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OBJECTIVE: To compare the retention of chairs in academic obstetrics and gynecology with other core clinical departments. METHODS: Ongoing data were collected from each medical school for the Association of American Medical Colleges Faculty Roster between 1979 and 2007. Primary outcome measures included 5-year and 10-year retention rates and survival curves of first-time chairs. Comparisons were made between first-time chairs in obstetrics and gynecology and other core clinical departments: internal medicine, family medicine, pediatrics, psychiatry, and surgery. RESULTS: Five-year retention rates of obstetrics and gynecology chairs declined from 80% for those who began in 1979-1982 to 53% for those who began in 1998-2002. Ten-year retention in obstetrics and gynecology declined from 54% for those beginning in 1979-1982 to 26% for those beginning in 1993-1997. Other clinical departments experienced more stable 5-year and 10-year retention rates. Although substantially longer than other clinical departments in the 1979-1982 cohort, the median tenure of obstetrics and gynecology chairs who began in 1993-1997 was comparable with or less than that of other clinical departments. Discrete-time survival analysis revealed this decline in obstetrics and gynecology chair retention to be significant (P

Binge drinking during pregnancy might lead to the development of Fetal Alcohol Spectrum Disorders in the offspring. Latinas are often considered a low-risk group for alcohol abuse, although recent reports indicate that the prevalence of alcohol consumption in this group is increasing due to changing cultural norms. The predictors of alcohol consumption during pregnancy among Latinas are largely unknown. We explored predictors of periconceptional drinking among Latinas (n = 155) recruited into an ongoing cohort study at the University of New Mexico. Women were interviewed by a bilingual trained interviewer about any episodes of binge drinking (≥4 drinks/occasion) a month around their last menstrual period (LMP) and were administered a TWEAK questionnaire. Sociodemographic, lifestyle, and reproductive health characteristics were also ascertained. Predictors of binge drinking were identified by Chi-square test and logistic regression in univariate and multivariable analyses, respectively. Backward selection procedure was used to identify covariates that were independently associated with binge drinking in the final model. The mean age of participants was 27.0 ± 5.8 years and 69% were foreign born. In the entire sample, 17.4% of pregnant Latinas admitted at least one binge-drinking episode in the month around their LMP. Results of multivariate analysis indicate that Latinas born in the United States have a much greater risk of binge drinking in the periconceptional period (odds ratio [OR] = 3.2; 95% confidence interval [CI]: 1.2, 8.9) compared with foreign-born Latinas. Similarly, Latinas who primarily speak English at home were at much greater risk (OR = 3.6; 95% CI: 1.3, 10.5) compared with primarily Spanish-speaking women. No other variables were identified as significant predictors in multivariable models. Our results indicate that more acculturated Latinas are at much greater risk of binge drinking before conception and in early pregnancy compared with less acculturated Latinas. Culturally sensitive interventions should be developed to address risky alcohol consumption among Latinas of reproductive age.

To describe a semi-annual dinner meeting between medical students and community obstetrician-gynecologists to aid students considering careers in obstetrics and gynecology.Between 2003 and 2008, third-year students were invited to a semi-annual dinner by the department chair at his home, with three community American College of Obstetricians and Gynecologists fellows. Students wrote 12 questions beforehand, with 4 assigned to each fellow. Fellows rotated to three dinner tables to speak with each student. An anonymous questionnaire about the value of the experience was completed by students at the end of the dinner and shortly before graduation.Seventy students attended at least 1 dinner; two thirds attended twice. Discussions dealt with lifestyle, work responsibilities and malpractice. Enthusiasm of the fellows was rated highly; none was viewed as neutral or discouraging. Students agreed their understanding of daily practices of women's healthcare providers was strengthened by attending the dinner. The same questionnaire, administered before graduation, confirmed the dinner added more insight, regardless of whether students matched in obstetrics and gynecology or another field.The dinners were a useful tool for students to gain a better perspective about lifestyles and work expectations of obstetrician-gynecologists.

Beer is the most commonly chosen and most heavily consumed alcoholic beverage by reproductive-age women. Lower cost, easy access, and a perception by many as being less harmful favors this alcoholic beverage, even after pregnancy awareness. Routine prenatal questioning should focus on beer drinking patterns. Drinking several consecutive beers is a particularly troublesome pattern before and after pregnancy recognition. Some pregnant women, especially heavy drinkers, will continue to drink beer. In addition to abstention-oriented health messages, it is prudent for the obstetrician to educate patients about beverage equivalency and standard drink sizes. Brief interventions and referrals to alcohol treatment programs are urged to reduce exposure and potential harm to the vulnerable fetus. Although evidence is inconclusive about effects from social drinking on fetal growth and neurobehavior development, it is recommended that women limit or preferably cease any alcohol consumption during pregnancy.

In a randomized study, uterine activity patterns were characterized with a portable pressure-sensitive device in 40 nonlaboring women at term with an unfavorable cervix who were undergoing preinduction cervical ripening with prostaglandin E2. The prostaglandin E2 was inserted into the posterior vaginal fornix as a single dose of either a 2.5 mg methylcellulose gel (20 cases) or 10 mg controlled-release pessary (20 cases). Uterine activity monitoring began 1 hour before dosing and continued for 12 hours. For those treated with the gel, low-amplitude, high-frequency contractions began within the first hour, reached a peak within 4 hours, and initiated sustained high-amplitude contractions in 10 (50%) cases. With the controlled-release pessary, low-amplitude, high-frequency contractions had a slightly later onset, reached a peak between the fifth and eighth hours, and initiated sustained high-amplitude contractions in 18 (80%) cases. Uterine hyperstimulation occurred in two (10%) pessary cases, with no adverse effect after removal. We conclude that low-amplitude, high-frequency uterine contractions began with either method of intravaginal prostaglandin E2 delivery but led to sustained, high-amplitude contractions primarily with the pessary.

