Obstetrics and Gynecology

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Cervical Incompetence

(GY002)

Introduction

Cervical Incompetence (CI) is a condition in which the cervix of a pregnant woman begins to open (dilate) and thin (efface) before the pregnancy has reached term. "Incompetence" refers to the weakness of the muscle of the cervix, which can not be voluntarily controlled. CI is a cause of miscarriage and preterm birth in the second and third trimesters.

In CI, the cervix dilates and effaces without pain or uterine contractions because of the growing pressure of the pregnant uterus. If these changes are not halted, rupture of the membranes and premature delivery can result.

CI occurs in only 1-2% of all pregnancies, however it is the cause of 20-25% of miscarriages in the second trimester as well as 10% of preterm deliveries.

The goal of intervention is the successful prevention of premature delivery. This allows the fetus time to develop as fully as possible, thus preventing the multitude of complications associated with prematurity.

Treatment consists mainly of a procedure called cerclage, along with bedrest and possibly medications to prevent contractions and premature delivery. Even with cerclage and additional therapies, the risk of preterm birth is high (about 25%).

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The Medifocus Guide on Cervical Incompetence provides answers to the following important questions and medical issues:

What are the most common symptoms of cervical incompetence?

Are there any recognized risk factors for developing cervical incompetence?

What kinds of medical tests are used to establish the diagnosis of cervical incompetence?

What is the current standard of care for the treatment of cervical incompetence?

What treatment options are available for the management of cervical incompetence?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in cervical incompetence?

Where are the leading hospitals and centers of research for cervical incompetence?

What are the most important questions to ask my doctor about cervical incompetence?

What Your Doctor Reads:

This MediFocus Guide contains an extensive listing of citations and abstracts of recent journal articles that have been published about this condition in trustworthy medical journals. This is the same type of information that is available to physicians and other health care professionals. A partial selection of journal articles that are abstracted in this MediFocus Guide includes:

Management of cervical cerclage after preterm premature rupture of membranes.

Obstetrical & Gynecological Survey. 1999

Can examination of the cervix provide useful information for prediction of cervical incompetence and following preterm labour?.

Australian & New Zealand Journal of Obstetrics & Gynaecology. 1999

Prevention of preterm birth.

Baillieres Clinical Obstetrics & Gynaecology. 1995

Emergency cerclage: a review.

Obstetrical & Gynecological Survey. 1995

Short cervical length by ultrasound and cerclage.

Journal of Perinatology. 2000

Amniocentesis for selection before rescue cerclage.

Obstetrics & Gynecology. 2000

Scanning electron microscopy and X-ray diffraction studies in the analysis of medical materials: Gore-Tex versus braided polyester tape for repair of the incompetent cervix.

Micron. 2000

Cervical incompetence: elective, emergent, or urgent cerclage.

American Journal of Obstetrics & Gynecology. 1999

Pregnancy outcomes in women treated with elective versus ultrasound-indicated cervical cerclage.

Ultrasound in Obstetrics & Gynecology. 1998

Comparison of elective and empiric cerclage and the role of emergency cerclage.

Journal of Maternal-Fetal Medicine. 1998

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Dysmenorrhea (Menorrhalgia)

(GY004)

Introduction

Dysmenorrhea, or painful menses, is one of the most common gynecological complaints in young women, thought to affect 50% of all menstruating women. Ten percent of women have severe enough symptoms to necessitate missing work, school or other responsibilities. Peak incidence is between 20 and 24 years of age.

Primary dysmenorrhea is due to the secretion of prostaglandin (PG) F2a in the lining of the uterus. PGF2a stimulates uterine contractions. It is also thought that chemicals called leukotrienes heighten sensitivity of pain fibers in the uterus.

The goal of treatment of primary dysmenorrhea is the minimization of discomfort and preservation of fertility. If efforts to treat primary dysmenorrhea are unsuccessful after a few months, then the diagnosis, and the possibility of secondary causes, should be reconsidered.

Treatment methods include medications for pain and oral contraceptive pills to regulate the menstrual cycle. Nutritional and lifestyle medications play an important role, as well. Several complementary and alternative therapies have been utilized in the management of the discomfort of dysmenorrhea, although there are few or no studies to support their effectiveness or safety. Surgery is required only when the dysmenorrhea is found to be secondary to an underlying cause.

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The Medifocus Guide on Dysmenorrhea provides answers to the following important questions and medical issues:

What are the most common symptoms of dysmenorrhea?

Are there any recognized risk factors for developing dysmenorrhea?

What kinds of medical tests are used to establish the diagnosis of dysmenorrhea?

What is the current standard of care for the treatment of dysmenorrhea?

What treatment options are available for the management of dysmenorrhea?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in dysmenorrhea?

Where are the leading hospitals and centers of research for dysmenorrhea?

What are the most important questions to ask my doctor about dysmenorrhea?

What Your Doctor Reads:

Dysmenorrhea.

Annals of the New York Academy of Sciences. 2000

Leukotrienes in gynaecology: the hypothetical value of anti-leukotriene therapy in dysmenorrhoea and endometriosis.

Human Reproduction Update. 2000

Dysmenorrhea.

Journal of the American Academy of Nurse Practitioners. 1999

Primary dysmenorrhea.

American Family Physician. 1999

Dysmenorrhea and pelvic pain in adolescents.

Pediatric Clinics of North America. 1999

Dysfunctional uterine bleeding and dysmenorrhea.

