Clinical experience reported by candidates for the American Board of Obstetrics and Gynecology 1995 and 1997 oral examinations.

OBJECTIVE: The purpose of this study was to report the clinical experience collated from the 1995 and 1997 case list summary sheets of United States and Canadian active candidates who were completing the American Board of Obstetrics and Gynecology oral examination for the first time. STUDY DESIGN: Data from the case list summary sheets were entered into a computerized database and collated. Data from active candidates who had subspecialty training and from other international graduates were excluded. RESULTS: The difference in the ratio of men to women candidates between 1995 and 1997 was statistically significant (P =.02). Both years, 31% of the major operations were hysterectomies, of which 60% and 62.5%, respectively, were performed through an abdominal incision. The mean total cesarean delivery rate was 20.5% in 1995 and 19.7% in 1997. The ratio of primary to repeat cesarean deliveries was 2 to 1 in both years. The ratio of forceps to vacuum extraction deliveries was 3:7 in 1995 and 2:5 in 1997. CONCLUSION: This data set provides a national overview of the clinical experiences of a relatively homogeneous group of practicing obstetrician-gynecologists who have recently completed their training.

A faculty development course in obstetrics and gynecology.

Sponsored by the nonprofit Berlex Foundation, this 6-day Faculty Development Course introduces small groups of new faculty to research design, critical appraisal of the literature, scientific writing, and evidence-based medicine. The course includes didactic presentations, small group discussions, and individual protocol development. Its influence on academic careers is impossible to determine, because defining an appropriate comparison group is not feasible. However, the cumulative effect should be to increase the research expertise of some young faculty in academic departments nationwide. In addition, many participants have introduced the principles of evidence-based medicine in their own teaching programs.

Electromyography with acrylic plug surface electrodes after delivery.

Pelvic floor neuromuscular function was evaluated with surface electromyography using acrylic plug electrodes and interactions between neuromuscular function and factors pertinent to the delivery process were explored. Fifty-two women who were primiparas participated in this prospective cohort study. Circumvaginal and circumrectal muscles were assessed. Corrected vaginal-rectal flicks and holds were calculated. The results were compared by delivery route, birthweight, race, lactational status, and delivery anesthetic and to a group of nulliparous subjects. The mean interval from delivery was 46.3 days. Birthweight, race, lactational status, and anesthetic technique were not associated with statistically significant changes in electrical activity, although our ability to detect such differences was low due to the small number of subjects. Women who delivered vaginally had lower vaginal flick voltage than those delivering abdominally. Women who delivered vaginally had lower vaginal flick and hold voltages and rectal flick voltage when compared with nulliparous women studied earlier. Abdominally delivered women had values similar to the nulliparous group. Women delivering vaginally had less surface electromyographic activity in the circumvaginal muscles, implying that vaginal delivery impairs the neuromuscular function of the pelvic floor.

Screening for ovarian carcinoma: hopeful and wishful thinking.

OBJECTIVE: The purpose of this study was to review the published articles on screening for ovarian carcinoma. STUDY DESIGN: A retrospective review was performed of the articles published in the English literature during the past 10 years. The articles of Herbst and Cohen, included in this panel discussion, were reviewed as part of this study. RESULTS: Compared with the prevalence of other cancers screened for by gynecologists, that of ovarian cancer is low. Neither CA 125 nor vaginal ultrasonography has consistently provided the mandatory high specificity and sensitivity values required for successful screening of a disease of low prevalence. The cost of vaginal ultrasonography and color flow Doppler studies is too high for mass screening programs. CONCLUSION: There is little evidence to support widespread screening of large populations of women who do not have familial or genetic risk factors for ovarian carcinoma. An informed patient and an informed physician should weigh the risk-benefit ratios of periodic screening versus prophylactic oophorectomy in the individual high-risk patient. The effectiveness of periodic screening has not been established or proved even for the high-risk patient.

Single- and multiple-dose pharmacokinetics of a low-dose oral contraceptive in women with chronic renal failure undergoing peritoneal dialysis.

