The effects of tamoxifen on the vaginal epithelium in postmenopausal women.

Although increased vaginal discharge occurs with treatment, clinicians often presume the effects of tamoxifen on the vaginal epithelium are antiestrogenic. We studied 16 postmenopausal women before they began tamoxifen treatment, at 6 months, and then at annual intervals for up to 6 years. Vaginal scrapings for cytology smears and maturation values (MV) for these were performed. MV scores increased by a mean of 32% and these were predictably related to baseline values, with greater increases seen when there were lower scores before treatment. Only one woman with an MV of 0 before treatment had no significant changes with 3 years' treatment. The effects of tamoxifen on the vaginal epithelium are influenced by the baseline hormonal milieu and are maturational in the majority of postmenopausal women.

Primary care in obstetrics and gynecology resident education: a baseline survey of residents' perceptions and experiences.

OBJECTIVE: To determine the perceptions and practices of American obstetrics and gynecology residents concerning primary care immediately before the institution of Residency Review Committee Special Requirements for Obstetrics and Gynecology. METHODS: The Council on Resident Education in Obstetrics and Gynecology In-Service Examination in 1995, given to 4361 residents, who represented all programs in the country, included a questionnaire on whether obstetrics and gynecology was primary care and whether they planned to do primary care after residency. Primary care services were categorized by counseling and screening, as defined by the U.S. Preventive Health Services Task Force. Variables included gender, residency level (upper or lower), and type of residency (community or university based). Data were analyzed using the chi2 text and multiple analyses of variance. RESULTS: The response rate was 94% (4099 of 4361), representing a nationwide complement. Eighty-seven percent of the respondents believed that obstetrics and gynecology was primary care and 85% planned to practice accordingly after residency. Residents spend less than 25% of their time counseling on nongynecologic subjects and less than 25% of their time screening for nongynecologic entities, so their perception as primary care providers focused on traditional obstetric and gynecologic counseling and screening services. When assessments were made by gender, level of training, and type of residency, significant differences were found in many variables regarding counseling and screening practices. CONCLUSION: Our survey results suggest that most American obstetrics and gynecology residents consider obstetrics and gynecology primary care but that there were limitations in the educational venues for learning about nongynecologic primary care before the implementation of the Residency Review Committee Special Requirements. Improvement in nongynecologic primary care teaching is a reasonable expectation because residency programs have had 3 years to institute the mandated changes and provide it to residents.

The in-training examination in obstetrics and gynecology: an attempt to establish a remediation indicator.

OBJECTIVE: With the use of a university- and community hospital-based faculty, we attempted to determine at what performance level remediation would be recommended. STUDY DESIGN: The Committee on In-Training Examinations for Residents in Obstetrics and Gynecology Task Force on Standard-Based Scoring sent the 1991 examination to 16 university- and 12 community hospital-based faculty members. Given a standardized definition of a "borderline third-year resident," each faculty scored each item on the examination on whether that hypothetic resident would or would not correctly answer the item. RESULTS: The mean expectation of correct responses on the 397-item test was 236 (59%). This was identical to the score obtained if 2 SDs were subtracted from the actual mean for all third-year residents taking the examination. University- and community hospital-based faculty members had generally similar expectations of this defined resident. CONCLUSION: Although poor examination results should not be recommended as the sole determinant for promotion, it appears that 2 SDs below the mean may be an appropriate score below which remediation could be recommended.

Assessment of the resident in-training examination in obstetrics and gynecology.

An integral component for the evaluation of resident's cognitive knowledge is the examination developed under the auspices of the Council on Resident Education in Obstetrics and Gynecology (CREOG). We sought to assess the usefulness of this annual examination from the perspective of both residents and residency program directors. We were particularly interested in comparing the contemporary use of this examination with the original intent of CREOG when the examination was developed in 1968. In addition, we were interested in determining the role of the examination in modifying educational programs. A questionnaire was mailed to all program directors before the 1994 examination and given to all house staff when the examination was administered. The response rate was 55 and 82%, respectively. Overall, the majority of residents (60%) and program directors (58%) found the examination to be an accurate assessment of cognitive knowledge; feedback on examination results varied widely, and residents used a variety of tools to prepare for the examination.

Changing patterns in ambulatory care: a more broad-based approach.

The obstetrician-gynecologist must assume a dual role in the future provision of health care to women. Not only should the obstetrician-gynecologist function as a consultant for medical and surgical problems peculiar to the female reproductive tract, but also assume a broader-based role for preventive medicine and health maintenance functions. This includes the provision of care which traditionally had not been offered in our specialty. To this end, a summary of preventive medicine measures is provided, including cardiovascular disease, cancer screening and nongynecologic metabolic disorders.

The fourth-year medical school curriculum: recommendations of the Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology.

OBJECTIVES: The Association of Professors of Gynecology and Obstetrics and the Council on Resident Education in Obstetrics and Gynecology have proposed a fourth-year medical school curriculum for a student interested in pursuing a residency in obstetrics and gynecology. STUDY DESIGN: Faculty members and residents in North Carolina, Illinois, and Michigan were surveyed as to the ideal curriculum that they would recommend for fourth-year students. The committee members representing the Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics then reviewed these surveys and proposed a final curriculum. RESULTS: A core curriculum of general medicine as an acting internship, an intensive care unit rotation, neonatology, and emergency medicine was recommended. Additional courses strongly considered were ambulatory obstetrics-gynecology, acting internship in obstetrics-gynecology, endocrinology, and general surgery. CONCLUSION: The committee recommends a curriculum that is broad and balanced in general medical education.

