The association between uterus shape and development of chronic conditions in a retrospective corhort of diethylstilbestrol-exposed women in Minnesota and Texas

Diethylstilbestrol (DES) exposed women are well known to be at increased risk of gynecologic cancers and infertility. Infertility may result from DES associated abnormalities in the shape of women's uteri, yet little research has addressed the effect of uterine abnormalities on risk of infertility and reproductive tract infection. Changes in uterine shape may also influence the risk of autoimmune disease and women's subsequent mental health. A sample of consenting women exposed in utero to hormone who were recruited into the DESAD project, underwent hysterosalpingogram (HSG) from 1978 to 1984. These women also completed a comprehensive health questionnaire in 1994 which included women's self-reports of chronic conditions. HSG data were used to categorize uterine shape abnormalities as arcuate shape, hypoplastic, wide lower segment, and constricted. Women were recruited from two of the four DESAD study sites in Houston (Baylor) and Minnesota (Mayo). All women were DES-exposed. Adjusted relative risk estimates were calculated comparing the range of abnormal uterine shaped to women with normal shaped uteri for each of the four outcomes: infertility, reproductive tract infection, autoimmune disease and depressive symptoms. Only the arcuate shape (n=80) was associated with a higher risk of infertility (relative risk [RR]= 1.53, 95% CI = 1.09, 2.15) as well as reproductive tract infection (RR= 1.74, 95% CI = 1.11, 2.73). In conclusion, DES-associated arcuate shaped uteri appeared to be associated with the higher risk of a reproductive tract infection and infertility while no other abnormal uterine shapes were associated with these two outcomes.^

US medical students' knowledge of obstetric fistula in developing countries

Obstetric fistula is a devastating child birth injury affecting millions of women worldwide. This paper explores the knowledge and understanding of medical students at the University of Texas Health Science Center at San Antonio regarding this global public health issue. Obstetric fistula has been eradicated in most industrialized nations, and has therefore faded from view of many modern medical organizations. The United Nations Population Fund has launched a “Campaign to End Fistula” in an attempt to bring global awareness to this preventable and treatable condition. Based on a survey administered to medical students at UTHSCSA, a baseline understanding of this disorder based on current curriculum is reviewed, with the objective of improving future physicians’ awareness of obstetric fistula. Despite a low survey response rate, there was a significant association between greater knowledge about causes, treatment, and complications of obstetric fistula and advanced years in medical school. However, the fourth year medical students averaged only a 70.5 percent of correct responses on the survey, indicating room for improvement in addressing this topic during medical school. ^

The association between maternal use of selective serotonin reuptake inhibitors during pregnancy and adverse pregnancy outcomes

Maternal use of SSRIs for depression and anxiety during pregnancy has increased over the last decade. Recent studies have questioned the safety of these antidepressants when used in during pregnancy. The aim of this project is to assess the associations between maternal SSRI use and GH, SGA, and preterm birth using data from a U.S. population-based study with self-reported exposure information. ^ The study population is comprised of mothers of control infants from the NBDPS, an ongoing, multi-state, population-based case-control study. Mothers were asked about any use of medications during pregnancy, including the dates they started and stopped taking each medication. Maternal GH was self-reported, while gestational age and birth weight were calculated from information on birth certificates or medical records. ^ Our study found that women exposed to SSRIs in the first trimester and beyond had a higher odds of GH compared to unexposed women (aOR=1.96, 95% CI=1.02-3.74). Women who used SSRIs only in the first trimester had no increased odds of GH (aOR=0.77, 95% CI=0.24-2.50). Women who used SSRIs throughout their entire pregnancy had a two-fold increase in the odds of delivering an SGA infant compared to unexposed women (aOR=2.16, 95% CI=1.01-4.62), while women who reported SSRI use only in the first trimester had a decreased odds of delivering an SGA infant (aOR=0.56, 95% CI=0.14-2.34). Finally, both women who used SSRIs in the first trimester only (aOR=1.58, 95% CI=0.71-3.51) and women who used SSRIs in the first trimester and beyond (aOR=1.49, 95% CI=0.76-2.90) had an increased odds of delivering preterm compared to unexposed women. ^ Results from our study suggest that women who use SSRIs in the first trimester and beyond have an increased and significant odds of GH and SGA. An increase in the odds of preterm birth was also observed among women exposed in this period and is consistent with the results of previous studies which had much larger sample sizes. Women who use SSRIs only in the first trimester appear to have no increased odds of GH or SGA, but may have an increased odds of preterm birth. These findings are consistent with previous studies and highlight how exposure to SSRIs at different points in gestation may result in different risks for these outcomes. ^