OBJECTIVE: Our purpose was to compare the pharmacokinetic parameters of oral administration of a 35 micrograms ethinyl estradiol, 1 mg norethindrone pill in peritoneal dialysis patients and normal women. STUDY DESIGN: A single-dose study was performed with five patients and four controls, followed by a multiple-dose study with five subjects in each group. Pharmacokinetic parameters were calculated by noncompartmental analysis and statistical analysis performed with Mann-Whitney U testing. RESULTS: There is no difference in the pharmacokinetic parameters for norethindrone in peritoneal dialysis patients compared with normal women. During multiple dosing an increased area under the concentration curve and decreased apparent oral clearance was observed for ethinyl estradiol in peritoneal dialysis patients compared with normal women. CONCLUSION: Peritoneal dialysis patients have decreased apparent oral clearance of ethinyl estradiol, leading to slightly higher serum concentrations compared with women with normal renal function. The clearance of norethindrone is the same in peritoneal dialysis patients and normal women.

PIP: In a single-dose and multiple-dose study, gynecologists from California, North Carolina, and Texas, compared pharmacokinetic parameters of the low dose oral contraceptive (OC), Ortho-Novum 1/35, (35 mcg ethinyl estradiol and 1 mg norethindrone) in premenopausal women with renal failure on peritoneal analysis and in age and weight matched controls. They used Mann-Whitney U testing and noncompartmental analysis to calculate pharmacokinetic parameters. In the multiple-dose study, peritoneal dialysis patients had higher serum levels of ethinyl estradiol than did controls 2, 3, and 12 hours after dosing (p .05). In the same study, no significant differences in norethindrone levels existed, however. Ethinyl estradiol levels were not significantly different between the cases and controls in the single-dose study. In the multiple-dose study, the dialysis patients had a much lower apparent oral clearance and a higher area under the concentration curve than did the controls (296.1 ml/hr x kg vs. 525.8 ml/hr x kg and 1930.2 pg/ml x hr vs. 1071.4 pg/ml x hr, respectively, p = .02). For pharmacokinetics of ethinyl estradiol, multiple dosing significantly increased the elimination of half-life, area under the curve, and mean residence time in both controls and dialysis patients. As for norethindrone, no significant difference between cases and controls in any pharmacokinetic parameter occurred in both the single- and multiple-dose studies. For norethindrone in cases and controls, the area under the curve and the maximum serum concentration increased with multiple dosing. Multiple dosing significantly decreased the clearance/bioavailability of norethindrone in both cases and controls. It increased greatly the mean residence time in dialysis patients. These findings indicated that physicians may administer a low dose OC to peritoneal dialysis patients to manage dysfunctional uterine bleeding or to prevent hypoestrogenemia.

Necrotizing fasciitis of the vulva.

OBJECTIVE: We attempted to characterize the natural history of necrotizing fasciitis of the vulva. STUDY DESIGN: The records of 29 nonpregnant women with necrotizing fasciitis of the vulva were evaluated. RESULTS: These women experienced a rapidly progressing polymicrobial infection. Initially, the infections in many women were thought to be labial cellulitis, appearing mild and innocuous. Delays in recognition and aggressive surgical management were associated with increased morbidity and mortality. Of 15 women with a delay greater than 48 hours between presentation and treatment, 11 died. Twenty of 29 (69%) were diabetic, accounting for 11 of the 14 deaths. CONCLUSION: Early diagnosis and aggressive surgical debridement in spite of mild symptoms will improve outcome in this serious disease process.

Sonographic diagnosis of advanced ectopic pregnancy. A case report.

The diagnosis of advanced extrauterine pregnancy is made most often sonographically by identification of a uterus separate from the fetus. Leiomyomas or other pelvic masses can make the sonographic diagnosis more difficult. In a woman with an advanced ectopic pregnancy and uterine leiomyoma, the sonographic diagnosis was made by passing a sterile probe through the endocervix with simultaneous, real-time ultrasound observation.

Assessment of perineal floor function: electromyography with acrylic plug surface electrodes in nulliparous women.

A new technique using acrylic plug surface electrodes was employed to record electromyographic activity in the musculature surrounding the rectum and vagina. Forty-one asymptomatic nulliparous women were tested. The group had a wide range of normal values. When eight women were chosen at random for a second testing session, intra-class correlation coefficients to compare readings between the two sessions ranged from 0.76-0.97, indicating adequate reliability. No demographic factor correlated with the voltage generated in these women.