European Journal of Contraception & Reproductive Health Care. 1997

Dysmenorrhea.

Current Therapy in Endocrinology & Metabolism. 1997

Dysmenorrhea and dysfunctional uterine bleeding.

Primary Care; Clinics in Office Practice. 1997

Exercise and primary dysmenorrhoea.

British Journal of Sports Medicine. 1999

High nocturnal body temperatures and disturbed sleep in women with primary dysmenorrhea.

American Journal of Physiology. 1999

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Ectopic Pregnancy

(GY005)

Introduction

Ectopic pregnancy (EP) (also called tubal pregnancy) occurs when a fertilized egg (ovum, embryo) implants at a site other than the endometrial lining of the uterus. The incidence of EP in 1992 was 108,000 or 19.7 per 1000 reported pregnancies. Four of out 10 ectopic pregnancies occur in women between 20 to 29 years old. Over 75% of these cases are caught before the 12th week of pregnancy.

With an EP, the embryo implants outside the uterus but continues to grow and expand. Occasionally, the ectopic pregnancy will simply deteriorate spontaneously and will be absorbed by the body. However, it can rupture, and if it is inside the fallopian tube (as the majority are), the tube may also rupture if not treated in time. This can cause many serious problems, especially bleeding, infection, infertility, and even death. Therefore, early diagnosis and assessment of the woman's condition is critical in determining the appropriate care to maintain her safety and health.

The goals of treatment for EP are the preservation of the mother's safety, and the protection of her reproductive ability. The woman's condition must be ascertained to determine if immediate surgical intervention is required, or if a more conservative approach may safely be taken.

Treatment may include medications or surgical intervention.

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The Medifocus Guide on Ectopic Pregnancy provides answers to the following important questions and medical issues:

What are the most common symptoms of ectopic pregnancy?

Are there any recognized risk factors for developing ectopic pregnancy?

What kinds of medical tests are used to establish the diagnosis of ectopic pregnancy?

What is the current standard of care for the treatment of ectopic pregnancy?

What treatment options are available for the management of ectopic pregnancy?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in ectopic pregnancy?

Where are the leading hospitals and centers of research for ectopic pregnancy?

What are the most important questions to ask my doctor about ectopic pregnancy?

What Your Doctor Reads:

Laparoscopic management of heterotopic pregnancy: a review.

Journal of Obstetrics & Gynaecology Research. 2000

Suspected ectopic pregnancy. Can it be predicted by history and examination?.

Canadian Family Physician. 2000

Cornual heterotopic pregnancy: contemporary management options.

American Journal of Obstetrics & Gynecology. 2000

Ectopic pregnancy.

Archives of Gynecology & Obstetrics. 2000

Ectopic pregnancy.

BMJ. 2000

Ectopic pregnancy.

Primary Care; Clinics in Office Practice. 2000

Extra-uterine pregnancy following assisted conception treatment.

Human Reproduction Update. 2000

Ectopic pregnancy.

American Family Physician. 2000

Current treatment of ectopic pregnancy.

Annals of Medicine. 1999

Conservative medical and surgical management of interstitial ectopic pregnancy.

Fertility & Sterility. 1999

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Endometriosis

(GY006)

Introduction

Endometriosis is characterized by the presence of endometrial tissue (tissue that lines the uterus) outside of the uterine cavity (ectopic). The areas most commonly affected are the ovaries and fallopian tubes, however, "endometrial implants" have been found in most organ systems of the female body, with the exception of the heart and the spleen. Commonly affected areas include the vagina, the vulva, the urinary system, and the gastrointestinal tract. More rarely affected are the lungs and diaphragm, the skin and the central nervous system.

Endometriosis is a progressive disease affecting approximately 10-15% of women, usually of childbearing age. Women are usually 25 to 29 years of age at the time of diagnosis especially if the primary symptom is pain. Women whose symptoms are related to infertility may not be diagnosed until later.

The cause of endometriosis is not well understood but there are several theories to explain its development.

Treatment goals and decisions are dictated by the woman's desire for reproduction. The goals of care for a woman who desires pregnancy (currently or in the future) are to preserve reproductive function. The goal for a woman who has completed childbearing is the minimization of discomfort and prevention of further complications.

Treatment methods include medications and surgery.

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The Medifocus Guide on Endometriosis provides answers to the following important questions and medical issues:

What are the most common symptoms of endometriosis?

Are there any recognized risk factors for developing endometriosis?

What kinds of medical tests are used to establish the diagnosis of endometriosis?

What is the current standard of care for the treatment of endometriosis?

What treatment options are available for the management of endometriosis?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in endometriosis?

Where are the leading hospitals and centers of research for endometriosis?

What are the most important questions to ask my doctor about endometriosis?

What Your Doctor Reads:

Implantation defect in endometriosis: endometrium or peritoneal fluid.

Journal of Reproduction & Fertility - Supplement. 2000

The pathophysiology of endometriosis-associated infertility: follicular environment and embryo quality.

Journal of Reproduction & Fertility - Supplement. 2000

Medical management of endometriosis and infertility.

Fertility & Sterility. 2000

Extracts from the "clinical evidence". Endometriosis.

BMJ. 2000

Endometriosis-associated intestinal tumors: a clinical and pathological study of 6 cases with a review of the literature.

Human Pathology. 2000

Umbilical endometriosis after unprotected removal of uterine pieces through the umbilicus.

