**News flash:**

**Focus on Maternal and Child Health Research in Indian Country**

**16th Annual Research Conference, IHS**

**May 11-13, 2004**

Scottsdale Arizona Sponsored by the Indian Health Service

3-day conference will focus on learning about American Indian/Alaska
Native research activities

See 'Save the Dates', below

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 3 March, 2004

**[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; Randomised controlled trial of labouring 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

###### 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}

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

Today, based on concerns about an increased risk of stroke, the National
Institutes of Health (NIH) announced that it has instructed the 11,000
healthy, postmenopausal women participating in the estrogen-alone arm of
the Women's Health Initiative (WHI) to stop taking their study pills and
to begin the follow-up phase of the study. This follow-up will include
data collection from mammograms and other outcomes.

Researchers found, after nearly 7 years of study, that use of estrogen
alone (hereafter referred to as estrogen therapy or ET) did not appear
to affect heart disease by either increasing or decreasing a woman's
risk of the disease. ET did not appear to increase the risk of breast
cancer during the period of the study. ET decreased the risk of hip
fracture, but it appeared to increase the risk of stroke at
approximately the same rate found in the WHI study of
estrogen-plus-progestin therapy (hereafter combined hormone therapy or
HT). In that study, reported in July 2002, women taking HT had 8 more
strokes per year for every 10,000 women than did women taking a placebo.

According to NIH, it appears that the risks associated with ET are less
adverse than those found in the WHI study of HT \-- which included
increased risks of breast cancer, heart disease, blood clots, and
stroke. In fact, the WHI Data and Safety Monitoring Board was split as
to whether women in the ET study should stop their pills or have the
option to continue their pills after being informed of the risks of
continued use. Nevertheless, the NIH decided to ask participants in the
ET study to stop their study pills because they believed (1) an
increased stroke risk is not acceptable in healthy women in a research
study, and (2) after 7 years of follow-up, results were unlikely to
change in the one year remaining in the ET study.

The NIH decision was made against the backdrop of the original purpose
of the WHI hormone therapy studies. These studies were intended to
assess the risks or benefits of postmenopausal hormone use for
conditions like heart disease, stroke, or breast cancer \-- not to rate
the effectiveness of HT or ET in treating menopausal symptoms such as
hot flashes.

ACOG has noted previously that to date ET and HT are the most effective
treatments for such menopausal symptoms as hot flashes. ET is generally
taken for relief of such menopausal symptoms in women who have had a
hysterectomy. HT \-- which adds progestin to estrogen \-- is the therapy
prescribed for women who have not had a hysterectomy, since estrogen
alone can increase the risk of uterine cancer.

The NIH also notes that in two months WHI researchers will publish not
only the results of the ET study, but also results of the WHI-Memory
Study (WHIMS), an ancillary study of women over 65 years of age in the
WHI hormone trials. The NIH says WHIMS data suggest that among women on
ET there was an increased risk of probable dementia and/or mild
cognitive impairment.

ACOG, through its Hormone Therapy Task Force, will be analyzing the ET
and WHIMS study data of the WHI when they become available. For now, the
Chair of ACOG's task force, Dr. Isaac Schiff, notes: "This should be
reassuring for women who have had a hysterectomy and are taking estrogen
only that there was no increased risk for breast cancer or heart disease
for this period of time." He adds, however, "It would not be appropriate
for women who have a uterus and are taking HT to stop taking the
progestin component."

In an advisory to physicians today, the NIH said, "Until such time as
the final data are available, and the FDA and the physician groups have
had an opportunity to consider revisions to practice guidelines, the NIH
advises physicians to follow the current FDA guidance."

ACOG concurs with this approach, particularly since the FDA's current
advice is similar to the recommendations ACOG issued on HT use following
the WHI announcement of July 2002. Among those ACOG recommendations:

-   HT is effective and FDA-approved for the relief of menopausal
    symptoms such as hot flashes.

-   Although HT is effective for prevention of postmenopausal
    osteoporosis, consider non-estrogen medications first if
    osteoporosis prevention is the sole reason for using HT.

-   HT should not be used for the prevention of heart disease.

-   Although the WHI study of HT used a specific prescription product
    \[Prempro™, estrogen plus progestin\], absent further data it should
    not be assumed that the risks would be different for any other
    hormone therapies or products.

-   Before using HT for symptoms such as hot flashes, a woman should
    discuss the risks and benefits of such use for her particular
    circumstances with her physician.

-   When using HT, women should do so at the lowest effective dose and
    for the shortest possible duration for her circumstances.

The current FDA guidance goes even farther by applying such
recommendations to both HT and ET use. Until ACOG has the opportunity to
review the forthcoming published articles on ET, it is reasonable for
physicians to follow FDA recommendations regarding ET use.

For NIH's announcements on the WHI's estrogen-alone study:

See the website of the National Heart, Lung, and Blood Institute (NHLBI)

<http://www.nhlbi.nih.gov/new/press/04-03-02.htm>

or the NIH website

<http://www.nih.gov/news/pr/mar2004/nhlbi-02.htm>

To review ACOG's earlier recommendations to women on the WHI's combined
HT study, announced in 2002: see "Questions and Answers About Hormone
Therapy"

<http://www.acog.org/from_home/publications/press_releases/nr08-30-02.cfm>

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

This is one further development that reinforces that hormone replacement
therapy should be limited to treating symptomatic postmenopausal women
for the shortest duration possible at the lowest dose possible. In
addition, estrogen is no longer the first line agent for osteoporosis
prevention if that is the sole reason for using HT. njm

## 

## From your colleagues:

##### From Melissa Boll, formerly ANMC 

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

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

In the Fynes study below, 13 of 59 (22 percent) previously nulliparous
women reported altered fecal continence after their first delivery.
Eight had persistent symptoms during their second pregnancy, of whom
seven worsened following delivery. Fecal incontinence developed for the
first time in five additional women after their second delivery, three
of whom had occult sphincter injury following their first delivery.\
These and the Faltin data below suggest that women who develop altered
fecal continence or who have occult sphincter injury following vaginal
delivery are at increased risk for the development or worsening of
symptoms after a second vaginal delivery. Thus, it is reasonable to
consider cesarean birth during subsequent deliveries in women who have
sustained a tear requiring operative repair or who have developed
persistent troubling symptoms after an initial vaginal delivery (McKenna
and Wattchow below). A decision analysis concluded two to three elective
cesarean deliveries would need to be performed to prevent one case of
incontinence (Wattchow). An instrumental delivery or prolonged second
stage of labor also increases the risk of incontinence and should be
avoided whenever possible.

On the other hand, vaginal delivery itself can result in fecal
incontinence immediately or after many years. The most common injuries
are anal sphincter tears or trauma to the pudendal nerve.

There have been no large studies on women who were asymptomatic
following vaginal delivery to provide a detailed estimate of how often
anal sphincter injuries occur. Most studies focused on women in whom
there was an increased clinical suspicion for sphincter disruption thus,
probably overestimating the rate of their occurrence. A systematic
review that included five such studies with more than 100 patients who
underwent endoanal ultrasonography after vaginal delivery estimated that
anal sphincter defects were detectable in up to 27 percent of
primiparous women However, only one-third were symptomatic. The
following are illustrative examples of studies on this topic:

Anal sphincter tears were detected by anal endosonography in 35 percent
of primiparous and 40 percent of multiparous women of whom symptoms of
anal incontinence or fecal urgency were present in 13 and 23 percent,
respectively. Symptoms of urgency or incontinence usually developed
within six weeks of delivery and were more likely in women who had
forceps delivery.

