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Umbilical cord blood (UCB) is a valuable source of stem cells that can be used to treat a variety of diseases including hematological malignancies. Although UCB stem cells were once viewed as an alternative source of stem cells for therapeutic transplant, this readily available source has gained acceptance among transplant physicians and is now often considered as a first-line treatment. UCB contains several classes of stem cells, including pluripotent forms, which offer promise in various emerging applications presently under preclinical and clinical investigation. Given both proven and nascent applications of UCB stem cells, expectant mothers should be educated about UCB options, including various banking options. There are essentially 3 options with regard to UCB -- donating to a public bank, storing with a family bank, or discarding the UCB. Each option is associated with its own benefits and drawbacks. Obstetricians have the ability and opportunity to play an important role in this education. This article details the advances in UCB research and banking and provides useful information and tools for physicians to help educate expectant mothers and their families about UCB options. [ABSTRACT FROM AUTHOR]

Context: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth.Objective: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy.Design and Setting: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13).Subjects: Obstetricians and their preterm delivery cases at participating hospitals.Intervention: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback.Main Outcome Measure: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122).Results: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways.Conclusion: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices. [ABSTRACT FROM AUTHOR]

This study details a programme which emphasized nursing interventions for women at high risk for preterm birth. Preterm birth continues to be a major health problem, with ongoing research being conducted both in the United States and internationally in an effort to find causative factors. Programmes designed to prevent preterm birth have been described often in the literature, with lifestyle factors being implicated in the incidence of preterm birth by many researchers. The purpose of this study was to determine the lifestyle factors most often associated with preterm birth in a high risk population of inner city women, and to examine the effect of change in lifestyle when change was possible. Women at high risk for preterm birth were interviewed extensively for prevalence of 12 lifestyle factors most often cited in the literature as being associated with preterm birth. Counselling and education were offered to each woman, with emphasis on symptom recognition and modification of lifestyle activities. Comprehensive prenatal care was administered by programme personnel. A profile of the women's reported lifestyle activities and stress factors is presented along with the relationship to outcome. The data suggested that, when change in lifestyle activity or stress was possible, women who decreased the activity or stressor were more likely to deliver at term. This study represents one of the first efforts in the United States to produce a prospective database to quantify risk and analyse the impact of change in activities associated with symptoms of preterm labour in high risk women. This study is particularly relevant for nursing since assessment, intervention and evaluation of lifestyle changes in the high risk perinatal client are integral parts of perinatal nursing practice. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff. STUDY DESIGN: Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life suppport pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring. RESULTS: Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017). CONCLUSION: Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event. [ABSTRACT FROM AUTHOR]

Background: Benefits of exposure to global health training during medical education are well documented and residents' demand for this training is increasing. Despite this, it is offered by few US obstetrics and gynaecology (OBGYN) residency training programmes., Objectives: To evaluate interest, perceived importance, predictors of global health interest and barriers to offering global health training among prospective OBGYN residents, current OBGYN residents and US OGBYN residency directors., Methods: We designed two questionnaires using Likert scale questions to assess perceived importance of global health training. The first was distributed to current and prospective OBGYN residents interviewing at a US residency programme during 2012-2013. The second questionnaire distributed to US OBGYN programme directors assessed for existing global health programmes and global health training barriers. A composite Global Health Interest/Importance score was tabulated from the Likert scores. Multivariable linear regression was performed to assess for predictors of Global Health Interest/Importance., Results: A total of 159 trainees (77%; 129 prospective OBGYN residents and 30 residents) and 69 (28%) programme directors completed the questionnaires. Median Global Health Interest/Importance score was 7 (IQR 4-9). Prior volunteer experience was predictive of a 5-point increase in Global Health Interest/Importance score (95% CI -0.19 to 9.85; p=0.02). The most commonly cited barriers were cost and time., Conclusion: Interest and perceived importance of global health training in US OBGYN residency programmes is evident among trainees and programme directors; however, significant financial and time barriers prevent many programmes from offering opportunities to their trainees. Prior volunteer experience predicts global health interest., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.

