Patricia A. Robertson

Neonatal morbidity according to gestational age and birth weight from five tertiary care centers in the United States, 1983 through 1986.

OBJECTIVES This study details the incidence, by gestational age and birth weight, of specific neonatal morbidities in singleton neonates without major congenital anomalies. STUDY DESIGN Data were prospectively collected on all deliveries at five tertiary centers in the United States during the years 1983 through 1986. Pregnancies were meticulously dated and the gestational ages of the neonates at delivery were confirmed by Dubowitz score. RESULTS The incidence of respiratory distress syndrome gradually decreases with increasing gestational age until 36 weeks. A marked decrease in the incidence of necrotizing enterocolitis, patent ductus arteriosus, intraventricular hemorrhage, and sepsis occurs after 32 completed weeks. The number of days of mechanical ventilation for respiratory distress syndrome and newborn stay in the tertiary care facility also were significantly reduced after 32 weeks. CONCLUSIONS The incidence of both respiratory distress syndrome and patent ductus arteriosus is markedly decreased by both increasing gestational age and birth weight. The incidence of grade III and IV intraventricular hemorrhage, necrotizing enterocolitis, and sepsis virtually vanishes after 34 weeks. These data relating neonatal morbidities to gestational age are important to the obstetrician in the critical decision regarding the timing of delivery and to the parents, who can benefit from a realistic prediction of the neonatal course.

Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries

Third- and fourth-degree perineal lacerations occur frequently during operative vaginal deliveries. To identify risk factors for lacerations, 2832 consecutive forceps and vacuum extraction deliveries were analyzed. Third- and fourth-degree lacerations occurred in 30% of deliveries. Multiple logistic regression was used to control for intercorrelation between potential risk factors. Factors associated with increased risk for third- and fourth-degree lacerations were midline episiotomy, nulliparity, second-stage arrest, occipitoposterior position, low or mid station, use of forceps instead of vacuum, use of local anesthesia, and Asian race. When these factors were controlled, there was no effect of birth weight, faculty versus resident operator, gestational age, abnormalities of first-stage labor, or several other factors. Prevention of perineal lacerations requires that the operator identify the patient at risk. Possible options for management of high-risk patients include use of mediolateral episiotomy or no episiotomy, use of vacuum extraction instead of forceps, and use of conduction anesthesia.

Cardiovascular complications associated with terbutaline treatment for preterm labor

Severe cardiovascular complications occurred in eight of 160 patients treated with terbutaline for preterm labor. Associated corticosteroid therapy and twin gestations appear to be predisposing factors. Potential mechanisms of the pathophysiology are briefly discussed.

Lesbian, Gay, Bisexual, and Transgender (LGBT) Physicians' Experiences in the Workplace

Little is known about the experiences of lesbian, gay, bisexual, and transgender (LGBT) physicians in the workplace. There is little formal education in medical school about LGBT issues, and some heterosexual physicians have negative attitudes about caring for LGBT patients or working with LGBT coworkers, setting the stage for an exclusive and unwelcoming workplace. The current study used an online survey to assess a convenience sample of 427 LGBT physicians from a database of a national LGBT healthcare organization, as well as a snowball sample generated from the members of the database. Although rates of discriminatory behaviors had decreased since earlier reports, 10% reported that they were denied referrals from heterosexual colleagues, 15% had been harassed by a colleague, 22% had been socially ostracized, 65% had heard derogatory comments about LGBT individuals, 34% had witnessed discriminatory care of an LGBT patient, 36% had witnessed disrespect toward an LGBT patients partner, and 27% had witnessed discriminatory treatment of an LGBT coworker. Few had received any formal education on LGBT issues in medical school or residency. It appears that medical schools and health care workplaces continue to ignore LGBT issues and operate in discriminatory fashion far too often.