Fynes M; Donnelly V; Behan M; O\'Connell PR; O\'Herlihy C Effect of
second vaginal delivery on anorectal physiology and faecal continence: a
prospective study. Lancet 1999 Sep 18;354(9183):983-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10501360>

Faltin DL; Sangalli MR; Roche B; Floris L; Boulvain M; Weil A Does a
second delivery increase the risk of anal incontinence? BJOG 2001
Jul;108(7):684-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11467691>

McKenna DS; Ester JB; Fischer JR Elective cesarean delivery for women
with a previous anal sphincter rupture. Am J Obstet Gynecol 2003
Nov;189(5):1251-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14634549>

Wattchow, DA et al Faecal incontinence after vaginal delivery. Lancet
1999 354:965

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10501352>

# [From Terry Cullen, Tucson]{.underline}

###### Screening for Family and Intimate Partner Violence

As you may be aware, USPSTF Finds Evidence Insufficient for Routine
Screening for Domestic Violence. That recommendation is attached.
<http://www.ahrq.gov/clinic/uspstf/uspsfamv.htm>

I have also included a response to these recommendations. Please see

<http://endabuse.org/programs/display.php3?DocID=275>

Our IHS GPRA indicator on domestic violence screening will remain in
place. Please contact Terry Cullen if you have any questions about this
decision. <Theresa.Cullen@ihs.gov>

**[From David Gahn, Tahlequah]{.underline}**

###### Medical trip to rural Brazil. Interested?

If anyone is interested in going on a 2-week medical trip to Brazil,
contact Wes DeRosier at

<derosier@nsuok.edu> This is the medical trip I did last year, but I
won\'t be going this year. Other teams include: Optometry, Dentistry,
and Construction <http://www.intellex.com/~firstluth/brazil/>

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

# AAP Indian Health - Special Interest Group Discussion Forum Site now available

This is the Forum that our ITU Primary Care Discussion Forum is
patterned after. The AAP site had previously been not open to non-AAP
members. The Summaries of the discussions are now available through the
IHS MCH Discussion page:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp#discsum>

The IH-SIG topics covered so far are:

Oral Health

Injury Prevention

Childhood Asthma

Please note the next Primary Care Discussion Topic will be open to the 2
combined listserv(s).

###### May 1, 2004

[Discussion facilitator:]{.underline} Donna Perry, Adolescent Medicine,
Chinle

Topic: Adolescent risk taking behaviors.....a.k.a. "Sex drugs and rock
and roll"

This will include discussion of methamphetamine (up to 15% AI youth in
some IHS Areas have tried it), alcohol and marijuana, driving while
"high" or riding with someone who it, and not wearing seatbelts.

Archived discussions and how to join listserv

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

##### From Sheila Kimble-Haas, Pine Ridge

**Can we use Lispro in pregnancy?**\
Yes, we can use lispro in pregnancy. The same clinical proviso(s) should
be used in pregnancy as outside of pregnancy, e.g., one should have the
food on the table prior to taking Lispro because of Lispo's rapid
action. There can be some difficulty mixing Lispro and insulins from
other manufacturers, but it is OK to mix Lispro with other insulins made
by the same manufacturer. Two good resources:

Diabetes in Pregnancy: Management and postpartum -- Perinatology Corner

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

UpToDate: Insulin Profiles

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

UpToDate: Insulin Basics

<http://www.uptodateonline.com/application/topic.asp?file=diabetes/11100&type=A&selectedTitle=1~2>

UpToDate: Treatment and course of gestational diabetes mellitus

<http://www.uptodateonline.com/application/topic.asp?file=diabetes/15088>

##### From Sandra Haldane, HQE 

###### Labor and Delivery Management Course 

May 3-28, 2004

June 7-July 2, 2004

August 2-27, 2004

Oklahoma City Area at WW Hastings Hospital, Tahlequah, Oklahoma

Reimbursement will be provided to eligible registered nurses for travel,
lodging and per diem.

Please send contact information for both the nominee and supervisor,
plus a brief statement of the nurse\'s experience in obstetrics. Contact
Rebecca Loving at <rebecca.loving@mail.ihs.gov>

**[From Tony Ogburn, Albuquerque]{.underline}**

######## DATE CHANGE: IHS/ACOG Postgraduate Course now in June, not September

Just wanted to remind everyone that the annual IHS/ACOG Postgraduate
Course on Ob, Neonatal, and Gyn Care will be held June 13-17th this year
instead of the usual September.

Same great course geared to IHS, Tribal and urban providers and nurses
with lots of CME at a very reasonable cost.

An addition this year is an NRP course to be held on Sunday morning
before the start of the regular course on Sunday afternoon.

For more information or to register contact Teddra Penland at
301-443-1840.

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

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

This is both a very good primer in health care for women and an update
on the latest care.

The dates were changed to June to avoid any travel restrictions late in
the fiscal year, yet registration is down so far because this is its
first year in the new time slot.

Each ITU facility that cares for women should one new staff member for a
primer and one experienced staff member for an update to take advantage
of this excellent resource njm

**[From Augustine Provencio, Whiteriver]{.underline}**

###### Are there alternatives to insulin use in pregnancy? Can you use glyburide in pregnancy?

Yes, there are a few good alternatives to insulin, or to improve glucose
control in addition to insulin.

A first step is to confirm that the patient has actually changed her
diet. Some patients have also had success by just decreasing their
intake of the 'high glycemic index' foods.

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

The best step, or series of them, is exercise.

Excuse the play on words, but there is level I data from randomized
controlled trials (RCT) to show that blood glucose can be improved with
exercise. We let patients use a treadmill at clinic visits and check
their BS before and after exercise. If the glucose was elevated to begin
with, it can drop 30-40 mg/dL during a short period to almost a normal
range. Plus exercise drives glucose into the striated muscle at 35x the
rate without exercise, so it better than taking an insulin-sensitizing
agent. So... just walking the nearest streets, a treadmill, nothing
fancy...3x/wk x 20-30 min/d
<http://www.ihs.gov/MedicalPrograms/MCH/M/DP22.asp#top>

After the Langer RCT study published in the NEJM in 2000 more staff have
been using glyburide. Unfortunately, glyburide is not FDA approved and
the latest GDM guidelines from ACOG said glyburide 'needed further
study'. 'Having said that, one could use glyburide under a Quality
Improvement or research protocol, or under the guidance of a consultant.
We use the same method as Langer, so we use up to 20 mg/ day divided
bid. We use it under a research guideline, RCT. It will save your
patients many injections. We haven't had the same success rate as
Langer, as approximately 20% of our glyburide patients need to either
add insulin or change completely to insulin

Langer et al RCT

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11036118&dopt=Abstract>

Are there alternatives to insulin?: Perinatology Corner

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP26.asp#top>

Other resources: our free CME on this subject

Diabetes in pregnancy: Screening and diagnosis

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

Diabetes in pregnancy: Management and postpartum

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

##### From Judy Thierry, HQE

######### Maternal Child Health Research in Indian Country

16th Annual Research Conference. The conference, held May 11-13, 2004 in
Scottsdale Arizona, is sponsored by the Indian Health Service and the
IHS Clinical Support Center.  This three 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>

Additionally the conference will discuss research methods, current
qualitative and quantitative research in Indian country, problems
encountered and how they were solved, concern for human safety
throughout the research process and on addressing the financing and
other logistical problems/issues associated with doing research. There
are opportunities to present a poster.  This is an opportunity for
people who have never or seldom presented research results to do so in a
friendly and supportive environment at a national meeting. CEU\'s
available.