Objective: We studied the clinical utility of chromosomal microarray analysis (CMA) in prenatal diagnosis in a clinical setting in New York City., Methods: Our center began offering CMA to pregnant women undergoing invasive diagnostic procedures for an abnormal structural finding on ultrasound, maternal age of 35 years or older, or elevated risk on aneuploidy screening, beginning March 2012. Our first six months experience is reported., Results: Benign familial variants were the most common finding (16/22 fetuses). Variants of uncertain significance were frequent, especially when fathers were not available for testing (4/22 fetuses). Most patients undertook CMA as part of evaluation of an ultrasound anomaly (52%). One patient terminated a pregnancy based on an ultrasound finding in the setting of a benign familial variant on CMA, and a second terminated a pregnancy based on a copy number variant identified on CMA., Conclusion: For CMA to be maximally useful in prenatal diagnosis, parental DNA samples as well as robust datasets to provide predictive phenotypic information are required. The most common reason for undertaking CMA was to evaluate an ultrasound anomaly, and benign familial variants were a common finding. Genetic services are required to provide pre- and post-test genetic counseling and help families interpret results.

Objective: To study the impact of a prenatal electronic medical record (EMR) on the adequacy of documentation., Study Design: The authors reviewed paper prenatal records (historical control arm and contemporaneous control arm), and prenatal EMRs (study arm). A prenatal quality index (PQI) was developed to assess adequacy of documentation; the prenatal record was assigned a score (range, -1 to 2 for each element, maximum score = 30). A PQI raw score and PQI ratio-that controlled for which elements of care were indicated for a patient-were calculated and compared between the study arm versus historical control arm and then the study arm versus contemporaneous control arm., Results: The median PQI raw score was significantly lower in the study arm compared with historical control arm; however, the PQI ratios were similar between these groups. The PQI raw score was similar in both the study arm and contemporaneous control arm; however the PQI ratio was significantly higher in the study arm when compared with the contemporaneous control arm., Conclusion: Implementation of this prenatal EMR did not have a significant impact on completeness of documentation when compared with a standardized paper prenatal record. Adequacy of documentation seems to be related to the type of practice., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety., (© 2014 American Society for Healthcare Risk Management of the American Hospital Association.)

Objective: Smoking cessation during pregnancy is a modifiable intervention that can improve maternal and neonatal outcomes. Encouraging smoking cessation is an assessed measure of the Meaningful Use incentives to ensure best practices with the increased use of the electronic medical record (EMR). Physician EMR prompts have been used shown to be successful with preventive care but there is a paucity of data evaluating prompts within obstetrics. The objective of this study is to determine the effectiveness of enhanced smoking cessation prompts in a prenatal EMR., Methods: A retrospective cohort study of an enhanced smoking cessation prompting system within our prenatal EMR was performed. Pregnant women who reported tobacco use at first prenatal visit were included. The number of times a smoking cessation method was offered and documented, the number of documented attempts at smoking cessation, and the final number of cigarettes smoked were compared pre and post the enhancement of the smoking cessation prompting system., Results: 95 patients were included (48 pre-enhancement; 47 post-enhancement). Post-enhancement, the documentation of smoking cessation method offered increased (0 vs. 1, p = 0.03) and documentation of smoking cessation attempts increased (1 vs. 2, p = 0.006). There was no change in the final number of cigarettes smoked (p = 0.9)., Conclusions: Enhanced prompting systems increase documentation related to smoking cessation with no change in number of cigarettes smoked. In the era of Meaningful Use guidelines which focus on documentation in the EMR, continued research must be done to assure that software enhancements and improved documentation truly result in improved patient care.

Objective: To compare eclampsia and magnesium toxicity management among residents randomly assigned to lecture or simulation-based education., Study Design: Statified by year, residents (n = 38) were randomly assigned to 3 educational intervention groups: Simulation→Lecture, Simulation, and Lecture. Postintervention simulations were performed for all and scored using standardized lists. Maternal, fetal, eclampsia management, and magnesium toxcity scores were assigned. Mann-Whitney U, Wilcoxon rank sum and χ(2) tests were used for analysis., Results: Postintervention maternal (16 and 15 vs 12; P < .05) and eclampsia (19 vs 16; P < .05) scores were significantly better in simulation based compared with lecture groups. Postintervention magnesium toxcitiy and fetal scores were not different among groups. Lecture added to simulation did not lead to incremental benefit when eclampsia scores were compared between Simulation→Lecture and Simulation (19 vs 19; P = nonsignificant)., Conclusion: Simulation training is superior to traditional lecture alone for teaching crucial skills for the optimal management of both eclampsia and magnesium toxicity, 2 life-threatening obstetric emergencies., (Published by Mosby, Inc.)