2000

Progestagens and anti-progestagens for pain associated with endometriosis.

Cochrane Database of Systematic Reviews [computer file]. 2000

Modern combined oral contraceptives for pain associated with endometriosis.

Cochrane Database of Systematic Reviews [computer file]. 2000

Ovulation suppression for endometriosis.

Cochrane Database of Systematic Reviews [computer file]. 2000

Gonadotrophin-releasing hormone analogues for pain associated with endometriosis.

Cochrane Database of Systematic Reviews [computer file]. 2000

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Female Infertility

(GY007)

Introduction

The most commonly used definition of infertility is the lack of pregnancy after 1 year of unprotected regular intercourse. Infertility affects 10-15% of all couples who are attempting to become pregnant.

The causes of infertility can be divided into four major categories: 1) the female factor [35%];

2) the male factor [30%]; 3) combined factors [20%]; and 4) unexplained infertility [15%].

Investigation of infertility necessitates the evaluation of both the male and female partners. There are several identified causes of female infertility.

The goals of care are the determination of any reversible causes of infertility and the initiation of appropriate treatments to maximize reproductive potential. The decision to undergo fertility treatment should be reached only after thorough consideration of the available treatments, potential outcomes (multiple births, failure to conceive), and expense, as well as the emotional and religious factors that may impact on this process.

The treatment depends on the underlying problem. Treatment modalities can be generally classified as medical, hormonal, surgical, or assisted reproductive technologies (ART). Often, a combination of modalities is utilized.

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The Medifocus Guide on Female Infertility provides answers to the following important questions and medical issues:

What are the most common symptoms of female infertility?

Are there any recognized risk factors for developing female infertility?

What kinds of medical tests are used to establish the diagnosis of female infertility?

What is the current standard of care for the treatment of female infertility?

What treatment options are available for the management of female infertility?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in female infertility?

Where are the leading hospitals and centers of research for female infertility?

What are the most important questions to ask my doctor about XXX?

What Your Doctor Reads:

Implantation defect in endometriosis: endometrium or peritoneal fluid.

Journal of Reproduction & Fertility - Supplement. 2000

The pathophysiology of endometriosis-associated infertility: follicular environment and embryo quality.

Journal of Reproduction & Fertility - Supplement. 2000

Evaluation and management of infertility in women: the internists' role.

Annals of Internal Medicine. 2000

Techniques for pelvic surgery in subfertility.

Cochrane Database of Systematic Reviews [computer file]. 2000

Postoperative procedures for improving fertility following pelvic reproductive surgery.

Cochrane Database of Systematic Reviews [computer file]. 2000

Liquid and fluid agents for preventing adhesions after surgery for subfertility.

Cochrane Database of Systematic Reviews [computer file]. 2000

Laparoscopic "drilling" by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome.

Cochrane Database of Systematic Reviews [computer file]. 2000

Oil-soluble versus water-soluble media for assessing tubal patency with hysterosalpingography or laparoscopy in subfertile women.

Cochrane Database of Systematic Reviews [computer file]. 2000

Ovulation induction with urinary follicle stimulating hormone versus human menopausal gonadotropin for clomiphene-resistant polycystic ovary syndrome.

Cochrane Database of Systematic Reviews [computer file]. 2000

Barrier agents for preventing adhesions after surgery for subfertility.

Cochrane Database of Systematic Reviews [computer file]. 2000

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Gestational Diabetes

(GY009)

Introduction

Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy and disappears following delivery of the baby. In GDM, the mother's body does not produce and use enough insulin to respond to glucose derived from food. This leads to high levels of glucose (hyperglycemia) in the mother's body, which then circulates to the fetus via the umbilical cord blood.

In response to the high glucose levels, the fetus grows larger than normal (macrosomia) which can lead to several complications at the time of delivery. Meanwhile, the fetus produces more insulin to handle the extra glucose. This can lead to complications in the management of the infant's glucose levels following delivery.

GDM affects 135,000 pregnant women (3-5 %) in the United States. While several risk factors have been identified, almost 50% of women with the disorder have no predisposing factors.

The management of GDM varies according to the individual physical, psychological, social, cultural, and educational needs of the woman. The mainstay of treatment is diet and exercise, although it may be necessary to use insulin injections to provide adequate control of blood glucose levels.

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The Medifocus Guide on Gestational Diabetes provides answers to the following important questions and medical issues:

What are the most common symptoms of Gestational Diabetes?

Are there any recognized risk factors for developing Gestational Diabetes?

What kinds of medical tests are used to establish the diagnosis of Gestational Diabetes?

What is the current standard of care for the treatment of Gestational Diabetes?

What treatment options are available for the management of Gestational Diabetes?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in Gestational Diabetes?

Where are the leading hospitals and centers of research for Gestational Diabetes?

What are the most important questions to ask my doctor about Gestational Diabetes?

What Your Doctor Reads:

Controversies in the diagnosis and treatment of gestational diabetes.

Cleveland Clinic Journal of Medicine. 2000

Gestational diabetes in primary care.

Medscape Womens Health. 2000

Carbohydrate and lipid metabolism in pregnancy: normal compared with gestational diabetes mellitus.

American Journal of Clinical Nutrition. 2000

Dietary regulation for 'gestational diabetes'.

Cochrane Database of Systematic Reviews [computer file]. 2000

The infant of the woman with gestational diabetes mellitus.