###### Interested in other resources to analyze infant mortality data?

Go to the National Center for Health Statistics and you can clarify
state data by race for more recent years.
<http://www.cdc.gov/nchs/releases/02facts/infantmort.htm>

For birth injury data, you need to go to and you can type in your
specific variables. Birth injuries are very different category from the
infant mortality data -- injuries include suffocation, homicide, traffic
-- motor vehicle occupant death, falls, drowning.  David Wallace at CDC
is a great contact for such data
 [\<http://www.cdc.gov/ncipc/wisqars/\>]{.underline}  

Other resources for Native natality: (see Focus on Women, among others)

[http://www.ihs.gov/nonmedicalprograms/ihs%5Fstats/ihs%5Fhq%5Fpublications.asp](http://www.ihs.gov/nonmedicalprograms/ihs_stats/ihs_hq_publications.asp)

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

**[Obstetrics]{.underline}**

######### New guidelines for management of hypertension in pregnancy available

# KEY POINTS

-Hypertensive disorders are the most common medical complications of
pregnancy with an incidence of 12-22% in pregnancy.

-The best screening test is a BP measured in the sitting position after
a 10-minute rest. The BP needs to be repeated in 6 hours for the
diagnosis. The patient should not use tobacco or caffeine for 30 minutes
preceding the measurement. Details below

-There is no good predictive test for preeclampsia, e.g., urine or blood
tests

-Urine dipstick testing has NO role in universal screening for
preeclampsia [in routine prenatal care]{.underline}, e.g., if BP \<
140/90 and asymptomatic

-Low dose aspirin therapy is indicated if the patient has had prior
severe preeclampsia, chronic hypertension, pre existing diabetes, or
significant renal disease. (Level I recommendation)

-It has been demonstrated that over 500 mild preeclamptic women have to
be treated to prevent one seizure. One in 30 severe preeclamptic women
may seize if untreated.

-There is, to date, no scientific evidence that antihypertensive therapy
will improve

perinatal outcome in chronic hypertension

-We do not use the term 'pregnancy induced hypertension' or 'PIH'
anymore. That term has been replaced with the term 'gestational
hypertension'. It involves hypertension without proteinuria.

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

######### 

######### RCT: Predominately Fetal Growth-Based Strategy to Guide Management of GDM 

CONCLUSIONS: GDM management based on fetal growth combined with high
glycemic criteria provides outcomes equivalent to management based on
strict glycemic criteria alone. Inclusion of fetal growth might provide
the opportunity to reduce glucose testing in low-risk pregnancies.

Schaefer-Graf UM, Kjos SL, Fauzan OH, Buhling KJ, Siebert G, Buhrer C,
Ladendorf B, Dudenhausen JW, Vetter K. A Randomized Trial Evaluating a
Predominately Fetal Growth-Based Strategy to Guide Management of
Gestational Diabetes in Caucasian Women Diabetes Care. 2004
Feb;27(2):297-302.

###### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14747203**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14747203)

###### How thorough is your VBAC or TOLAC consent?

There are now two versions of VBAC or TOLAC consents now available on
the MCH page if you want to improve your facility's consent. Go to this
link and scroll down to Section 5 B

<http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>

**Maternal smoking in pregnancy, fetal development, and childhood
asthma.**\
[CONCLUSIONS:]{.underline} Maternal smoking in pregnancy increases the
risk of asthma during the first 7 years of life, and only a small
fraction of the effect seems to be mediated through fetal growth.

Jaakkola JJ, Gissler M.Maternal smoking in pregnancy, fetal development,
and childhood asthma. Am J Public Health. 2004 Jan;94(1):136-40.

###### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14713711**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14713711)

###### 

###### Effects of Automobile Crashes Occurring During Pregnancy: Protects fetus

Nearly 3 percent of births can be linked to a significant automobile
crash in which the pregnant mother was the driver. If a seatbelt is
worn, pregnancy outcomes do not appear to be significantly altered by
crashes. Conversely, pregnant drivers who [do not use a
seatbelt]{.underline} are more likely to experience significant bleeding
and to have a low-birth-weight infant, and three times more likely to
have a fetal death than pregnant women who crash while wearing a
seatbelt.

<http://www.aafp.org/afp/20040301/tips/31.html>

###### 

###### Randomised controlled trial of labouring in water

CONCLUSIONS: Labouring in water under midwifery care may be an option
for slow progress in labour, reducing the need for obstetric
intervention, and offering an alternative pain management strategy.\
Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ.Randomised
controlled trial of labouring in water compared with standard of
augmentation for management of dystocia in first stage of labour. BMJ.
2004 Feb 7;328(7435):314. Epub 2004 Jan 26.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14744822>

###### Practical Selection of Antiemetics

<http://www.aafp.org/afp/20040301/1169.html>

**Calcium supplementation appears to be beneficial** for women at high
risk of gestational hypertension **and in communities with low dietary
calcium intake.**

Two areas of evidence are presented:

1.) Cochrane Library of randomized controlled trials: Reviewers\'
conclusions

Calcium supplementation appears to be beneficial for women at high risk
of gestational hypertension and in communities with low dietary calcium
intake. Optimum dosage requires further investigation.

[Implications for practice]{.underline}

The lack of convincing evidence of effectiveness from the largest trial
to date (CPEP 1997) may discourage the use of calcium supplementation.
It should be borne in mind that the latter trial included women with a
low risk of hypertension, adequate dietary calcium intake and, in
addition, all women in both groups received low-dose calcium
supplementation as part of their routine prenatal supplementation. Data
from this trial are not necessarily applicable to the care of women who
may be more likely to benefit from calcium supplementation.

The data included in this review support calcium supplementation for
women at high risk of gestational hypertension, and **in communities
with low dietary calcium intake**, provided that reduction in the
diagnosis of hypertension or pre-eclampsia is regarded as important.
Whether lower dosages of calcium than used in the trials reviewed may
have similar effects, cannot be determined from this review.

Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during
pregnancy for preventing hypertensive disorders and related problems
(Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester,
UK: John Wiley & Sons, Ltd.

<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link=http://www.cochranelibrary.com/enter/>

CPEP 1997 {published data only}

Levine RJ for the CPEP Study Group. The trial of calcium for
preeclampsia prevention (CPEP). 8th World Congress on Hypertension in
Pregnancy - Protagonists and Presentations; 1992 November 8-12; Buenos
Aires, Argentina, 1992:94. .

Levine RJ, Esterlitz JR, Raymond EG, DerSimonian R, Hauth JC, Ben Curet
L et al. Trial of calcium for preeclampsia prevention (CPEP): rationale,
design, and methods. Controlled Clinical Trials 1996;17:442-69.

