Legal issues impacting women's access to care in the United States-the malpractice insurance crisis.

Professional liability insurance costs have increased rapidly in the last 10 years in the United States, while availability of companies offering professional liability insurance has decreased. The result is that ob-gyn physicians are changing their practice patterns. Many are no longer performing difficult or complex surgical procedures while others have stopped caring for obstetrical patients. Some physicians are retiring early or moving to other localities where there are less liability concerns. These changes all impact on the availability of health care for women. In addition, these problems have become a concern of medical students, and this is reducing the numbers considering a career in ob-gyn. Even where ob-gyns are available, hospitals and insurance carriers are limiting their ability to practice the wide range of procedures for which they were trained. Although legislative efforts to correct the problems are proposed, very few have been enacted. The end result is that women's health care has been threatened and will continue to face shortages and restrictions.

Hormonal evaluation of the intrauterine progesterone contraceptive system.

Nine women were studied for one menstrual cycle prior to the insertion of an intrauterine progesterone contraceptive system (IPCS) delivering 65 microng progesterone/day into the uterus and again at 1 month after its insertion. Eight of these women were again studied between 6-8 months after the insertion of the IPCS. Luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol-17beta, progesterone, prolactin and relaxin were measured in each plasma sample. The data from each study were combined according to the day of the LH peak. Ovulation occurred in all the cycles studied in spite of an elevation in plasma estradiol-17beta and a depression of prolactin and relaxin immunoactivities at the 6-8 month follow up. Menstruations noted at the 6-8 month of use occurred while levels of estradiol-17beta and progesterone were elevated.

PIP: Plasma levels of luteinizing hormone, follicle stimulating hormone, estradiol-17beta, progesterone, prolactin, and relaxin were studied in 9 women before and after insertion of an Alza, progesterone-releasing, IUD. The IUD releases approximately 65 mcg/day of progesterone into the uterus. The lengths of the preovulatory and postovulatory phases of the menstrual cycle were not affected by the device. Ovulation occurred in all the cycles, even though plasma levels of estradiol-17beta were significantly (p less than .05) increased and plasma levels of prolactin and relaxin were significantly (p less than .05) decreased as late as 6-8 months after insertion. During menstruation at 6-8 months after insertion, plasma levels of estradiol-17beta and progesterone were high. The results are discussed.

Meconium aspiration syndrome without evidence of fetal distress in early labor before elective cesarean delivery.

Seventy-seven cases of meconium aspiration were documented among 14,527 deliveries. Four cases occurred in early labor and with normal fetal heart tracings. Three cases followed repeat cesarean sections at term, and one followed an elective cesarean section for a primigravid breech presentation. Aggressive airway management was used in every case, and included intrapartum pharyngeal suctioning with a DeLee catheter and intubation of the trachea with suctioning under direct vision. These cases suggest that meconium aspiration may occur before the onset of active labor and without evidence of fetal distress.

Hydrops fetalis secondary to Bart hemoglobinopathy.

Alpha-thalassemia is the most common cause of hydrops fetalis among Southeast Asians. With the recent influx of Southeast Asian refugees and the rapidly growing Filipino population this will become an increasingly important obstetric problem in the United States. Homozygous alpha-thalassemia, or Bart hemoglobinopathy, is invariably fatal to the fetus and produces significant maternal morbidity. Eighteen cases of homozygous alpha-thalassemia in one hospital are reviewed. This is the largest series reported in the United States. Recommendations are made for antenatal screening, diagnosis, and management of alpha-thalassemia.

Massive fetomaternal hemorrhage preceded by decreased fetal movement and a nonreactive fetal heart rate pattern.

