Antepartum and postpartum Papanicolaou smears. Are they both necessary?

OBJECTIVE: To determine if a Papanicolaou smear performed during pregnancy needs to be repeated at the postpartum visit. STUDY DESIGN: A retrospective chart review was performed on women who received prenatal care from our obstetric clinic and returned for a postpartum visit. All pregnant women who had both a Papanicolaou smear in pregnancy and another at the postpartum visit, about six weeks after delivery, were included. Six hundred one patients were studied who had complete records between 1995 and 1996. RESULTS: The average length of time between the two smears was 209 days. With the exception of a lower frequency of the presence of endocervical cells in the antepartum Papanicolaou smears, there were no differences between the distribution of Papanicolaou smear results. In patients without risk factors and a normal antepartum Papanicolaou smear, the prevalence of squamous intraepithelial lesion on the postpartum smear was very low (4 in 1,000). CONCLUSION: In patients without risk factors for cervical intraepithelial neoplasia and a normal Papanicolaou smear in pregnancy, a Papanicolaou smear should be repeated at the recommended yearly interval.     

Is colposcopy always necessary with atypical glandular cells of undetermined significance on Papanicolaou smears?

The objective of this study was to review a 5-year experience with atypical glandular cells of undetermined significance (AGUS) on Papanicolaou smear and to use the information to devise a triage method for patients presenting with this abnormality. Our Papanicolaou smear database was used to identify patients who were found to have AGUS results between January 1, 1994 and December 31, 1998. The medical records of these patients were reviewed for the results of follow-up studies, including repeat Papanicolaou smear, endocervical curettage, colposcopic directed biopsies, and endometrial biopsy. During the study period, 27,859 Papanicolaou smears were performed, with 306 (1.1%) being reported as AGUS; 18 patients had two AGUS smears. An additional 24 patients did not meet study criteria. The study group then consisted of 264 patients, of whom 244 (92.4%) reported for follow-up. There were 167 (63.3%) with atypical endocervical cells of undetermined significance (AECUS), 14 (5.3%) with atypical endometrial cells of undetermined significance, and 83 (31.4%) with AECUS plus a squamous cell abnormality. The overall prevalence of a high-grade squamous intraepithelial lesion (HSIL) was 11.8%. The prevalence of HSIL in the AECUS plus squamous cell abnormality group was 25.4%. None of the atypical endometrial cell group had HSIL. In the AECUS, favor dysplasia category, 29.4% had HSIL, whereas in the AECUS, favor reactive process or in unqualified, 2.3% had HSIL. Eighty-one patients underwent endometrial biopsy: three (3.7%) were found to have endometrial adenocarcinoma, and two (2.5%) had complex atypical endometrial hyperplasia. The prevalence of HSIL in patients with AECUS, favor reactive process or AECUS, unqualified Papanicolaou smears is low. Colposcopy is not necessary as an initial triage process for this category of patients. A significant percentage of patients with AECUS, favor dysplasia or AECUS with a squamous epithelial abnormality Papanicolaou smears have HSIL; this subset of patients should be investigated with colposcopy.     

Is direct large loop electric excision for the transformation zone reasonable in the investigation of high-grade squamous intraepithelial lesions in cervical smears?

PURPOSE OF INVESTIGATION: To evaluate women with cytological high-grade squamous intraepithelial lesions (HGSIL) who received standard colposcopic evaluation and direct diagnostic large loop electric excision for the transformation zone (LLETZ) to determine the feasibility of using LLETZ alone (ie, skipping the colposcopic examination). METHODS: From May 1999 to May 2001, 70 women, with the mean age of 49.58 years (range, 20-82 years) and with cervical HGSIL categorized by the Bethesda system were all evaluated by colposcopic evaluation and LLETZ. Cases with a satisfactory colposcopy examination were classified as group A and those with an unsatisfactory colposcopy examination were classified as group B. "Over-treatment" was determined if the women did not need further LLETZ for evaluation or management. "Under-treatment" was determined if treatment might be potentially inadequate or invasive cancer could be ruled out during a satisfactory colposcopic evaluation. RESULTS: Group A consisted of ten women who were evaluated satisfactorily by colposcopy and group B consisted of 30 women who were not evaluated satisfactorily by colposcopy. Overall 8.6% of the patients (6/70) were considered "over-treated". The rate of over-treatment was 10.0% (4/40) in group A compared with 6.7% (2/30) in group B. In contrast, overall 10% of the patients (7/70) were considered "under-treated". The rate of under-treatment was 10% (1/40) in group A compared with 10% (3/30), in group B. The positive predictive values of group A and B were 90.6% and 88.0%, respectively. The negative predictive values were 33.2% and 40%, respectively. CONCLUSION: Direct diagnostic and therapeutic LLETZ for the management of cervical HGSIL may be a better alternative to colposcopy. This method of treatment avoids the possibility of under-treatment and is associated with an acceptable over-treatment rate, especially for postmenopausal women with cytological HGSIL. LLETZ has a good diagnostic accuracy with minimal morbidity and, most importantly, may help reduce patient anxicty, although further studies are needed to directly examine this effect.     

