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Maternal Child

Maternal Child Health ‹ CCC Corner ‹ September 2007
OB/GYN CCC Corner - Maternal Child Health for American Indians and Alaska Natives

Volume 5, No. 8, September 2007

Abstract of the Month | From Your Colleagues | Hot Topics | Features   

Features

American College of Obstetricians and Gynecologists

Prevention of Deep Vein Thrombosis and Pulmonary Embolism

Summary of Conclusions and Recommendations

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

  • Alternatives for thromboprophylaxis for moderate-risk patients include the following:
    1. Graduated compression stockings placed before initiation of surgery and continued until the patient is fully ambulatory
    2. Pneumatic compression devices placed before the initiation of surgery and continued until the patient is fully ambulatory
    3. Unfractionated heparin (5,000 units) administered subcutaneously 2 hours before surgery and every 12 hours after surgery until discharge
    4. Low molecular weight heparin (dalteparin 2,500 antifactor-Xa units, or enoxaparin 40 mg) administered subcutaneously, 12 hours before surgery and once a day postoperatively until discharge
  • Alternatives for prophylaxis for high-risk patients undergoing gynecologic surgery include the following:
    1. Pneumatic compression devices placed before surgery and continued until hospital discharge
    2. Unfractionated heparin (5,000 units) administered subcutaneously 2 hours before surgery and every 8 hours postoperatively and continued until discharge
    3. Low molecular weight heparin (dalteparin 5,000 antifactor-Xa units or enoxaparin 40 mg) administered subcutaneously, 12 hours before surgery and once daily postoperatively until discharge

The following recommendations are based on limited scientific evidence (Level C).

  • Alternatives for prophylaxis for highest-risk patients include the following:
    1. Combination prophylaxis (such as the combination of pneumatic compression and either low-dose unfractionated heparin or low molecular weight heparin)
    2. Consideration of continuing low molecular weight heparin prophylaxis as an outpatient for up to 28 days postoperatively
  • If administration of low molecular weight heparin 12 hours before surgery is impractical, initial dosing should commence 6–12 hours postoperatively.
  • Low-risk patients who are undergoing gynecologic surgery do not require specific prophylaxis other than early ambulation.
  • Until more evidence is accumulated, patients undergoing laparoscopic surgery should be stratified by risk category (and provided prophylaxis) similar to patients undergoing laparotomy.

Prevention of Deep Vein Thrombosis and Pulmonary Embolism. ACOG Practice Bulletin No. 84. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:429-40.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666620

Sexual Misconduct

ABSTRACT: The physician-patient relationship is damaged when there is either confusion regarding professional roles and behavior or clear lack of integrity that allows sexual exploitation and harm. Sexual contact or a romantic relationship between a physician and a current patient is always unethical, and sexual contact or a romantic relationship between a physician and a former patient also may be unethical. The request by either a patient or a physician to have a chaperone present during a physical examination should be accommodated regardless of the physician's sex. If a chaperone is present during the physical examination, the physician should provide a separate opportunity for private conversation. Physicians aware of instances of sexual misconduct have an obligation to report such situations to appropriate authorities.

Sexual Misconduct. ACOG Committee Opinion No. 373. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:441-4

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666621

Nalbuphine Hydrochloride Use for Intrapartum Analgesia

ABSTRACT: Nalbuphine hydrochloride (formerly marketed as Nubain) is a synthetic opioid agonist– antagonist analgesic commonly used for intrapartum analgesia. Concerns for fetal safety have been raised by one pharmaceutical company that no longer manufactures this agent ( www.fda.gov/medwatch/safety/2005/aug_PI/Nubain_PI.pdf). To date there are insufficient data to support these concerns or to recommend any change in the administration of this medication for analgesia in labor .

Nalbuphine Hydrochloride Use for Intrapartum Analgesia. ACOG Committee Opinion No. 376. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:449.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666624

Expert Testimony

ABSTRACT: It is the duty of obstetricians and gynecologists who testify as expert witnesses on behalf of defendants, the government, or plaintiffs to do so solely in accordance with their judgment on the merits of the case. Obstetrician–gynecologists must limit testimony to their sphere of medical expertise and must be prepared adequately. They must make a clear distinction between medical malpractice and medical maloccurrence. The acceptance of fees that are greatly disproportionate to those customary for professional services can be construed as influencing testimony given by the witness, and it is unethical to accept compensation that is contingent on the outcome of litigation.

Expert Testimony. ACOG Committee Opinion No. 374. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:445–6

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666622

Brand Versus Generic Oral Contraceptives

ABSTRACT:The U.S. Food and Drug Administration considers generic and brand name oral contraceptive (OC) products clinically equivalent and interchangeable. The American College of Obstetricians and Gynecologists supports patient or clinician requests for branded OCs or continuation of the same generic or branded OCs if the request is based on clinical experience or concerns regarding packaging or compliance, or if the branded product is considered a better choice for that individual patient.

Brand Versus Generic Oral Contraceptives. ACOG Committee Opinion No. 375. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:447–8 .

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666623

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American Family Physician**

Screening and Treatment for Sexually Transmitted Infections in Pregnancy

Many sexually transmitted infections are associated with adverse pregnancy outcomes. The Centers for Disease Control and Prevention recommends screening all pregnant women for human immunodeficiency virus infection as early as possible. Treatment with highly active antiretroviral therapy can reduce transmission to the fetus. Chlamydia screening is recommended for all women at the onset of prenatal care, and again in the third trimester for women who are younger than 25 years or at increased risk. Azithromycin has been shown to be safe in pregnant women and is recommended as the treatment of choice for chlamydia during pregnancy. Screening for gonorrhea is recommended in early pregnancy for those who are at risk or who live in a high-prevalence area, and again in the third trimester for patients who continue to be at risk. The recommended treatment for gonorrhea is ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Hepatitis B surface antigen and serology for syphilis should be checked at the first prenatal visit. Benzathine penicillin G remains the treatment for syphilis. Screening for genital herpes simplex virus infection is by history and examination for lesions, with diagnosis of new cases by culture or polymerase chain reaction assay from active lesions. Routine serology is not recommended for screening. The oral antivirals acyclovir and valacyclovir can be used in pregnancy. Suppressive therapy from 36 weeks' gestation reduces viral shedding at the time of delivery in patients at risk of active lesions. Screening for trichomoniasis or bacterial vaginosis is not recommended for asymptomatic women because current evidence indicates that treatment does not improve pregnancy outcomes. Am Fam Physician 2007;76:265-70, 272.

http://www.aafp.org/afp/20070715/265.html (see Patient Education)

Recommendations for Preconception Care

Every woman of reproductive age who is capable of becoming pregnant is a candidate for preconception care, regardless of whether she is planning to conceive. Preconception care is aimed at identifying and modifying biomedical, behavioral, and social risks through preventive and management interventions. Key components include risk assessment, health promotion, and medical and psychosocial interventions. Patients should formulate a reproductive life plan that outlines personal goals about becoming pregnant based on the patient's values and resources. Preconception care can be provided in the primary care setting and through activities linked to schools, workplaces, and the community. Am Fam Physician 2007;76:397-400

http://www.aafp.org/afp/20070801/397.html

Turner Syndrome: Diagnosis and Management

Turner syndrome occurs in one out of every 2,500 to 3,000 live female births. The syndrome is characterized by the partial or complete absence of one X chromosome (45,X karyotype). Patients with Turner syndrome are at risk of congenital heart defects (e.g., coarctation of aorta, bicuspid aortic valve) and may have progressive aortic root dilatation or dissection. These patients also are at risk of congenital lymphedema, renal malformation, sensorineural hearing loss, osteoporosis, obesity, diabetes, and atherogenic lipid profile. Patients usually have normal intelligence but may have problems with nonverbal, social, and psychomotor skills. Physical manifestations may be subtle but can include misshapen ears, a webbed neck, a broad chest with widely spaced nipples, and cubitus valgus. A Turner syndrome diagnosis should be considered in girls with short stature or primary amenorrhea. Patients are treated for short stature in early childhood with growth hormone therapy, and supplemental estrogen is initiated by adolescence for pubertal development and prevention of osteoporosis. Almost all women with Turner syndrome are infertile, although some conceive with assisted reproduction. Am Fam Physician 2007;76:405-10 http://www.aafp.org/afp/20070801/405.html

Varenicline (Chantix) for Smoking Cessation

Varenicline (Chantix) is a selective alpha4-beta2 neuronal nicotinic acetylcholine receptor partial agonist approved as an aid to smoking cessation therapy. This receptor is believed to play a significant role in reinforcing the effects of nicotine and in maintaining smoking behaviors. The agonist effect of varenicline at the nicotinic receptor is approximately half that of nicotine, which may lessen craving and withdrawal without inducing dependence. In theory, stimulation of the nicotinic receptor by a partial agonist could provide enough stimulation to reduce craving and withdrawal while competitively blocking the binding of smoked nicotine.1,2 Varenicline represents a new approach to smoking cessation by mitigating some of the satisfying and reinforcing aspects of smoking.

Safety

Studies of more than 4,500 patients have established a favorable safety profile for varenicline, and there have been no reports of abuse or serious safety issues. Because varenicline is excreted by the kidney, the manufacturer recommends reducing the dosage in patients with impaired renal function. There are currently no known drug interactions, and the safety of varenicline used in combination with other smoking cessation therapies has not been established. Because smoking may alter the metabolism of some medications (e.g., warfarin [Coumadin], theophylline), dosing adjustments of other drugs the patient is receiving may need to be made upon smoking cessation.2 Varenicline is U.S. Food and Drug Administration pregnancy category C.

Tolerability

The most common adverse effect associated with varenicline is nausea, which occurs in about 30 percent of patients taking the maintenance dose. Although the nausea is not typically severe, it may persist for the duration of treatment in a small number of persons. Other common adverse effects that occur in more than 10 percent of patients include headache, insomnia, abnormal dreams, and flatulence. The rate of discontinuation because of side effects was 12 percent for patients receiving varenicline compared with 10 percent for patients receiving placebo.2

Effectiveness

Varenicline has been compared with placebo in five studies3-7 and with sustained-release bupropion (Wellbutrin SR) in three studies of healthy persons highly motivated to quit smoking.5-7 On average, patients had been smokers for 20 to 25 years and reported smoking approximately one pack per day. Most patients (approximately 90 percent) had tried to quit at least once.3-7 Based on these studies, about 20 percent of patients taking varenicline will be continuously abstinent from smoking one year after treatment compared with less than 10 percent of patients taking placebo. In other words, for approximately every nine patients treated with varenicline instead of placebo, one additional patient will remain abstinent for one year.3-7

Varenicline treatment seems to be as effective or more effective than treatment with sustained-release bupropion. Two studies found that treatment with varenicline had similar results to treatment with bupropion,5,7 and one study found better abstinence rates with varenicline at one year compared with bupropion (23.0 versus 14.6 percent, respectively).6

Varenicline has not been compared with nicotine replacement therapy or for use in combination with other smoking cessation therapies. Also, varenicline has not been studied in patients who use tobacco products other than cigarettes or in patients who have significant cardiopulmonary disease or psychological disorders.

Price

A one-month supply of varenicline will cost approximately $120 for the maintenance dose. This is more than the cost of generic sustained-release bupropion ($116) but less than the cost of Wellbutrin SR ($150). Patients who smoke one pack per day will spend an average of $130 per month on cigarettes.8

Simplicity

Varenicline is taken with a full glass of water twice daily after a meal. The initial dose is 0.5 mg once daily starting one week before the quit date and increased to 0.5 mg twice daily after three days. At the start of the second week, the dose is increased to 1 mg twice daily and continued for 12 weeks. If a patient relapses during the 12 weeks of therapy or after therapy is completed, he or she should be encouraged to make another attempt to quit once contributing factors have been identified and addressed. Patients unable to tolerate the side effects at the maintenance dose should have the dose lowered temporarily or permanently. Patients with pronounced renal dysfunction (creatinine clearance less than 30 mL per minute [0.5 mL per second]) should take half the usual dose.2

Bottom Line

For every nine highly-motivated patients who use varenicline instead of placebo, one will not be smoking one year later. Although the cost of therapy is a limitation (total cost is approximately $360 for a three-month course), the easy dosage titration, lack of drug interactions, and favorable side-effect profile make varenicline an appealing alternative to sustained-release bupropion for smoking cessation

http://www.aafp.org/afp/20070715/steps.html

CDC Publishes Statement on Cough and Cold Medications in Children

Cough and cold medications that contain expectorants, antihistamines, nasal decongestants, and cough suppressants are commonly used to treat symptoms of upper respiratory infection in children younger than two years. However, in 2004 and 2005 an estimated 1,519 children younger than two years were treated in U.S. emergency departments for adverse events associated with use of cough and cold medications. Although the U.S. Food and Drug Administration (FDA) has approved the use of cough and cold medications for children two years and older, no FDA-approved dosing recommendations exist for children younger than two years. Therefore, the Centers for Disease Control and Prevention (CDC) has released a statement on the risks of cough and cold medications in children younger than two years. The statement appears in the January 12, 2007, issue of Morbidity and Mortality Weekly Report.

Evidence of the effectiveness of cough and cold medications in children younger than two years is limited. Systematic reviews of controlled trials involving these medications conclude that they are no more effective than placebo in reducing symptoms of upper respiratory tract infection. Additionally, cough suppressants containing codeine (Robitussin AC) and dextromethorphan (Delsym) have not been proven effective, and their use could lead to potential adverse events in children younger than two years.

Health care professionals should advise parents against administering cough and cold medications to children younger than two years because of the risk of toxicity and the lack of dosing recommendations. As an alternative to pseudoephedrine (Sudafed) and other nasal decongestants, physicians should recommend clearing the child's nasal congestion with a rubber suction bulb or using saline nose drops or a cool-mist humidifier to soften secretions.

Health care professionals also should be aware of the risks of serious illness or fatal overdose in children younger than two years who have been given cough and cold medications. To avoid overdose, physicians should prescribe these medications with extreme caution and should inquire about additional over-the-counter medications the child is being given. Additionally, physicians should be certain that parents understand the importance of administering these medications only as directed and are aware of the risk of an overdose if the child is given additional medications with the same ingredients.

http://www.aafp.org/afp/20070715/practice.html

Common Problems in Endurance Athletes

Endurance athletes alternate periods of intensive physical training with periods of rest and recovery to improve performance. An imbalance caused by overly intensive training and inadequate recovery leads to a breakdown in tissue reparative mechanisms and eventually to overuse injuries. Tendon overuse injury is degenerative rather than inflammatory. Tendinopathy is often slow to resolve and responds inconsistently to anti-inflammatory agents. Common overuse injuries in runners and other endurance athletes include patellofemoral pain syndrome, iliotibial band friction syndrome, medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, and lower extremity stress fractures. These injuries are treated with relative rest, usually accompanied by a rehabilitative exercise program. Cyclists may benefit from evaluation on their bicycles and subsequent adjustment of seat height, cycling position, or pedal system. Endurance athletes also are susceptible to exercise-associated medical conditions, including exercise-induced asthma, exercise-associated collapse, and overtraining syndrome. These conditions are treatable or preventable with appropriate medical intervention. Dilutional hyponatremia is increasingly encountered in athletes participating in marathons and triathlons. This condition is related to overhydration with hypotonic fluids and may be preventable with guidance on appropriate fluid intake during competition. Am Fam Physician 2007;76:237-44

http://www.aafp.org/afp/20070715/237.html

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AHRQ

Women: Stay Healthy at Any Age, Your Checklist for Health

The Agency for Healthcare Research and Quality (AHRQ) now has available 2 evidence-based checklists designed to help men and women understand which medical checkup tests they need to stay healthy at any age. Each list uses the US Preventive Services Task Force (USPSTF) recommendations to inform patients about screening tests, preventive medicine, and other healthy lifestyle behaviors.

