Faculty Bibliography

OBJECTIVE: The objective of this study is to gain insight into the nature of obstetric fistulae in Africa through patient perspectives. STUDY DESIGN: At l'Hopital Saint Jean de Dieu in Tanguieta, Benin, 37 fistula patients underwent structured interviews about fistula cause, obstacles to medical care, prevention, and reintegration by 2 physicians via interpreters. RESULTS: The majority of participants (43%) thought their fistulae were a result of trauma from the operative delivery. Lack of financial resources (49%) was the most commonly reported obstacle to care, and prenatal care (38%) was most frequently reported as an intervention that may prevent obstetric fistulae. The majority (49%) of the participants requested no further reintegration assistance aside from surgery. CONCLUSION: Accessible emergency obstetric care is necessary to decrease the burden of obstetric fistulae in Africa. This may be accomplished through increased and improved health care facilities and education of providers and patients.

OBJECTIVE:To assess the feasibility, utility and resident attitudes towards an interactive, Web-based computer learning program. STUDY DESIGN/METHODS:Pretest/ posttest evaluation of an interactive curriculum to teach current recommendations for cervical cancer screening and classification and management of abnormal Pap smears. Thirty-five Obstetrics and Gynecology (OB/ GYN) residents were encouraged to complete a Web-based computer program that consisted of a pretest, 9 educational sections (3 didactic and 6 case based), a posttest and an exit survey. Clinical cases involved virtual case management of patients' cytologic, histologic and colposcopic images. Mastery was set at 82% (or 23/28 correct answers). RESULTS:Thirty-one of the 35 residents (89%) completed the curriculum. No resident demonstrated mastery (82%) on the pretest; 15 of 31 residents demonstrated mastery on the posttest (p = 0.04). Mean improvement for all residents was 9 additional questions answered correctly. All the residents thought that the Web site was useful and covered all the learning objectives and would recommend it to other residents. CONCLUSION/CONCLUSIONS:A program to teach current cervical cancer screening, classification and abnormal Pap smear management guidelines was useful, feasible and well accepted by residents in this population.

OBJECTIVE:The purpose of this study was to assess whether a surgical skills simulator laboratory improves resident knowledge and operative performance of laparoscopic tubal ligation. STUDY DESIGN/METHODS:Twenty postgraduate year 1 residents were assigned randomly to either a surgical simulator laboratory on laparoscopic tubal ligation together with apprenticeship teaching in the operating room or to apprenticeship teaching alone. Tests that were given before and after the training assessed basic knowledge. Attending physicians who were blinded to resident randomization status evaluated postgraduate year 1 performance on a laparoscopic tubal ligation in the operating room with 3 validated tools: a task-specific checklist, global rating scale, and pass/fail grade. RESULTS:Postgraduate year 1 residents who were assigned randomly to the surgical simulator laboratory performed significantly better than control subjects on all 3 surgical assessment tools (the checklist, the global score, and the pass/fail analysis) and scored significantly better on the knowledge posttest (all P < .0005). CONCLUSION/CONCLUSIONS:Compared with apprenticeship teaching alone, a surgical simulator laboratory on laparoscopic tubal ligation improved resident knowledge and performance in the operating room.

OBJECTIVE:This study was undertaken to assess whether a surgical skills laboratory improves residents' knowledge and performance of episiotomy repair. STUDY DESIGN/METHODS:Twenty-four first- and second-year residents were randomly assigned to either a surgical skills laboratory on episiotomy repair or traditional teaching alone. Pre- and posttests assessed basic knowledge. Blinded attending physicians assessed performance, evaluating residents on second-degree laceration/episiotomy repairs in the clinical setting with 3 validated tools: a task-specific checklist, global rating scale, and a pass-fail grade. RESULTS:Postgraduate year 1 (PGY-1) residents participating in the laboratory scored significantly better on all 3 surgical assessment tools: the checklist, the global score, and the pass/fail analysis. All the residents who had the teaching laboratory demonstrated significant improvements on knowledge and the skills checklist. PGY-2 residents did not benefit as much as PGY-1 residents. CONCLUSION/CONCLUSIONS:A surgical skills laboratory improved residents' knowledge and performance in the clinical setting. Improvement was greatest for PGY-1 residents.