Clinical Obstetrics & Gynecology. 2000

Management of gestational diabetes.

Clinical Obstetrics & Gynecology. 2000

Making the diagnosis of gestational diabetes mellitus.

Clinical Obstetrics & Gynecology. 2000

Physiologic and molecular alterations in carbohydrate metabolism during pregnancy and gestational diabetes mellitus.

Clinical Obstetrics & Gynecology. 2000

Gestational diabetes: risk or myth?.

Journal of Clinical Endocrinology & Metabolism. 1999

Gestational diabetes mellitus: controversies and current opinions.

Current Opinion in Obstetrics & Gynecology. 1999

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Hormone Replacement Therapy

(GY010)

Introduction

Hormone replacement therapy (HRT) refers to the administration of exogenous (outside the body) estrogen (and sometimes progestin) to women who have experienced physiologic depletion of their natural estrogen because of menopause. Menopause, which is the permanent cessation of menstruation after loss of ovarian follicular function, is clinically defined as the absence of menses for 12 months. Natural menopause occurs at an average of 51 years. Approximately 1% of women become postmenopausal before 40 years of age, and 5% become postmenopausal after 55 years of age. During the several years before menopause, a period known as menopause transition, levels of follicle-stimulating hormone (FSH) increase and ovarian follicles abnormally mature; as a result, estrogen and progesterone levels become erratic.

The two basic reasons to take HRT are the management of the symptoms of menopause and the prevention of certain diseases (such as heart disease and osteoporosis) which are common among postmenopausal women. A common concern regarding HRT is the increased risk of some kinds of cancer which has been associated with taking estrogen.

Not all women are candidates for HRT and the decision must be based on a thorough consideration of the risks and potential benefits for each individual.

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The Medifocus Guide on Hormone Replacement Therapy (HRT) provides answers to the following important questions and medical issues:

What are the most common symptoms of hormone depletion?

Are there any recognized risk factors for taking HRT?

What is the current standard of care for the treatment of HRT?

What treatment options are available for the management of HRT?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in HRT?

Where are the leading hospitals and centers of research for HRT?

What are the most important questions to ask my doctor about HRT?

What Your Doctor Reads:

The role of hormone replacement therapy in the prevention of postmenopausal heart disease.

Archives of Internal Medicine. 2000

Continuation rates for oral contraceptives and hormone replacement therapy. The ESHRE Capri Workshop Group.

Human Reproduction. 2000

Management of the climacteric. Options abound to relieve women's midlife symptoms.

Postgraduate Medicine. 2000

Estrogens are indicated for the prevention of coronary artery disease: a debate for estrogen.

Canadian Journal of Cardiology. 2000

Estrogens should not be initiated for the secondary prevention of coronary artery disease: a debate.

Canadian Journal of Cardiology. 2000

Hormone replacement therapy in women with rheumatic diseases.

Scandinavian Journal of Rheumatology. 2000

Estrogen replacement therapy and the surgeon.

American Journal of Surgery. 2000

Prevention and treatment of osteoporosis: efficacy of combination of hormone replacement therapy with other antiresorptive agents.

Journal of Clinical Densitometry. 2000

Postmenopausal osteoporosis management.

Current Opinion in Obstetrics & Gynecology. 2000

The menopause in Europe.

International Journal of Fertility & Womens Medicine. 2000

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Ovarian Cysts

(GY011)

Introduction

Cysts are sacs filled with fluid or semi-solid tissue that can develop in almost any part of the body. The ovaries, however are a particularly common location for the development of cysts in women. Most ovarian cysts are benign.

Ovarian cysts (OC) are very common in women of childbearing age and are even found in children and newborns. Cysts that occur in postmenopausal women have a higher risk of malignancy and are usually evaluated and treated aggressively.

OC often do not cause any symptoms. Symptoms may be caused by: a cyst bleeding or breaking open (rupture) and spilling contents that irritate the abdominal tissues; a twisting (torsion) cyst that blocks blood flow to the ovary; or a cyst that is very large.

Treatment decisions are based on the woman's age, the size of the cyst, and the ultrasound appearance, which usually provides adequate information to determine which cysts are appropriate for observation and which necessitate surgical removal.

Most cysts, especially smaller ones, resolve spontaneously over the course of 2-3 months and require no intervention. Cysts that are 8 centimeters and larger are generally removed surgically.

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The Medifocus Guide on Ovarian Cysts provides answers to the following important questions and medical issues:

What are the most common symptoms of ovarian cysts?

Are there any recognized risk factors for developing ovarian cysts?

What kinds of medical tests are used to establish the diagnosis of ovarian cysts?

What is the current standard of care for the treatment of ovarian cysts?

What treatment options are available for the management of ovarian cysts?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in ovarian cysts?

Where are the leading hospitals and centers of research for ovarian cysts?

What are the most important questions to ask my doctor about ovarian cysts?

What Your Doctor Reads:

Cystic pelvic pathology presenting as falsely elevated post-void residual urine measured by portable ultrasound bladder scanning: report of 3 cases and review of the literature.

Urology (Online). 2000

Can GnRH agonists act directly on the ovary and contribute to cyst formation?.

Human Reproduction. 2000

Ovarian disorders. Benign cysts.

Harvard Womens Health Watch. 1999

Ovarian masses.

Adolescent Medicine. 1999

Fetal ovarian cysts: prenatal diagnosis and management. Report of two cases and review of literature.

