Cost effectiveness of bedside fetal fibronectin testing varies according to treatment algorithm

OBJECTIVE

To determine the cost effectiveness of implementing fetal fibronectin testing in women with threatened preterm labor.

METHODS

We developed a cost analysis model based upon our institution's experience with threatened preterm labor. Model estimates related to fetal fibronectin were obtained from the literature. The model considered hospital admission and assay cost.

RESULTS

Approximately 2000 women deliver annually at our tertiary care facility. In the prior 11 months, 340 (19%) presented for threatened preterm labor with 45 (13%) admissions. In a group of individuals with threatened preterm labor and < 3 cm cervical dilatation, approximately 25% can be expected to have a positive fetal fibronectin test. If fetal fibronectin testing were used to influence the decision of admission, 93 (25%) would have a positive test over a 12-month period, potentially increasing admissions by 94%. At a cost of $225 per test, our institution's antepartum admission cost of $1919, a prevalence of threatened preterm labor of 19% and admission rate of 13%, fetal fibronectin testing applied prior to the decision to admit would result in a total cost of $262 583 with 373 assays performed, and 93 admissions. If only those who would have been admitted based on traditional criteria are considered, > 25% should have a positive fetal fibronectin test. If we assume a positive rate of 70%, fetal fibronectin testing employed after the decision to admit would result in a total cost of $75 963, with 48 assays performed and 34 admissions. Without using the assay, total costs are $92 950 for 48 admissions.

CONCLUSION

This cost analysis suggests that fetal fibronectin testing on all patients presenting with threatened preterm labor significantly increases the cost, while fetal fibronectin testing after the decision to admit may reduce the cost.

Hand-held computer operating system program for collection of resident experience data

OBJECTIVE

To describe a system for recording resident experience involving hand-held computers with the Palm Operating System (3 Com, Inc., Santa Clara, CA).

PROGRAM DESCRIPTION

Hand-held personal computers (PCs) are popular, easy to use, inexpensive, portable, and can share data among other operating systems. Residents in our program carry individual hand-held database computers to record Residency Review Committee (RRC) reportable patient encounters. Each resident's data is transferred to a single central relational database compatible with Microsoft Access (Microsoft Corporation, Redmond, WA). Patient data entry and subsequent transfer to a central database is accomplished with commercially available software that requires minimal computer expertise to implement and maintain. The central database can then be used for statistical analysis or to create required RRC resident experience reports. As a result, the data collection and transfer process takes less time for residents and program director alike, than paper-based or central computer-based systems.

CONCLUSION

The system of collecting resident encounter data using hand-held computers with the Palm Operating System is easy to use, relatively inexpensive, accurate, and secure. The user-friendly system provides prompt, complete, and accurate data, enhancing the education of residents while facilitating the job of the program director.

Videoteleconferencing for administration of a multisite obstetrics and gynecology core clerkship

Recent changes and trends in health care delivery have required medical schools to use multiple sites to obtain adequate patient exposure for their students. Decentralization of clinical undergraduate medical education may lead to a lack of continuity in curricula, evaluation, and feedback. We describe the use of interactive videoteleconferencing as a tool to link and improve a multi-site undergraduate core clerkship in obstetrics and gynecology. The Uniformed Services University of the Health Sciences, Bethesda, Maryland, currently utilizes five geographically separate sites for its 6-week core clerkship in obstetrics and gynecology. The site coordinators, clerkship director, and administrative personnel from the parent institution meet approximately 3 weeks after the completion of each core clerkship for live, real-time, and interactive broadcast to complete student evaluations, review curricula, and discuss problems with current students and other pertinent educational issues. Videoteleconferencing provides a mechanism to ensure consistency in curriculum and student evaluations and provides administrative support to distant sites. Furthermore, it enables site coordinators to keep the clerkship director abreast of students and clerkship issues.

Effect of meconium on the hemoglobin-oxygen association curve

OBJECTIVE

Our purpose was to determine the effect of meconium-stained amniotic fluid on the hemoglobin-oxygen association curve of maternal whole blood.

METHODS

Whole blood was obtained from term gravidas in active labor. Hemoglobin-oxygen association curves were generated for blood incubated with meconium vs. controls. Oxygen association curves were determined at pH 7.4 and 37 degrees C utilizing an automated device consisting of a spectrophotometer cuvette fitted with a magnetic stirrer, gas exchange line, and a Clark oxygen electrode. The samples were deoxygenated with nitrogen and association curves recorded while reoxygenating. Data was analyzed with Sigma Plot and Sigma Stat software. Analysis included log transformation, linear regression, and paired t-test.

