Evaluation of the prognosis of in vitro fertilization pregnancies with initially low serum human chorionic gonadotropin levels.

OBJECTIVE: The objective of this study was to investigate the prognostic significance of initially low serum early human chorionic gonadotropin levels in in vitro fertilization pregnancies that progress to an intrauterine gestational sac. STUDY DESIGN: This retrospective cohort study compared 65 in vitro fertilization pregnancies with an initial human chorionic gonadotropin value at 4 weeks of < or =20 mIU/mL with 130 pregnancies with human chorionic gonadotropin values >20 mIU/mL. All pregnancies had a singleton intrauterine sac at 6 weeks' gestational age. Spontaneous abortion rates and pregnancy complications were compared. RESULTS: Women with a low initial serum human chorionic gonadotropin level showed a statistically significant increase in first-trimester pregnancy loss (36.5% vs 9.2%; odds ratio, 5.7; 95%; confidence interval, 2.6, 12.4; P <.0001). Once pregnancies progressed to 13 weeks, there were no significant differences. CONCLUSIONS: In vitro fertilization pregnancies with a low initial human chorionic gonadotropin value, despite progressing to a gestational sac, are at an increased risk of spontaneous abortion.

Induced abortion. Physician training and practice patterns.

OBJECTIVE: To examine the relationship between training in induced abortion during residency and subsequent practice patterns in providing abortion services. STUDY DESIGN: An anonymous survey of all obstetrician-gynecologists with admitting privileges at a tertiary care hospital in New England was conducted. Physicians were asked about their residency training experience in performing abortions, current practices and attitudes toward abortion. RESULTS: Ninety-two of 110 physicians (84%) completed the questionnaire. Six physicians who received training after residency and two with incomplete information were excluded from the analysis. Forty-four respondents received training specifically in first-trimester abortion, and 42 did not. Physicians who received training were more likely to provide abortion services (49% vs. 21%, P = .01), to ask patients about their plans for continuing pregnancy (65% vs. 41%, P = .007) and to support medical assistance funding for abortion (84% vs. 45%, P = .001) than were physicians who did not receive training during residency. Beliefs were significantly associated with current practice, even after controlling for differences in residency training in abortion. CONCLUSION: Differences in practice patterns exist between physicians who receive abortion training and those who do not. Practice patterns are associated with beliefs even after controlling for variations in training.

What to expect from a residency program: answers from a directory of residency programs in obstetrics and gynecology.

OBJECTIVE: To answer questions about obstetric-gynecologic resident salary, night call, vacation, outside employment, gender mix, and training experiences using data from a national directory of residency programs in obstetrics and gynecology. METHODS: The 259 US civilian residency programs were analyzed, using information from the 1996 directory database. We compared programs by size (four or fewer residents per year versus more than four residents per year) and geographic region for each of the questions. We used parametric and nonparametric statistical tests to determine statistical significance. RESULTS: First-year residents earn an average of $31,414 annually and receive a 5% increase each year, although salary varies significantly by region. Residents are on call an average of every 3rd night (twice a week) in the 1st year and every 4th or 5th night in the chief year. Residents in small programs take more night call than those in large programs. A separate night call rotation was more common in large programs. Vacation time varied by year of training and region. Male-to-female ratios in training differed significantly by year in training, program size, and region. The median number of training experiences was identified in each of the categories required by the Residency Review Committee in obstetrics and gynecology. Training experiences varied significantly by program size in three of the 15 categories. CONCLUSION: Program size and geographic region should be considered when comparing programs with regard to pay, work, time off, outside employment, gender mix, and training experiences. Program advisors and potential applicants are encouraged to use this information in comparing programs.

Answers to applicant selection from a directory of residency programs in obstetrics and gynecology.

OBJECTIVE: To answer six questions applicants commonly ask of programs, using the data base of a directory of residency programs in obstetrics and gynecology. METHODS: We analyzed data from a directory of 258 civilian residency programs in the United States compiled from a 1994-1995 survey. We expanded the analysis to compare small and large residency programs on the six questions. RESULTS: The average-size program of four residents per year received 50 applications for each position, offered interviews to less than a third of its applicants, and interviewed 15 applicants for each position. An interview gives an applicant a 7% chance of matching with a program. Small programs (fewer than four residents per year) interviewed more of their applicants than did large programs. Programs reported that their residents' scores on part I ranged from the 25th to the 90th percentile, and on part II from the 38th to the 92nd percentile. In general, residents in large programs scored better on these tests than did residents in small programs. Most programs (74%) considered electives beneficial in obtaining a residency position and reported a higher percentage of elective takers than programs without this policy. One in four residents in a program either took a senior elective there, graduated from the same institution, or both. Residents from programs offering fellowship training were twice as likely to pursue fellowship training than residents from programs with no fellowships. Large programs were four times more likely to sponsor fellowships than were small programs. CONCLUSION: Getting an interview in a residency program is a major accomplishment, whereas becoming known in a program may improve the applicant's odds of matching there. Applicants should review a program's policy on electives and selection record. Those considering fellowships should probably apply to programs that offer them. The directory offers a valuable data source for comparing residency programs in obstetrics and gynecology.