Levine RJ, Hauth JC, Curet LB, Sibai BM, Catalano PM, Morris CD et al.
Trial of calcium to prevent preeclampsia. New England Journal of
Medicine 1997;337(2):69-76.

Levine RJ, for the CPEP Study Group. Calcium for preeclampsia prevention
(CPEP): a double-blind, placebo-controlled trial in healthy nulliparas.
American Journal of Obstetrics and Gynecology 1997;176:S2.

\# 2: Some AI/AN women have low calcium baselines

74 Anchorage Native women (18-45y) were surveyed in 1996 had low calcium
intakes (88% didn\'t meet the recommended intakes (mean 631mg/d). In
1987-88 intakes for 186 women (21-60) were also low (mean 516mg/d) and
less than NHANES II intakes.

Its likely that women with lactose intolerance would have a hard time
meeting calcium recommended intakes. I\'ve never seen a break down of
intakes analyzed by lactose tolerance however.

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

Overall the CPEP study showed no improvement for calcium supplementation
in the general population. Please note that the findings above support
calcium supplementation for women at high risk of gestational
hypertension, and **in communities with low dietary calcium intake**.
One AI/AN example is given, Alaska Native women, please consult with
your local Area nutrition colleagues to see if this recommendation may
apply to pregnant women in your region. njm

**Impact of iron deficiency anemia on prevalence of gestational diabetes
mellitus.**\
CONCLUSIONS: The prevalence of GDM is reduced in iron deficiency anemia,
which probably served as a surrogate for other factors such as
nutritional inadequacy and reduced gestational weight gain. Further
studies on the relationship between nutritional improvement and the
increasing prevalence of GDM in the developing world are warranted.\
Lao TT, Ho LF. Impact of iron deficiency anemia on prevalence of
gestational diabetes mellitus. Diabetes Care. 2004 Mar;27(3):650-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14988280>

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

<http://www.aafp.org/afp/20040315/tips/19.html>

**[Gynecology]{.underline}**

###### Abbreviated Surveillance Safe After Treatment of High-Grade Cervical Dysplasia

###### [CONCLUSION]{.underline}: 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.

Skinner EN, Gehrig PA, Van Le L. High-grade squamous intraepithelial
lesions: abbreviating posttreatment surveillance. Obstet Gynecol. 2004
Mar;103(3):488-92.

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

###### Medical treatment of miscarriage in a general hospital is safe and effective up to 12 weeks

The findings are reported of a retrospective study of 207 women
undergoing medical evacuation of the uterus for first trimester
miscarriage, using mifepristone followed by a single dose of oral
misoprostol. All women had the diagnosis confirmed by ultrasonography.
Complete medical evacuation was achieved in 88% of cases. The success
rate and incidence of complications was observed to be the same
regardless of whether gestation was below or above 9 weeks. The number
of cases in which antibiotic treatment for presumed pelvic infection was
prescribed was 3%. The incidence of anaemia requiring blood transfusion
was 3%.

Greenland H, Ogunbiyi I, Bugg G, Tasker M. Medical treatment of
miscarriage in a district general hospital is safe and effective up to
12 weeks\' gestation. Curr Med Res Opin. 2003;19(8):699-701.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14687439>

###### 

###### Estrogen withdrawal has been described as a trigger for migraine headache, 

###### and some studies suggest that estrogen and progestin may exacerbate migraine. This study examined the association between HT and migraine headache in postmenopausal women among 17,107 postmenopausal female health professionals enrolled in the Women\'s Health Study

[CONCLUSIONS:]{.underline} In this cross-sectional study, current HT use
was associated with higher rates of migraine headache than nonuse.
Clinical trials are needed to determine if HT increases the incidence of
migraine in postmenopausal women.

Misakian AL, Langer RD, Bensenor IM, Cook NR, Manson JE, Buring JE,
Rexrode KM. Postmenopausal hormone therapy and migraine headache. J
Womens Health (Larchmt). 2003 Dec;12(10):1027-36.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14709191>

###### Raloxifene inhibits leiomyoma growth in premenopausal women

[CONCLUSION(S):]{.underline} In premenopausal women, high-dose
raloxifene is well tolerated and inhibits the growth of leiomyomas.

Jirecek S, Lee A, Pavo I, Crans G, Eppel W, Wenzl R. Raloxifene prevents
the growth of uterine leiomyomas in premenopausal women. Fertil Steril
2004;81:132-136.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14711556>

###### Reproductive endocrine disorders common among women treated for epilepsy

[CONCLUSIONS]{.underline}: Epilepsy during pubertal maturation does not
affect reproductive endocrine health in female subjects who discontinue
the medication before adulthood. However, an increased prevalence of
endocrine disorders is detected if the patients remain on antiepileptic
drugs, especially VPA, until adulthood.\
Mikkonen K, Vainionpaa LK, Pakarinen AJ, Knip M, Jarvela IY, Tapanainen
JS, Isojarvi JI. Long-term reproductive endocrine health in young women
with epilepsy during puberty. Neurology. 2004 Feb 10;62(3):445-50

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14872028>

###### Therapeutic Options for External Genital Warts: Medscape CME module

<http://www.medscape.com/viewprogram/2834?mpid=23837>

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

OC use is associated with a modest decline in the risk of development of
functional ovarian cysts, but that the use of modern low-dose OCs has
little or no clinical effect on the likelihood of developing functional
ovarian cysts. Conversely, sterilization, especially at a young age,
appears to significantly increase the risk of functional ovarian cysts.
This finding confirms those of an earlier study in which the risk of
ovarian cysts was doubled (from 12.4 percent to 24.1 percent) in women
who had been sterilized. Because surgical sterilization is the most
common form of contraception in the United States, the authors call for
further studies to confirm this increased risk
<http://www.aafp.org/afp/20040315/tips/20.html>

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

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

In 2002, a woman who had WNV encephalitis during the 27th week of her
pregnancy delivered a full-term infant with chorioretinitis, cystic
destruction of cerebral tissue, and laboratory evidence of congenitally
acquired WNV infection. Although this case demonstrated intrauterine WNV
infection in an infant with congenital abnormalities, it did not prove a
causal relation between WNV infection and these abnormalities. During
2002, CDC investigated three other instances of maternal WNV infection.
In all three cases, the infants were born at full term with normal
appearance and negative laboratory tests for WNV infection; cranial
imaging studies and ophthalmologic examinations were not performed.
During 2003, CDC received reports of approximately 9,100 cases of WNV
illness, including approximately 2,600 cases of neuroinvasive disease.

Centers for Disease Control and Prevention (CDC). Interim guidelines for
the evaluation of infants born to mothers infected with West Nile virus
during pregnancy.b MMWR Morb Mortal Wkly Rep. 2004 Feb 27;53(7):154-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14985654>

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

Trial stopped: HABITS (hormonal replacement therapy after breast
cancer\--is it safe?)