RESULTS

Twenty-eight hemoglobin oxygen association curves were generated. In all 14 pairs, meconium shifted the hemoglobin-oxygen association curve to the right. Partial pressures of oxygen required for various degrees of hemoglobin saturation were higher in meconium-exposed samples; P50 (30.1+/-0.6 vs. 27.8+/-0.4 mmHg, P < 0.01); P75 (46.9+/-0.6 vs. 43.1+/-0.5 mmHg, P < .001); P90 (69.2+/-1 vs. 63.3+/-1 mmHg, P < 0.01).

CONCLUSIONS

Meconium-stained amniotic fluid causes a statistically significant, but clinically small, right shift in the hemoglobin-oxygen association curve.

Effect of residency program merger on undergraduate medical student education in obstetrics and gynecology

OBJECTIVE

To evaluate the effect of residency program merger on third-year medical student clerkships using student evaluations of their experiences and standardized subject examination scores.

METHODS

End-of-clerkship ratings from student evaluations and National Board of Medical Examiners standardized subject examination scores in obstetrics and gynecology were used from clerkship sites where three separate military residency programs in obstetrics and gynecology recently merged into two new programs. Mean student evaluation scores and subject examination scores for the year preceding and the year following the merger were compared.

RESULTS

The mean differences in medical student evaluation scores before and after merger of the residency programs were 0.1 (Mann-Whitney rank sum, P = .1), -0.1 (Mann-Whitney rank sum, P = .8), and 0.2 (Mann-Whitney rank sum, P = .3). The mean differences for subject examination scores before and after merger of the residency programs were -3.5 (95% confidence interval [CI] -33.2, 26.2; paired t test), -30.1 (95% CI -58.9, -1.4; paired t test), and -35.3 (95% CI -74.8, 4.3; paired t test).

CONCLUSION

Merger of residency programs in obstetrics and gynecology does not appear to have a deleterious effect on medical students' satisfaction with the clerkship or their performance on standardized subject examinations at our institution.

Development and use of military-unique standardized gynecology patients in military undergraduate medical education

Performance-based testing using standardized patients is becoming increasingly popular as a means to assess the clinical competence of medical students. Medical students entering postgraduate training in military treatment facilities have the additional responsibility of military readiness. The increasing number of women in the active armed forces and the diverse missions encountered by the military today necessitate inclusion of military-unique standardized gynecologic patients and scenarios into curricula. We developed a military-unique standardized gynecology patient and scenario and an objective structured clinical examination to evaluate medical students' skills in data gathering and synthesis, development of differential diagnoses, problem solving, and working through military-unique issues of the patient scenario. Integration of an objective structured clinical examination of military-unique gynecology standardized patient scenarios into the obstetrics and gynecology curriculum at the Uniformed Services University of the Health Sciences can lead to successful assessment of student clinical skills and provide a means of ongoing military readiness training.

A survey of military residencies regarding 4th-year medical school clerkships

OBJECTIVE

To determine the value of 4th-year medical student clerkships assessed by military obstetric and gynecologic program directors and residents.

METHODS

A questionnaire was sent to all Department of Defense obstetric and gynecologic residency program directors and residents. All of the program directors and 124 of 194 (64%) residents responded, reporting the value of 4th-year medical student clerkships for students entering their programs. Descriptive statistics are reported.

RESULTS

Primary care clerkships were valued most highly by program directors who valued obstetric and gynecologic clerkships at their program sites or audition electives higher than those done at other sites. Residents most highly valued obstetric and gynecologic and intensive care clerkships. Most surgical subspecialties were believed to be of minimal or no value.

CONCLUSION

For students entering their programs, military program directors placed the highest value on primary care clerkships. Program directors also highly valued obstetric and gynecologic clerkships at their programs, whereas residents considered obstetric and gynecologic and intensive care clerkships to be most helpful.

Development and use of military-unique standardized gynecology patients for military residents in obstetrics and gynecology training programs

Focused military curricula and readiness training are often inadequate for military resident physicians. We developed a standardized gynecologic military-unique patient scenario and examination to assess obstetrics and gynecology residents' clinical and operational problem-solving abilities. Integration of military-unique gynecologic standardized patients, clinical scenarios, and objective structured clinical examinations into obstetrics and gynecology curricula is a novel approach for realistic medical readiness training for resident physicians. This tool can become a cornerstone in the ongoing development of needed military-unique curricula.

Delaying surgery for thyroid cancer in pregnancy. A case report

BACKGROUND

Management of thyroid cancer in pregnancy is controversial, as evidenced by disagreement in recommendations cited in leading obstetrics textbooks. Most thyroid carcinomas are well differentiated and pursue an indolent course. Many physicians recommend delay in surgical therapy until after delivery because of operative morbidity.

CASE

A 27-year-old primigravida was found to have a solitary thyroid nodule at her initial obstetrics appointment. Fine needle aspiration was consistent with papillary carcinoma. Although detected at 8 weeks' estimated gestational age (EGA), the decision was made to defer surgical therapy until postpartum. The patient was referred to a tertiary care facility at 24 weeks' EGA secondary to rapid growth of the nodule. Surgery performed at that time revealed invasive disease.

