In the second part of the 19th century, maternal mortality following classical cesarean section was nearly 100%. In 1876, the Italian obstetrician, Eduardo Porro, developed a cesarean section technique consisting of uterine corpus amputation and suturing of the cervical stump into the abdominal wall incision in an attempt to prevent life-threatening hemorrhage and infection. The successful outcome in Porro’s test case was due to his adherence to surgical principles that are well recognized today, but were not firmly established in 1876. He achieved hemostasis by use of the occluding snare of Cintrat. He irrigated the peritoneal cavity with carbolized sponges, drained the operative bed, and exteriorized the cervical stump in an effort to prevent access of bacteria from the lower genital tract into the peritoneal cavity. Despite the lack of blood products, intravenous fluids, and antibiotics, the Porro operative technique subsequently decreased maternal mortality to 58%. His innovative, carefully planned approach for cesarean hysterectomy was a major innovation in obstetric surgery.
As the population ages, increasing numbers of older women will undergo gynecologic surgical procedures. Optimizing the perioperative care of older women requires an understanding of and attention to usual perioperative issues such as cardiac risk assessment and venous thromboembolism prophylaxis, as well as geriatric-specific issues such as functional status, dementia, delirium, polypharmacy, pressure sores, geriatric physiology, and bowel and bladder management.
Jonas Salk began his career in microbiology working with the inactivated influenza vaccine. He would later use the formalin inactivation process to create the poliomyelitis vaccine. Using a newly created modern cell culture technique, Salk was able to mass produce vaccines for the large-scale polio vaccine field trial. Under the direction of Thomas Francis, Jr., the field trial utilized both a double-blinded placebo-controlled trial and an observational study, and included almost 2 million American schoolchildren as subjects. The vaccine proved to be both safe and effective. Although later replaced by the Sabin oral vaccine, the Salk inactivated vaccine played a large part in the eventual eradication of polio from the Western Hemisphere. After his work on the polio vaccine, he created the Salk Institute, a private institution dedicated to research. Subsequently, until his death in 1995, Salk conducted research on an HIV vaccine.
Technological advances in the diagnosis of human immunodeficiency virus (HIV) infection provide the clinician with greater opportunities to reduce HIV transmission rates. The main drawback of conventional methods of HIV testing is a potential delay of 1–2 weeks for obtaining results, making routine screening a two-step method. Many of those tested never return to learn of their results, limiting our efforts to notify seropositive individuals and their contacts. Consequently, our ability to educate them on strategies for optimizing their health and reducing their risk for transmitting the disease is impaired. For pregnant women who present to Labor and Delivery with late prenatal care, having unknown HIV serological status reduces our ability to prevent transmission to neonates. Two new rapid HIV tests have become available commercially. These tests are just as accurate as conventional methods and offer the advantage of producing preliminary results within hours rather than days. As a result, case- finding and prevention counseling can be completed in a single visit, making the process more efficient and, hopefully, more effective. Additionally, faster identification of seropositive pregnant women who present later for prenatal care allows us to more precisely target intrapartum antiretroviral therapy for prevention of vertical HIV transmission.
Viral hemorrhagic fever (VHF) is a severe, often fatal disease in humans and nonhuman primates (e.g., monkeys and chimpanzees). The two main causes of VHF are Marburg and Ebola virus infection. Lassa fever and Crimean-Congo hemorrhagic fever occur less commonly. Marburg and Ebola viruses are RNA filoviruses. Filoviruses first emerged as the cause of significant clinical outbreaks of VHF in Marburg, Germany in 1967 and later at multiple sites in Africa in 1976. Pathogenesis appears to involve initial infection of the mononuclear phagocytic system, resulting in a generalized cytopathic effect of other cell types and eventual disruption of the coagulation system, hemorrhage, and shock. The typical fulminant disease course is attributed to an immunosuppressive effect caused by the virus. Viral transmission occurs with close, personal contact and exposure to body fluids, especially in caregivers. The risk for person-to-person transmission of VHF is highest during late-stage disease. Contact with cadavers at the time of funerals is considered an independent risk factor for exposure because of the high levels of viral antigens and particles in skin tissues. The incubation period ranges from 2 to 21 days (average 1 week). Clinical manifestations include an abrupt onset of influenza-like symptoms, sore throat, diarrhea, and abdominal pain. Other common symptoms include high fever, headaches, arthralgias, myalgias, abdominal pain, asthenia, fatigue, and hiccups. A transient morbilliform rash develops and eventually desquamates by the end of the first week of illness. Other physical findings include an exudative pharyngitis and, less commonly, conjunctivitis, jaundice, and edema. Hemorrhagic complications appear as petechiae or frank bleeding from any location, but most commonly the gastrointestinal tract. Within 1 week of infection, symptoms may progress into retrosternal pain, fulminant shock, and death. Diagnosis is based on clinical symptomatology, serologic tests, and virus isolation. Isolation must be performed in a biosafety level four facility. There is no antiviral agent or vaccine for EHF. Supportive therapy is the mainstay of treatment. Case fatality rates range from 50 to 90%.