In the 1990s, two randomised clinical trials started in Scandinavia
addressing whether hormone replacement therapy (HRT) is safe for women
with previous breast cancer. We report the findings of the safety
analysis in HABITS (hormonal replacement therapy after breast
cancer\--is it safe?), an open randomised clinical trial with allocation
to either HRT or best treatment without hormones. The main endpoint was
any new breast cancer event. All analyses were done according to
intention-to-treat. Until September, 2003, 434 women were randomised;
345 had at least one follow-up report. After a median follow-up of 2.1
years, 26 women in the HRT group and seven in the non-HRT group had a
new breast-cancer event. All women with an event in the HRT group and
two of those in the non-HRT group were exposed to HRT and most women had
their event when on treatment. We decided that these findings indicated
an unacceptable risk for women exposed to HRT in the HABITS trial, and
the trial was terminated on Dec 17, 2003

Holmberg L; Anderson H. HABITS (hormonal replacement therapy after
breast cancer\--is it safe?), a randomised comparison: trial stopped
Lancet 2004 Feb 7;363(9407):453-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14962527>

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

First and foremost, the old dictum comes to mind: Do no harm. Second,
remember those medical school lessons about taking a careful, thorough
personal and family history, doing a physical exam, and laboratory
screening. Make sure you have a negative mammogram report back before
you prescribe any menopausal hormone therapy \-- however much your
patient is begging for relief of menopausal symptoms.

Explore with your patients other ways of alleviating those symptoms.
Simple changes in bedding, thermostats, fabrics, layers of clothing, and
diet (eg, avoidance of spicy, alcoholic, or caffeinated foods and
beverages) may be just enough to tide her over, or help her cope with
other problems. Exercise can help mental health while also reducing
risks of osteoporosis.

And maybe remind yourself, and your patients, that whether menopausal
symptoms last months or even years, they are, in the long run,
transient. Death is not.

(Comment from Sally Faith Dorfman, MD) njm

Screening for Coronary Heart Disease : Level D, e.g., Recommends against

The U.S. Preventive Services Task Force (USPSTF) [recommends against
routine screening]{.underline} with resting electrocardiography (ECG),
exercise treadmill test (ETT), or electron-beam computerized tomography
(EBCT) scanning for coronary calcium for either the presence of severe
coronary artery stenosis (CAS) or the prediction of coronary heart
disease (CHD) events in adults at low risk for CHD events. U.S.
Preventive Services Task Force

[**http://www.ahrq.gov/clinic/uspstf/uspsacad.htm**](http://www.ahrq.gov/clinic/uspstf/uspsacad.htm)

**Virtual colonoscopy is an accurate method for the detection of
colorectal neoplasia**\
Virtual colonoscopy represents a noninvasive test for the examination of
the colonic lumen that involves the generation of both 2-dimensional and
3-dimensional views of the colon and rectum using data derived from
computed tomography. This imaging modality has been explored as an
alternative to conventional endoscopic colonoscopy, in particular as an
alternative screening tool for colorectal cancer. Although virtual
colonoscopy does not require sedation and requires less time for
completion, the study requires the same bowel-cleansing preparation as
conventional colonoscopy as well as gas insufflation of the intestine,
which may be associated with patient discomfort.

[CONCLUSIONS:]{.underline} CT virtual colonoscopy with the use of a
three-dimensional approach is an accurate screening method for the
detection of colorectal neoplasia in asymptomatic average-risk adults
and compares favorably with optical colonoscopy in terms of the
detection of clinically relevant lesions.

Pickhardt PJ, Choi JR, Hwang I, Butler JA, Puckett ML, Hildebrandt HA,
Wong RK, Nugent PA, Mysliwiec PA, Schindler WR.Computed tomographic
virtual colonoscopy to screen for colorectal neoplasia in asymptomatic
adults. N Engl J Med. 2003 Dec 4;349(23):2191-200

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14657426>

Antibiotic use in relation to the risk of breast cancer.

[CONCLUSIONS:]{.underline} Use of antibiotics is associated with
increased risk of incident and fatal breast cancer. It cannot be
determined from this study whether antibiotic use is causally related to
breast cancer, or whether indication for use, overall weakened immune
function, or other factors are pertinent underlying exposures. Although
further studies are needed, these findings reinforce the need for
prudent long-term use of antibiotics.

Velicer CM, Heckbert SR, Lampe JW, Potter JD, Robertson CA, Taplin SH.
Antibiotic use in relation to the risk of breast cancer. JAMA. 2004 Feb
18;291(7):827-35.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14970061>

###### Finnish study supports anti-diabetes effect for coffee

CONCLUSION: Coffee drinking has a graded inverse association with the
risk of type 2 DM; however, the reasons for this risk reduction
associated with coffee remain unclear.

Tuomilehto J, Hu G, Bidel S, Lindstrom J, Jousilahti P. Coffee
consumption and risk of type 2 diabetes mellitus among middle-aged
Finnish men and women. JAMA. 2004 Mar 10;291(10):1213-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15010442>

**Initial Evaluation of Hypertension**

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

##### Other

**Nail Abnormalities: Clues to Systemic Disease**

<http://www.aafp.org/afp/20040315/1417.html>

**Alcohol Withdrawal Syndrome**

See also Patient Education below

<http://www.aafp.org/afp/20040315/1443.html>

**Screening for Dementia: Recommendation and Rationale**\
The USPSTF concludes that the evidence is insufficient to recommend for
or against routine screening for dementia in older adults. **I
recommendation.**

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

##### Features

## American Family Physician

###### Patient-Oriented Evidence that Matters (POEMS)\*

Does it make sense to test for human papillomavirus (HPV) if cervical
cytology shows low-grade squamous intraepithelial lesion (LSIL)?

No, go directly for Colposcopy with LSIL Pap.

[Bottom Line:]{.underline} Women with LSIL cervical cytology results can
be referred directly to colposcopy. HPV testing is not very useful,
since the majority of women will test positive.

Clinician Reviews 13(10):66-67, 2003

<http://www.medscape.com/viewarticle/463592?mpid=24626> (Medscrape)

**One-Day Drug Regimen Eliminates *H. pylori***

**Bottom Line:** A four-drug, single-day treatment was as effective as
seven days of treatment with three drugs in eradicating *H. pylori* and
symptoms in patients with *H. pylori*-positive dyspepsia. (Level of
Evidence: 1b) <http://www.aafp.org/afp/20040315/tips/5.html>

**\*POEM Rating system**: <http://www.infopoems.com/levels.html> **POEM
Definition:** <http://www.aafp.org/x19976.xml>

###### British Medical Journal: Clinical Evidence Concise, Evidence Based Medicine Excerpt

###### HIV: Mother-to-Child Transmission

What are the effects of measures to reduce mother-to-child transmission
of human immunodeficiency virus (HIV)?

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

##### ACOG

**Chronic Pelvic Pain: Practice Bulletin** NUMBER 51, MARCH 2004

**Summary of Recommendations**

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

-   Combined oral contraceptives should be considered as a treatment
    option to decrease pain from primary dysmenorrhea.

-   Gonadotropin-releasing hormone agonists are effective in relieving
    pelvic pain associated with endometriosis and irritable bowel
    syndrome, as well as in women with symptoms consistent with
    endometriosis who do not have endometriosis. Thus, empiric treatment
    with GnRH agonists without laparoscopy should be considered as an
    acceptable approach to treatment.

-   Nonsteroidal antiinflammatory drugs, including COX-2 inhibitors,
    should be considered for moderate pain and are particularly
    effective for dysmenorrhea.

-   Progestins in daily, high doses should be considered as an effective
    treatment of chronic pelvic pain associated with endometriosis and
    pelvic congestion syndrome.

