Order of rotation in third-year clerkships. Influence on academic performance.

OBJECTIVE: To determine if student performance during the third-year clerkship is influenced by the order of departmental rotation. STUDY DESIGN: In this retrospective, descriptive study, the National Board of Medical Examiners (NBME) scores, departmental examination grade (DE) and final block grade (FG) were stratified into six segments based on the order of block time in obstetrics-gynecology, pediatrics, psychiatry, internal medicine, surgery and family medicine. Consistency was validated by comparing these performance criteria from 1988 to 1992. RESULTS: When all six clerkships were assessed by year, there was no uniform trend of improved performance over time. In the obstetrics-gynecology block, however, NBME scores and FGs were highest for students assigned to the fifth and sixth rotation as compared to the first two groups (P < .02). No such trend was noted with the departmental written examination. In surgery, DE and FG were always lower in the first rotation (P = .0001). Psychiatry DE scores were significantly higher on the second or third blocks as compared to the fifth and sixth rotation positions (P < .001). Students had a higher FG in pediatrics when the sixth position was compared to the second block (P = .02), but the DE grades and NBME scores were not altered by rotational schema. In family medicine and internal medicine, no effect of rotation was noted. CONCLUSION: Third-year clerks tended to have higher NBME scores and FGs in obstetrics-gynecology if they selected this rotation later in the academic year. Surgery DEs and FGs were lowest if selected first in the academic year. There was no similar trend in other nonsurgical specialties. These data suggest that prior clinical rotations positively influence student performance in obstetrics-gynecology.

Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence.

OBJECTIVE: Our purpose was to compared the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence. STUDY DESIGN: A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented. RESULTS: Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean +/- SD) was 66.6 +/- 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p < 0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p < 0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p < 0.05). CONCLUSION: Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the likelihood of success and may reflect subtle modifications of technique.

Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia.

OBJECTIVES: We reviewed our experience with the use of iliococcygeus fascia for repair of vaginal vault prolapse. STUDY DESIGN: A retrospective chart review identified 110 patients who had repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus fascia from March 1981 to April 1991. All patients were followed for a minimum of 3 years. RESULTS: Thirty-seven (33.6%) patients had uterine prolapse with enterocele. Posthysterectomy enterocele was present in 73 (66.4%) patients. All had a complex pelvic floor defect including cystocele or rectocele. Mean age was 54.5 +/- 14.6 years and mean parity was 4.1 +/- 3.2 births. Forty-two (38%) were grand multiparous patients. Five were nulliparous. Length of the procedure was 163.2 +/- 11.4 minutes. Estimated blood loss was 358.2 +/- 253.6 ml. Postoperative urinary catheterization was required for 6.1 +/- 4.1 days. Duration of hospital stay was 5.5 +/- 2.0 days. Three patients had hemorrhage > 750 ml and two required transfusion. One bowel injury and one bladder injury occurred. Forty-one patients had postoperative complications. The patients have been followed up for a minimum of 3 years, and four have had recurrent defects. All recurrent defects involved the anterior vaginal wall. CONCLUSIONS: Suspension of the vagina to the iliococcygeus fascia for repair of vaginal vault prolapse provides excellent long-term results. Critical to the success of vaginal vault suspension are adequate dissection and repair of all fascial defects. Adequate repair of the perineal body also plays a pivotal role. The anterior vaginal wall remains susceptible to recurrence.

Resident research projects: frequency of presentation and publication in a national forum.

OBJECTIVE: Our aim was to determine the fate of mandatory resident research projects with regard to subsequent presentation and publication. STUDY DESIGN: In this retrospective descriptive study required research projects were assessed for frequency of presentation at regional and national meetings or publication in medical journals, or both, over a 10-year period (1983 through 1992). Rising second-year house officers elected to initiate their own study with departmental support under the guidance of a faculty advisor or selected a research project from a list of potential investigations offered by departmental faculty. Projects were presented at the annual alumni meeting in April of the junior and senior years. The faculty advisor assisted in research design, protocol development, obtaining human investigation committee approval, data collection, statistical analysis, manuscript preparation, and coaching for the oral presentation. After local presentation these projects were evaluated for submission to regional and national meetings and prepared for peer-review publication. RESULTS: During a 10-year period 104 resident research projects resulted in 72 regional or national presentations and 52 peer-review publications. There was a significant increase in the proportion of projects presented at national meetings over time (r = 0.99; p < 0.0001). There was also an increase in the number of projects published in peer-review journals during the decade-long study period (r = 0.96, p = 0.0001). CONCLUSIONS: Required completion of two research studies during residency bolstered by early selection of prospective projects and departmental fiscal support, as well as intensive faculty advisor direction and assistance, has resulted in resident projects with increasingly frequent national recognition.

