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Staging & Management for Uterine Cancer

The carcinoma of the endometrium is easily diagnosed, but the well-differentiated cancers may be difficult to separate from advanced atypical hyperplasia. This document also outlines the rationale for the use of chemotherapy in selected patients with endometrial cancer. In a disease long regarded as the province of the surgeon and radiation oncologist, a new look at chemotherapy is producing promising results. After the diagnosis of endometrial carcinoma has been histologically confirmed, the patient should undergo a thorough evaluation. A complete physical examination can discover suspicious lymph nodes and areas of spread within the pelvis. These patients often have other medical problems that must be evaluated for their effect on treatment choices for the cancer.

Surgical Management of Lower Urinary Tract Fistulas

Obstructed labor remains the most important cause of vesicovaginal fistulas in developing countries. Absent or untrained birth attendants, reduced pelvic dimensions (caused by early childbearing, chronic disease, malnutrition, and rickets), uncorrected inefficient uterine action, malpresentation, hydrocephalus, and introital stenosis secondary to tribal circumcision all contribute to obstructed labor. The purpose of this document is to explore various surgical techniques for surgical repairs of lower urinary tract fistulas. Obstetric fistulas are characterized by considerable necrosis, sloughing, tissue loss, and cicatrisation. Vesicovaginal fistulas commonly occur in the setting of wide range of other immediate problems, such as stillbirth, ruptured uterus, third- or fourth-degree perineal lacerations with resultant rectovaginal fistulas and anal incontinence, and pelvic infection. In modern obstetrics, most of these conditions do not exist. Generalists should be trained to repair simple fistulas, with referral of complex cases to specialized fistula hospitals.

Syphilis in Pregnancy: Prevention of Congenital Syphilis

The purpose of this document is offers recommendations for treating infants and adults. It will also high-light the need to view syphilis screening and control programs through the perspectives of multiple stakeholders so as to identify barriers to, and opportunities for improving the formulation and implementation of national policies. Devising an effective political strategy might represent one of the most challenging facets of implementing a sustainable program. Both structured and unstructured approaches are useful, and applying aspects of both may provide rich analysis of why an intervention like antenatal syphilis screening is not being implemented. In USA a record low incidence of congenital syphilis, 20.6 cases per 100,000 live births, was recorded in 1998 by the Centers for Disease Control and Prevention (CDC) (1999a), resulting in creation of the National Plan for Syphilis Elimination.

Ultrasound Evaluation of Uterine Scar

Between 1996 and 2003 the cesarean delivery rate in the United States increased dramatically from21.2% to 27.1%. Over the same interval vaginal birth after cesarean birth (VBAC) has decreased from 28.3% to 10.6%. This decrease may be attributed to concerns regarding the risks during trial of labor, such as uterine rupture, estimated to occur in 0.3-4.0% of pregnancies with history of cesarean delivery. As the VBAC rate increased, so did the number of well-publicized reports of uterine rupture and other complications during trials of labor after previous cesarean deliveries. As a result, many physicians and hospitals have discontinued the practice altogether. This abrupt change in practice has contributed to the cesarean delivery rate in the United States increasing again, reaching an all-time high of 26.1% in 2002, while the VBAC rate has decreased by 55% to 12.6%. The risk for poor obstetric outcome in a subsequent pregnancy has been shown to be related to surgical technique, with classical cesarean delivery having the highest risk for rupture and lower segment incisions having a lower risk. Clinical significance of uterine scar dehiscence in women with previous cesarean delivery is also discussed.

Preterm Labor Management

Preterm labor is the leading cause of neonatal mortality in the United States and accounts for about 11.5% of all live births. It is responsible for three quarters of neonatal mortality and one half of long-term neurologic impairments in children. Despite the numerous management methods proposed, the incidence of preterm birth has changed little over the past 40 years. Uncertainty persists about the best strategies for managing preterm labor. The purpose of this document is to discuss the various methods proposed to manage preterm labor and the evidence for their roles in clinical practice. The information is designed to aid practitioners in making decisions about appropriate obstetrical care. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Vulvodynia

Vulvovaginal disorders are increasingly recognized as a source of significant pain and discomfort and lead to a substantial decrease in quality of life for many women. The purpose of this document is to discuss signs, symptoms and management of vulvodynia. Provoked vestibulodynia, formerly referred to as vulvar vestibulitis syndrome, is suspected to be the most frequent type of vulvodynia in premenopausal women. In addition to disrupting sexual functioning, there is preliminary evidence to suggest that this pain problem can adversely affect general psychological well-being and overall quality of life. Despite its high prevalence and associated negative sequelae, there is a dearth of controlled treatment outcome studies focusing on vulvodynia. Although there are now several published studies evaluating different treatment approaches for vestibulodynia, there are only a handful of randomized trials, resulting in a hodgepodge of interventions for which there is little empirical support. Thus, current guidelines and recommendations are largely based on clinical observations and uncontrolled data rather than being anchored in findings from rigorous studies.

Effects of Regional Analgesia on Labor

Most women experience significant pain during their first labor that is why obstetricians spend a considerable amount of time counseling women about their pain control options. Epidural analgesia is attractive to both patients and clinicians because it is the most effective pain control method available, are relatively safe, and have only moderate effects on the course of labor. Despite its popularity and safety, epidural analgesia is not without side effects. The most common of which are maternal fever, effects on uterine basal tone and fetal heart rate (FHR) abnormalities. Of the various pharmacologic methods of pain relief during labor and delivery, regional analgesia techniques — spinal, epidural, and combined spinal epidural — are the most flexible, effective, and least depressing to the central nervous system, allowing an alert, participating woman and an alert neonate.

Massachusetts Resources: Domestic Violence

SafeLink 24-Hour DV Hotline 1-877-785-2020 English/Spanish 1-877-521-2601 (TTY) Jane Doe, Inc. www.janedoe.org 617-248-0922 Resources and referrals for victims of domestic violence and sexual assault. Online statewide resource guide. Massachusetts Medical Society www.massmed.org Comprehensive guide on domestic violence for health care professionals. MDPH Sexual Assault and Survivor Service www.state.ma.us/dph/sapss/sapss.htm 617-492-7273 Information and referral for rape crisis […]

The Pap Smear

Before the Pap smear was introduced into clinical practice, carcinoma of the cervix was the leading cause of cancer-related deaths among American women. No other test has been as successful as the Pap smear in eradicating cervical cancer. Cervical cancer is still a leading cause of cancer deaths in women where Pap smear screening is not widely available. Screening for cervical cancer and its precursors with Pap tests represents the most successful cancer detection strategy ever developed. This document reflects emerging clinical and scientific advances. This information should not be constructed as dictating an exclusive course of treatment or procedure to be followed. Variation in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the type of practice or institution.

Culture and Health

As the health system changes and increasingly focuses on primary care and prevention, it is critical that health care providers develop ongoing and trusting relationships with their patients. Cultural sensitivity and awareness is particularly relevant to maternity care. The birth of a child initiates another generation into a family and affords a new opportunity for cultural traditions to be solidified, thus strengthening the bond between parents and child and serving to unify family members. Communication is at the heart of who we are as human beings. It is our way of exchanging information; it also signifies our symbolic capability. Medicine has a culture of its own, with traditional codes of conduct that have been passed on from generation to generation. From that point of view, Women’s Health and Education Center (WHEC)’s community and family health approaches are particularly important for achieving social and cultural relevance in health work.