Preoperative evaluation of the gynecologic patient: considerations for improved outcomes

The preoperative evaluation serves several purposes for the gynecologist. Patients with previously undiagnosed, or incompletely managed, medical concerns are identified and appropriate treatment initiated. In women with known medical concerns, the surgeon can anticipate problems and plan for appropriate postoperative care. In certain cases, the preoperative evaluation identifies medical conditions that are unstable enough to adversely affect the postoperative outcome, and appropriate referral for medical management can be made. One of the most important aspects of the evaluation is the identification of women at high risk for cardiovascular complications. A stepwise approach is useful to identify those women who may proceed to surgery and those who need further testing. Much of the preoperative evaluation of the woman with pulmonary disease can be done during the history and physical examination without additional testing. Deep venous thrombosis is a significant concern in gynecologic surgery; appropriate identification of the woman at risk is important, with initiation of prophylaxis occurring shortly after the surgery concludes. Many women undergoing gynecologic surgery have diabetes. Careful management of diabetes in the perioperative period has become more germane, with evidence of improved outcomes as tight control is achieved. Much of the preoperative evaluation falls easily into the purview of the gynecologist, with advice presented as to when medical consultation should be considered.     

Collagen 1Alpha1 and transforming growth factor-beta polymorphisms in women with cervical insufficiency

OBJECTIVE: To estimate whether polymorphisms in the collagen 1Alpha1 gene (COL1Alpha1) and the transforming growth factor-beta gene (TGF-beta;1) are more common in women with cervical insufficiency than in those without the condition. METHODS: Medical, obstetric, and family histories and blood were obtained from women with (n=121) and those without (n=165) cervical insufficiency. DNA was extracted and purified by using commercial DNA isolation kits. Samples were analyzed for variants in two genes, the COL1A1 intron 1SP1 and TGF-beta Arg-25-Pro polymorphism, by using an allele-specific polymerase chain reaction assay. RESULTS: Thirty-four of 125 (27.2%) women with cervical insufficiency had at least one first-degree female relative affected. The frequency of the homozygous TT genotype in the COL1A1 gene was increased in women with a history of cervical insufficiency compared with controls (10.8% compared with 3.1%, P=.04). The TGF-beta polymorphisms (ArgPro and ProPro) also were increased in cases (38.3% compared with 14.6%, P<.001). CONCLUSION: Over one fourth of women with cervical insufficiency have a family history of cervical insufficiency, and the COL1A1 intron 1SP1 and TGF-beta Arg-25-Pro polymorphisms are associated with the condition. These observations suggest that, in part, cervical insufficiency is mediated by genetic factors. LEVEL OF EVIDENCE: II.     

Assessing Strengths in Residential Treatment: Looking at the Whole Child

This article outlines the importance of assessing both within-child and environmental strengths for children and adolescents admitted to residential treatment facilities (RTFs). Discussed are the theoretical underpinnings behind strength-based assessment, as well as a number of organizations and initiatives that aim at raising the bar for children's care, creating a holistic viewpoint. Assessments such as the BASC-2, ASEBA, and Vineland-II are well-established measures that have moved to meet these demands, and measures like the BERS-2, RSCA, and DESSA have an overt strengths orientation. The CASA and the DCASC are omnibus strengths measures that can be utilized to fill the “intake gap.”