Breast cancer screening in women at average risk and high risk

Recent controversies over the recommendations for breast cancer screening have created some uncertainty about the best methods of providing this care for women, particularly women at average risk for breast cancer. This article reviews the current recommendations for breast cancer screening from various national organizations and the scientific data behind these recommendations, and it highlights some of the controversies and the reasons behind the differing viewpoints. This article focuses on providing the obstetrician-gynecologist with evidence-based recommendations for counseling and screening women who are at average and high risk for breast cancer. The ability to identify women at higher risk for breast cancer and the appropriate clinical use of mammography, ultrasonography, MRI, clinical breast examination, and self-breast examination ("breast self-awareness") for breast cancer screening in these different populations are discussed. Finally, incorporating specific recommendations for breast cancer screening in women at average and high risk into practice are included.     

Adverse and beneficial effects of tocolytic therapy

In addition to questions raised about the efficacy of many tocolytics, appropriate concern has been voiced about the safety of these potent drugs. Although some degree of risk for adverse effects with drugs promising a strong therapeutic effect can be accepted, caution needs to be exercised when benefits are marginal or unproven. Unfortunately, some of the tocolytics, most notably the betamimetics and magnesium sulfate, have been found to have considerable potential for adverse maternal cardiovascular and respiratory effects. Although less clearly established, the use of indomethacin appears to be associated with increased fetal and neonatal risks. Concerning magnesium sulfate, in addition to the well-known maternal effects, the accumulating evidence showing an increased frequency of adverse outcomes in the fetus and neonate has led to the recommendations to abandon its use entirely as a tocolytic. Given the limitations of our current state of knowledge, nifedipine would appear to be among the more efficacious and safer tocolytics available to use when properly indicated.     

Unintended pregnancy and contraception among active-duty servicewomen and veterans

The number of women of childbearing age who are active-duty service members or veterans of the US military is increasing. These women may seek reproductive health care at medical facilities operated by the military, in the civilian sector, or through the Department of Veterans Affairs. This article reviews the current data on unintended pregnancy and prevalence of and barriers to contraceptive use among active-duty and veteran women. Active-duty servicewomen have high rates of unintended pregnancy and low contraceptive use, which may be due to official prohibition of sexual activity in the military, logistic difficulties faced by deployed women, and limited patient and provider knowledge of available contraceptives. In comparison, little is known about rates of unintended pregnancy and contraceptive use among women veterans. Based on this review, research recommendations to address these issues are provided.     

Ethical issues associated with routine screening and prophylaxis for group B streptococcus in pregnancy

An increased awareness of the impact of group B streptococcus (GBS) infection on neonataloutcome has prompted several seemingly discordant committee recommendations. Intrapartumantibiotics are effective in reducing the risk of neonatal morbidity when administered to a colonizedwoman who has a clinical condition that places her neonate at high risk for early-onset sepsis.However, less is known about the efficacy of prophylactic antibiotics in the colonized woman whodoes not have obvious risk factors. Some authorities have suggested that providers refrain fromadministering intrapartum antibiotics to colonized women who do not have any of these risk factors,primarily due to concerns about potential adverse reactions, selection of resistant pathogens, andcost-effectiveness. These recommendations may conflict with the desires of an informed womanwho weighs the real, albeit low, risk for serious neonatal disease against the lower perceived riskof adverse maternal sequelae from allergic reactions to the antimicrobial agents. Selective prophylaxisfor GBS disease that is limited to the colonized parturient with risk factors has the potentialfor creating conflict because maternal beneficence-based obligations of the physician may be atodds with maternal autonomy-based obligations. We believe that, given all currently availableinformation, providers have a moral obligation to discuss GBS screening and treatment issues withpatients. The potential for conflict between patient and physician at the time of delivery can beminimized through the use of preventive ethics, allowing patients to develop advance directivesregarding intrapartum management within the confines of reasonable and cost-effective care. Untila consensus is reached among experts, the most prudent approach would be to address such issuesproactively and individualize care based upon the overall estimation and anticipation of risk as wellas the patient's specific desires.     