Clinical & Experimental Obstetrics & Gynecology. 1998

Oral contraceptive use and benign gynecologic conditions. A review.

Contraception. 1998

Ovarian cysts in the pediatric population.

Seminars in Pediatric Surgery. 1998

Office management of ovarian cysts.

Mayo Clinic Proceedings. 1997

Neonatal ovarian cysts: pathogenesis, diagnosis and management.

Pediatric Radiology. 1997

"Daughter cyst" sign: a sonographic finding of ovarian cyst in neonates, infants, and young children.

AJR. American Journal of Roentgenology. 2000

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Pelvic Inflammatory Disease

(GY012)

Introduction

Pelvic Inflammatory Disease (PID) refers to infection of the uterus, fallopian tubes and other pelvic structures. It occurs when bacteria or other organisms ascend from the vagina or cervix to the upper genital tract.

PID affects approximately 1 million women in the US every year and accounts for 250,000-300,000 hospitalizations. These numbers are actually thought to be significantly higher because of the many cases that cause no symptoms or are not recognized as PID ("silent" or "sub-clinical").

PID is the leading cause of infertility in women. Approximately 13% of women become infertile after a single episode of PID. The risk of infertility doubles with each subsequent episode. Women with a history of PID have a seven to tenfold increased risk for ectopic (tubal) pregnancy.

Education regarding safe sexual practices is key to the ultimate goal of preventing sexually transmitted disease and PID. Recognition of symptoms, however mild, is important to prompt early evaluation and treatment of early or mild cases that might otherwise go undetected.

Once PID has occurred, early treatment with antibiotics to minimize severity and complications is critical. Long term sequelae such as infertility are evaluated and managed as appropriate.

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The Medifocus Guide on Pelvic Inflammatory Disease (PID) provides answers to the following important questions and medical issues:

What are the most common symptoms of PID?

Are there any recognized risk factors for developing PID?

What kinds of medical tests are used to establish the diagnosis of PID?

What is the current standard of care for the treatment of PID?

What treatment options are available for the management of PID?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in PID?

Where are the leading hospitals and centers of research for PID?

What are the most important questions to ask my doctor about PID?

What Your Doctor Reads:

PID: a chance to make a difference.

Practitioner. 2000

Pelvic inflammatory disease epidemiology: what do we know and what do we need to know?.

Sexually Transmitted Infections. 2000

Pelvic inflammatory disease--an evidence-based approach to diagnosis.

Journal of Infection. 2000

Pelvic inflammatory disease after tubal sterilization: a review.

Obstetrical & Gynecological Survey. 2000

Pelvic inflammatory disease in the postmenopausal woman.

Infectious Diseases in Obstetrics & Gynecology. 1999

Pelvic inflammatory disease in adolescents.

Pediatric Clinics of North America. 1999

Anaerobes in pelvic inflammatory disease: implications for the Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases.

Clinical Infectious Diseases. 1999

Pelvic inflammatory disease. From diagnosis to prevention.

Dermatologic Clinics. 1998

Pelvic inflammatory disease: the importance of aggressive treatment in adolescents.

Cleveland Clinic Journal of Medicine. 1998

Pelvic inflammatory disease.

Lippincott's Primary Care Practice. 1998

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Placenta Previa

(GY013)

Introduction

During the early part of pregnancy, the placenta is typically attached at the lower portion of the uterus (low-lying), however as pregnancy progresses and the uterus grows, the placenta usually migrates upward.

In Placenta Previa (PP), the placenta remains attached in the lower portion of the uterus and either touches or obscures (partially or completely) the internal cervical os through which the baby must pass to be born. Sometimes this is due to a condition called placenta accreta, which is the abnormally firm attachment of the placenta to the uterine wall.

PP affects 1 in 200 births. The risk increases to 1-4 % after one previous cesarean delivery and up to 10% after four or more cesarean deliveries.

The focus of care for the initial episode of bleeding is the assessment and stabilization of the situation and the determination of the safety of outpatient versus in-hospital monitoring. If the fetus is preterm (< 37 weeks) and there is no need for immediate delivery (no hemorrhage), then outpatient monitoring will probably be deemed appropriate. Three quarters of women with PP will be delivered by cesarean section.

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The Medifocus Guide on Placenta Previa provides answers to the following important questions and medical issues:

What are the most common symptoms of placenta previa?

Are there any recognized risk factors for developing placenta previa?

What kinds of medical tests are used to establish the diagnosis of placenta previa?

What is the current standard of care for the treatment of placenta previa?

What treatment options are available for the management of placenta previa?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in placenta previa?

Where are the leading hospitals and centers of research for placenta previa?

What are the most important questions to ask my doctor about placenta previa?

What Your Doctor Reads:

Interventions for suspected placenta praevia.

Cochrane Database of Systematic Reviews [computer file]. 2000

Placenta previa, placenta abruptio.

Clinical Obstetrics & Gynecology. 1998

Obstetric history and the risk of placenta previa.

Acta Obstetricia et Gynecologica Scandinavica. 2000

Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound.

Ultrasound in Obstetrics & Gynecology. 2000

Maternal serum second trimester AFP and hCG in pregnancies with placenta previa.

Prenatal Diagnosis. 2000

Emergency postpartum hysterectomy in women with placenta previa and prior cesarean section.

