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Adolescent Health Care

Adolescent is a time of psychosocial, cognitive, and physical development as young people make the transition from childhood to adulthood. The Women’s Health and Education Center (WHEC) believes healthcare professionals have an obligation to provide the best possible care to respond to the needs of their adolescent patients. The delivery of preventive services to adolescents differs from the delivery of preventive services to adults. Furthermore, not all adolescents of the same age are at the same stage of development, thus necessitating further examination of adolescent’s physical, sexual, psychosocial, and cognitive development. Understanding the milestones and developmental stages of adolescence is beneficial to obstetricians and gynecologists treating adolescents. Comprehensive services may be delivered to adolescents in a variety of sites, including schools, physician offices, and community-based and other health care facilities. Legal barriers that restrict the freedom of healthcare practitioners to provide these services are also discussed.

Medical Liability: Risk Management

Risk management in the healthcare profession refers to strategies designed to enhance patient safety, decrease the risk of malpractice claims, and minimize loss. The goal of this program is to improve patient safety, decrease patient injury, and decrease liability losses through an educational program that identifies and initiates specific risk-reduction clinical practices and creates a comprehensive culture of safety. This effective risk management program includes both proactive and reactive components. The proactive component consists of strategies to prevent adverse occurrences, and the reactive component includes strategies for responding to such occurrences (i.e. minimizing loss). Given that obstetrics is the number one cause of admission to hospitals and that the professional liability system, as it now exists, threatens both the ability of obstetric providers to continue care and women to access care, it is imperative to take a leading role in patient safety and work towards optimizing outcome for our patients. One of the major results of health reform is the development of health-insurance exchanges, which will expand quality measurement. Enhancing safety of women in the hospitals and minimizing errors is not only an ethical and moral obligation, but also an essential component of liability reform.

Hereditary Cancer Risk Assessment in Gynecology

The purpose of this document to review current recommendations for genetic testing for susceptibility to cancers, including ovarian, fallopian tube, breast, endometrial, and colon cancers due to inherited mutations in the BRCA genes or in the mismatch repair genes associated with hereditary nonpolyposis colon cancer (HNPCC) syndrome. Family history remains the cornerstone of patient identification. Genetic testing of appropriate individuals further enables us to identify patients with hereditary cancer syndromes, for their own benefit as well that of their entire family. Clinical genetic testing for gene mutations allows physicians to more precisely identify women who are at substantial risk of breast cancer and ovarian cancer.

Neural Tube Defects Screening

Neural tube defects (NTDs) are congenital structural abnormalities of the brain and vertebral column that occur either as an isolated malformation, along with other malformations, or as a part of genetic syndrome. The purpose of this document is to review prenatal screening, diagnosis that are widely available and prenatal therapy is being investigated. Neural tube defects (NTDs) are among the few birth defects for which primary prevention is possible. Yet identification of selected anomalies, such as ventriculomegaly and spina bifida, remains a challenge in many cases. Anencephaly accounts for one half of all cases of NTDs and is incompatible with life; with treatment, 80-90% of infants with spina bifida survive with varying degrees of disability. In this chapter, the sonographic investigation, screening for NTDs and role of folic acid are also reviewed.

Infertility: Evaluation & Management

An estimated 10% to 15% of couples who want to have a child have difficulty conceiving. At least 6.2 million couples in USA are infertile. Some experts place that number closer to 8 million. It is clear that infertility is an immense problem, not only because of the vast number of people affected, but also because of the heartache they suffer and the costs incurred by the healthcare system. The purpose of this document is to provide the understanding of evaluation of infertile couple and strategies for the management of infertility. One of the main challenges before us today is matching the right patient with the right intervention. Fertility decreases with age, especially in women; therefore the common practice of delaying childbearing for a variety of economic and social reasons has probably added to number of couples who are unable to conceive naturally. The incidence of sexually transmitted diseases that can damage reproductive structures in both men and women has risen significantly. Fortunately, we have more resources than ever for investigating the causes of infertility and then treating the condition effectively.

