Medical education for obstetricians and gynecologists should incorporate environmental health.

Obstetricians-gynecologists can protect the reproductive health of women, men, and their offspring from environmental hazards through preconception and prenatal counseling and encouraging patients to take actions to reduce environmental exposures. Although obstetricians-gynecologists are well positioned to prevent hazardous exposures, education on environmental health in medical education is limited. The Mid-Atlantic Center for Children's Health and the Environment and the Department of Obstetrics and Gynecology of George Washington University convened a meeting to begin integration of environmental health topics into medical education for obstetricians-gynecologists. Several avenues were identified to incorporate environmental health topics into medical education including continuing education requirements, inclusion of environmental health questions on board certification examinations and the creation of a curriculum on environmental health specific to obstetrics-gynecology.

Severity and prevalence of small lungworm infection on three South Australian farms and associations with sheep carcass characteristics.

This field and abattoir study assessed the association of the severity and prevalence of small lungworm lesions with the carcass characteristics of 1332 lambs and adult sheep bred on three farms in southeast SA. Liveweight and measures of lungworm infection were measured on farm, then lung lesions and carcass characteristics assessed at slaughter. The overall prevalence of small lungworm lesions at slaughter was 79 % (928/1177; 95 % CI 76, 81), with a prevalence of 87 % (569/658; 95 % CI 84, 89) in lambs, and 69 % (359/519; 95 % CI 65, 73) in adults, respectively. Small lungworm infected lambs and adults had a similar hot standard carcass weight and dressing percentage compared to non-infected animals, both overall and within their respective cohort. Overall, the mean carcass weight for non-infected and infected lambs was 23.4 kg (95 % CI 18, 29), and 23.6 kg (95 % CI 18, 29), respectively, with a mean difference of 0.2 kg (95 % CI -0.4, 0.8; P = 0.5). Mean carcass weight for non-infected and infected adults was 21.3 kg (95 % CI 15, 28), and 21.5 kg (95 % CI 15, 28), with a mean difference of 0.2 kg (95 % CI -0.5, 0.9; P = 0.5). This study confirmed a very high prevalence of small lungworm lesions in sheep bred on farms in this region of SA, but their hot standard carcass weights were not reduced by these lesions. Additional information to compare the presence of lesions with productivity within an individual was collected at slaughter which provided more detailed information than is currently collected by routine abattoir surveillance. The limitations of the currently available diagnostic tests for small lungworm were also demonstrated. This indicated a need for the development of more sensitive tests to assess lungworm infections both on farm and at the abattoir. Currently, farmers in this region are concerned about the very high prevalence of small lungworm in their sheep, but this study provides reassurance that the presence of mild lesions does not reduce production.

The effect of pasture molluscicide on small lungworm infections and the productivity of grazing lambs.

The aim of this study was to assess the effect of pasture molluscicide treatment on the prevalence and severity of small lungworm infections, and the productivity of lambs grazing improved pastures in southeastern Australia. A randomised control field trial of 260 Merino-cross lambs was conducted on a commercially managed farm in South Australia with a history of high small lungworm prevalence. Separate groups of lambs rotationally grazed irrigated lucerne paddocks treated with iron chelate molluscicide or untreated control paddocks. Lambs were monitored every 2-6 weeks from weaning until slaughter with liveweight, lungworm and gastrointestinal nematode infection status measured. At slaughter indicators of small lungworm infection via inspection and carcass characteristics were assessed. The density of the intermediate host snail and lucerne pasture availability were also measured. There was a higher population of adult Prietocella barbara molluscs in the Control paddocks compared to the Treatment paddocks after molluscicide had been applied and prior to grazing commencing (206 vs. 14 snails/m2, respectively; P = 0.03; 95 % CI 8, 528). However, the overall mollusc density was similar between Control and Treatment. The prevalence of small lungworm infections was quite low during the trial (0-13 %), in both Control and Treatment lambs, except at day 94 when 48 % of 28 Control lambs were positive compared to none of 27 Treatment lambs (P < 0.001; 95 % CI 30, 66). A similar proportion of Treatment and Control lambs had evidence of small lungworm infection lesions at slaughter (both 67.8 %). Control lambs grew slightly faster than Treatment lambs, with an average daily gain of 202 (± 3 SEM) g/head/day for Control and 190 (± 4 SEM) for Treatment (P < 0.001) during the 112-day trial. Despite historic evidence of very high prevalence of lungworm infection in this region of southeastern Australia, iron chelate molluscicide treatment prior to lambs grazing the pasture had no demonstrable effect on the prevalence and severity of small lungworm infections, nor the productivity of lambs grazing these pastures. This study indicates that for a commercial sheep farm, additional molluscicide treatments of pastures after they are established, for the prevention of small lungworm infection, may not be warranted. Furthermore, requirements for more precisely monitoring snails are discussed.

