January 2005 CCC Corner > From Your Colleagues

From Your Colleagues:

Burt Attico, Phoenix

Smoking During Pregnancy Tied to Gestational Diabetes Risk
Mean plasma glucose concentrations increased by 0.5 mg/dL for each cigarette smoked per day.

Previous studies have linked smoking to the risk of type 2 diabetes, but the relationship between smoking and diabetes remains unclear.  If the association between smoking and gestational diabetes mellitus is causal, the researchers write, "then 47% of gestational diabetes mellitus in smokers and 10% in all women in our study population could potentially be attributed to tobacco exposure."…"smoking may be an important modifiable risk factor for gestational diabetes mellitus."  England LJ, et al. Glucose tolerance and risk of gestational diabetes mellitus in nulliparous women who smoke during pregnancy. Am J Epidemiol. 2004 Dec 15;160(12):1205-13.            http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15583373

VBAC Backlash: Why are hospitals forbidding women who have had C-sections the right to have vaginal births? By David Dobbs     http://slate.msn.com/id/2111499/

Donna Brown, Anchorage

Hand foot and mouth disease in pregnancy

Q. How does one manage possible exposure to hand foot and mouth disease in pregnancy?

A. With reassurance, unless the mother has a febrile illness during the last week of pregnancy.

Hand, foot, and mouth syndrome — The hand, foot, mouth syndrome (HFM) is a common acute illness, affecting mostly children, which is characterized by fever, oral vesicles on the buccal mucosa and tongue, and peripherally distributed small, tender cutaneous lesions on the hands, feet, buttocks and (less commonly) genitalia. The group A coxsackieviruses are recovered most often from hand-foot-mouth syndrome patients.

The illness usually resolves in two to three days without complication. Concomitant central nervous system (CNS) disease may occur when HFM syndrome is caused by enterovirus 71.

Pregnancy — Enterovirus infections in pregnant women do not readily cross the placenta and cause fetal disease, nor is there an association with miscarriage or preterm birth. However, rare cases of intrauterine fetal death (from echoviruses or coxsackieviruses) and severe maternal abdominal pain suggestive of abruption have been reported. Vertical transmission is much more likely to occur in the perinatal period. There is no strong evidence that maternal enterovirus infections cause congenital malformation even though a few reports have suggested a possible relationship with certain anomalies.

Neonatal infections — Most newborns with life-threatening enterovirus disease acquire the infection from a symptomatic mother in the perinatal period; approximately 60 to 70 percent of women who bear infected infants have a febrile illness during the last week of pregnancy. Ample experimental evidence indicates that the fetus is relatively protected during maternal infection by the placenta, but the newborn has a high risk of infection, perhaps as a result of exposure to either virus-positive cervical secretions or viremic maternal blood.

UpToDate

Clinical manifestations and diagnosis of enterovirus infections

http://www.uptodateonline.com/application/topic.asp?file=viral_in/13577&type=A&selectedTitle=1~4

Editorial Comment: George Gilson

That's as much info as is available to my knowledge, really just case reports mostly, and maternal reassurance is best.

Terry Cullen, Tucson

IHS prenatal assessment form - ETOH, tobacco, substances, DV, other home issues

This IHS form (for identifying potentially at risk women of childbearing age) is far superior to any form that is currently being used (e.g. CAGE) for this purpose. Aberdeen Area is implementing the form area wide.  Assess - ETOH, tobacco, substances, DV, other home issues. This may be a good activity for an FAS/D initiative – to go with the new GPRA indicator 11.

http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#ETOH

George Gilson, Anchorage

Q. Which fetal heart rate and contraction patterns are worrisome with misoprostol use?

A. The hyperstimulation syndrome is worrisome and contraindicates further use of the drug.  

     See Below

There are 3 types of uterine contraction patterns associated with misoprostol use, only one of which is worrisome:

1) tachysystole refers to the occurrence of more than 7 uterine contractions in any 15 minute monitoring window,

2) hypertonus refers to 2 or more uterine contractions lasting more than 120 seconds in any 15 minute monitoring window,  

3) the hyperstimulation syndrome refers to any instance of 1) or 2) accompanied by a nonreassuring fetal heart tracing (i.e., tachycardia, decreased variability, repetitive variables or lates).