BACKGROUND: Massive fetomaternal hemorrhage occurs in one in 1000 deliveries and has been associated with decreased fetal movements and a sinusoidal fetal heart rate (FHR) pattern. CASES: Three women presented with decreased fetal movements, nonreactive FHR patterns, and positive Kleihauer-Betke tests. All three were at a viable gestational age and were immediately delivered by cesarean. The three infants were severely anemic, with hemoglobin levels of 6.5, 5.3, and 5.1 g/dL, respectively. CONCLUSION: A patient who presents with decreased fetal movement associated with a nonreactive FHR pattern and a positive Kleihauer-Betke test of more than 140 mL should be considered for immediate delivery if the gestational age is consistent with neonatal viability.

What is the significance of the human chorionic gonadotropin value in ectopic pregnancy?

Surgical and pathology data were analyzed with the quantitative serum hCG values from 131 patients with tubal pregnancies. The hCG value correlated with both the size and contents of the eccyesis. Patients with ruptured tubal pregnancies had significantly greater serum hCG levels than did those with intact tubal gestations. Isthmic tubal pregnancies were associated with more frequent rupture and larger amounts of hemoperitoneum than were pregnancies in the ampullary segment of the tube. Tubal rupture with hCG values below 100 mIU/mL occurred in two isthmic pregnancies but in no ampullary pregnancies. With serum hCG levels below 300 mIU/mL, significant hemorrhage did not occur unless the tube was ruptured. Half of the patients had hCG levels sufficient to use a vaginal sonographic hCG discriminatory zone to assist in the diagnosis. A maximum of 15% of tubal pregnancies may be diagnosed by ultrasonographic detection of adnexal cardiac activity. A serum hCG assay sensitive to 10 mIU/mL will detect nearly all tubal pregnancies. The hCG level frequently has diagnostic value when used in conjunction with vaginal sonography. At hCG levels of 100 mIU/mL or less, tubal rupture is very unlikely for ampullary, but not for isthmic, tubal pregnancies.

Intramuscular (15S)-15-methyl prostaglandin F2alpha for midtrimester and missed abortions.

The efficacy of intramuscular 15-me-PGF2alpha as an abortifacient was evaluated in 40 women between 14 and 20 weeks of gestation and 6 patients with missed abortions. Pregnancy was successfully terminated in all the cases. The injection-abortion interval was significantly lower in 20 patients (Group II) who had intracervical laminaria insertion prior to treatment with 15-me-PGF2alpha than in 10 women (Group I) without laminaria insertion (t = 7.2; P less than .001). Abortion was also accomplished in 10 women with ruptured membranes and 6 patients with missed abortions. Gastrointestinal side effects were minimal and acceptable when premedication with antiemetics and an antidiarrheal was used. This study demonstrates the availability of the intramuscular route--a simple, safe, reliable means of terminating pregnancy, especially during the early midtrimester period.

Long-term tocolysis with combined intravenous terbutaline and magnesium sulfate: a 10-year study of 1000 patients.

OBJECTIVE: To determine whether long-term intravenous (IV) tocolysis using combined terbutaline and magnesium sulfate is safe and effective. METHODS: One thousand consecutive women in preterm labor were treated with combination IV tocolytic therapy. Terbutaline was initiated with an infusion rate of 1.75 micrograms/minute and increased to a maximum of 80 micrograms/minute. Magnesium sulfate was infused at 2 g/hour without any bolus and increased to maintain a serum level of 6.5-7.5 mg/dL. Tocolysis was continued until fetal lung maturity was achieved or delivery occurred. RESULTS: Combination tocolytic therapy prolonged pregnancy by a mean (+/- standard deviation) of 61 +/- 23.6 days in 751 women with intact membranes and by 20.5 +/- 17.4 days in 249 with ruptured membranes. The longest durations of continuous IV tocolysis were 123 days in a patient with intact membranes and 77 days in one with ruptured membranes. The most common side effects were nausea and vomiting, followed by chest tightness and shortness of breath. CONCLUSION: Long-term IV tocolysis appeared to be safe and to have acceptable side effects, allowing patients to receive combined terbutaline and magnesium sulfate until delivery.

Persistent ectopic pregnancy.

