ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Pain in labor is a nearly universal experience for childbearing women. A recent evidence-based symposium on the nature and management of labor pain brought together family physicians, obstetricians, midwives, obstetric anesthesiologists, and childbirth educators to discuss a series of commissioned systematic reviews. Although management of labor pain plays a relatively minor role in a woman's satisfaction with childbirth compared with the quality of the relationship with her maternity caregiver and the degree of participation she has in decision making, it is an important topic for women and their caregivers. Nonpharmacologic methods of pain relief such as labor support, intradermal water blocks, and warm water baths are effective techniques for management of labor pain. An increased availability of these methods can provide effective alternatives for women in labor.
Repair of Obstetric Perineal Lacerations - Article
ABSTRACT: Family physicians who deliver babies must frequently repair perineal lacerations after episiotomy or spontaneous obstetric tears. Effective repair requires a knowledge of perineal anatomy and surgical technique. Perineal lacerations are classified according to their depth. Sequelae of obstetric lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. With lacerations involving the anal sphincter complex, particular attention must be given to anatomy and surgical technique because of the high incidence of poor functional outcomes after repair. An overlapping technique to repair the external anal sphincter, rather than the traditional end-to-end technique, is being investigated to determine if it might decrease the incidence of anal incontinence. Minimizing the use of episiotomy and forceps deliveries can decrease the occurrence of severe perineal lacerations.
ABSTRACT: Gestational diabetes mellitus is a common but controversial disorder. While no large randomized controlled trials show that screening for and treating gestational diabetes affect perinatal outcomes, multiple studies have documented an increase in adverse pregnancy outcomes in patients with the disorder. Data on perinatal mortality, however, are inconsistent. In some prospective studies, treatment of gestational diabetes has resulted in a decrease in shoulder dystocia (a frequently discussed perinatal outcome), but cesarean delivery has not been shown to reduce perinatal morbidity. Patients diagnosed with gestational diabetes should monitor their blood glucose levels, exercise, and undergo nutrition counseling for the purpose of maintaining normoglycemia. The commonly accepted treatment goal is to maintain a fasting capillary blood glucose level of less than 95 to 105 mg per dL (5.3 to 5.8 mmol per L); the ambiguity (i.e., the range) is due to imperfect data. The postprandial treatment goal should be a capillary blood glucose level of less than 140 mg per dL (7.8 mmol per L) at one hour and less than 120 mg per dL (6.7 mmol per L) at two hours. Patients not meeting these goals with dietary changes alone should begin insulin therapy. In patients with well-controlled diabetes, there is no need to pursue delivery before 40 weeks of gestation. In patients who require insulin or have other comorbid conditions, it is appropriate to begin antenatal screening with nonstress tests and an amniotic fluid index at 32 weeks of gestation.
Practical Selection of Antiemetics - Article
ABSTRACT: An understanding of the pathophysiology of nausea and the mechanisms of antiemetics can help family physicians improve the cost-effectiveness and efficacy of therapy. Nausea and vomiting are mediated primarily by visceral stimulation through dopamine and serotonin, by vestibular and central nervous system causes through histamine and acetylcholine, and by chemoreceptor trigger zone stimulation through dopamine and serotonin. Treatment is directed at these pathways. Antihistamines and anticholinergic agents are most effective in patients with nausea resulting from vestibular and central nervous system causes. Dopamine antagonists block dopamine in the intestines and chemoreceptor trigger zone; indications for these agents are similar to those for serotonin antagonists. Serotonin antagonists block serotonin in the intestines and chemoreceptor trigger zone, and are most effective for treating gastrointestinal irritation and postoperative nausea and vomiting. Complementary and alternative therapies, such as ginger, acupressure, and vitamin B6, have variable effectiveness in the treatment of pregnancy-induced nausea.
Shoulder Dystocia - Article
ABSTRACT: Shoulder dystocia can be one of the most frightening emergencies in the delivery room. Although many factors have been associated with shoulder dystocia, most cases occur with no warning. Calm and effective management of this emergency is possible with recognition of the impaction and institution of specified maneuvers, such as the McRoberts maneuver, suprapubic pressure, internal rotation, or removal of the posterior arm, to relieve the impacted shoulder and allow for spontaneous delivery of the infant. The "HELPERR" mnemonic from the Advanced Life Support in Obstetrics course can be a useful tool for addressing this emergency. Although no ideal manipulation or treatment exists, all maneuvers in the HELPERR mnemonic aid physicians in completing one of three actions: enlarging the maternal pelvis through cephalad rotation of the symphysis and flattening of the sacrum; collapsing the fetal shoulder width; or altering the orientation of the longitudinal axis of the fetus to the plane of the obstruction. In rare cases in which these interventions are unsuccessful, additional management options, such as intentional clavicle fracture, symphysiotomy, and the Zavanelli maneuver, are described.