Seroprevalence of toxoplasmosis and current thinking regarding screening in pregnancy: A review of the literature and case study discussion

The approach to the diagnosis and treatment of congenital toxoplasmosis has been one of flux and debate, fueled by lack of knowledge, lack of consensus, different methods of screening and different national policies for screening in different parts of the world. Countries with higher prevalence of disease such as in Europe and South America have a heightened awareness of the need to screen and treat for this parasitic infection during pregnancy. In contrast, in the United States, it is a condition scarcely discussed and has been largely ignored except in some large centers and by a few researchers. Policies and research strategies for any condition should start with obtaining good data. The aims of this thesis included a review of prevalence studies conducted in the United States, focused on the past 20 years, combined with a description of original research conducted by the author several years ago. The latter was a cross-sectional study performed in Houston, one of the largest American cities with a great ethnic mix. The study analyzed prevalence rates of Toxoplasma gondii IgG antibody in sera of women of reproductive age. Overall seroprevalence was 12.3%. In keeping with other studies, higher prevalence correlated with lower socioeconomic status, Black and Hispanic and Asian ethnicities, and increasing age. A literature search revealed only three prevalence studies performed in the United States over the past 20 years, with another four studies only referred to as personal communications or within a textbook, without further study detail available. The literature review also revealed a lack of consensus on whether or not to screen for toxoplasmosis in pregnancy, and even whether or not treatment in utero is worthwhile.^ Proponents of screening and treatment in pregnancy site studies both in the United States and France, emphasize that treatment reduces disease manifestations in infants. Opponents cite other studies that show only marginal benefits, together with potential side effects of medication regimens and generation of anxiety in parents. What is agreed on so far is the value of educating pregnant women on how to avoid contracting toxoplasmosis, and educating physicians on making the best use of reference laboratories before major treatment decisions are made. Further research to reevaluate the literature critically, review new treatment regimens and examine costs and benefits of screening and treatment of toxoplasmosis in pregnancy, bringing together European and American researchers, is needed.^

A systematic review of selected birth outcomes in diabetic women who received preconception care and/or used multivitamins prior to pregnancy

Objective. To conduct a systematic review of published literature on preconception care in pre-existing diabetic women looking at the effect of glycemic control and multivitamin usage on the frequency of spontaneous abortion and birth defects.^ Methods. Articles were retrieved from Medline (1950–Dec 2007), Cochrane Library (1800–Dec 2007), Academic Search Complete (Ebsco) (Jan 1800–Dec 2007) and Maternal and Child Health Library (1965–Dec 2007). Studies included women with pre-existing, non-gestational diabetes and a comparison group. Participants must have either received preconception care and/or consumed a multivitamin as part of the study.^ Results. Overall, seven studies met the study criteria and applicability to the study objectives. Four of these reported the frequency of spontaneous abortion. Only one found a statistically significant increased risk of spontaneous abortion among pregnant women who did not receive preconception care compared with those who did receive care, odds ratio 4.32; 95% CI 1.34 to 13.9. Of the seven studies, six reported the frequency of birth defects. Five of these six studies found a significantly increased rate of birth defects among pregnant women who did not receive preconception care compared with those who did receive care, with odds ratios ranging from 1.53 to 10.16. All seven studies based their preconception care intervention on glycemic control. One study also used multivitamins as part of the preconception care.^ Conclusion. Glycemic control was shown to be useful in reducing the prevalence of birth defects, but not as useful in reducing the prevalence of spontaneous abortion. Insulin regimen options vary widely for the diabetic woman. No author excluded or controlled for women who may have been taking a multivitamin on their own. Due to the small amount of literature available, it is still not known which preconception care option, glucose control and/or multivitamin usage, provides better protection from birth defects and spontaneous abortion for the diabetic woman. An area for future investigation would be glycemic control and the use of folic acid started before pregnancy and the effects on birth defects and spontaneous abortion.^