Objective: The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC., Study Design: This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program., Results: Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively., Conclusion: Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC., (Copyright 2010 Mosby, Inc. All rights reserved.)

The previous century was characterized by tremendous advances in reducing maternal mortality and morbidity, as well as dramatic improvements in perinatal outcomes for fetus and newborn. However, there has now developed a plateauing or even a worsening in some of the commonly tracked indicators of reproductive health. In this section, leading policy experts focus on redefining how the health system approaches the task of continuing to improve the reproductive outcomes of women and their offspring. They analyze key underlying fundamentals and offer their individual suggestions for new initiatives to reverse these disturbing negative trends.

Objective: The objective of the study was to determine whether a simulation-based educational program would improve residents' and attending physicians' performance in a simulated shoulder dystocia., Study Design: Seventy-one obstetricians participated in an unanticipated simulated shoulder dystocia, an educational debriefing session, and a subsequent shoulder dystocia simulation. Each simulation was scored, based on standardized checklists for 4 technical maneuvers and 6 communication tasks, by 2 physician observers. Paired Student t tests were used for analysis., Results: Forty-three attendings and 28 residents participated. Residents showed significant improvement in mean maneuver (3.3 +/- 0.9 vs 3.9 +/- 0.4, P = .001) and communication (3.5 +/- 1.2 vs 4.9 +/- 1.0, P < .0001) scores after simulation training. Attending physicians' communication (3.6 +/- 1.6 vs 4.9 +/- 1.1, P < .0001) scores were significantly improved after training., Conclusion: Our program improved physician performance in the management of simulated shoulder dystocia deliveries. Obstetric emergency simulation training can improve physicians' communication skills, at all levels of training, and should be incorporated into labor and delivery quality improvement measures.

In 2002 the Institute of Medicine called for implementation of information technologies in health care settings to improve quality of care and reduce the incidence of medical errors. Nowhere is this need more critical than in obstetrics. In recent years numerous electronic prenatal medical records have become available. To date there has been little literature to identify what constitutes the important features in these systems, nor research into whether these systems actually improve the quality of care or the outcome of pregnancies. In this article we will elucidate some of the features that we feel are critical if we are to achieve these goals. Some of these features are: (1) availability across a computer network so that providers can access the record in a variety of settings, (2) simplicity of the user interface to ensure provider compliance with the system, (3) an intelligent system to encourage completeness of documentation in the medical record, (4) a problem-oriented obstetric chart so that no issue is overlooked and each is adequately addressed, and (5) administrative features to allow evaluation to ensure improved quality of care. These features together, we believe, will help to minimize medical errors, improve patient outcomes and reduce liability exposure.

Objective: To identify risk factors for life-threatening maternal outcomes., Study Design: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression., Result: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status., Conclusion: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

Preterm birth (PTB) is a common, serious, and costly health problem affecting nearly 1 in 8 births in the United States. Burdens from PTB are especially severe for the very preterm infant (<32 weeks' gestation), comprising 2% of all US births. Successful prevention needs to include newly focused and adequately funded research, incorporating new technologies and recognition that genetic, environmental, social, and behavioral factors interact in complex pathogeneses and multiple pathways leading to PTB. The March of Dimes Scientific Advisory Committee created this prioritized research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of PTB, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress, and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care.

Objective: The purpose of this study was to compare alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol levels in women who take protease inhibitors and those women who do not., Study Design: This retrospective review from August 2000 to May 2003 was performed for maternal serum screen results, medication use, pregnancy, and perinatal outcomes., Results: Thirty-nine women met study criteria. Sixteen women were treated with protease inhibitors, and 23 women were not treated with protease inhibitors. There was no difference in initial viral load or initial CD4 count between the groups. No difference was found for human chorionic gonadotropin and estriol levels; significantly lower alpha-fetoprotein multiples of the median were found for the women who were treated with protease inhibitors compared with the women who were not (0.97 +/- 0.32 [SD] MoM vs 1.2 +/- 0.4 MoM, respectively; P = .04). Six of 39 women (15%) had positive maternal serum screens. All the babies were normal at birth, and there were no cases of perinatal transmission of human immunodeficiency virus., Conclusion: Protease inhibitors are associated with lower alpha-fetoprotein levels in women who are infected with human immunodeficiency virus.