Sample size and statistical power in reproductive research.

The calculation of sample size should be an integral part of the planning stages of all research projects to avoid wasting time, money, and valuable resources. The necessary information for sample size calculations includes the alpha (type I) error level, the beta (type II) error, delta (or the difference you would like to be able to detect), and, for continuous variables, the variance. We review these terms and outline their importance in the calculation of sample size and statistical power. When necessary, the investigator should seek expertise and advice to perform these calculations.

The effects of a course in cadaver dissection on resident knowledge of pelvic anatomy: an experimental study.

OBJECTIVE: To determine whether a course in cadaver dissection can significantly increase resident knowledge of pelvic anatomy beyond that of current educational practices. METHODS: Thirteen first- and second-year residents were randomly assigned to a cadaver dissection course (seven) or a control group (six). The dissection group performed dissections with instruction, using a dissection guide designed specifically for the course. The control group received study references on pelvic anatomy and protected study time. Each participant took a practical and written examination at the beginning and end of the study. RESULTS: The two groups did not differ statistically in their scores on the pre-test. Both groups improved on the post-test, but the dissection group scored nearly 50% higher on the test than did the controls. The two groups differed significantly on the post-test, adjusted for pre-test performance (P < .01). In their evaluation of the course, participants from the dissection group emphasized its educational value and urged that it be offered to residents as a regular part of their training. CONCLUSION: Dissection of a human cadaver provides a valuable experience, allowing participants to gain a greater understanding of surgical anatomy and surgical procedures in a no-risk, unhurried setting. Residents who participated in a cadaver dissection course designed specifically for their needs showed a statistically significant increase in knowledge compared with those without this experience. Both objectively and subjectively, a cadaver dissection course is an excellent tool for instructing gynecology residents.

Unrecognized association of sleep disorders and depression with chronic pelvic pain.

Assessment of cases of chronic pelvic pain presents a challenging problem, and many physicians overlook the association of sleep disorders and depression with such pain. We examined these linkages in our chronic pelvic pain clinic, using a questionnaire that assists in diagnosis and management of these cases. To date, the cases of 72 patients (both physician- and self-referred) with pelvic pain have been evaluated. Of these patients, 51 of 71 (72%) reported sleep disorders, and 37 of 72 (51%) had clinical depression, as determined by the Beck Depression Inventory. After adjustment for a sleep-related item on the Beck scale, these two measures showed a positive correlation of .355 (P < .01). The scores of pain patients differed significantly from those of a control group of asymptomatic patients on the depression and sleep disorder measures. By being aware and using a simple questionnaire, the clinician may readily identify overlooked factors, such as sleep disorders and depression, when assessing cases of chronic pelvic pain.

Antepartum assessment of the maternal peripheral venous system with light reflection rheology.

The noninvasive detection of deep venous thrombosis (DVT) in pregnancy is a significant problem. The Hemodynamics AV-1000 uses light reflection rheology in superficial capillaries to detect DVT but has not been evaluated adequately in pregnancy. Four hundred one pregnant women in the second and third trimesters were studied with the AV-1000; none had symptoms of DVT or thrombophlebitis, and all had uncomplicated pregnancy outcomes. AV-1000 reflection curves were related to maternal age, gestational age, weight gain, Quetelet index and device sensitivity settings. No statistically significant differences in test outcomes were found for any variable. The high incidence of abnormal (25%) and inadequate (19%) tracings, coupled with an overall specificity of 45%, suggests that the system would not be useful in distinguishing patients with DVT from normal ones and could lead to excessive follow-up testing.

Considering obstetrics and gynecology as a specialty: current attractors and detractors.

We surveyed senior students at 11 medical schools to identify the criteria they used in considering obstetrics and gynecology (OBG) as a career. Nearly half (49.6%) of the students responded. Their demographic characteristics compared well with national figures. Regression analyses identified 15 significant predictors of specialty choice among the 445 students who ranked OBG as one of their top four choices. More women than men chose OBG. Students attracted to the specialty liked contact with (mostly healthy) patients. They expressed strong beliefs on reproductive issues and perceived a need for more obstetrician-gynecologists. They associated their interests in operative procedures with certain risks and responsibilities. Physicians in OBG modestly affected their decision. Students who chose a different specialty wanted more variety in disease and patient mix. They wanted a more controllable life-style, particularly in residency training. They felt that the insurance costs and the risk of lawsuit detracted from OBG. These findings offer a stimulus for discussion between students and their advisors. Students need sufficient exposure to the specialty to help them assess the value they place on these specialty characteristics.