Group B Streptococcus and pregnancy: a review.

In the 1960s, early onset neonatal sepsis caused by group B Streptococcus (GBS) had an attack rate of 2 per 1000 live births and a 50% fatality rate. Early treatment and then antibiotic prophylaxis were shown to reduce morbidity and mortality rates; however, GBS remains a leading cause of perinatal infection. This article will review our investigations and related studies, including our studies in monkeys, that have contributed to current diagnosis, treatment, and prevention of disease caused by GBS. Although it has not been possible to eradicate GBS colonization, intravenous antibiotic prophylaxis given during parturition has been effective in the prevention of vertical transmission in animals and humans. Recently, diagnostic tests with polymerase chain reaction have offered promise for rapid accurate detection. This could lead to a major shift in the timing of diagnosis from the office setting to delivery suite. The potential for immunization remains a challenge.

Rapid growth of a fetal sacrococcygeal teratoma in an HIV-infected woman: a case report.

BACKGROUND: Sacrococcygeal teratoma, the most common congenital neoplasm of the newborn, associated with fetal hydrops and high morbidity and mortality related to the secondary effects of the tumor mass, is of unknown etiology. Prompt diagnosis and early treatment have proven to be effective. CASE: A 24-year-old woman, gravida 3, para 2, at 385/7 weeks' gestation, with a pregnancy complicated by HIV diagnosed during pregnancy, seizure disorder and tobacco use, presented with premature rupture of membranes. Ultrasound examination at 17 weeks' gestation showed normal fetal anatomy. Cesarean delivery was complicated by difficulty delivering a live infant with a large sacral mass. Successful surgical excision of a 650-g mass and stabilization of the infant occurred in the neonatal period. CONCLUSION: This is the first case report to describe a rapidly growing sacrococcygeal teratoma in a neonate from a pregnancy complicated by HIV. Ultrasound in the first and second trimesters identified no fetal abnormalities of the spine. Further research concerning sacrococcygeal teratoma and HIV in pregnancy is necessary for prompt and early diagnosis and treatment of antepartum and peripartum complications.

Implementation and evaluation of a genetics curriculum to improve obstetrician-gynecologist residents' knowledge and skills in genetic diagnosis and counseling.

OBJECTIVE: This study was undertaken to develop, implement, and evaluate a genetics curriculum for obstetrician-gynecologist residents. STUDY DESIGN: We prospectively evaluated the effect of a genetics curriculum on obstetrician-gynecologist residents' knowledge and skills. Residents completed a needs assessment and pretest. Educational intervention included 2 3-hour didactic sessions with 1 hour of lecture followed by case discussion and 1 3-hour session of experiential learning using standardized patients who evaluated residents' knowledge and skills in taking family history, drawing genetic pedigrees, and counseling patients. Posttest scores were compared with pretest scores. RESULTS: Needs assessment was completed by all 40 obstetrics and gynecology residents and identified limited and variable genetics education in medical school. Twenty-eight of 40 residents attended the entire educational intervention and completed the pretest and posttest, and 25 of 28 showed improved test scores. Residents stated that they were more confident in their ability to take a family history, record a 3-generation pedigree, and counsel patients about genetic conditions after completion of the genetics curriculum. CONCLUSION: This multifaceted genetics curriculum improved residents' knowledge of genetics as well as their confidence in applying genetic concepts as assessed by the pretest and posttest and by their comments in the debrief session.