From 1982-1986, 625 tubal ectopic pregnancies were treated at the University of Hawaii School of Medicine Affiliated Hospitals. The percentage of cases in which the involved tube was preserved increased from 7% in 1982 to 26% in 1986. The presence of persistent trophoblastic tissue was diagnosed by elevated serum levels of the beta subunit of human chorionic gonadotropin (beta-hCG) after conservative surgery in four patients. Three of the four patients developed intra-abdominal hemorrhage and required laparotomy. One patient remained asymptomatic despite elevated beta-hCG levels, which disappeared 60 days after surgery. Evaluation of histologic slides demonstrated persistent intraluminal trophoblastic tissue without invasion in two patients, and extraluminal invasion into the tubal wall in one patient. The use of postoperative serial beta-hCG titers might facilitate recognition of this complication in time to prevent further tubal damage and hemorrhage.

Adnexal masses in pregnancy: occurrence by ethnic group.

Two hundred twenty-eight adnexal masses during pregnancy were discovered among 37,159 deliveries occurring between January 1, 1983 and October 31, 1988 at Kapiolani Medical Center for Women and Children in Honolulu. Hydatid cysts of morgagni (45.6%) occurred most frequently, followed by benign cystic teratomas (15.8%), epithelial cystadenomas (15.4%), and paraovarian cysts (13.6%). There were no malignant or borderline tumors. The patients were categorized as 22.1% part Hawaiian, 18.5% white, 17% Filipino, and 16% Japanese. We demonstrated an increased incidence of benign cystic teratomas in Filipinas (P less than .01). There was no significant predisposition for the occurrence of non-neoplastic or other neoplastic lesions among any of the other ethnic groups studied.

Evaluation of the cost-effectiveness of home monitoring of uterine contractions.

In 1988, the major health insurance carrier in the state of Hawaii initiated a prospective study to determine the cost-effectiveness of ambulatory uterine activity monitoring. At the end of the study, 79 patients had completed 3189 days on the monitor. Thirty-six patients (45.6%) did not have preterm labor; the daily monitoring resulted in an average loss to the insurance carrier of $3300 per patient, or $118,800. Forty-three patients (54.4%) experienced preterm labor and were found to have benefited from the monitoring system. Earlier detection of preterm labor and better management of oral tocolysis in this group resulted in earlier initiation of maternal tocolytic therapy, which ultimately decreased the preterm birth rate and hospitalization days in the neonatal intensive care unit. Cost analysis of this group demonstrated an average savings of $24,000 per patient, or an overall savings of $1,032,000. The total group of high-risk patients (79) resulted in a net savings to the insurance carrier of $913,200, or $11,500 per patient, suggesting that use of the ambulatory uterine activity monitoring system significantly reduced the cost associated with preterm labor and early delivery.

Rapid hCG-specific radioimmunoassay for menstrual aspiration.

Fifty-one women with missed periods ranging from 5 to 14 days who suspected a pregnancy underwent an aspiration curettage with a flexible soft-tipped cannula attached to a Karman-type syringe. Sera from these women were measured for human chorionic gonadotropin (hCG) by a rapid 2-hour solid phase radioimmunoassay using an antibody with a specificity for the beta subunit of hCG. The sensitivity and specificity of this assay insured detection of bCG with 100% accuracy at the time of the missed period. Of the 51 women, 33 (64.7%) were found to have hCG in their serum, and 29 (56.8%) had histologic evidence diagnostic of pregnancy.

PIP: Aspiration curettage was performed on 51 women who suspected pregnancy and had missed periods from 5 to 14 days. Sera obtained from the patients were analyzed for human chorionic gonadotropin (HCG) by a rapid, 2-hour solid-phase radioimmunoassay using an antibody with a specificity for the beta subunit of HCG. 33 of the women (64.7%) were found to have serum values ranging from 8 mIU/m1 to 3997 mIU/m1. 29 of the women (56.8%) showed histologic evidence of pregnancy. Generally, more women had HCG in their serum as the number of days following the missed period increased. The test can detect HCG with 100% accuracy at the time of the missed period.

