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Clinical Obstetrics and Gynecology

Bharti Jasra, Laila Samiian, Andrew M Kaunitz
Because of conflicting guidelines, providing appropriate breast cancer screening recommendations to our patients has become challenging. Given the high prevalence of genitourinary syndrome of menopause (GSM) overall, and among breast cancer survivors, and the understandable reluctance of physicians to prescribe effective hormonal treatments to survivors with this condition, addressing the needs of breast cancer survivors with bothersome GSM is both a common and controversial issue. In this review, we detail current breast cancer screening recommendations, breast cancer risk assessment, and management of GSM in breast cancer survivors...
June 27, 2019: Clinical Obstetrics and Gynecology
Victor R Klein
This article will review the basic principles of risk management, the role of the risk manager, and the importance of risk management in the patient safety movement as it pertains to obstetrics and gynecology. Several tools that are used by risk managers including risk assessments and root cause analyses will be used to illustrate positive patient safety measures that can be initiated to decrease adverse outcomes and reduced risk to an organization. The dramatic reduction in adverse outcomes and claims after the introduction of patient safety initiatives in a major obstetrical service will be reviewed...
June 27, 2019: Clinical Obstetrics and Gynecology
Amy L Garcia
Evaluation and management of abnormal uterine bleeding (AUB) are possible in the office. Approaching AUB evaluation from an etiology-based perspective allows the gynecologist to focus evaluation efforts on the most probable causes of AUB for a particular patient and therefore customize the management accordingly. Developing skills with imaging such as transvaginal ultrasound, saline infusion sonography, and diagnostic hysteroscopy are important for AUB etiology diagnosis. Operative hysteroscopy experience can be developed for AUB management in the office and endometrial ablation provides a minimally invasive solution for some patients...
June 27, 2019: Clinical Obstetrics and Gynecology
Eleftheria Kalogera, Sean C Dowdy
Enhanced recovery pathways were first developed in colorectal surgery and have since been adapted to other surgical subspecialties including gynecologic surgery. Mounting evidence has shown that the adoption of a standardized perioperative pathway based on evidence-based literature reduces length of hospital stay, reduces cost, reduces opioid requirements with stable to improved pain scores, and accelerates return to normal function as measured by validated patient reported outcomes measurements. The many elements of enhanced recovery may be distilled into 3 concepts: (1) optimizing nutrition before and after surgery, recognizing that nutritional status directly impacts healing; (2) opioid-sparing analgesia, considering the current American prescription opioid crisis and the importance of pain control to regaining functional recovery; and (3) maintenance of euvolemia before, during, and after surgery...
June 21, 2019: Clinical Obstetrics and Gynecology
Fidelma B Rigby, Blythe Bynum, Sally A Santen, Aruna Anabazhagan, Nicole Karjane
In this article we address the concept of burnout first in the medical student setting then in the residency setting. We will review the prevalence followed by a discussion of risk factors, consequences, and finally thoughts on prevention and intervention.
June 21, 2019: Clinical Obstetrics and Gynecology
Elizabeth A Howell, Zainab N Ahmed, Shoshanna Sofaer, Jennifer Zeitlin
Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes...
June 14, 2019: Clinical Obstetrics and Gynecology
Washington C Hill, Joseph B Paruolo, Amarilis C Giovino
As more women at increased risk for tuberculosis (TB) reactivation immigrate to the United States, perinatal screening and chemoprophylaxis are increasingly important. Interferon-gamma release assays and the tuberculin skin test are acceptable screening tests with the latter supported by more data in pregnancy. Women screening positive should have active TB excluded, and if negative, latent TB is likely. Prophylaxis should be deferred until 3 months postpartum except in those severely immunosuppressed, human immunodeficiency virus positive, or recently exposed...
June 13, 2019: Clinical Obstetrics and Gynecology
Tara B Rouse, Jodi Dejoseph, Arthur T Ollendorff
The quality of maternal care in the United States has garnered attention as the public has been made aware of outcome data and stories of patients' experiences. Calls to action from national leaders include a focus on evidence-based clinical practice and on interventions that meaningfully include patients and their families in their own care and in identifying promising practices to fill existing gaps. This article provides a look at the methods to identify needs from the patient and family perspective to help improve the quality of maternal care...
June 7, 2019: Clinical Obstetrics and Gynecology
Krista M Mehlhaff, Christian M Pettker
There is no single framework for a successful obstetric patient safety program. However, there are ample resources for the important components needed to create a patient safety program. All labor and delivery units should formulate their own quality and safety program that is individualized to the patients and staff that they serve. Here we will lay out the infrastructure as has been supported by the literature and reinforced in our experience.
June 4, 2019: Clinical Obstetrics and Gynecology
Audrey Lyndon
Failure to rescue refers to the inability to prevent death from health care complications. The fact that more than half of severe maternal morbidity and maternal deaths are classified as preventable, and black women have 2 to 3 times the risk for adjusted severe morbidity and maternal mortality suggest there is a problem with failure to rescue in US maternity care. This article reviews national efforts to improve rescue capacity in maternity care and data on communication breakdowns and disrespect in maternity care, and outlines individual and organizational actions that can be taken to improve communication and rescue processes...