To determine phase III study design using the phase II data for a proprietary controlled-release misoprostol vaginal insert for cervical ripening and labor induction.The reported experiences in 2 phase II trials involving induction of labor in 168 women are discussed.Combining data from 2 phase II studies, we reported a median induction to vaginal delivery interval of15 hours regardless of parity using the 100-microg insert. This misoprostol vaginal insert was well tolerated with few maternal systemic effects. Uterine hyperstimulation occurred in5% of cases in the 100-microg and lesser dose groups. Hyperstimulation syndrome attributed to insert led to cesarean delivery in 1 (2.4%) subject in the 200-microg and 2 (33.3%) in the 300-microg dose groups. The lowest cesarean rates were 4.7% (2 of 43) in the 100-microg group and 5.7% (2 of 35) in the 50-microg group.Misoprostol vaginal 50-microg and 100-microg inserts had acceptable efficacy and safety profiles, and we agreed to test these doses in a randomized phase III multicenter study using dinoprostone (Cervidil, Forest Pharmaceuticals, St. Louis, Missouri), a dinoprostone vaginal insert, as the blinded comparator.

Most women have an appreciation of what are generally considered healthy habits including more exercise; eating a healthy diet; avoiding cigarettes, alcohol, and drugs; using seatbelts; and being current on preventive care, such as good dental status. Being pregnant can be a strong motivator to change or modify behavioral choices. This is an optimal time for a provider to build on this potential motivator to effect change. Frequent follow-up visits allow re-enforcement of attempted change. This constant encouragement and support helps to impress on the woman and her family the importance of change.

Gorham and Kasabach-Merritt syndrome are rare diagnoses that can complicate pregnancy by increasing the risk of pelvic fracture and consumptive coagulopathy, respectively.A 23-year-old woman, gravida 2, para 0101, with a prenatal diagnosis of Gorham syndrome from her previous pregnancy was admitted at 32 weeks' gestation with severe back and flank pain. Computed tomographic findings revealed multiple lytic lesions of the pelvis in addition to large hemangiomas. Similar to her first pregnancy, she quickly developed consumptive coagulopathy and required prompt preterm delivery. The postoperative course was complicated by prolonged intensive care and multiple transfusions.The consumptive coagulopathy associated with Gorham syndrome and secondary Kasabach-Merritt syndrome can mimic severe preeclampsia, especially when recurrent.

Pseudoephedrine, a stereoisomer of ephedrine with alpha- and beta-adrenergic properties, is the active ingredient in over-the-counter oral decongestants. Its safety during pregnancy has not been studied adequately. The purpose of this investigation was to evaluate the effects of pseudoephedrine on uterine and fetal Doppler blood flows. Twelve healthy pregnant women between 26-40 weeks' gestation ingested a standard 60-mg dose of pseudoephedrine. A pulsed Doppler system was used to perform blood flow measurements of the uterine arcuate artery, fetal aorta, and umbilical artery before dosing, immediately thereafter, and at 15-minute intervals during the first 3 hours after drug ingestion. Blood flow velocities were not altered significantly after dosing in either the maternal or fetal circulation. In no case did absolute fetal or uterine blood flow velocities decrease significantly or systolic/diastolic ratios persistently elevate to abnormal values. We conclude that no significant alterations in the uterine or fetal circulations occur after the ingestion of a single dose of oral pseudoephedrine by healthy pregnant patients in the third trimester.

PN is required to maintain or restore an anabolic state when oral enteral routes are not feasible. Despite 22 years of experience with PN, its use during pregnancy has only recently been reported. Most of this information is anecdotal but suggests that this mode of therapy is safe, effective, and occasionally lifesaving. PN during pregnancy has been used most often to provide adequate nutrition for those who suffer from prolonged hyperemesis or who have difficulty absorbing adequate nutrients because of such conditions as Crohn's disease. The proper selection and administration of dextrose, fat, protein, vitamins, trace elements, and electrolytes for pregnant women have been associated with favorable perinatal outcomes. Fat emulsion use does not appear to be associated with any abnormal outcomes. Preterm deliveries and intrauterine fetal growth retardation appear to relate to preexisting or coexisting medical or obstetric complications. Principles for PN with all patients would apply during pregnancy. As with any therapy, the benefits must be weighed against the risks and costs. Sufficient favorable clinical experience over the last 10 years suggests that PN is a relatively safe and effective method for reversing maternal malnutrition and promoting normal fetal growth and development.

Recording fetal activity serves as an indirect measure of central nervous system integrity and function. The coordination of whole body movement, which requires complex neurologic control, is likely similar to that of the newborn infant. Short-term observations of the fetus are best performed using real-time ultrasound imaging. Monitoring fetal motion has been shown to be clinically worthwhile in predicting impending death or compromise, especially when placental insufficiency is longstanding. The presence of a vigorous fetus is reassuring. Perceived inactivity requires a reassessment of any underlying antepartum complication and a more precise evaluation by fetal heart rate testing or real-time ultrasonography before delivery is contemplated.