An exploratory study of screening practices and barriers for postpartum depression in Texas

Purpose. To evaluate the prevalence of Postpartum Depression (PPD) screening among practicing obstetrician-gynecologists in Texas, and to identify factors and barriers associated with routine depression screening practices.^ Subjects. One hundred and eighty-nine fellows and junior fellows of the Texas Association of Obstetricians & Gynecologists (District XI).^ Methods. A survey questionnaire was developed and sent to 2,028 obstetriciangynecologists, asking about their current screening practices related to PPD. The survey questions were related to the physician's demographics, the patient population, screening practices, barriers to screening, and perceptions about resources in the community. Responses were analyzed to determine associations between these factors and the physician's screening practices. ^ Results. The respondents (n=189) constituted 9.3% of the surveyed population, thus the findings cannot be considered representative of all practicing Ob-Gyns in Texas. However, the following trends were observed. Of the respondents, 85.4% reported routinely screening for PPD, while 14.6% did not. However, of those that screened, only 20.2% used the Edinburgh Postnatal Depression Scale and 7.6% screened with the Postpartum Depression Screening Scale, both validated screening tools. The majority (77.2%) reported using an informal patient interview to screen. For those who did not routinely screen, inadequate training and inadequate resources to screen for PPD were the top two barriers. Physician's age was associated with routine screening practice, as older physicians were less likely to screen routinely. Primary insurance coverage of the patient population was also associated with screening practice; physicians with Medicaid and uninsured patients were less likely to screen routinely. Lastly, physicians that believed that adequate resources existed in their communities for the treatment of PPD were more likely to screen than those that did not.^ Conclusions. The present study is the first attempt at assessing Postpartum Depression screening practices and barriers in Texas. Although the response rate was low, the findings related to informal screening methods and inadequate training indicated that education and training with regards to PPD screening and validated screening tools among Ob-Gyns stand to be improved. Connecting physicians to psychiatric resources may also improve screening rates. This first look at screening practices in Texas serves as a platform for future research in order to gain definitive insight into the diagnosis and treatment of PPD, and ultimately design interventions to improve detection rates and treatment.^

A case-control study to identify risk factors for preterm labor in Colorado Springs, Colorado

The study objectives were to determine risk factors for preterm labor (PTL) in Colorado Springs, CO, with emphasis on altitude and psychosocial factors, and to develop a model that identifies women at high risk for PTL. Three hundred and thirty patients with PTL were matched to 460 control patients without PTL using insurance category as an indirect measure of social class. Data were gathered by patient interview and review of medical records. Seven risk groups were compared: (1) Altitude change and travel; (2) Psychosocial ((a) child, sexual, spouse, alcohol and drug abuse; (b) neuroses and psychoses; (c) serious accidents and injuries; (d) broken home (maternal parental separation); (e) assault (physical and sexual); and (f) stress (emotional, domestic, occupational, financial and general)); (3) demographic; (4) maternal physical condition; (5) Prenatal care; (6) Behavioral risks; and (7) Medical factors. Analysis was by logistic regression. Results demonstrated altitude change before or after conception and travel during pregnancy to be non-significant, even after adjustment for potential confounding variables. Five significant psychosocial risk factors were determined: Maternal sex abuse (p = 0.006), physical assault (p = 0.025), nervous breakdown (p = 0.011), past occupational injury (p = 0.016), and occupational stress (p = 0.028). Considering all seven risk groups in the logistic regression, we chose a logistic model with 11 risk factors. Two risk factors were psychosocial (maternal spouse abuse and past occupational injury), 1 was pertinent to maternal physical condition ($\le$130 lbs. pre-pregnancy weight), 1 to prenatal care ($\le$10 prenatal care visits), 2 pertinent to behavioral risks ($>$15 cigarettes per day and $\le$30 lbs. weight gain) and 5 medical factors (abnormal genital culture, previous PTB, primiparity, vaginal bleeding and vaginal discharge). We conclude that altitude change is not a risk factor for PTL and that selected psychosocial factors are significant risk factors for PTL. ^