Serial salivary estriol to detect an increased risk of preterm birth

Objective To evaluate serial measurements of salivary estriol (E3) to detect increased risk of spontaneous preterm labor and preterm birth. Methods A masked, prospective, multicenter trial of 956 women with singleton pregnancies was completed at eight United States medical centers. Saliva was collected weekly, beginning at the 22nd week of gestation until birth, and tested for unconjugated E3 by enzyme-linked immunosorbent assay. Women were separated into high-risk and low-risk groups using the Creasy scoring system. Results A single, positive (at or above 2.1 ng/mL) salivary E3 test predicted an increased risk of spontaneous preterm labor and delivery in the total population (relative risk [RR] 4.0, P < .005), in the low-risk population (RR 4.0, P ≤ .05), and in the high-risk population (RR 3.4, P = .05). Two consecutive positive tests significantly increased the RR in all study groups, with a dramatic improvement in test specificity and positive predictive value but only a modest decrease in sensitivity. In women who presented with symptomatic preterm labor, salivary E3 identified 61% of those who delivered within 2 weeks, using a threshold of 1.4 ng/mL. Conclusion Elevated salivary E3 is associated with increased risk of preterm birth in asymptomatic women and symptomatic women who present for evaluation of preterm labor.

Risk Factors for Ovarian Cancer: Lesbian and Heterosexual Women

PURPOSE/OBJECTIVES To compare the distribution of risk factors for developing ovarian cancer in lesbian and heterosexual women. DESIGN Secondary analysis of a retrospective medical record review. SETTING Urban health clinic with special outreach to lesbians. SAMPLE Typical participant (N = 1,019) was 42.9 years old and white (70%). Most were without health insurance, and 99% were poor (<

Development of a longitudinal integrated clerkship at an academic medical center

15,780 annual income). The majority (58%, n = 586) described themselves as heterosexual; 42% (n = 433) said they were lesbian. METHODS Data were collected from medical records and analyzed using analysis of covariance and logistic regression techniques. MAIN RESEARCH VARIABLES Ovarian cancer risk factors (parity, exogenous hormone use, smoking, body mass index [BMI], and tubal ligation/hysterectomy). FINDINGS Lesbians had a higher BMI; heterosexual women had higher rates of current smoking and a higher incidence of the protective factors of pregnancy, children, miscarriages, abortions, and use of birth control pills. CONCLUSIONS The results of this study indicate that lesbians may have an increased risk for developing ovarian cancer. A study designed specifically to explore the risk factors of lesbian and heterosexual women for developing ovarian cancer must be undertaken to confirm these findings. IMPLICATIONS FOR NURSING PRACTICE Differences in risk levels may exist for lesbians; therefore, healthcare providers must become comfortable asking questions about sexual orientation and behavior.

Neonatal and maternal outcome in low-pelvic and midpelvic operative deliveries

Abstract In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSFs traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants’ career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.

Maternal morbidity associated with isoxsuprine and terbutaline tocolysis

A retrospective analysis of low-pelvic and midpelvic operative deliveries (according to the new definitions by the American College of Obstetricians and Gynecologists, 1989) matched with cesarean section deliveries of similar station was undertaken. In all vaginally delivered groups there was significantly decreased maternal morbidity, maternal hospital stay, and estimated blood loss. In the midpelvic deliveries, there was a significant increase in the frequency of neonatal resuscitation and an increase in base deficit for the umbilical artery. In both the midforceps and low-forceps groups, there was a significant increase of neonates with cord arterial pH less than 7.10, and an increase of base deficit, even when cases of fetal distress were eliminated. The midforceps group also had an increased rate of admission to the intensive care nursery and an increase in the risk of significant birth trauma. In considering a midforceps or midvacuum operative delivery, the potential associated risks to the neonate must be balanced against the benefits to the mother.

Development and pilot testing of a reflective learning guide for medical education

A retrospective study of 343 women treated with isoxsuprine and/or terbutaline for preterm labor (PTL) was performed to determine the incidence and nature of maternal morbidity which is associated with this treatment. The incidence of mild cardiovascular (CV), neurological and gastrointestinal side effects was similar with both medications. The incidence, however, of severe CV complications such as pulmonary edema and myocardial ischemia was higher among women treated with i.v. terbutaline (5.3%) than among those treated with isoxsuprine (0.8%, P less than 0.05). Patients with multiple gestations on i.v. terbutaline therapy had an exceptionally high incidence of severe CV complications (43%), while none of the twin pregnancies on i.v. isoxsuprine had such complications. Corticosteroid treatment was not associated with a significant increase of complications with either tocolytic medication. Both medications had similar success in inhibiting PTL.