CONCLUSION

Review of the literature suggests that delay in definitive therapy stems from early reports of fetal loss related to surgery, but contemporary data suggest that the risk of fetal loss related to surgery is minimal.

Delayed diagnosis of bowel infarction secondary to maternal midgut volvulus at term

BACKGROUND

Intestinal volvulus is responsible for 25% of acute bowel obstructions in pregnant women but only 3-5% in nonpregnant patients. Pregnancy may hinder early diagnosis.

CASE

A woman in early labor subsequently developed hypotension and a nonreassuring fetal heart rate tracing. Emergency cesarean was performed and a live infant was born. At surgery, the patient was noted to have ascites, necrotic bowel, and a congenital gut malrotation with a complete midgut volvulus. Several congenital peritoneal bands were lysed, the volvulus was reduced, and 184 cm of small bowel were resected.

CONCLUSION

This patient represents a case of midgut volvulus with bowel infarction and necrosis secondary to congenital malrotation of the gut.

Oxytocin labor stimulation of twin gestations: effective and efficient

OBJECTIVE

To test the hypothesis that oxytocin labor stimulation of twin gestations is similar to that of singletons regarding dosage, time, complications, and ability to achieve vaginal delivery.

METHODS

This retrospective investigation included 124 gravidas receiving oxytocin for augmentation or induction of labor. Sixty-two women with twin gestations were matched by parity, cervical dilation at initiation of oxytocin, gestational age, oxytocin dosage regimen, and indications for oxytocin to controls with singleton pregnancies. Outcome variables included maximum dosage of oxytocin, incidence of hyperstimulation and fetal heart rate (FHR) abnormalities, time from oxytocin to delivery, cesarean deliveries, and maternal and neonatal outcomes. Statistical analysis was done using McNemar test, paired t test, and Wilcoxon signed-rank test for paired samples.

RESULTS

Women with twin pregnancies and those with singletons responded similarly regarding maximum oxytocin dosage (21 +/- 1.5 and 18 +/- 2.4 mU/minute, respectively, P = .1), time from oxytocin to delivery (7.0 +/- 0.8 and 6.7 +/- 0.6 hours, respectively, P = .88), and successful vaginal delivery (90% and 90%, respectively). Oxytocin stimulation of twins resulted in fewer interruptions of the infusion for FHR abnormalities (5% compared with 26%, odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16, 0.47) and hyperstimulation (6% compared with 18%, OR 0.19, 95% CI 0.36, 0.99).

CONCLUSION

Twin gestation has no adverse impact on the effectiveness or efficiency of oxytocin labor stimulation. Twin pregnancy seems to be associated with fewer side effects.

Physical and sexual abuse in a middle-class obstetric population

To evaluate the prevalence of a history of physical and sexual abuse in pregnant, economically stable, middle-class women with access to comprehensive health care, we issued self-report questionnaires to prenatal orientation classes at Wilford Hall Medical Center from October 19, 1992, to March 15, 1993. After identifying women who had been physically or sexually abused, we identified the assailant, the number of occurrences, and injuries resulting from the abuse. Of the 563 women who responded, 100 (18%) reported previous physical or sexual abuse. Seven women (1%) stated that they were physically abused during the pregnancy. Women were more likely to be physically than sexually abused by a spouse or lover (46% versus 13%). To identify women who have a history of abuse and to address their needs, practitioners should incorporate taking a history of physical and sexual abuse during the routine new obstetric visit.

The pharmacokinetics of oxytocin as they apply to labor induction

OBJECTIVE

Our purpose was to determine the relationship among plasma oxytocin levels, metabolic clearance rate of oxytocin, and uterine activity in gravid women undergoing labor induction.

STUDY DESIGN

Ten women receiving oxytocin for labor induction and agreeing to participate had blood sampled before initiation of oxytocin and at different levels of uterine pressure. Samples were analyzed with 200 microliter extracts from 1 ml of plasma with an oxytocin radioimmunoassay. The intraassay coefficient of variation was < 3%. Sensitivity of the assay was 1.5 pg/ml. Pharmacokinetic parameters including plasma levels and metabolic clearance rates were calculated. Data were analyzed with the paired t test and linear and logistic regression.

RESULTS

Mean oxytocin levels and metabolic clearance rates were 26.6 pg/ml and 7.97 ml/min. There was no correlation between changes in oxytocin level and metabolic clearance rate. Increases in infusion rates were correlated with increases in oxytocin levels (r = 0.71, p < 0.001). Cervical dilatation and uterine contraction pressures did not correlate with oxytocin levels.

