fluid: FAQs**

The FDA has approved the OraQuick test for use with oral fluid and on
plasma specimens. Until now, the test was approved only for whole blood
specimens. Frequently Asked Questions

<http://www.cdc.gov/hiv/rapid_testing/materials/oralfluidqandafin1_1.pdf>

**[Osteoporosis]{.underline}**

**Osteoporosis: Evidence Based Periodic Exam in the Elderly Native
Americans**

Dr. Bruce Finke presented as set of Guidelines for Preventive Care
Service for the Elderly developed by an Indian Health workgroup, which
very closely follow the USPSTF guidelines for persons over 65 with some
"expert opinion" recommendations added. See issues here:
[www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ElderExamPrimer11604.doc](http://www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ElderExamPrimer11604.doc)

See full discussion here:

[www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ExamElderlyDiscussion32004.doc](http://www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ExamElderlyDiscussion32004.doc)

**[\# 1 Osteoporosis Summary]{.underline}**

1.  Osteoporosis screening is clearly an "emerging issue" in the Indian
    health system, with clinicians and programs struggling with whether
    published guidelines should be applied to the AIAN population and if
    so, how.

2.  Many of the discussants were uncomfortable with the lack of AIAN
    specific data on which to base decisions. While there is some,
    limited data suggesting that self-identified Native American women
    may be at the same risk as Caucasian women, the heterogeneity of the
    AIAN population make generalizations difficult. As is often the case
    in AIAN health, we are forced to make judgments about implementing
    guidelines not based in our specific practice settings. Two sites
    that have initiated more comprehensive screening (one with DEXA,
    another with heel ultrasound) reported that they are seeing
    significant numbers of women with T-scores \< -2.5.

3.  Access to screening is problematic for many sites, with geographic
    barriers to DEXA scanning featuring prominently. Some discussants
    have had difficulty with the financial implications of a widespread
    screening effort. Others felt that the USPSTF recommendation for
    screening should set the standard for level of service.

4.  There was a great deal of discussion about modalities of screening.
    DEXA represents the "gold standard" but presents access problems.
    Several sites are using heel ultrasound as a primary screening
    approach. They argued that the data for heel ultrasound, although
    limited, shows ultrasound to be a good predictor of fracture rate
    and that a screening program based on heel ultrasound can improve
    access to treatment for those at highest risk. Others do not believe
    that the evidence base supports the use of ultrasound. We were
    reminded that our goal is to prevent fractures, and that fracture
    rates are the real gold standard.

5.  Diabetes is reported as a risk factor for osteoporosis. This of
    course has significant implications for our population.

6.  Several sites reported routinely offering calcium carbonate and a
    multivitamin containing vitamin D to all older persons.

7.  In many ways this robust and lively discussion gets to the heart of
    what we are trying to do in the Indian health system: provide high
    quality, evidence-based personal health care within the framework of
    a strong public health model.

**Osteoporosis in American Indian / Alaska Native Women, 2004**

Preliminary report from the National Indian Women's Health Resource
Center

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHdownloads/OsteoporosisNIWHRC4104.doc>

**Early Discontinuation of Osteoporosis Treatment**

Tosteson AN, et al. Early discontinuation of treatment for osteoporosis.
Am J Med August 15, 2003;115:209-16.
<http://www.aafp.org/afp/20040301/tips/29.html>

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

**Eating Disorders**

<http://www.aafp.org/afp/20040401/1731ph.html>

**Anorexia Nervosa**

<http://www.aafp.org/afp/20040401/1729ph.html>

**Sports and Women Athletes: The Female Athlete Triad**

"If you have the female athlete triad, you have stopped eating the right
way. Your menstrual periods have stopped or become irregular. You also
may have osteoporosis....."

<http://www.aafp.org/afp/20040401/1734ph.html>

**[Primary Care Listserv]{.underline}**

**Adolescent Risk Taking Behavior**

On May 1, 2004, Donna Perry in Chinle, will moderate a discussion of
Adolescent Risk Taking Behavior on the Primary Care Discussion Forum.
This will be a combined listserv Discussion with the Special Interest
Group -- Indian Health of the AAP.