Only the hyperstimulation syndrome is worrisome and contraindicates use of the drug for further attempts at ripening or induction. It's incidence in most studies is usually under 5%. Tachysystole in early labor after use of misoprostol is a common finding and is usually not a cause of either maternal discomfort or fetal intolerance of the process, and does not contraindicate further usage. See also:

UpToDate: Induction of labor: Indications, techniques, and complications

http://www.uptodateonline.com/application/topic.asp?file=labordel/8409&type=A&selectedTitle=4~32

Steve Holve, Tuba City

Oral Rehydration Solution: 5 articles – January Indian Child Health Notes

The development of ORS has probably saved more lives worldwide than any other medical device in the past 30 years. It was rapidly adopted overseas but there was initial resistance to its use in the United States. Much of the resistance was based on the assumption that intravenous fluid (more sophisticated and intensive technology) must be better than something so simple as drinking salt and sugar water. Numerous studies in the past thirty years have shown not only the safety, but the superiority of ORS over intravenous therapy except in cases of severe diarrhea or children with decreased levels of consciousness.

The CDC article is a great summary for anyone not familiar with ORS; its development, scientific rationale and clinical use. I would like to point out that much of the early work on the use of ORS in this country was done by Dr. Matu Santosham of Johns Hopkins University. Much of his work was done with the Indian Health Service on the Whiteriver Apache reservation in Arizona. Dr. Santosham has also done many other studies of tremendous benefit to American Indians and Alaskan Natives through his work on development of vaccines against Hemophilus influenza type B and pneumococcus               http://www.ihs.gov/MedicalPrograms/MCH/C/documents/PedNotes0105.doc

Chuck North, Albuquerque

Serving Native American Communities

….the University of South Dakota School of Medicine and University of New Mexico Health Sciences Department of Family Medicine have a central focus of reducing health disparities, especially for the American Indian population. This work is done through medical student rotations in preventive medicine, obstetrics-gynecology, and community health at IHS clinics and hospitals, medical student research projects addressing tribal and IHS priorities, faculty research and service grants/contracts with tribes, and an epidemiology contract through the Center for Rural Health Improvement with the Aberdeen Area IHS. Medical student projects include helping a tribe develop its own cancer plan, conducting a research survey of IHS provider screening habits and training needs for domestic violence, and a follow-up project the next year that provides ACOG domestic violence screening training CME to IHS providers. Department faculty and residents provide community lectures on educational opportunities in medicine and the health sciences to students in the communities where they work.

Like politics, health care is inherently a local issue, and the needs and concerns of local groups are as varied as the groups themselves. Academic departments must adapt to the local environment, build on local strengths, and respond to local needs. The programs described here represent only a small part of the diversity of departmental programs, but they are models of how departments have responded to their local conditions and built programs and systems that reach out to, collaborate with, and help those we seek to serve.

Burns, EA, North, C, Patrick, S. Serving Native American Communities Annals of Family Medicine 3:93- (2005) http://www.annfammed.org/cgi/content/full/3/1/93

Lori de Ravello, Albuquerque

National Summit on Preconception Care

JUNE 21-22, 2005, Atlanta, Georgia, Mark your calendar!

Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR), the March of Dimes, and others http://www.signup4.net/Public/ap.aspx?EID=NATI14E

Summer Institute in Reproductive and Perinatal Epidemiology, July 10-16, 2005

Participants will be given a travel stipend (up to $1,500 provided by IHDCYH); room and board also will be covered. Subjects to availability, up to 20 qualified students will be selected. Graduate students, postdoctoral and clinical fellows interested in a research career in reproductive or perinatal epidemiology are invited to apply. All documents must be received by March 1, 2005. 

Gwendoline Simard, course coordinator, gsimard@cihr-irsc.gc.ca  or Phone 613-941-0424

Judy Thierry, HQE

Birth Simulator for Shoulder Dystocia - Rubin's maneuver requires the least traction

Without expeditious and appropriate management, both mother and fetus are at risk for injury, even death. Up to 27% of shoulder dystocia deliveries are associated with brachial plexus palsy, of which 10% are permanent. A novel birth simulator designed by biomedical engineers at Johns Hopkins University in Baltimore, Maryland, helps identify the least traumatic delivery procedure for shoulder dystocia and other problem deliveries and assists in physician training. See details below    Conclusion:  In a laboratory model of initial maneuvers for shoulder dystocia, anterior Rubin's maneuver requires the least traction for delivery and produces the least amount of brachial plexus tension. Further study is needed to validate these results clinically.

Gurewitsch ED et al Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: An objective evaluation. Am J Obstet Gynecol. 2005 Jan;192(1):153-60.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672018

or           http://www.medscape.com/viewarticle/496721?src=search

OB/GYN CCC Editorial comment:

Shoulder dystocia is rare, but can be a devastating problem. Timely application of known maneuvers can reverse the problem instantly.  I recommend everyone who provides obstetric care, directly or indirectly, complete the Advanced Life Support in Obstetrics Course (ALSO) at least every 5 years.               http://www.ihs.gov/MedicalPrograms/MCH/M/PR01.cfm#AdvancedLifeSupport

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OB/GYN

Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.