Temporal changes in rates and reasons for medical induction of term labor, 1980-1996.

OBJECTIVE: This study was undertaken to assess temporal changes in rates and reasons for medical induction of term labor. STUDY DESIGN: A retrospective medical record review was conducted on a population-based cohort of 1293 women with term deliveries. RESULTS: The rate of medical labor induction increased from 12.9% in 1980 to 25.8% in 1995. Stated indications also changed, with a 2-fold increase in induction for postdate gestation, a 23-fold increase in induction for macrosomia, a 15-fold increase in elective induction, and a 22-fold decline in induction for premature rupture of membranes. The average gestational age at delivery of postdate pregnancies declined from 41.9 weeks in 1980 to 41.0 weeks in 1995. By 1995, the average maternal length of stay and the percentage of cesarean deliveries were higher among women with induced labor at term than among those with spontaneous labor at term. CONCLUSION: Induction of term labor has almost doubled in prevalence during the past 15 years. The most common indications are elective induction and postdate pregnancy, often applied to gestations of 40 to 41 weeks' duration.

Shoulder dystocia. Rotational maneuvers revisited.

Shoulder dystocia is an acute obstetric emergency that necessitates prompt, skillful intervention in order to prevent serious fetal trauma or death. Of the maneuvers described to deal with this difficult problem, rotational maneuvers are among the most ingenious. In spite of the effectiveness of these techniques, various technical deviations have led to the incorrect description and implementation of these maneuvers. This review of the rotational maneuvers used to counter shoulder dystocia gives particular attention to the techniques described originally.

Effects of long-term transdermal administration of estradiol on serum lipids.

OBJECTIVE: To evaluate the effect of three different dosages of transdermally administered 17beta-estradiol on serum lipoproteins in women who had recently experienced surgical menopause. MATERIAL AND METHODS: We undertook a 2-year, randomized, double-blind, placebo-controlled study in which 126 subjects were recruited and stratified by age, and 93 patients completed the protocol. Serum lipoproteins were assessed before initiation of treatment and after 12 and 24 months of therapy with 0.025, 0.05, or 0.1 mg of estradiol daily. RESULTS: Total serum cholesterol and low-density lipoprotein cholesterol showed dose-dependent decreases that reached statistical significance after 2 years of treatment with transdermally administered estradiol. CONCLUSION: This study confirms that transdermally administered 17beta-estradiol has a modest beneficial effect on serum lipoproteins, with decreased levels of total cholesterol and low-density lipoprotein cholesterol.

Barriers to prenatal care: factors associated with late initiation of care in a middle-class midwestern community.

BACKGROUND: Barriers to prenatal care have been extensively investigated in low-income and inner-city communities. Less attention has been directed to the study of prenatal care among middle- and upper-class pregnant women. This study describes perceived barriers and factors associated with late initiation of prenatal care in a predominantly middle- to upper-class midwestern community. METHODS: Consenting women in Olmsted County, Minnesota, who were attending a clinic for their first obstetric visit completed a self-administered questionnaire that queried the presence of factors making it difficult to receive prenatal care, perception about the importance of prenatal care, expectations at the first prenatal care visit, and sociodemographic factors. RESULTS: Of the 813 women aged 14 to 47 years, 692 (86%) had their first prenatal visit within the first trimester of pregnancy. Only 98 (12%) women reported external barriers to receiving prenatal care. These factors included difficulty in getting an appointment (46.9%), problems finding child care (26.5%), and lack of transportation (14.3%). In multivariable logistic regression analyses, late initiation of care was associated with patient perception of prenatal care as being less than very important (odds ratio [OR] = 4.1, 95% confidence interval [CI], 1.7-9.7); external barriers to prenatal care (OR = 2.9, 95% CI, 1.6-5.4); annual income < $17,000 (OR = 2.9, 95% CI, 1.5-5.7); and an unintended pregnancy (OR = 2.1, 95% CI, 1.3-3.5). Multiparous women and women older than 35 years were more likely to perceive prenatal care as less than very important (OR = 3.9, 95% CI, 2.5-14.6 and OR = 2.9, 95% CI, 1.2-6.8, respectively). CONCLUSIONS: These findings suggest that perceptions about the importance of prenatal care may play a greater role in the initiation of care among this group of women than is recognized. Women with more experience with pregnancy appear to place slightly less importance on prenatal care.