A woman's right to know: A policy review of abortion legislation in Texas

Introduction: Despite its legalization, abortion remains a controversial issue, one that has many divided on either side of the political spectrum. While there have been several changes made to abortion policy over the past few decades, one that continues to have many asking questions is the Woman’s Right to Know Act, a piece of state imposed abortion legislation that has implemented strict restrictions and requirements of women seeking abortion, including pre-abortion mandatory counseling and a 24 hour waiting period. This project analyzed four controversial components of the mandatory counseling materials in Texas in an attempt to examine the scientific validity behind this legislation. Methods: In order to understand the scientific validity behind the content of the preabortion mandatory counseling, I conducted a systematic literature review to analyze: the purported link between abortion and breast cancer, the existence of fetal pain, the risk of abortion to future fertility, and the negative psychological effects of abortion. An electronic search in EBSCO and PubMed of review articles published between 1995 and 2010 resulted in fourteen reviews. Results: Results of the systematic review found (1) inconclusive evidence suggesting a link between abortion and breast cancer, (2) that fetal pain likely does not occur until the third trimester of pregnancy, (3) that associations exist between induced abortion and subsequent preterm birth and placenta previa, and (4) that there is mixed evidence relating to the negative psychological effects that exist among women having had an abortion and those who have not had abortion. Conclusion: Based on these conclusions, a recommendation was made to revise the current state mandated counseling materials to reflect more accurate and scientifically-based information about abortion and its potential risks.^

Puerperal Fever from Hippocrates to Pasteur

The death of a mother in childbirth leaving a newborn deserted is a sort of a desecration. This was a frequent event for early physicians. It was felt to be caused by miasmas or punishment from the gods. DaVinci felt the cause was milk stasis, Hippocrates - lochia, Virchow - weather. Then came Semmelweis, Pasteur and Lister. They started a battle with ignorance, hospital administration, budget and academic politics. Ending with the murder of Semmelweis!

ATTITUDES TOWARD AND UTILIZATION OF NON-INVASIVE PRENATAL TESTING FOR CHROMOSOME ANEUPLOIDY AMONG OB/GYNS

Prenatal diagnosis is traditionally made via invasive procedures such as amniocentesis and chorionic villus sampling (CVS). However, both procedures carry a risk of complications, including miscarriage. Many groups have spent years searching for a way to diagnose a chromosome aneuploidy without putting the fetus or the mother at risk for complications. Non-invasive prenatal testing (NIPT) for chromosome aneuploidy became commercially available in the fall of 2011, with detection rates similar to those of invasive procedures for the common autosomal aneuploidies (Palomaki et al., 2011; Ashoor et al. 2012; Bianchi et al. 2012). Eventually NIPT may become the diagnostic standard of care and reduce invasive procedure-related losses (Palomaki et al., 2011). The integration of NIPT into clinical practice has potential to revolutionize prenatal diagnosis; however, it also raises some crucial issues for practitioners. Now that the test is clinically available, no studies have looked at the physicians that will be ordering the testing or referring patients to practitioners who do. This study aimed to evaluate the attitudes of OB/GYN’s and how they are incorporating the test into clinical practice. Our study shows that most physicians are offering this new, non-invasive technology to their patients, and that their practices were congruent with the literature and available professional society opinions. Those physicians who do not offer NIPT to their patients would like more literature on the topic as well as instructive guidelines from their professional societies. Additionally, this study shows that the practices and attitudes of MFMs and OBs differ. Our population feels that the incorporation of NIPT will change their practices by lowering the amount of invasive procedures, possibly replacing maternal serum screening, and that it will simplify prenatal diagnosis. However, those physicians who do not offer NIPT to their patients are not quite sure how the test will affect their clinical practice. From this study we are able to glean how physicians are incorporating this new technology into their practice and how they feel about the addition to their repertoire of tests. This knowledge gives insight as to how to best move forward with the quickly changing field of prenatal diagnosis.

