Carolyn W. Swenson

Self-administered misoprostol or placebo before intrauterine device insertion in nulliparous women: A randomized controlled trial

OBJECTIVES: To estimate the effects of self-administered misoprostol compared with placebo before intrauterine device (IUD) insertion in nulliparous women. METHOD: Nulliparous women requesting either the copper T380A or levonorgestrel IUD were randomized to self-administer either 400 &mgr;g of misoprostol or placebo (vaginally or buccally) 3–4 hours before the IUD insertion appointment. The primary outcome was health care provider–perceived ease of insertion recorded on a visual analog scale (anchors: 0 extremely easy, 100 impossible). Patients completed questionnaires addressing pain using a validated visual analog scale (anchors: 0 none, 100 worst imaginable) before insertion, immediately postinsertion, and before clinic discharge. RESULTS: Of the 108 women enrolled in the study, 54 received misoprostol and 54 received placebo. There was no significant difference in perceived ease of insertion between the two groups (25.0 mm [standard error 3.5] compared with 27.4 mm [standard error 3.5], P=.64). Patients who received misoprostol before IUD insertion had significantly higher pain scores before placement (17.1 mm [standard error 3.5] compared with 4.7 mm [standard error 2.0], P=.003). Groups did not differ in perception of pain during IUD insertion (58.4 mm [standard error 3.3] compared with 56.9 mm [standard error 3.0], P=.74). There were two expulsions in the misoprostol group and none in the placebo group. Failed insertions, need for adjuvant pain medication, and need for cervical dilation or ultrasonographic guidance did not differ between the two groups. CONCLUSION: Self-administered misoprostol before IUD insertion does not ease IUD insertion or reduce patient-perceived pain in nulliparous women. These data do not support the routine use of misoprostol before IUD insertion in nulliparous women. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00886834. LEVEL OF EVIDENCE: I

Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy.

OBJECTIVE: To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy. METHODS: A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving &bgr;-lactam antibiotics and those receiving alternatives to &bgr;-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results. RESULTS: The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of “any surgical site infection” were 1.8%, 3.1%, and 3.7% for &bgr;-lactam, &bgr;-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the &bgr;-lactam antibiotics (reference group), the risk of “any surgical site infection” was higher for the group receiving &bgr;-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27–2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31–3.1). CONCLUSION: Compared with women receiving &bgr;-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended &bgr;-lactam alternative or nonstandard regimen.

Risk factors for venous thromboembolism after hysterectomy.

OBJECTIVE: To assess the prevalence of and risk factors for venous thromboembolism after hysterectomy. METHODS: This is a retrospective analysis of data from a voluntary, statewide surgical quality improvement collaborative. Demographics and perioperative data were obtained for hysterectomies performed from January 1, 2008, to April 4, 2014. Postoperative venous thromboembolism was defined as a deep vein thrombosis, pulmonary embolism, or both diagnosed within 30 days of hysterectomy. Significant variables related to postoperative venous thromboembolism were identified using bivariate analyses, and then logistic mixed modeling was used to develop a final model for venous thromboembolism. RESULTS: The rate of postoperative venous thromboembolism was 0.5% (110/20,496). Women who had a postoperative venous thromboembolism more frequently had a body mass index 35 or greater (40.0% compared with 25.2%, odds ratio [OR] 1.96, 95% confidence interval [CI] 1.08–3.56, P=.03), abdominal hysterectomy (referent nonabdominal hysterectomy; 61.8% compared with 29.9%, OR 2.67, 95% CI 1.46–4.86, P=.001), and gynecologic cancer as the indication for surgery (16.4% compared with 9.6%, OR 2.49, 95% CI 1.22–5.07, P=.01). Increasing surgical time (hours; referent 1 hour; OR 1.55, 95% CI 1.31–1.84, P<.001) was also an associated factor. In bivariate analyses, women with, compared with without, venous thromboembolism more frequently received both preoperative and postoperative heparin (31.9% compared with 15.2%, P<.001 and 55.9% compared with 33.5%, P<.001, respectively), but this did not remain significant in the final model. CONCLUSION: Body mass index 35 or greater, abdominal hysterectomy, increasing surgical time, and cancer as the indication for surgery are risk factors for venous thromboembolism after hysterectomy. LEVEL OF EVIDENCE: III

Universal Cystoscopy After Benign Hysterectomy: Examining the Effects of an Institutional Policy.