Plasma exchange for preeclampsia: II. Unsuccessful antepartum utilization for severe preeclampsia with or without HELLP syndrome.

OBJECTIVE: To explore the efficacy of plasmapheresis/plasma exchange as the primary therapy to arrest and reverse the progression of severe preeclampsia with or without HELLP syndrome in order to postpone delivery and improve perinatal outcome in very preterm pregnancies. STUDY DESIGN: In this case series of patients managed over a 4-year period from 1984 to 1987, seven gravidas with severe preterm preeclampsia underwent 1-2 plasmaphereses/plasma exchange procedures using the IBM 2997 Cell Separator with continuous electronic fetal heart rate monitoring (n = 7 patients) and central cardiovascular monitoring (n = 3 patients). RESULTS: The seven patients (one with HELLP syndrome, six without HELLP) presented between 24 and 30 weeks gestation and, despite plasmapheresis/plasma exchange, the severity of each study subject's preeclampsia persisted without clinically significant improvement. Maternal-fetal deterioration required cesarean delivery in all cases within 48 (in four patients within < 36) hours of therapy. No clinically significant adverse effect of plasma exchange therapy was recorded during cardiovascular and laboratory monitoring; two fetuses developed repetitive late decelerations during exchange despite adequate maternal fluid preload. The only patient with HELLP syndrome developed eclampsia as her third plasma exchange within 25 hours was being initiated. Significant problems with fluid retention and displacement (variable amounts of pulmonary edema, pleural effusions, large volume ascites) were encountered in all patients. Four neonates died (24-27 weeks/438-820 g) and three survived intact (740, 950, and 1,280 g). One mother (case 5) developed end-stage renal disease 21 months postpartum. CONCLUSIONS: The application of plasmapheresis/plasma exchange therapy as described in order to prolong very preterm pregnancies in the undelivered patient with severe preeclampsia/eclampsia with or without HELLP syndrome did not produced encouraging results. Patients in general were exposed to additional medical and surgical risk without a corresponding improvement in perinatal outcome.

The effect of provider education on blood utilization practices.

OBJECTIVE: Our aim was to determine prospectively if a process of provider education and subsequent audit of transfusion criteria can reduce inappropriate blood product infusion. STUDY DESIGN: Beginning in December 1990, a year-long process of provider education and quality assurance audit, with the use of guidelines based on National Institutes of Health blood product consensus conferences, was instituted. After this orientation and education period, the medical records were reviewed for patients on the obstetrics and gynecology service from Dec. 1, 1990, through Sept. 30, 1991, who received blood products (packed red blood cells, fresh-frozen plasma, cryoprecipitate). This group was compared with patients cared for by our service over a similar period before the institution of these guidelines. The incidence of cesarean birth and operative intervention for gynecologic malignancies, as well as the number of major operative gynecologic procedures, was found to be unchanged during the total study period (Dec. 1, 1988, through Sept. 30, 1991). RESULTS: In 1989 there were 1236 units of blood products transfused; in contrast, in 1991 428 units of blood were transfused. In 1989, 107.9 +/- 59.9 units of packed cells per month were used in 33.6 +/- 16.8 patients (3.2 units per patient). In contrast, in 1991, 14.4 +/- 5.8 patients per month received transfusions (2.82 units per patient) with 40.7 +/- 17.2 units of packed cells (p < 0.0001). This represents a 75% decrease in the total number of packed cells and a 60% decrease in the number of patients undergoing transfusion per month. Similar reductions in the usage of cryoprecipitate and fresh-frozen plasma were noted (p = 0.024 and 0.002, respectively). Acute operative blood loss was the most common indication for transfusion. Abdominal hysterectomy was the most common procedure followed by exploratory laparotomy and cesarean section. No patients in whom blood was not used had untoward effects. CONCLUSION: Education as to appropriate blood utilization and concurrent quality assurance audit techniques can safely reduce blood usage on a busy obstetrics and gynecology service in a tertiary care center.

The diagnosis and management of dystocia of the shoulder.