International Journal of Gynaecology & Obstetrics. 2000

Previous cesarean section and abortion as risk factors for developing placenta previa.

Journal of Obstetrics & Gynaecology Research. 1999

Placenta previa: a 22-year analysis.

American Journal of Obstetrics & Gynecology. 1999

Placenta previa: preponderance of male sex at birth.

American Journal of Epidemiology. 1999

Neonatal outcomes with placenta previa.

Obstetrics & Gynecology. 1999

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Preeclampsia

(GY014)

Introduction

The terms pregnancy-induced hypertension and preeclampsia are often used interchangeably, which may cause significant confusion. Pregnancy-induced hypertension, preeclampsia and eclampsia should actually be considered as a spectrum of hypertensive disorders in pregnancy.

Preeclampsia is a complex disorder of the placenta usually occurring in the third trimester of pregnancy, and involving several body systems. Also known as gestational hypertension, pregnancy-induced hypertension or toxemia, it is defined as a triad of hypertension, proteinuria (protein in the urine) and generalized edema (swelling in the face, hands and legs).

Preeclampsia complicates 5-10% of all pregnancies. Women under the age of 20 are at highest risk.

For most women, the disease resolves within 24 hours of delivery. However, preeclampsia can progress into a life-threatening situation (eclampsia) for both the mother and the fetus.

The goals of therapy for preeclampsia are the safety of the mother and the delivery of a healthy newborn as close as possible to full gestation. The only "cure" for preeclampsia is the delivery of the baby. The decision to deliver the baby early is dependent on the severity of the disease and the status of the mother and child.

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The Medifocus Guide on Preeclampsia provides answers to the following important questions and medical issues:

What are the most common symptoms of preeclampsia?

Are there any recognized risk factors for developing preeclampsia?

What kinds of medical tests are used to establish the diagnosis of preeclampsia?

What is the current standard of care for the treatment of preeclampsia?

What treatment options are available for the management of preeclampsia?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in preeclampsia?

Where are the leading hospitals and centers of research for preeclampsia?

What are the most important questions to ask my doctor about preeclampsia?

What Your Doctor Reads:

Same nutrient, different hypotheses: disparities in trials of calcium supplementation during pregnancy.

American Journal of Clinical Nutrition. 2000

Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic principles.

Clinical Pharmacokinetics. 2000

Plasma volume expansion for treatment of women with pre-eclampsia.

Cochrane Database of Systematic Reviews [computer file]. 2000

Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems.

Cochrane Database of Systematic Reviews [computer file]. 2000

Antiplatelet agents for preventing and treating pre-eclampsia.

Cochrane Database of Systematic Reviews [computer file]. 2000

Anticonvulsants for women with pre-eclampsia.

Cochrane Database of Systematic Reviews [computer file]. 2000

Abdominal decompression for suspected fetal compromise/pre-eclampsia.

Cochrane Database of Systematic Reviews [computer file]. 2000

Preeclampsia prevention and management.

Journal of the Society for Gynecologic Investigation. 2000

Can murine uterine natural killer cells give insights into the pathogenesis of preeclampsia?.

Journal of the Society for Gynecologic Investigation. 2000

Calcium, nitric oxide, and preeclampsia.

Seminars in Perinatology. 2000

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MediFocus MedCenter ©

Pregnancy in Diabetes

(GY003)

Introduction

Diabetes complicates more than 100,000 pregnancies every year. Women with all types of diabetes (Type I, Type II, and gestational) and their infants are at greater risk for a number of different complications. Women who are diabetic and become pregnant face different risks than a woman who develops diabetes during the later stages of pregnancy (gestational diabetes).

Diabetes is complicated by the hormonal changes that occur during pregnancy. These hormones antagonize and break down insulin; meanwhile the mother's body produces increased amounts of glucose.

High levels of glucose (hyperglycemia) in the mother's body circulate to the fetus via the umbilical cord blood. This occurs throughout the pregnancy, and is especially dangerous during the process of organogenesis (the development of the baby's internal organs). It is at this time that the risk of congenital anomalies is very high.

Pregnancy care for a diabetic woman should begin before she becomes pregnant. It is very important to discuss plans to become pregnant with your health care provider months in advance so that preconception care can be instituted to increase the chances of a healthy, uncomplicated pregnancy.

Achieving and maintaining euglycemia (normal blood glucose levels) is the main goal of management for diabetic pregnancies.

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The Medifocus Guide on Pregnancy in Diabetes provides answers to the following important questions and medical issues:

What is the current standard of care for the treatment of pregnancy in diabetes?

What treatment options are available for the management of pregnancy in diabetes?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in pregnancy in diabetes?

Where are the leading hospitals and centers of research for pregnancy in diabetes?

What are the most important questions to ask my doctor about pregnancy in diabetes?

What Your Doctor Reads:

Peri-implantation embryopathy induced by maternal diabetes.

Journal of Reproduction & Fertility - Supplement. 2000

Kinetics of palmitic acid transport in insulin-dependent diabetic pregnancies: in vitro study.

Pediatrics International. 2000

Effects of diabetic pregnancy on the fetus and newborn.

Seminars in Perinatology. 2000

Elective delivery in diabetic pregnant women.

Cochrane Database of Systematic Reviews [computer file]. 2000

Very tight versus tight control for diabetes in pregnancy.

Cochrane Database of Systematic Reviews [computer file]. 2000

Effect of medical therapy on progressive nephropathy: influence of pregnancy, diabetes and hypertension.