You can download these checklists for distribution to your patients, by clicking on:

Women: Stay Healthy at Any Age, Your Checklist for Health

http://www.ahrq.gov/ppip/healthywom.htm

Men: Stay Healthy at Any Age: Your Checklist for Health

http://www.ahrq.gov/ppip/healthymen.htm

Today's teen smokers are more likely to engage in risky behaviors than teens who smoked in the early nineties

http://www.ahrq.gov/research/jul07/0707RA3.htm

Inadequate communication of mammogram results may prevent women from fully benefiting from screening

http://www.ahrq.gov/research/jul07/0707RA6.htm

Prophylactic antibiotics given to prevent surgical site infections are more timely if given in the operating room

http://www.ahrq.gov/research/jun07/0607RA12.htm

While most diabetes drugs provide similar glucose control, some offer important advantages

http://www.ahrq.gov/research/jul07/0707RA1.htm

Mandatory limits on medical resident work hours may constrain hospital house staff and affect patient outcomes and resource use

http://www.ahrq.gov/research/jul07/0707RA18.htm

Incentives combined with peer counseling are a cost-effective way to get adolescents to adhere to a tuberculosis control program

http://www.ahrq.gov/research/jun07/0607RA8.htm

Better outpatient care processes can improve the quality of life for patients with chronic disease

http://www.ahrq.gov/research/jun07/0607RA11.htm

Risk factors can help predict which patients with hospital-acquired urinary tract infections will develop blood infections

http://www.ahrq.gov/research/jun07/0607RA16.htm

Rate of childbirth-related hospital stays decreases for girls under age 18

http://www.ahrq.gov/research/jun07/0607RA20.htm

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Ask A Librarian: Diane Cooper, M.S.L.S. / NIH

Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

A toolkit to help Native communities protect their children from the harm caused by drinking alcohol during pregnancy is now available from the Substance Abuse and Mental Health Services Administration.

The American Indian/Alaska Native/Native Hawaiian Resource Kit is designed to help mothers-to-be and their friends, relatives, health professionals, and leaders understand and prevent fetal alcohol spectrum disorders. FASD describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications.

Each year, at least 40,000 babies are born with an FASD in the United States, and Native communities have some of the highest rates. This new resource will support prevention and treatment efforts in American Indian, Alaska Native and Native Hawaiian communities.

The kit, which was developed and reviewed by representatives from Native communities and FASD experts, includes the following:

  • Current data and statistics on FASD
  • Fact sheets and brochures for women, men, youth and communities on how to prevent FASD and how to find help
  • Strategies for FASD education and prevention
  • Posters that can be copied and shared
  • FASD--The Basics , a slide presentation for people with no prior knowledge of or experience with FASD
  • A CD with an electronic version of the entire resource kit

The American Indian/Alaska Native/Native Hawaiian Resource Kit is available on the Web at http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702.

Copies may be obtained free of charge by calling SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request inventory number SMA07-4264.

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Breastfeeding - Suzan Murphy, PIMC

Progress toward achieving Healthy People 2010 objective for breastfeeding

Further research is needed to identify successful programs and policies to support exclusive breastfeeding, especially among subgroups with the lowest rates. Healthy People 2010 objectives for breastfeeding initiation and duration were updated in 2007 to include two new objectives on exclusive breastfeeding: (1) to increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60% and (2) to increase the proportion of mothers who exclusively breastfeed their infants through age 6 months to 25%.

The authors found that

* Among infants born in 2000, breastfeeding rates for the early postpartum period, 6 months, and 12 months were 70.9%, 34.2%, and 15.7%, respectively. For infants born in 2004, these rates had consistently increased to 73.8%, 41.5%, and 20.9%, respectively.

* Based on the revised questions, rates for exclusive breastfeeding through ages 3 and 6 months were 30.5% and 11.3%, respectively, among infants born in 2004.

* Disparities were observed in rates of exclusive breastfeeding among infants born in 2004. Rates of exclusive breastfeeding through age 3 months were lowest among black infants (19.8%) and among infants of mothers ages 19 and younger (16.8%), those who had a high school education or less than a high school education (22.9% and 23.9%, respectively), those who were unmarried (18.8%), those who resided in rural areas (23.9%), and those who had an income-to-poverty ratio of less than 100% (23.9%).

Scanlon KS , Grummer-Strawn L, Shealy KR, et al. 2007. Breastfeeding trends and updated national health objectives for exclusive breastfeeding: United States, birth years 2000-2004. MMWR Weekly 56(30):760-763 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a2.htm?s_cid=mm5630a2_e

Cup feeding not be recommended over bottle feeding as a supplement to breastfeeding

AUTHORS' CONCLUSIONS: Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.

Flint A, et al Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005092

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443570

Despite the benefits of early breastfeeding, many women find it unexpectedly difficult and painful http://www.ahrq.gov/research/may07/0507RA18.htm

New IHS Breast feeding Family Support web page: Have pictures to share?

When family and friends support breastfeeding,
it makes the challenges easier.
Your encouragement will touch a lifetime.

Tell mom that she is doing great.
Let dad know that his patience is beautiful.
Let the new family how proud you are of them.
Praise grandparents/aunts/uncles/cousins/friends
for their wonderful care and wisdom.

Give the new family a boost:

  • Tackle some household chores
  • Bring a meal over
  • Change some diapers
  • Make the trip to the grocery store
  • Give the baby a bath
  • Take the new siblings to the park
  • Read a book or watch TV with the new siblings
  • Keep mom resting, bring the baby to her

If you have pictures to share, please email them to suzan.murphy@ihs.gov

http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.cfm

What to do when Mom says, “My newborn likes the bottle better.”

Why does it happen?

In a normal, healthy newborn, bottle preference is usually from overuse of a bottle and/or pacifier. However, it is helpful to rule out unusual newborn issues that can effect sucking like a short frenulum or thrush.

What is the cause?

Formula or breast milk comes out of the bottle quickly, just a little tug. Also, the plastic nipple can rub the roof of the mouth, stimulating the suck. It is not much work for the baby - and there is no waiting for let down. It is easy. Breastfeeding takes more work. Often, but not always, a baby will begin to favor the bottle and avoid breastfeeding. Unfortunately, it is hard to know which baby will be influenced by frequent bottles/pacifiers.

In the first couple weeks, there is probably still time for the mom’s supply to bounce back. To get mom and baby back to breastfeeding:

Assure the mom that her baby is getting enough:

Have her count diaper changes - if her baby has least 6 in 24 hours, her baby is probably has an adequate intake.

Check her baby’s weight gain – ½ oz – 1 oz per day, 3.5 - 7 oz per week is normal

Tell the mom to breastfeed about 2 hours – 8 to 12 times in 24 hours. The baby’s suck muscles and mom’s milk supply will get up to speed together and the frequency will slow down within a couple days.

Discourage the “pump and feed” method – it has a near 100% burn out rate.

Tell the mom to praise her baby for sucking well. The baby knows mom’s happier voice and will respond appropriately.

Recommend less use of the bottle. If the bottle can be weaned down to once or twice a day, the mom’s milk supply will probably be protected. Less is best in the first 4-6 weeks.

Suggest that the pacifier be avoided – and saved for difficult times like car trips with screaming a baby or challenging moments.

If it looks like it really is a supply issue, or the “bounce back” is not happening, consider medication. Clinical studies indicate that metoclopromide can increase milk supply in difficult situations. For more information, refer to Thomas Hales’ text, Medications and Mother’s Milk or sources like the San Diego Breastfeeding Coalition web page.

If the baby won’t latch, refer the mom to WIC or a Lactation Consultant. It is OK to call us for over-the-phone-ideas at 1- 877-868-9473. It is toll-free - best times are 7 am – 10 pm, Mountain Standard Time.

What about extra fluids?

Clinical studies have not agreed with the common practice of encouraging fluids to increase milk supply. Unfortunately the studies were small, each with less than 30 participants, and did not correct for climate issues – such as excessive heat/cold, or the typical amount of outdoor exposure the mother experienced. So while encouraging water is a healthy practice, excessive fluids are not necessary. A reasonable recommendation is to keep water nearby and drink to thirst.

Please note: If it is believed that a specific (safe) beverage will help, it probably will. Confidence is a powerful tool with parenting, especially breastfeeding.

References

Dusdieker LB et al. Prolonged maternal fluid supplementation in breast-feeding. Pediatrics,

1990 Nov;86(5):737-40.

Morse JM et al. The effect of maternal fluid intake on breast milk supply: a pilot study.

Canadian Journal of Public Health, 1992 May-Jun;83(3):213-6.

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CCC Corner Digest

Nicely laid out hard copy - A compact digest of last month’s CCC Corner

Highlights include

- Within the Hidden Epidemic: STDs and HIV/AIDS Among AI/AN

- American Indian / Alaska Native population has the shortest timeline HIV to AIDS

- VBAC: Smaller attributable risk than previously reported

- LEEP doubles risk of preterm delivery: Patients need to be informed

- Physical Activity Alone May Not Reduce Obesity in Children

- Teratogenicity of SSRIs--serious concern or much ado about little?

- Management of Herpes in Pregnancy: Practice Bulletin

- Scopus ™: A New Database

- What to do when: Mom says, “My newborn likes the bottle better.”

- IHS-ACF DV Project: Conference CD: Patient Education, Safety Planning, etc….

- Waiting until the menses to start hormonal contraceptives: Needless Obstacle

- Can oral or sublingual misoprostol be used for postpartum hemorrhage?

- Integrated case management software application release

- Maternal survival redux: a view from Malawi - Failure of justice

- Who needs liquor stores when parents will do?

- Taking a harder line on blood transfusions

- Nausea and Vomiting in Pregnancy

- Hormone Replacement Therapy Linked to Ovarian Cancer 

- Midwifery’s approach to pre-labor SROM supported by professional organization’s journal

- The evolution of management of Actinomyces on a Pap report

- Health Care Without Harm: Nurses Take Action

- Preconception Health of Women Delivering Live-Born Infants — Oklahoma, 2000–2003

- Anemia in Pregnancy: The Common to the Unusual – including IV therapy

- Chronic Renal Disease: How is Primary Care Effected?

- Updated Screening for Chlamydial Infection Recommendations, USPSTF

- (How) can we prevent type 2 diabetes?

- Why do Native American women have the poorest 5-year survival for breast cancer?

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_07.pdf

If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc

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Domestic Violence – Denise Grenier, Rachel Locker

Sexual assault among American Indian/Alaska Native women

Colleagues:

The URL below will take you to the page on the National Public Radio website featuring their story on sexual assault that they featured last night on their news show “All Things Considered”.  

Contact Carolyn.Aoyama@ihs.gov

http://www.npr.org/templates/story/story.php?storyId=12203114

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Elder Care News

'What Older Women Want' launches new website for doctors and patients: New Website

Urinary incontinence, memory loss and exercise top the list of older women's unmet health needs and concerns

A Canadian study of older women's health needs and concerns published in the Canadian Medical Association Journal and reported widely in the media, has sparked a new website directed at both patients and health practitioners: www.wowhealth.ca

Known widely as 'WOW' or the 'What Older Women Want' study, conducted by Drs. Cara Tannenbaum, Nancy Mayo and Francine Ducharme, the study asked 5000 older women across Canada which of their health needs they felt were not being met or addressed adequately by their health practitioners.

Their answers surprised many in healthcare provision, since the key topics the women highlighted were not concerned so much with critical care concerns or disease treatment, but primary care and disease prevention.

Among the top unmet concerns Canadian senior women mentioned were: screening and treating urinary incontinence; counselling about memory loss (or perceived memory loss); and exercise strategies to address falls and functional decline.

"Women were very satisfied with the care they were receiving to treat their blood pressure and prevent heart attacks and stroke, but emphasized gaps in care surrounding more 'taboo' issues, such as discussing urine or memory loss," says Dr. Tannenbaum, a Geriatrician at the Institut universitaire de gériatre de Montréal, and lead author of the WOW study.

"It may be that women are uncomfortable talking about these issues with their physicians because it is embasrassing, because they believe it is a part of normal aging or because they are unaware that treatments exist."

In order to address this gap in primary health provision and give older women what they want, Dr. Tannenbaum teamed up with the Canadian Women's Health Network and the Centre de recherche de l'Institut universitaire de gériatrie de Montréal to create the WOW website.

The website contains a portal for health consumers that provides health information on the three unmet health needs of older Canadian women:

urinary incontinence, memory loss and exercise. The information is clear, straight-forward and easy-to-read, with engaging illustrations and diagrams. The focus is on prevention, with tips on diet, lifestyle changes and exercise; treatment options are also provided.

But the onus is not left only up to older women to seek and address their own health needs. The WOW website also has a portal for health practitioners, outlining the kinds of questions that practitioners should be asking their older female patients routinely, and the ways in which they can provide prevention and improvement strategies to their patients for urinary incontinence, memory loss, as well as the particular exercise needs of older women.

"When asked, clinicians admitted that they often do not pursue these issues because there is rarely enough time during the medical visit and they often get the impression that their patients are reluctant to talk about it," states Dr. Tannenbaum. "That is why it is so important that we get the message out that something like urinary incontinence can be effectively treated in up to 75% of patients with simple behavioural techniques, and that clinicians should routinely screen for it."

"The goal with the WOW website was to find an effective means to translate the research we have done on older women's health concerns into tangible results. We want women to be able to articulate their needs and clinicians to learn what questions they ought to be asking," Dr.

Tannenbaum adds.

The WOW website is the essential first step to make sure that older women's unmet health needs and concerns are present in health care provision, and communicated in ways that both senior women and their health practitioners can understand.

For full study details on the What Older Women Want study, visit:

www.wowhealth.ca/pdf/wowCMAJ.pdf

Tannenbaum C , Mayo N , Ducharme F . Older women's health priorities and perceptions of care delivery: results of the WOW health survey. CMAJ. 2005 Jul 19;173(2):153-9.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16027431

A fall management program in nursing homes improves care and reduces use of physical restraints

http://www.ahrq.gov/research/jun07/0607RA10.htm

Certain resident and facility characteristics and medications increase the risk of fractures among nursing home residents

http://www.ahrq.gov/research/jul07/0707RA7.htm

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Family Planning

Various Implantable Contraceptives Equally Effective in Preventing Pregnancy

CONCLUSIONS: Implanon, Norplant and Jadelle are highly effective contraceptive methods. No significant differences were found in contraceptive effectiveness or continuation. The most common side-effect with all implants was unpredictable vaginal bleeding. Time taken for removal of Implanon and Jadelle was less than that for Norplant.Although this systematic review was unable to provide a definitive answer on relative effectiveness, tolerability and acceptability of contraceptive implants in comparison to other contraceptive methods, it has raised issues around the conduct of contraceptive research.

Power J, French R, Cowan F. Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy.

Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001326

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636668

Oral Contraceptives Today: Changes, Challenges, Risks, and Benefits: Medscape CME

http://www.medscape.com/viewprogram/7384?src=mp

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Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator

New Online Training Tool Available for Treatment of Adolescents with HIV

A new online training program developed for health care providers entitled Treating Adolescents with HIV: Tools for Building Skills in Cultural Competence, Clinical Care, and Support will be launched Monday, July 23. Continuing education credits are available for participating in this training which can be accessed at www.hivcareforyouth.org

This project is supported by the Department of Health and Human Services' Health Resources and Services Administration's HIV/AIDS Bureau. The series begins, and is framed, by an introductory module covering best practices in adolescent care and the impact of the AIDS epidemic on minority youth. The four additional modules in this series: Psychosocial Issues, Antiretroviral Treatment and Adherence, Transitioning Care, and Prevention with Positives address core issues in HIV care for adolescents. The expert authors and editors come from diverse clinical settings around the country, and present course information from the perspective of a culturally aware care provider. Throughout the course, practical tools are provided to assist with "operationalizing" culturally sensitive best practices in the clinic setting.

http://hab.hrsa.gov/

From Lori de Ravello Lori.deRavello@ihs.gov

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Frequently asked questions

Moderate morning sickness only partially responding to doxylamine and pyridoxine

QUESTION One of my patients suffers from a moderate-to-severe form of morning sickness. She responded only partially to doxylamine and pyridoxine, and I wish to try adding another medication. What should my priority be?

ANSWER
An algorithm used by Motherisk to manage thousands of patients takes a hierarchical approach to this condition. This approach is evidence based with regard to fetal safety as well as efficacy. (Go to ‘algorithm used by Motherisk’ and scroll down page to see algorithm, link below)

Nausea and vomiting of pregnancy (NVP) affects an estimated 80% of all pregnant women, making it the most common medical condition during pregnancy. In most cases, symptoms are worse in the morning; severity usually peaks by 8 to 12 weeks' gestation. Some women are affected throughout the day, and the condition sometimes continues beyond the first trimester and even until the birth.