Urinary urgency and frequency: what should a clinician do?

Obstetrician-gynecologists often care for women with urinary symptoms of urgency and frequency. These symptoms are bothersome and treatable. Although it is rare that serious disease is causative, the clinician must be alert to ominous signs and physical findings. Most patients experience relief of their symptoms after a simple initial evaluation with appropriately directed treatment. A step-wise evaluation includes the directed history and physical, assessment of urinary habits, typically with a urinary diary, and occasionally an assessment of voiding efficiency, typically with a postvoid residual. Treatments may include myofascial therapy when trigger points are present on physical examination. Behavioral therapy and pharmaceuticals also play an important role. Persistent symptoms, hematuria, severe de novo postoperative symptoms, and ominous physical findings may warrant specialty consultation.     

Mending a growth-restricted fetal heart: should we use glucocorticoids?

Clinical and experimental studies suggest that the growth-restricted fetus at increased risk of impaired cardiovascular function that likely contributes to both increased mortality rate and in survivors, to cardiovascular dysfunction apparent in childhood and later life. Fetal growth restriction is also associated with a high risk of preterm birth. Accordingly, the growth-restricted fetus is more likely than average to receive antenatal glucocorticoids to accelerate lung maturation in preparation for birth. However, glucocorticoids are powerful regulators of vascular tone and antenatal glucocorticoid administration to the intrauterine growth restriction (IUGR) fetus results in systemic cardiovascular changes that are not observed in the healthy normal grown fetus. These responses to glucocorticoids may disturb the IUGR fetus’ ability to appropriately compensate to placental insufficiency. Indeed is it possible that in the setting of severe IUGR exogenous glucocorticoids are detrimental rather than beneficial to the fetus?     

Is fibroid heterogeneity a significant issue for clinicians and researchers?

The clinical and scientific literature overwhelmingly deals with fibroids as a single entity or disease. This convenient assumption of homogeneity may be an important oversight given that substantial evidence exists for heterogeneity between fibroids at many levels. Failure to recognize and accommodate fibroid heterogeneity can have significant ramifications for both clinical treatment decisions and research protocol design. The aim of this article is to review the current knowledge of fibroid heterogeneity and to identify key areas where fibroid heterogeneity should be taken into consideration both clinically and when designing research protocols. Uterine leiomyomata display significant and well-documented heterogeneity in symptoms, diagnostic imaging appearance, pathology, genetic background and therapeutic requirements. Additional research is needed to better understand fibroid heterogeneity as it relates to pathogenesis, molecular targets for potential new therapies, patient symptoms and, ultimately, treatment. To this list should also be added heterogeneity of genetics, lifestyle and individual clinical characteristics of the fibroid. Increasingly, an understanding of uterine leiomyoma heterogeneity will be of importance for clinicians who see patients with this common and costly disease.The clinical and scientific literature overwhelmingly deals with fibroids as a single entity or disease. This convenient assumption of homogeneity may be an important oversight given that substantial evidence exists for heterogeneity between fibroids at many levels. Failure to recognize and accommodate fibroid heterogeneity can have significant ramifications for both clinical treatment decisions and research protocol design. The aim of this article is to review current knowledge of fibroid heterogeneity and to identify key areas where fibroid heterogeneity should be taken into consideration both clinically and when designing research protocols. Uterine leiomyomata display significant and well-documented heterogeneity in symptoms, diagnostic imaging appearance, pathology, genetic background and therapeutic requirements. Additional research is needed to better understand fibroid heterogeneity as it relates to pathogenesis, molecular targets for potential new therapies, patient symptoms and, ultimately, treatment. To this list should also be added heterogeneity of genetics, lifestyle, and individual clinical characteristics of the fibroid. Increasingly, an understanding of uterine leiomyoma heterogeneity will be of importance for clinicians who see patients with this common and costly disease.     

Cervicitis in adolescents: do clinicians understand diagnosis and treatment?