The objective of the present study is to determine the recurrence risk of a third-degree (into the anal sphincter) or a fourth-degree (into the rectum) perineal tear in women with a prior extensive laceration.Data were gathered from our computerized perinatal database between January 1990 and December 1994. Women who had two consecutive singleton deliveries were chosen as subjects.The rate of an extensive perineal laceration was greater if a tear had occurred in a previous pregnancy (19 of 178 cases, 10.7% vs. 56% of 1563 cases, 3.6%, odds ratio 3.4. A 95% confidence interval: 1.8-6.4; p0.0001). A prior tear remained a risk factor after controlling for other variables (epidural analgesia, episiotomy, oxytocin use, operative vaginal delivery, fetal macrosomia).A prior third-degree or fourth-degree perineal tear is associated with a 3.4-fold increased risk of a recurrent severe obstetrical laceration.

To assess the efficiency of labor induction using low dose misoprostol for cervical ripening among nulliparous patients with severe preeclampsia.This retrospective investigation involved cases gathered from our perinatal database for nulliparous women with severe preeclampsia delivering singleton gestations between January 2002 and May 2006. After a review of 229 hospital records, we selected only those cases (N = 145) that were eligible for a trial of labor and were administered intravaginal misoprostol (25 mcg every 3 to 6 h) for an unfavorable cervix. Primary outcomes related to the success and timing of vaginal deliveries. Secondary outcomes involved maternal and neonatal morbidity rates. Statistical evaluations included Chi-square testing and regression analysis.Vaginal delivery was successful in 95 cases (65.5%). This rate increased from 55.1% in cases at34 weeks to 68.9% in cases at between 34 and 36 weeks, and to 72.5% in those ator=37 weeks. Most of those who delivered vaginally did so within 24 h (82 of 95 cases, 86.3%), regardless of gestational age. Vaginal delivery was associated with a shorter postpartum stay (2.5 vs. 3.2 days; p = 0.001) and with less neonatal respiratory distress (4.2% vs. 26.0%; p0.001).Vaginal delivery within 24 h was common, with less morbidity than cesarean delivery, in this nulliparous group presenting with severe preeclampsia and an unfavorable cervix.

A systematic review of the literature was performed on the risks associated with elective induction of labor. A MEDLINE search was undertaken of articles based on the criterion that elective induction was central to the article. Manuscripts were in English in core clinical journals from 1996 to 2005. Articles before 1996 were included if they added historical information relevant to the topics. Despite not being evidence based, elective inductions are becoming more acceptable and account for approximately 10% of deliveries. A high cesarean rate for nulliparas is the most undesired effect when undergoing induction with an unfavorable cervix. A longer intrapartum course can overutilize resources. Until larger, prospective clinical trials are performed, it will be difficult to evaluate the impact of the elective induction of labor on populationwide cesarean delivery rates. More attention should be directed toward whether the experience of elective induction is satisfactory to the patient, obstetrician and intrapartum crew.

To determine if student attendance at a specialized prenatal clinic would yield any change in their comfort level and in their attitudes toward pregnant women with drinking problems.A total of 117 third-year students rotating consecutively on our core obstetrics-gynecology clerkship consented to enrolling in this prospective cohort study between February 2004 and June 2005. Each was assigned either to attend a half-day prenatal clinic designed specifically for women with alcohol and substance use disorders (study group) or not to attend the clinic (control group). The students answered anonymously a 15-question survey (using a 5-point Likert scale from 'strongly disagree' to 'strongly agree') at the beginning and at the midway point of the eight-week clerkship. Scores averaged for each question at the two points were compared within and between the two groups using paired-samples and independent-samples t-tests.No differences in responses to the survey were found between the study and control groups at the beginning of the clerkship. Students who attended the clinic became more comfortable in inquiring about patient alcohol consumption (p0.001) and about social problems such as domestic violence (p0.001). After attending the clinic, students reported that alcoholism was associated less with a weak will (p0.01) and that group therapy has more importance (p0.05). In contrast, the control group disagreed less that alcohol use was more of a moral and legal problem than a medical problem (p0.05).An experience at this special prenatal clinic improved medical student awareness of complexities faced by problem drinkers, enhanced their comfort in talking to pregnant alcohol drinkers, and favored more sympathy toward alcoholism in general but not necessarily during pregnancy.

OBJECTIVE: To assist in predicting future leadership needs, this longitudinal study examines turnover and net retention rates among chairs at university obstetrics and gynecology departments between 1981 and 2005. METHODS: A database of appointment dates and tenure of chairs at each of 125 Association of American Medical Colleges-approved United States medical schools was collated using membership listings from the Association of Professors of Gynecology and Obstetrics and from the Council of University Chairs in Obstetrics and Gynecology. Complete data from 118 departments were confirmed by selective correspondence at individual departments and further review by the investigators. RESULTS: A total of 260 individuals (232 men, 28 women) became new chairs between 1981 and 2005. The annual turnover rate increased gradually from 6.0% to 12.7%. Five-year net retention rates remained steady between 1982 and 1997 but dropped after 1997 (85.6% compared with 63.2%; P=.03). A chair's tenure ranged widely (1 to 23 years; median 8 years), regardless of gender or school type, size, or location. Approximately one half of interim chairs became permanent chairs, usually at their own institution. The number of new women chairs increased from none in 1981 to 17 (15.2% of total chairs) in 2005. CONCLUSION: Academic chair positions in obstetrics and gynecology experienced a doubling in annual turnover rates, while retention rates declined. The proportion of chairs occupied by women increased progressively. LEVEL OF EVIDENCE: II-2.