Labor pain: a comparison of parturients in a Dutch and an American teaching hospital.

Women giving birth in two university hospitals, one in the Netherlands and the other in the United States, were surveyed postpartum regarding expectations of pain in labor and availability of medication for its relief, perceptions of the painfulness of labor, and use of analgesia and anesthesia. American women expected labor to be more painful, anticipated that they would receive medication for it, and did receive such medication in significantly greater proportions compared with Dutch parturients. These findings point to fundamental, culturally determined differences between these two societies with respect to women's views of the painfulness of childbirth.

Preinduction cervical ripening with prostaglandin E2 intracervical gel.

A double-blind, placebo-controlled, dose-ranging study was undertaken to evaluate the efficacy of two doses of intracervical prostaglandin E2 gel in patients with unfavorable Bishop scores. Mean change in Bishop score, success of softening, time to labor, and time to delivery were all significantly different in the two treatment groups as compared with the placebo group. Twenty-three of 30 treated patients had uterine contractions lasting greater than four hours and eight patients delivered during the observation period. Moreover, one case of uterine hyperactivity and five cases of severe fetal heart rate decelerations were noted in the treatment groups. Although efficacious for cervical ripening, caution is warranted when using this technique in patients at risk for placental insufficiency.

Pregnancy in a patient with aneurysms of the right coronary artery and an arterioventricular fistula. A case report.

A woman with aneurysms of the right coronary artery and right coronary sinus of Valsalva and a right coronary arterioventricular fistula developed angina during pregnancy. Lumbar epidural anesthesia was utilized during induction of labor and cesarean delivery. The patient had no intrapartum evidence of ischemia or congestive heart failure, and she recovered without an immediate recurrence of angina.

A histopathologic evaluation of nevocellular nevi in pregnancy.

A detailed histopathologic study was performed on 128 nevi removed from 86 pregnant white patients. None of the patients had clinical evidence of the dysplastic nevus syndrome, and none of the excised nevi were clinically suspicious for melanoma. One third of patients reported some change in nevi during pregnancy. Nevi from an age-matched male control population (50 patients) had a spectrum of histologic features essentially identical to the pregnant patients, while nevi from a female control population (51 patients) showed slightly less atypia according to our criteria. The differences found between the nevi from pregnant and control women suggest that a mild degree of histopathologic atypia or "activation" is associated with pregnancy. However, in the population studied, these changes were never of sufficient degree to result in diagnostic confusion.

Endometriosis causing ureteral obstruction.

Although endometriosis accounts for 15 to 20% of all gynecologic laparotomies, ureteral obstruction secondary to this disease has received little attention. This may be partly the result of diagnostic difficulties secondary to the unusual symptoms and atypical age groups of the patients. Five cases of obstructive uropathy caused by endometriosis are reported. Each case was documented by urologic evaluation as well as excretory urograms, surgical exploration, and histologic confirmation. All patients had significant radiographic and laboratory renal compromise, including marked degrees of hydronephrosis. Follow-up included excretory urograms obtained in all cases, which showed cure of original symptoms with radiographic improvement in four of five patients, whereas one patient developed chronic renal failure and hypertension. The present report suggests that with thorough preoperative assessment of the urinary tract, including contrast radiography in select cases of pelvic pathology, curative gynecologic and urologic surgery can be performed.

Improvement of reliability of an oral examination by a structured evaluation instrument.

The main purposes of this study were to estimate the reliability of oral examinations administered to medical students during a clinical clerkship and to improve the reliability of this evaluation technique. In the first part of the study, the reliability of oral examinations as traditionally administered was estimated. The average intraclass reliability coefficient for these examinations was .48. Cassette recordings of these oral examinations were also rated by the faculty members. The average intraclass reliability coefficient of the ratings of the taped performances was .82. In the second part of the study, the reliability of oral examinations was investigated with the raters using a newly developed evaluation form. The average intraclass reliability of the oral examination using the evaluation form was .67, a noticeable increase over the .48 obtained without the form. The average intraclass reliability of ratings made from tape recordings of these oral examinations was .62.

Experience with an alternative birth center in a university hospital.

Consumer interest has generated the widespread popularity of the alternative birth center (ABC) in recent years. The Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, recently incorporated such a center into a tertiary care educational facility. Intrapartum transfer of 39 (20%) ABC patients to a conventional delivery area demonstrated the need for careful clinical assessment of the patient. The cesarean section rate and forceps delivery rate of all ABC patients were less than half those of the overall obstetric population in the period studied. Serious fetal and maternal complications occurred infrequently but underscored the need for access to full hospital facilities. Low-risk, consumer-oriented obstetric service can be provided safely within the confines of a tertiary care referral service while providing the additional advantage of professional and patient education.

Fetomaternal bleeding as a cause for "unexplained" fetal death.

Among a series of 29 antepartum fetal deaths without apparent cause, 4 (13.8%) were apparently due to transplacental fetal exsanguination. This represents 3.4% of all fetal deaths and 0.04% of all births in a series of 9223 deliveries. The principal conclusion of this study is that massive fetal maternal hemorrhage occurring without apparent cause or predisposing factors represents a significant cause of fetal wastage, examination of which should be included in evaluation of these patients.