Primary care update for Ob/Gyns最新文献

When one thinks of the field of women's health in the developing world, traditionally, one immediately relates it to maternal health and care of those women of reproductive age. Little attention is given to older women's health care. Yet it has been documented that older women with poor access to care have higher age-adjusted mortality. As the abundant existing reproductive-aged women become older, the number of older women in the developing world will increase. In 1994, nearly 312 million of the world's 469 million elderly women resided in developing countries. Currently, out of the 600 million older women worldwide, there are over 400 million older women living in the developing world. It is estimated that by 2020 five out of seven will reside in developing countries, an absolute increase of about 360 million compared to 87 million in developed countries. This article focuses on some of the existing health problems, such as breast and cervical cancer, and their barriers in prevention, diagnosis, and treatment in older women in developing countries. It then discusses the emerging issues from a neglect of the multifaceted problems of older women’s health. Finally, there is a call for a multidisciplinary approach to proposed solutions for future directions in this desperately needed field.

The hypothesis of this study is that nucleated red blood cells (nRBCs) released in response to low [O₂] are correlated with components of such a response (e.g., reticulocytes and increased erythrocyte number), and that such a response is correlated with abnormal placental growth, pathology, and reduced fetal growth. 166 term births had complete blood counts (CBC) and differentials performed on cord blood. Of these, 139 had placental examination blinded to hematologic data. Total nRBC count was calculated from nRBC count/100 white blood cells (WBC) and corrected WBC count. Nonparametric (Spearman's) correlations assessed associations with hematocrit and total RBC, reticulocyte, and neutrophil counts and with placental parameters. Logtransformed nRBC counts served in multivariate regression. Our results were that nRBCs and reticulocytes were correlated (p = 0.03, r = 0.21). nRBC and reticulocytes did not correlate with hematocrit. After adjustment for reticulocyte count, nRBCs were correlated with band neutrophils (p = 0.02, r = 0.30). Reticulocytes correlated with neither myeloid count. nRBC count was related to birthweight (r = 0.21) and placental weight (r = 0.20), but not to other placental measures. Reticulocyte count was related to placental volume (r = 0.20, p = 0.02) and fetal/placental weight ratio (r = −0.31, p = 0.007). No placental pathology was related to fetal hematology. A predictive equation including birthweight and placental weight showed p = 0.05, although each individual p was >0.4. In conclusion, our data suggest that elevated nRBC and reticulocyte counts identify clinically well term fetuses with compensatory responses to altered [O₂]. A portion of nRBC variance is independent of reticulocyte count, and attributable to change in band neutrophil count. In well term newborns, nRBC count is related to birthweight and placental weight, but this relationship is likely complex and non-linear.

Cervical cancer is one of the most common female malignancies worldwide. In the United States, the mortality from cervical cancer has decreased 70–80% since the introduction of the conventional Papanicolaou smear. Despite its success, the conventional Papanicolaou smear has a sensitivity of only 51% and a false negative rate of 5–10%. The ThinPrep smear has been shown to improve the adequacy of cervical cytology, thereby increasing the sensitivity and decreasing the false negative rate of cervical cancer screening. The ThinPrep has the theoretical potential to reduce the incidence of invasive disease by 28%, increase life-expectancy, and decrease the lifetime costs associated with diagnosis and management of cervical abnormalities. Unfortunately, absent or suboptimal screening is associated with 50–60% of cancer cases. Ultimately, it will take not only improving the sensitivity of the Pap test, but also increasing the participation in screening programs, especially in high-risk populations, in order to continue to reduce the morbidity and mortality associated with cervical cancer.

Cerebrovascular disease is one of the leading causes of morbidity and mortality in Americans, especially affecting the elderly. Recognition of patients at risk for stroke and transient ischemic accidents may help to decrease the incidence of this significant disease. Identification of carotid insufficiency and the appropriate investigation of its severity in the context of the patient's clinical status is a fundamental skill in stroke prevention. The clinical history and physical examination are the invaluable first steps in assessing the degree of disease. Recognition of risk factors and initiation of medical therapy should be the initial approach. When the severity of symptoms or degree of arterial disease are moderate to severe, surgical intervention, such as carotid endarterectomy, should be considered. The obstetrician-gynecologist, as a primary care physician, must be skilled in the assessment, prevention, and appropriate referral of carotid insufficiency.