Dystocia of the shoulder is an unpredictable obstetric emergency that may result in injury to the mother or fetus. In an effort to reduce such risks, attempts have been made to identify patients having a fetus who may subsequently develop shoulder dystocia. The literature, however, clearly reflects that even the combination of prenatal historic facts, estimated fetal weight and sequence of intrapartum events is ineffective in prospectively identifying infants whose births are complicated by shoulder dystocia. During a ten year period at the University of Mississippi Medical Center, the incidence of macrosomia, shoulder dystocia and subsequent brachial plexus injury was reviewed. The majority of instances (89 percent) of shoulder dystocia occurred in patients weighing less than 8 pounds 13 ounces at birth. In the current retrospective review, only 11 percent of the women had risk factors for macrosomia or shoulder dystocia and among these, none were identified prospectively. Additionally, 91 percent of patients with brachial plexus injury recovered with no sequelae. One instance of brachial plexus injury occurred at the time of cesarean section. These data reveal that macrosomia and subsequent shoulder dystocia cannot be predicted. Therefore, it is not feasible to prevent brachial plexus injury prospectively by prophylactic cesarean section. Great clinical acumen and technical expertise by the obstetrician using a variety of methods may be useful in avoiding, as much as possible, injury to the mother and fetus when shoulder dystocia does occur.

Benign symptomatic hyperandrogenism in a postmenopausal woman.

Hyperandrogenemia in postmenopausal women requires an evaluation to exclude pathologic ovarian or adrenal causes. Our patient exhibited no signs of hypercortisolism, congenital adrenal hyperplasia, or adrenal or ovarian neoplasia based on biochemical testing and pelvic sonography. We hypothesized that unexplained androgen excess in our patient was due to the development of gonadotropin-dependent excess ovarian stromal androgen production. This syndrome may be comparable to gestational hyperreactio luteinalis where elevated gonadotropins stimulate ovarian stromal androgen production. If tumor can confidently be excluded, such women may benefit from gonadotropin suppression with long-acting GnRH-a.

Use of continuous flow erythrocytapheresis in pregnant patients with sickle cell disease.

The role of partial prophylactic red cell exchange transfusion in the management of pregnant patients with major sickle hemoglobinopathies is unclear. Over a 10-year period, 131 pregnant patients with major hemoglobinopathies (HbS 101, HbS-C 30) were managed by the same group of physicians. Of these, 103 received partial prophylactic exchange transfusion early during prenatal care while 28 received blood only when serious complications developed (control group). Patients treated with exchange transfusion received continuous flow erythrocytapheresis on an outpatient basis. The results indicate that there were fewer crises (P = .0001), a reduction in other significant medical complications (P = .002), and a decrease in maternal hospital days (P = .05) in those receiving prophylactic transfusions compared to women in the control group. The number of preterm deliveries (P = .004), the prevalence of low birthweight infants (P = .01), and the perinatal death rate (P = .01) were significantly lower among those who were routinely transfused. Two patients developed hepatitis, five had transfusion reactions, and 11 were found to have alloantibodies among those receiving prophylactic transfusions versus one, two, and five patients, respectively, in the control group. The results indicate a benefit of this methodology in the treatment of pregnant sickle cell patients in our population. However, a national collaborative randomized study is needed to adequately address the controversy regarding the use of red cell exchange in the pregnant sickler.

Pregnancy after successful vaginoplasty and cervical stenting for partial atresia of the cervix.

We previously reported surgical correction of vaginal agenesis and partial cervical atresia in an 11-year-old girl with amenorrhea and a pelvic mass. This patient, the subject of this report, conceived 7 years later and delivered at term. An abdominal cerclage was placed at 12 weeks' gestation to protect the cervix, and delivery was by cesarean.

The incidence of preterm labor and specific risk factors.

A retrospective review of patients at high risk for preterm delivery because of twin gestation, uterine malformation, incompetent cervix, or previous preterm delivery was carried out to assess the rates of preterm labor and spontaneous preterm birth. Among the 119 patients with multifetal gestation, 46% had preterm labor and 36% delivered before 37 weeks' gestation. In the 58 patients with an anomalous uterus, the rate of preterm labor was 19%, and 14% had early deliveries. Of those with incompetent cervices (115), one-fourth had preterm labor and 17% had an early birth. When a history of one or more preterm deliveries was present, the preterm labor rate ranged from 41-68%, with an early delivery rate of 30-47%. Prophylactic tocolytic therapy did not prolong gestations significantly. Maternal smoking did not have an adverse effect on the incidence of preterm labor except in twin pregnancies, for which early delivery was more likely. The percentages for preterm delivery are slightly lower than those found in the literature; this may be attributable to improvement in preterm birth prevention efforts including patient education, more frequent examinations, home uterine activity monitoring, and daily nursing contact.

Plasma exchange for preeclampsia. I. Postpartum use for persistently severe preeclampsia-eclampsia with HELLP syndrome.