Induction of labor rates have more than doubled nationwide in the past 15 years. The increase in medically induced inductions was slower than the overall increase, suggesting that inductions for marginal or elective reasons rose more rapidly. Elective inductions seem to account for at least half of all inductions and 10% of all deliveries. Whether the experience of an elective induction is satisfactory to the patient, obstetrician, and intrapartum crew warrants more widespread attention. Cesarean rates are high for nulliparas undergoing an induction with an unfavorable cervix. Prospective studies are limited or nonexistent to recommend induction of labor for elective or marginal indications. Until more prospective work is performed, it will be difficult to evaluate the true impact of the elective induction of labor on population-wide cesarean delivery rates. Strategies for increased obstetrician awareness are proposed through practice guidelines and through clinical research trials.

The purpose of this study was to compare the effect of halogen light and vibroacoustic stimulation on fetal heart rate (FHR) responsiveness and on nonstress test (NST) results.Sixty consecutively-chosen patients between 33 and 39 weeks of gestation underwent an NST on at least three weekly occasions. Each received halogen light (Vector Compact Sport Spot, Ft Lauderdale, FL, USA), vibroacoustic (SolaTone Artificial Larynx, Temecula, CA, USA), and no stimulation in a randomized order. The transabdominal light or vibroacoustic stimulation lasted for 10 seconds. If no initial FHR acceleration occurred, then the stimulus was repeated 10 minutes later up to a maximum of three times. The investigators who interpreted the FHR patterns were blinded as to the type of stimulus used.Reactive results were present in 171 tests (vibroacoustic: 98.3%; light: 96.6%; none: 93.3%). Compared with no stimulation, the mean difference in time from the onset of recorded "stimulation" to the first FHR acceleration was shorter (p0.01) with either light (2.7 minutes, 95% confidence interval (CI) 0.9-4.5 minutes) or vibroacoustic stimulation (2.6 minutes, 95% CI 0.8-4.4 minutes). The mean time difference until a reactive result was also shorter (p0.05) with either light (2.7 minutes, 95% CI 0.1-4.9 minutes) or vibroacoustic stimulation (2.4 minutes, 95% CI 0.1-4.7 minutes) than with no stimulation. The need for repeated stimulation during each test was infrequent (light: 5.0%; vibroacoustic: 3.3%). No adverse effect from external stimulation was noted on the FHR tracing.Halogen light stimulation is an acceptable alternative to vibroacoustic stimulation in provoking a more rapid fetal heart rate response and in shortening the time before a reactive nonstress test result.

To report our intrapartum experience with routine delivery at 38 weeks of gestation of A-2 diabetic pregnancies requiring primarily oral hypoglycemic therapy.This retrospective study consisted of 143 consecutive women with gestational diabetes not controlled with diet alone (A-2). Each underwent a routine trial of labor at 38 weeks of gestation. The preinduction condition of the cervix, need for oxytocin, and primary cesarean rates were primary endpoints. For comparison, a control group during that same period consisted of 137 consecutive diet-controlled diabetic (A-1) pregnancies with the same eligibility criteria who underwent expectant management at 38 weeks.The study group was more likely to have an unfavorable cervix (75% versus 45%; p0.001) and to require oxytocin (76% versus 56%; p0.001). Early onset meconium was less common in the study group (3.5% versus 13.1%; p0.01). Primary cesarean rates were low and not different between the study and control groups (12.7% versus 11.7%; p0.8). The only stillbirth was in the control group and was associated with a tight double nuchal cord encirclement. Mean birth weights and the frequency of birth weights4000 g were not different between groups. Shoulder dystocia, low Apgar scores, and admissions to the special care nursery were infrequent in either group. No respiratory difficulties requiring resuscitation or prolonged nursery care were encountered.Routine delivery at 38 weeks in an A-2 diabetic population is not associated with additional intrapartum morbidity or a greater need for cesarean delivery.

To compare outpatient with inpatient misoprostol for preinduction cervical ripening at term.This concurrent cohort study was conducted between August 1999 and July 2002 at a rural community hospital. Pregnanciesor =38 weeks with an unfavorable cervix were eligible if there was a reactive nonstress test with no regular contractions or active medical/obstetric complications. Outpatients were given a single dose of misoprostol (50 microg intravaginally). A cohort group consisted of similar patients undergoing misoprostol therapy in the hospital.No differences were found between the outpatient (n=177) and inpatient (n=96) misoprostol groups for maternal age, parity, gestational age, and initial cervical dilation and station. No home deliveries occurred with outpatient therapy. Advanced cervical dilation at hospital admission the next morning was more common with outpatient misoprostol (10.2% vs. 2.1%; RR 5.0, 95% CI 1.2, 21.5). Differences in mean times from admission to vaginal delivery were significantly shorter with outpatient than inpatient misoprostol (nulliparas, 3.1 hours, 95% CI 1.5, 4.7; multiparas, 5.3 hours; 95% CI 3.8, 6.8). The very low proportions of fetal intolerance to labor, low Apgar scores and newborn complications were not different between the 2 groups.Outpatient vaginal misoprostol in a selected population led to more advanced cervical dilation at hospital admission the next morning and explained the shorter time until vaginal delivery.