-   Laparoscopic surgical destruction of endometriosis lesions should be
    considered to decrease pelvic pain associated with stages I--III
    endometriosis.

-   Presacral neurectomy may be considered for treatment of centrally
    located dysmenorrhea but has limited efficacy for chronic pelvic
    pain or pain that is not central in its location. Uterine nerve
    ablation or transection of the uterosacral ligament also can be
    considered for centrally located dysmenorrhea, but it appears to be
    less effective than presacral neurectomy. Combining uterine nerve
    ablation or presacral neurectomy with surgical treatment of
    endometriosis does not further improve overall pain relief.

-   Adding psychotherapy to medical treatment of chronic pelvic pain
    appears to improve response over that of medical treatment alone and
    should be considered.

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

-   Gonadotropin-releasing hormone agonists should be considered as a
    treatment option for chronic pelvic pain because they have been
    shown to relieve endometriosis-associated pelvic pain.

-   Surgical adhesiolysis should be considered to decrease pain in women
    with dense adhesions involving the bowel, but it is unclear if lysis
    of other types of adhesions is effective.

-   Hysterectomy is an effective treatment for chronic pelvic pain
    associated with reproductive tract symptoms that results in pain
    relief in 75--95% of women and should be considered.

-   Sacral nerve stimulation may decrease pain in up to 60% of women
    with chronic pelvic pain and should be considered as a treatment
    option.

-   Various physical therapy modalities appear to be helpful in the
    treatment of chronic pelvic pain and should be considered as a
    treatment option.

-   Nutritional supplementation with vitamin B~1~ or magnesium may be
    recommended to decrease pain of dysmenorrhea.

-   Injection of trigger points of the abdominal wall, vagina, and
    sacrum with local anesthetic may provide temporary or prolonged
    relief of chronic pelvic pain and should be considered.

-   Treatment of abdominal trigger points by the application of magnets
    to the trigger points may be recommended to improve disability and
    reduce pain.

-   Acupuncture, acupressure, and transcutaneous nerve stimulation
    therapies should be considered to decrease pain of primary
    dysmenorrhea.

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

-   A detailed history and physical examination are the basis for
    differential diagnosis of chronic pelvic pain and should be used to
    determine appropriate diagnostic studies.

-   Antidepressants may be helpful in the treatment of chronic pelvic
    pain.

-   Opioid analgesics can be used to provide effective relief of severe
    pain with a low risk of addiction but do not necessarily improve
    functional or psychologic status and are not well studied in
    patients with chronic pelvic pain.

Chronic pelvic pain. ACOG Practice Bulletin No. 51. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2004;103:589--605.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990428&dopt=Abstract>

ACOG Statement of Policy: CERVICAL CANCER PREVENTION IN LOW-RESOURCE
SETTINGS.

ACOG recognizes the world-wide burden of cervical cancer and supports
the use of the single visit approach with the visual inspection of the
cervix with an acetic acid wash

Obstet Gynecol. 2004 Mar;103(3):607-609.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14990429&dopt=Abstract>

ACOG Members

<http://www.greenjournal.org/cgi/reprint/103/3/607.pdf>

##### AHRQ

######### Cervical cancer rates among younger women decreased over the past 25 years

<http://www.ahrq.gov/research/jan04/0104RA8.htm#head1>

###### Screening for Obesity in Adults: Level B recommendation

The USPSTF recommends that clinicians screen all adult patients for
obesity and offer intensive counseling and behavioral interventions to
promote sustained weight loss for obese adults.

<http://www.ahrq.gov/clinic/uspstf/uspsobes.htm>

##### Breastfeeding

###### Exclusive Breastfeeding or supplement with Vitamin D?

Recent data shows Vitamin D levels are significantly decreased in one
Indian Health area. The AAP Section on Breastfeeding recommended Vitamin
D supplementation even in our sun-drenched Southwest. Here is a
discussion with various Indian Health providers as they try to sort out
the feasibility of Vitamin D supplementation in AI/AN.

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

###### Breast-Feeding During Infancy May Lower Blood Pressures in Childhood

[CONCLUSIONS:]{.underline} Breast-feeding is associated with a lowering
of later blood pressure in children born at term. If the association is
causal, the wider promotion of breast-feeding is a potential component
of the public health strategy to reduce population levels of blood
pressure.

Martin RM, Ness AR, Gunnell D, Emmett P, Smith GD. Does Breast-Feeding
in Infancy Lower Blood Pressure in Childhood? The Avon Longitudinal
Study of Parents and Children (ALSPAC). Circulation. 2004 Mar 1\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14993142>

**Learn how to determine whether a drug is safe for lactating mothers.**

The current rise in breastfeeding rates coincides with a continuously
expanding prescription medication market. Now more than ever, pediatric
nurse practitioners (PNP) are responsible for ordering and consulting on
maternal medications during lactation. PNPs are obligated to determine
the safety of medications by critically reviewing recommendations that
are based on recent clinical research. Review of the data enables PNPs
to effectively evaluate drugs and their actual risks to a breastfeeding
infant, thereby supporting integration of sound evidence-based care into
clinical practice.

Marks JM, Spatz DL.Medications and lactation: what PNPs need to know. J
Pediatr Health Care. 2003 Nov-Dec;17(6):311-7; quiz 318-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14610445>

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

###### Improving Screening of Women for Violence 

Basic Guidelines for Physicians. Medscape CME

<http://www.medscape.com/viewprogram/2777>

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

Statin therapy significantly reduces the risk of stroke regardless of
age.

Meta-analyses of the large secondary prevention trials with statins have
suggested a reduction in risk of stroke associated with statin therapy
in those with CAD or CAD equivalents. This is the first randomized
controlled trial with sufficient numbers to evaluate the effect of
statin therapy on stroke risk directly. 3280 adults with cerebrovascular
disease and 17256 adults with CHD, DM, or other known vascular disease
were assigned to either 40mg Simvastatin or placebo. Overall there was a
25% reduction in ischemic stroke in those treated with Simvastatin over
the 5 year period. This was true of those subgroups with and without
known CHD, with and without DM, over 70 and under 70, regardless of
blood pressure or lipid level on entry. Among the smaller group of
patients (3280) with a history of cerebrovascular disease there was not
a significant decrease in recurrent stroke risk, but there was a 20%
reduction in the risk of any major vascular event and the study is not
powered to show a reduction in stroke rate in this smaller subgroup.
There was no impact on the rate of hemorrhagic stroke.

**Bruce Finke:** This study confirms that treating those with CHD or CHD
equivalents (DM, PVD) with statin significantly reduces the risk of
stroke (and resultant disability) regardless of age. It also suggests
that a history of cerebrovascular disease benefit from aggressive lipid
lowering, and history of stroke or TIA might be considered a CHD
equivalent.

Effects of cholesterol-lowering with Simvastatin on stroke and other
major vascular events in 20536 people with cerebrovascular disease or
other high-risk conditions.

Collins R, Armitage J, Parish S, Sleight P, Peto R; Heart Protection
Study Collaborative Group.\
Effects of cholesterol-lowering with simvastatin on stroke and other
major vascular events in 20536 people with cerebrovascular disease or
other high-risk conditions. Lancet. 2004 Mar 6;363(9411):757-67.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15016485>

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

###### Sterilization procedures in non-Native women with Native partners

Q. To what extent are IHS and tribal facilities Indian Health, Tribal,
or urban (ITU) providing sterilization procedures in non-Native women
with Native Partners?