CONCLUSION

Peripheral plasma levels of oxytocin may not accurately reflect uterine activity or progress in labor. Plasma levels of oxytocin may merely reflect the rate of oxytocin infusion.

The impact of sexual abuse on job attrition in military recruits

OBJECTIVE

To determine whether recruits entering the U.S. Air Force with a history of sexual abuse had a higher attrition rate from basic military training (BMT).

METHODS

Retrospective, case-control study involving 28,918 recruits entering BMT from October 1, 1991, to September 30, 1992. Self-report questionnaires were given to all recruits on the second day of BMT. We compared recruits revealing a history of sexual abuse to all other recruits at the end of BMT and at the end of the next fiscal year.

RESULTS

We found that victims of sexual abuse had a higher attrition rate from BMT than non-victims (10.6 versus 4.1%, p < 0.0001). Four and one-tenth percent of all recruits (1,289) reported a history of sexual abuse, and fewer male than female recruits reported a history of sexual abuse (1.5 versus 15.1%, p < 0.0001). However, after BMT there were no differences in any job performance indicators between victims and non-victims.

CONCLUSION

We conclude that recruits with a history of sexual abuse had a higher attrition rate from BMT than those without a history of abuse; however, those recruits who did complete BMT were as successful as those who did not report a similar history of abuse.

Cerebellar hemangioblastoma complicating pregnancy. A case report

BACKGROUND

Cerebellar hemangioblastomas are unusual benign neoplasms that may go undetected for years. When associated with pregnancy, however, these tumors may undergo rapid expression and promote progression of symptomatology.

CASE

A 28-year-old woman with ataxia and left-sided weakness was diagnosed with cerebellar hemangioblastoma in the second trimester of pregnancy following repeated hospital admissions for nausea and vomiting. Surgical removal was uneventful, and she delivered vaginally at term.

CONCLUSION

Cerebellar hemangioblastomas, although rare, should be considered in the differential diagnosis of persistent nausea and vomiting when accompanied by an abnormal neurologic examination.

Trial of labor: a disciplined approach to labor management resulting in a high rate of vaginal delivery

A disciplined approach to labor management has resulted in a low cesarean rate (9%) in our population. We wondered if this management scheme was applicable and safe applied to women with previous cesareans. Women with a previous cesarean delivering in a 5-year period were included. Labor management included encouragement of trial of labor, labor stimulation with oxytocin when indicated, epidural analgesia only after entering the active phase, and continuous monitoring. Demographic, labor and delivery, and neonatal data were electronically stored and analysis performed using SPSS release 4.1 for VAX/VMS. Statistical analysis was performed using chi-square and Fisher's exact test where appropriate. Multiple logistic regression was performed to control for potentially confounding variables. A previous cesarean had been performed in 713 (11%) gravidas who met the inclusion criteria. Vaginal delivery was attempted in 588 (82%) and 517 (88%) achieved vaginal birth. Older women (14 versus 1 versus 8%, p = 0.04), of higher parity (63 versus 35 versus 17%, p = 0.0001), requiring preterm delivery (14 versus 8 versus 4%) were more likely to have an elective repeat cesarean than a successful or failed trial of labor. Pregnancies requiring oxytocin (90 versus 53%, p = 0.02), receiving epidural analgesia (62 versus 49%, p = 0.05), developing chorioamnionitis (20 versus 4%, p < 0.0001) were more likely to fail a trial of labor. Four uterine ruptures occurred and only one patient was receiving oxytocin. There were no differences in umbilical artery blood acidemia among elective repeat cesarean sections and successful or failed trial of labor.(ABSTRACT TRUNCATED AT 250 WORDS)

Physical and sexual abuse. A middle-class concern?

This study evaluated the prevalence of physical and/or sexual abuse in a population of employed, middle-class women who all have access to health care. Questionnaires were given to all patients who came to the ambulatory gynecology clinic at Wilford Hall Medical Center from October 19, 1992, to November 13, 1992. Questions were asked to ascertain the number of women who had experienced at least one episode of forced sexual contact or physical abuse. Other questions allowed identification of the relationship of the assailant to the respondent, number of occurrences and injuries resulting from the abuse. Of the 531 women who responded, 72 reported a history of only physical abuse, and 37 reported a history of only sexual abuse. Forty women reported that they were both physically and sexually abused. The typical victim of abuse was younger (32.6 vs. 39.8 years old, P < .001) and was more likely to work outside the home (63.1% vs. 47.9%, P < .005). Women were significantly more likely to be battered by a husband or lover than to be sexually assaulted by an intimate partner (75% vs. 16%, P < .001). Women who were both physically and sexually abused were injured more often than women who were only physically or sexually abused (60% vs. 28%, P < .01, and 60% vs. 24%, P < .01, respectively). Victims abused by an intimate partner were more likely to be abused on more than one occasion. All women should be asked about a recent history of abuse so that individuals identified can be counseled appropriately and attempts can be made to intervene to prevent further episodes of abuse.

