Do we practice what we preach? A review of actual clinical practice with regards to preconception care guidelines.
Curtis M. Abelman S. Schulkin J. Williams JL. Fassett EM. (2006). Maternal & Child Health Journal. 10 Suppl 7:53-8.
Objectives: To review what past studies have found with regard to existing clinical practices and approaches to providing preconception care. Methods: A literature review between 1966 and September 2005 was performed using Medline. Key words included preconception care, preconception counseling, preconception surveys, practice patterns, pregnancy outcomes, prepregnancy planning, and prepregnancy surveys. Results: There are no current national recommendations that fully address preconception care; as a result, there is wide variability in what is provided clinically under the rubric of preconception care. Conclusions: In 2005, the Centers for Disease Control and Prevention sponsored a national summit regarding preconception care and efforts are underway to develop a uniform set of national recommendations and guidelines for preconception care. Understanding how preconception care is presently incorporated and manifested in current medical practices should help in the development of these national guidelines. Knowing where, how, and why some specific preconception recommendations have been successfully adopted and translated into clinical practice, as well as barriers to implementation of other recommendations or guidelines, is vitally important in developing an overarching set of national guidelines. Ultimately, the success of these recommendations rests on their ability to influence and shape women's health policy.
What obstetrician-gynecologists think of preconception care.
Morgan MA. Hawks D. Zinberg S. Schulkin J. (2006) Maternal & Child Health Journal. 10 Suppl 7:59-65.
Objectives: To describe obstetrician-gynecolog-ists' opinions of preconception care (PCC) and ascertain patient uptake for this service. Methods: A questionnaire was mailed to 1105 ACOG members in August 2004. Results: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% said very few pregnant patients came in for PCC. Of those who obtain PCC, they were believed to do so more likely to assure a healthy pregnancy (83%) than because of an elevated risk for birth defects (20%). Of 11 issues presented, cigarette smoking and folic acid supplementation were rated the most important for PCC counseling; exercise and environmental concerns were the least important. Conclusions: Physicians are willing to provide PCC but few patients are accessing such services.
Obstetrician-gynecologists' practice and knowledge regarding spina bifida.
Shaer CM. Chescheir N. Erickson K. Schulkin J. (2006). American Journal of Perinatology. 23(6):355-62.
The purpose was to assess practicing obstetrician-gynecologists' knowledge about the prenatal diagnosis and postnatal prognosis of spina bifida. Written questionnaires designed to assess practicing obstetrician-gynecologists' knowledge of spina bifida were mailed to 1000 randomly selected American College of Obstetricians and Gynecologists Fellows. More than 50% did not identify many of the sonographic features indicative of an open neural tube defect in the fetus and more than one third overestimated the risks of stillbirth, whereas more than two thirds overestimated the risk for premature delivery in a pregnancy complicated by fetal spina bifida. Just more than 50% correctly estimated the 1-year survival rate and just less than 50% correctly estimated survival at 6 years. Sixty-six percent overestimated the incidence of mental retardation associated with spina bifida. Maternal-fetal medicine specialists returning the survey exhibited a much better understanding of the prenatal issues and prognostic and outcome factors related to spina bifida. There are gaps in obstetrician-gynecologists' knowledge about the diagnostic features of and prognosis for fetal spina bifida. It is important for them to take advantage of continuing medical education opportunities to learn more about the management of pregnancies complicated by fetal spina bifida and about the prognosis for affected individuals.
Obstetrician-gynecologists' patients' knowledge of and attitudes toward hormone therapy: a survey. (2006).
Power ML. Schulkin J. Journal of Reproductive Medicine. 51(7):525-32.
OBJECTIVE: To investigate the opinions of obstetrician-gynecologists' patients toward hormone therapy (HT). STUDY DESIGN: Survey questionnaires for patients were mailed to obstetrician-gynecologists who belong to the Collaborative Ambulatory Research Network. RESULTS: Surveys were returned by 1,659 patients from 39 states and the District of Columbia. Women over 50 years old and postmenopausal women of all ages were more likely to report being well informed. Perimenopausal and postmenopausal women were significantly more likely than premenopausal women to have extensively considered the risks and benefits of HT (p<0.001). More highly educated women were more likely to be aware of the results of the recent clinical trials of HT and to have formed an opinion about the risks and benefits of HT. Women who had formed an opinion were essentially divided over whether HT use after menopause would be helpful or harmful. Less than half the women thought that physicians know enough about HT to give appropriate advice. CONCLUSION: There was little consensus regarding the risks and benefits of HT. Postmenopausal and more educated women considered themselves more informed and were more likely to have reached a decision regarding HT but were as evenly divided regarding the risks and benefits.
Functions of corticotropin-releasing hormone in anthropoid primates: from brain to placenta.
Power ML. Schulkin J. (2006). American Journal of Human Biology. 18(4):431-47.
Corticotropin-releasing hormone (CRH) is an ancient regulatory molecule. The CRH hormone family has at least four ligands, two receptors, and a binding protein. Its well-known role in the hypothalamic-pituitary-adrenal (HPA) axis is only one of many. The expression of CRH and its related peptides is widespread in peripheral tissue, with important functions in the immune system, energy metabolism, and female reproduction. For example, CRH is involved in the implantation of fertilized ova and in maternal tolerance to the fetus. An apparently unique adaptation has evolved in anthropoid primates: placental expression of CRH. Placental CRH stimulates the fetal adrenal zone, an adrenal structure unique to primates, to produce dehydroepiandrosterone sulfate (DHEAS), which is converted to estrogen by the placenta. Cortisol induced from the fetal and maternal adrenal glands by placental CRH induces further placental CRH expression, forming a positive feedback system that results in increasing placental production of estrogen. In humans, abnormally high placental expression of CRH is associated with pregnancy complications (e.g., preterm labor, intrauterine growth restriction (IUGR), and preeclampsia). Within anthropoid primates, there are at least two patterns of placental CRH expression over gestation: monkeys differ from great apes (and humans) by having a midgestational peak in CRH expression. The functional significance of these differences between monkeys and apes is not yet understood, but it supports the hypothesis that placental CRH performs multiple roles during gestation. A clearer understanding of the diversity of patterns of placental CRH expression among anthropoid primates would aid our understanding of its role in human pregnancy.