Ovarian suspension in massive ovarian edema.

Massive ovarian edema is an uncommon condition found in young women that is speculated to occur as a result of incomplete ovarian torsion. We present the second patient to our knowledge to undergo ovarian suspension as a treatment for this condition. This approach succeeded after ovarian wedge resection had failed. Our patient remained symptom-free at 1 year of follow-up. Ovarian suspension should be considered when this pathologic entity is diagnosed.

Student evaluation in obstetrics and gynecology: self- versus departmental assessment.

Self-assessment of clerkship performance in obstetrics and gynecology was completed by 142 medical students and compared with departmental evaluations. Significant positive correlations existed between self- and departmental assessments for each of seven parameters in three categories of evaluation (clinical activities, written examination, and oral examinations). Students graded themselves lower than the actual faculty ratings and higher than the actual resident ratings. There was no difference in self- or departmental evaluations in regard to student gender. The amount of previous clerkship experience did not correlate with either the actual or perceived grades. Overall, self-assessments are consistent with those rendered by the department.

Profile of student clerkship administration in obstetrics and gynecology.

To determine a current profile of clerkships in obstetrics and gynecology, a national survey was conducted. The average clerkship director is 48 years old and has held that post for 6 years. Board certification has been accomplished by 91%, of whom 23% are also certified in a subspecialty. An advanced degree in education is held by 14%. Of full-time faculty, 81% are actively involved with medical student teaching; of part-time faculty, 62% teach students. The average number of 16 students completing the clerkship each 7 weeks is similar to that in previous reports. Evaluation of student performance varies but generally involves assessment of clinical activities (98% of programs), a written examination (96%), and an oral examination (54%). Clerkship directors find the responsibility of coordinating undergraduate education an important task from which they derive personal satisfaction.

Low dose dopamine in the treatment of persistent oliguria in pre-eclampsia.

Oliguria in pre-eclamptic women is most often a result of decreased intravascular volume. In a small number of patients, renal vascular spasm may be the cause of decreased urine output. Prolonged oliguria/anuria secondary to vasospasm may lead to permanent renal damage. When volume repletion is unsuccessful in restoring urine output, some authors have suggested the use of peripheral vasodilators such as hydralazine. Dopamine in low doses 2 micrograms/kg per min was used successfully to restore urine output within an hour in a pre-eclamptic patient who had been essentially anuric for 8 h. Volume administration and hydralazine were unsuccessful. In the rare instance of a patient who is unresponsive to conventional methods, low dose dopamine may provide an adjunctive therapy to restore urine output after delivery. Central monitoring is essential in following such patients.

Triphasic Randomized Clinical Trial: Comparison of effects on carbohydrate metabolism.

One hundred thirty women were randomly assigned to treatment with one of three triphasic oral contraceptives and 43 women using nonhormonal methods served as controls for a 6-month study of the metabolic effects of these formulations. One of the oral contraceptives contained ethinyl estradiol and levonorgestrel, and the other two contained ethinyl estradiol and norethindrone. Compared with pretreatment assessment, all three triphasic oral contraceptives produced small increases in the mean plasma glucose levels that were statistically significant but clinically unimportant. No subjects had abnormal glucose response curves in glucose tolerance test results. Compared with pretreatment assessment, all of the oral contraceptive preparations produced small increases in the mean insulin levels at 3 months but not at 6 months. Overall there were no statistically significant differences among the three formulations in their effects on carbohydrate metabolism as measured by glucose or insulin levels after 6 months of treatment.

Triphasic Randomized Clinical Trial: comparative frequency of intermenstrual bleeding.