Preventive effects of transdermal 17 beta-estradiol on osteoporotic changes after surgical menopause: a two-year placebo-controlled trial.

OBJECTIVE: The purpose of our study was to evaluate the effects of three dosages of transdermally administered 17 beta-estradiol on markers of bone loss in women who had recently undergone surgical menopause. STUDY DESIGN: This was a 2-year, randomized, double-blind, placebo-controlled study that reviewed 127 women stratified by age. Biochemical indicators of bone metabolism in urine and serum were periodically assessed, as was bone mineral content of the lumbar spine and radius. Statistical analysis examined the percent changes from baseline in bone mineral density by using an analysis of covariance with treatment as a factor and the baseline value as a covariant, by performing all-pairwise comparisons among the three estradiol groups, and by testing for a linear dose-response relationship. RESULTS: After 2 years of therapy, a significant dose-response relationship was detected. CONCLUSION: This 2-year study demonstrates that transdermally administered 17 beta-estradiol is a safe and effective regimen for preventing bone loss in recently postmenopausal women.

Treatment of endometriosis with the GnRH agonist nafarelin acetate.

Additional details of a multicenter study of nafarelin acetate with particular attention to a unique endometriosis scoring system utilized are reviewed. Additional information regarding the relapse of symptoms of 10 patients treated with nafarelin and danazol during a 6- to 12-month follow-up interval is described. Transient decreases in leukocytes previously reported by other investigators were observed in 3 of 8 patients, but appear to represent a laboratory artifact.

Surgical techniques for cesarean section.

Cesarean section is probably one of the oldest and certainly one of the most commonly performed surgical procedures in obstetrics and gynecology. There is always a risk in attempting to elaborate excessively on such a common operation. Each of us will develop our own personal biases based on individual experience and expertise. These differences are superficially distinct but usually have underlying similarities that allow us to achieve similar outcomes and expectations. At the same time, however, it is important to recognize that there is a difference between repetition and habit as opposed to altering a technique in order to meet a specific end. Obviously, with cesarean section, there can be several ways to accomplish the same result, and certain situations will dictate the individualization (patient, not physician) of technique. Certainly, one has to be aware of his or her own expertise and at the same time know his or her options. It seems best not to limit oneself to the same technique under all circumstances but to be able to anticipate problems and know how to rectify them in a manner that will avoid undue injury or compromise to the infant and mother.

Dysfunctional uterine bleeding.

Dysfunctional uterine bleeding is classified by the character of the menstrual cycle: ovulatory or anovulatory. Anovulation can occur at any age and is physiologic in the first year or two after menarche and for several years before menopause. Anovulatory cycles are characteristically irregular and marked by prolonged episodes of bleeding unassociated with signs or symptoms of ovulation. Specific causes of anovulation such as hyperprolactinemia, thyroid disease, androgen excess, anorexia, obesity, and excess exercise can be treated specifically; otherwise, therapy depends upon patient goals. Cycle regulation can be affected by monthly courses of progestin, such as medroxyprogesterone acetate (Provera), 10 mg daily for 10 days each month. Contraception and cycle regulation can both be accomplished with oral contraceptives. Fertility, on the other hand, will require ovulation induction. Ovulatory dysfunctional uterine bleeding most prevalent in parous women between the ages of 20 and 40 is associated with regular cycle intervals and premenstrual molimina. Midcycle and perimenstrual spotting can often be treated with observation only, but depending upon patient and/or physician concerns, periodic hormonal suppression is effective. The management of menorrhagia should include the following: (1) exclusion of pathology in the genital tract; (2) reduction in activity during days of heavy flow; (3) the avoidance of aspirin in the week before and on days of flow; (4) nonsteroidal anti-inflammatory drugs; (5) cycle suppression--oral contraceptives, danazol (Danocrine), depo-progestin; (6) luteal phase progestin; and (7) surgical intervention.

CA-125 levels in endometriosis.