OBJECTIVE: To evaluate the association between a universal cystoscopy policy at the time of benign hysterectomy and the detection of urologic injuries. METHODS: This is a retrospective cohort study at a tertiary care academic center where a policy of universal cystoscopy at the time of benign hysterectomy was instituted on October 1, 2008. Benign hysterectomies performed from March 3, 2006, to September 25, 2013, were included and dichotomized into preuniversal and postuniversal cystoscopy groups. Medical records were reviewed for baseline and perioperative characteristics, cystoscopy use, and urologic injuries related to hysterectomy. Urologic injuries were identified by using a search engine and a departmental quality improvement database. RESULTS: Two thousand nine hundred eighteen hysterectomies were identified during the study time period, 96 of which were excluded for indications of abdominopelvic cancers and peripartum indications. Therefore, 973 women were in the preuniversal cystoscopy group and 1,849 were in the postuniversal cystoscopy group. Thirty-six percent (347/973, 95% confidence interval [CI] 32.8–38.8%) and 86.1% (1,592/1,849, 95% CI 84.5–87.7%) of patients underwent cystoscopy prepolicy and postpolicy, respectively. The urologic injury rates were 2.6% (25/973, 95% CI 1.6–3.6%) and 1.8% (34/1,849, 95% CI 1.2–2.5%) in the prepolicy and postpolicy groups, respectively. Delayed urologic injuries decreased significantly (0.7% [7/973], 95% CI 0.3–1.2% compared with 0.1% [2/1,849], 95% CI 0.0–0.3%). Of the nine patients with delayed injuries, four had normal intraoperative cystoscopy findings and five had no cystoscopy performed. CONCLUSION: The practice of universal cystoscopy at the time of hysterectomy for benign indications is associated with decreased delayed postoperative urologic complications.

Outpatient Narcotic Use After Minimally Invasive Urogynecologic Surgery.

Objectives To quantify outpatient narcotic use in the first 2 weeks after urogynecologic surgery. Methods Using a convenience sample, women who underwent minimally invasive urogynecologic surgery between May and October 2014 were contacted by telephone 2 weeks postoperatively and given a questionnaire regarding their postoperative pain experience. To quantify narcotic use, patients were asked to count the tablets remaining from their discharge narcotic prescription. Postoperative pain scores and pain expectations were also assessed. Women using more than 30 narcotics were in the top quartile for use; therefore, those using 30 or fewer versus more than 30 were compared. Logistic regression was used to identify independent factors associated with women in the top quartile for postoperative narcotic use. Results Fifty women were included in the study. Median number of narcotics used was 13 (interquartile range (IQR), 1-30) versus 40 (IQR, 35-60) prescribed. Compared to women who used 30 or fewer narcotics (n=38), those using more than 30 (n=12) more frequently were taking narcotics before surgery (13.2% vs 41.7%; P=0.03) and had a chronic pain diagnosis (15.8% vs 58.3%; P=0.003). Although pain scores were similar, women who took more than 30 narcotics more frequently reported their postoperative pain to be much worse or worse than expected (7.9% vs 33.3%; P=0.048). In logistic regression, chronic pain remained the only factor associated with using more than 30 narcotics (odds ratio, 7.36; 95% confidence interval, 1.00-54.03; P=0.0496). Conclusions Women used one third of the narcotics they were prescribed after minimally invasive urogynecologic surgery. These data may be useful for establishing narcotic prescription guidelines.