May 27, 2019: Clinical Obstetrics and Gynecology
Emily M English, Daniel M Morgan
Patient safety bundles and checklists have been shown to improve outcomes in medicine, surgery, and obstetrics. Until recently, there has been less study into their use in the gynecology setting. Here, we review the available evidence and examples of successful checklist and bundle implementation in gynecology and encourage more robust implementation and standardization in our field going forward.
May 27, 2019: Clinical Obstetrics and Gynecology
Fatima Estrada Trejo, Catherine M Igel, Meleen Chuang, Komal Bajaj, Peter S Bernstein
Checklists, huddles, and debriefs are tools being more commonly adopted in health care with the goal to achieve a safer health system. Details regarding what, how and when to implement these tools in different circumstances related to women's health are described in this review.
May 27, 2019: Clinical Obstetrics and Gynecology
Patricia A Lee King, Danielle Young, Ann E B Borders
The Illinois Perinatal Quality Collaborative developed a framework for successfully engaging teams and implementing statewide obstetric and neonatal quality improvement (QI) initiatives. This framework includes: (1) engaging hospitals to create an environment of improvement; (2) motivating hospital teams to facilitate change at their hospital; and (3) supporting hospital teams through the 3 pillars of QI-collaborative learning opportunities, rapid-response data, and QI support-to achieve initiative goals and improve outcomes for mothers and newborns...
May 27, 2019: Clinical Obstetrics and Gynecology
Susan D Moffatt-Bruce, Michelle C Nguyen, Beth Steinberg, Scott Holliday, Maryanna Klatt
With the continuously changing health care environment and dramatic shift in patient demographics, institutions have the responsibility of identifying and dedicating resources for maintaining and improving wellness and resilience among front line providers to assure the quality of patient care. Our institution, the Ohio State University Wexner Medical Center (OSUWMC), has addressed the goal to decrease burnout for providers in a multistep, multiprofessional, and multiyear program starting firstly with institutional cultural change then focused provider interventions, and lastly, proactive resilience engagement...
May 15, 2019: Clinical Obstetrics and Gynecology
Patrick Duff
The critical measures of importance in reducing the frequency of postcesarean infection are preoperative cleansing of the vagina with a povidone-iodine solution, administration of cefazolin plus azithromycin before surgery, preparation of the abdomen with a chlorhexidine solution, removal of the placenta by traction on the cord, closure of the deep part of the subcutaneous layer, and closure of the skin with sutures rather than staples.
May 15, 2019: Clinical Obstetrics and Gynecology
Robert S Egerman
Between 70 and 170 million people worldwide are infected with hepatitis C virus (HCV) which frequently causes chronic liver disease and cirrhosis. There are several genotypes and many subtypes of HCV. Direct-acting antiviral agents are effective at eradicating HCV in the vast majority of patients, producing much higher cure rates than were seen with interferon and ribavirin regimens only a few years ago. The chapter reviews the epidemiology and virology of HCV infection. Treatment regimens are complex but a straightforward approach to selection of patients, choice of direct-acting antiviral agents and follow-up is presented...
May 13, 2019: Clinical Obstetrics and Gynecology
Olivia Moumne, Patrick Duff
Streptococcus pneumoniae, a gram-positive diplococcus, is the most common cause of bacterial pneumonia. The diagnosis of pneumococcal pneumonia is usually confirmed by chest x-ray and gram stain. The most appropriate antibiotics for treatment pneumococcal infection are macrolides, beta-lactams, and quinolones. Two vaccines, PPSV23 and PCV13, are highly effective in preventing infection.
April 18, 2019: Clinical Obstetrics and Gynecology
Monica Hagan Vetter, Ritu Salani, Thomas E Williams, Christopher Ellison, Bhagwan Satiani
Although there has been discussion of a shortage of surgical specialties including OB/GYN, consensus is difficult because of the multiple variables involved in estimating both supply and demand. In addition, burnout has become more recognized as a variable that has not been taken into account in estimating a shortage of OB/GYNs. We estimate OB/GYN physician shortages of 17%, 24%, and 31% by 2030, 2040, and 2050, respectively. Here, we examine the impact of burnout on the OB/GYN workforce. Specifically, we address the associations of burnout, reduction in clinical productivity as well as early retirement...
April 18, 2019: Clinical Obstetrics and Gynecology
Alison K Chapman, Zachary J Farmer, Lucy D Mastrandrea, Kristal A Matlock
Thyroid hormone is essential for normal fetal brain development in utero and for the first 2 years of life. The developing fetus is initially reliant upon maternal thyroid hormones that cross the placenta, until the fetal thyroid begins to supply thyroid hormone for the fetus. Maternal thyroid status affects fetal thyroid function and maternal thyroid dysfunction can have a significant impact on the fetus and neonate. There are also several neonatal factors that can influence thyroid function. Here, we describe thyroid function in the fetus and neonate and discuss the most common thyroid disorders seen in neonates...
June 2019: Clinical Obstetrics and Gynecology
Ryan D Cuff
Hyperthyroidism is relatively uncommon during pregnancy. However, those caring for pregnant patients should be versed in the evaluation and management of hyperthyroidism, as there are potential maternal and fetal implications that are related to the disease and to treatment. The differential diagnosis of hyperthyroidism includes clinical and subclinical entities, as well as transient laboratory findings that are related to the pregnancy itself. The clinical management, including the indications for the use of thioamide or antithyroid medications, will be discussed in the context of pregnancy...
June 2019: Clinical Obstetrics and Gynecology
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