The economic advantages of measured change in health care: an example from obstetrics

To evaluate the economic effects of an increased oxytocin dosage for labor stimulation at a large urban hospital, a cost analysis of a before and after cohort, analytic clinical trial was performed. Delivery outcomes for two different oxytocin dosages were evaluated from the perspective of provider and consumer costs attributable to the oxytocin regimen. The high-dose oxytocin regimen resulted in an estimated provider and consumer cost savings of approximately $350,000 per year. We conclude that a small change in health care, such as an increased infusion rate of a single drug, can have economic advantages.

The effect of indomethacin tocolysis on maternal coagulation status

OBJECTIVE

To investigate the effect of indomethacin tocolysis on maternal coagulation.

METHODS

Twenty gravidas at 24-32 weeks' gestation were treated for preterm labor with 50 mg indomethacin orally, followed by 25 mg every 6 hours for 3 days. Bleeding time, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were measured before and 48 hours after initiation of therapy. Statistical analysis was performed by paired t test and Fisher exact test.

RESULTS

The typical participant was 22 years old, nulliparous, and 26.2 weeks' gestational age at enrollment. The mean bleeding time was 4.5 minutes before therapy and 8.8 minutes after therapy (P < .0001, mean difference 4.3 minutes, 95% confidence interval 2.9-5.8). Nineteen of the 20 subjects experienced an increase in bleeding time and 13 had abnormal bleeding times. No clinically significant changes in PT or aPTT were noted. The mean period from treatment to delivery was 60.2 days. No cases of neonatal intraventricular hemorrhage or maternal postpartum hemorrhage were noted.

CONCLUSION

Oral indomethacin treatment for tocolysis has no impact on PT and aPTT; however, profound acute changes in maternal bleeding time occur.

Maternal youth and pregnancy outcomes: middle school versus high school age groups compared with women beyond the teen years

OBJECTIVE

We sought to measure and compare pregnancy complications in middle school versus high school versus older maternal age groups.

STUDY DESIGN

From January 1988 through December 31, 1991, maternal and infant data from 16,512 consecutive nulliparous women were collected and electronically stored. These women were divided into three study groups: middle school (11 to 15 years old), high school (16 to 19 years old), and women 20 to 22 years old at delivery. Statistical analysis included logistic regression to control for potentially confounding demographic variables.

RESULTS

Middle school-aged mothers were disproportionately black (50% vs 36% Hispanic vs 14% white), and very low birth weight (4% vs. 2%, p = 0.003) was increased in these youthful mothers. First births to high school-aged mothers were not found to be compromised compared with those of women 20 to 22 years old, and, indeed, cesarean birth was less frequent in these women compared with those > or = 20 years old.

CONCLUSIONS

We conclude that the health hazard associated with school-age pregnancy is predominantly prematurity and is increased only in middle school-aged mothers. High school-aged mothers do not experience excess medical complications of pregnancy compared with older women. We suggest that middle school pregnancy, particularly for inner-city teenagers, should be a special focus for pregnancy prevention and intervention.

High-dose oxytocin: 20- versus 40-minute dosage interval

OBJECTIVE

To determine whether an increase in the oxytocin dosing interval would decrease the incidence of uterine hyperstimulation.

METHODS

This study included 1801 consecutive pregnancies receiving high-dose oxytocin. Oxytocin was used for labor augmentation in 1167 and induction in 634 women. Twenty- and 40-minute dosage intervals were compared. The study period was based on an 80% likelihood of detecting 5 and 10% differences in the cesarean and hyperstimulation rates, respectively. Statistics were analyzed with chi 2, Fisher, and Wilcoxon rank-sum tests where appropriate. Multivariate logistic regression and analysis of covariance were used to control for confounding demographic variables.

RESULTS

Comparison of the 20- and 40-minute regimens for labor induction yielded no differences in the rates of cesarean delivery for dystocia (16 versus 19%) or fetal distress (5 versus 6%). The 20-minute regimen for augmentation was associated with a significant reduction in cesarean for dystocia (8 versus 12%; P = .05). The incidence of uterine hyperstimulation was greater with the 20-minute than the 40-minute regimen for induction (40 versus 31%; P = .02), but not for augmentation (31 versus 28%). Neonatal outcomes were unaffected by the dosage interval for both augmentation and induction.

CONCLUSION

A 40-minute dosing interval for high-dose oxytocin offers no clear advantage over a 20-minute interval. Both regimens were safe and efficient, with no differences in perinatal outcome. The 20-minute interval was associated with fewer cesareans for dystocia when used for labor augmentation, whereas the 40-minute interval resulted in less hyperstimulation when used for labor induction.