Limitations of physician ratings in the assessment of student clinical performance in an obstetrics and gynecology clerkship.

A review of the grading process used in an obstetrics and gynecology clerkship prompted an analysis of physician ratings of student clinical performance. The study assessed the following: 1) the degree to which raters distinguished among six categories of performance, 2) the concordance among raters in terms of evaluation criteria used, 3) the degree of inter-rater agreement, and 4) the relationship between the ratings and student performance on the National Board of Medical Examiners Subject Examination in obstetrics and gynecology. Data from physician ratings and examination scores of 82 students were analyzed. The physicians received no standardized training in using the evaluation form. Seven raters (three faculty, four residents [one per postgraduate year]) were randomly selected from each student's set of evaluations. Contrary to expectations, physicians made global ratings of the students using a single criterion and did not distinguish among the six evaluation categories. Each of the five groups of physicians used a different criterion to evaluate students. The ratings were inflated and suffered from low inter-rater reliability. First-year residents were more lenient in their grading tendencies than the other physician groups. The ratings showed a weak correlation with the examination scores, and the strength of this relationship varied with the physician group and performance category. These findings and supporting literature should remind clerkship directors to periodically check the quality of clinical performance ratings and to recognize the limitations of these ratings for grading purposes. Suggestions are presented for improving the student evaluation process.

The effects of epidural anesthesia on the Doppler velocimetry of umbilical and uterine arteries in normal and hypertensive patients during active term labor.

To study the effects of epidural anesthesia on uterine and umbilical artery blood flow in preeclampsia, we observed 25 patients in active labor at 36 or more weeks' gestation. Seven had preeclampsia, eight had chronic hypertension, and ten had no complications. Doppler velocimetry of the uterine and umbilical arteries was performed before and after intravenous fluid loading and at 30 and 60 minutes after epidural blockade. Maternal vital signs and fetal heart rate were monitored continuously. After epidural block, mean maternal blood pressure fell significantly in all groups, but no maternal hypotension was observed. Mean maternal and fetal heart rates were unchanged. After epidural block, mean uterine artery systolic-diastolic (S-D) ratios did not change in the chronic-hypertension and normal groups, but fell significantly in the preeclamptic group to values similar to those of the normal group. Umbilical artery S-D ratios did not change in any group. In preeclamptic pregnancy, epidural anesthesia may help to reduce uterine artery vasospasm and may benefit intrapartum fetal well-being.

The effects of epidural anesthesia on the Doppler velocimetry of umbilical and uterine arteries in normal term labor.

To study the possible effects of epidural anesthesia on the Doppler velocimetry of the fetal umbilical and maternal uterine arteries, 15 normal term parturients were examined during active labor. Each Doppler study, conducted over 90 minutes after a 500-mL intravenous volume pre-load, was divided into three phases: 30 minutes of pre-anesthetic control, 30 minutes during epidural catheter placement and dosing, and 30 minutes after establishing effective regional blockade. During each phase, maternal blood pressure and pulse were monitored every 5 minutes, and continuous-wave Doppler recordings of the umbilical and uterine arteries were made at three separate intervals. Epidural placement and dosage techniques were similar for all patients; 0.25% bupivacaine solution was used and sensory levels of T6 obtained. The mean maternal systolic and diastolic blood pressures and pulse rate declined significantly, but no woman experienced hypotension. Mean systolic/diastolic ratios and pulsatility indices of the umbilical and uterine arteries did not change significantly during the study. We conclude that effective epidural anesthesia does not have a significant impact on Doppler flow characteristics of either the maternal or fetal umbilical vasculature, despite lowered maternal blood pressure and pulse rate.

Assessment of epidermal growth factor in the healing process of clean full-thickness skin wounds.

Epidermal growth factor is a potent stimulant of epithelialization. However, the usefulness of topical applications of epidermal growth factor in accelerating wound healing in full-thickness skin wounds with a large panniculus adiposus has not been clear. Four full-thickness skin incisions were made in the back of 10 female pigs that treated twice a day for 14 days with 2 ml of epidermal growth factor (300 ng/ml) or 2 ml of Ringer's lactate solution in a single-blind, randomized fashion. Two pigs received only epidermal growth factor, two pigs received only Ringer's lactate solution, and six pigs were treated with both solutions. The original skin plug was weighed to ensure similarity of groups. Photographs and measurements of each incision were taken every 7 days. The mean surface areas of the incisions treated with epidermal growth factor were 8.45, 7.50, and 2.30 cm2; in the incisions treated with Ringer's lactate solution the measurements were 8.42, 8.16, and 2.37 cm2 on observation days 1, 7, and 14, respectively. Although a trend toward a faster healing rate was noted in the incisions treated with epidermal growth factor, this difference was not statistically significant. With the doses and the time interval used between treatments, minimal benefit was obtained with epidermal growth factor when compared with Ringer's lactate solution.