Montefiore Medical Center increased the collections of the Department of Obstetrics & Gynecology and Women's Health by $1.2 million without cutting costs or increasing its charges. Instead, the organization appointed a billing director to take charge of revenue-cycle performance and redesign its billing processes by: Implementing standard processes organizationwide Involving physicians in data collection to ensure accurate claims Collecting copayments at the front end.

Objective: To improve the documentation and delivery of preconception care to all women of reproductive age attending an inner city hospital's outpatient gynecology clinic. A secondary goal was to evaluate the knowledge and awareness of providers regarding preconception care., Study Design: A preintervention chart review of a convenience sample of non-pregnant women with reproductive potential who attend an inner city hospital gynecology clinic (n = 100) was conducted to evaluate delivery of preconception care. Items screened for included: family planning services, domestic violence, nutrition and medical risk factors, medication use, appropriate counseling and use of referral services. All providers in the clinic were surveyed to assess their knowledge of and attitudes toward preconception care. A two-part intervention was then carried out: (1) a one-hour lecture for all providers, and (2) a standardized preconception care form inserted in all charts. A postintervention chart review of a second convenience sample (n = 100) and repeat provider survey were then conducted to evaluate the effectiveness of the two interventions., Results: Following the two-pronged intervention, there was evidence of improved documentation of the delivery of preconception care. Documentation of screening in almost all categories was significantly improved (P < .05). The greatest improvements were noted in complete screening for medical risk factors (from 15% to 44%), for over-the-counter and prescription medication use (from 10% to 70% and 30% to 77%, respectively), domestic violence (from 10% to 57%) and nutrition (from 9% to 50%). However, provider knowledge of and attitudes toward preconception care were not significantly changed., Conclusion: The combination of education about preconception care and insertion of a standardized form into a patient's chart led to a clear improvement in the documentation of preconception care. Given the significance of preconception care, insertion of a standardized form should be considered to help providers complete and appropriate care to their patients.

Objective: To evaluate whether ACOG's patient education pamphlets comply with the recommended readability level for health education materials intended for the general public., Methods: All 100 English-language pamphlets available during 1997 (created or revised between 1988 and 1997) were evaluated using four standard readability formulas., Results: Mean readability levels of ACOG's pamphlets were between grade 7.0 to grade 9.3, depending on the formula used. Analysis of readability over the 10 years showed a trend toward lower readability levels. Analysis by category of pamphlet found that the lowest readability levels were in "Especially for teens" pamphlets., Conclusion: Our data suggested that most of ACOG's patient education pamphlets currently available are written at a higher readability level than recommended for the general public. The readability of those pamphlets improved in the 10 years since the organization published its first pamphlet, but the goal of sixth-grade readability level has not been reached.

Objective: To determine if women who received information from a provider and viewed a videotape about maternal serum alpha-fetoprotein (MSAFP) screening understood enough to sign informed consent., Design: A prospective qualitative design using tape recorded interviews of women who were provided information regarding MSAFP testing from a provider and from viewing a videotape., Participants: Fifty-three inner city pregnant women (58% Hispanic, 39% African-American, 3% white)., Results: Two women answered all questions correctly; no one answered all questions incorrectly. Sixty-two percent correctly answered "What is MSAFP?" Sixteen percent thought "something has to be taken from my belly" for the test. Fifty-nine percent understood that children with spina bifida could have difficulty walking or urinary problems. Seventy-two percent thought their infant would be healthy in all respects if the test was negative. Only 45% could describe the follow-up to a positive test. Eighty percent planned to have the test. Many misconceptions were apparent, and for some knowledge items, as many as 80% of the women answered incorrectly., Conclusions: Obtaining truly informed consent for a complex test is not a simple process. Participants met a few, but not all, of the criteria for informed consent. Women understood that the test was voluntary, but their comprehension of the meaning and implication of a positive test results was deficient. Despite this, they signed the informed consent document. The larger question of just how much comprehension is required to consider a woman "informed" has not been answered.

Objective: To describe a new technique for open laparoscopy., Design: Prospective case series., Setting: Ambulatory surgical unit., Patient(s): Fifty-six women undergoing laparoscopic sterilization., Intervention(s): Intra-abdominal placement of an optical surgical obturator., Main Outcome Measure(s): Evaluation of surgical technique., Result(s): The technique was completed successfully in all cases., Conclusion(s): This new surgical approach may assist surgeons in avoiding inadvertent injuries.

