Physician Tiering: Efficacité,Qualité, ParcimonieJames A. Greenberg, MD,* Errol R. Norwitz, MD, PhD†*Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Division of Gynecology,Faulkner Hospital, and Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard MedicalSchool, Boston, MA; of Medicine, New Haven, CT†Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School[Rev Obstet Gynecol. 2009;2(2):73-74]© 2009 MedReviews®, LLC

Submucous MyomaJames A. Greenberg, MDDepartment of Obstetrics and Gynecology, Brigham and Women’s Hospital, Division of Gynecology,Faulkner Hospital, and Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard MedicalSchool, Boston, MA[Rev Obstet Gynecol. 2009;2(2):75]© 2009 MedReviews®, LLC

Spontaneous pregnancy loss is a surprisingly common occurrence, withapproximately 15% of all clinically recognized pregnancies resulting inpregnancy failure. Recurrent pregnancy loss (RPL) has been inconsistentlydefined. When defined as 3 consecutive pregnancy losses prior to 20 weeksfrom the last menstrual period, it affects approximately 1% to 2% of women.This review highlights the current understanding of the various etiologiesimplicated in RPL, including factors known to be causative, as well as thoseimplicated as possible causative agents. The appropriate diagnosticevaluation, therapy, and prognosis are also addressed.[Rev Obstet Gynecol. 2009;2(2):76-83]

Transcervical sterilization has moved female sterilization from a minimallyinvasive laparoscopic technique, which requires entry into the abdominalcavity, to a less invasive hysteroscopic procedure. Along with the decreasedpotential for complications, its ease of performance with minimal anesthesiahas facilitated a move from the operating room to the office. This reviewcompares the available data on transcervical sterilization procedures to betterunderstand the strengths and weakness of each system.[Rev Obstet Gynecol. 2009;2(2):84-92]

The obstetrician-gynecologist is often solely responsible for analgesia/sedation and regional blocks during office-based and outpatient procedures.The American Society of Anesthesiologists guidelines for the provision ofanalgesia/sedation for nonanesthesiologists provide helpful recommendationsto maximize patient safety during office-based and outpatient procedures.This article provides a review of the fundamentals of sedation/analgesia,monitored anesthesia care, and local anesthetics.[Rev Obstet Gynecol. 2009;2(2):93-100]

Cervical carcinoma is clinically staged according to the InternationalFederation of Gynecology and Obstetrics system; however, this staging systemis frequently inaccurate, particularly with advancing stage. Imaging modalitiesare often used in guiding therapeutic decisions for advanced cervicalcancer. However, despite technologic radiographic advances, imagingresults correlate variably with the histopathology of surgical specimens.The transperitoneal laparoscopic lymphadenectomy approach offers lessmorbidity than the traditional laparotomy approach to surgical staging, andthe retroperitoneal laparoscopic approach has been demonstrated to decreasethe risk of bowel injury and reduce abdominal adhesion formation, and priorabdominal surgery does not appear to be a factor. Further prospective clinicaltrials are necessary to better define the role of retroperitoneal laparoscopicsurgery in the management of gynecologic malignancies.[Rev Obstet Gynecol. 2009;2(2):101-106]

Preterm birth (PTB), defined as birth before 37 weeks of gestation, is theleading cause of perinatal morbidity and mortality. PTB is a major cause oflong-term health problems in neonates, including respiratory distress syndrome,chronic lung disease (bronchopulmonary dysplasia), infection, intraventricularhemorrhage, and severe neurologic deficit. In the absence of reliableclinical predictors of PTB, obstetric care providers should focus theirattention on the 2 best and most widely accepted methods of identifyingwomen at high risk of PTB in both nullipara and multipara: fetal fibronectinand cervical length measurements.[Rev Obstet Gynecol. 2009;2(2):107-115]

Multiple antimuscarinic agents are available for the treatment of overactivebladder. Many of the agents have undergone reformulation in an attempt toimprove patient adherence and drug tolerability. Oxybutynin evolved froman immediate-release pill to a once-daily oral preparation, and is nowavailable as a transdermal patch and gel. This article discusses the clinicalimpact of oxybutynin reformulation and reviews the evolution and benefitsof transdermal therapy.[Rev Obstet Gynecol. 2009;2(2):116-121]

Every year, worldwide, about 42 million women with unintended pregnancieschoose abortion, and nearly half of these procedures, 20 million, are unsafe.Some 68,000 women die of unsafe abortion annually, making it one of theleading causes of maternal mortality (13%). Of the women who survive unsafeabortion, 5 million will suffer long-term health complications. Unsafeabortion is thus a pressing issue. Both of the primary methods for preventingunsafe abortion—less restrictive abortion laws and greater contraceptiveuse—face social, religious, and political obstacles, particularly in developingnations, where most unsafe abortions (97%) occur. Even where these obstaclesare overcome, women and health care providers need to be educatedabout contraception and the availability of legal and safe abortion, andwomen need better access to safe abortion and postabortion services. Otherwise,desperate women, facing the financial burdens and social stigma ofunintended pregnancy and believing they have no other option, will continueto risk their lives by undergoing unsafe abortions.[Rev Obstet Gynecol. 2009;2(2):122-126]