9/23/03

OB/GYN Chief Clinical Consultant's Corner

September 23, 2003 Update

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

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

Aspirin for Prevention of Preeclampsia in Women With Historical Risk
Factors: A Systematic Review. (Level I)

[From your colleagues:]{.underline}

From Melissa Boll: New Indian Health Breastfeeding page, thanks to
Melissa Boll, CNM.

From Ruth Lagerberg: New Indian Health Genetics page, thanks to Ruth
Lagerberg, CNM.

From Larry Leeman: The Nature and Management of Labor Pain

From Chuck North: Breast cancer and HRT in the Million Women Study.

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

##### Obstetrics: Rapid Point-of-Care Testing for HIV-1 During Labor and Delivery; Continuous support for women during childbirth; Exercise in Pregnancy; Seven ways to Control Postpartum Hemorrhage; 

**Gynecology:** Does HIV Status Make a Difference in the Experience of
Lifetime Abuse? Endometriosis and subfertility: is the relationship
resolved? Unique approach to understanding adolescents' sexual
relationships; Assisted Reproductive Technology Surveillance, 2000

###### Chronic Illness and Disease: Findings on relationship between obesity and food insecurity; Prevalence of Diabetes and Impaired Fasting Glucose in Adults; One-year outcome of a combination of weight loss therapies for subjects with type 2 diabetes 

Other: Consumption of dark chocolate \-- but not milk chocolate \--
could help protect against heart disease; Modest activity reduces risk
of breast cancer while women lose weight; MedScape OB/GYN Discussion
Boards;

[Features:]{.underline}

##### AAFP: Practice Guidelines: Epigastric Discomfort and Management of Dyspepsia and GERD

ACOG: Cervical cerclage for prevention of preterm delivery:
meta-analysis of randomized trials.

**AHRQ:** Researchers examine cost-effectiveness and quality of life
following surgery for early breast cancer; More assertive outreach
programs may be needed to link homeless women to case managers and a
broader range of services; Physicians have an important role in
identifying victims of domestic violence and referring them for
appropriate services; Parental misconceptions about respiratory
illnesses, not day care pressure, lead parents to pressure physicians
for antibiotics; Medical treatment of one child for an injury may signal
a period of increased injury risk for other children in the family;
School-based health centers reduce asthma-related hospitalization and
absenteeism among urban children

**Breastfeeding:** New Indian Health Breastfeeding web page; lactational
atrophic vaginitis.

**Hormone Replacement Update**: Phytoestrogen Intake and Endometrial
Cancer Risk; Ultralow-Dose Micronized 17-Estradiol and Bone Density and
Bone Metabolism in Older Women

International Health: The International Experience and Technical
Assistance Program

Patient Education: Labor Pain: What to Expect and Ways to Relieve Pain;
Prenatal Care - What will happen during prenatal visits? Pregnancy and
Exercise; Respiratory Infections during Pregnancy

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

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

# [Abstract of the Month]{.underline}

Aspirin for Prevention of Preeclampsia in Women with Historical Risk
Factors: A Systematic Review.

Coomarasamy A, et al Obstet Gynecol June 2003, Volume 101, Number 6:
1319 - 1332

**Objective**: To examine the effectiveness of aspirin in preventing
perinatal death and preeclampsia in women with predisposing historical
risk factors, such as previous history of preeclampsia, chronic
hypertension, diabetes, and renal disease.

**Data Sources**: Searches were conducted in MEDLINE, EMBASE, Cochrane
Library, National Research Register, SCISEARCH, and ISI Conference
Proceedings without any language restriction.

**Methods of Study Selection**: We included all randomized trials that
evaluated the effectiveness of aspirin compared with placebo or no
treatment in women with predisposing historical risk factors and
reported clinically relevant perinatal or maternal outcomes. Study
selection, quality appraisal, and data extractions were performed
independently and in duplicate.

**Tabulation, Integration, and Results**: We identified 14 relevant
trials, including a total of 12,416 women. Meta-analysis showed a
significant benefit of aspirin therapy in reducing perinatal death (odds
ratio \[OR\] 0.79, 95% confidence interval \[CI\] 0.64, 0.96) and
preeclampsia (OR 0.86, 95% CI 0.76, 0.96). Aspirin was also associated
with a reduction in rates of spontaneous preterm birth (OR 0.86, 95% CI
0.79, 0.94), and an increase of 215 g in mean birth weight (weighted
mean difference 215, 95% CI 90, 341). There was no increase in the risk
of placental abruption with aspirin (OR 0.98, 95% CI 0.79, 1.21). Funnel
plot analysis indicated that publication and related biases were
unlikely (Egger test, *P* = .84).