Background

Cervicitis is widespread, but no studies have examined cervicitis in accordance with established guidelines for diagnosis and treatment. Study objectives were to describe adherence to Centers for Disease Control and Prevention guidelines for diagnosis and treatment of cervicitis within an adolescent population and to compare factors associated with adherence to guidelines in a primary care setting and the Emergency Department.

Methods

Data were collected as part of a retrospective chart review of evaluation, diagnosis, and treatment of STI in adolescent women in an outpatient setting. Participant charts were eligible for review if they were 12–21 years of age and were given an ICD-9 and chart diagnosis of cervicitis. Two primary outcome variables: meeting cervicitis guidelines and correct treatment among those meeting cervicitis guidelines (no/yes) were utilized; the study controlled for age, race, venue, past infection with chlamydia or gonorrhea.

Results

Subjects (n = 365) were examined for the primary outcome variables and 75.1% (274/365) met at least one criterion for cervicitis. Of these, 166 (60.9%: 166/274) subjects were found to meet criteria for cervicitis alone, versus subjects meeting criteria for both cervicitis and pelvic inflammatory disease (PID) (39.4%: 108/274). The majority, 89.3%, (326/365) were treated for both chlamydia and gonorrhea, but only 64.7% (211/326) were treated correctly for both infections.

Conclusions

Our findings suggest that knowledge deficits exist in diagnosis and treatment of cervicitis in adolescent patients and in differentiating between cervicitis and PID. Educational tools, simulated patient exercises, and order sets may be warranted for quality improvement to allow for improved care of this at risk sexually active population.     

Prolonged pregnancy: when should we intervene?

The timely onset of labor and birth is an important determinant of perinatal outcome. Prolonged (postterm) pregnancy--defined as delivery at or beyond 42 weeks' gestation--complicates 10% of all gestations and is associated with increased risks to both fetus (stillbirth, macrosomia, birth injury, meconium aspiration syndrome) and mother (cesarean delivery, severe perineal injury, postpartum hemorrhage). The risk of routine induction of labor (failed induction leading to cesarean delivery) in the era of cervical ripening is lower than previously reported. For these reasons, the authors favor a policy of routine induction of labor for low-risk pregnancies at 41 weeks' gestation.     

Postnatal unhappiness: who should direct support?

Depression following childbirth is a common, distressing but frequently underreported disorder. It involves a spectrum of symptoms, some of which may be self-limiting, while others can have major mental health implications in the post partum period. A range of health professionals, including midwives and mental health nurses, come into contact with women who suffer from postnatal depression; however, there is often little attempt made to integrate maternity and mental health care approaches. More collaborative frameworks of care are vital if health professionals are to adequately meet the needs of 'unhappy' women in the postnatal period.     

When should a gynecologist refer a patient for specialty care in osteoporosis?

The field of obsteterics and gynecology occupies a unique position among those who care for patients with osteoporosis. As a generalist or primary care giver, the gynecologist is often the first physician to detect low bone mass or osteoporosis in an aging woman. As a specialist, the gynecologist may also have inner knowledge about this disease and is equipped to handle both the straightforward and the most challenging individuals with osteoporosis. Therefore, in some instances, the gynecologist will rarely refer patients to a specialist; other times, a gynecologist will consider referral to a specialist to be routine and often indicated. In this article, I suggest six reasons why someone in obstetrics and gynecology might refer a patient to a specialist in osteoporosis. These points include the discovery of low bone mass in a premenopausal woman; possible etiologies besides aging and the menopause, the occurrence of a fragility fracture in a woman whose T-score is not in the osteoporotic range; lack of access to instruments that measure central (spine and hip) bone density; challenging therapeutic settings; and the patient who is not improving on FDA-approved therapy.     

Integrative medicine outcomes: What should we measure?

The outcomes of Integrative medicine (IM) that combine biomedicine with traditional, complementary and alternative medicine (TCAM) are broad, reflecting the integration. IM is concerned with acute and chronic diseases, holistic approaches, and health promotion and wellness. Before commencing a research program in a primary care IM clinic, stakeholders were interviewed about IM outcomes.Everyone thought Physical Health and Mental Health were important. Those with a more holistic view of health thought a broader range of topics should be measured. Less important topics were lifestyle; health-related aspects of life satisfaction and quality of life; and healthcare evaluation. However, no one thought these should be excluded. Spirituality was the most contentious. Some commended its inclusion. For others, once religiousness and God were removed, the remaining elements should be relocated to the domains of mental health and life satisfaction.The results highlight the importance of consulting stakeholders before measuring outcomes.