Adolescent emergency contraception: attitudes and practices of certified nurse-midwives

Teenage pregnancy has reached epidemic proportions in the United States with I million pregnancies and more than 500,000 live births occurring each year among women under the age of 20. The safety and efficacy of postcoital administration of oral contraceptives, commonly called "emergency contraception" (EC), have been well documented. However, EC is dramatically underused in the United States. Because low use of EC may be attributable, in part, to both lack of knowledge, as well as misinformation on the part of health care providers, further research in this area is warranted. Because midwives play a significant role in the provision of reproductive health care to adolescents, their attitudes about the use of EC among teens may impact the availability of emergency contraception options to these clients. This article presents results of a survey of certified nurse-midwives with respect to their attitudes, practices, and policies related to EC and provides recommendations specific to this provider population.     

Survey of Folk Beliefs About Induction of Labor

Background: Many folk beliefs concerning the induction of labor are circulated among women in their final months of pregnancy. This study sought to identify the prevalence of some of these beliefs and whether or not they were more commonly shared in certain subsets of the community. Method: A survey was conducted of women receiving prenatal care at a group of Midwestern urban prenatal clinics. Women were asked about exposure to certain recommendations about inducing labor and to what extent each recommendation was believed. Results: One hundred and two women responded to the survey. Walking and having sex were the activities most commonly believed to hasten labor. These beliefs were equally prevalent across ages, parities, and levels of education. Conclusions: Folk beliefs about the induction of labor are varied and pervasive in an urban community. A review of scientific evidence relating to these beliefs can alert perinatal caregivers to potential benefit and harm that could ensue if certain recommendations are followed.     

Surveillance of the endometrium in tamoxifen treated women

There is much debate about the risks and benefits of tamoxifen, most specifically about the incidence of associated endometrial cancer. Nearly all of the published trials on the subject have been criticized for methodological flaws and various forms of bias, making resolution of this controversy difficult. There is a consensus, however, that tamoxifen results in an increased incidence of both premalignant and malignant lesions of the endometrium. As the indications for tamoxifen continue to broaden, a larger number of women will be subjected to the potential adverse effects of tamoxifen. Many techniques for screening patients on tamoxifen for the development of endometrial abnormalities have been suggested. None of these methods appears to be consistently clinically or cost effective. We have reviewed the literature on endometrial surveillance in tamoxifen treated women with a focus on the larger publications reported within the past year. From this, we have provided what we hope to be safe and cost-effective recommendations for the management of these patients.     

Pregnant Women’s Knowledge of Influenza and the Use and Safety of the Influenza Vaccine During Pregnancy

IntroductionWe wished to assess pregnant women’s knowledge of influenza, vaccine safety during pregnancy and breast feeding, and the recommendations for use of the influenza vaccine in pregnancy.MethodsWe performed a cross-sectional survey of postpartum women during influenza season in 2006.ResultsPregnant women’s overall knowledge of these subjects was poor. Most women (95%) knew that influenza is highly contagious, but almost 90% incorrectly believed that pregnant women have the same risk of complications as non-pregnant women. Only one half of the women were aware of national recommendations for vaccination during pregnancy and that the vaccine is safe during pregnancy and breast feeding, and 80% incorrectly believed that the vaccine can cause birth defects. Only 20% of women had been offered the vaccine during the current pregnancy or a prior pregnancy.ConclusionsPregnant women’s knowledge about influenza vaccine recommendations and safety during pregnancy is poor. There is substantial room for improvement among prenatal care providers in both patient education and offering the vaccine.     

Treatment options for human immunodeficiency virus-infected pregnant women. Obstetric-Gynecologic Working Group of the AIDS Clinical Trials Group of the National Institute of Allergy and Infectious Diseases.

The increasing seroprevalence of human immunodeficiency virus (HIV) among women of reproductive age and the risks of vertical transmission of HIV have led to recommendations for routine prenatal HIV counseling and testing. The incentive to undergo such testing is related not only to fetal concerns, but also to the potential benefit of early and comprehensive therapy for women. Treatments that should be considered for use during pregnancy include the antiretroviral agent zidovudine and prophylactic agents to prevent Pneumocystis carinii pneumonia, the most common opportunistic infection seen in patients progressing to AIDS. Assessment of the risks and benefits of these treatments during pregnancy is complex and requires discussions between physician and patient. This paper reviews current information and provides recommendations for incorporating therapies into obstetric practice.     