**Conclusion**: Aspirin reduces the risk of perinatal death and
preeclampsia in women with historical risk factors. Given the importance
of these outcomes and the safety and low cost of aspirin, aspirin
therapy should be considered in women with historical risk factors.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12798543&dopt=Abstract>

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

This is a Level I systematic review and meta-analysis of randomized
trials finds that a daily low dose of aspirin therapy among high-risk
women significantly reduces the risk of perinatal death and
preeclampsia. They found that women with a history of preeclampsia or
who had chronic hypertension, diabetes or renal disease that took a
daily low dose (50mg - 150mg) of aspirin were significantly less likely
to develop preeclampsia than were similar women who didn\'t take
aspirin. There was also a significant reduction in the rate of
spontaneous preterm births and an increase in birth weights with aspirin
therapy. The researchers did not find any evidence of harm from aspirin
therapy in pregnant women.

They conclude that given the importance of these outcomes and the safety
and low cost of aspirin, aspirin therapy should be considered for
pregnant women at high risk for preeclampsia and who have chronic
hypertension, diabetes or renal disease.

As most of the evidence relates to low dose aspirin, this is the
antiplatelet agent that should be used in clinical practice for
prevention of preeclampsia. As the reductions in risk are
small-moderate, relatively large numbers of women will need to be
treated to prevent a single adverse outcome. However, from a public
health perspective even these moderate benefits may be worthwhile, and
low dose aspirin may be worth considering for more widespread use.

NB:

-This recommendation is not for all patients with previous preeclampsia,
rather it should be limited to high risk patients defined as one or more
of the following: previous severe preeclampsia, diabetes, chronic
hypertension, renal disease, or autoimmune disease, e.g.,
antiphospholipid syndrome.

-The dose of aspirin should preferably be 75 mg, or less. In our
formulary system, logistically, that may mean 81 mg though.

-Starting aspirin before 12 weeks and using higher doses can NOT be
recommended for clinical practice until more information is available
about safety.

-Indian Health providers should use the above information as a best
practice benchmark. njm

## From your colleagues:

##### From Melissa Boll

There is a new Breastfeeding page, thanks to Melissa Boll, CNM. Take a
look

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/index.cfm>

From Ruth Lagerberg

There is a new Genetics page, thanks to Ruth Lagerberg, CNM. Take a
look.

<http://www.ihs.gov/NonMedicalPrograms/NC4/Genetics.cfm>

##### From Larry Leeman

The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain
Relief

<http://aafp.org/afp/20030915/1109.html>

The Nature and Management of Labor Pain: Part II. Pharmacologic Pain
Relief

<http://www.aafp.org/afp/20030915/1115.html>

Management of Labor Pain: Promoting Patient Choice

<http://www.aafp.org/afp/20030915/editorials.html>

Patient Information: Labor Pain: What to Expect and Ways to Relieve Pain

<http://www.aafp.org/afp/20030915/1121ph.html>

**[From Chuck North:]{.underline}**

**Breast cancer and hormone-replacement therapy in the Million Women
Study.**\
METHODS: 1084110 UK women aged 50-64 years were recruited into the
Million Women Study between 1996 and 2001, provided information about
their use of HRT and other personal details, and were followed up for
cancer incidence and death.

INTERPRETATION: Current use of HRT is associated with an increased risk
of incident and fatal breast cancer; the effect is substantially greater
for oestrogen-progestagen combinations than for other types of HRT.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12927427&dopt=Abstract>

Comment in Lancet

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12927422>

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

###### Obstetrics

###### 

###### Rapid Point-of-Care Testing for HIV-1 During Labor and Delivery, 2002, CDC

The findings in this report indicate that point-of-care rapid testing
provided valid HIV test results faster than laboratory testing

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5236a4.htm>

###### 

###### Continuous support for women during childbirth 

The Labor Support Initiative cited the New Cochrane Review. below, to
support the practice that all women should have continuous support
throughout labor and birth.