The number of individuals infected by the human immunodeficiency virus type-l (HIV) continues to increase on a worldwide basis.' A significant percentage, ifnot all, of these individuals will eventually develop the acquired immunodeficiency syndrome (AIDS).2 While horizontal transmission in the homosexual population may be contained or decreasing,' heterosexual transmission and infection through contaminated blood supplies continues to increase: Additionally, vertical transmission from infected females to their fetuses is also on the rise with a resultant increase in the number of children with AIDS.S New strategies, therefore, must be devised in order to limit more effectively the spread of this virus.

The principal reason for employing an optical trocar has been described by Kaali.' The potential clinical benefits of a visually directed trocar entry system have been identified in a follow-up clinical series. 2 Current experience with the commercially developed Endopath Opt.iview" trocar has suggested an ad- ditional surgical advantage through an enhanced abdominal wall stability of the trocar sheath. The purpose of the current investigation was to determine whether or not this clinical observation could be mechanically quantified.

Blind insertion of the Veressneedle and the conventional primary trocar have remained troublesome steps during laparoscopic surgical procedures. The standard primary trocar can be inserted directly without preexisting pneumoperitoneum, thus avoiding use of the Veressneedle. This approach still requires blind insertion, and inadvertent traumatic injuries have been reported.' Complications from such trocar insertions can be severe and at times lethal. Although the rate of such complications is acknowledged to be small, the ab- solute number becomes a relevant public health issue in light ofthe high frequency of both operative and di- agnostic laparoscopic procedures worldwide. Traumatic injuries to vessels, bowel, and other abdominal or- gans continue to occur despite proper surgical training, operator experience, and use of up-to-date equipment.

The objective of this study was to determine the impact of an inner-city, hospital-based preterm-birth prevention program on the outcome of twin pregnancies. A retrospective study of delivery outcomes from 1985 to 1992 of eligible consecutive twin deliveries that were > or = 20 weeks' gestation compared two inner-city hospitals in the Bronx, New York: one with a preterm prevention program for twin births and a comparable site offering conventional prenatal care. A group of patients receiving no prenatal care was also included. Outcomes were evaluated by prenatal-care site, except for those who received no prenatal care and delivered at either site. Data were analyzed by chi-square analysis and analysis of variance. Of the 377 twin pregnancies, 330 pregnancies were eligible deliveries. One hundred thirty-four women received prenatal care from the preterm prevention program, 161 received conventional prenatal care at a comparable site, and 35 received no prenatal care. Maternal age, parity, and mode of delivery were similar in the two delivery sites. There was an increased incidence of complications in the no-prenatal-care group compared with the groups who received the preterm prevention or conventional prenatal care. The percentage of low-birth-weight (< 2500 g) and very-low-birth-weight (< 1000 g) infants was similar in the preterm prevention and the conventional care groups. The percentage of extremely low-birth-weight (< 1000 g) infants was significantly lower in twin births of the preterm prevention site (9.7%) and the conventional site (11.3%) compared with the no-prenatal-care group (28.6%) (P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

We attempted to determine whether video-aided visual imaging during laparoscopic insertion of the trocar would improve the surgeon's ability to localize the sharp penetrating tip of the instrument. A newly described, visually directed laparoscopic trocar was inserted in 184 subjects to correlate visual localization of the tip with the accuracy of the conventional tactile sensory approach. In 164 of the 184 cases the fascia was recognized visually at the same time that the surgeon acknowledged tactile resistance. However, partial intraabdominal penetration was noted in 102 of these cases just before the anticipated loss of resistance could be felt manually. More important, in 20 women there was no subjective manual confirmation of the tip location by the time intraabdominal placement of the trocar was confirmed visually. In this limited series there were no multiple insertions or complications under visually directed trocar entry. Video-aided direct visualization improves the surgeon's ability to localize the tip of the trocar throughout the insertion. It may help the surgeon to recognize and possibly avoid some inadvertent distant intraabdominal organ injuries.