Cervical Cancer Prevention: Managing Low-Grade Cervical Neoplasia

Cervical cancer is the most common cancer in women, and caused by the human papillomavirus (HPV). Most sexually active women will acquire HPV in their lifetime. Although infection clears in most cases, it does persist in some women. Long-term persistence of HPV — particularly with high-risk types — has been established as a necessary cause of precancerous lesions. Cervical screening programs have been very successful in the United States, Europe, and other regions, are able to achieve broad and sustained coverage. Cervical cancer prevention can now be made even better. Substantial modifications of practice are forthcoming, motivated by improved understanding of HPV natural history and cervical carcinogenesis.  The focus of this discussion is on management of atypical squamous cells of undermined significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL). This series on Cervical Cancer Prevention, will also serve as a baseline for understanding the future effects of HPV vaccination on the cervical cancer screening results.

Medical Liability: Current Status and Patient Safety

Accusations of negligence and the harm they do can be greatly reduced by a no-fault compensation, more realistic expectations, and an appropriate continuing education system for health professionals. In recent years, a science of patient safety has developed. Harm to patients is not inevitable and can be avoided. To achieve this, clinicians and institutions must learn from past errors, and learn how to prevent future errors. We need to adapt our ways of working to make safe health care a robust and achievable goal. Clinicians, managers, healthcare organizations, governments (worldwide) and consumers must become familiar with patient safety concepts and principles. Though medical curricula are continually changing to accommodate the latest discoveries and new knowledge, patient safety knowledge is different from other because it applies to all areas of practice. It is therefore fitting that the Women’s Health and Education Center (WHEC) with its partners in health, has developed this curriculum which will enable and encourage medical schools and healthcare facilities to include patient safety in their courses. Reducing harm caused by health care is a global priority. These skills are fundamental to patient safety.

Urinary Tract Injury: Prevention & Management

The evolution of pelvic surgical procedures has been influenced by uncommon but potentially devastating injuries to the lower urinary tract (bladder and ureters). These injuries are associated with known risk factors, though not all such injuries are predicable or avoidable. Knowledge of anatomy and careful intraoperative ureteral identification are hallmarks in injury prevention. Accurate diagnosis and safe, timely repair of bowel, bladder and ureter is crucial in reducing morbidity, and potentially mortality. This review focuses on the literature regarding the incidence, diagnosis and management of injuries to the lower urinary tract. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Identifying the injury intraoperatively reduces postoperative complications and long-term sequalae. The use of cystoscopy and agents that allow for easy discernment of ureteral efflux aid in identifying urinary tract injuries intraoperatively.

Current Concepts in Pelvic Floor Anatomy

Exploring current concepts in pelvic floor anatomy and support. The endopelvic fascia divides the lesser pelvis in a manner that is similar to the way the urorectal septum divides the embryonic cloaca. Connecting descriptions of the geometry of the organs visible by magnetic resonance imaging with descriptions of their individual connections to the endopelvic fascia is also discussed. The study aims to discuss the applied anatomy and embryology of pelvic floor structures. The relevance of pelvic floor to anal opening and closure function discusses new findings with regards to the role of three muscles in the vaginal closure mechanisms. The anal-rectal angle was previously thought to be important in maintaining fecal continence, but its importance has been questioned. More recent studies suggest that fecal incontinence in women is often related to denervation of the muscles of the pelvic diaphragm, as well as to disruption and denervation of the external anal sphincter.

Premature Rupture of Membranes: Diagnosis and Management

Premature rupture of the fetal membranes (PROM) is one of the most common and controversial problems facing the obstetric clinician. The fetal membranes and the amniotic fluid that they encase have functions that are critical for normal fetal protection, growth, and development. The purpose of this document is to review the current understanding of premature rupture of membranes (PROM) and to provide management guidelines that have been validated by appropriately conducted outcome-based research. There is some controversy over the optimal approaches to clinical assessment and treatment of women with term and preterm PROM. Management hinges on knowledge of gestational age and evaluation of the relative risks of preterm birth versus infection, abruptio placentae, and cord accident that could occur with expectant management. The risk factors, diagnosis, and management of PROM are discussed here. Additional guidelines on the basis of consensus and expert opinion also are included.