Autosomal dominant polycystic kidney disease in pregnancy complicated by twin gestation and severe preeclampsia: a case report.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD), an autosomal dominant genetic disorder with a reported prevalence of 1 in 1,000, may be associated with hypertensive disease in pregnancy. The evaluation of a pregnant woman with an adult-onset genetic disorder is complex and involves counseling about inheritance, prenatal diagnosis and management of the current pregnancy. CASE: A 33-year-old woman presented for obstetric care with a history of hypertension and ADPKD for 6 years. The patient had secondary infertility, which was treated by in vitro fertilization. The case was complicated by twin gestation and superimposed severe preeclampsia, leading to preterm cesarean delivery at 26 weeks' estimated gestational age. CONCLUSION: Because of the heritable nature of ADPKD and the long-term risk of end-stage renal disease requiring dialysis and/or renal transplantation, the evaluation and counseling of women with ADPKD who are pregnant or considering pregnancy should include a discussion of the modes of inheritance, natural history, available prenatal diagnostic options, and pregnancy risks and management options. Specific counseling issues in this case include the genetic concepts of variable expression and penetrance and the medical management of chronic hypertension and preeclampsia.

First trimester dating by fetal heart rate assessment: a comparison with crown-rump length measurement.

OBJECTIVE: The purpose of this study was to determine whether fetal heart rate (FHR) can be used to date pregnancies in the early first trimester using the gold standard of crown-rump length (CRL) dating as a reference. METHODS: This single center study evaluated women undergoing obstetrical ultrasounds between 4.5 and 8.5 weeks. FHR and gestational age (GA) based on CRL were obtained. Linear regression analysis and a Bland-Altman plot were used to demonstrate the relationship between the two measurements. A further simplified version of the relationship between CRL and FHR that may be clinically useful was calculated. RESULTS: 176 patients were included in the study. The Pearson correlation coefficient was 0.95, indicating a strong correlation between the two dating methods. The Bland-Altman plot demonstrated agreement across GA tested. A simple arithmetic formula of GA(weeks)=FHR (beats per minute)/20 was calculated. 169/176 patients had <4 days discrepancy between FHR- and CRL-based dating using this formula. CONCLUSION: We found that a simple formula based on FHR may accurately date early pregnancies. This method, if further validated, may represent an important tool for pregnancy dating.

Sample size considerations for livestock movement network data.

The movement of animals between farms contributes to infectious disease spread in production animal populations, and is increasingly investigated with social network analysis methods. Tangible outcomes of this work include the identification of high-risk premises for targeting surveillance or control programs. However, knowledge of the effect of sampling or incomplete network enumeration on these studies is limited. In this study, a simulation algorithm is presented that provides an estimate of required sampling proportions based on predicted network size, density and degree value distribution. The algorithm may be applied a priori to ensure network analyses based on sampled or incomplete data provide population estimates of known precision. Results demonstrate that, for network degree measures, sample size requirements vary with sampling method. The repeatability of the algorithm output under constant network and sampling criteria was found to be consistent for networks with at least 1000 nodes (in this case, farms). Where simulated networks can be constructed to closely mimic the true network in a target population, this algorithm provides a straightforward approach to determining sample size under a given sampling procedure for a network measure of interest. It can be used to tailor study designs of known precision, for investigating specific livestock movement networks and their impact on disease dissemination within populations.

Maternal temperature variation during parturition.

OBJECTIVE: To characterize temperatures for normal full-term parturients. METHODS: A retrospective chart review of 189 consecutive singleton deliveries during 1996 was conducted. All available maternal sublingual temperatures were collected from the time of admission to the time of discharge from the delivery area. To evaluate the effect of prophylactic antibiotics in labor, maximum labor temperatures of patients who did not receive (group 1) and who received (group 2) antibiotics were compared. Using simple linear regression, temperature slopes were calculated for patients who had at least two temperature observations during labor. RESULTS: A total of 147 (77.7%) patients met inclusion criteria. No statistical difference was found between the maximum temperatures of patients who received and did not receive prophylactic antibiotics for labor or recovery. The mean maximum temperature in labor was 37.0 +/- 0.42C. The average of each patient's mean temperature was 36.8 +/- 0.33C, and 95% of the observations were between 36.2C and 37.5C. The mean temperature slope of the 100 patients who had more than one labor temperature observation was 0.01 +/- 0.12C per hour. CONCLUSION: In the normal full-term parturient, labor alone does not significantly increase normal body temperature.

A molecular diagnostic tool to replace larval culture in conventional faecal egg count reduction testing in sheep.