Chemotherapy may be indicated for the treatment of cancer during pregnancy. The decision to use chemotherapy significantly impacts the pregnancy, and in turn the pregnancy may affect the treatment options available to patients with cancer. This review provides information about the effects of chemotherapeutic agents in pregnancy, taking into account both the mother and the fetus. For convenience, the agents are divided into categories based upon class and mechanism of action. These include alkylating agents, antimetabolites, nucleoside analogs, topoisomerase I inhibitors, topisomerase II inhibitors, vinca alkaloids, taxanes, and biologics such as signaling and growth factor blocking agents.

Objective: To determine the sensitivity of seven over-the-counter pregnancy tests (OTC-PTs) using urine containing a mixture of human chorionic gonadotropin (hCG)-related molecules as found on the first day of missed menstrual period. Design: Blinded in vitro sensitivity analysis. Setting: Medical school laboratory. Participants: None. Interventions: Urine was tested with OTC-PT devices at titers of 100, 50, 25, 12.5, 6.3, and 0 mIU/mL hCG immunoreactivity, and laboratory workers rated their confidence in the test result based on whether the test result was a clear, sharp, and unquestionable band in the test window. Main Outcome Measures: Analytical sensitivity, defined as the urine concentration at which all OTC-PTs tested gave a positive result regardless of operator confidence score; clinical sensitivity of OTC-PTs, defined as the proportion of pregnancies likely to be detected on the first day of a missed period and calculated from the analytical sensitivity and a recently published regression curve for total urine hCG immunoreactivity in 25 urine samples from this period of gestation; percentage of tested devices showing a band in the test window at a specific hCG concentration measured devices positive; percentage faulty devices, defined as the proportion of tested devices failing to yield a band in the control window; and confidence score, determined from operator ratings for each device at each concentration of hCG. Results: First Response Early Result had an analytical sensitivity of 6.3 mIU/mL, which was estimated to detect greater than 95% of pregnancies on the day of missed period. The sensitivity of Clearblue Easy Earliest Results was 25 mIU/mL, which indicated detection of 80% of pregnancies. The sensitivity of the five other products was 100 mIU/mL or greater, indicating detection of 16% or less of pregnancies. Three of these last products included faulty devices. Conclusion: Universal claims for OTC-PTs of more than 99% laboratory accuracy and use as early as the first day of missed period, while cleared for use by the U.S. Food and Drug Administration, are ambiguous and inappropriate for many products, according to these data. The majority of products tested were found to detect only a small percentage of pregnancies on the first day of a missed menstrual period. Until more data become available on the actual clinical sensitivity of these products, pharmacists should advise consumers to be cautious in interpreting test results.

Objective This study searches for association between the subject of medical students' required research projects and subsequent choices of residency, focusing specifically on women's health fields. Study design Students at our school graduating between 1997 and 2004 (n = 535) were required to undertake a research project beginning in the preclinical years. The subject of their required research project was related to their subsequent choice of residency. Results Ninety-nine of the 535 projects (18.5%) were women's health related. Although overall there was no significant relationship between the research project and residency choice, students who completed a women's health care project were nearly twice (1.8, 95% CI, 1.4-2.3) as likely to enter a women's health (obstetrics and gynecology or family medicine) residency than those who did not. Conclusion An association exists between student participation in women's health research beginning during preclinical years and the subsequent choice of a women's health residency.

Objective The purpose of this study was to identify the maximum tolerable dose and to determine the efficacy of different misoprostol dose reservoirs in an intravaginal controlled-release hydrogel polymer. Study design Nulliparous women at ≥37 weeks' gestation requiring cervical ripening and induction of labor were treated with misoprostol in a controlled-release, retrievable hydrogel polymer vaginal insert. Sequential cohorts of 6 patients were to be treated with escalating dose reservoirs of 25, 50, 100, 200, and 300 μg. The insert was to be removed upon onset of active labor, at 24 hours, or earlier if treatment-related adverse events occurred. The safety end point was determination of the maximum tolerable dose (MTD) based on occurrence of hyperstimulation syndrome. Our primary efficacy end point was time to vaginal delivery. Results Increasing reservoir doses of misoprostol up to 100 μg produced more rapid increases in modified Bishop scores, less need for oxytocin, and a shorter time to vaginal delivery. Doses above 100 μg did not further enhance cervical ripening or shorten time to vaginal delivery. The median time to vaginal delivery was 14.2 hours using the 100 μg dose. Uterine hyperstimulation and adverse fetal heart rate effects occurred with the 200 and 300 μg inserts. Conclusion The 100 μg vaginal insert resulted in successful cervical ripening and rapid vaginal delivery with an acceptable safety profile for future randomized clinical trials.

Objective: The purpose of this study was to assess variables that might predict which intern candidates will become excellent teachers of medical students. Study design: This retrospective cohort study compared demographic characteristics, previous work experience, United States Medical Licensing Examinations scores, honors on core clerkships, membership in Alpha Omega Alpha, and match list ranking of 43 residents to identify predictors of excellent teaching evaluations during residency. Results: Fifteen residents (35%) were identified as excellent teachers. They were more likely to have had previous work experience, to be older, or to be male. They were not more likely to have higher United States Medical Licensing Examinations test scores, more honors grades, Alpha Omega Alpha membership, or a higher rank list position. Conclusion: Work experience, age, and male gender are associated with increased likelihood of being identified as an excellent teacher by medical students. Programs in which residents have a significant role as teachers of students may consider these factors in the residency selection process.