The effects of oral contraceptives on respiration.

The effect synthetic progestins found in current oral contraceptives may exert on respiratory function has not been thoroughly investigated. This study monitored potential changes in respiratory parameters 3 and 6 months subsequent to beginning administration. Static and timed spirometric maneuvers showed significant increases in only tidal volume (P = 0.01). Ventilatory response to treadmill exercise monitored the oxygen uptake, CO2 elimination (VCO2), minute ventilation (VE), and respiratory exchange ratio at each of four workloads. An analysis of the covariance (ANCOVA) for the slopes revealed no significant variation between test periods. The ANCOVA for the means showed increases in VE and VCO2. These results suggest a stimulatory role for synthetic progestins, although ventilatory performance in response to moderate exercise does not appear compromised.

Monitoring of suspected infertile men with varicocele by the sperm penetration assay.

Although varicocele remains the most frequently diagnosed cause of male infertility, and improvement in semen quality is associated with repair of varicocele, improvement in spermatozoal fertilizing capacity has not been conclusively demonstrated. The sperm penetration assay was employed to monitor prospectively surgical (n = 59) and nonsurgical (n = 40) groups of men with varicocele. There were no significant increases in the average count, motility, morphologic features, or sperm penetration assay results for either group. Varicocele surgery enhanced assayable egg penetration rates in 14 of the 59 patients (23.7%), whereas the nonsurgical group had 10% spontaneous improvement. Of those in the surgery group who showed assayable fertility enhancement and were attempting conception, pregnancies were achieved in 70% (7 of 10 patients). Of patients in the nonsurgical group who improved in the assay, no pregnancies were obtained.

Variability in the human-hamster in vitro assay for fertility evaluation.

Sources of variability in the zona-free hamster egg penetration assay were evaluated. Internal consistency in the assay was examined in replicate experiments using sperm from 23 donors. The average difference in the percentage of fertilization between the replicates was 3.9%. Optimal preincubation conditions and insemination time were examined and shown to be 0.5 to 1.0 X 10(7) sperm/ml and 2 to 3 hours. Abstinence time was found to be a variable, and a critical abstinence of more than 12 hours was required. Prolonged exposure to seminal plasma (i.e., more than 30 minutes) produced a reduction in the fertilization test results. If the variables studied here are consistently controlled, then changes in the assay results greater than the experimental error should reflect true changes in the semen sample.

Effects of white blood cells on the in vitro penetration of zona-free hamster eggs by human spermatozoa.

The presence of white blood cells in semen has been associated with male infertility. Previous studies indicate that pyospermia occurs in conjunction with decreases in sperm motility, number of normal sperm forms, and penetration rates in the zona-free hamster egg sperm penetration assay. We have evaluated the relationship of seminal white blood cells and sperm function, as reflected in the zona-free hamster egg penetration assay, and have investigated the possible mode of action of the white cells. Egg penetration rates decreased when white blood cells from fertile or potentially fertile donors were added to their sperm suspensions prior to preincubation and at insemination in the in vitro assay. Zona-free hamster egg penetration assay results were also inhibited when the supernatant from white blood cells incubated in Biggers, Whitten, and Whittingham (BWW) medium overnight were introduced to sperm-oocyte suspensions at insemination. Conversely, egg penetration rates were enhanced in samples from hypofertile individuals when white blood cell concentrations in the semen or WBC/sperm ratios were reduced, either by physical removal or as a result of antibiotic therapy. The physical presence of leukocytes, and possibly, the extracellular release of lysosomal enzymes may be responsible for the inhibitory effects in vitro. Although the mechanism(s) by which white blood cells interfere with the fertilizing capacity of spermatozoa are not clear, it is quite obvious that their presence in the in vitro environment is undesirable and can mask an individual's actual fertilizing potential.

Sperm morphology assessment as an indicator of human fertilizing capacity.

