Roy M. Pitkin

Laminaria as an adjunct in induction of labor.

The safety and efficacy of laminaria tents as an adjunct to labor induction near term were examined in a prospective, controlled, and randomized study involving insertion of laminaria into the cervical canal the evening prior to planned induction. Six of 35 subjects in whom laminaria were used entered labor spontaneously and delivered overnight, compared with 1 of 39 controls. Of the remainder, the Bishop score increased an average of 3.7 points, a highly significant change, in the laminaria-treated group compared with no change in the controls. Labor, induced primarily by amniotomy with intravenous oxytocin then given to patients in whom regular contractions did not begin within 8 hours, was shorter with laminaria use than in controls, though the amniotomy-to-delivery interval did not differ significantly. However, comparison of the subgroup with cervices relatively unfavorable for induction, indicated by an initial Bishop score of 5 or less, showed both length of labor and amniotomy-to-delivery interval to be significantly shorter (each by an average of 3 hours) in the laminaria-treated group compared with controls. Complications, including febrile morbidity, did not differ. We conclude that laminaria tents are both effective and safe as an adjunct to labor induction, acting by accelerating the preparatory changes in the cervix which normally occur in late pregnancy.

Operative Laparoscopy: A Second Look After 18 Years

A 1992 editorial in Obstetrics & Gynecology titled “Operative Laparoscopy: Surgical Advance or Technical Gimmick?” raised a number of concerns about a then-nascent field, concerns based mainly on the paucity of evidence regarding the appropriateness and outcomes of performing gynecologic operations endoscopically.1 The editorial provoked considerable reaction, most of it variations on the theme “How dare you!” The journal received many letters about the editorial, far more than ever came in response to a single publication. It seems appropriate now to ask where we stand 18 years later. A substantial body of evidence has accumulated in recent years to support the laparoscopic approach to various gynecologic operations. Despite well-recognized difficulties in assessing surgical procedures by randomized trial, many of the reports have been based on this more rigorous and more meaningful design. Additionally, there have been several meta-analyses of randomized trials. From this extensive literature, it is now clear that many if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches to various operations, including tubal pregnancy surgery (salpingectomy or salpingostomy), myomectomy, hysterectomy (especially when vaginal hysterectomy is not feasible by itself), ovarian-cyst surgery, and certain gynecologic-cancer operations (including lymph node dissections). The benefits of the laparoscopic approach include less pain and shorter postoperative convalescence, both in-hospital and after discharge. Operative and postoperative complications are typically no more frequent with laparoscopy and often occur less frequently. In an era of concern regarding health care costs, considerable attention has been devoted to economic matters. All health care financial studies are complicated by inconsistencies and uncertainties regarding the meaning of “cost,” but the research is quite consistent in finding that hospital charges due to some increase in operating time with laparoscopic surgery and disposable instruments are offset, sometimes substantially, by decreased charges reflecting shortened postoperative hospital stays. If a “societal cost” that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater. All of this, of course, assumes that the disease in a given woman is amenable to either approach and that the surgeon is equally experienced and equally competent with the two. Choosing the best surgery or other treatment to recommend to a given patient is part of that ill-defined and often nebulous quality called “clinical judgment.” What about technical competence? That issue goes most directly to the formal training period— residency. When a relatively new surgical technique becomes popular, The authors are from the Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; e-mail: r.pitkin@earthlink.net.

The peer-review system.

A good system (practice) of peer review should be organized around  Multiple Sources o Instructors o Colleagues o Administrators o Students  Multiple Methods o Narrative documents (teaching philosophy, letters of recommendation) o Course Materials/Student work o Ratings/rankings (course evals, observation checklists) o Observations o Counts (numbers of theses) o interviews  Multiple Points in Time  Constructive Alignment o “Identification of the teaching practice we wish to see should be aligned with the ways in which we try to develop teaching and the ways we assess it”

Urinary urea-nitrogen ratio as an index of protein nutrition in diabetic pregnancy.

Urinary urea nitrogen-total nitrogen ratio (UN/TN) was measured at intervals throughout pregnancy in 12 normal women and in 10 with insulin-dependent diabetes mellitus and the results were related to protein ingestion estimated by dietary history. While urea and nitrogen correlated significantly with each other in both normal and diabetic subjects, the relationship between UN/TN and protein intake was quite different in the two groups. Nondiabetic patients exhibited generally close correlation between UN/TN and protein intake with statistically significant correlation coefficients (r = 0.74-0.99) in 11 of 12 subjects. In none of the 10 diabetic patients, however, was significant correlation found. While the reliability of the index in diabetic patients tended to improve as hyperglycemia lessened, even under conditions considered clinically to indicate excellent metabolic control (mean plasma glucose less than or equal to 125 mg/dl), UN/TN still did not correlate significantly with protein intake. These observations suggest that the unstable carbohydrate metabolism characteristic of diabetes mellitus may be responsible for altered protein retention during pregnancy. From a clinical point of view, the utility of urinary urea studies as a simple and objective index of protein intake in the normal pregnant women does not apply in the diabetic patients.