The accurate diagnosis of parasitic nematode infections in livestock (including sheep and goats) is central to their effective control and the detection of the anthelmintic resistance. Traditionally, the faecal egg count reduction test (FECRT), combined with the technique of larval culture (LC), has been used widely to assess drug-susceptibility/resistance in strongylid nematodes. However, this approach suffers from a lack of specificity, sensitivity and reliability, and is time-consuming and costly to conduct. Here, we critically assessed a specific PCR assay to support FECRT, in a well-controlled experiment on sheep with naturally acquired strongylid infections known to be resistant to benzimidazoles. We showed that the PCR results were in close agreement with those of total worm count (TWC), but not of LC. Importantly, albendazole resistance detected by PCR-coupled FECRT was unequivocally linked to Teladorsagia circumcincta and, to lesser extent, Trichostrongylus colubriformis, a result that was not achievable by LC. The key findings from this study demonstrate that our PCR-coupled FECRT approach has major merit for supporting anthelmintic resistance in nematode populations. The findings also show clearly that our PCR assay can be used as an alternative to LC, and is more time-efficient and less laborious, which has important practical implications for the effective management and control strongylid nematodes of sheep.

Maternal asthma, race and low birth weight deliveries.

BACKGROUND: Asthma during pregnancy may compromise the well-being of the fetus and potentially impact an infant's birth weight via different mechanisms. AIMS: 1) To assess the influence of asthma during pregnancy on the incidence of LBW outcomes in white non-Hispanic (WNH) and black non-Hispanic (BNH) women. 2) To identify other risk factors that affect low birth weight (LBW) (birth weight<2500g) outcomes among asthmatic women. DESIGN/SUBJECTS: We conducted a retrospective analysis of compiled perinatal data on 17,073 patients including 9348 WNH and 7725 BNH women delivering at the George Washington University Hospital between 1990 and 2003. Univariate and logistic regression analyses were used to examine associations. RESULTS: A total of 423 (2.5%) women had an asthma diagnosis, with a higher incidence in BNH women when compared to WNH women (3.4% vs. 1.7%, P<0.001). In the WNH population, asthmatic women had higher incidences of gravidity, thyroid disease, and illicit drug use, whereas in the BNH population, asthmatic women had higher incidences of increased body mass index (BMI), and use of alcohol, tobacco and illicit drugs. After controlling for confounders in multiple logistic regression analyses, there was an association between asthma and LBW outcomes in BNH women (OR: 1.7, CI: 1.1-2.6, p=0.01), but not in WNH women (OR=0.99, CI=0.5-2.2, p=0.97). CONCLUSIONS: Asthma during pregnancy is a risk factor for LBW outcomes in BNH but not WNH women. The increased alcohol and illicit drug use in BNH women with asthma is an unexpected finding that deserves further study.

Guidelines for the diagnosis, treatment and prevention of postoperative infections.

Bacterial contamination of the operative site is a common occurrence in obstetrics and gynecology. The widespread use of antibiotic prophylaxis has reduced but not eliminated serious postoperative infections. For most operations, a single dose of a limited-spectrum drug has been as effective as a multidose regimen. In the differential diagnosis it is important to consider cellulitis, abscess, necrotizing fasciitis and septic pelvic thrombophlebitis. Abscess and necrotizing fasciitis are expected to require invasive therapy in addition to antibiotics, while cellulitis and septic pelvic thrombophlebitis should respond to medical management alone. Although a postoperative fever is a warning sign of possible infection, it may also be caused by the antibiotics that are given for treatment. The use of prolonged courses of antibiotics once the patient is clinically well is discouraged. While clinical guidelines are provided for use in the diagnosis and management of postoperative infections, these recommendations are intended for general direction and not as an exclusive management plan.

Combined first-trimester versus second-trimester serum screening for Down syndrome: a cost analysis.

OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of combined first-trimester screening for fetal Down syndrome with second-trimester maternal serum triple screening. STUDY DESIGN: A first-trimester screening approach that used nuchal translucency measurement and maternal serum screening was evaluated against second-trimester maternal serum triple screening in a hypothetic population. Screening sensitivities and screen-positive rates were 91% and 5% for the first-trimester approach and 70% and 7.5% for the second-trimester approach, respectively. The costs of fetal Down syndrome, live-born Down syndrome cost, and total costs (screening plus live-born costs) were calculated for each screening program. RESULTS: First-trimester screening was associated with lower screening and live-born Down syndrome costs versus second-trimester serum screening. Total Down syndrome screening costs were 29.1% lower with first-trimester screening. CONCLUSION: In this hypothetic model, combined first-trimester screening for fetal Down syndrome was more cost-effective than universal second-trimester triple serum screening.