The Discussion Forum provides an e-mail listserv based discussion
moderated by national leaders or experts in a particular field. The
discussion is captured and summarized online, here:
[[www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp)

To subscribe, go the site below and click the word 'subscribe' in the
first paragraph, or contact me

[[www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp)

**Adult Asthma**

On August 1, 2004, thanks to Charles (Ty) Reidhead, Whiteriver, we will
start an Adult Asthma Discussion. Ty is the IHS Internal Medicine CCC.

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

**New Perinatology Corner Module - Free CEU /CME available**

**Thyroid Disorders in Pregnancy:**

<http://www.ihs.gov/MedicalPrograms/MCH/M/THYR01.cfm>

**Adverse outcome with one elevated OGTT value**

<http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#advout>

###### Q. Is a cesarean delivery indicated after a prior fourth degree laceration?

**A. Yes, a decision analysis concluded only two to three elective
cesarean deliveries would need to be performed to prevent one case of
fecal incontinence**

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/FecalIncontinence31304.doc>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

**Basic IHS Colposcopy Course April 26-29, 2004**

Albuquerque, New Mexico

[http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#April2004]{.underline}

For more information, contact:
[roberta.paisano@mail.ihs.gov]{.underline}

FYI: 2002 brochure

[http://www.ihs.gov/MedicalPrograms/MCH/M/ArchDownloads/2002_colposcopy.pdf]{.underline}

**Refresher IHS Course April 27-29, 2004**

Albuquerque, New Mexico

[http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#April2004]{.underline}

For more information, contact:
[roberta.paisano@mail.ihs.gov]{.underline}

FYI: 2002 brochure

[http://www.ihs.gov/MedicalPrograms/MCH/M/ArchDownloads/2002_colposcopy.pdf]{.underline}

**Focus on IHS Maternal and Child Health: 16th Research Conference**

**May 11-13, 2004**

Scottsdale Arizona Sponsored by the Indian Health Service

3-day research conference will focus on learning about American
Indian/Alaska Native research activities focusing this year on Maternal
and Child Health in Indian Communities. 

<http://www.ihs.gov/medicalprograms/Research/Documents/Conffinal2004.doc>

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

May 25 - 28, 2004 

Los Angeles, California 

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

#### National IHS PA / APN Annual Meeting, June 7-11, 2004

Scottsdale, Arizona

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

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

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

-   June 13-17, 2004 **with separate NRP Course on first morning
    session, 6/13/04**

-   Denver, CO

-   Contact Teddra Penland at 301 443 1840

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June2004>

-   2004 brochure
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Brochure2004.doc>

-   June 13th at 8:00 am: Separate NEONATAL RESUSCITATION PROGRAM

-   NRP Class size limited. Sign up now

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

**2004 Biennial OB/GYN meeting: Prevention in Women's Health**

August 4-6, 2004

Albuquerque, New Mexico

Great CEU /CME, plus good networking for leaders of Women's Health / MCH

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

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

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

The **March 2004 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner31504.doc>

Here are the topics covered:

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

**[Abstract of the Month]{.underline}: page 2**

ACOG Statement On the NIH Announcement To Halt Estrogen-Only Arm Of The
WHI Study

[From your colleagues:]{.underline} page 4

From Melissa Boll: Is a cesarean delivery indicated after a prior fourth
degree laceration?

From Terry Cullen: Screening for Family and Intimate Partner Violence

From David Gahn: Medical trip to rural Brazil. Interested?

From Bill Green: AAP Indian Health - Special Interest Group Discussion
Forum Site available

From Sheila Kimble-Haas: Can we use Lispro in pregnancy?

From Sandra Haldane: Labor and Delivery Management Course

From Tony Ogburn: DATE CHANGE: IHS/ACOG Postgraduate Course in June,
[not]{.underline} September

From Augustine Provencio: Are there alternatives to insulin use in
pregnancy? Can you use glyburide in pregnancy?

From Judy Thierry: Maternal Child Health Research in Indian Country May
11-13, 2004; Interested in other resources to analyze infant mortality
data?