The postpartum use of plasma exchange with fresh-frozen plasma was assessed in a group of seven women with severe preeclampsia-eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) that persisted greater than 72 hours after delivery. During the study interval in which a total of 107 gravid women with HELLP syndrome were seen in our referral center, these seven patients (6.5%) demonstrated persistent thrombocytopenia (platelet count usually less than 30,000/mm3), rising lactic dehydrogenase (greater than 1000 IU/L) and evidence of multiorgan dysfunction. The seven case histories emphasize the variety of clinical and laboratory profiles that can be encountered in this small group of gravid women at risk for severe morbidity or mortality. Up to three 3 L plasma exchanges were required to effect permanent disease arrest and reversal. Utilization of the IBM 2997 Cell Separator system permitted bedside performance of procedures with enhanced convenience and optimal medical management. Successful plasma exchange was associated with (1) sustained increases in the mean platelet count at 24, 48, and 72 hours that were 2.2, 3.6, and 4.5 times the preexchange platelet counts and (2) a decreasing trend in lactic dehydrogenase concentrations below 1000 IU/L within 48 hours of exchange plasmapheresis. The current series of patients supports our recommendation that a trial of plasma exchange(s) with fresh-frozen plasma be considered for treatment of the infrequent postpartum case of HELLP syndrome that fails to abate within 72 hours of delivery and in which other evidence develops of an ongoing, widespread, and life-threatening thrombotic microangiopathy.

Perinatal aspects of abdominal surgery for nonobstetric disease.

Surgical interventions for nonobstetric reasons during pregnancy are reported to occur in 0.2% to 2.2% of all gestations with obvious perinatal implications. In this retrospective study, 57 parturients were identified who underwent nonobstetric abdominal surgery. Thirty-one patients underwent exploratory celiotomy for suspected appendicitis, 16 for adnexal disease other than ectopic pregnancy, six for cholecystectomy, three for intestinal disorders, and one with a pheochromocytoma. Alterations in disease expression are related to the severity of the disease and advancing gestational age, being more important in cases of appendicitis. Preterm labor reflecting fetal morbidity relates to the presence of peritonitis and then only during the third trimester. In this retrospective study, tocolysis with intravenous magnesium sulfate had an uncertain effect on the incidence of preterm delivery. Prospective studies will be required to assess the indications and limitations of tocolysis for nonobstetric abdominal surgical conditions.

Incarceration of the retroverted gravid uterus: report of four patients managed with uterine reduction.

Incarceration of the retroverted gravid uterus may have an adverse effect on pregnancy. To evaluate these effects, we reviewed obstetric records to identify parturients with the diagnosis of incarceration of the retroverted uterus during the years 1977 to 1987. Four such patients were identified by this retrospective review, for a calculated incidence in our primary population (patients not referred for evaluation who also received prenatal care at only one hospital) of one case per 10,384 live births. The incarceration was successfully reduced in all four patients without surgical intervention, and all had a normal infant of appropriate weight at term.

Cost effectiveness of ambulatory uterine activity monitoring.

A cost analysis is presented comparing 34 patients who received uterine activity monitoring versus 33 patients who attempted to detect uterine activity by palpation. All patients were at high risk for preterm delivery and were given the same educational information and prenatal care regarding signs and symptoms of preterm labor. The results revealed an increase in newborn days (640) and cost to those patients who were in the self-palpation group ($13,364) compared to monitored parturients (268 days and $8,633). The difference was attributed to neonatal morbidity from an increased number of preterm deliveries greater than 26 weeks but less than 37 weeks (P = 0.04). The increase in NICU days was significant (P = 0.03). No difference in normal newborn costs for infants delivered after greater than 33 weeks could be detected between the two groups, but morbidity was increased among control infants delivering between 34 and 36 weeks. Uterine activity monitoring to prevent preterm birth appears to be medically effective and reduces cost.

Prostaglandin E2 induction of abortion and fetal demise.

Prostaglandin E2 (PGE2) suppositories have been shown to be active contractile agents and are effective in uterine evacuation for mid-trimester abortion or fetal demise. In this study, 85 patients were treated with vaginal PGE2 suppositories. When laminaria were used in patients with closed cervices, and compared to those who had minimal cervical dilatation, there was no difference in the time from induction to expulsion. Ninety-three percent of the 85 patients aborted successfully within 24 h. In each of the seven "failures", three or less suppositories were used prior to a dilatation and evacuation procedure. In this study, 81% of the abortions were complete, and in one-third of the remaining patients dilatation and curettage was performed just after delivery of the fetus. The incidence of minor side-effects ranged from 12 to 21%, and there were no major complications. It is concluded that the use of vaginal prostaglandin E2 suppositories for induction of mid-trimester abortion or fetal demise in the third trimester is safe and effective.