Hormonal Contraceptive Options for Women With Headache: A Review of the Evidence

Migraine affects as many as 37% of reproductive-age women in the United States. Hormonal contraception is the most frequently used form of birth control during the reproductive years, and given the significant proportion of reproductive-age women affected by migraine, there are several clinical considerations that arise when considering hormonal contraceptives in this population. In this review, key differences among headache, migraine, and migraine with aura, as well as strict diagnostic criteria, are described. The recommendations of the World Health Organization and the American College of Obstetricians and Gynecologists regarding hormonal contraception initiation and continuation in women with these diagnoses are emphasized. Finally, information about the effect of hormonal fluctuations on headache is provided with recommendations regarding contraception counseling in patients who experience headache while taking hormonal contraception.Key Words: Migraine without aura, Migraine with aura, Hormonal contraceptives, Stroke, Estrogen, ProgesteroneForty-three percent of women in the United States are affected by migraine.¹ The prevalence of migraine increases with age: 22% of women age 20 to 24 years, 28% age 25 to 29 years, 33% age 30 to 34 years, and as many as 37% of women age 35 to 39 years are affected.¹ During these reproductive years, hormonal contraception is the most prevalent form of birth control used, with 43% of contracepting US women using hormone-containing pills, patches, ring, shots, implants, or intrauterine devices.² Given the significant proportion of reproductive-age women affected by migraine, there are several clinical considerations that arise when considering hormonal contraceptives in this population. Key considerations include physician selection of appropriate candidates for initiation of hormone-containing contraceptives, and decision making about method continuation in patients complaining of headache while taking hormonal contraceptives.It is critical for physicians prescribing hormonal contraception to distinguish among common headache, migraine, and migraine with aura, to decide when the use of estrogen-containing contraception is appropriate. In addition, headache is a frequently reported side effect of hormonal contraception and a leading reason cited for contraceptive discontinuation.³ Contraceptive discontinuation is thought to account for 20% of the 3.5 million unplanned pregnancies in the United States annually.⁴ Separate from the risk of unintended pregnancy, women who discontinue hormonal contraceptives due to headaches are unable to reap the noncontraceptive benefits of these medications, including relief of chronic pelvic pain, and endometrial protection in polycystic ovary syndrome and other anovulatory states.This review outlines key differences among headache, migraine, and migraine with aura, and describes the strict diagnostic criteria. Society recommendations for hormonal contraception initiation and continuation in women with these diagnoses are emphasized. Finally, we provide information about the effect of hormonal fluctuations on headache, and recommendations regarding contraception counseling in patients who experience headache while taking hormonal contraception.     

Analysis and implications of the omission of offenders in the DoD Care for Victims of Sexual Assault Task Force report

This note addresses the weaknesses in the Department of Defense (DoD) Care for Victims of Sexual Assault Task Force (CVSATF) Report, released in May 2004. Sound policy and protocol cannot be developed to prevent and to respond to sexual assault in the military if the role of sex offenders is not understood, yet the report excludes information relevant to understanding sex offender behavior and to responsibility. Shortcomings in the CVSATF recommendations to improve military definitions of sexually violent behavior and data collection are summarized, as are limitations in the recommendations for sexual assault prevention strategies. This analysis highlights problems with the DoD CVSATF recommendations to improve offender accountability and secure safety for communities and discusses how the military social climate is prohibitive to facilitating these goals. This note suggests that policy and procedures guided by recommendations that omit information about sex offenders may actually leave communities at continued risk of sexual assault.     

Enhancing Latinas' participation in research on sexual assault: cultural considerations in the design and implementation of research in the Latino community

To provide a more complete picture of the prevalence, impact, and treatment of sexual assault among Latinas, researchers must begin to develop and employ culturally competent recruitment and data-collection procedures that can facilitate participation and disclosure. In this article, we sought to synthesize recommendations from research with Latino populations, community-based and participatory action research, and research on sexual assault to provide a list of suggestions for conducting culturally competent research about sexual assault with Latino populations. Innovative examples from our own focus group study with Latinas are provided throughout.     

Management of breast cancer treatment -- a multidisciplinary approach

The management of breast cancer care poses very high expectations on implementing the treatment recommendations and guidelines for diagnostic procedures into routine treatment. Most recently a majority of these tasks has been transferred to the responsibilities of the breast centers being established all over Germany these days. Guidelines on treatment and diagnostic procedures and minimal invasive techniques have therefore been discussed among 1 300 colleagues and experts at the Duesseldorfer Symposium in June 2004.     

The essentials of a fetal therapy center

Consensus about complex clinical decisions among specialists with diverse backgrounds will always be a challenge. A specialized center, which focuses on the fetus with an anomaly, provides the most accurate diagnosis and maternal-fetal management recommendations to referring physicians. The essential components of a fetal therapy center facilitate a systematic approach for the mother carrying a fetus with an anatomic malformation.     