Hyperemesis gravidarum is the most severe form of morning sickness, affecting 0.05% to 1% of pregnant women. Hyperemesis gravidarum is characterized by dehydration and electrolyte imbalance, and might require hospitalization. Nausea and vomiting of pregnancy has serious detrimental effects on the lives of women, even those with a milder presentation. Termination of otherwise wanted pregnancies among women suffering from severe and prolonged NVP has been reported.

Inappropriate treatment common
Ample evidence indicates that most women with NVP do not receive appropriate pharmacologic or nonpharmacologic treatment for the condition. In 1996, the Motherisk Program in Toronto, Ont, initiated the NVP Healthline (1-800-436-8477) to counsel and support women and health professionals in managing NVP. Members of Motherisk systematically review available data on treatment in an attempt to obtain the best available evidence on efficacy and safety. Callers and clinic patients are advised on both pharmacologic and nonpharmacologic management.

This paper provides clinicians with a simple evidence-based algorithm on the efficacy and safety of treatments for NVP.

Rationale
In planning and evaluating management of NVP, fetal safety is clearly the primary concern, followed by efficacy. This order of priorities dictates that, in general, older medications, for which there are more data on fetal safety, are preferred over newer, perhaps more effective, drugs for which there are as yet fewer data on safety.

Methods

The algorithm is based on a recent systematic review of the literature on safety and efficacy of management of NVP conducted by members of the Motherisk Team. The course of NVP ranges in severity, length, and response to treatment. We addressed treatment of NVP in a decision tree (Figure 1, at link below) It begins with pharmacologic management of relatively mild cases and progresses to treatment of patients who cannot tolerate oral treatment or are dehydrated, or both. At any stage of the algorithm, physicians can add or, when there is improvement, withdraw treatment. The systematic review included meta-analyses whenever the data permitted.

The quality of the evidence on fetal safety and maternal efficacy varies. There is large and convincing evidence on the safety and efficacy of doxylamine and pyridoxine (Diclectin). Evidence on the safety of other H1 blockers is as strong, but evidence of efficacy is less strong. Many studies on the efficacy of phenothiazines offer convincing evidence, but the number of studies on safety is much smaller (birth defects are generally rare). Evidence on the safety and efficacy of ondansetron and metoclopramide is preliminary.

The hierarchy presented in the algorithm is based on the strength of evidence for fetal safety, and only treatments shown to be efficacious were included. It has been used by the Motherisk Program for treating a large number of patients.

Levichek Z et al Nausea and vomiting of pregnancy: Evidence-based treatment algorithm Canadian Family Physician 2002;48:267-8,277.

http://www.motherisk.org/prof/updatesDetail.jsp?content_id=348

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Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant

September 2007

-First time that prophylaxis for infective endocarditis has been written using evidenced based guidelines. The difference is significant.

-RPMS Immunization Package: Version 8.2 coming this summer

-Substance abuse in Native American communities. It is no secret that substance abuse poses a serious threat to the health of children, youth, families, and communities all across the nation.

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN907.doc

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Information Technology

Save 750 mega watts/hour per year: It is easy

If Google had a black screen, taking in account the huge number of page views, according to calculations, 750 mega watts/hour per year would be saved.

In response, Google created a black version of its search engine, called Blackle, with the exact same functions as the white version, but with lower energy consumption:   http://www.blackle.com/

iCare Training

The IHS Office of Information Technology is pleased to continue offering WebEx training for the new iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.

iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).

There are two types of training offered:

  • iCare Technical Overview
  • iCare – Nuts and Bolts

The target audience is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)

NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all, however, space is limited so be sure to register right away. Below are the agendas and date/times for both classes. It is recommended that you attend them sequentially.

Each session is limited to 30 participants.   Therefore, if there is a group of people who would like to attend at your facility, our recommendation is that you attend as a group and have only one person register for the session.  For the group, you will need a conference room, conference phone, computer and projector.  Please ensure someone at your facility is responsible for taking care of these arrangements.

Please note this is a live, internet-based training, not a recorded session, and people will be able to ask questions and actively participate in the class.

NOTE:  All training times shown above are for the Pacific Daylight Time zone.  Please ensure you adjust the time for your particular time zone.

Training Schedule

  • iCare – Nuts and Bolts

Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)

Agenda

  • Introductions and Context
  • Set Up and Background (Server) Processes
  • Establishing and Changing User Preferences
  • Panel Creation
  • Panel Modification
  • Flags
  • Diagnostic Tags
  • National Performance Measures
  • Patient Record
  • Question and Answer Session
Session Date and Time   Reg Password
iCare Nuts and Bolts Mon 07/16/2007 12:00-14:00 PDT coyote
  Tue 07/31/2007 11:00-13:00 PDT coyote
  Thur 08/23/2007 09:00-11:00 PDT coyote
  Mon 08/27/2007 13:30-15:30 PDT coyote
  Fri 09/14/2007 10:30-12:30 PDT coyote
  • The Practical Use of iCare

Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)

Agenda

  • Introductions and Context
  • Scenarios
  • Tips
  • Using the Performance Measure views to improve outcomes
  • Questions and Answers
Session Date and Time   Reg Password
The Practical Use of iCare Wed 07/18/2007 09:00-10:30 PDT coyote
  Thur 08/02/2007 09:30-11:00 PDT coyote
  Fri 08/24/2007 10:00-11:30 PDT coyote
  Thur 08/30/2007 12:00-13:30 PDT coyote
  Wed 09/19/2007 11:00-12:30 PCT coyote

Registration Information

  • Click this link:https://ihs-training.webex.com/
  • At the Search For box, type in "iCare" (do not type in the quotation marks) and click the Go button.  NOTE:  If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window, immediately under “webex.”
  • All of the scheduled sessions will then be displayed in the window below.  Choose the one you want to attend and click “Registration” in the Status column.
  • Enter the Registration password that is shown above that corresponds to the class you want to attend.
  • Click the OK button.
  • Complete the registration form.
  • Click the Register button.
  • A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session.  Click the OK button to finish.

Setup (Software Install) Information:

You must have the WebEx software installed on your computer prior to attending the WebEx session.  You should setup the software at least a day before the training session.  You should not need anyone such as the Site Manager to install it for you.  Below are the instructions.

  • On the left side of the window, click Set Up.
  • Immediately under Set Up you will see two options:  Training Manager, Preferences.
  • Click Training Manager.
  • A message is displaying giving you information about the setup process. Click the Set Up button.
  • After the software is installed, click the OK button.

Attending the Session:

When you are ready to attend the session, connect to the WebEx session first using the information contained in your registration confirmation e-mail and then connect to the conference line.  The dial information for the conference line is shown below and is also included in your registration confirmation message.

Phone Number: (877) 781-4791

Passcode: 135963#

Questions? Contact Cynthia Gebremariam at Cynthia.Gebremariam@ihs.gov

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International Health Update: Claire Wendland, Madison, WI

Sex, Soap & Social Change - The Sabido Methodology

As anyone who’s gotten seriously hooked on a TV drama knows, viewers can start thinking of fictional characters as real, even as friends. Health educators worldwide take advantage of this response by using serial dramas – soap operas – to reach diverse audiences with behavior-change messages through what has come to be called the “Sabido method.” Miguel Sabido, a Mexican TV executive in the 1970s, built on the social learning theory of Albert Bandura to produce telenovelas encouraging Mexican couples to use contraception. Sabido’s key insight was that television characters could be role models, allowing viewers to learn vicariously from the troubles and successes of others. To work, the shows had to be entertaining, and the audience had to become attached to the characters.

Acompaname, “Come Along,” was Sabido’s first serial drama to address health. It spared viewers none of the drama for which soaps are famous: infidelities, amnesia, unwanted pregnancies. Among the suffering heroines and evil villains, however, was Martha, the “transitional character” with whom the audience was meant to identify – a fallible but likeable protagonist who envied her sister’s small and happy family, and feared sharing the fate of her mother, burdened with too many children and not enough resources. As Martha and her husband tentatively began to use family planning, many of the members of her audience did too. Sales of over-the-counter contraceptives rose nearly twenty-five percent the first year the show was on the air, and there is evidence suggesting that Acompaname and Sabido’s next four telenovelas were important factors in the 34% drop in Mexico’s population growth rate over the next few years.

Fine-tuning the shows through audience research is an important part of their design. Wila Kasta (an Aymara-language radio show in Bolivia focused on HIV/AIDS and condom use) initially made the mistake of putting prevention messages in the mouth of a Western-trained doctor character. Though handsome, musical, and powerful, he was a far less popular character than anticipated. The show fared better, and the audience paid greater attention, when the same messages came through a grandmother midwife.

The formula for producing such dramas was exported by the mid-1980s, and serial dramas intended to create social change have hit the airwaves in a hundred countries, from Ethiopia (where the radio drama Yeken Kignit, “Journey of Life,” is credited with tripling HIV-testing rates among listeners) to India (where the musical soap Tinka Tinka Sukh, “Happiness Lies in Small Pleasures,” convinced at least one village to abolish the dowry system) to Burma (where the military junta has made listening to a shortwave drama on health and civil engagement a treasonous offence). They have addressed topics from literacy to agricultural techniques to women’s rights to condom use. In the twenty-first century, the urgent need to interrupt the HIV epidemic has spawned even more shows.

Do they work? It is very difficult to distinguish correlation from causation, and to some extent the jury is still out. After all, people who own a television or radio may also be better off, more comfortable with Western lifestyles, and already more likely to use a condom or get an HIV test than those who don’t. What little evidence there is, however, suggests an effect greater than that seen in more traditional public health campaigns. Perhaps it’s time to try the Sabido method in the US?

  • Readers looking for more can find an overview in Global Health Watch at http://www.globalhealth.org/reports/ – click on “Sex, Soap & Social Change - The Sabido Methodology.”
  • The best available summary of evidence on these programs’ efficacy is an open-access article from http://her.oxfordjournals.org – Bertrand JT, O’Reilly K et al. Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries. Health Education Research 21(4):567-597, 2006
  • Interested in making a serial drama for your own community? You can download a step-by-step guide free from the United Nations Population Fund at http://www.unfpa.org/upload/lib_pub_file/538_filename_training_guide.pdf

Other

Association of arsenic exposure during pregnancy with fetal loss and infant death: a cohort study in Bangladesh.

The authors evaluated the effect of arsenic exposure on fetal and infant survival in a cohort of 29,134 pregnancies identified by the health and demographic surveillance system in Matlab, Bangladesh, in 1991-2000. Arsenic exposure, reflected by drinking water history and analysis of arsenic concentrations in tube-well water used by women during pregnancy, was assessed in a separate survey conducted in 2002-2003. Data on vital events, including pregnancy outcome and infant mortality, were collected by monthly surveillance at the household level. The risk of fetal loss and infant death in relation to arsenic exposure was estimated by a Cox proportional hazards model. Drinking tube-well water with more than 50 microg of arsenic per liter during pregnancy significantly increased the risks of fetal loss (relative risk = 1.14, 95% confidence interval: 1.04, 1.25) and infant death (relative risk = 1.17, 95% confidence interval: 1.03, 1.32). There was a significant dose response of arsenic exposure to risk of infant death (p = 0.02). Women of reproductive age should urgently be prioritized for mitigation activities where drinking water is contaminated by arsenic.

Rahman A et al Association of arsenic exposure during pregnancy with fetal loss and infant death: a cohort study in Bangladesh. Am J Epidemiol.  2007; 165(12):1389-96 

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17351293

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MCH Alert

Preconception brochure released

A Woman's Guide to Preventing or Planning Pregnancy provides information on pregnancy and pregnancy-prevention program services in California, as well as tips for staying healthy before and during pregnancy. The brochure, developed by the Center for the Health Professions' Network for Multicultural Health, builds on the project undertaken by LEAD (LEADing Organizational Change: Advancing Quality Through Culturally Responsive Care) program Cohort 1, Contra Costa Health Services, and its focus on community outreach. The services of two specific programs are highlighted: (1) Family PACT, a state- and federally funded program to provide comprehensive family planning services to individuals with eligible incomes and (2) Presumptive Eligibility for Pregnant Women, a Medi-Cal program to provide immediate, temporary coverage for prenatal care pending a formal Medi-Cal application. The brochure may be downloaded and customized by inserting specific information on the back, center panel. http://futurehealth.ucsf.edu/TheNetwork/LinkClick.aspx?link=WomansGuide_English.pdf&mid=2181

School based programs decrease rates of violence among adolescents

"On the basis of this evidence, the Task Force on Community Preventive Services recommends the implementation of universal, school-based programs to prevent violent behavior," state the authors of a report published in a supplement to the August 2007 issue of the American Journal of Preventive Medicine. Violence is widespread and causes considerable morbidity and mortality in the United States. Research has shown that childhood violence is predictive of later violent pathways.

The report summarizes the findings of a systematic review of the effects of universal, school-based programs intended to prevent violent behavior. Information on interpreting and using the recommendation are provided. http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0126-0

The other systematic reviews of the effectiveness of selected population-based interventions designed to reduce or prevent violence by and against children and adolescents are available from the Guide to Community Preventive Service at http://www.thecommunityguide.org/violence/default.htm

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MCH Headlines: Judy Thierry HQE

Motor vehicle restraint use in American Indian children: Meaningful interventions

Results: Of 775 children age 1-8 years, 29 percent were properly restrained, 30 percent were incorrectly restrained, and 41 percent were completely unrestrained in the vehicle. The strongest associations with proper child restraint use, rather than no restraint use, were seat eligibility (Odds Ratio [OR] for infant seat vs booster seat: 25.1; OR for child seat vs booster seat: 8.7), driver seat belt use (OR: 6.5), and driver relationship to the child (OR for parents vs non-parents: 3.9). Being subject to a state seat belt law was associated with both proper (OR: 4.4) and incorrect restraint use (OR: 6.6), rather than no restraint use, compared to children riding in areas with no law. Being subject to a tribal seat belt law was also associated with incorrect restraint use (OR: 2.4), rather than no restraint use, compared to children riding in areas with no law. The three factors that were differently associated with proper and incorrect restraint use were the child’s seat eligibility (OR for infant seat vs booster seat:15.7; OR for child seat vs booster seat: 7.5),seating position (OR for rear-outboard seated vs front seated: 1.9), and whether or not the child was riding with his or her own parent (OR for parents vs non-parents:2.9).

Conclusions : AI/AN children are at risk for incorrect and non-use of motor vehicle restraints. Understanding barriers and facilitators to the use of child passenger restraint systems in tribal communities can guide prevention efforts for American Indian communities across the United States. Such interventions might include strategies to get all occupants (adults and children) to use proper restraints; stressing importance of regular use, even for short trips; increase availability of proper seats for all vehicles that children ride in regularly; include training on proper use, not only for parents, but all regular caregivers.

Nicole Smith, MPH

MCH Biostatistician

Northwest Portland Area Indian Health Board

nsmith@npaihb.org

Toolkit Supports Efforts in Native Communities to Prevent FAS Disorders

The American Indian/Alaska Native/Native Hawaiian Resource Kit is available on the Web at http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702 .

Copies may be obtained free of charge by calling SAMHSA’s (working hours) Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request inventory number SMA07-4264.

For related publications and information, visit http://www.samhsa.gov/ and the FASD Native Initiative Web site at http://fasdcenter.samhsa.gov/nativeinitiative/indexhtmlorflash.cfm

Sister Study seeks more Native women 

The study must have 50,000 women participate; and in order to ensure accurate research results representative of the entire U.S. and Puerto Rican population, organizers hope to have at least 750 American Indian participants. As of August, 565 Native women were enrolled in the study. ''Breast cancer is the second leading cause of cancer death among Native women, and their five-year survival rate is lower than that of white women,'' said Sara Williams, the Sister Study's recruitment coordinator in charge of Native recruitment.

Previous breast cancer research has been limited to mostly white women, Williams said, and scientists are hoping to learn a great deal from the study. The participants must be between the ages of 35 and 74, must never have had cancer and must have a sister who was diagnosed with breast cancer.

Because there is so little known about the environmental causes of breast cancer, many women are compelled to join the study to try and help future families. The study was officially launched in 2004 after a few years of planning. Organizers have worked diligently to spread the word of the study, publicizing their intent and creating a user-friendly Web site. Reaching Indian country can be more difficult. ''We want the cohort to really be diverse and not have everyone in the study be white and middle-aged and work at a desk job,'' Williams said. Native women who sign up must be residents of the United States; however, they do not need to give their tribal affiliation.