This review summarizes contemporary concepts of abdominal surgical incision creation and closure. The Ovid computerized database was searched for articles published in English from 1996 to 2003 using keywords pertaining to the specific topic of interest (e.g., suture, drain, surgical technique, fascia). Human prospective, randomized trials; meta-analyses; and evidence-based-focused reviews were assessed and data abstracted. Several earlier and animal-based studies on specific issues were included. The data indicate that: (1) the direction of the incision should be based upon obtaining adequate exposure; (2) hair should either be left in place or clipped at the time of surgery; (3) a single dose of prophylactic antibiotics should be given 30 minutes prior to surgery; (4) using a "deep" scalpel is unnecessary; (5) a scalpel and electrocautery are comparable for deepening the incision; (6) minimal peritoneal lavage with non-antibiotic containing solutions is adequate; (7) the peritoneum should not be routinely closed; (8) the fascia should be loosely approximated by a continuous mass closure using a slowly absorbable, monofilament suture with the smallest possible caliber and a suture:wound length ratio of at least 4:1; (9) retention sutures, subcutaenous sutures and drains do not appear to reduce the risk of wound complications; and (10) the skin may be closed in a variety of methods, but a semiocclusive dressing should be applied. As scientific evidence accumulates to refute traditional dogma, management of the surgical patient has undergone substantial changes. Surgeons should now be able to create and close an abdominal wound based upon sound scientific principles rather than simply "doing what I always do."

To analyze gestational trophoblastic neoplasia (GTN) trends among American Indians (AI) using population-based data.GTN incidence, by race and age, was calculated using data collected by the New Mexico Tumor Registry over 29 years (1973-2001). Live birth, pregnancy and women at risk were tabulated using data derived from the state's vital record annual reports and from the registry. Statistical methods included trends analysis and Poisson regression. There is no national registry in the United States for all GTN. Therefore, the Surveillance, Epidemiology and End Results (SEER) database was used to identify choriocarcinoma cases in American Indians between 1973 and 1999.Within New Mexico, 1,082 cases of GTN were identified among 752,374 live births and 904,831 pregnancies, with ratios of 1:695 and 1:836, respectively, affecting 234 AI, 355 non-Hispanic whites (NHW), 463 Hispanic whites (HW) and 30 other nonwhites. Ratios per live births (pregnancy), respectively, were significantly higher in AI (AI 1:439 [1:487], NHW 1:739 [1:949], HW 1:783 [1:903]), as was age-adjusted incidence per 100,000 woman-years (AI 10.62, NHW 3.53, HW 5.15; all P.0001). Using Poisson models with live birth and woman-year denominators, AI were found to be at increased risk for all GTN histologic subsets (complete, partial and invasive hydatidiform mole and choriocarcinoma). Of 524 total gestational choriocarcinoma cases identified within SEER, 8 (1.8%) affected American Indians; of them, 7 were from New Mexico.In New Mexico, AI continue to be at higher risk of GTN than are other groups. Given the rarity of choriocarcinoma within SEER, especially among AI, the New Mexico dataset provides the best available estimate of trends in U.S. AI GTN risk.

To assess the impact of chronic prenatal exposure to phenobarbital on long-term behavior in mice offspring.Twenty-eight C3H/He mice were randomized to receive diet chow containing either a daily therapeutic dose of phenobarbital (2.5 mg in 10-g chow) or a placebo for 1 week before mating and throughout gestation. Offspring from eight litters of each treatment group were evaluated using motor function, arousal/motivation, anxiety-provoking and cognition tasks.No significant differences between groups were found in duration of gestation, litter size and birth weights. Fewer counts in a locomotor chamber were observed in phenobarbital-exposed offspring (524 +/- 31 vs. 688 +/- 54 for 60 min, p0.02; 4174 +/- 229 vs. 5230 +/- 406 for 22 h, p0.05). Initial reactions to a startle were more apparent among phenobarbital-exposed offspring (p0.03). Impaired co-ordination of hindlimbs was observed in the phenobarbital-exposed offspring during the wire maneuver (p0.001). Fewer entries into the mirrored chamber were observed after phenobarbital exposure (2.1 vs. 4.5; p0.05). Exposure to phenobarbital was not found to affect responses to learning and memory tasks (homing, tube runway, water runway, Morris maze).Although cognition was unaffected by prenatal exposure to phenobarbital, subtle effects on locomotor activity, hindlimb co-ordination and responses to anxiety-provoking conditions require human correlation.

This study was undertaken to determine whether external stimulation using a halogen light source influences fetal heart rate (FHR) responsiveness and nonstress test results.A total of 107 patients at 32 to 42 weeks' gestation undergoing a nonstress test were randomly assigned to have either transabdominal light stimulation or no light stimulation. The light (Vector Compact Sport Spot, Ft Lauderdale, Fla) was turned on for 10 seconds. If no qualifying FHR acceleration was observed, then the stimulus was repeated at 10-minute intervals for a maximum of 3 times. The investigators were blinded as to light stimulation for FHR interpretation.Reactive results were present in 52 cases in each group. Light stimulation led to a significantly shorter time (P.02) until the first FHR acceleration (difference: 2.1 minutes; 95% CI 0.4-3.8 minutes). The height and width of the first acceleration were indistinguishable between groups. The time until a reactive result was significantly shorter after light stimulation (difference: 4.2 minutes; 95% CI 2.0-6.4 minutes).The earlier onset of FHR accelerations after halogen light stimulation prompted a more rapid reactive nonstress test result.