Defining the role of in vitro fertilization and embryo transfer in humans

Based on socialist moral and law recommendations about clinical use of in vitro fertilization and application of human oocytes and early embryonal stages in the German Democratic Republic have been formulated as a result of interdisciplinary discussion.     

Which contraceptive methods are recommended for young women with type 1 diabetes mellitus? A survey among gynaecologists in Greece.

BACKGROUND: Type 1 diabetes mellitus is common in Europeans. Optimal glucometabolic control at conception and during early pregnancy is necessary to reduce the risk of early miscarriage and congenital malformations. Safe and effective contraceptive methods are essential for these women in order to have a "planned pregnancy" under optimal conditions. AIM: To find out which recommendations Greek gynaecologists give to young patients with type 1 diabetes mellitus with respect to contraception. To regard the experience of Greek gynaecologists in counselling with women. To compare the Greek gynaecologists with German gynaecologists in a previously published similar survey. SUBJECTS AND METHODS: A structured questionnaire containing questions about attitude, health care and contraception in young women with type 1 diabetes was given to 400 Greek gynaecologists working in Athens. RESULTS: Only 70 (17.5%) of the Greek gynaecologists returned the questionnaire. Condoms were the preferred recommendation as contraceptive method for young women with diabetes mellitus type 1 in 64%. About 57% of the gynaecologists recommended this type of contraception as first line contraceptives for young women with diabetes type 1 who smoke. The two most important criteria for selection of a contraceptive method for Greek gynaecologists were the safety and the diabetes specific problems. The Greek gynaecologists had only limited experience in regard to counselling and treating young and adolescent women with type 1 diabetes. CONCLUSION: There was no consensus with respect to contraception among Greek gynaecologists. This is similar to our previous findings in a survey involving German gynaecologists. Practical experience in counselling and treating adolescent and young women with type 1 diabetes was limited among the gynaecologists who participated in this study. Working out proper recommendations for contraception crucial for optimal medical care for type 1 diabetic women in Europe.     

The practice of caesarean birth in the UK.

A survey of 231 clinical directors in obstetrics and gynaecology in the British isles in 2005 asking about attitudes and practice relating to Caesarean Section (CS) had a 68.3% response rate. This paper reports on consultants' practice. Since our previous survey done in 1990 relating to births in 1989 the use of epidural anaesthesia had increased and the vast majority of caesarean sections were done under epidural or spinal aneasthesia and the majority of consultants allowed the partner to be present at the birth compared with 55% in 1989. Practice varied considerably between consultants in regard to the risks of surgery routinely mentioned, the proportion who would allow a trial of scar after two previous CS and those who would perform a CS at 24 weeks for fetal distress. A third accepted the NICE guidleines about CS fully and only 5% did not accept these with 61% accepting partially despite the lack of evidence for some of their recommendations. The proportion of women monitored routinely in labour had dropped from 45% to 11% although half still had an admission strip performed despite the 2001 guidelines. Few had read, the FIGO Ethics committee recommendations about non-medically indicated CS and it is suggested that the RCOG should bring such information to the attention of members through O&G news. A leaflet explaining the possible risks of CS and the long term implications should be produced by the RCOG alone or in conjunction with the Dept of Health so that women are better informed about these.     

宫颈神经内分泌癌诊治困惑与对策

神经内分泌肿瘤占宫颈癌的1%~3%。虽然罕见,但是一种较其他宫颈癌侵袭性更强的病理类型。至今,没有针对该疾病的前瞻性的研究来指导该疾病的诊断和治疗。美国妇科肿瘤学会(SGO)和国际妇科肿瘤协会(GCIG)基于现有的回顾性文献和专家经验发表了该疾病的诊治指南。目前的研究主要集中在进一步明确最佳治疗方案,明确肿瘤的分子机制以寻求新的治疗方法。文章目的在于复习文献,总结目前推荐的诊疗方法,建议可行的研究方向。     

Safe Sound Exposure in the Fetus and Preterm Infant

Exposure to sound can have beneficial and harmful effects on the developing fetus and preterm infant. Although recommendations for safe exposure to sound have existed for more than three decades, reports indicate that these recommendations are not being followed. Recommendations are made to promote attention to the problem of unsafe exposure to sound in early development, and a multidisciplinary team, including representatives from disciplines beyond medicine and nursing, must readdress safe exposure.