Journal of Maternal-Fetal Medicine. 2000

Selecting antihypertensive therapy in the pregnant woman with diabetes mellitus.

Journal of Maternal-Fetal Medicine. 2000

Risk factors, pregnancy complications, and prevention of hypertensive disorders in women with pregravid diabetes mellitus.

Journal of Maternal-Fetal Medicine. 2000

Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus.

Journal of Maternal-Fetal Medicine. 2000

Present and future perspectives on the use of free or encapsulated pancreatic islet cell transplantation as a treatment of pregnancy complicated by type 1 diabetes.

Journal of Maternal-Fetal Medicine. 2000

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Pregnancy-Induced Hypertension

(GY015)

Introduction

Pregnancy-induced hypertension (PIH) is defined as a rise in blood pressure above 140/90 on two or more occasions, at least 6 hours apart. It occurs in the second half of pregnancy (usually after 20 weeks of gestation) in a woman who previously had normal blood pressure. There are no other associated symptoms.

PIH in and of itself has no deleterious effect on pregnancy, and the blood pressure returns to normal levels by 6 weeks after delivery. However, new onset of hypertension in the late second or early third trimester is regarded potentially as an early sign of preeclampsia.

The important aspect of care in PIH is close monitoring of the blood pressure levels and the development of any other symptoms that may indicate the onset of preeclampsia. Medications to lower blood pressure in PIH are usually not required and are generally avoided due to risks of harm to the developing fetus by many anti-hypertensive preparations.

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The Medifocus Guide on Pregnancy-Induced Hypertension provides answers to the following important questions and medical issues:

What are the most common symptoms of pregnancy-induced hypertension?

Are there any recognized risk factors for developing pregnancy-induced hypertension?

What kinds of medical tests are used to establish the diagnosis of pregnancy-induced hypertension?

What is the current standard of care for the treatment of pregnancy-induced hypertension?

What treatment options are available for the management of pregnancy-induced hypertension?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in pregnancy-induced hypertension?

Where are the leading hospitals and centers of research for pregnancy-induced hypertension?

What are the most important questions to ask my doctor about pregnancy-induced hypertension?

What Your Doctor Reads:

Same nutrient, different hypotheses: disparities in trials of calcium supplementation during pregnancy.

American Journal of Clinical Nutrition. 2000

Dietary calcium and pregnancy-induced hypertension: is there a relation?.

American Journal of Clinical Nutrition. 2000

Drugs for rapid treatment of very high blood pressure during pregnancy.

Cochrane Database of Systematic Reviews [computer file]. 2000

Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems.

Cochrane Database of Systematic Reviews [computer file]. 2000

Management of hypertension in pregnancy.

1999

Hypertension in pregnancy: a potential window into long-term cardiovascular risk in women.

Journal of Clinical Endocrinology & Metabolism. 1999

Triage and management of the pregnant hypertensive patient.

Journal of Nurse-Midwifery. 1999

Calcium supplementation in pregnancy to prevent pregnancy induced hypertension (PIH).

Journal of Perinatal Medicine. 1998

Hypertension in pregnancy and preeclampsia--diagnosis and treatment.

Scandinavian Journal of Rheumatology - Supplement. 1998

Hypertension in women with gestational diabetes.

Diabetes Care. 1998

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Premenstrual Syndrome (PMS)

(GY016)

Introduction

Premenstrual syndrome (PMS) can be defined as emotional, behavioral, and physical symptoms that occur in the premenstrual (luteal) phase of the menstrual cycle, which are relieved by the start of menses. Studies have suggested that as many as 80% of women experience mild to moderate premenstrual symptoms, and approximately 3-8% experience severe symptoms.

PMS can begin at any time during the reproductive years and symptoms resolve with menopause (although symptoms may worsen initially in the perimenopausal interval).

Although there seems to be a strong association with depression, the cause of PMS is not known.

PMS occurs only with cycles in which an egg is released awaiting fertilization (ovulatory cycle).

Therefore, the target of some therapies is the inhibition of ovulation.

Because PMS is not a disease, the goal of therapy is the alleviation of symptoms rather than finding a cure. Treatments need to be individualized for each woman based on her symptoms.

Often, lifestyle measures such as dietary modification and moderate aerobic exercise (at least three times per week) are all that are required to completely control premenstrual symptoms. Medications or nutritional supplements are commonly used. Surgery is considered a last-resort and is rarely performed for PMS alone.

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The Medifocus Guide on Premenstrual Syndrome provides answers to the following important questions and medical issues:

What are the most common symptoms of premenstrual syndrome?

Are there any recognized risk factors for developing premenstrual syndrome?

What is the current standard of care for the treatment of premenstrual syndrome?

What treatment options are available for the management of premenstrual syndrome?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in premenstrual syndrome?

Where are the leading hospitals and centers of research for premenstrual syndrome?

What are the most important questions to ask my doctor about premenstrual syndrome?

What Your Doctor Reads:

Premenstrual syndrome is real and treatable.

Practitioner. 2000

Desideratum dermatologicum--cause and control of premenstrual acne flare.

International Journal of Dermatology. 2000

Is it premenstrual syndrome? Keys to focused diagnosis, therapies for multiple symptoms.

Postgraduate Medicine. 2000

Evaluating and managing premenstrual syndrome.

Medscape Womens Health. 2000

Micronutrients and the premenstrual syndrome: the case for calcium.