Compliance stands between the physician and the successful treatment of the patient. The physician labors to accumulate, update, master, and apply a vast and growing store of medical knowledge and to communicate well-founded diagnostic and treatment recommendations to patients. Patients come to physicians with physical and psychological pain and disability. If recommendations are not utilized, pain and disability persist. The rates of compliance with the whole range of medical recommendations, from smoking cessation to medication, is surprisingly low. Non-compliance with medical advice is enormously frustrating to physicians. Careful analysis of the reasons for non-compliance—cognitive deficits, miscommunications, language barriers, unvoiced fears, financial difficulties—turns non-compliance into a treatable problem.
N. gonorrhoeae is an infection found only in humans. In the United States, an estimated 600,000 new cases occur each year, with the peak incidence occurring in the summer months. Adolescents and young adults are at the highest risk of infection. N. gonorrhoeae affects both men and women. Infection in men typically produces symptoms that lead patients to seek treatment. On the other hand, N. gonorrhoeae infection in women often is asymptomatic and can lead to sterility or ectopic gestation. N. gonorrhoeae becomes disseminated in 1–3% of all gonococcal infections. Disseminated gonococcal infection (DGI) usually presents as an arthritis-dermatitis syndrome; patients experience migrating polyarthalgias usually affecting the knees, elbows, and distal joints. Approximately 75% of patients have a characteristic dermatitis consisting of discrete papules and pustules with a hemorrhagic component. If untreated, the arthritis tends to progress in one to two joints, usually the knee, ankle, elbow, or wrist. Treatment consists of hospitalization, evaluation for serious sequelae such as endocarditis and meningitis, and antibiotic therapy. Additionally, the patient's partner also should be treated. Disseminated gonococcal infection can cause serious complications during pregnancy such as septic abortion or chorioamnionitis, as well as preterm labor and preterm premature rupture of membranes.
Walter Reed, son of a Methodist minister, was born in 1851. His father sent each of his five sons to the University of Virginia, but in order to preserve family finances, Walter completed his education quickly. He remains the University of Virginia School of Medicine's youngest graduate, receiving his degree at age 18. He pursued further training in New York, but found civilian medicine disillusioning. At age 24, he passed the Army Medical Corps entrance examination and subsequently spent 14 years as an Army surgeon on the American frontier. He treated soldiers, prospectors, and Indians for little, if any, payment. Yearning to become part of the scientific revolution, Reed returned to academia, auditing pathology and bacteriology courses at Johns Hopkins University. He learned the principles of the scientific method and made important contacts during that period of training. The Surgeon General then called him to aid in the definition and resolution of the epidemics of infectious diseases affecting American troops. He presided over the investigative board that refuted the water-borne theory of typhoid fever and identified files, feces, and fomites as the source of this dreaded illness. After his success with this epidemic, he was sent to Cuba to tackle the problem of yellow fever. In approximately 6 months, he was able to disprove a bacterial cause of the illness, establish the mosquito as the likely source, and conduct a controlled trial to successfully confer illness throughthat vector. This information facilitated elimination of a horrific tropical pest. At 51, just one and a half years after his landmark work with yellow fever, he fell victim to appendicitis and died.
In 2000, the Surgeon General of the United States issued the first-ever report on oral health, to alert Americans on its importance to general health and well-being. Women, due to gender, display oral disease differentially. The most common oral diseases are dental caries and periodontal disease. Both of the diseases are infectious in nature, and are responsive to a variety of interventions including: community wide, professional care and self-care. Eating disorders, which are prevalent in adolescent women, have oral manifestations that need to be addressed by the dentist as well as the primary care Ob/Gyn. Oral health in women is markedly affected by hormonal fluctuations. Specific oral conditions are associated with puberty, adolescence, menses, pregnancy, and menopause. These conditions are discussed along with available effective preventive modalities that can optimize oral health.