###### Main Results 

Fifteen trials involving 12,791 women are included. Primary comparison:
Women who had continuous intrapartum support were less likely to have
intrapartum analgesia, operative birth, or to report dissatisfaction
with their childbirth experiences. Subgroup analyses: In general,
continuous intrapartum support was associated with greater benefits when
the provider was not a member of the hospital staff, when it began early
in labor, and in settings in which epidural analgesia was not routinely
available.

###### Reviewers\' conclusions 

All women should have support throughout labor and birth.

From:

Hodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women
during childbirth (Cochrane Review). In: *The Cochrane Library*, Issue
3, 2003. Oxford: Update Software

Labor support Initiative web site:
<http://www.maternitywise.org/prof/laborsupport/>

Labor support Initiative Review (72 page)
<http://www.maternitywise.org/pdfs/continuous_support.pdf>

######### 

###### Exercise in Pregnancy

Society of Obstetricians and Gynecologists of Canada (SOGC) has gone a
step further in its latest guidelines by suggesting that failure to
exercise during pregnancy may be associated with some risks.

The SOGC/CSEP document is evidence-based and indicates the quality of
evidence assessment for each of its recommendations. Its 6 basic
recommendations are the following:

1.  All pregnant women without contraindications (listed) should be
    encouraged to participate in aerobic and strength-conditioning
    exercises;

```{=html}
<!-- -->
```
1.  Their goals should be to maintain a good fitness level throughout
    their pregnancy, without trying to reach peak fitness, or train for
    competition;

2.  They should choose activities with the least risk of loss of balance
    or fetal trauma (suggestions given);

3.  They should be advised that adverse outcomes are not increased with
    exercise;

4.  They should be advised that pelvic floor exercises initiated
    immediately postpartum may reduce the risk of future urinary
    incontinence;

5.  They should be advised that moderate exercise during lactation does
    not adversely affect breast milk.

######### [**http://www.sogc.org/SOGCnet/sogc_docs/common/guide/pdfs/ps129.pdf**](http://www.sogc.org/SOGCnet/sogc_docs/common/guide/pdfs/ps129.pdf)

######### Seven ways to Control Postpartum Hemorrhage

From Contemporary OB/GYN

<http://www.contemporaryobgyn.net/be_core/MVC?mag=g&action=viewArticle&y=2003&m=03&d=03&article=/be_core/content/journals/g/data/2003/0303/grebarber.html&title=Cover@Story:@Seven@ways@to@control@postpartum@hemorrhage&template=past_issues_show_article.jsp&navtype=g>

# 

# Gynecology

**Does HIV Status Make a Difference in the Experience of Lifetime Abuse?
Descriptions of Lifetime Abuse and Its Context among Low-Income Urban
Women.**\
These findings have implications on many clinical and research fronts.
They suggest that \"HIV prevention services need to be expanded to
include violence and other elements of women\'s lives\" and that \"the
field of HIV and lifetime abuse is in need of increased comprehensive
investigation.

McDonnell KA, Gielen AC, O\'Campo P J Urban Health. 2003
Sep;80(3):494-509.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12930886&dopt=Abstract>

**Endometriosis and subfertility: is the relationship resolved?**\
D\'Hooghe TM, Debrock S, Hill JA, Meuleman C. Semin Reprod Med. 2003
May;21(2):243-54.

###### Explanation of 8 reasons supporting the hypothesis that there is a relationship between endometriosis and subfertility

###### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12917793&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12917793&dopt=Abstract)

###### Unique approach to understanding adolescents' sexual relationships

The First Time: Characteristics of Teens\' First Sexual Relationships
provides a picture of adolescents ages 12 to 18 who report a first
sexual relationship

[**www.childtrends.org/PDF/FirstTimeRB.pdf**](http://www.childtrends.org/PDF/FirstTimeRB.pdf)

###### 

###### Assisted Reproductive Technology Surveillance, 2000

[**http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5209a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5209a1.htm)

Chronic Illness and disease

Findings on relationship between obesity and food insecurity

Food insecurity, defined as not having access at all times to enough
safe and nutritious food for an active, healthy lifestyle because such
foods are not available consistently or because household resources are
insufficient to meet the cost of such foods.

