Catherine Cansino

Contraceptive use among women with a history of bariatric surgery: a systematic review.

BACKGROUND Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years. STUDY DESIGN We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery. RESULTS From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon. CONCLUSIONS Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified.

Contraceptive use among women with inflammatory bowel disease: A systematic review

BACKGROUND There are theoretical concerns that use of hormonal contraceptives by women with inflammatory bowel disease (IBD) might increase disease relapse and risk of other adverse health outcomes, including thrombosis. In addition, there are concerns that IBD-related malabsorption might decrease the effectiveness of orally ingested contraceptives. The objective of this systematic review was to evaluate the evidence on the safety and effectiveness of contraceptive use among women with IBD. STUDY DESIGN We searched the PubMed database for peer-reviewed articles relevant to contraceptive use and IBD that were published in any language from inception of the database through February 2009. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS From 207 articles, we identified 10 studies that met our inclusion criteria. Evidence from five cohort studies (Level II-2, fair to good) suggests no increased risk of IBD relapse with use of oral contraceptives. Evidence from two pharmacokinetic studies (not graded) suggests that women with mild ulcerative colitis and those with an ileostomy following a proctocolectomy with small ileal resections have plasma concentrations of steroid hormones after oral ingestion of higher doses of combined oral contraceptives that are similar to the plasma concentrations among healthy volunteers. No studies were found that examined the risk of thrombosis among women with IBD who used hormonal contraceptives. CONCLUSIONS Limited evidence suggests there is no increased risk of disease relapse among women with IBD who use oral contraceptives, and there seem to be no differences in the absorption of higher-dose combined oral contraceptives between women with mild ulcerative colitis and small ileal resections and healthy women.

Understanding women's desires for contraceptive counseling at the time of first-trimester surgical abortion.

OBJECTIVE The objective was to investigate whether or not women presenting for a first-trimester surgical abortion want to discuss contraception on the day of their procedure. STUDY DESIGN Between October 2012 and January 2013, an anonymous self-administered survey was distributed to women receiving first-trimester surgical abortions at four northern California family planning clinics. The survey obtained demographic information about each woman and inquired about her desire for contraceptive counseling during her appointment. Results were analyzed using both univariate and multivariable regression analyses to assess trends in responses related to desire for contraceptive counseling based on demographic and other variables. RESULTS Of the 199 respondents, 64% reported that they did not want to talk to a counselor or doctor about contraception on the day of their abortion. About half of the women (52%) who did not want to discuss contraception indicated they already knew what they wanted for pregnancy prevention. Of the 25% who reported that they did want to discuss contraception, the most important topic desired from the counseling was identification of methods that were easier to use than what they used previously. CONCLUSION The majority of women seeking first-trimester surgical abortion may not desire additional information about contraception on the day of the procedure. IMPLICATIONS STATEMENT This study demonstrates that a significant proportion of women may not want contraceptive counseling on the day of a planned surgical abortion.

Paracervical Block With Combined Ketorolac and Lidocaine in First-Trimester Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE: To study the effects of a paracervical block with combined ketorolac and lidocaine on perceived pain during first-trimester surgical abortion. METHODS: A double-masked, placebo-controlled, randomized clinical trial of 50 women undergoing first-trimester surgical abortions (before 11 weeks of gestation) received either oral ibuprofen with a lidocaine-alone paracervical block or an oral placebo and paracervical block with combined ketorolac and lidocaine. Women completed a series of 100-mm visual analog scales (anchors: 0=none, 100 mm=worst imaginable) to measure their perceived pain (anticipated pain, pain during and after surgical abortion, and total satisfaction). RESULTS: Twenty-five women received preoperative oral ibuprofen followed by paracervical block with lidocaine alone, and 25 received oral placebo followed by paracervical block with combined ketorolac and lidocaine. Groups were similar with respect to sociodemographic variables. Women who received paracervical block with combined ketorolac and lidocaine reported significantly less pain after cervical dilation (59.8 compared with 74.8 mm, P<.05). The groups did not differ in perceived procedure-related or postoperative pain. There was no difference in overall satisfaction with pain control between the two groups (63.6 compared with 62.9 mm, P=.93). CONCLUSION: Paracervical block with combined ketorolac and lidocaine significantly decreases perceived pain associated with cervical dilation during first-trimester surgical abortion. This analgesic mixture may be offered as an alternative pain regimen to women seeking first-trimester surgical abortion. It may also offer improved pain control in other gynecologic procedures necessitating cervical dilation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00617097. LEVEL OF EVIDENCE: I