Journal of the American College of Nutrition. 2000

The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms.

Journal of the American College of Nutrition. 2000

Calcium treatment for premenstrual syndrome.

Annals of Pharmacotherapy. 1999

Premenstrual syndrome: diagnosis and intervention.

Nurse Practitioner. 1998

Premenstrual syndrome.

Psychiatric Clinics of North America. 1998

Treatment strategies for premenstrual syndrome.

American Family Physician. 1998

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Uterine Fibroids

(GY017)

Introduction

Uterine leiomyomas, also known as myomas or fibroids, are benign growths within the uterus. It is thought that fibroids exist in 50-75% of women, however, fewer than half of these cause symptoms.

Fibroids are the most common tumors in the female pelvis and are responsible for one third to one half of the 600,000 hysterectomies performed in the U.S. each year.

Fibroids rarely become cancerous. In fact, it is thought to occur in no more than .1% of all fibroids. Uterine leiomyomas are not to be confused with leiomyosarcomas, which are malignant uterine tumors that usually affect post-menopausal women. The two conditions are totally unrelated.

The goals of care are the minimization of complications such as anemia, pain, and infertility while maintaining fertility in women who so desire.

Because most women have no symptoms, the majority are appropriately managed with observation alone. The subsequent worsening of symptoms or the development of other complications would warrant further consideration.

Treatment options include medications, radiologic procedures such as Uterine Artery Embolization and surgery.

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The Medifocus Guide on Uterine Fibroids provides answers to the following important questions and medical issues:

What are the most common symptoms of uterine fibroids?

Are there any recognized risk factors for developing uterine fibroids?

What kinds of medical tests are used to establish the diagnosis of uterine fibroids?

What is the current standard of care for the treatment of uterine fibroids?

What treatment options are available for the management of uterine fibroids?

Are there any promising new developments or potential breakthroughs in treatment?

Who are the most notable medical authorities who specialize in uterine fibroids?

Where are the leading hospitals and centers of research for uterine fibroids?

What are the most important questions to ask my doctor about uterine fibroids?

What Your Doctor Reads:

Uterine fibroid embolization.

American Family Physician. 2000

Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids.

Cochrane Database of Systematic Reviews [computer file]. 2000

An agenda for research into uterine artery embolization: results of an expert panel conference.

Journal of Vascular & Interventional Radiology. 2000

Uterine artery embolisation for symptomatic fibroids.

Medical Journal of Australia. 2000

Smooth muscle, endometrial stromal, and mixed Mullerian tumors of the uterus.

Modern Pathology. 2000

Lumbosacral radiculopathy secondary to metastatic uterine leiomyosarcoma: a case report.

Spine. 2000

Role of vaginal sonography and hysterosonography in the endoscopic treatment of uterine myomas.

Fertility & Sterility. 2000

Leiomyoma of the ciliary body extending to the anterior chamber: clinicopathologic and ultrasound biomicroscopic correlation.

Survey of Ophthalmology. 2000

The pathology of uterine smooth muscle tumors and mixed endometrial stromal-smooth muscle tumors: a selective review with emphasis on recent advances.

International Journal of Gynecological Pathology. 2000

Ambulatory management of uterine leiomyomata.

Clinical Obstetrics & Gynecology. 1999

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Vaginal Birth After Cesarean Section (VBAC)

(GY018)

Introduction

For decades, it was thought that women who had a previous cesarean delivery (CD) had to deliver subsequent babies by CD because of the risk of complications such as rupture of the old abdominal and uterine incision sites during contractions and the birthing process.

The old medical adage, "Once a cesarean, always a cesarean" is no longer accepted as a general standard. VBAC is now considered a safe, and even preferable, alternative for most women, including women who have undergone more than one CD in the past. In fact, it is thought that 80-90% of women are candidates for VBAC which are successful in 60-80% of cases.

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The Medifocus Guide on Vaginal Birth after Cesarean Section (VBAC) provides answers to the following important questions and medical issues:

What are the recognized risks for VBAC?

What is the current standard of care for the treatment of VBAC?

Are there any promising new developments or potential breakthroughs in the procedure?

Who are the most notable medical authorities who specialize in VBAC?

Where are the leading hospitals and centers of research for VBAC?

What are the most important questions to ask my doctor about VBAC?

What Your Doctor Reads:

Vaginal birth after cesarean delivery.

Obstetrics & Gynecology Clinics of North America. 1999

ACOG practice bulletin. Vaginal birth after previous cesarean delivery. Number 2, October 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists.

International Journal of Gynaecology & Obstetrics. 1999

Vaginal birth after cesarean section: selection and management.

Clinical Obstetrics & Gynecology. 1999

Vaginal birth after cesarean.

Clinical Obstetrics & Gynecology. 1998

Avoiding labor problems during vaginal birth after cesarean delivery.

Clinical Obstetrics & Gynecology. 1997

Vaginal birth after cesarean section: current opinion.

International Journal of Gynaecology & Obstetrics. 1996

Vaginal birth after cesarean delivery.

Clinics in Perinatology. 1996

Rupture of a cesarean-scarred uterus: a community hospital experience.

Journal of the National Medical Association. 2000

Labor after previous cesarean: influence of prior indication and parity.

Obstetrics & Gynecology. 2000

U.S. cesarean and VBAC rates stalled in the mid-1990s.

Birth. 2000

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