[**www.cdc.gov/mmwr/PDF/wk/mm5235.pdf**](http://www.cdc.gov/mmwr/PDF/wk/mm5235.pdf)

**Prevalence of Diabetes and Impaired Fasting Glucose in Adults,
1999---2000**

[**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5235a1.htm)

**One-year outcome of a combination of weight loss therapies for
subjects with type 2 diabetes:** a randomized trial. Diabetes Care. 2003
Sep;26(9):2505-11. Redmon JB, Raatz SK, Reck KP, Swanson JE, Kwong CA,
Fan Q, Thomas W, Bantle JP

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12941710&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12941710&dopt=Abstract)

Other

Consumption of dark chocolate \-- but not milk chocolate \-- raises
plasma antioxidant levels, an effect that could help protect against
heart disease

Serafini M, Bugianesi R, Maiani G, Valtuena S, De Santis S, Crozier A.
Plasma antioxidants from chocolate. Nature. 2003 Aug 28;424(6952):1013.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12944955&dopt=Abstract>

###### Modest activity reduces risk of breast cancer while women lose weight

Even modest levels of physical activity may decrease the risk of breast
cancer, and coupled with reduced calorie intake, can also help women
lose weight.

See articles below.

Recreational Physical Activity and the Risk of Breast Cancer in
Postmenopausal Women

The Women\'s Health Initiative Cohort Study Anne McTiernan, MD, et al
*JAMA.* 2003;290:1331-1336.
<http://jama.ama-assn.org/cgi/content/abstract/290/10/1331>

Effect of Exercise Duration and Intensity on Weight Loss in Overweight,
Sedentary Women

A Randomized Trial John M. Jakicic, PhD; Bess H. Marcus, PhD; Kara I.
Gallagher, PhD; Melissa Napolitano, PhD; Wei Lang, PhD *JAMA.*
2003;290:1323-1330.

<http://jama.ama-assn.org/cgi/content/abstract/290/10/1323>

**MedScape OB/GYN Discussion Boards ( It's free, but you need to create
a password)**

Hundreds of topics range from Chronic Monilial vaginosis to
Hyperprolactinemia and PCOS

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Vaccination Coverage Among Children Entering School \-\-- 2002\--03
School Year**\
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5233a3.htm>

##### Features

## American Academy of Family Physicians 

**Practice Guidelines**: **Evaluation of Epigastric Discomfort and
Management of Dyspepsia and GERD**

<http://www.aafp.org/afp/20030915/practice.html>

##### ACOG

**Cervical cerclage for prevention of preterm delivery: meta-analysis of
randomized trials.** Drakeley AJ, Roberts D, Alfirevic Z. Obstet
Gynecol. 2003 Sep;102(3):621-7

**OBJECTIVE:** To estimate the effectiveness of prophylactic and
therapeutic cerclage by meta-analysis of randomized clinical trials.
DATA SOURCES: We searched the Cochrane Pregnancy and Childbirth Group
specialized register of clinical trials (May 2002). Congress proceedings
of international society meetings of fetal-maternal and reproductive
medicine were searched by hand.

**METHODS OF STUDY SELECTION**: Meta-analysis of randomized clinical
trials comparing cervical cerclage with expectant management during
pregnancy was performed. Further clarification was sought from trial
authors when required.

**TABULATION, INTEGRATION, AND RESULTS:** Six trials describing a total
of 2175 women were analyzed. Prophylactic cerclage was compared with no
cerclage in four trials. Pooled results failed to show a statistically
significant reduction in pregnancy loss and preterm delivery rates,
although a small reduction in births less than 33 weeks\' gestation was
seen in the largest trial (relative risk \[RR\] 0.75; 95% confidence
interval \[CI\] 0.58 to 0.98). Cervical cerclage was associated with
mild pyrexia, increased use of tocolytic therapy, and hospital admission
but no serious morbidity. Two trials examined the role of therapeutic
cerclage when ultrasound examination revealed a short cervix. Pooled
results failed to show a reduction in total pregnancy loss, early
pregnancy loss, or preterm delivery before 28 and 34 weeks in women
assigned to cervical cerclage.

#### CONCLUSION: The effectiveness of prophylactic cerclage in preventing preterm delivery in women at low or medium risk for second-trimester pregnancy loss has not been proven. The role of cerclage in women whose ultrasound reveals short cervix remains uncertain.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12962953&dopt=Abstract>

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

This Level I systematic review of randomized trial confirms that there
is no role for prophylactic cerclage in low or medium risk patients.
This is benchmark information that should be incorporated as best
practice information.

Until more data become available cervical cerclage should not be offered
to women considered at low or medium risk of second trimester
miscarriage or extreme preterm labor.