A. Yes, non-Native partners can receive limited care in Indian Health
System facilities

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/NonNativeBTL2604.doc>

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

###### Major results back in Estrogen only arm of WHI

###### See Abstract of the month, above

###### Benefits of HRT depend on menopausal symptoms and perceived quality of life

CONCLUSIONS: HRT for primary prevention of chronic diseases in women
without menopausal symptoms is unjustified. Perceived quality of life in
women with symptoms should be taken into account when deciding on HRT.
Thus, a decision analysis tailored to an individual woman is more
appropriate in clinical practice than a population based approach.\
Minelli C, Abrams KR, Sutton AJ, Cooper NJ. Benefits and harms
associated with hormone replacement therapy: clinical decision analysis.
BMJ. 2004 Feb 14;328(7436):371.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14962874>

**Transdermal Estrogen and Venous Thromboembolism**

The authors conclude that no association was found between transdermal
estrogen use and venous thromboembolism, but that the increased risk in
patients taking oral estrogen was confirmed. They note that the
difference could be attributed to the reduced plasma
estrone-to-estradiol ratios achieved by transdermal preparations. This
ratio is approximately one with transdermal estrogen but closer to five
with oral preparations. Oral preparations also increase plasma
concentrations of clotting factors and have other effects on
coagulability.

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

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

The authors estimate that 10 years\' use of estrogen-only therapy
results in three to seven additional breast cancers per 1,000 women
treated; in women using combination therapy, 18 to 20 additional breast
cancers per 1,000 women will develop. Reliable estimates of the effect
of hormone therapy on breast cancer deaths cannot yet be established.
The authors call for further studies to clarify the risks for different
subgroups of hormone therapy users and to establish the effect of
therapy on breast cancer mortality

<http://www.aafp.org/afp/20040315/tips/24.html>

# [Information Technology]{.underline}

###### One click: UpToDate Online now on the IHS Home page

In response to a request from the Chief Clinical Consultants Terry was
able to get UpToDate Online linked from the IHS Home page so that staff
and get to the UpToDate resource in one click.

As the IHS Home page is valuable \'real estate\', so to speak, it is
actually quite a statement of commitment to get this item linked from
the Home page, <http://www.ihs.gov/index.asp>

UpToDate can now be found in the **IHS Resources** box, second box from
the top on the left margin. Please share this information with your
colleagues. From Terry Cullen

# [International Health Update]{.underline}

###### Violence and Human Rights Abuses Against Women in the Developing World

###### Women's Health in perspective

###### [**http://www.medscape.com/viewarticle/464255**](http://www.medscape.com/viewarticle/464255)

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

###### Prevent Bullying and youth violence 

Take a Stand. Lend a Hand. Stop Bullying Now! is a national public
health campaign designed to reduce and prevent bullying among children
and adolescents. A panel of 18 children ages 9-13 provided creative
direction during the development of the campaign with the Health
Resources and Services Administration\'s Maternal and Child Health
Bureau. The campaign\'s Web site offers animated \"webisodes,\" which
will be updated every 2 weeks; camera-ready print public service
announcements; and a resource kit.
[http://www.stopbullyingnow.hrsa.gov](http://www.stopbullyingnow.hrsa.gov/)

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

###### New Guidelines for Polycystic Ovary Syndrome 

<http://www.medscape.com/viewarticle/467811>

######### 

######### 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}**

**Racial disparity in pregnancy-related mortality persists:
Pregnancy-Related Mortality\
**During 1991-1999, a total of 4,200 deaths were determined to be
pregnancy-related. The overall pregnancy related mortality ratio was
11.8 deaths per 100,000 live births and ranged from 10.3 in 1991 to 13.2
in 1999. Older women, particularly women aged \>35 years and women who
received no prenatal care, were at increased risk for pregnancy-related
death. The distribution of the causes of death differed by pregnancy
outcome. Among women who died after a live birth (i.e., 60% of the
deaths), the leading causes of death were embolism and pregnancy-induced
hypertension. In addition, racial disparity in pregnancy-related
mortality ratios persists; since 1940, mortality ratios among blacks
have been at least three to four times higher than those for whites.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm>

**[Osteoporosis]{.underline}**

######### Good association with broadband ultrasound attenuation of the calcaneus and hip fracture

INTERPRETATION: Quantitative calcaneum ultrasound predicts total and hip
fracture risk in men and women in a continuous relation. The challenge
now is to identify interventions to improve bone health in the whole
population.\
Khaw KT, Reeve J, Luben R, Bingham S, Welch A, Wareham N, Oakes S, Day
N.Prediction of total and hip fracture risk in men and women by
quantitative ultrasound of the calcaneus: EPIC-Norfolk prospective
population study. Lancet. 2004 Jan 17;363(9404):197-202.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14738792>

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

This study is the first to demonstrate that ultra-low-dose estrogen can
increase BMD over the long term. A daily dose of 0.25 mg of
17-beta-estradiol increased BMD at the hip, spine, and wrist, and
decreased markers of bone turnover in a three-year period. The
side-effect profile was similar to that of placebo. Higher estradiol
levels may not provide additional benefit to bone while increasing risk
of adverse events. The authors call for longer studies to establish the
efficacy of low dosages of estrogen in preventing fractures.

<http://www.aafp.org/afp/20040315/tips/21.html>

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

**Genital Herpes Patient Education Center**\
This resource has ready-to-print FAQs, information for the newly
diagnosed, regularly updated news reports, and more. Featured in the
Genital Herpes Resource Center from Medscape.

<http://www.medscape.com/pages/editorial/resourcecenters/public/herpes/rc-herpes7>

**List of recommended patient resources on birth control with FAQs**\
BCP, condoms, Depo Provera, Norplant, spermicides, etc....

<http://www.medscape.com/viewarticle/470150?mpid=25533>

**Alcohol Abuse: How to Recognize Problem Drinking**

<http://www.aafp.org/afp/20040315/1497ph.html>

**Alcohol Withdrawal Syndrome**

<http://www.aafp.org/afp/20040315/1500ph.html>

###### Substance Abuse 

<http://www.aafp.org/afp/20040315/1501ph.html>

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

Adolescent risk taking behaviors..a.k.a. \"Sex drugs and rock and roll\"

Starts May 1, 2004

Discussion facilitator: Donna Perry, Adolescent Medicine, Chinle

This will include discussion of methamphetamine (up to 15% AI youth in
some IHS Areas have tried it), alcohol and marijuana, driving while
\"high\" or riding with someone who it, and not wearing seatbelts.