OBJECTIVE:To report our experience of selective embolotherapy in 8 consecutive patients with cervical pregnancy (CxP) presenting with vaginal bleeding. STUDY DESIGN/METHODS:A total of 9 selective pelvic embolization procedures were performed on 8 patients with CxP, either as an emergency, for control of vaginal hemorrhage (2 patients), or on a nonemergency basis, for moderate vaginal bleeding (6 patients). One patient underwent 2 embolization procedures, once for each indication. RESULTS:Successful hemostasis was obtained in both emergency cases. In 3 of the nonemergency cases, the CxP rapidly resolved. In the 3 other nonemergency cases, elevated beta-human chorionic gonadotropin levels persisted, with a new episode of vaginal bleeding in 2 patients 2 and 4 weeks later, respectively; the bleeding resolved after the administration of methotrexate. Significant vaginal hemorrhage occurred 4 weeks later in the third patient and responded to repeat embolotherapy. One patient required a blood transfusion. The uterus was preserved in all 8 patients. One patient was lost to follow-up, but normal menses resumed in all 7 of the others; and 2 patients had subsequent successful pregnancies. CONCLUSION/CONCLUSIONS:Embolotherapy is effective in treating and preventing vaginal hemorrhage associated with CxP while allowing uterine preservation. Along with methotrexate and other medical treatment of CxP, we recommend routine use of embolization in patients presenting with vaginal bleeding.

OBJECTIVE:Our purpose was to determine whether a borderline amniotic fluid index observed during antepartum testing confers a significant risk of adverse perinatal outcome. STUDY DESIGN/METHODS:We conducted a retrospective review of all patients entering antepartum testing at Los Angeles County-University of Southern California Women's and Children's Hospital during a 4-month period beginning January 1, 1996. Women with singleton pregnancies who underwent antepartum testing within 1 week of delivery and who were delivered at our institution were identified for our study. An amniotic fluid index >5 and <10 cm was defined as "borderline" and an amniotic fluid index of 10 to 24 cm was considered normal. Markers of adverse perinatal outcome included intrapartum fetal distress, 5-minute Apgar score <7, meconium-stained amniotic fluid, and intrauterine growth restriction. RESULTS:There was a 2-fold increase in the incidence of adverse perinatal outcome among the women with borderline amniotic fluid index in comparison with control subjects with normal amniotic fluid volume. This difference reflected a 4-fold increase in the incidence of fetal growth restriction among women with a borderline amniotic fluid index. CONCLUSIONS:A borderline amniotic fluid index observed in antepartum testing is associated with an increased risk of intrauterine growth restriction and overall adverse perinatal outcome. These observations suggest that borderline amniotic fluid index merits twice-weekly antepartum testing.

The purpose of this study was to determine if a group of patients with unexplained second or third trimester fetal demise have an increased prevalence of antinuclear antibodies (ANA) when compared to controls. During a 5-year period from January 1989 through December 1993, the records of all fetal deaths > or = 500 g or > or = 20 weeks of gestation that occurred at our institution were reviewed. In these women the ANA titers were checked at the discretion of the physician. The proportion of positive ANA tests in the group of women with explained fetal deaths was compared to that in women with unexplained fetal deaths. These results were then compared to a control group of healthy gravidas presenting to labor and delivery in the third trimester. During this time period, 848 fetal deaths were recorded. Our study population consisted of 286 patients who had an unexplained second or third trimester fetal demise with a record of having an ANA drawn. Of the 376 explained fetal deaths, 190 had an ANA assayed. The control group included 299 healthy third trimester gravidas. In the group of patients with unexplained fetal death, 11.5% (33/286) had a positive ANA, whereas 16% (31/190) of ANA tests were positive in cases of explained fetal death (P = 0.17). In the control group, 14% (43/299) had a positive ANA. There were three distinct immunofluorescence patterns: nucleolar, speckled, and homogeneous. The first two were seen more often in the control group, whereas the latter was seen more frequently in those patients with fetal death (P = 0.10). The incidence of a significant circulating ANA titer was similar in patients and controls. Moreover, there was no significant association between circulating antinuclear antibody titers and fetal outcome. More patients with a fetal death had a homogeneous nuclear fluorescence pattern when compared to controls; however, this finding was not statistically significant. Therefore, we do not recommend routine testing for ANA in women with unexplained second or third trimester fetal death.

We present three cases of shoulder dystocia unrelieved by standard maneuvers, including cephalic replacement. Symphysiotomy was performed in an effort to preserve fetal life. All three infants sustained severe neurologic injury and later died. Maternal morbidity including urinary incontinence was significant but responded to treatment. Symphysiotomy may be the only method of relieving some cases of shoulder dystocia, but its role remains unclear because of operator inexperience and maternal morbidity.