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

##### Obstetrics: page 8

##### New guidelines for management of hypertension in pregnancy available; RCT: Predominately Fetal Growth-Based Strategy to Guide Management of GDM; How thorough is your VBAC or TOLAC consent? Maternal smoking in pregnancy, fetal development, and childhood asthma; Effects of Automobile Crashes Occurring During Pregnancy: Protects fetus; Randomized controlled trial of laboring in water; Practical Selection of Antiemetics; Calcium supplementation appears to be beneficial for women at high risk of gestational hypertension and in communities with low dietary calcium intake; Impact of iron deficiency anemia on prevalence of gestational diabetes mellitus; Can Biophysical Profiles in Labor Predict C-Section?

Gynecology: page 10

Abbreviated Surveillance Safe After Treatment of High-Grade Cervical
Dysplasia; Medical treatment of miscarriage in a general hospital is
safe and effective up to 12 weeks; Estrogen withdrawal has been
described as a trigger for migraine headache; Raloxifene inhibits
leiomyoma growth in premenopausal women; Reproductive endocrine
disorders common among women treated for epilepsy; Therapeutic Options
for External Genital Warts; Effect of Oral Contraceptives on Functional
Ovarian Cysts

Child Health: page 11

Full term infant with laboratory evidence of congenitally acquired West
Nile Virus infection

Chronic Illness and Disease: page 11

Trial stopped: HABITS (hormonal replacement therapy after breast
cancer\--is it safe?); Screening for Coronary Heart Disease : Level D,
e.g., Recommends against; Virtual colonoscopy is an accurate method for
the detection of colorectal neoplasia; Antibiotic use in relation to the
risk of breast cancer; **Finnish study supports anti-diabetes effect for
coffee;** Initial Evaluation of Hypertension

Other: page 13

Nail Abnormalities: Clues to Systemic Disease; Alcohol Withdrawal
Syndrome; Screening for Dementia: Recommendation and Rationale

Features[:]{.underline} page 13

###### AFP: Does it make sense to test for human papillomavirus (HPV) if cervical cytology shows low-grade squamous intraepithelial lesion (LSIL)? One-Day Drug Regimen Eliminates *H. pylori;* British Medical Journal: Clinical Evidence Concise, Evidence Based Medicine Excerpt HIV: Mother-to-Child Transmission

ACOG: Chronic Pelvic Pain: Practice Bulletin; Cervical cancer prevention
in low resource settings

**AHRQ:** Cervical cancer rates among younger women decreased over the
past 25 years; Screening for Obesity in Adults: Level B recommendation

Breastfeeding: Exclusive Breastfeeding or supplement with Vitamin D?
Breast-Feeding During Infancy May Lower Blood Pressures in Childhood;
Learn how to determine whether a drug is safe for lactating mothers.

**Domestic Violence:** Improving Screening of Women for Violence

**Elder Care News:** Statin therapy significantly reduces the risk of
stroke regardless of age

**Frequently asked questions:** Sterilization procedures in non-Native
women with Native partners

**Hormone Replacement Update**: Benefits of HRT depend on menopausal
symptoms and perceived quality of life; Transdermal Estrogen and Venous
Thromboembolism; Breast Cancer Risk Related to Type of Hormone Therapy

**Information Technology:** One click: UpToDate Online now on the IHS
Home page

International Health: Violence and Human Rights Abuses: Women in the
Developing World

#### MCH Alert: Prevent Bullying and youth violence

#### Medscape: New Guidelines for Polycystic Ovary Syndrome

#### Office of Women's Health, CDC: Racial disparity in pregnancy-related mortality persists: Pregnancy-Related Mortality

Osteoporosis: Good association with ultrasound attenuation of the
calcaneus and hip fracture; Use of Ultra-Low-Dose Estrogen to Prevent
Bone Loss

Patient Education: Genital Herpes Patient Education Center; List of
recommended patient resources on birth control with FAQs; Alcohol Abuse:
How to Recognize Problem Drinking; Alcohol Withdrawal Syndrome;
Substance Abuse

Primary Care Discussion Forum: Adolescent risk taking behaviors a.k.a.
\"Sex drugs and rock and roll\" **May 1, 2004**

**What's new on the ITU MCH web pages:** **page 19**

Who is Yolanda Adams? Who is Margaret Baldwin? and what they can do for
you ? About Denise Exendine: Indian Health Urban MCH programs;
Cardiovascular Disease Prevention in Women; Disparities in Premature
Deaths from Heart Disease

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

\*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, contact Jason
Crim at: [jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov)

4/19/04