''Because this is not a study comprised of only Native women, it was never the intention to study any differences in breast cancer risk at a tribal level,'' Williams said. ''There will only be broad analyses done among all Native women generally, regardless of tribal affiliation. Still, so much is going to be learned at this level.''

The Sister Study is a long-term research project. When participants sign up, they'll be asked to take part in two hour-long phone interviews in which they'll give detailed information about their medical history, environment and lifestyle. Then, the individual will set up an in-home appointment with a female examiner, who will draw blood and take a urine, house dust and toenail sample.

The participants will receive a kit in the mail that has all the information and questionnaires organized in tabbed form. After the initial period, the women will then be contacted every year for 10 years to provide updated information, such as any changes to their health.

''You don't have to take any medicine, you don't have to go anywhere,'' Williams stressed. ''You never even have to leave your house ... I think the most important message now is that you just have to step up to the plate and realize that this is really important to do for future generations of women.'' Women are not paid for their participation and their motivation to join comes from their desire to contribute to scientific research.

The study is being conducted by the U.S. Department of Health and Human Services through their National Institute of Environmental Health Sciences; and because it is a federally funded program, there isn't an open-ended budget. ''I wish we could say, 'Join this program and we'll give you $500!' Williams said. ''We are at the mercy of people's good will. To me, it's almost like a social justice issue. We're really working hard to encourage these women to enroll because we know so little [about Native breast cancer].''

To learn more about the study, visit http://www.sisterstudy.org/English/index1.htm  

To sign up, call toll-free (877) 4SISTER

One size doesn't fit all: Helmet Safety Poster

Three page poster with chart and narrative matches’ helmet with activity from CPSC's Neighborhood Safety Network

The Neighborhood Safety Network has a very special poster to share with you this month.  In March of this year, the Raffaelli family of San Mateo, Calif., tragically lost their son Casey, 20, after he fell from his skateboard.  Casey’s parents and uncle have courageously partnered with CPSC to share a powerful safety message about the unquestionable importance of wearing a helmet when out on a bicycle, skateboard, scooter, etc.  The visual and written message from the Raffaellis should motivate everyone to “strap a helmet on – it could save your life!”    

To honor Casey and to help create a safer community where you live, we ask that you download this poster (www.cpsc.gov/nsn/helmets.pdf ) and share it with friends, family and neighbors.

Get Your Head in the Game

Concussion Tool Kit for Youth Sports Coaches, Parents, and Athletes

A concussion is a brain injury caused by a bump or blow to the head that can change the way your brain normally works. Even what seems to be a mild bump or blow to the head can be serious. As many as 3.8 million sports- and recreation-related concussions are estimated to occur in the United States each year.

To help ensure the health and safety of young athletes, the Centers for Disease Control and Prevention (CDC), in collaboration with 26 leading organizations, developed the new "Heads Up: Concussion in Youth Sports" tool kit for youth sports coaches, parents, and athletes. The tool kit offers important information on preventing, recognizing, and responding to a concussion—a type of traumatic brain injury—to coaches, parents, and athletes involved in youth sports.

CDC wants to equip coaches, parents, and young athletes across the country with the " Heads Up: Concussion in Youth Sports" tool kit, which contains a:

§         Fact sheet for coaches, parents, and athletes on concussion;

§         Clipboard with concussion facts for coaches;

§         Magnet with concussion facts for coaches and parents;

§         Poster with concussion facts for coaches and sports administrators; and

§         Quiz for coaches, athletes, and parents to test their concussion knowledge.

The "Heads Up: Concussion in Youth Sports" tool kit can be ordered or downloaded free-of-charge at: http://www.cdc.gov/ConcussionInYouthSports

To view the MMWR on sports- and recreation-related traumatic brain injury: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a2.htm

Usage of Booster Seats (NSUBS) are now posted online on the NHTSA website

The study is NHTSA’s first formal foray into the development of a reliable scientific estimate of booster seat use in the U.S. Three “Research Notes” analyzing and describing the NSUBS results are posted at www.nhtsa.gov

These are:

Booster Seat Use in 2006

Child Restraint Use in 2006 -- Demographic Results

Child Restraint Use in 2006 -- Use of Correct Restraint Types

A fourth Research Note (“Preliminary Data Indicate That Booster Seat Laws Increase Child Safety Seat Use”) has been published in conjunction with the NSUBS findings. That link is:

Preliminary Data Indicate That Booster Seat Laws Increase Child Safety Seat Use

The NSUBS’ primary purpose is to estimate booster seat use among 4- to 7-year-olds, but it also collects very rich information on the restraint use of all children under age 13, and on race/ethnicity results on restraint use among all ages. In particular, the NSUBS provides the best data to date on the premature graduation of children age 0-12 to restraint types that are inappropriate for their height or weight.

The survey was conducted by NHTSA’s National Center for Statistics and Analysis (NCSA) in July 2006, and the second year survey is in the field this month.

Although clear progress in increasing booster seat use is evident -- thanks to a host of developments and interventions conducted by many people over many years -- much work remains to be done to more fully protect booster-aged/-sized child passengers.

FASD Online Course
Online Course: (2004) FASD 4-Digit Diagnostic Code - individual-start, self-paced, fully online program. The course includes readings, exercises, quizzes and video segments of an actual FAS Diagnostic Evaluation. This 20-hour course is designed for completion in 4 weeks. Students may complete the course in less time or may take up to 8 weeks. Students may start the course on any date.  $100 COURSE FEE. RECOMMEND REVIEW OF THE INTRO VIDEO – LINK BELOW.  

FAS is a permanent birth defect syndrome caused by maternal consumption of alcohol during pregnancy. FASD is the leading known cause of mental retardation and developmental disabilities and is entirely preventable. Learn an interdisciplinary clinical approach to diagnosing FASD using the (2004) 4-Digit Diagnostic Code. The 4-Digit Code has been practiced by interdisciplinary diagnostic teams across the U.S. and Canada since 1997 with documented high performance. This online course includes case studies, animations, practice sessions and self-assessment.

The Online Course is now open for registration.
Earn 2 Continuing Education Units.
The Course was developed by Susan J. Astley, Ph.D. and the University of Washington FAS DPN Clinical Team. This course was developed in partnership with UW Extension, Distance Learning Division.

Click here to view an introductory video of the Online Course.   http://depts.washington.edu/fasdpn/htmls/online-train.htm  

The video requires Windows Media Player software to view. If you are using a computer with Microsoft's Windows operating system, you may already have this software loaded in your computer. If you do not have this software, or the version you have is outdated, a free copy of the software can be downloaded from Microsoft.

Let me know if you are interested in taking this online course.

Judith.Thierry@ihs.gov

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Medical Mystery Tour

Nausea and Vomiting in Pregnancy

As you recall from last month, we presented 3 case scenarios and then asked 3 questions. Here are the questions. The correct answers and explanations are given below.

Editorial Note

This month’s Perinatology Picks CCC Corner submission (below) offers background on Nausea and Vomiting of Pregnancy for these 3 questions. This background is based on the Perinatology Corner CME module on Nausea and Vomiting of Pregnancy

After you peruse this material and answer the questions, you should go to the link directly below, take the Posttest and receive free CME credit. http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm

The module itself has many other available references and links to hundreds of other resources.

Case 1

MTB is a 24 y/o G1P0 at 10 weeks by her dates who presents to her first prenatal visit complaining of morning sickness. Her symptoms are not incapacitating, but she would like to feel better. She has tried various herbal teas without much relief. Your most useful recommendation at this initial visit would be:

  • reassurance, small frequent intake, pyridoxine (vitamin B-6)
  • prescribe a cholinomimetic agent (e.g., metoclopramide)
  • prescribe a 5-HT-3 receptor inhibitor (e.g., ondansetron)
  • clear liquid diet and bismuth subsalicylate (Pepto-Bismol)

Case 2

HB is a 30 y/o G3P2 at 9 weeks by her dates who presents for her first prenatal visit complaining of nausea with vomiting that lasts pretty much all day, but she is able to keep some food down. She says this has occurred with each of her pregnancies, but this time it is especially troublesome. She has had a small amount of spotting but no cramping. She appears to be well hydrated. Your initial work up at this time should include:

  • complete metabolic panel, thyroid functions, amylase and lipase
  • electrolytes, alanine aminotransferase, pelvic ultrasound
  • upper abdominal ultrasound, H.pylori antigen testing, stool guiac testing
  • no laboratory studies are indicated at this time

Case 3

EP is a 19 y/o G1P0 at 11 weeks by her dates who presents to the emergency department complaining of severe nausea and vomiting. She is wretching, appears ill, and is only able to produce a small amount of concentrated urine that is strongly positive for ketones. Your initial management should include:

  • oral hydration, mental health consult
  • intravenous hydration, admit for parenteral alimentation
  • intravenous hydration, nasogastric tube, H2-blocker drip
  • intravenous hydration, parenteral anti-emetics

Case 1

Correct answer: a
Ms B is a primigravida at 10 weeks who has mild pregnancy associated nausea. It should begin to resolve by 12 weeks as serum HCG levels taper. In the meantime, reassurance that this is a normal pregnancy symptom is appropriate. Dietary modification in the form of small, frequent, usually dry, not fatty, meals is often helpful. Pyridoxine, which is vitamin B6, is the pharmacotherapy that most often is helpful for mild cases such as that described here, and usually has no side effects. If pyridoxine is not helpful for her, she may supplement it with over the counter doxylamine (the ingredient in mild sleep aids such as 'Sominex'). This combination was formerly marketed as 'Bendectin ®', which is no longer available, but which is definitely not a teratogen. It may also be supplemented with a phenothiazine or an antihistamine anti-emetic for more severe symptoms, but she should know that these are usually quite sedating. If these interventions are not helpful, metoclopramide or a 5-HT-3 receptor inhibitor, such as ondansetron, can be added, but mild symptoms, such as described, usually will not require these more costly drugs, at least initially. Oral hydration is important, but fasting is not helpful. Bismuth subsalicylate is often helpful for nausea in non-pregnant individuals, but the high dose of salicylate is not recommended during pregnancy, and may also cause constipation.

Case 2

Correct answer: b
Ms H is a multiparous woman at 9 weeks with symptoms which are quite distressing, but she is able to accomplish some oral intake and does not appear to be dehydrated. When we aren't able to offer a great deal therapeutically, we often 'go overboard' diagnostically! Such 'mega work ups' for a problem that the patient knows is recurrent each pregnancy is usually not cost-effective. A simple basic workup is helpful however, and might include electrolytes (hypokalemia is the most common abnormality encountered) and a screen for hepatitis. The alanine aminotransferase (ALT, formerly known as SGPT or the serum glutamic pyruvate transaminase) is usually the most sensitive. If it is abnormal, you can investigate further from there. There is usually a history to suggest other gastrointestinal problems (colicy RUQ pain radiating to the shoulder for gallbladder disease, epigastric pain and pyrosis for peptic ulcer disease, a history of ethanol ingestion, etc.). If your initial therapy proves unhelpful and the symptoms become worse or evolve, then more of a GI work up may certainly be indicated later. While nausea and vomiting is not a common symptom of hyperthyroidism, it has somehow become routine to order thyroid functions on these women. If you have read a former 'Perinate's Corner' on thyroid disease in pregnancy, you will recall that these women, who typically have high human chorionic gonadotrophin (HCG) levels, will frequently have an assay for TSH that often returns very low, suggesting hyperthyroidism. This may occur in up to 20% of pregnant women in whom the newer third generation, ultrasensitive TSH assays are obtained. These women may even have a mildly elevated free T4, but they will be clinically euthyroid, without tremor, tachycardia, hyperreflexia, or the other signs of hyperthyroidism. Both these biochemical abnormalities will resolve by 18 weeks and anti-thyroid medications should not be started. (They will not help the nausea and vomiting either!) They may cause the fetus, who is totally dependent on its mother's thyroxine until its own gland becomes functional at about 18 weeks, to become hypothyroid, with the accompanying later intellectual deficits. 'Primum non nocere' (first do no harm)!

Case 2

Correct answer: d
Ms P is a 19 y/o primigravida at 11 weeks with symptoms probably severe enough to be characterized as hyperemesis gravidarum. She is clinically dehydrated and may well need to be admitted. She certainly needs an IV for hydration as she is unlikely to tolerate PO. Despite a common belief that this disorder is largely 'psychological', there is no evidence that these women have any higher incidence of mental health issues than other pregnant women who do not have such severe symptoms. This patient will almost certainly need parenteral anti-emetics. Either a phenothiazine or an antihistamine type may be very helpful here. Severe symptoms such as these may also benefit from IV metoclopramide and/or dolasetron or ondansetron. These classes of drugs are usually very effective, but the 5-HT-3 receptor inhibitors are quite costly, usually upwards of $50 a dose, so they should be reserved for women who are unresponsive to other forms of therapy. Nasogastric suction and therapy aimed at reducing gastric acidity are usually not helpful for this disorder. Further work up may well be indicated in patients such as this who have severe and recurrent symptoms that are not amenable to therapy. Specific therapy can then be tailored to any pathology that may be uncovered. Parenteral nutrition was formerly used in hyperemesis patients who were unable to maintain oral intake, but, as noted above, they have fallen out of favor because of the associated complications.

After you absorb (sic) the material above and the Background in the Perinatology Picks below, you should go to the link directly below, take the Posttest and receive the free CME credit. http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm

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Medscape*

HPV-16/18 Vaccination Should Not Be Used to Treat Prevalent Infections 

http://www.medscape.com/viewarticle/561418?src=mp

Interactive Case: Overactive Bladder in a Menopausal Woman With Complicating Conditions

http://www.medscape.com/viewprogram/5780?sssdmh=dm1.286131&src=0_mp_cmenl_0#2

Management of Depression and Premenstrual Dysphoria in a Woman Planning Pregnancy

http://www.medscape.com/resource/pmdd?sssdmh=dm1.294520&src=rcupdate

Management of Premenstrual Dysphoric Disorder Throughout the Ages: A Series of Interactive Cases

http://www.medscape.com/viewarticle/558957?sssdmh=dm1.288228&src=0_tp_nl_0

Premenstrual Syndrome/Premenstrual Dysphoric Disorder: Treatment With Oral Contraceptives

http://www.medscape.com/resource/pmdd?sssdmh=dm1.289582&src=rcupdate#1

Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape

http://www.medscape.com/pages/editorial/public/ate/index-womenshealth

OB GYN & Women's Health Clinical Discussion Board Index, Medscape

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

Clinical Discussion Board Index, Medscape

Hundreds of ongoing clinical discussions available

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

Free CME: MedScape CME Index by specialty

http://www.medscape.com/cmecenterdirectory/Default

*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.

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Menopause Management

Study Supports HRT Use for Short Term, but Little Benefit in Older Women

CONCLUSIONS: Hormone replacement therapy increases cardiovascular and thromboembolic risk when started many years after the menopause. The results are consistent with the findings of the women's health initiative study and secondary prevention studies. Research is needed to assess the long term risks and benefits of starting hormone replacement therapy near the menopause, when the effect may be different.

Vickers MR et al Main morbidities recorded in the women's international study of long duration oestrogen after menopause (WISDOM): a randomised controlled trial of hormone replacement therapy in postmenopausal women. BMJ. 2007 Aug 4;335(7613):239.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17626056

Hormone Therapy Safer in Younger Women? A Best Evidence Review

CONCLUSIONS: Women who initiated hormone therapy closer to menopause tended to have reduced CHD risk compared with the increase in CHD risk among women more distant from menopause, but this trend test did not meet our criterion for statistical significance. A similar nonsignificant trend was observed for total mortality but the risk of stroke was elevated regardless of years since menopause. These data should be considered in regard to the short-term treatment of menopausal symptoms. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00000611.

Rossouw JE, et al Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007 Apr 4;297(13):1465-77

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17405972

Caffeine Reduces Cognitive Decline in Women

CONCLUSIONS: The psychostimulant properties of caffeine appear to reduce cognitive decline in women without dementia, especially at higher ages. Although no impact is observed on dementia incidence, further studies are required to ascertain whether caffeine may nonetheless be of potential use in prolonging the period of mild cognitive impairment in women prior to a diagnosis of dementia.