Reversible hypertension in pregnancy caused by obstructive uropathy

BACKGROUND

Hypertension with deterioration of renal function after mid-pregnancy often signifies preeclampsia and the need for delivery.

CASES

We have encountered three women with reversible hypertension related to obstructive uropathy. The women presented between 21-30 weeks' gestation with hypertension accompanied by significantly increased serum creatinine. Although pregnancy-induced hypertension was considered initially in all, there was no other evidence of preeclampsia. In all three, ureteral obstruction was confirmed radiographically and found to be associated with uterine overdistention or congenital urinary anomalies. Relief of obstruction by ureteral stent placement or percutaneous nephrostomy was followed by diuresis and resolution of hypertension. In all three women, pregnancy was extended by more than 6 weeks.

CONCLUSION

Urinary obstruction is a rare but potentially reversible cause of hypertension in pregnancy. Relief of obstruction may lead to normalization of blood pressure and negate the need for immediate delivery.

Sexual assault in postmenopausal women

OBJECTIVE

To examine patient characteristics, patterns of injury, forensic evidence, and the frequency of sexual assault in postmenopausal rape victims from 1986-1991.

METHODS

Medical and forensic records were reviewed from 129 postmenopausal women (50 years of age or older) and 129 women from a comparison group (14-49 years of age) who reported having been sexually assaulted. Statistical analysis was performed by Student t test, chi 2, multiple logistic regression, or Fisher exact test.

RESULTS

Postmenopausal women represented 2.2% of women reporting sexual assault in Dallas County. The postmenopausal victim was more often white (64%), whereas the younger victim was more often black (53%). Drug or alcohol use within the previous 24 hours was more common in the younger group. Trauma, in general, was common, occurring in 67% of the postmenopausal women and 71% of the younger group (P = not significant). Genital trauma was more common in the postmenopausal group (43 versus 18%; P < .001). Nearly one in three postmenopausal women had genital abrasions or edema. Almost one in five older women had genital lacerations, with one in four severe enough to require surgical repair. In contrast, the frequency of extragenital trauma was more common in younger victims (66 versus 49%; P < .01). Forensic findings were similar in both groups; however, in postmenopausal women motile spermatozoa were seen only in those examined within 6 hours of the assault.

CONCLUSION

Postmenopausal women who have been sexually assaulted are more likely to sustain genital trauma than younger victims.

The prevalence of sexual assault: a survey of 2404 puerperal women

OBJECTIVE

The purpose of this investigation was to determine the prevalence of sexual assault, to characterize pregnancy complications, and to report pregnancy outcomes of assault victims.

STUDY DESIGN

Puerperal women (n = 2404) were interviewed regarding a history of forced sexual contact. Obstetric, medical, and forensic records were reviewed. Statistical analysis was performed by Student t test, chi 2 test, or Fisher's exact test.

RESULTS

The lifetime prevalence of sexual assault in this obstetric population was 5% (n = 120). Rape victims had a higher incidence of sexually transmitted diseases (9% vs 4%, p < 0.01), urinary tract infections or vaginitis (32% vs 21%, p = 0.02), drug use (9% vs 2%, p < 0.001), and multiple hospitalizations during the index pregnancy (15% vs 8%, p < 0.01). There was no difference between victims and nonvictims in neonatal outcome as reflected by umbilical artery blood pH, gestational age, or birth weight.

CONCLUSIONS

A history of sexual assault is common in an urban indigent obstetric population. These women have more frequent pregnancy complications but achieve normal pregnancy outcomes.

Creatine kinase and creatine kinase isoenzymes as a marker of uterine activity

Creatine kinase (CK) and CK isoenzymes are known to fluctuate in labor. Reliable information about the longitudinal changes of CK and CK isoenzymes during labor is sparse. Nevertheless, they have been used to direct care in women with cardiopulmonary disease and preterm labor requiring tocolysis. This study evaluated fluctuations of CK and its isoenzymes longitudinally across labor in 49 women. Blood samples were obtained at 33 to 34 weeks' estimated gestational age, on admission in labor at 3 cm or less dilation, 8 cm to complete dilation, and postpartum in the recovery room. Specimens were analyzed for total CK, CK-MM, CK-MB, and CK-BB activity. CK levels increased for all peripartum patients (p < 0.001). CK activity at 3 cm was greater than at 34 weeks (p < 0.01). Furthermore, the early rise in CK activity was greater in those in active labor compared with those who required oxytocin stimulation (p < 0.001). CK values at 8 cm and postdelivery (mean IU/liter) were often above nonpregnant norms. The early rise of CK in spontaneously laboring patients versus those requiring oxytocin augmentation may represent a difference in uterine activity. Nonpregnant normative data for CK is not appropriate when assessing cardiovascular side effects of betamimetic therapy.