The purpose of this study was to assess the impact of chronic prenatal exposure to a therapeutic dose of carbamazepine on the behavior of mice offspring in a randomized, placebo-controlled manner.Twenty-eight C3H/He mice were assigned randomly to treatment groups that were given food that contained either carbamazepine (25 mg in 10 g food) or a placebo for 1 week before mating and throughout gestation. Adult offspring from eight litters of each group were evaluated for standard tasks for motor, arousal/motivation, anxiety, and cognition. Statistical comparisons included analysis of variance and the Fisher exact test.Compared with the placebo group, there were no significant differences among the carbamazepine offspring in the duration of gestation, litter size, and birth weights. Fewer locomotor chamber movements were recorded in the carbamazepine group than in the placebo-exposed group at postnatal day 21 (469 vs 555 counts for 60 minutes, P.03) and as adults (510 vs 688 counts for 60 minutes, P.03) Coordination, balance, and exploratory behavior did not differ between exposure groups. A startle response from auditory arousal was decreased in carbamazepine-exposed adults (1.4% vs 21.9%, P.03). Performances on anxiety/motivation tasks and on learning/memory tasks revealed no significant differences between exposure groups.Although prenatal exposure induced subtle arousal effects and slower locomotor activity, carbamazepine did not have an impact on coordination, cognition, or responses to anxiety-provoking conditions. Correlation in humans is recommended.

Objective The purpose of this study was to compare the efficacy of two protocols for active management of labor at term in the presence of an unfavorable cervix. Study design Pregnancies that underwent labor induction at ≥37 weeks of gestation with an unfavorable cervix (Bishop score, ≤6) were randomly assigned to receive vaginally either a single dose of sustained-release dinoprostone (Cervidil) with concurrent low-dose oxytocin or multidosing of misoprostol (25 μg every 4 hours) followed by high-dose oxytocin. The primary outcome was the time interval from induction to vaginal delivery. Other parameters included excess uterine activity and cesarean delivery rates. Results A total of 151 patients (dinoprostone, 74 patients; misoprostol, 77 patients) were enrolled. The mean time from the initiation of induction to vaginal delivery was the same in the dinoprostone and misoprostol groups (15.7 hours; 95% CI, 13.7-17.7 hours vs 16.0 hours; 95% CI, 14.1-17.8 hours; P =.34), regardless of parity. The dinoprostone and misoprostol groups did not differ statistically in the percent of patients who were delivered vaginally by 12 hours (36.2% vs 29.7%), 18 hours (63.8% vs 56.3%), and 24 hours (81.0% vs 81.3%). Excess uterine activity was not more common in either group, and hyperstimulation syndrome was absent in all cases. Primary cesarean delivery rates were similar (dinoprostone, 21.6%; misoprostol, 16.9%; relative risk, 1.3; 95% CI, 0.7-2.5), with a failed induction that occurred in one case in each group. Conclusion Sustained-release dinoprostone with concurrent low-dose oxytocin and intermittent misoprostol with delayed high-dose oxytocin are effective alternatives for active management of labor with an unfavorable cervix.

Objectives This study was undertaken to determine a daily therapeutic dose of carbamazepine and to measure its effect on reproductive performance and perinatal outcomes of mice. Study design Adult C3H/He mice were given carbamazepine in rodent chow in either a 0.25% or a 1.0% mixture. Comparisons between doses included nongravid weight change, plasma drug steady-state concentrations, and response to a maximal electroshock seizure test. The strain was then fed either the preferred dose of carbamazepine or a placebo 1 week before starting to mate and throughout gestation to compare reproductive performance and offspring early development. Results Mice who ate the 0.25% carbamazepine mixture displayed no evoked seizure activity and, in contrast to the 1.0% mixture, did not lose weight. This daily dose of 542±35 mg/kg produced a trough steady-state plasma concentration that was consistent with a protective threshold in humans. Differences from placebo controls were not statistically significant for the number of cycles necessary to conceive or for the duration of gestation. The litter size, survival rates, birth weights, weight gain, and onset of eye openings and teeth eruptions of the pups were not statistically significant between the two groups. Conclusion Long-term prenatal exposure to a subtoxic yet therapeutic dose of carbamazepine did not impair reproductive performance or early growth and development of exposed mice offspring.

To compare two daily fetal movement charting techniques to determine which chart was preferred by patients and which promoted more patient adherence.This randomized trial included patients with singleton gestations between 28 and 34 weeks' gestation, with intact membranes and not in labor. Consenting women were given a Hollister chart and a 'count to 10' chart in a cross-over manner over two consecutive 1-week periods. Each patient answered a questionnaire establishing which chart was preferred. All returned charts were evaluated for patient adherence. Data were analyzed using either the Yates-corrected chi2 test or Fisher's exact test when appropriate.Forty patients agreed to participate, and 31 completed and returned both charts. The 'count to 10' chart was clearly preferred over the Hollister chart (29 vs. 2; p = 0.002) because of the shorter recording period (median 23 min vs. 1 h; p0.01). The proportion of patients who fully completed the 'count to 10' chart during the week was significantly higher than the proportion completing the Hollister chart (68% vs. 26%; p0.001).The 'count to 10' fetal movement chart was clearly preferred and promoted a higher level of adherence.