The effects of adequacy and content of prenatal care on birth outcomes in a high -risk Missouri population

The purpose of this observational study was investigation of the relationship between quantitative adequacy of prenatal care, specific prenatal care content and pregnancy outcome in a high risk Missouri population. A sample of 1484 women from three Missouri regions known to have high rates of low birth weight, infant mortality, and inadequate prenatal care rates participated in structured post-partum interviews. Approximately one-half of the sample had received adequate prenatal care and the other half inadequate prenatal care as determined by an index utilized by the Missouri Department of Health.^ Prenatal care content was assessed by reports of prenatal education in six different areas: Diet, smoking, alcohol, drug, preterm labor counseling, and advice on when to call the health provider if preterm labor was suspected by the woman. Low birth weight, in both term and preterm infants, were the two birth outcomes examined. A variety of maternal socio-demographic variables were also considered.^ The results of this study suggest that specific educational content, delivered during prenatal care, may have lessen the risk of giving birth to a preterm-low birth weight infant. Prenatal education for recognition of preterm labor, and advice on when to call the health provider if preterm labor was suspected were found to be associated with a decreased risk of preterm delivery. Specific educational content was not, however, associated with risk of term-low weight birth nor was quantitative adequacy of care associated with the risk of either term- or preterm-low birth weight.^ These findings reinforce a body of literature which stresses the importance of appropriate prenatal care in preventing preterm low birth weight. Additionally, the findings suggest interventions that may be specifically effective for prematurity prevention. ^

Correlates of prenatal care initiation among low -income Hispanic women

Because Hispanic women are even less likely than women of other ethnic groups to receive early prenatal care, the purpose of this study was to identify factors that may influence these women to initiate care. After giving consent, 300 Hispanic women (100 who initiated first trimester care, 100 who initiated second trimester care, and 100 who initiated third trimester care or received no care) were interviewed in the post partum unit of a local public hospital. The interview included recollection of events leading to the first prenatal appointment, including first physical indicators of pregnancy, confirmation of pregnancy, feelings about the pregnancy, appointment making behavior, and system barriers encountered. The Health Belief Model was used as the theoretical framework for determining psychosocial variables. Using this model, perceived susceptibility to problems during pregnancy, perceived seriousness of possible problems, perceived benefits of prenatal care, perceived barriers to care, and cues to action were assessed. Time of entry into prenatal care was assessed by interview.^ In this sample of low-income Hispanic women, a higher perception of barriers to care was associated with later initiation of care and non-use of care, higher perceived benefits of care for the baby were associated with earlier care, especially in women without a card to access hospital district services, and having a card to access hospital district services was associated with earlier care. Several barriers to care were mentioned by women on open-ended questioning including long waiting times, embarrassment, and lack of transportation.^ Recommendations for practice included decreasing the number of visits for low-risk women while increasing the time spent with the provider, decreasing the number of vaginal exams for low-risk women, increasing the use of midwives, training lay workers to do risk assessment, giving specific messages about benefits of care to baby, and increasing general health motivation through community intervention methods. More research on the psychosocial and cultural factors associated with initiation of care is needed. In the meantime, the recommendations for practice can be implemented now to increase the use of prenatal care by low-income Hispanic women. ^

Planning, implementation, and evaluation of an HIV -screening program for pregnant women

The purpose of this study was to evaluate the effectiveness of an HIV-screening program at a private health-care institution where the providers were trained to counsel pregnant women about the HIV-antibody test according to the latest recommendations made by the U.S. Public Health Service (PHS) and the Texas legislature. A before-and-after study design was selected for the study. The participants were OB/GYN nurses who attended an educational program and the patients they counseled about the HIV test. Training improved the nurses' overall knowledge about the content of the program and nurses were more likely to offer the HIV test to all pregnant women regardless of their risk of infection. Still, contrary to what was predicted, the nurses did not give more information to increase the knowledge pregnant women had about HIV infection, transmission, and available treatments. Consequently, many women were not given the chance to correctly assess their risk during the counseling session and there was no evidence that knowledge would reduce the propensity of many women to deny being at risk for HIV. On the other hand, pregnant women who received prenatal care after the implementation of the HIV-screening program were more likely to be tested than women who received prenatal care before its implementation (96% vs. 48%); in turn, the likelihood that more high-risk women would be tested for HIV also increased (94% vs. 60%). There was no evidence that mandatory testing with right of refusal would deter women from being tested for HIV. When the moment comes for a woman to make her decision, other concerns are more important to her than whether the option to be tested is mandatory or not. The majority of pregnant women indicated that their main reasons for being tested were: (a) the recommendation of their health-care provider; and (b) concern about the risks to their babies. Recommending that all pregnant women be tested regardless of their risk of infection, together with making the HIV test readily available to all women, are probably the two best ways of increasing the patients' participation in an HIV-screening program for pregnant women. ^