Lead poisoning among pregnant women is a significant public health problem, especially in urban settings with large immigrant populations. Serious toxic effects of lead on the fetus are well established, and prenatal exposure is a major cause of childhood lead poisoning. Symptomatic lead poisoning with very high maternal blood lead levels is a medical emergency and warrants immediate intervention for maternal indications. Special efforts should be made to identify asymptomatic women with blood lead levels ≥10 μg/dL. An office screening questionnaire can be used for this purpose. Other approaches are identification of women at risk by zip code or immigrant status. In inner-city prenatal populations universal testing of blood lead levels is often advisable. The appropriate health authorities should be notified when a woman is found to have an elevated blood lead level, and a thorough search for the source of exposure must be initiated. Removal from the source is the most crucial step in management. There are insufficient data about the fetal safety of chelation agents in pregnancy, and their use should be limited to maternal indications. Other important measures to reduce lead levels include smoking cessation, improvement of diet, and calcium and other nutritional supplementation.

More women are planning pregnancy after the age of 35. Unfortunately for these individuals, aging is associated with compromised ovarian function and decreasing fecundity. Compromised oocyte quality is associated with fetal aneuploidies and poor quality embryos with an increased miscarriage rate. Secondary to this compromised oocyte quality, success rates of assisted reproductive techniques decline. Follicle stimulating hormone (FSH) and estradiol levels on day 3 of the menstrual cycle help to assess the ovarian reserve. Fertility potential can also be assessed by the clomiphene challenge test. In order for women to plan for their childbearing, an understanding of the influence of age on fertility is essential. It is the responsibility of caregivers to educate patients regarding this issue. Assisted reproductive techniques (ART), ovum donation, and preimplantation diagnostic techniques help to improve the successful pregnancy outcomes in older women.

The objective of this study was to evaluate knowledge regarding folic acid among postpartum Mexican-American patients. A survey regarding folate was administered to postpartum women at a public hospital serving primarily Mexican-Americans (n = 393). English and Spanish speakers were compared. Fifty eight percent cited prevention of birth defects as a reason to take folate. English speakers were less likely to know this than Spanish speakers (p = 0.005). Fifty-one percent of women stated they had learned about folate from radio or television. Of these, 83% knew that folic acid prevents birth defects and that it should be taken prior to pregnancy. Only 16% learned about folate from a health care provider. Compared to previous research, Mexican-American women have increased awareness of the association between folate consumption and birth defects, especially Spanish speakers. Patients citing radio/television as a source of information tended to answer questions correctly, suggesting that media efforts in this area have been effective.

The American College of Obstetricians and Gynecologists defines emergency contraception, also known as post-coital contraception and the “morning after pill,” as “a therapy for women who experience an act of unprotected sexual intercourse.” It has been estimated that post-coital contraception could reduce the number of unintended pregnancies by 2 million and the number of induced abortions by 1 million. Several methods of emergency contraception are widely accepted including an estrogen-progestin combination, progestin only, mifepristone (RU486), and the copper intrauterine device (IUD). The major side effects of post-coital contraception include nausea, vomiting, and menstrual cycle abnormalities. Currently, the biggest obstacles to post-coital contraception in the United States are limited experience among practitioners and lack of awareness and accessibility among patients. Analogous to a fire extinguisher in homes, emergency contraception requires immediate access for success. There is a nationwide campaign, supported by major national medical organizations, to increase physician acceptability and to make hormonal emergency contraception available over-the-counter, thereby increasing visibility and patient convenience. Until the availability improves, it is prudent for physicians to prescribe emergency contraception as well as provide prevention counseling during routine visits.