High- versus low-dose oxytocin for labor stimulation

The number of cesarean births for dystocia has increased dramatically in the United States. Central to the management of dystocia is correction of ineffective labor by oxytocin administration, and contemporary obstetric practice is to stimulate labor with a low-dose oxytocin regimen. We prospectively compared a low-dose oxytocin regimen (1-mU/minute dosage increments) with a high-dose regimen (6-mU/minute dosage increments) in 2788 consecutive singleton cephalic pregnancies. The low-dose regimen was used first for 5 months in 1251 pregnancies, and the high-dose regimen in 1537 pregnancies during the subsequent 5 months. Indications for oxytocin stimulation were divided into augmentation (N = 1676) and induction (N = 1112). Labor stimulation was more than 3 hours shorter (P less than .0001) with the high-dose oxytocin regimen and associated with a reduction in neonatal sepsis (0.2 versus 1.3%; P less than .01). Uterine hyperstimulation was more common (55 versus 42%; P less than .0001) with the high-dose regimen, but no adverse fetal effects were observed. High-dose augmentation resulted in significantly fewer forceps deliveries (12 versus 16%; P = .03) and fewer cesareans for dystocia (9 versus 12%; P = .04). Similarly, failed induction was less frequent with high-dose compared with low-dose oxytocin (14 versus 19%; P = .05). Although the high-dose induction regimen was associated with a significantly increased cesarean incidence for fetal distress (6 versus 3%; P = .05), the incidence of umbilical artery cord blood acidemia was not increased in this subset. Induction of labor with high-dose oxytocin is problematic because of risk-benefit considerations. Although induction failed less frequently with the high-dose regimen, cesarean for fetal distress was performed more frequently. In contrast, high-dose oxytocin to augment ineffective spontaneous labor minimized the number of cesareans done for dystocia.

Chorioamnionitis: a harbinger of dystocia

The impact of chorioamnionitis on the course of labor is controversial. Some clinicians believe the infection has stimulatory effects, whereas others suspect inhibitory influences. Two hundred sixty-six pregnancies with chorioamnionitis requiring labor stimulation with oxytocin were matched to uninfected women for maternal age, race, parity, gestational age, oxytocin dosage regimen, indication for labor stimulation, type of labor stimulation, cervical dilatation at initiation of oxytocin, and time for rupture of membranes to initiation of labor stimulation. Chorioamnionitis diagnosed before oxytocin infusion was associated with shorter oxytocin initiation-to-delivery intervals (4.3 versus 5.6 hours; P = .04) and had no significant impact on the cesarean rate compared with matched controls. In contrast, pregnancies complicated by chorioamnionitis detected late in labor were associated with markedly longer oxytocin initiation-to-delivery intervals (12.6 versus 7.9 hours; P less than .0001) and a fourfold increase in cesarean for dystocia compared with matched controls (40 versus 10%; P less than .0001). Thus, the impact of chorioamnionitis on the course of labor can be divided into two clinical presentations. That diagnosed before labor stimulation does not increase the use of cesarean, whereas that diagnosed after oxytocin stimulation may be a sign of abnormal labor, as it was associated with a marked increase in abdominal delivery for dystocia.

Esophageal achalasia in late pregnancy

Esophageal achalasia is a rare disorder that may mimic nausea and vomiting of pregnancy. Presentation or persistence of these symptoms in the latter half of pregnancy is unusual. We describe a case of third-trimester weight loss due to the nausea and vomiting of achalasia. Pneumatic dilation of the esophagus is often necessary to improve oral intake. However, advances in nutritional supplementation may prevent malnutrition and allow treatment and its complications to be delayed until after delivery.

Factors affecting the dose response to oxytocin for labor stimulation

For nearly 40 years synthetic oxytocin has been used for labor stimulation by titrating dosage rate to uterine contractions. We used a computerized data base to determine variables affecting the dose response to oxytocin in 1773 pregnancies. Statistically important predictors of required oxytocin dosage included cervical dilatation, parity, and gestational age. Maternal body surface area was found to be associated with a higher oxytocin dosage in women undergoing induction of labor. However, the broad range of the statistical confidence intervals precluded prediction of a given pregnancy's oxytocin requirement.