Semen samples from 95 men were examined by routine semen analysis and specific histologic staining for sperm morphology. The men were classified into fertile and infertile groups on the basis of clinical evaluation and in vitro testing, using the zona-free hamster egg penetration assay. Thirty men were designated as fertile, as they had fathered children and their sperm showed penetration of greater than 20% of the zona-free hamster eggs with the in vitro fertilization test. Subjects classified as infertile were men from infertile couples whose wives showed no evidence of infertility and whose in vitro fertilization ability was 10% or less. The semen analysis parameters of the fertile and infertile groups were significantly different. Fertile men had mean values of 108 X 10(6) sperm/ml, 61% motile, 64% normal forms (sperm with oval morphology), and 69% penetration in vitro. The mean values for infertile men were significantly lower: 42 X 10(6) sperm/ml, 45% motile, 32% normal forms, and 3.2% penetration in vitro. The importance of the morphology parameter was revealed by comparison of the percentage of penetration with count, motility, and morphology. Penetration correlated best with morphology (r = 0.730) as compared with motility (r = 0.451) and count (r = 0.605). The distribution of abnormalities in the infertile group revealed 81.6% with abnormal morphology (less than 50%), 53.8% with abnormal motility (less than 50%), and 38.5% with abnormal count (less than 20 million/ml). As a single parameter, decreased number of normal forms appears to be a good indicator for clinical infertility if in vitro fertilization testing is not available.

Comparison of the penetration ability of human spermatozoa into bovine cervical mucus and zona-free hamster eggs.

In vitro bovine cervical mucus (BCM) penetration tests, sperm penetration assays (SPA) using zona-free hamster eggs, and routine semen analyses were performed on a total of 136 freshly collected semen samples from men who were seen at an infertility clinic. The correlations between bovine cervical mucus penetration and other semen parameters were the percent motile spermatozoa (r = 0.48), progressive motility grade (r = 0.44), sperm count (X 10(6)/ml) (r = 0.47), the percent normal morphology (r = 0.32) and the percent eggs penetrated (r = 0.46) (P less than 0.0001 for each correlation coefficient). When known fertile (n = 32) and infertile (n = 18) groups were tested, positive mucus penetration was associated 75% correctly and positive egg penetration was associated 90% correctly to clinical status. The mucus test had no false-negative results and the SPA had no false-positive results in these groups. It appears, then, that the mucus test and sperm penetration assay, although contributing different elements of data to an infertility evaluation, are both useful adjuncts to a semen analysis.

The elite athlete and exercise in pregnancy.

As the opportunities for women to compete in elite sports competition increase, it is inevitable that pregnancy will occur during training and competition. The effect of the high-intensity exercise needed to compete at the elite level will be found in anatomic changes such as ligament relaxation, change in posture, and increased weight. These will all detract from the ability to attain peak performance. The effect of the high-intensity training on the athlete and the fetus must also be considered. The physiological and metabolic changes will have a variable effect; however, awarenees of these changes should prevent problems. There is some evidence suggesting an increase in low birthweight infants but no evidence of preterm birth. Unfortunately, much of our information is based on limited studies, so caution and careful evaluation are essential.

Sexual and contraceptive behavior on a college campus. A five-year follow-up.

In the spring of 1974, the authors surveyed students on the campus of the University of Hawaii to determine their sexual attitudes, behavior, and contraceptive practice. In 1979 this same survey was repeated to ascertain what, if any, changes had occurred within this five-year span. It was found that sexual activity among single students had increased slightly, with the increase being the same for both males and females. Other findings included an increase in the number of unmarried students living together; however, it was also found that students living in on-campus dorms had less sexual activity than those living off campus. A surprise finding was an increase in sexual activity by Chinese and Japanese students, while there was a decrease in sexual activity by Filipino students. It was found that sexually active students were using less contraception in 1979. The reason mentioned most frequently for not using contraception was fear of side effects. The number of students who had been pregnant increased slightly, and it was found that there was also a slightly higher incidence of intentional termination.