There may be a role for cervical cerclage for women considered \'at very
high risk\' of second trimester miscarriage due to a cervical factor
e.g. greater than two second trimester losses or progressive shortening
of the cervix on ultrasound.

However, predicting those women who will miscarry due to a cervical
factor remains elusive and many women may be treated unnecessarily. The
numbers involved in randomized studies are too few to draw firm
conclusions. njm

**[Agency for Healthcare Research and Quality (AHRQ) July
2003]{.underline}**

Researchers examine cost-effectiveness and quality of life following
surgery for early breast cancer

[\<http://www.ahrq.gov/research/jul03/0703RA12.htm\>]{.underline}

More assertive outreach programs may be needed to link homeless women to
case managers and a broader range of services

[\<http://www.ahrq.gov/research/jul03/0703RA13.htm#head2\>]{.underline}

Physicians have an important role in identifying victims of domestic
violence and referring them for appropriate services

[\<http://www.ahrq.gov/research/jul03/0703RA14.htm#head3\>]{.underline}

Parental misconceptions about respiratory illnesses, not day care
pressure, lead parents to pressure physicians for antibiotics

[\<http://www.ahrq.gov/research/jul03/0703RA15.htm#head4\>]{.underline}

Medical treatment of one child for an injury may signal a period of
increased injury risk for other children in the family

[\<http://www.ahrq.gov/research/jul03/0703RA16.htm#head5\>]{.underline}

School-based health centers reduce asthma-related hospitalization and
absenteeism among urban children

[\<http://www.ahrq.gov/research/jul03/0703RA17.htm#head6\>]{.underline}

**[Breastfeeding]{.underline}**

**There is a new Indian Health Breastfeeding page, thanks to Melissa
Boll, CNM.**

Take a look

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/BF/index.cfm>

Lactational atrophic vaginitis.

Atrophic vaginitis is typically associated with the hypoestrogenic state
of menopause. However, lactation also decreases estrogen levels and can
cause symptomatic urogenital atrophy. Discussion of this clinical
phenomenon in the literature is minimal. A case report of atrophic
vaginitis at 13 months postpartum is presented. Mechanisms of action,
evaluation, and treatments for lactational atrophic vaginitis are
reviewed\
Palmer AR, Likis FE. J Midwifery Womens Health. 2003
Jul-Aug;48(4):282-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12867914&dopt=Abstract>

##### Hormone Replacement Update

###### See also Chuck North's posting above

Phytoestrogen Intake and Endometrial Cancer Risk

Regular consumption of estrogens found in plant foods may reduce the
risk of endometrial cancer for some women,.

Pamela L. Horn-Ross, Esther M. John, Alison J. Canchola, Susan L.
Stewart, Marion M. Lee

Journal of the National Cancer Institute, Vol. 95, No. 15, 1158-1164,
August 6, 2003

<http://jncicancerspectrum.oupjournals.org/cgi/content/abstract/jnci;95/15/1158>

**Ultralow-Dose Micronized 17-Estradiol and Bone Density and Bone
Metabolism in Older Women: A Randomized Controlled Trial**

Karen M. Prestwood, MD; Anne M. Kenny, MD; Alison Kleppinger, MS; Martin
Kulldorff, PhD

*JAMA.* 2003;290:1042-1048.

In this randomized trial in older women, ultralow-dose micronized 17
beta-estradiol also reduced bone turnover without increasing adverse
events.

# [International Health Update]{.underline}

**The International Experience and Technical Assistance Program** (IETA)
is accepting applications for the 2004 training class until c.o.b.
Wednesday, October 15, 2003

The IETA is a one-year training program that consists of three workshops
in Atlanta and a supervised short-term (approximately 3 month)
international assignment.

Application materials and further information are available at
<http://www.cdc.gov/nchstp/od/faso/ieta/>

IETA is a developmental training program for Federal public health
employees. The National Center for HIV/STD/TB Prevention, Prevention
Support Office, announces a developmental training opportunity through
the International Experience and Technical Assistance (IETA) program.
Established in 1997 to expand the pool of CDC staff with international
training and

experience, IETA offers professional staff an opportunity to enhance
skills to work effectively in an international public health context
through a combination of classroom and work experience. Participants
will continue to work in their current positions with time away to
attend workshops and developmental activities. IETA will recruit a class
of 25 participants, minimum GS-11 or Commissioned Corps grade 03 and
above. If you have questions or need additional information, please
contact the IETA Coordinator, Cynthia Housworth at <cat0@cdc.gov> or
404-639-3226.