The relationship among exercise, stress, and primary dysmenorrhea.

This study considers primary dysmenorrhea from a biopsychosocial perspective in examining the relationship between physical exercise and menstrual pain. Despite widespread claims of the benefits of exercise for perimenstrual symptoms, the evidence seems weak. Stronger evidence indicates that exercise helps relieve stress and elevates mood and that stress heightens menstrual discomfort. Student nurses (n = 176) completed a questionnaire disguised as a general health survey that contained these measures. The hierarchial regression analysis demonstrated that, contrary to the expected, regular exercise increased with the severity of menstrual symptoms, after controlling for medications, disposition, perceived stress, and mood. The findings suggest that exercise presents a tradeoff; it relieves the stress that may intensify dysmenorrhea, yet it may aggravate these same symptoms.

The effects of vibroacoustic stimulation on baseline heart rate, breathing activity, and body movements of normal term fetuses.

To determine the fetal biophysical effects of vibroacoustic stimulation produced by an electronic artificial larynx we studied 20 normal term pregnancies assigned either to control (no stimulus) or experimental (stimulus) groups. Each fetus was observed for 3 hours; either no stimulus or a 3-second stimulus was delivered after the first hour. Fetal heart rate baseline and variation, breathing movement incidence, rate, and variation, and body movement incidence data were acquired concurrently and analyzed at 15-minute intervals. Intergroup comparisons showed that, after stimulation, fetal heart rate baseline and variation increased significantly, whereas breathing incidence fell during the first 15 minutes. Within-group analyses showed that poststimulus elevation of fetal heart rate baseline was the only significant time interaction over the 3 hours. Vibroacoustic stimulation appears to be primarily associated with transient alterations in fetal heart rate baseline; concomitant changes in breathing activity probably reflect normal biologic cycles.

The preterm nonstress test: effects of gestational age and length of study.

The application of the nonstress test between 24 and 32 weeks' gestation has been limited by high rates of "false" nonreactivity in normal fetuses, by use of term criteria, and the lack of age-appropriate interpretative standards. To establish such standards, we studied 30 normal fetuses undergoing 90-minute fetal heart rate recordings at 2-week intervals from 24 to 32 weeks' gestational age. Using a specially programmed computer we quantified (1) baseline fetal heart rate, (2) incidence of 10- and 15-beat accelerations, and (3) incidence of fetal heart rate decelerations. With a criterion of three 15-beat accelerations per 30 minutes 91% of tests were reactive within 90 minutes. A criterion of three 10-beat accelerations per 30 minutes was associated with 100% reactivity within 60 minutes. Suitable interpretative criteria may be established for nonstress tests before 32 weeks' gestation by extending the testing time or by decreasing the minimum amplitude required of fetal heart rate accelerations.

Student performance on the NBME Part II subtest and subject examination in obstetrics-gynecology.

Clerkship directors in obstetrics-gynecology often use the National Board of Medical Examiners (NBME) norms to evaluate third-year medical students' performance on the NBME obstetrics-gynecology subject examination. A comparison of the scores of 342 students at the Medical College of Georgia School of Medicine showed that the students performed significantly better on the NBME subject examination than on the Part II subtest in obstetrics-gynecology. These results concur with the findings of the NBME, which advises directors wishing to adjust the criterion group norms to determine the average difference observed in a school's performance on the two examinations and to use that difference or some portion of it in their interpretation of percentile scores on the subject examination. Additional analyses revealed that a single, linear weight may inappropriately adjust these scores, that student performance on the Part II subtest depends on specialty choice (obstetrics-gynecology versus all others), and that time and sequence of the clerkship were unrelated to the students' performance on the two examinations.

The resident and fellow relationship in obstetrics and gynecology.

In a nationwide survey, chief administrative residents reported their views on how subspecialty fellowships affect their residency training in obstetrics and gynecology. The residents felt that fellows improve the quality of their training, depending on the degree they consider fellows as junior faculty involved in teaching and modeling patient care. Competition for surgical cases, and the surgical priority fellows have over residents in the new technology and nonroutine cases, potentially detract from the resident-fellow training relationship. These factors varied by subspecialty and the particular content areas of the fellowship. The residents' comments highlight the positive and negative components of each fellowship and identify the features of their relationship with the fellows. The implications of these findings for enhancing this relationship are presented.