Obstetricians must be familiar with the diagnosis and treatment of postpartum depression (PPD), as they are the first contact physicians of most postpartum depressed women. Postpartum depression is particularly critical to treat as it has significant impact on the mother, the infant, and the family if left untreated. Clinicians should be able to identify the risk factors for depression in postpartum women. Self-report scales can be used to detect depressive symptoms in new mothers especially in nonpsychiatric settings, to facilitate making the diagnosis of postpartum depression. Although the symptoms of PPD are not significantly different from a major depressive episode, physicians must note that the neurovegetative signs of depression may be confused with normal physiological changes associated with the puerperal period. Assessment of suicide risk is essential, although the postpartum period is regarded as a low-risk period for self harm. Psychiatric referral is mandatory if there is any suspicion of suicidal or infanticidal ideation. The presence of psychotic and manic symptoms also requires referral to a psychiatrist as this may be a manifestation of postpartum psychosis or bipolar disorder. PPD should be treated as any major depressive episode. Untreated PPD has significant impact on the child including adverse effects on cognitive, emotional, and social development of the child in addition to impaired mother-infant bonding.
Paternity establishment for 90% of births to unwed mothers is a recent federal mandate designed to optimize parental rights and childhood benefits. Using a statewide database, this study examines the relationship between selected demographic and clinical variables and in-hospital paternity establishment. Vital statistics for the year 2000 were obtained pertaining to live birth deliveries in the state of Michigan. Data were developed by the Michigan Department of Community Health through linkage of state birth data files with a central paternity registry. Statistical comparisons were made of the frequency distributions of the study variables, using a normal approximation of binomial distribution. There were a total of 134,917 live births in Michigan during 2000. Of these, 46,057 (34.1%) were to unmarried women. The overall rate of in-hospital paternity establishment for these cases was 56% in 2000. A review of selected characteristics indicated a wide range of variability in the proportion of cases for which paternity is established. The following characteristics were significantly different (P<0.05) from the overall average rate (56%) of paternity establishment in 2000: African American, 37.3%; less than high school education, 48.3%; birth weight under 1500 g, 44.8%; birth weight 1500–2499 g, 48.4%; no prenatal care, 30.1%; third trimester care, 37.9%; second trimester care, 47.3%; abnormal newborn, 53.2%; gestational age ≤37 weeks, 50.7%; age less than 20, 52.8%. A greater than average rate of paternity establishment was noted with first trimester care (61.3%), high school or greater education (60.7%), and non–African-American race (71.3%). In conclusion, key demographic and clinical variables limiting the successful establishment of paternity are readily identifiable. In order to achieve the legislative mandate of 90% success, strategies must be developed to improve overall paternity establishment, with special emphasis on these target populations. In addition, these data suggest that racial and ethnic factors are important determinants of paternity establishment in the state of Michigan.
Pelvic malignancy complicating pregnancy poses a difficult management problem. Survival of the patient is the foremost concern, but fetal viability and well-being are also factors that have to be addressed in these cases. Cervical cancer is rarely diagnosed during pregnancy, but is still the most commonly diagnosed malignancy in pregnancy. Because of the relative infrequency of this condition, guidelines for management are not clearly defined. The basis of treatment for cervical malignancy in a pregnant patient is similar to that of a nonpregnant patient, with variations done to achieve the best possible outcome for the fetus without compromising the mother. Over the last decade, investigators have reported and advocated a more conservative approach to the management of this disease. This article will review the literature on the management of invasive cervical cancer in pregnancy and suggest a treatment scheme.
Twenty-seven years into the malpractice “crisis” in the United States, physicians continue to be subject to the threat of litigation. They know that they can be sued even when they meet the standard of care. This threat gives rise to a range of specific fears that represent an ongoing emotional burden for practitioners and contribute to work dissatisfaction. This article identifies a range of these fears and suggests ways to cope with them.
Robert Koch was one of the founding fathers of biology. His contributions to the field of infectious disease are rivaled only by those of Pasteur and Lister. Koch rose from humble beginnings, working as a country doctor, and catapulted to the pinnacle of a scientific career to receive the Nobel Prize for Medicine in 1905. Confirming Pasteur’s germ theory, describing the entire life cycle of Bacillus anthracis, formulating his famous postulates, isolating the tubercle bacillus, isolating the cholera vibrio, inventing new methods for microscopy, and taking the first photomicrograph of a bacterium are just a few of the tremendous accomplishments that Robert Koch achieved in his lifetime.
Cervical cancer is one of the most common female malignancies worldwide. In the United States, the mortality from cervical cancer has decreased 70–80% since the introduction of the conventional Papanicolaou smear. Despite its success, the conventional Papanicolaou smear has a sensitivity of only 51% and a false negative rate of 5–10%. The ThinPrep smear has been shown to improve the adequacy of cervical cytology, thereby increasing the sensitivity and decreasing the false negative rate of cervical cancer screening. The ThinPrep has the theoretical potential to reduce the incidence of invasive disease by 28%, increase life-expectancy, and decrease the lifetime costs associated with diagnosis and management of cervical abnormalities. Unfortunately, absent or suboptimal screening is associated with 50–60% of cancer cases. Ultimately, it will take not only improving the sensitivity of the Pap test, but also increasing the participation in screening programs, especially in high-risk populations, in order to continue to reduce the morbidity and mortality associated with cervical cancer.