To sign up for this, or other discussion on the Primary Care Listserv,
go here:

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

Let me know if you have any trouble getting on the Primary Care Listserv

[nurphy@anmc.org](mailto:Nmurphy@anmc.org)

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

###### Who is Yolanda Adams?

Yolanda is a great MCH contact in the Albuquerque Area. Take a look

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC18.cfm#top>

###### Who is Margaret Baldwin?

Margaret is a great MCH contact in the Alaska Area. Take a look

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC20.cfm#top>

###### About Denise Exendine: Indian Health Urban MCH programs

###### [**http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC19.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC19.cfm)

###### Cardiovascular Disease Prevention in Women

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcvd.asp#cardprev>

###### Disparities in Premature Deaths from Heart Disease

AI/AN are over represented in premature deaths

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcvd.asp#predeath>

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}

###### 

###### 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>

**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 **February 2004 OB/GYN CCC Corner** is available at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/CCCCorne21304.doc>

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

**[Abstract of the Month]{.underline}: page 3**

Low-risk deliveries in a collaborative care birth center have outcomes
similar to hospital deliveries by obstetricians

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

From Donald Clark: Prevalence and correlates of mental disorders in AI
women in primary care

From Terry Cullen: Healthcare Disparities: Unequal Treatment, One Year
Later; Management of TB, STDs, HIV and Hepatitis C -- Strategies for
today's clinician

From Barbara Fine: Grant Writing Workshop: National Indian Women's
Health Resource Center;

"Falls During Pregnancy" March 12, Interactive Web Seminar

From Jim Galloway: Guidelines for Cardiovascular Disease Prevention in
Women; Disparities in Premature Deaths from Heart Disease, CDC; Coronary
Heart Disease in Women with Diabetes

From Sandra Haldane: Call for CNMs -- Needed in Afghanistan; SIDS
International Conference

From Howard Hays: Towards an Electronic Patient Record in Fort
Lauderdale FL

From Maria Martinez: Advances in cervical cancer prevention -- FREE CME

From Kelly Moore: Call to action for clinicians: The escalating
pandemics of obesity and lifestyle

From Chuck North: Strength of Recommendation Taxonomy (SORT): A
Patient-Centered Approach to Grading Evidence in the Medical Literature

From Jon Perez: Elder Care Resources from the Division's February 2004
Newsletter

From Sharon Phelan: Know any pregnant AI women interested in quitting
smoking or have quit?

From Jennifer Retsinas: American Indian, Alaska Native and Native
Hawaiian Caucus

**From Laura Shelby:** Do you have policies and procedures on treatment
of STDs?

Challenges faced in STD management in Indian County; Insurance coverage
among American Indians/Alaska Natives and Whites; Chlamydial Infections:
Primary Care Clinicians Guide

**From Arnold Sperling:** 4^th^ year students: Sub Internship in OB/GYN
available at Rosebud, S.D

**From Judy Thierry:** Do you want to impact Indian Health MCH for
decades to come? Office for Victims of Crime (OVC) Clearinghouse

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

##### Obstetrics: page 8

##### First-Trimester Screening Protocol for Trisomies 18 and 21; Maternal morbid obesity in early pregnancy is strongly associated with pregnancy complications; Management of Gestation Hypertension-Preeclampsia; Predicting failed trial of labor after primary cesarean delivery; Coverage for U urealyticum improves cesarean prophylaxis; Using Rectal Misoprostol in the Third Stage of Labor; SARS and Pregnancy: A Case Report; Health literacy and pregnancy preparedness in pregestational diabetes

Gynecology: page 9

Continuous combination oral contraceptive pills to eliminate withdrawal
bleeding; I just gained all this weight....I wonder if it was the
'Pill'; What is the best kind of dressing to use on a surgical wound? If
using HPV DNA testing, then consider this; New Contraceptive Options;
Increasing Adherence to Pap Screening Guidelines; Evaluation and
Management of Hirsutism in Women; **2004 National Women\'s Health Week
celebration: May 9-15, 2004**

Child Health: page 11

Infant physical abuse in Alaska higher than expected; Who are "Fragile
Families" and What Do We Know About Them? What is up with soft drinks
being sold in schools? What is up with soft drinks being sold in
schools? Child Passenger Deaths Involving Drinking Drivers; Low glycemic
index diet as practice-based treatment for overweight children; Reducing
the risk of SIDS in child care; Azithromycin for Persistent or Recurrent
Otitis Media; Prevention and Treatment of Type 2 Diabetes Mellitus in
Children

Chronic Illness and Disease: page 12

Screening for Type 2 Diabetes Mellitus in Adults; Strength Training
Among Adults Aged Greater Than or Equal to 65 Years; Moderate intensity
exercise works: RCT in overweight, sedentary women; Alaska Natives have
a disproportionately high percentage of HIV; Cognitive Behavior Therapy
vs. Relaxation Therapy for IBS; Do you have Medicaid patients who smoke?
**Prevalence of Diabetes and Impaired fasting glucose in Adults**

[Features:]{.underline} page 13

##### AFP: POEMS - First-Trimester Screening Protocol for Trisomies 18 and 21; Ultrasound Alone Does Not Diagnose PCOS

ACOG: Uterine artery embolization. ACOG Committee Opinion; Ethics of
Elective Primary Cesarean Delivery

**AHRQ:** Web M + M - A pregnant woman arrives at the ED with severe
abdominal pain; Total and supracervical hysterectomy: Surgical /
clinical outcomes are similar; More aggressive treatment recommendations
for women with diabetes; Reducing by at least half the incidence of
false-positive mammogram readings; Home visits by a nurse-health
advocate team can improve the outcomes

Breastfeeding: Lower rates of overweight among children who were
breastfed for longer duration; Easy Guide to Breastfeeding for American
Indian and Alaska Native Families

**Domestic Violence:** Screening for Partner Violence: Direct
Questioning or Self-Report?

**Elder Care News:** Routine screening for thyroid disease in adults?

Frequently asked questions: Are pharmacologic agents safe to use for
smoking cessation in pregnancy? Why do patients blood sugars go up so
high after certain meals? How does the intensity of the exercise affect
weight loss, etc?

**Hormone Replacement Update**: Nonhormonal alternatives for the
treatment of hot flashes; Understanding the Risks and Benefits of
Hormone Therapy

**Information Technology:** New Domestic Violence code for recording
GPRA information

International Health: Overseas contraceptives with no active
ingredients; Agencies Pledge to Cut Maternal Deaths; British Medical
Journal: Epidemiology for the Uninitiated

#### MCH Alert: Contraceptive use within adolescents' first sexual relationships; An argument for EC: Unintended pregnancy despite a family planning referral

#### Medscape: Efficacy and Tolerability of Oral Zolmitriptan in Menstrually Associated Migraine; Uterovaginal Packing With Rolled Gauze in Postpartum Hemorrhage;

#### Office of Women's Health, CDC: West Nile Virus During Pregnancy, Infant Guidelines

Osteoporosis: Relative value of heel Ultrasound in the diagnosis of
osteoporosis

Patient Education: Fiber: How to Increase Fiber in Your Diet; Nutrition:
Choosing Healthy, Low-Fat Foods; Nutrition: Tips for Improving Your
Health; Pelvic Inflammatory Disease: Updated Facts

Primary Care Discussion Forum: Ongoing now -- Bruce Finke Evidence based
periodic health screening for the elderly....."What is really necessary
in the "Annual Exam" for mature adults"

Osteoporosis screening? PSA screening? Lipid screening?

**Coming May 1, 2004** Donna Perry, Adolescent Medicine, Chinle

Topic: Adolescent risk taking behaviors.....a.k.a. "Sex drugs and rock
and roll"

#### What's new on the ITU MCH web pages: page 20

Who is Diane Jeanotte? Who is Mary Lynn Eaglestaff? Who is Diana Hu? and
what they can do for you ?

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)
3/18/04