ABSTRACT: Impaired glucose tolerance and impaired fasting glucose form an intermediate stage in the natural history of diabetes mellitus. From 10 to 15 percent of adults in the United States have one of these conditions. Impaired glucose tolerance is defined as two-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients. These glucose levels are above normal but below the level that is diagnostic for diabetes. Patients with impaired glucose tolerance or impaired fasting glucose have a significant risk of developing diabetes and thus are an important target group for primary prevention. Risk factors for diabetes include family history of diabetes, body mass index greater than 25 kg per m2, sedentary lifestyle, hypertension, dyslipidemia, history of gestational diabetes or large-for-gestational-age infant, and polycystic ovary syndrome. Blacks, Latin Americans, Native Americans, and Asian-Pacific Islanders also are at increased risk for diabetes. Patients at higher risk should be screened with a fasting plasma glucose level. When the diagnosis of impaired glucose tolerance or impaired fasting glucose is made, physicians should counsel patients to lose 5 to 7 percent of their body weight and engage in moderate physical activity for at least 150 minutes per week. Drug therapy with metformin or acarbose has been shown to delay or prevent the onset of diabetes. However, medications are not as effective as lifestyle changes, and it is not known if treatment with these drugs is cost effective in the management of impaired glucose tolerance.
Diethylstilbestrol Exposure - Article
ABSTRACT: Diethylstilbestrol is a synthetic nonsteroidal estrogen that was used to prevent miscarriage and other pregnancy complications between 1938 and 1971 in the United States. In 1971, the U.S. Food and Drug Administration issued a warning about the use of diethylstilbestrol during pregnancy after a relationship between exposure to this synthetic estrogen and the development of clear cell adenocarcinoma of the vagina and cervix was found in young women whose mothers had taken diethylstilbestrol while they were pregnant. Although diethylstilbestrol has not been given to pregnant women in the United States for more than 30 years, its effects continue to be seen. Women who took diethylstilbestrol during pregnancy have a slightly higher risk of breast cancer than the general population and therefore should be encouraged to have regular mammography. Women who were exposed to diethylstilbestrol in utero may have structural reproductive tract anomalies, an increased infertility rate, and poor pregnancy outcomes. However, the majority of these women have been able to deliver successfully. Recommendations for gynecologic examinations include vaginal and cervical digital palpation, which may provide the only evidence of clear cell adenocarcinoma. Initial colposcopic examination should be considered; if the findings are abnormal, colposcopy should be repeated annually. If the initial colposcopic examination is normal, annual cervical and vaginal cytology is recommended. Because of the higher risk of spontaneous abortion, ectopic pregnancy, and preterm delivery, obstetric consultation may be required for pregnant women who had in utero diethylstilbestrol exposure. The male offspring of women who took diethylstilbestrol during pregnancy have an increased incidence of genital abnormalities and a possibly increased risk of prostate and testicular cancer. Routine prostate cancer screening and testicular self-examination should be encouraged.
HIV Counseling, Testing, and Referral - Article
ABSTRACT: Over the past decade, the annual number of new cases of human immunodeficiency virus (HIV) infection has been relatively stable but remains unacceptably high (an estimated 40,000 new cases per year). Furthermore, the demographics for HIV infection are changing. Rates of new infections are declining in newborns, older men who have sex with men, and whites. However, rates of new infections are rising in young persons, women, Hispanics, and blacks. In 2001, the Centers for Disease Control and Prevention issued revised guidelines for HIV counseling, testing, and referral. The guidelines focus on the reduction of barriers to testing, voluntary routine testing of high-risk populations and persons with risk factors, case management and partner tracing for infected persons, and universal testing of pregnant women. Effective strategies for reducing HIV infection include behavioral interventions, comprehensive school-based HIV and sex education, access to sterile drug equipment, screening of the blood supply, and postexposure prophylaxis for health care workers.
Blunt Trauma in Pregnancy - Article
ABSTRACT: Trauma is the most common cause of nonobstetric death among pregnant women in the United States. Motor vehicle crashes, domestic violence, and falls are the most common causes of blunt trauma during pregnancy. All pregnant patients with traumatic injury should be assessed formally in a medical setting because placental abruption can have dire fetal consequences and can present with few or no symptoms. Evaluation and treatment are the same as for nonpregnant patients, except that the uterus should be shifted off the great vessels. After initial stabilization, management includes electronic fetal monitoring, ultrasonography, and laboratory studies. Electronic fetal monitoring currently is the most accurate measure of fetal status after trauma, although the optimal duration of monitoring has not been established. Prevention of trauma through proper seat belt use during pregnancy and recognition of domestic violence during prenatal care is important.
Pregnancy Prevention in Adolescents - Article
ABSTRACT: Although the pregnancy rate in adolescents has declined steadily in the past 10 years, it remains a major public health problem with lasting repercussions for the teenage mothers, their infants and families, and society as a whole. Successful strategies to prevent adolescent pregnancy include community programs to improve social development, responsible sexual behavior education, and improved contraceptive counseling and delivery. Many of these strategies are implemented at the family and community level. The family physician plays a key role by engaging adolescent patients in confidential, open, and nonthreatening discussions of reproductive health, responsible sexual behavior (including condom use to prevent sexually transmitted diseases), and contraceptive use (including the use of emergency contraception). This dialogue should begin before initial sexual activity and continue throughout the adolescent years.