A high index of suspicion is critical in the prevention of serious complications of gonorrheal infection. This article reviews published information regarding the pathophysiology, epidemiology, clinical characteristics, diagnosis, and treatment of gonorrhea. MEDLINE was used to search the literature for articles and studies that have a bearing on these issues. Keywords used were disseminated gonococcal infection; septic arthritis; gonorrhea and pregnancy; and gonorrhea and pathophysiology. We conclude that disseminated gonococcal infection (DGI) should be in the differential diagnosis of any sexually active patient who presents with arthritis, dermatitis, and/or tenosynovitis. Although the incidence of DGI has declined in recent years, it still is the most common cause of newly diagnosed arthritis requiring hospitalization. Careful culturing of every site that could be infected is imperative to aid in diagnosis and treatment. Prompt therapy with appropriate antibiotics such as ceftriaxone will prevent the more serious complications of DGI.
More women are planning pregnancy after the age of 35. Unfortunately for these individuals, aging is associated with compromised ovarian function and decreasing fecundity. Compromised oocyte quality is associated with fetal aneuploidies and poor quality embryos with an increased miscarriage rate. Secondary to this compromised oocyte quality, success rates of assisted reproductive techniques decline. Follicle stimulating hormone (FSH) and estradiol levels on day 3 of the menstrual cycle help to assess the ovarian reserve. Fertility potential can also be assessed by the clomiphene challenge test. In order for women to plan for their childbearing, an understanding of the influence of age on fertility is essential. It is the responsibility of caregivers to educate patients regarding this issue. Assisted reproductive techniques (ART), ovum donation, and preimplantation diagnostic techniques help to improve the successful pregnancy outcomes in older women.
The purpose of this study was to assess obstetrician knowledge and behavior as it relates to paternity establishment for unwed mothers in the state of Michigan. Masked questionnaires were sent to 1328 obstetricians. Statistics were based on the binomial distribution, with significance reported at P < .05. Ordinal logistic regression was performed evaluating the relationship between physician attitudes and paternity establishment success rates. The response rate was 44%. Respondents were more likely male (56%), married (82%), white (80%), and with children (78%). Few (13%) provided their unwed gravidas with paternity establishment information. Only 37% knew that their hospital had a paternity establishment program. Forty-four percent knew the State unwed rate for live births; 20% knew the average hospital paternity establishment rate; 13% correctly answered when federal sanctioning occurred. Knowledge regarding statewide unwed delivery rates and paternity establishment was correlated to rates within the respondent’s own institution (P < .05). Physician attitudes were significantly associated with individual hospital paternity establishment rates. Most obstetricians agreed that it was important to have a legal father (91%) and that paternity establishment is important for the child (76%). Few thought that it was an invasion of privacy (10%) or that it was primarily for child support (40%). Only 21% thought that the paternity establishment process was clearly defined. In our survey, the obstetricians were generally poorly informed regarding data related to unwed deliveries, paternity establishment regulations, and current government mandates. Attitudinal responses suggested that clinicians are supportive of paternity establishment goals. Physician behavior correlates with hospital paternity establishment success rates.
The Surgeon General has identified obesity as a leading threat to public health in the United States. It is associated with a wide variety of chronic diseases, which are exacerbated by increasing degrees of overweight. Starting points for treatment of obesity include diet, exercise, and behavioral therapy. Medication can be added to help effect weight loss. However, there is a growing consensus that weight reducing (bariatric) surgery is the treatment of choice for extremely obese individuals who have failed to reduce their weight through dietary, behavioral, and pharmacologic interventions. The two operations that have been most widely used in the United States are vertical banding gastroplasty and Roux-en-Y gastric bypass. Between these, gastric bypass appears to have better long-term effectiveness in reducing weight and managing comorbidities related to obesity. More important than enabling the patient to reach an ideal body weight, bariatric surgery can be very effective in ameliorating, or even resolving, obesity-related diseases.
Thanks to the efforts of Pasteur and Jenner, the widespread use of immunization has had a dramatic effect on public health in the 20th century. As the 21st century begins, public health advocates, researchers, and health practitioners alike are continuing the work of these pioneers. However, many barriers remain that prevent access and delivery of vaccinations. Obstetrician/gynecologists are at the forefront of delivering quality primary care services to a diverse population of women, and are in a unique position to impact this important public health issue. This article will provide an overview of the most common immunizations used in clinical practice today. Target populations, indications, and side effects will be addressed as well as suggestions for promoting this service in an obstetrics and gynecology primary care setting.