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

Patient Information: Labor Pain: What to Expect and Ways to Relieve Pain

[**http://www.aafp.org/afp/20030915/1121ph.html**](http://www.aafp.org/afp/20030915/1121ph.html)

Pregnancy: Prenatal Care - What will happen during prenatal visits?

<http://www.aafp.org/afp/20030915/1165ph.html>

Pregnancy and Exercise

<http://www.aafp.org/afp/20030915/1168ph.html>

Respiratory Infections During Pregnancy

<http://www.aafp.org/afp/20030915/1171ph.html>

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

New Breastfeeding page, thanks to Melissa Boll, CNM

<http://www.ihs.gov/NonMedicalPrograms/nc4/breastfeed/BF/index.cfm>

New Genetics page, thanks to Ruth Lagerberg, CNM

<http://www.ihs.gov/NonMedicalPrograms/NC4/Genetics.cfm>

New Fetal Alcohol Syndrome page, thanks to Judy Thierry, MD

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

Healthy Weight, Overweight, and Obesity among U.S. Adults

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whdm.asp#HealthyWeightOverweight>

Incorporating HIV Prevention Medical Care of Persons Living with HIV

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whhiv.asp#IncorporatingHIVPrevention>

Prevalence of Physical Activity

<http://www.ihs.gov/MedicalPrograms/MCH/W/Whdm.asp#PrevalencePhysicalActivity>

There are several upcoming **Conferences**

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

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

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

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

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN08.asp#top>

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

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

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

#### Comprehensive Colposcopy: ASCCP

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

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

######## 

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

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

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

Tentative dates: Jan 30 -- Feb 1, 2004.

2004 brochure = pending

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

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

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

**[Contents: August 2003]{.underline}**

**[Abstract of the Month]{.underline}:** Cervical Cytology Screening:
ACOG Practice Bulletin

[From your colleagues:]{.underline}

From Burt Attico: Teenage pregnancy

From Sandra Dodge: Powerful Bones. Powerful Girls

From Ursula Knoki-Wilson: Outbreak of Syphilis in Indian Country

From Kelly Moore: CATCH and Medical Home National Conference, Reducing
Nationwide Obesity Starts In Neighborhoods, MCH Alert: Items of Interest
Related to Public Health, AAP Weighs in on preventing childhood obesity

From Lois Steele: Teenage pregnancy

From Judy Thierry: WHAT IS THE MCH ALERT?

From Alan Waxman: Cervical cancer screening in the older woman, Cervical
Cancer Mortality Data for AI/AN Females, 1994-98

**[Hot Topics:]{.underline}** Emergency Contraception: Easier and better
tolerated; HPV Vaccine and screening: cost effective; Native American
Health Disparities. CDC; Earlier, more aggressive treatment of
hypertension; How to treat TB in pregnancy? Is Mammacare a better way to
detect breast cancer? Ob/Gyn and Women\'s Health MedPulse.

##### 

[Features:]{.underline}

##### AAFP: Screening for Cervical Cancer: Case Study from the USPSTF; Current Perspectives in Polycystic Ovary Syndrome; Misconceptions about vaccination in pregnancy; Family Physicians Make a Substantial Contribution to Maternity Care: Case of the State of Maine 

**Breastfeeding:** The Effectiveness of Primary Care-Based Interventions
to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis
for the US Preventive Services Task Force; Behavioral Interventions to
Promote Breastfeeding: Recommendations and Rationale US Preventive
Services Task Force; NATIONAL BREASTFEEDING AWARENESS CAMPAIGN TO LAUNCH
IN AUGUST 2003

**Hormone Replacement Update**: Manson JE et al NEJM August
349(6):523-34; Postmenopausal Osteoporosis and Estrogen: AAFP

**Information Technology:** HEALTHeFORCES™

International Health: Cervical cancer screening and treatment performed
by village nurses; From Health Canada\'s First Nations and Inuit Health
Branch

#### National Guidelines Clearinghouse: What are some of the 20 latest guidelines on cervical cancer screening?

Patient Education: What natural products actually work? Try this
comprehensive analysis; Red clover's effectiveness rating for menopausal
hot flashes has been downgraded

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

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

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

The **August 2003 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorner81703C.doc>

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)