Ritchie K, et al The neuroprotective effects of caffeine: a prospective population study (the Three City Study). Neurology. 2007 Aug 7;69(6):536-45

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17679672

Treatment Options for Insomnia (see Patient Education)

The frequency of sleep disruption and the degree to which insomnia significantly affects daytime function determine the need for evaluation and treatment. Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. There is good evidence supporting the effectiveness of cognitive behavior therapy. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. Routine use of over-the-counter drugs containing antihistamines should be discouraged. Alcohol has the potential for abuse and should not be used as a sleep aid. Opiates are valuable in pain-associated insomnia. Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena. The better safety profile of the newer-generation nonbenzodiazepines (i.e., zolpidem, zaleplon, eszopiclone, and ramelteon) makes them better first-line choices for long-term treatment of chronic insomnia. Am Fam Physician 2007;76:517-26, 527-8

http://www.aafp.org/afp/20070815/517.html

NAMS Releases Updated Position Statement on the Use of Estrogen and Progestogen in Perimenopausal and Postmenopausal Women

There are risks and benefits associated with the use of estrogen therapy (ET) and combined estrogen-progestogen therapy (EPT) in perimenopausal and postmenopausal women. For this reason, the North American Menopause Society (NAMS) evaluated the latest evidence and created the following recommendations and guidelines to update its 2004 position statement.

Recommendations

PRETREATMENT

Before initiation of treatment, a thorough history should be obtained and a complete physical examination performed, including mammography in accordance with national guidelines.

VASOMOTOR SYMPTOMS

All ET and EPT products are approved for use in treating vasomotor symptoms, such as night sweats or hot flashes. Treatment of these symptoms is the main reason for systemic ET and EPT use.

VAGINAL SYMPTOMS

Nearly all systemic and vaginal ET and EPT products are approved for the treatment of symptoms of vulvar and vaginal atrophy (e.g., dryness, dyspareunia); however, local vaginal ET is typically recommended only when needed solely for this purpose.

PROGESTOGEN INDICATION AND REGIMEN

In women with intact uteruses, unopposed ET can increase the risk of endometrial cancer; progestogen is primarily used for protection against this. Physicians should provide continuous-combined EPT or continuous-sequential EPT for women with intact uteruses who are taking ET. EPT should not be prescribed for postmenopausal women without uteruses who are taking systemic estrogen.

Progestogen may have adverse effects in some women who take EPT. There is insufficient evidence to recommend alternative options, such as off-label use of long-cycle progestogen, vaginal administration, the use of the levonorgestrel-releasing intrauterine system (Mirena), or the use of low-dose estrogen without progestogen.

CORONARY HEART DISEASE

ET and EPT are not recommended for use as coronary protection in women. One arm of the Women's Health Initiative (WHI) study showed a significant association between time since start of EPT and coronary heart disease (CHD) risk, with an increased risk in the first year and a decreased risk in later years. It is important to note that the WHI study population did not include enough younger, symptomatic, newly postmenopausal women to determine if there are similar CHD risk patterns in that population.

Observational data have shown a pattern of reduced CHD events in women who started hormone therapy within the first 10 years of menopause, and a pattern of greater CHD risk if therapy was started more than 10 years after the start of menopause. The risk of early CHD is lower in the younger cohort of newly postmenopausal women compared with the older women studied in the WHI trial.

VENOUS THROMBOEMBOLISM

Studies have shown that women have a significantly increased risk of venous thromboembolism if they are using systemic ET and EPT. This risk appears within the first two years after starting therapy, but it decreases over time. In the WHI study, excess risk was low overall and lower still in women younger than 60 years who were randomized to ET and EPT. There were few data available regarding differences in venous thromboembolism risk in transdermal 17 beta-estradiol (Estrace) and oral therapies.

STROKE

ET and EPT both seem to increase ischemic stroke risk in postmenopausal women. Although some large trials have shown no increased risk, the ET arm of the WHI study had eight additional strokes per 10,000 women, and the EPT arm had 12. For this reason, it is recommended that ET and EPT should not be used for primary or secondary prevention of stroke, and they should not be prescribed to women who are already at increased risk.

DIABETES

Randomized controlled trials (RCTs) have shown that ET and EPT lower the risk of new-onset diabetes. Women taking EPT in the WHI study had a 0.61 percent annual incidence of diabetes requiring treatment compared with 0.76 percent in women taking placebo (number needed to treat to prevent one case of diabetes = 670 per year of EPT). Women receiving ET in the WHI study had a similarly small reduction. EPT is not recommended for preventing diabetes in postmenopausal women.

BREAST CANCER

EPT use beyond five years is associated with increased breast cancer risk. Evidence shows that ET alone has little or no impact; however, some limited observational data have suggested that if ET lasts longer than 15 years, risk may increase. There are few data showing any change in breast cancer mortality with ET or EPT. Both therapies increase breast cell proliferation, breast pain, and mammographic density, and EPT can obstruct the diagnostic reading of mammograms.

OSTEOPOROSIS

Evidence has shown that ET and EPT reduce osteoporotic fracture risk in postmenopausal women; many of these products are approved for this use.

DEPRESSION

Studies have shown an increased risk of onset of major depression in perimenopausal versus premenopausal women without a history of depression, and an increased risk of major and minor depression in early postmenopause versus premenopause. Effectiveness of ET as an antidepressant in perimenopausal women has been demonstrated in two RCTs, whereas one RCT did not demonstrate effectiveness in older postmenopausal women. There is insufficient evidence to recommend using ET or EPT to treat depression.

PREMATURE MENOPAUSE OR OVARIAN FAILURE

Premature menopause and ovarian failure are linked to a lower risk of breast cancer, early osteoporosis, and CHD; it is unknown if ET or EPT affect morbidity and mortality rates from these conditions. It also is unknown if the risk/benefit ratio may be favorable for younger women who start ET or EPT at an earlier age.

RISK/BENEFIT RATIO

ET and EPT use should be consistent with treatment goals, benefits, and risks. It also should take into account factors such as the cause of menopause; time since menopause; symptoms; and other issues that could affect quality of life or risk of cardiovascular disease, stroke, venous thrombosis, or other conditions.

LOWER DOSES

Studies have shown similar relief of vasomotor or vulvovaginal symptoms and maintenance of bone mineral density with lower-dose ET or EPT (e.g., 0.3 mg of oral conjugated estrogen daily, 0.25 to 0.50 mcg of oral micronized 17 beta-estradiol) compared with standard doses. These lower doses appear to better tolerated and have a better risk/benefit ratio; however, lower doses have not been evaluated in long-term studies.

NONORAL THERAPY

The risk/benefit ratio of nonoral EPT or ET administration is unknown. Differences between oral and nonoral administration are related to the role of first-pass hepatic effect, hormone concentrations in the blood by the given administration option, and biologic activity of active ingredients. Some evidence exists regarding an association between 17 beta-estradiol and a lower risk of deep venous thrombosis compared with oral ET.

LONG-TERM THERAPY IN SYMPTOMATIC WOMEN

Although RCTs in symptomatic perimenopausal women have not been performed, results of the WHI suggest that physicians should use caution in prescribing long-term therapy for these patients.

Extended use of ET or EPT in women who are aware of the risks and benefits and are under physician supervision is acceptable under certain circumstances: (1) the patient feels that the benefit of relief from menopause outweighs the risk of extended use; (2) the patient has moderate or severe menopausal symptoms and is at high risk of osteoporotic fracture; or (3) the patient has reduced bone mass and wants to prevent future bone loss, and alternative therapies are inappropriate (e.g., cause adverse effects, have unknown outcomes).

SYMPTOM RECURRENCE

If ET or EPT is discontinued, symptoms have a 50 percent chance of returning. Decisions about whether or not to continue therapy should be based on symptom severity and the current risk/benefit ratio.

QUALITY OF LIFE

Because ET and EPT improve menopausal symptoms, there typically is an associated increase in health-related quality of life. However, there is disagreement about whether this is true in asymptomatic women as well. Validated instruments should be incorporated into future studies to help determine the effects of ET and EPT on quality of life.

CLASS VS. PRODUCT EFFECT

RCTs are the only way to determine the different outcomes of various therapies. It is not possible to extrapolate the results of one study to another. However, if data specific to a certain agent are lacking, results from one trial can be generalized to other agents within the same family if they are given in equivalent dosages.

BIOIDENTICAL HORMONES

Safety concerns about ET and EPT products have prompted an increase in the use of alternative dose forms (e.g., gels, suppositories) that are not commercially available. Because there are no safety or effectiveness data for these forms, a generalized risk/benefit ratio based on commercially available products can be used instead. However, it is recommended that these alternative dose forms be used cautiously in case of possible lack of quality or purity or batch-to-batch ingredient inconsistencies.

Discussion

NAMS found insufficient or inconsistent evidence regarding several major factors of ET and EPT. There was disagreement over the best way to discontinue therapy, such as whether it should be abruptly discontinued or gradually tapered off. There also was insufficient evidence to determine if continuous-combined EPT has a different effect than continuous ET with continuous-sequential EPT. Lastly, there was conflicting evidence regarding signs that some continuous progestogen doses could be linked to adverse breast cancer or cardiovascular outcomes.

NAMS recognizes that each woman's willingness to accept risks associated with ET or EPT varies, and that disease outcomes are dependent on age and time since start of menopause. It cannot be assumed that the risks and benefits of ET and EPT apply to all ages and therapy durations. It is important to understand that even if ET and EPT are not being used, there is still a risk of developing all diseases under consideration in this statement, an idea that is demonstrated in the rates of disease seen in the RCT placebo groups. NAMS concludes that there are still many areas needing further research (e.g., timing of starting therapy, comparison of different formulations, long-term risks and benefits) with regard to ET and EPT in perimenopausal and postmenopausal women.

http://www.menopausejournal.com/pt/re/menopause/home.htm;jsessionid
=GLcWXZGbHkQsvYx7HQKLnJv3G1j2bWWFSnGG7LLxfm5G8jC10ZVc!-362743511!181195628!8091!-1

or

http://www.aafp.org/afp/20070715/practice.html

Atrophic Vaginitis and Estrogen Treatment: Medscape CME

http://www.medscape.com/viewprogram/7489?sssdmh=dm1.291271&src=nlcmealert

Hormone Therapy Safer in Younger Women? A Best Evidence Review

http://www.medscape.com/viewprogram/7404?src=mp

Vitamin E Does Not Protect Cognitive Function

Results: At the end of the trial, the total study population was 5,845, and the mean follow-up time was 9.6 years. The vitamin E and placebo groups had similar characteristics except for a higher level of education in the placebo group. Cognitive function scores at the start of the study were similar for the placebo and treatment groups. There was no difference between the groups with regard to cognitive change over time.

Conclusions: Vitamin E supplementation does not offer cognitive benefits in healthy older women. Although the study did not address the use of vitamin E at younger ages, it showed that vitamin E supplementation of 10 years or less did not offer neuroprotection.

Kang JH, et al. A randomized trial of vitamin E supplementation and cognitive function in women. Arch Intern Med December 11/25, 2006;166:2462-8.

http://www.aafp.org/afp/20070815/tips/6.html

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Midwives Corner - Lisa Allee, CNM

Group prenatal care reduces preterm births and increases breastfeeding initiation: RCT

CONCLUSION: Group prenatal care resulted in equal or improved perinatal outcomes at no added cost. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00271960 LEVEL OF EVIDENCE: I.

Ickovics JR, et al Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol. 2007 Aug;110(2 Pt 1):330-9

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17666608&dopt=AbstractPlus

Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior

CONCLUSIONS: The infants in the skin-to-skin group were comforted, that is, they stopped crying, became calmer, and reached a drowsy state earlier than the infants in the cot group. The father can facilitate the development of the infant's prefeeding behavior in this important period of the newborn infant's life and should thus be regarded as the primary caregiver for the infant during the separation of mother and baby.

Erlandsson K; et al Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior. Birth.  2007; 34(2):105-14 

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17542814

Midwifery’s approach to pre-labor SROM supported by professional organization’s journal

Morwitz and Jordan present a review of the literature on pre-labor rupture of membranes at term. Most significantly, they point out some of the flaws in the TERMPROM study by Hannah et al. The biggest problem was that there was no control of the number of vaginal exams, which have been shown to be directly correlated with increased risk of infection by Hannah et al. and others. Speculation has been made that if the number of vaginal exams had been limited in the study pool the results may have been different. Another problem has to do with GBS-positive management being very different and inconsistent during the study time period as compared to today. The authors’ concluding statements support the time-honored midwifery practice of having options in the management of pre-labor SROM tailored to the individual patient and setting and the integral role played by the woman herself in the decision making process.

‘Two practices supported by current research findings should be incorporated into midwifery care of women with term PROM. The first is to strictly limit vaginal examinations. There is considerable evidence documenting the increased risk of perinatal infection related to digital vaginal examination, yet little change has occurred in this aspect of practice. Despite ACOG’s recommendation that vaginal examination should be deferred during the initial evaluation, doing a “baseline vaginal exam” is common practice. Requiring vaginal examinations at set intervals to prove labor progression is another entrenched habit. A speculum examination to determine initial cervical status is sufficient in most cases, and digital examinations should be done only when the information is needed to make management decisions. The second practice is to consistently provide information about the options of expectant management and immediate induction to women with term PROM, and to involve them in the decision-making process. This is congruent with midwifery hallmarks and philosophy of care. In addition, it is explicitly supported by Cochrane reviewers and the TERMPROM researchers.

In an editorial accompanying the publication of the term PROM study, Duff stated his view that the practice of expectant management should be abandoned. An unquestioning acceptance of this view is not justified based on available evidence. Women should be fully informed on the risks and benefits of induction and expectant management, and offered both options. Midwives should strive to remain champions of a care approach that involves women in decision making and supports the value of nonintervention.’

Marowitz, A; Jordan, R Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health. 2007 May-Jun;52(3):199-206

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17467586

Editorial Comment by Lisa Allee, CNM:

I couldn’t have said it better myself. But I will add my two cents, too. I think the ACOG statement that induction should be started immediately upon SROM is over interventionist, not evidence based, and disrespectful of the inherent wisdom and intelligence of women’s bodies and minds. I encourage midwives to feel supported by our professional organization’s journal in continuing evidence-based approaches to pre-labor SROM by offering options of induction or awaiting spontaneous labor. AND most importantly keep your fingers out of there!!! (Really folks, the vaginal exam does not make much difference –her cervix is what is and her labor goes as it goes no matter if we check the cervix or not AND there are other ways to tell how her labor is progressing—tune in and labor sit.)

Hannah ME, et al Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. N Engl J Med. 1996 Apr 18;334(16):1005-10 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=8598837

Duff P. Premature rupture of the membranes at term. N Engl J Med. 1996 Apr 18;334(16):1053-4

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=8598845

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Navajo News, John Balintona, Shiprock

Evaluation of the pregnant patient for non-obstetric surgery

This is Part one of a two Part series on evaluation of the pregnant patient for non-obstetric surgery.

Nonobstetric surgical conditions that occur during pregnancy require communication between obstetric providers specialists. One large retrospective study cited the incidence of nonobstetric surgical intervention as occurring in roughly 0.75% of pregnancies. The anatomic and physiologic changes that occur during pregnancy can be profound and the obstetric provider should be familiar with the effects that surgical illness can have on pregnant patients. Furthermore, the obstetric provider can be called on to direct the evaluation of a pregnant patient who may require a surgical procedure. The purpose of this paper is to review generalizations for care and offer a rational approach for management. Pre-operative evaluation with specific focus on physiologic changes in the cardiovascular, pulmonary, gastrointestinal, and renal systems will be addressed. Other topics that will be reviewed include laboratory data, imaging techniques, anesthetic and surveillance considerations.

Maternal Adaptation in Pregnancy

At term, the pregnant uterus can reach a capacity of 500 to 1000 times the capacity of a nonpregnant uterus. The sheer size of this organ may complicate the evaluation of a patient. After the 12th week of pregnancy, the uterus typically has grown out of the pelvis and can be considered an abdominal organ. As the pregnancy progresses and the uterus enlarges, the intestines are displaced laterally and superiorly. This fact is specifically important when evaluating a patient for suspected appendicitis as McBurney’s Point is directed toward the right upper quadrant. The growth of the uterus can also be a cause for abdominal pain. Tension is exerted upon the broad and round ligaments that subsequently can be manifested as pain in certain patients.

The large pregnant uterus is known to compress the venous system in the lower half of the body, which can reduce cardiac filling and cardiac output. Placing the patient in the left lateral recumbent position can alleviate this effect. It has been reported that uteroplacental blood flow ranges from 450 to 650 ml/min is term pregnancies. Placental perfusion by maternal blood is dependent in turn upon blood flow to the uterus through the uterine and ovarian arteries; therefore hypoperfusion before, during, and after surgical procedures must be properly addressed.