Surgical site infection following hysterectomy: adjusted rankings in a regional collaborative

BACKROUND Surgical site infection after abdominal hysterectomy (defined as open and laparoscopic) will be a metric used to rank and penalize hospitals in the Hospital Acquired Condition Reduction program. Hospitals whose Hospital Acquired Condition Reduction score places them in the bottom quartile will lose 1% of reimbursement from the Centers of Medicaid and Medicare Services. OBJECTIVES The objectives of this analysis were to develop a risk adjustment model for surgical site infection after hysterectomy, to calculate adjusted surgical site infection rates, to rank hospitals by the predicted to expected (P/E) ratio, and to compare the number of outlier hospitals with the number in the bottom quartile. STUDY DESIGN This was a retrospective analysis of hysterectomies from the Michigan Surgical Quality Collaborative performed between July 1, 2012, and July 1, 2014. Superficial, deep, and organ space surgical site infections were categorized according to Centers for Disease Control and Prevention criteria. Deep and organ space surgical site infections were considered 1 group for this analysis because these spaces are contiguous after hysterectomy. Hospital rankings focused on deep/organ space events because the Hospital Acquired Condition Reduction program will rank and penalize based on them, not superficial surgical site infection. Hierarchical multivariable logistic regression, which takes into account hospital effects, was used to identify risk factors for all surgical site infections and deep/organ space surgical site infections. Predicted to expected ratios for deep surgical site infection were calculated for each hospital and used to determine hospital rankings. Outliers were defined as those hospitals who predicted to expected confidence intervals crossed the reference line of 1. The number of outlier hospitals was compared with the number in the bottom quartile. RESULTS The overall surgical site infection rate following hysterectomy was 2.1% (351 of 16,548). Deep/organ space surgical site infection accounted for 1.0% (n = 167 of 16,548). Deep surgical site infection was associated independently with younger age, longer surgical times, gynecological cancer, and open hysterectomy. There was a marginal association with blood transfusion. After risk adjustment of rates and ranking by the predicted to expected ratio, there was a change in quartile rank for 42.8% of hospitals (21 of 49). Two hospitals were identified as outliers. However, if the bottom quartile was identified, as called for by the Hospital Acquired Condition Reduction program, 10 additional hospitals would be targeted for a penalty. Hospitals with < 300 beds were most likely to see their quartile rank worsen, whereas those > 500 beds were most likely to see their quartile rank improve (P = .01). CONCLUSION After adjusting for patient-related factors and site variation, more than 40% of hospitals will change quartile rank with respect to deep surgical site infection. Identifying a quartile of hospitals that are statistically different from others was not feasible in our collaborative because only 2 of 12 hospitals were outliers. These findings suggest that under the Hospital Acquired Condition Reduction program, many hospitals will be unjustly penalized.

Hollow Viscus Injury During Surgery

Reproductive tract surgery carries a risk of injury to the bladder, ureter, and gastrointestinal (GI) tract. This is due to several factors including close surgical proximity of these organs, disease processes that can distort anatomy, delayed mechanical and energy effects, and the inability to directly visualize organ surfaces. The purpose of this article is to review strategies to prevent, recognize, and repair injury to the GI and urinary tract during gynecologic surgery.

Analysis of High-, Intermediate-, and Low-Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.