PIP: Prostaglandin (PG) E2 suppositories have been shown to be effective in uterine evacuation for mid-trimester abortion. At the University of Mississippi Medical Center, vaginal PGE2 suppositories have been used routinely to effect termination of pregnancies following fetal death at any age and in the majority of therapeutic abortions performed at over 14 weeks' gestation. This study evaluated the results of PGE2 treatment in 85 patients seen at the center during an 18-month period, the majority (65%) of whom were delivered because of fetal death. Prior to the procedure, 55% of these patients had a closed cervix and laminarias were inserted. The average time from induction with PGE2 to expulsion of the fetus was 9.3 hours (range, 1.4-23.2 hours), with no significant difference between the groups with and without laminaria unless the cervix was dilated more than 2 cm at the time of admission. 94% of study subjects required 3 or fewer suppositories to effect delivery. Of the 85 patients, 78 (91%) aborted successfully within 24 hours. There were no major complications; the incidence of minor side effects ranged from 12% (for diarrhea) to 21% (for hyperpyrexia). Overall, these findings suggest that medical induction using prostaglandins is a safe, convenient method of evacuating the uterus, particularly in the case of fetal death after 20 weeks. The minor side effects such as nausea and vomiting, fever, diarrhea, headache, and chills can be reduced when patients are premedicated with anti-emetics and antidiarrheal preparations. Moreover, these side effects may be further decreased by the use of newer compounds, such as the 15-methylated prostaglandins, that are believed to induce less reaction in the gastrointestinal tract.

Vaginal birth after cesarean section: the demise of routine repeat abdominal delivery.

In light of the abundant very favorable data and considerable published patient experience regarding vaginal birth after cesarean for selected gravidas, the authors are moved to repeat with emphasis the question asked by Dr. Danforth in his recent treatise on cesarean delivery: "The question now is not whether the dictum of automatic repeat cesarean section is still valid, but rather why we continued to adhere to it for more than 60 years, as though it had been carved in stone." From recently published American data, it is obvious that more providers and more patients must be convinced of the safety, efficacy, and cost effectiveness of a selective program of trial of labor and vaginal delivery following previous cesarean birth if we are to effect a significant reduction in this nation's cesarean birth rate. The policy of "once a cesarean section, always a cesarean section" should be applied correctly only to its intended group of patients with previous uterine fundal or upper-segment incisions. As the advisability of insisting on a trial of labor for all parturients who have no contraindications becomes a signal part of the fabric of obstetric practice in the United States and the remainder of the world, we shall witness the demise of routine repeat abdominal delivery.

Comparison of oral ritodrine and magnesium gluconate for ambulatory tocolysis.

Magnesium sulfate has been administered intravenously to arrest preterm labor but the oral form of this drug cannot be used for continual tocolysis. This trial involved the administration of oral magnesium gluconate to determine its effectiveness compared with that of ritodrine hydrochloride in 50 patients whose labor had been arrested by parenteral therapy. Group A (n = 25) received 1 gm of oral magnesium gluconate every 2 to 4 hours for tocolysis and group B (n = 25) received 10 mg of ritodrine every 2 to 4 hours. The number of patients who progressed to 37 weeks' gestation was similar (group A, 21 versus group B, 19) and the time gained in utero was not different (group A, 6.4 weeks versus group B, 5.9 weeks). There was a trend toward more side effects with the use of ritodrine (40%) compared with magnesium gluconate (16%), but the numbers were too small to reveal a significant difference. These data suggest that magnesium gluconate used as an oral tocolytic is as effective as a beta-agonist in patients whose labor is arrested initially with intravenous therapy.

A program of uterine activity monitoring and its effect on neonatal morbidity.

In a recent study 34 patients at high risk for preterm delivery who received uterine activity monitoring were compared with 33 similar patients who attempted to detect contractions by palpation. The incidence of preterm delivery was significantly reduced among those using the uterine activity detection device, although all patients in both groups had the same prenatal care and educational intervention. When short-term neonatal morbidity associated with preterm delivery was compared between the two groups, adverse effects decreased significantly among those in the monitored group (p = 0.001). The majority of short-term morbidity in both groups was noted in those delivering preterm and thus was gestational age related. No significant difference was found in neonatal morbidity between the groups when the infants were delivered at less than 37 weeks' gestation. Uterine activity monitoring, which is effective in preventing preterm birth, is also efficacious in decreasing short-term neonatal morbidity.