The resting pulse increases on average 10 to 15 beats per minute during pregnancy. Sinus tachycardia, however, is not considered normal during pregnancy and should be evaluated. The cardiac output of a pregnant patient at rest is markedly increased, in part this is due to increase in maternal weight and increase in basal metabolic rate. Arterial blood pressure in a pregnant individual tends to decreases to a nadir during mid-pregnancy and rises thereafter, however, hypertension in an otherwise non-hypertensive pregnant patient does deserve an evaluation. It is reported that normal pregnancy induces no characteristic change in an ECG other than a slight left axis deviation. The heart is displaced in the thorax to the left and upward due to the elevation of the diaphragm. This in turn leads to an increase in the size of the cardiac silhouette on chest x-ray.

During pregnancy, the diaphragm rises appreciably and the subcostal angle widens, both of which can be seen on plain chest x-ray. This physiologic change affects certain aspects of pulmonary function in these patients, but overall pulmonary function is not impaired during pregnancy. It is known that the tidal volume, minute ventilatory volume and minute oxygen uptake increase as pregnancy advances. It is believed that the increased tidal volume is responsible for the increased perception of breathing in these patients, which may be interpreted as dyspnea. Evaluation of the cardiovascular and pulmonary systems under this circumstance tends to be within normal limits. Normal pregnancy is associated with little change in the respiratory rate, therefore, tachypnea does deserve further evaluation. The lung sounds of a pregnant patient should be similar to a nonpregnant individual and any finding on auscultation should be addressed.

As previously noted, during normal pregnancy the uterus displaces the stomach and intestines. This physiologic change, along with hormonal factors, contributes to the delayed gastric emptying and intestinal transit times in pregnant patients. This condition is especially significant during cases requiring general anesthesia where regurgitation and aspiration is a risk. Pregnancy can induce a focal highly vascular swelling of the gums, known as epulis of pregnancy. Patients with this condition often complain of bleeding when brushing their teeth. An exam of the oral cavity by a qualified provider should rule out most other causes of bleeding gums. This condition usually regresses spontaneously after delivery and pregnancy is not known to promote tooth decay. Hemorrhoids are also common during pregnancy that is caused in large part to constipation and elevated pressure in veins below the level of the enlarged uterus. This condition may regress after delivery and therefore many general surgeons may defer definitive treatment until the postpartum period. Bloody stool or blood from the rectum may be associated with the aforementioned hemorrhoids, but other more serious conditions may exist or result and therefore at a minimum a rectal exam should be performed on these individuals.

The urinary system undergoes a remarkable number of changes during normal pregnancy that need to be recognized when evaluating the pregnant patient. There is a normal dilation of pelves, calyces, and ureters, which can be shown during ultrasound and IVP. Typically this phenomenon is more evident on the right. In absence of other clinical findings, this should not automatically be interpreted as obstructive uropathy.

Renal length can increase about 1 cm during pregnancy and decrease after delivery should not necessarily be interpreted as parenchymal loss.

Stay tuned for next month’s Navajo Corner for the conclusion which will include discussion of

Laboratory Data and Imaging Studies and Anesthetic and Operative Considerations

Questions? Contact John Balintona John.Balintona@ihs.gov

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Nurses Corner - Sandra Haldane, HQE

Nursing education scholarship opportunities

I want to alert you to the HRSA web site below where you can get information on nursing education scholarship opportunities.  Questions Carolyn.Aoyama@ihs.gov

http://www.hrsa.gov/help/healthprofessions.htm

Behavioral and Social Sciences Research: National Assoc. of Clinical Nurse Specialists

EBBP.org is the beta version of a web-based training resource funded by NIH's Office of Behavioral and Social Sciences Research.  The site is being developed to provide information and tools to promote evidence-based behavioral practice (EBBP).  

We are interested in your opinions about the appearance, content, organization, and overall quality of the website. The evaluation survey will take approximately 5 minutes to complete. In appreciation for your time, survey participants may enter a drawing to win one of three $100 gift cards to Amazon.com.

To view the website and complete the evaluation survey, please click here: http://www.ebbp.org

Bonnie Spring, Ph.D., ABPP
Telephone:  312-908-2293
FAX:  312-908-9588
e-mail:   bspring@northwestern.edu

Companion Animals and Human Health Risk: Animal Bites and Rabies

Topics in Advanced Practice Nursing: Medscape

http://www.medscape.com/viewprogram/7550?src=mp

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Office of Women's Health, CDC

STD Treatment Guidelines - Personal Digital Assistant Version

This point-of-care tool includes the complete 2006 STD Treatment Guidelines. The recommendations for each category have been moved to the top of the screen for efficiency, and the table of contents has been prioritized according to the needs of clinicians.

http://www.cdc.gov/std/treatment/PDA/default.htm

Perinatal Group B Streptococcal Disease After Universal Screening Recommendations

This report indicates that annual incidence of early onset Group B streptococcus (GBS) disease (i.e., in infants aged 0-6 days) was 33% lower during 2003-2005 than during 2000-2001. However, although incidence among white infants decreased steadily during 2003-2005, incidence increased 70% among black infants. Incidence of GBS disease among infants aged 7-89 days (i.e., late-onset disease) and pregnant women remained stable after revised universal screening guidelines were issued. Continued surveillance is needed to monitor the impact of the guidelines on perinatal GBS disease and trends in racial disparities and to guide interventions to reduce disparities.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5628a1.htm

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Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center

Preconception Health of Women Delivering Live-Born Infants — Oklahoma, 2000–2003

The U.S. Public Health Service recommends that all women of childbearing age consume >400 µg of folic acid daily through either supplementation or fortified foods. CDC recommends offering, as a component of maternity care, one pre-pregnancy visit to a health care provider for women planning pregnancy to enable women to receive risk assessment, health education, and specific interventions to address identified risks before conception. Analysis of data collected from women in Oklahoma during 2000–2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS) indicated that 21.5 percent of women with a recent live birth were not aware of folic acid benefits before they became pregnant, 73.5 percent did not consume multivitamins at least four times per week during the month before pregnancy, and 84.8 percent did not receive preconception counseling from a health-care provider. Although pre-pregnancy awareness of the benefits of taking vitamins with folic acid in the prevention of some birth defects was high among Oklahoma women with a recent live birth, actual consumption of multivitamins during the month before pregnancy was low. Promoting preconception health of women is a key public health strategy in the United States to decrease morbidity and mortality associated with negative maternal and infant outcomes. Increased folic acid consumption before conception and during the first trimester of pregnancy can reduce the incidence of neural tube defects by 50–70 percent.

Surveillance of Preconception Health Indicators Among Women Delivering Live-Born Infants --- Oklahoma, 2000—2003 MMWR June 29, 2007 / 56(25);631-634

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a3.htm

Editorial comment: Greggory Woitte – Hastings Indian Medical Center

Preconception Counseling

I am sure that most of your patients are similar to mine in that your first visit with them is after they have become pregnant. They show up at the clinic for a confirmatory pregnancy test, to schedule their first prenatal visit and to get started on prenatal vitamins (or as I am frequently seeing to start Flintstones vitamins). However, as I am sure you are aware, by the time the patient reaches our doorstep, we have missed a very important part of the pregnancy that we may have had some dramatic affect upon.

Between 2000 and 2003, the state of Oklahoma developed and administered a preconception survey. (See above) They found that 84.8% of women did not have any preconception counseling by a provider. 21.5% of women did not know about the benefits of preconception folic acid and equally disturbing was that 73.5% did not take vitamins before trying to become pregnant.

In accordance with the ACOG Committee Opinion No. 313, patients who are in the reproductive ages should be questioned about the possibility of becoming pregnant, especially if they are not on contraception. Women should be encouraged to formulate a reproductive health plan. We, as practitioners of Women’s Health, should be encouraging women to take steps to get as healthy as possible at every visit. This is especially important in women of reproductive ages where we have the opportunity to provide education regarding the benefits to the fetus, as well as to identify patients at high risk for adverse pregnancy outcomes.

We also need to remind our colleagues from other disciplines of medicine to ask their patients about potentially becoming pregnant and refer those who may be in need of pre-conceptional counseling or those in need of contraceptive counseling.

ACOG Committee Opinion Number 313. The importance of preconception care in the continuum of women's health care. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2005 Sep;106(3):665-6 .

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16135611

Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/nccdphp/

Office of Communication (770) 488-5131

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Osteoporosis

Lifestyle Intervention and BMD in Adolescent Girls

Results: Of 228 girls, 113 were randomized to the intervention group. The intervention group had significantly higher BMD at the spine and trochanter regions at one year compared with the control group; they maintained this increase during year 2. The intervention group also had biomarkers for bone turnover that were more consistent with an increase in bone building. Compared with the control group, the intervention group had greater consumption of calcium and fruits and vegetables in both years and vitamin D consumption in the first year. There were no differences between the two groups with regard to soda consumption or exercise rates.

Conclusions: The authors conclude that increasing BMD in adolescent girls can be accomplished through a comprehensive health care-based lifestyle intervention. They note that this study is the first nonschool-based intervention that emphasized self-directed behavior changes.

DeBar LL, et al. YOUTH: a health plan-based lifestyle intervention increases bone mineral density in adolescent girls. Arch Pediatr Adolesc Med December 2006;160:1269-76.

http://www.aafp.org/afp/20070815/tips/4.html

Decision Rules Useful for Selecting Women for Bone Mineral Density Testing

CONCLUSION: In a complementary way with previous studies in older women, where decision rules were valuable to identify the majority of women likely to have osteoporosis, our data indicate that in younger postmenopausal women, decision rules are useful as a screening method to rule out the presence of osteoporosis and the need for BMD scanning

Martínez-Aguilà D et al Decision rules for selecting women for bone mineral density testing: application in postmenopausal women referred to a bone densitometry unit. J Rheumatol. 2007 Jun;34(6):1307-12

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17552058

SSRI Use in Older Women Linked to Accelerated Hip Bone Loss

CONCLUSION: Use of SSRIs but not TCAs is associated with an increased rate of bone loss at the hip in this cohort of older women.

Diem SJ, et al Use of antidepressants and rates of hip bone loss in older women: the study of osteoporotic fractures. Arch Intern Med. 2007 Jun 25;167(12):1240-5

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17592096

Effects of the phytoestrogen genistein on bone metabolism in osteopenic postmenopausal women: a randomized trial

CONCLUSION: Twenty-four months of treatment with genistein has positive effects on BMD in osteopenic postmenopausal women

Marini H et al osteopenic postmenopausal women: a randomized trial. Ann Intern Med.  2007; 146(12):839-47

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17577003

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Patient Information

Women's Health Booklets

Colleagues:

Below are URLs that will take you to a Medicare site offering patient education materials on women’s health topics.  For example, one booklet explains the mammogram and provides information about breast health. (24 pages), another answers to commonly asked questions from older women about Pap tests, HPV, and the Medicare benefit for Pap test screening. (2 pages), includes information women need to know about heart disease. (2 pages).  There is a charge for these booklets. Link to other CMS women’s health publications.

http://www.medicare.gov/Publications/Search/Results.asp?PubName=women&PubCat
=All%7CAll+Publications&Type=NameCat&Language=English&pagelist=Home&dest=NAV%
7CHome%7CSearch%7CResults%7CSearchCriteria&comingFrom=13&version=default&browser
=IE%7C6%7CWinXP&go2.x=14&go2.y=8

Contact Carolyn.Aoyama@ihs.gov

Site to order other CMS publications http://pubordering.cms.hhs.gov/mailinglist/

STIs in Pregnancy: Protecting Yourself and Your Baby

http://www.aafp.org/afp/20070715/272ph.html

Monitoring Your Blood Pressure at Home

http://www.aafp.org/afp/20070715/261ph.html

Monitoring Your Blood Sugar at Home

http://www.aafp.org/afp/20070715/262ph.html

Insomnia: What You Should Know

http://www.aafp.org/afp/20070815/527ph.html

Preventing Another Stroke: What You Should Know

http://www.aafp.org/afp/20070801/389ph.html

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Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC

Nausea and Vomiting of Pregnancy

Editorial Note

This month’s Perinatology Picks submission offers background on Nausea and Vomiting of Pregnancy for the 3 questions posed in last month’s Medical Mystery Tour. This background is based on the Perinatology Corner CME module on Nausea and Vomiting of Pregnancy

After you peruse this material, you should go to the link directly below, take the Posttest and receive free CME credit. http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm

Background

Over 75 per cent of pregnant women experience some degree of nausea and vomiting during pregnancy. Up to 2 per cent of pregnancies are complicated by the severe syndrome referred to as hyperemesis gravidarum, which frequently prompts hospital admission for control of symptoms and the accompanying biochemical abnormalities.

A treatment algorithm for this spectrum of symptoms, based on the available evidence, will be suggested for mild nausea and vomiting and for severe nausea and vomiting (hyperemesis gravidarum) One clinical definition is persistent vomiting, with weight loss exceeding 5 percent of pre-pregnancy body weight, and ketonuria.

Clinical Features

There are several classic features of hyperemesis gravidarum. It presents early in the first trimester of pregnancy, usually in the fourth to tenth week of gestation, with intractable vomiting. Many patients have weight loss exceeding 5 percent of their body weight. Abdominal pain is infrequent.

Patients may present with ketosis and electrolyte derangements such as hypokalemia and metabolic alkalosis. There is often an increase in hematocrit, indicating hemoconcentration due to plasma volume depletion. The degree of hemoconcentration may be underestimated unless the decline in hematocrit seen in normal pregnancies is considered. Abnormal liver enzymes may also be present.

Risk factors

Studies of the risk factors for hyperemesis gravidarum have been small, and results not always definitive. Advanced maternal age (age >35) and cigarette smoking (perhaps due to the effect of nicotine may be protective. An association with gestational trophoblastic disease has been well-described.

Non-pregnant women who experience nausea and vomiting after estrogen exposure, from motion sickness, with migraine, or with exposure to certain tastes (supertasters) are more likely to have pregnancy-related nausea and vomiting. In contrast, anosmic women appear to be at low risk for this disorder.

Case Scenario

Mrs. B is a 24 y/o G1P0 at 10 weeks by her dates who presents to her first prenatal visit complaining of morning sickness. Her symptoms are not incapacitating, but she would like to feel better. She has tried various herbal teas without much relief.

Your most useful recommendation at this initial visit would be?

Try the following in a stepwise or cumulative fashion:

  1. Advise the patient to temporarily discontinue her prenatal vitamins with iron if she feels they are upsetting her stomach.
  2. Make dietary adjustments (small, frequent, low fat meals, etc.).
  3. Avoidance of triggers
  4. Try alternative therapies such as ginger, chamomile, or peppermint teas. (Acupressure at the wrist P6 locus has not been shown to be superior to placebo in the available aggregate data.)
  5. Prescribe pyridoxine (vitamin B6) 25 mg po tid.
  6. Add the H1-receptor blocker doxylamine 12.5 mg po tid if needed.
  7. Anti-emetic for p.r.n. use if intermittent more severe symptoms.

Prescribe a phenothiazine: promethazine 12.5-25 mg po/pr

Prescribe an antihistamine: hydroxyzine 12.5-25 mg po

If symptoms persists despite the above methods, consider adding:

  1. metoclopramide 5-10 mg po tid,

a cholinomimetic agent

(manufacturer’s nonrandomized study demonstrated 78 % efficacy)

  1. if relief is not obtained, consider the 5-HT-3 receptor inhibitor, dolasetron 25-100 mg po tid. (expensive, over 80 % effective in only randomized controlled trial)

(None of the above medications have been associated with an increased risk of fetal malformations.)

Initial Work-up: History

Case Scenario

Mrs. H is a 30 y/o G3P2 at 9 weeks by her dates who presents for her first prenatal visit complaining of nausea with vomiting that lasts pretty much all day, but she is able to keep some food down. She says this has occurred with each of her pregnancies, but this time it is especially troublesome. She has had a small amount of spotting but no cramping. She appears to be well hydrated.

Your initial work up at this time should include?

Hyperemesis is generally a diagnosis of exclusion, based on its occurrence in pregnancy before 10 weeks of gestation and likely gradual resolution

A simple basic workup is helpful and might include:

History: Anything to suggest:

Gastrointestinal problems?