Suivi postnatal à domicile après un congé précoce : Critères de sélection et Appréciation du délai

Aujourd’hui, la satisfaction des utilisateurs des services de santé est reconnue comme une mesure de la qualité des soins. Au Québec, le congé précoce en obstétrique constitue la norme pour les mères ayant donné naissance à un bébé en santé. Selon la littérature, cette pratique n’entraîne pas de répercussions négatives pour la santé des mères et de leur nouveau-né à condition qu’un suivi adéquat soit assuré. D’autre part, bien qu’il semble que la diminution de la durée du séjour hospitalier soit appréciée par les mères, peu de données sont disponibles relativement aux caractéristiques menant à l’appréciation du suivi postnatal. Objectifs : Cette étude s’intéresse principalement à la première visite à domicile effectuée par une infirmière suite au congé précoce en obstétrique. Dans un premier temps, elle vise à tracer un portrait des mères en fonction du délai de la première visite à domicile et, dans un second temps, à connaître les facteurs associés à l’appréciation, par les mères, du délai de cette visite. Méthode : Les données de cette étude ont été recueillies au Québec, entre janvier 2002 et janvier 2003, lors d’une enquête téléphonique effectuée auprès de mères de bébés nés en santé, un mois suivant leur accouchement vaginal sans complication (n=1548). Pour nos analyses, nous avons retranché les mères ayant eu une durée de séjour de plus de 60 heures, une grossesse de moins de 37semaines et un bébé pesant moins de 2500 g à la naissance. Notre échantillon se compose donc de 1351 mères. Résultats : 86,2 % des mères ont reçu une offre de visite à domicile. La majorité (80.2 %) des mères ont reçu la visite dans les trois premiers jours suivant leur retour à la maison, dont près du tiers (28,1 %), dans les 24 premières heures. Comparativement aux mères visitées au deuxième ou troisième jour suivant le congé, celles visitées dans les 24 premières heures ont jugé la durée de séjour hospitalier trop courte (p=0,018) et reçu un appel de l’infirmière qui a duré plus longtemps (p=0, 009). De plus, au moment du congé, elles perçoivent leur bébé en moins bonne santé (p=0,029). Elles ont aussi accouché d’un bébé plus petit (p=0,052) qui a tendance à avoir présenté des signes d’ictères pendant le séjour hospitalier (p=0,100). D’autre part, la majorité des mères (86,4 %) disent que le délai de la première visite à domicile est adéquat alors que 11,6 % le jugent trop court et 2,3 % trop long. Pour les mères visitées au premier jour, l’analyse multivariée révèle que certaines caractéristiques et certains besoins sont associés à la perception que le délai de la visite est trop court : une seule visite postnatale, un revenu familial de plus de 40 000 $, la perception que la durée de séjour est trop longue et le fait de ne pas allaiter. Pour les mères qui reçoivent la visite au deuxième et troisième jour, ce sont, seulement, le fait d’avoir été au rendez-vous médical et le fait d’avoir reçu une seule visite qui sont associés à la perception que le délai de la visite est trop court. Pour conclure, au Québec, le programme de suivi postnatal universel semble en mesure d’offrir une visite à domicile dans les délais prescrits à une majorité de mères. Les résultats de cette étude suggèrent que le délai de la première visite à domicile n’est pas optimal pour toutes les mères et permettent d’envisager que certaines mères auraient souhaité recevoir une seconde visite plus tardivement au cours de la période postnatale. D’autres recherches devront être effectuées afin de parfaire nos connaissances relativement au moment idéal pour réaliser les interventions postnatales.Mots clefs : Satisfaction, appréciation des utilisateurs, qualité des soins, programme universel, suivi postnatal, congé précoce en obstétrique, visite à domicile, délai de la visite, provision des services.