Although the adverse effects of sickle cell disease on pregnancy outcome are well recognized, the contribution of placental pathology to these events remains controversial. Placentas from single, term deliveries of 21 women with sickle cell (SS) disease and 63 low-risk control women with hemoglobin AA, matched for maternal age, gestational age, and parity, were examined and findings correlated with neonatal outcome. Gross and microscopic examinations of these placentas were performed by a pathologist unaware of the pregnancy outcome. All placentas were weighed, and the relative placental weight was calculated and examined for the presence of infarction, villous sclerosis, and intervillous fibrin deposits. The mean birth weight of infants of the SS women was significantly lower than that of the low-risk controls (2830 +/- 310 g versus 3415 +/- 250 g, P < .05). The mean placental weight was also lower in the SS group compared with controls (445 +/- 78 g versus 568 +/- 86 g). The mean relative placental weight for the SS women was 12.9 +/- 4% and for the controls, 15.2 +/- 3.4%. Moderate-to-severe villous sclerosis, infarction, and intervillous fibrin deposits were present in 7 of 21 SS placentas but absent in placentas of low-risk controls. These 7 pregnancies with SS disease and abnormal placental findings had small-for-gestational-age infants, and their relative placental weight was less than 10%. We conclude that in SS disease, relative placental weight less than 10% and placental lesions of moderate-to-severe villous sclerosis, intervillous fibrin deposits, and infarction are associated with small-for-gestational-age infants.

Objectives: In 1989 the United States Public Health Service Expert Panel on the Content of Prenatal Care reported that health education should become a more integral part of prenatal care. Key questions about providing this education have not been examined. Our study compared the type of information provided to women who sought prenatal care in a public clinic and to those who were seen in a private practice and the degree to which the patients were satisfied with the information they received., Study Design: One hundred fifty-nine pregnant women (80 seen in a public clinic, 79 seen in a private practice) completed two questionnaires about 38 topics commonly cited as important during pregnancy. At the first prenatal visit, the women reported their level of interest in each of the topics. At 36 to 40 weeks' gestation the women completed a second questionnaire to assess whether information was provided for each topic and whether they had learned as much as desired., Results: Overall, the women in the public sector received more information than did the women who were cared for privately. This was statistically significant at the p < 0.05 level for 25 of the 38 topics. Satisfaction with information learned was highly correlated with information received during prenatal care, but, surprisingly, it was not shown to be associated with the patient's interest level at the first visit. Fewer than 50% of private patients reported having received information about such important topics as acquired immunodeficiency syndrome, sexually transmitted diseases, preterm birth prevention, family planning, and family violence., Conclusions: The one-on-one approach to health education in pregnancy usually used in the private setting may not facilitate addressing many topics believed to be important components of contemporary prenatal care. Providers of private prenatal care should initiate discussion of prenatal health education topics rather than relying on patient interest in requesting information. Just as public prenatal care programs have devoted significant resources to more comprehensive prenatal education, the providers in the private sector must assure that pregnant women receive the same comprehensive information. In so doing, these providers can help promote an optimal outcome for their patients, their patients' unborn children, and the family unit.

Objective: To compare client and health-care provider perceptions concerning health topics., Design: A survey conducted at the first prenatal visit asked women to indicate levels of interest in 38 topics. Providers answered the same survey, indicating perceptions of clients' interests., Setting: A prenatal clinic and a private office, both in an inner city area., Participants: Two groups of prenatal clients (n = 135 private care and n = 250 public care) and their health-care providers (n = 32 nurses and physicians)., Results: Significant differences were found (p < .01 for four topics, p < .05 for six topics) between the clients' interests and the providers' perceptions. Women in private and public care differed significantly (p < .01) in their levels of interest. Interest was significantly affected by parity, but not maternal education., Conclusions: Nurses and other health professionals should be aware of the range of topics in which clients express interest. This study suggests that site of care and parity should be considered when developing prenatal health education.

Objective: Our objective in this study was to evaluate the rate of spontaneous version in twin gestation throughout the third trimester., Study Design: Serial ultrasonographic examinations were performed on 119 consecutive patients with twin gestation. The incidence of spontaneous version as a function of gestational age was calculated., Results: The mean birth weight and gestational age at delivery were 2640 gm and 37 weeks, respectively. Nineteen percent had birth weight discordancy, and 37% were delivered by cesarean section. The incidence of spontaneous version decreased from 60% at 28 to 30 weeks' gestation to 25% to 30% at term. The lowest incidence of spontaneous version was observed in pregnancies with a cephalic-cephalic presentation (7%). All other presentations were relatively unstable. Neither the patients' parity nor the presence of birth weight discordancy, the placental location, or the amniotic fluid volume had a significant association with the incidence of spontaneous version., Conclusion: These data should be incorporated into the routine antepartum counseling of patients with twin gestation. Their use in this capacity may result in a decreased cesarean delivery rate if clinicians realize that malpresentations may spontaneously resolve before the onset of labor.