-gastroenteritis, hepatitis, pancreatitis, cholelithiasis, ulcer

-colicy RUQ pain radiating to the shoulder for gallbladder disease, epigastric pain and pyrosis for peptic ulcer disease, a history of ethanol ingestion, etc…

Metabolic problems?

-diabetes, porphyria

Neurologic disease?

-migraine, tumor, vestibular lesions

Pregnancy related?

(typically in the latter half of pregnancy)

-Preeclampsia

-HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets)
-Acute fatty liver of pregnancy

Other

Drug toxicity, genitourinary tract disorders, and psychological problems

Nausea and vomiting that develop after 10 weeks of gestation are not likely due to hyperemesis gravidarum.

Associated symptoms suggesting other etiologies discussed above include abdominal pain, fever, headache, goiter, abnormal; neurologic findings, or hypertension.

Initial Work-up: Physical exam and lab

Hyperemesis gravidarum is a clinical diagnosis, without uniform criteria. As discussed above, one clinical definition is persistent vomiting, with weight loss exceeding 5 percent of pre-pregnancy body weight, and ketonuria.

Nausea and vomiting that develop after 10 weeks of gestation are not likely due to hyperemesis gravidarum. Associated symptoms suggesting other etiologies include abdominal pain and headache. See physical findings and lab abnormalities below.

Physical Exam:

-measurement of weight, orthostatic blood pressures

-fever

-hypertension

-goiter

-abnormal neurologic findings

Lab:

Thyroid function testing

See What about thyroid disease in pregnancy?

Unine

-Ketones

Electrolytes

(hypokalemia is the most common abnormality encountered)

Screen for hepatitis

Serum aminotransferase elevation is usually lower in hyperemesis than in viral hepatitis. Similarly, serum amylase levels are usually elevated to a lesser degree than in patients with acute pancreatitis and are of salivary rather than pancreatic

Alanine aminotransferase

(ALT, formerly known as SGPT or the serum glutamic pyruvate transaminase)

-usually the most sensitive.

-if it is abnormal, then you can investigate further from there.

If your initial therapy proves unhelpful and the symptoms become worse or evolve, then more of a GI work up may certainly be indicated later.

Ultrasound

An ultrasound examination is performed to exclude molar pregnancy and multiple gestation, both of which are associated with hyperemesis.

What about thyroid disease in pregnancy?

While nausea and vomiting is not a common symptom of hyperthyroidism, it has somehow become routine to order thyroid functions on these women.

signs of hyperthyroidism.

If you have read the Perinatologist Corner on Thyroid Disease in Pregnancy, you will recall that these women, who typically have high human chorionic gonadotrophin (HCG) levels, will frequently have an assay for TSH that often returns very low, suggesting hyperthyroidism. This may occur in up to 20% of pregnant women in whom the newer third generation, ultrasensitive TSH assays are obtained. These women may even have a mildly elevated free T4, but they will be clinically euthyroid, without tremor, tachycardia, hyperreflexia, or the other signs of hyperthyroidism.

Both these biochemical abnormalities will resolve by 18 weeks and anti-thyroid medications should not be started. (They will not help the nausea and vomiting either!) They may cause the fetus, who is totally dependent on its mother’s thyroxine until its own gland becomes functional at about 18 weeks, to become hypothyroid, with the accompanying later intellectual deficits.

Features that distinguish the transient hyperthyroidism of hyperemesis gravidarum from hyperthyroidism of other causes (which in a pregnant woman is most likely to be due to Graves' disease) are the vomiting, absence of goiter and ophthalmopathy, and absence of the common symptoms and signs of hyperthyroidism (heat intolerance, muscle weakness, tremor). In addition, serum free T4 concentrations are only minimally elevated and serum T3 concentrations are not elevated in women with hyperemesis gravidarum, whereas both are usually unequivocally elevated in pregnant women with true hyperthyroidism. Treatment of hyperthyroidism should not be undertaken without clear evidence of a primary thyroid disorder (eg, goiter, elevated free thyroid hormone or elevated TSH receptor antibody levels).

“Primum non nocere” (first do no harm)!

Hyperemesis gravidarum: What is helpful ?

Case Scenario

Mrs P is a 19 y/o G1P0 at 11 weeks by her dates who presents to the emergency department complaining of severe nausea and vomiting. She is wretching, appears ill, and is only able to produce a small amount of concentrated urine that is strongly positive for ketones.

Your initial management should include?

Severe Nausea and Vomiting of Pregnancy (Hyperemesis gravidarum)

The diagnosis of hyperemesis gravidarum is applied to the most severely affected patients, approximately 0.5 to 2 percent of pregnancies.

Hyperemesis gravidarum is intractable vomiting, not responsive to the above outpatient treatments. It is associated with dehydration, 4+ ketonuria, and/or electrolyte derangements, such that hospitalization for intravenous hydration is required.

  1. Admit.
  2. NPO; advance to sips and chips as tolerated.
  3. IV hydration, with electrolyte replacement as indicated.
  4. Rule out other causes (cholecystitis/pancreatitis, pyelonephritis, hepatitis, hyperthyroidism, etc…..)
  5. Many patients with hyperemesis will demonstrate biochemical evidence of a hyperthyroid state, but this is usually secondary to their high HCG levels. Treatment with anti-thyroid medications is usually not indicated, does not relieve nausea and vomiting, and may cause the patient, and the fetus, to become hypothyroid if continued beyond 18 weeks gestation.
  6. IV multivitamin replacement (especially thiamine 100 mg per liter, to prevent a Wernicke’s encephalopathy-like picture) if symptoms very severe and protracted.
  7. Any of the following parenteral anti-emetics:
    1. dimenhydrinate 50 mg in 50 mL NS q4-6h IV over 20 minutes
    2. metoclopramide 5-10 mg q8h IV
    3. promethazine 12.5-25 mg q4h IV
    4. dolasetron 4-8 mg over 15 minutes q12h IV

When the patient tolerates adequate oral intake, she may be considered for outpatient management. She may be sent home on the pharmacologic interventions recommended above for “Moderate Nausea and Vomiting of Pregnancy”.

Algorithm

Here is another helpful approach from Levichek Z et al 2002

QUESTION One of my patients suffers from a moderate-to-severe form of morning sickness. She responded only partially to doxylamine and pyridoxine, and I wish to try adding another medication. What should my priority be?

ANSWER
An algorithm used by Motherisk to manage thousands of patients takes a hierarchical approach to this condition. This approach is evidence based with regard to fetal safety as well as efficacy. (Go to ‘algorithm used by Motherisk’ and scroll down page to see algorithm)

(This link is available in the CME module)

Hyperemesis gravidarum: What is NOT helpful

Interventions considered not helpful for the treatment of hyperemesis:

1.Total parenteral nutrition has been associated with life-threatening complications. These complications are usually secondary to central intravenous access complications. This form of therapy may have more hazards to the patient than the underlying disorder, and is not recommended.

Short-term peripheral parenteral nutrition (through a “PICC-Line”) may be appropriate for selected cases.

2. Parenteral steroids (e.g., methylprednisolone) have not been consistently shown to be helpful in the aggregate meta-analysis data, and are no longer recommended for inpatient treatment of hyperemesis.

Most obstetricians avoid chronic administration of corticosteroids in pregnant women, when possible, because prolonged use appears to increase the risk of preterm premature rupture of membranes (PPROM). There may also be a slightly increased risk of oral clefts when the drugs are administered before 10 weeks of gestation. Data on the efficacy of this therapy largely derives from case reports; most randomized controlled trials using corticosteroids for treatment of hyperemesis failed to show a significant decrease in nausea and vomiting or number of hospital admissions.

3. There is little evidence that psychotherapy is helpful for hyperemesis, but the social situation of some patients may make short-term counseling a helpful adjunctive treatment modality.

Are these medications harmful to my fetus?

The agents below are Pregnancy Class A – C. (see Table, below). None of the above medications have been associated with an increased risk of fetal malformations. See Drug Safety below

Agent

Drug Class

Dose

Pregnancy Class

Rx

Pyridoxine

(Vitamin B6)

Vitamin

25 mg po

A

Oral: 25 mg po tid

Doxylamine

Antihistamine

(H-1 Blocker)

 

12.5 mg po

A

Oral: 12.5 mg po tid

Fructose, dextrose, and orthophosphoric acid

Antiemetic

15-30 mL

A

Oral: 15-30 mL on arising; repeat every 3 hours or when nausea threatens

Doxylamine

/ pyridoxine

Available in Canada, not available in U.S.

Antihistamine

(H-1 Blocker)

Vitamin

 

Doxylamine succinate 10 mg po

/ pyridoxine hydrochloride 10 mg po

 

A

 

Oral: Two delayed release tablets (a total of doxylamine 20 mg and pyridoxine 20 mg) at bedtime.

In severe cases or in cases with nausea/vomiting during the day, dosage may be increased by 1 tablet in the morning and/or afternoon.

 

Promethazine

Antihistamine
Phenothiazine Derivative
Sedative

12.5-25 mg po

C

Oral, I.M., I.V., rectal:

12.5-25 mg every 4-6 hours as needed

Hydroxyzine

Antihistamine

12.5-25 mg po

C

Oral: 12.5-100 mg/dose every 4-6 hours as needed

Dimenhydrinate

Antihistamine

50-100 mg

50 mg IV

B

Oral : 50-100 mg every 4-6 hours, not to exceed 400 mg/day

I.V.
50 mg in 50 mL NS q4-6h IV over 20 minutes

Metoclopramide

Cholinomimetic

5-10 mg po

B

Oral: 10-15 mg/dose up to 4 times/day 30 minutes before meals or food and at bedtime. Single doses of 20 mg are occasionally needed for provoking situations

I.V.:

5-10 mg q8h IV

(5-10 mg/kg)

Dolasetron

Selective 5-HT3 Receptor Antagonist

25-100 mg po

4-8 mg IV

 

B

Oral: 25-200 mg single dose

I.V.:
4-8 mg over 15 minutes q12h IV

(0.6-5 mg/kg as a single dose
50 mg 1-2 minute bolus
2.4-3 mg/kg 20-minute infusion)

Drug Safety

A number of reports have demonstrated that antiemetic drug therapy is effective and does not increase the incidence of congenital anomalies. Some examples are illustrated below:

  • The safety of antihistamines was affirmed in a meta-analysis that examined the association between antihistamine use and major malformations. This review of 24 controlled studies including over 200,000 first trimester exposures found that H1-receptor blockers actually had a protective effect (odds ratio 0.76, 95 percent CI 0.60 to 0.94). Pooled analysis also demonstrated efficacy of this class of drugs (RR 0.34, 95 percent CI 0.27 to 0.43).
  • The most common anticholinergic drug used for treatment of nausea is dicyclomine which had been a component of Bendectin until it was removed because of lack of efficacy. A meta-analysis of studies on outcome of pregnancies exposed to Bendectin reported no increase in the incidence of birth defects. Pooled analysis demonstrated efficacy of Bendectin (RR 0.53, 95 percent CI 0.41 to 0.68). In addition, data from a Swedish registry on women who took promethazine or meclizine in the first trimester did not show an increase in the rate of birth defects.
  • Evidence from systematic review (n = 2948 exposed patients) showed that dopamine antagonists (eg, phenothiazines, droperidol, metoclopramide) were not teratogenic (RR 1.03, 95 percent CI 0.88 to 1.22)]. The best studied drugs in this class are the phenothiazines, which appeared effective (RR 0.31, 95 percent CI 0.24 to 0.42).
  • Ondansetron is the most widely used HT3 antagonist. Animal data are reassuring as to safety in pregnancy, but human data on safety or efficacy are sparse.

What about natural products and lifestyle changes?

The first steps in managing nausea and vomiting in pregnancy should be diet and lifestyle changes.

Avoidance of triggers

The cornerstone of nonpharmacologic therapy of hyperemesis gravidarum is avoidance of environmental triggers. Examples of some triggers include: stuffy rooms, odors (eg, perfume, chemicals, food, smoke), heat, humidity, noise, and visual or physical motion (eg, flickering lights, driving). Brushing teeth after eating, quickly changing position, and not getting enough rest may also aggravate symptoms. Supplements containing iron should be avoided until symptoms resolve.

Diet

Advise your patient to make dietary adjustments, e.g., small, frequent, low fat meals, etc . . .

Dietary management generally consists of frequent high carbohydrate, low fat, small meals. Dietary manipulations, such as eliminating foods high in fat or spicy foods or eating salty or high protein snacks/meals appear to help some women. Fluids are better tolerated if cold, clear, and carbonated or sour (eg, ginger ale, lemonade) and if taken in small amounts between meals.

Aromatic therapies involving lemon (lemonade), mint (tea), or orange have also been described as useful. Women with hyperemesis should eat before or as soon as they feel hungry in order to avoid an empty stomach that may aggravate nausea.

Herbal or Natural alternatives

Other patients may want to pursue herbal or natural alternatives. These agents are unregulated products, hence one can never be certain what dose, potency, or contaminants are actually present in these preparations. Caution should be exercised when using any unregulated products like those listed below.

Here are some examples

Name

Category

Plant Part

Dose

Comments

Ginger

(Zingiber officinale)

Herb

Root

Oral: 250 mg 3 -4 times/day with food, standardized to contain 4% volatile oils or 5% total pungent compounds (most prominently 6-gingerol and 6-shogaol) per dose

Ginger has been used extensively as both a culinary herb and an agent in traditional medicine. In the US, it has been popularized for motion sickness, dyspepsia, and nausea. Its lack of sedative effects may be an advantage over other antiemetic agents.

Ginger is beneficial as an antiemetic, for both nausea and vomiting, in women ≤ 17 weeks gestation. In one study, subjects took ginger at doses up to 1 g daily for a maximum of 4 days. Follow-up and assessment took place for 7 days following the treatment period. No side effects were reported during this study and evaluation period

German chamomile

Herb

Flower

Oral: 400-1600 mg/day in divided doses, standardized to contain 1.2% apigenin and 0.5% essential oil per dose

Tea: 1 heaping teaspoonful of dried flowers in hot water; steep for 10 minutes, drink up to 3 times/day

 

Chamomile has been used for centuries as a mild sedative and anxiolytic. In contrast to many anxiolytic agents, it does not generally cause drowsiness or motor impairment. Chamomile also has spasmolytic and anti-inflammatory properties which may contribute to its apparent value in relieving a number of gastrointestinal complaints.

Peppermint

(Mentha piperita)

Herb

 

Leaf, oil

Oral: One tablet (enteric coated), 2-3 times/day, containing 0.2 mL oil per tablet
Note: The oil should contain:

≥ 4.5% w/v and ≤ 10% w/w of esters calculated as menthyl acetate
≥ 44% w/v of free alcohols calculated as menthol
≥ 15% w/v and ≤ 32% w/v ketones calculated as menthone

Peppermint oil is used for digestive complaints as a carminative and spasmolytic. It is also used in Irritable Bowel Syndrome (IBS).

 

What about ‘alternative’ therapies?

Other options are P6 acupuncture or acupressure wristbands and powdered ginger (1 gram daily). (See Herbal or ‘Natural’ alternatives)

Although acupuncture has been shown to be useful when compared to no treatment, there appears to be a strong placebo effect. A Cochrane type review did not find P6 acupuncture or acupressor to be clearly effective.

Although ginger has been shown to be more effective than placebo and equivalent to vitamin B6 (pyridoxine), its safety in pregnancy has not been firmly established.

Hypnosis has been reported to be helpful in selected patients. It has been suggested that hypnotized women with severe nausea and vomiting of pregnancy are more easily influenced by suggestion than controls, and at least one controlled study supports this hypothesis. In a limited number of studies, all lacking controls, hypnosis has been shown to decrease vomiting in patients undergoing chemotherapy and those with hyperemesis gravidarum.

Psychotherapy can also be a useful adjunctive therapy, if other psychological sources of anxiety are identified and can be ameliorated. There is little evidence for a therapeutic effect of traditional psychotherapy in hyperemesis gravidarum. No controlled trials have evaluated behavioral therapy in nausea and vomiting of pregnancy, but there are data to indicate that delayed and anticipatory nausea and vomiting after chemotherapy is diminished by systematic desensitization and relaxation therapy.