CA-125 is a cellular antigen detected in many patients with ovarian cancer, but it has also been detected in patients with endometriosis. Preoperative CA-125 levels were drawn from 113 patients before they underwent laparoscopy. Patients were categorized into diagnostic groups on the basis of pathologic findings. CA-125 levels in patients with evidence of intraabdominal adhesions were not statistically different from those in patients with normal pelvic anatomy. However, patients with advanced endometriosis had significantly elevated levels of CA-125 when compared with patients with normal pelvic anatomy (P less than 0.05). The clinical and immunologic implications of elevated CA-125 levels in patients with advanced endometriosis are discussed.

Adolescent pregnancy: critical review for the clinician.

Adolescent pregnancy is a major health and socioeconomic problem with unique medical and psychosocial consequences for the patient and society. Consequently, it demands our attention and understanding of the problem and its causative factors. Survey data have documented that a majority of adolescents are sexually active, and that currently, almost 1 in 10 adolescents become pregnant each year. Over the last 2 decades, comprehensive adolescent pregnancy programs have shown that the high frequency of adverse obstetric and neonatal outcomes are closely associated with low socioeconomic status, poor prenatal nutrition and general health, and chemical use, but not maternal age. These adverse medical consequences and the psychosocial problem of the parents and infant are treatable with programs that adapt to the patient population and provide extensive support, education, and counseling in addition to continuity obstetric care initiated early in the pregnancy. One of the greatest needs of the adolescent is a competent and caring adult to serve as an advocate to guarantee access to medical and support services. To this end, responsible and qualified professionals who can relate to adolescents should resume this role in the coordination of a comprehensive care approach. This approach will not only reduce the medical risks associated with adolescent pregnancy, but it will decrease the number of repeat teenage pregnancies, promote school retention, increase compliance with health care regimens for the parent and child, and stimulate personal growth and development. All communities should develop programs to promote optimal medical care, psychosocial support, necessary financial support, and accessible education, since adolescent pregnancy occurs in all social, racial, ethnic, and economic groups in all parts of our country. Finally, the role of the adolescent father should be continually emphasized as a potential source of support to the adolescent mother and their infant and a stabilizer in the teenage family unit. In accord with such emphasis, recognition should be afforded to the psychologic and interpersonal needs of the adolescent father.

Effect of serum source on human fertilization and embryonic growth parameters in vitro.

A total of 100 mature oocytes from 13 consecutive patients were randomly assigned from each patient to one of two treatment groups (n = 53 for group 1, n = 47 for group 2). Group 1 oocytes were incubated throughout the culture periods in medium supplemented with 7.5% homologous patient serum. Group 2 oocytes were treated similarly, except the serum supplement was of fetal cord origin. End points for examination included fertilization frequency, normality of fertilization, stage of embryonic development at two time periods, and quality of embryonic development at two time periods. None of the end points examined revealed significant differences between patient serum and fetal cord serum.

High-risk pregnancy. Identification and monitoring to improve outcome.

High-risk pregnancy is a problem that directly affects both the patient and the physician. Technological advances have provided improved methods of monitoring the fetus, especially through ultrasonography and electronic fetal heart rate monitoring. However, it is still up to the physician to identify the pregnancy at risk and to properly interpret the information obtained by monitoring. To date, expert clinical management still offers the best hope for a good obstetric outcome.

Adolescent pregnancy: a combined obstetric and pediatric management approach.

During the past decade, the relative increase in adolescent pregnancy has forced physicians and other health professionals who provide services to teenagers to be aware of the factual data relating to teenage pregnancy and the pertinent social issues in order to serve as advocates for both the parent and the child. In this article, we review the existing demographic data regarding adolescent pregnancy in conjunction with current approaches to intervention programs for the maintenance of a stable environment and optimal development of the parent and the child.

Hypertension in pregnancy.

Any pregnancy complicated by hypertension must be considered to be at increased risk. Proper management dictates early diagnosis, liberal use of hospitalization, appropriate antihypertensive therapy, and timely intervention with consideration being given to maternal and fetal compromise if the pregnancy is allowed to continue. Unfortunately, the decision as to the proper timing for delivery is not always easily made, especially if the fetus is premature and there is an absence of compelling complications. Consequently, the liberal use of perinatal referral sources in these cases is both appropriate and indicated. Fortunately, the diligence and the care employed by the physician in dealing with these patients can be expected to be rewarded by a good outcome for both mother and infant.