The purpose of this study was to conduct, in a randomized placebo-controlled manner, social behavior testing on mice offspring that were exposed prenatally to alprazolam.A previously described, clinically relevant dose of 0.32 mg/kg of alprazolam (n=8 mice) or a placebo (n=9 mice) was given to gravid C57BL/6 mice by gavage on gestational day 18. Social play, sleep/wake patterns, and male aggression of the exposed offspring were assessed during prejuvenile, juvenile, and adult periods.Alprazolam did not produce treatment differences in pregnancy outcomes or in dam-pup interactions. Compared with the placebo group, alprazolam-exposed offspring demonstrated less desire to escape (P.01), more desire to remain alone (P.02), and shorter periods of being awake (P.03) on PND 17. Alprazolam-exposed male offspring exhibited more aggression on food restriction (P.01) and on cage changing (P.01).Mice offspring that were exposed prenatally to alprazolam demonstrated more individual rather than group activities, avoidance of open areas, and aggression in males. Correlation of these findings in humans is encouraged.

To describe reported medication errors in the obstetric inpatients in 1 hospital.We analyzed all errors, reported voluntarily in a nonpunitive manner, from December 1996 to November 2001.The 164 medication errors led to 154 class 1 (no harm), 10 class 2 (additional therapy but no additional harm) and 0 class 3 (permanent harm) adverse drug events. Omissions and incorrect timing of drug administration were the most common reasons. The rate of class 1 adverse drug events was lower in labor and delivery than on the ward (0.8 versus 1.4 per 1,000 patient days; P.05). Excess dosing with intravenous magnesium sulfate was the most common class 2 event.Reported medication errors on 1 inpatient obstetric service were very rare and not associated with permanent harm. Reporting these errors may identify system improvements and avoid recurrences.

To provide an update on the current trend toward increasing use of emergency postcoital contraception, continuous (or "extended-use") oral contraceptives (OCs) and longer-acting contraceptive delivery systems.This review is based largely upon patient care-oriented clinical experience data, including some original work submitted to the U.S. Food and Drug Administration by the primary investigators of these novel methods, supplemented, when appropriate, with basic pharmacologic and pharmacokinetic information.This review is a distillation based on an exhaustive literature search of each of the following topics: emergency postcoital contraception, continuous (extended-use) oral contraception, the weekly patch, the monthly vaginal ring and the monthly injectable. The issue of OC formulations recently begun to be marketed in this country was excluded since they have been extensively reviewed elsewhere.Emergency postcoital contraception is highly effective, though not as effective as available proactive methods of hormonal contraception. Of the popular regimens available, all have similar efficacy; those without estrogen are associated with less nausea and vomiting. The prophylactic administration of an antiemetic 1 hour prior to the first contraceptive dose can mitigate this adverse side effect. Continuous (or "extended" use) of OCs has become increasingly popular. This can decrease or eliminate menstruation as well as several menstruation-related complaints (e.g., dysmenorrhea, menstrual migraines and premenstrual symptoms). Despite the fact that combination OC regimens offer highly reliable contraception as well as several noncontraceptive health benefits, they are limited by the issue of daily compliance. To address this limitation, several longer-acting delivery systems were recently developed. The weekly patch, monthly vaginal ring and monthly injectable have efficacy and side effect profiles similar to those of comparable OC formulations. They offer the advantages of longer action and lower and more steady steroid levels and are free of the challenges associated with daily compliance.We need to continue to develop new and highly effective means of contraception that offer women ease of use and minimal side effects, hence leading to successful and effective use.

Objective The purpose of this study was to evaluate the qualities that medical students value most in department chairs during clinical clerkships. Study design All fourth-year students were asked to complete an anonymous survey voluntarily. The students ranked nine qualities of a chair using a visual analog scale that ranged from “strongly disagree” to “strongly agree.” Also assessed was the student's level of contact with each department chair during the six core clerkships. Results Sixty-seven of 73 students (91.8%) completed the survey. Almost two thirds of the students (63%) had minimal or no contact with clinical chairs. The most desirable qualities of the department chair included advocating teaching by the residents and faculty, meeting with students (if possible, at the beginning, middle, and end of the clerkship), and participating in teaching in the classroom or clinic settings. Least important qualities involved knowing the student as a person and displaying an air of authority. The most common theme of written comments was that the department chair sets the tone for the department by advocating teaching and by encouraging respect for students. Conclusion Medical students want clinical chairs to be visibly proactive toward teaching, meet with them periodically, and participate in teaching.

To determine if the presence of a single or multiple nuchal cord encirclement has a negative effect on fetal growth.Data were retrieved from consecutive deliveries at our institution between January 1991 and December 1996. Our computerized database included live-born single and multiple births with a birth weight ofor = 300 g. ANOVA and multiple linear regression were used for statistical analysis.Among the 13,256 deliveries, a single nuchal cord encirclement was observed in 3,250 (24.5%), and multiple encirclements were present in 504 (3.8%). There was no association between the diagnosis of growth restriction and the presence of a cord encirclement. The mean birth weight was no different in the presence of a single or multiple nuchal cord encirclement than with no encirclement (3,206 g or 3.135 g vs. 3,252 g; F = .08, P = .7). After controlling for substance abuse, medical or obstetric complications, race, infant sex, congenital anomalies and gestational age, there was no effect of a single or multiple cord encirclement on mean birth weight.Birth weight is unaffected by a single or multiple nuchal cord encirclement.

Mayer-Rokitansky-Kuster-Hauser syndrome is challenging to diagnose and manage. A multisystem approach serves patients best. Appropriate treatment successfully improves patient self-image and sexual satisfaction.