ACOG Resources

Nausea and Vomiting of Pregnancy

ACOG Practice Bulletin #52 April 2004

Summary of Recommendations

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

  • Taking a multivitamin at the time of conception may decrease the severity of nausea and vomiting of pregnancy.
  • Treatment of nausea and vomiting of pregnancy with vitamin B6 or vitamin B6 plus doxylamine is safe and effective and should be considered first-line pharmacotherapy.
  • In patients with hyperemesis gravidarum who also have suppressed thyroid-stimulating hormone levels, treatment of hyperthyroidism should not be undertaken without evidence of intrinsic thyroid disease (including goiter and/or thyroid autoantibodies).

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

  • Treatment of nausea and vomiting of pregnancy with ginger has shown beneficial effects and can be considered as a nonpharmacologic option.
  • In refractory cases of nausea and vomiting of pregnancy, the following medications have been shown to be safe and efficacious in pregnancy: antihistamine H1 receptor blockers, phenothiazines, and benzamides.
  • Early treatment of nausea and vomiting of pregnancy is recommended to prevent progression to hyperemesis gravidarum.
  • Treatment of severe nausea and vomiting of pregnancy or hyperemesis gravidarum with methylprednisolone may be efficacious in refractory cases; however, the risk profile of methylprednisolone suggests it should be a treatment of last resort.

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

  • Intravenous hydration should be used for the patient who cannot tolerate oral liquids for a prolonged period or if clinical signs of dehydration are present. Correction of ketosis and vitamin deficiency should be strongly considered. Dextrose and vitamins, especially thiamine, should be included in the therapy when prolonged vomiting is present.
  • Enteral or parenteral nutrition should be initiated for any patient who cannot maintain her weight because of vomiting.

Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 52. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:803–15

Again, after you peruse this material, you should go to the link directly below, take the Posttest and receive free CME credit. http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm

Other

Miscarriage risk from amniocentesis performed for abnormal maternal serum screening

RESULTS: The miscarriage rate with amniocentesis, 0.46% (69/15,005), was no different than without, 0.53% (90/17,045), P = .38. There was no difference in maternal age, serum biochemical factors, gestational age at miscarriage (21.1 weeks for both groups), or days until miscarriage (23 after amniocentesis and 20.4 without). Log-rank test revealed no difference for gestational age at miscarriage (P = .61) or number of days until miscarriage (P = .40). CONCLUSION: The rate and timing of miscarriage was similar with or without amniocentesis in California women with abnormal maternal serum screening.

Towner D et al Miscarriage risk from amniocentesis performed for abnormal maternal serum screening. Am J Obstet Gynecol.  2007; 196(6):608.e1-5;

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17547917

Evidence base of predictive markers and therapies (eg, progesterone) for preterm birth

Rates of preterm birth have continued to rise despite intensive research efforts over the last several decades. A woman who has a spontaneous preterm birth is at high risk for a subsequent preterm birth. Studies have identified clinical, sonographic, and biochemical markers that help to identify the women at highest risk. Determining cervical length and measuring cervicovaginal fibronectin have been proposed as useful tools for evaluating women at risk of preterm birth and may identify those who might benefit from a timely course of antenatal corticosteroids, but effective interventions to prevent preterm birth remain elusive. In the prevention of recurrent spontaneous preterm birth, recent trials have confirmed the use of progesterone beginning in the second trimester as an effective intervention. Optimal management of women with a history of spontaneous preterm birth includes a thorough review of the obstetric, medical, and social history, with attention to potentially reversible causes of preterm birth (eg, smoking cessation, acute infections, strenuous activities), accurate ultrasound dating, consideration of progesterone therapy beginning at 16-20 weeks of gestation, and close surveillance during the pregnancy for evolving findings. Results from the ongoing trials of cerclage as an interventional therapy and omega-3 fatty acid supplementation as a preventive therapy will provide additional knowledge for the optimal management of these high-risk women.

Spong CY. Prediction and prevention of recurrent spontaneous preterm birth. Obstet Gynecol. 2007 Aug;110(2 Pt 1):405-15

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17666618&dopt=AbstractPlus

Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics.

Prevention of congenital cardiovascular defects has been hampered by a lack of information about modifiable risk factors for abnormalities in cardiac development. Over the past decade, there have been major breakthroughs in the understanding of inherited causes of congenital heart disease, including the identification of specific genetic abnormalities for some types of malformations. Although relatively less information has been available on noninherited modifiable factors that may have an adverse effect on the fetal heart, there is a growing body of epidemiological literature on this topic. This statement summarizes the currently available literature on potential fetal exposures that might alter risk for cardiovascular defects. Information is summarized for periconceptional multivitamin or folic acid intake, which may reduce the risk of cardiac disease in the fetus, and for additional types of potential exposures that may increase the risk, including maternal illnesses, maternal therapeutic and nontherapeutic drug exposures, environmental exposures, and paternal exposures. Information is highlighted regarding definitive risk factors such as maternal rubella; phenylketonuria; pregestational diabetes; exposure to thalidomide, vitamin A cogeners, or retinoids; and indomethacin tocolysis. Caveats regarding interpretation of possible exposure-outcome relationships from case-control studies are given because this type of study has provided most of the available information. Guidelines for prospective parents that could reduce the likelihood that their child will have a major cardiac malformation are given. Issues related to pregnancy monitoring are discussed. Knowledge gaps and future sources of new information on risk factors are described.

Jenkins KJ et al. Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics. Circulation.  2007; 115(23):2995-3014

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17519397

1st trimester US of the nasal bone may improve Down syndrome screening

Increasingly, women are choosing first-trimester risk assessment for Down syndrome and other aneuploid conditions. Recent studies have suggested that adding ultrasound assessment of the nasal bone to nuchal translucency thickness and maternal serum analytes in the first trimester will improve performance. This report assesses the current literature and discusses practical issues that must be addressed before widespread implementation of nasal bone screening in the United States

Rosen T, et al First-trimester ultrasound assessment of the nasal bone to screen for aneuploidy. Obstet Gynecol. 2007 Aug;110(2 Pt 1):399-404

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17666617&dopt=AbstractPlus

A meta-analysis on the influence of inflammatory bowel disease on pregnancy

CONCLUSION: The study has shown a higher incidence of adverse pregnancy outcomes in patients with IBD. Further studies are required to clarify which women are at higher risk, as this was not determined in the present study. This has an effect on the management of patients with IBD during pregnancy, who should be treated as a potentially high-risk group.

Cornish J et al A meta-analysis on the influence of inflammatory bowel disease on pregnancy Gut.  2007; 56(6):830-

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17185356

A comprehensive analysis of adverse obstetric and pediatric complications in women with asthma

CONCLUSIONS: We found some increased risks in women with asthma that need to be considered in the future; however, our results indicate that women with asthma have similar reproductive risks compared with women without asthma in the general population for most of the range of outcomes studied

Tata LJ et al A comprehensive analysis of adverse obstetric and pediatric complications in women with asthma. Am J Respir Crit Care Med.  2007; 175(10):991-7

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17272783

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Primary Care Discussion Forum - Ann Bullock, Cherokee, NC

Chronic Kidney Disease: CKD is Part of Primary Care

Moderator: Andrew Narva, MD

September 4, 2007

  • What is the burden of CKD in AI/AN?
  • How should CKD patients be identified and followed?
  • What should we be doing for CKD patients in the primary setting?
  • When should patients be referred?

How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26

Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26

Questions on how to subscribe, contact nmurphy@scf.cc directly

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STD Corner - Lori de Ravello, National IHS STD Program

Culture, context, and sexual risk among Northern Plains American Indian Youth

American Indian adolescents have two to four times the rate of sexually transmitted diseases (STDs) compared to whites nationally, they shoulder twice the proportion of AIDS compared to their national counterparts, and they have a 25% higher level of teen births. Yet little is known about the contemporary expectations, pressures, and norms that influence American Indian youth or how those might be shaped by today's lived cultural experiences, which frustrates attempts to mitigate the apparent disparity in sexual health. This paper used data from focus groups, in-depth interviews, and surveys with American Indian adolescents and young male and female adults from a Northern Plains tribe to contextualize sexual risk (and avoidance). Placing the findings within an adapted indigenist stress-coping framework, we found that youth faced intense pressures for early sex, often associated with substance use. Condoms were not associated with stigma, yet few seemed to value their importance for disease prevention. Youth encountered few economic or social recriminations for a teen birth. As such, cultural influences are important to American Indian sexual health and could be a key part of prevention strategies.

Kaufman CE et al Culture, context, and sexual risk among Northern Plains American Indian Youth Social Science & Medicine. 64(10):2152-64, 2007 May

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17379373

Perceptions of Sexual Assertiveness among Adolescent Girls: Initiation, Refusal, and Use of Protective Behaviors

Conclusions:  Most of these girls perceived themselves as sexually assertive. Given that sexual experience, not relationship factors, were related to perceptions of sexual assertiveness, the design of counseling messages should incorporate sexual experience. These messages should find effective ways to help girls both to communicate their sexual desires and to enhance their ability to protect themselves.

Auslander BA et al Perceptions of Sexual Assertiveness among Adolescent Girls: Initiation, Refusal, and Use of Protective Behaviors Journal Of Pediatric And Adolescent Gynecology, Volume 20, Issue 3, Pages 157-162 (June 2007)

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17561183

Sexually Transmitted Infections in Preadolescent Children

Pediatric nurse practitioners may be called on to conduct an assessment for sexual abuse of a young child. Depending on the type of sexual contact, a decision may have to be made to obtain cultures for sexually transmitted infections (STIs). Recognizing the symptoms of STIs in preadolescent children, along with having knowledge of the modes of transmission, diagnostics, and treatment, are part of the clinical decision. The impact of STI in preadolescent children has physical and emotional consequences for the child and family, along with legal consequences for an accused perpetrator. Knowledge about types of sexual contact that necessitate STI cultures, incubation periods, and symptomatology is essential. Accurate techniques and appropriate selection of culture materials are necessary. Proper positioning of the child for obtaining cultures can decrease the potential for discomfort during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex virus, human papillomavirus virus, syphilis, Trichomonas vaginalis, hepatitis B, and HIV are reviewed.  

Lewin LC. Sexually Transmitted Infections in Preadolescent Children Journal of Pediatric Health Care, Volume 21, Issue 3, May-June 2007, Pages 153-161

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17478304

Screening for Chlamydial Infection: USPSTF Recommendation Statements

The USPSTF recommends screening for chlamydial infection for all sexually active nonpregnant young women age 24 years or younger and older nonpregnant women who are at increased risk. This is a grade A recommendation .

The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 years or younger and for older pregnant women who are at increased risk.

This is a grade B recommendation.

The USPSTF recommends against routinely screening for chlamydial infection for women age 25 years or older, regardless of whether they are pregnant, if they are not at increased risk.

This is a grade C recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men.

This is an I statement.

http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiars.pdf

Home screening for sexually transmitted diseases in high-risk young women: RCT

Results: Of 197 women in the intervention group, 140 (71%) returned at least one home test and 25 of 249 (10%) home tests were positive. Women who received home screening tests completed significantly more STD tests overall (1.94 vs 1.41 tests per woman-year, p<0.001) and more STD tests in the absence of symptoms (1.18 vs 0.75 tests per woman-year, p<0.001). More women in the intervention group completed at least one test when asymptomatic (162 (82.2%) vs 117 (61.3%), p<0.001). The intervention was most effective among women recruited outside medical clinics. There was no significant difference in the overall rate of STDs detected.

Conclusions: Home screening significantly increased the utilisation of chlamydia and gonorrhoea testing in this sample of high-risk young women, and thus represents a feasible strategy to facilitate STD testing in young women.

Cook R et al Home screening for sexually transmitted diseases in high-risk young women: randomised controlled trial Sexually Transmitted Infections July  2007; Vol 83: p.  286-291.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17301105

Defining Virginity and Abstinence: Adolescents' Interpretations of Sexual Behaviors

The authors of the current study set out to examine adolescent conceptualizations of virginity and abstinence. They further sought to learn whether differences in youths' definitions of these terms varied by age, gender, ethnicity, and sexual experience.

The researchers conducted a series of logistic regressions to study whether gender, age, ethnicity, and sexual experience predicted whether an individual was still a virgin after taking part in genital touching, oral sex, anal sex or vaginal sex.

The results indicated that youths' concept of loss of virginity was linked primarily with vaginal and anal intercourse, while a greater proportion of respondents attributed a loss of abstinence to other behaviors, such as genital touching and oral sex. Sexual experience was the strongest predictor of how the adolescents defined virginity and abstinence.

The fact that significant differences in youths' definitions of abstinence and virginity existed "suggests that additional attention is needed to ensure a common understanding of these terms to achieve successful sexual education and prevention programs," the authors concluded.

Bersamin M et al Defining Virginity and Abstinence: Adolescents' Interpretations of Sexual Behaviors Journal of Adolescent Health Vol. 41; No. 2: P. 182-188    (08..07)

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17659223

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Barbara Stillwater, Alaska State Diabetes Program

Within eight years, 75% of adults will be obese or overweight

An astonishing doubling in American obesity took place in the two decades after the nation's bicentennial, epidemiologists reported.

By 2015, 75% of adults will be overweight or obese, and 41% will be obese. In conclusion, obesity has increased at an alarming rate in the United States over the past three decades. The associations of obesity with gender, age, ethnicity, and socioeconomic status are complex and dynamic. Related population-based programs and policies are needed.

Wang Y, et al. The Obesity Epidemic in the United States -- Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis Epidemiol Rev. 2007;29:6-28.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17510091

Regular and Diet Soft Drinks Linked To Increase In Risk Factors For Heart Disease

Drinking more than one soft drink daily — whether it’s regular or diet — may be associated with an increase in the risk factors for heart disease

CONCLUSIONS: In middle-aged adults, soft drink consumption is associated with a higher prevalence and incidence of multiple metabolic risk factors.

Dhingra R, et al Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17646581

Very Low Birth Weight Is Associated With Impaired Glucose

Young adults with very low birth weight had significantly higher indexes of glucose intolerance and insulin resistance, and higher blood pressure, compared with those born at term. These differences, however, were not attributable to body size or composition, or fat

distribution. The authors suggested that persons with very low birth weight might be more vulnerable to type 2 diabetes and cardiovascular disease later in life, and young adults with very low birth weight might benefit from targeted preventive interventions.

Hovi P et al. Glucose regulation in young adults with very low birth weight. N Engl J Med. 2007;356:2053-2063.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17507704

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Women's Health Headlines, Carolyn Aoyama, HQE

APN scope of practice: colonoscopy?

Study Finds Colonoscopy Most Effective Method of Colon Cancer Screening (especially for women!) Colon cancer is the third leading cause of cancer deaths for AI/AN women and the second leading cause of cancer deaths for AI/AN men.  Given the prevalence of colon cancer among AI/AN people, one would assume that colonoscopy would be available at the majority of IHS hospitals.   This is not the case.   Consideration is being given to training interested APNs in colonoscopy. 

I have heard from two APNs who include colonoscopy within their scope of practice; one practicing in a Tribal facility and one in a federal facility. If you are interested in broadening your scope of practice to include colonoscopy, please email me.  If there is sufficient interest in colonoscopy, I will convene an advisory group to consider this change in scope and the necessary training.  Contact Carolyn.Aoyama@ihs.gov

Schoenfeld P, et al Colonoscopic screening of average-risk women for colorectal neoplasia. N Engl J Med. 2005 May 19;352(20):2061-8

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15901859

Templates for Protocols and Procedures for Maternity Services 2nd Edition

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) has developed a reference entitled, “Templates for Protocols and Procedures for Maternity Services”.  The reference (hard copy and disc) can be used to update intrapartum, postpartum, and newborn protocols and procedures, plus discharge instructions and sample orders. 

I have scanned in a few pages of this reference to give you an idea of content.   The Division of Nursing at Headquarters will supply any IHS facility with a copy. 

Contact Carolyn.Aoyama@ihs.gov

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What's new on the ITU MCH web pages?

New Breastfeeding Family Support webpage, Indian Health
http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.cfm

There are several upcoming Conferences

and Online CME/CEU resources, etc….

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

…or just take a look at the What’s New page

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Save the dates

3rd Annual American Indian and Alaska Native Long Term Care Conference

I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course

  • September 16 – 19, 2007
  • Denver , CO
  • Contact Yvonne Malloy at 202-863-2580 or YMalloy@acog.org

Second National Summit on Preconception Health and Health Care

2007 National HIV Prevention Conference

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

The August 2007 OB/GYN CCC Corner is available.

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Abstract of the Month | From Your Colleagues | Hot Topics | Features   

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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.

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