Oral contraceptives have the highest theoretic efficacy of all reversible forms of contraception, yet in practice they have an actual failure rate equivalent to that of some barrier methods. The efficacy of oral contraceptives depends primarily on patient compliance. So-called "nuisance" side effects, such as intermenstrual bleeding (breakthrough bleeding or spotting), play a major role in their discontinuation. The Triphasic Randomized Clinical Trial compared the incidence of these side effects in three groups of subjects taking NET (A) (Ortho-Novum 7/7/7), LNG (Tri-Levlen), or NET (B) (Tri-Norinyl). Subjects taking NET (A) had the highest incidence of intermenstrual bleeding (63%) followed by NET (B) (44%) and LNG (33%). Only the difference between NET (A) and LNG attained statistical significance (p less than 0.030). Control subjects had no breakthrough bleeding and a 4% incidence of spotting. Further research is warranted to establish the cause of the disparity in the incidence of intermenstrual bleeding among patient groups assigned to the three oral triphasic contraceptives.

Morbidity of lymph node sampling in cancers of the uterine corpus and cervix.

To assess the morbidity of lymph node sampling, medical records were reviewed for all patients with cancers of the uterine corpus and cervix who underwent primary surgical therapy between January 1, 1980 and December 31, 1986. Five hundred fifty-four patients were identified. Of the 292 patients with corpus cancer undergoing total abdominal hysterectomy, lymph node sampling was performed in 65.4%. Operative blood loss, transfusion requirements, and length of hospital stay were not increased significantly (P greater than .05) in women having node sampling. Of the 262 patients with cervical cancer, 72 underwent abdominal hysterectomy, 111 underwent radical hysterectomy, and 79 underwent staging laparotomy, with lymph node sampling performed in 82, 100, and 92% of these groups, respectively. The incidence of perioperative complications in this group was similar to that in the corpus cancer group. Vascular injuries, hematomas, and lymphocysts were more frequent after lymph node sampling. One postoperative death was attributed to complications from node sampling, but there were no other long-term sequelae. The low overall risk associated with lymph node sampling supports its inclusion in the surgical evaluation of gynecologic malignancies.

Nylon brush improves collection of cervical cytologic specimens.

A prospective, randomized study was performed to compare the efficacy of a combined endocervical and ectocervical nylon brush with the cotton-tipped swab and wooden spatula for obtaining cervical cytologic specimens. Strict objective criteria were used to determine the adequacy of Papanicolaou smears on the basis of the number of cells present. The two methods were equally effective in collecting ectocervical smears. However, 96% of endocervical smears obtained with the nylon brush contained greater than 50 cells, compared with 58% of swab and spatula smears. Only 1.4% of brush samples contained no endocervical cells, versus 19% of swab and spatula smears. The presence of endocervical cells confirms adequate sampling of the transitional zone. Use of the cytologic Papanicolaou brush may result in fewer false negative and inadequate Papanicolaou smears.

Perimortem cesarean delivery.

Postmortem cesarean delivery is an operation that has been practiced since antiquity. In previous centuries low infant survival rates led to negative opinions regarding the operation's usefulness. A review of the past centuries' cases and a review of fetal physiology suggest that to obtain optimum infant survival, cesarean delivery should be initiated within four minutes of maternal cardiac arrest. The physiology of cardiopulmonary resuscitation during pregnancy is analyzed, and recent cases of maternal cardiac arrest with successful maternal resuscitation are reviewed. This data suggests that perimortem cesarean delivery initiated within four minutes of maternal cardiac arrest will yield the highest rates of maternal survival. Legal liability from the operation is minimal.

Studies on nonoxynol-9. IV. Biochemical and morphological effects in the liver, kidneys and lungs of rats following intravaginal and intraperitoneal administration.

The content of DNA and collagen was significantly increased in the liver of young adult rats injected intraperitoneally for five consecutive days with Nonoxynol-9 (N-9; 5 mg/100 g). No changes were observed in the lung. A single dose of N-9 increased the activity of SGOT, reaching a maximum 4 to 8 hours after injection. In transmission electron microscopy the hepatocytes showed a dramatic increase of the rough endoplasmic reticulum. Rats injected intravaginally 5 mg/100 g of N-9 daily demonstrated after 15 injections a significant increase of collagen in the liver and kidney. After 15 days, DNA was significantly increased in the kidney. SGOT increased after 5 applications of N-9. Light and electron microscopy of the liver showed signs of nonspecific inflammation. We conclude that N-9 administered to young adult rats intravaginally or intraperitoneally induces biochemical and morphological changes in organs involved in the excretion of this detergent.