Objectives To determine if surgeon volume is associated with differences in the use of apical colpopexy and cystoscopy and in the rate of intraoperative complications during hysterectomy for prolapse. Methods We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008, and December 31, 2011. Low (⩽10 cases)-, intermediate (11–49 cases)-, and high (≥50 cases)-volume surgeon groups for the 4-year period were established a priori. Rates of concomitant colpopexy, cystoscopy, and intraoperative complications were determined by chart review for 15% of the cases. Multivariate logistic regression models adjusted for site and other clinical and patient variables were used to estimate associations between surgeon case volume and the use of apical colpopexy and cystoscopy and the rate of intraoperative complications. Results Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Six hundred thirty-eight patients were selected for chart review. The rates among high-, intermediate-, and low-volume surgeons for performing colpopexy were 85.2% versus 77.8% versus 61.1% (P < 0.001) and for cystoscopy were 96.8% versus 78.3% versus 74.7% (P < 0.001), respectively. Rates of intraoperative complications among the 3 groups were 4.4%, 11.6%, and 6.3% (P = 0.011), respectively. With adjustment, high-volume surgeons were more likely to do a colpopexy than low-volume surgeons (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1–3.1); however, the likelihood of colpopexy did not differ between high- and intermediate-volume surgeons (OR, 1.9; 95% CI, 0.84–4.3) or between intermediate- and low-volume surgeons (OR, 0.99; 95% CI, 0.50–2.0). High-volume surgeons were more likely than intermediate-volume (OR, 4.4; 95% CI, 1.7–11.0) and low-volume (OR, 4.5; 95% CI, 2.6–8.0) surgeons to do a cystoscopy. High-volume (OR, 0.42; 95% CI, 0.30–0.61) and low-volume (OR, 0.32; 95% CI, 0.15–0.66) surgeons were less likely than intermediate-volume surgeons to have intraoperative complications. The difference between high- and low-volume surgeons was not statistically significant (OR, 0.77; 95% CI, 0.5–1.2). Conclusions Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and avoidance of injury.

Removal of the LNG IUD when strings are not visible: a case series ☆ ☆☆

OBJECTIVES To report length of intrauterine device (IUD) and strings as well as technique for extraction when IUD removal occurs without visible strings. STUDY DESIGN A prospective case series of 29 women who had IUDs removed in-office when strings were not visible at the external cervical os. RESULTS One third (n=11) were found to have a total length of IUD and strings <7.5 cm. All IUD removals were successfully performed as outpatient procedures. CONCLUSION Removal of IUDs without visible strings can be successfully done as an in-office procedure. IMPLICATIONS In-office removal of IUDs without visible strings is effective, safe and economically sound.

Opioid Prescribing Patterns by Obstetrics and Gynecology Residents in the United States

ABSTRACT Background: Despite the opioid epidemic in the U.S., little data exist to guide postoperative opioid prescribing in Obstetrics & Gynecology (Ob/Gyn). Objective: To describe Ob/Gyn resident opioid prescription patterns in the U.S. and assess influential factors. Methods: An anonymous survey was emailed to Ob/Gyn residents in the U.S. between January–February 2015. Respondents reported the typical number of discharge narcotic tablets prescribed following six common procedures. Responses to questions addressed potential factors influencing prescription practices and knowledge about opioid abuse in the U.S. Residents who prescribed a number of discharge narcotic tablets in the top quartile were compared to those who never did. Logistic regression was used to identify factors associated with top quartile prescribers. Results: 267 residents responded. Median number of discharge narcotics prescribed following cesarean section was 30 (IQR 28, 40) and after laparoscopic hysterectomy was 29 (IQR 20, 30). Factors associated with increased odds of prescribing in the top quartile included training in the West (aOR 3.15, 95% CI 1.05–9.45, p = 0.04) and agreeing with: “I prescribe postoperative narcotics to avoid getting reprimanded by attendings” (aOR 2.72, 95% CI 1.20–6.15, p = 0.02). Factors associated with decreased odds of prescribing in the top quartile included training in a community-based program (aOR 0.33, 95% CI 0.15–0.71, p = 0.005) and agreeing with: “I am conservative with the number of narcotics I prescribe after surgery” (aOR 0.34, 95% CI 0.17–0.71, p = 0.004). Conclusions/Importance: Opioid prescribing practices of Ob/Gyn residents are influenced by region of country, program-type, and factors related to hospital culture and personal insight.