A prospective study of two dosing regimens of oxytocin for the induction of labor in patients with unfavorable cervices

The ideal regimen for induction of labor with oxytocin with respect to the magnitude and frequency of dosage changes has not been defined. In spite of few data regarding labor induction with an unfavorable cervix, the initial dose recommended by the American College of Obstetricians and Gynecologists is lower than that of other commonly used protocols. Eighty patients with unfavorable cervices and unruptured membranes, without evidence of labor, were randomized to one of two protocols and met criteria for data analysis. Patients in both protocols were given an initial dose of oxytocin of 2 mU/min. Patients in protocol A (n = 32) then received incremental increases of oxytocin of 1 mU/min at 30-minute intervals, while those in protocol B (n = 48) received incremental increases of 2 mU/min at 15-minute intervals. Induction failures were higher among patients on protocol A (31% vs 8%, p less than 0.05). Patients on protocol B had shorter times to delivery (mean = 10 hours 57 minutes vs 8 hours 3 minutes; p less than 0.05). The number of operative deliveries were similar regardless of protocol. There were no significant differences (p = NS) among groups and protocols in maternal and fetal complications, cesarean section rate, and uterine hyperstimulation. In this population a more aggressive protocol may lead to fewer induction failures and shorter induction-to-delivery intervals.

Renal pelvicalyceal dilation in antepartum pyelonephritis: ultrasonographic findings

The purpose of the present study was to determine whether pregnant women with pyelonephritis have differences of pelvicalyceal systems, compared with normal pregnant control subjects, that might predispose to upper urinary tract infection. Ultrasonographic examination of both kidneys in coronal and axial planes of 24 women with clinical pyelonephritis and positive urine cultures was compared with results in control subjects matched for gestational age, parity, and race. Women with right or bilateral pyelonephritis had increased dilation of the right calyceal system, compared with controls (1.7 cm vs 0.8 cm, p less than 0.001). Renal pelvis volume was increased as well (29.3 vs 5.5 cm3, p less than 0.001). Renal pelvicalyceal dilation in antepartum pyelonephritis was significantly increased compared with normal physiologic dilation of pregnancy. Follow-up nephrosonography in a small number of women (N = 10) after treatment of pyelonephritis did not reveal a consistent decrease in renal dilation, suggesting that dilation of the renal pelvis may antedate pyelonephritis. Further study of this phenomenon is warranted.

Sexual assault in pregnancy

Little is known about the acute effects of sexual assault on pregnant victims and the outcome of their gestations. A retrospective review of sexual assault victims in Dallas County from 1983-1988 revealed that 114 of 5734 (2%) were pregnant. There were 0.55 and 0.75 gravid sexual assault victims per 1000 deliveries for Dallas County and Parkland Memorial Hospital, respectively. The purposes of this study were to examine patient demographics, forensic evidence and patterns of injury in pregnant victims compared with 114 matched nonpregnant sexual assault victims, and to compare pregnancy outcome with that of the Parkland Memorial Hospital obstetric population. The typical victim was a black, parous gravida in her twenties at a mean gestational age of 15 weeks, without previous prenatal care. Vulvar (95%), oral (27%), and anal (6%) penetration were reported with similar frequency in both groups. The detection of whole and motile sperm from the vaginal specimens was similar in pregnant and nonpregnant women. Physical trauma was more common in nonpregnant victims (63 versus 43%; P less than .004), especially genital trauma (21 versus 5%; P less than .001). Injury was more common to the head and neck or extremities than to the abdomen, chest, or back in both groups. There was no difference in the pattern of trauma by gestational age, but there were no truncal injuries in women at 20 weeks' gestation or greater. There were no spontaneous abortions or deliveries within 4 weeks of the assault, but low birth weight delivery (24%) and preterm delivery (16%) were common.(ABSTRACT TRUNCATED AT 250 WORDS)

Relapsing Clostridium difficile toxin-associated colitis in ovarian cancer patients treated with chemotherapy

Symptomatic relapse of Clostridium difficile toxin-associated colitis occurred in three patients with ovarian cancer. In two patients, C difficile toxin-positive diarrhea initially appeared in association with antibiotic therapy. The third patient developed diarrhea after chemotherapy, without recent antecedent antibiotic administration. Patients were initially treated with oral metronidazole and became asymptomatic and toxin-negative. A symptomatic toxin-positive recurrence then developed after the subsequent course of systemic chemotherapy. Recurrent C difficile toxin-associated colitis or pseudomembranous colitis after chemotherapy has not been reported previously in the gynecologic oncology literature. Clostridium difficile-induced diarrhea must be considered in chemotherapy patients with diarrhea because management concepts vary from those for noninfectious diarrhea.

Induction of labor in the postdate fetus

Once a decision to induce a postdate pregnancy is reached, the likelihood of achieving a vaginal delivery can be predicted by the Bishop or pelvic score and the willingness or lack thereof to commit to sequential inductions. Cesarean delivery rates will be significantly increased if an amniotomy is performed in the woman with an unfavorable cervix. Accordingly, we advocate sequential induction of the postdate pregnancy in the absence of other maternal or fetal mandates for imminent delivery. A host of oxytocin induction protocols exist and are acceptable, as are guidelines for what constitutes an adequate labor pattern. Although an increasing number of agents are available for cervical ripening, for the foreseeable future dilute intravenous oxytocin will remain the labor induction agent of choice.