Factors influencing women's satisfaction with surgical abortion

Abstract Objective Investigate which specific factors of abortion-related healthcare influence the overall satisfaction of women undergoing surgical abortion. Study Design Between May and December 2014, we invited women undergoing first-trimester surgical abortion without sedation at six Northern California reproductive health clinics from two clinic systems (four clinics in System A and two clinics in System B) to complete an anonymous survey in the recovery room. The survey obtained demographic information and inquired about the womens level of satisfaction with different aspects of care (very satisfied, somewhat satisfied, not satisfied or dissatisfied, somewhat dissatisfied or very dissatisfied). The survey asked women to rank the three most important factors that contributed to their level of satisfaction. We analyzed the results using univariate and descriptive analyses to assess trends in responses related to level of satisfaction based on demographic and other variables. Results A high percentage of women were very satisfied with their overall experience in both systems (A=79%, B=84%, p=0.34). Only 2% of women in System A and 1% in System B responded that they were neutral or not satisfied. The top three aspects of care ranked as most important were the same from both systems: ability to get an appointment in a timely manner, courtesy of staff and being informed as much as they wanted to know. Women were very satisfied or somewhat satisfied with these features of their care within both systems. Conclusion Women are generally very satisfied by the first-trimester surgical abortion care they receive in different clinics. Although each clinic and system provides unique care, the factors contributing to womens level of satisfaction are consistent. Implications Statement The most important factors that contribute to womens satisfaction with their first-trimester surgical abortion experience include the ability to get an appointment quickly, courtesy of the staff and being provided with information and responses to their questions.

Training the next generation of robotic surgeons using guided mentorship: A randomized controlled trial

STUDY OBJECTIVE To evaluate the effect of expert guided mentorship on technical score and time for a set of robotic training drills. DESIGN Prospective randomized controlled trial (Canadian Task Force classification I). SETTING Academic institution. SUBJECTS Fifty trainees in robotic surgery. INTERVENTION Inexperienced trainees underwent either a 20-minute expert guided mentorship session or no intervention. The primary outcomes were technical score and time-to-drill completion for a set of dry lab robotic training drills evaluated at an initial and final skills assessment. The t-test, including paired analyses, was used to evaluate outcomes. MEASUREMENTS AND MAIN RESULTS Forty-nine of 50 trainees (98%) completed the study. There were no significant differences in participant characteristics or initial performance between the 2 groups. During the final skills assessment, the intervention group demonstrated significantly better performance on 1 of 8 objective measures. They had a higher mean score for the bead transfer drill when compared with the control group (21.6 vs 19.9; p = .03). No differences in time-to-drill completion were noted between the 2 groups. Regardless of randomization, all participants had significantly improved scores for each of the drills on the final compared with the initial skills assessment (p < .01). CONCLUSIONS Although expert guided mentorship in a dry lab simulation environment seems feasible, further investigation is warranted before its widespread use because it may be more resource intensive than other teaching methods, without consistent objective improvements in technical performance.

Long-Acting Reversible Contraception Initiation With a 2- to 3-Week Compared With a 6-Week Postpartum Visit.

OBJECTIVE To evaluate whether a department policy changing the scheduling of the postpartum visit from 6 weeks to 2-3 weeks after delivery is associated with higher long-acting reversible contraception initiation at the postpartum visit. METHODS We conducted a quasiexperimental before-after study to evaluate long-acting reversible contraception initiation, specifically an intrauterine device or contraceptive implant, at the postpartum visit between women scheduled for follow-up at 6 weeks (before policy change) and 2-3 weeks after delivery (after policy change). Secondary outcomes included postpartum visit completion, overall contraception initiation at the postpartum visit, overall contraceptive use at 6 months after delivery, and repeat pregnancies by 6 months postpartum. We obtained delivery and postpartum information using the electronic medical record and contacted participants 3 and 6 months after delivery to assess contraception use and repeat pregnancies. RESULTS We enrolled 586 participants between December 2014 and November 2015, of whom 512 women (256 in each cohort) continued to meet eligibility criteria after delivery. Long-acting reversible contraception initiation rates at the postpartum visit were lower in the 2- to 3-week (16.5%, 95% CI 12.2-21.8) compared with the 6-week group (31.1%, 95% CI 25.2-37.7, P<.01), primarily as a result of patient and health care provider preferences for delaying intrauterine device insertion to a later visit. More women completed a scheduled 2- to 3-week postpartum visit (90.2%, 95% CI 86.0-93.3) compared with a 6-week visit (81.6%, 95% CI 76.4-85.9, P<.01). Deferral of any contraception initiation was higher in the 2- to 3-week group (27.3%, 95% CI 21.9-33.4) compared with the 6-week group (15.8%, 95% CI 11.5-21.4, P<.01), but there were no differences in overall contraceptive use patterns at 6 months postpartum. No intrauterine device perforations or expulsions were observed in women who underwent insertion at 2-3 weeks postpartum. Five pregnancies were reported in each cohort by 6 months after delivery. CONCLUSION Scheduling a visit at 2-3 weeks after delivery was not associated with increased long-acting reversible contraception initiation at this visit despite higher postpartum visit attendance.

Survival outcomes of obese patients in type II endometrial cancer: Defining the prognostic impact of increasing BMI

OBJECTIVE To investigate the role of obesity as a risk factor for type II endometrial cancer (EC), as well as the prognostic significance of increasing body mass index (BMI) on survival. METHODS A single institution retrospective analysis of 154 type II EC cases from 1987 to 2010 was conducted. Patients were categorized into cohorts by BMI (normal (<25), overweight (25-29.9), obese class I (30-34.9), and obese class II-III (≥35)). Descriptive, regression and ANOVA analyses were performed. Kaplan-Meier curves were compared with log rank tests. RESULTS The BMI distribution was 22.8% normal BMI; 24% overweight; 17.5% class I; and 35.7% class II-III. The median follow up was 41 months. The median progression-free survival (PFS) was 45.4, 36.0, 35.3 and 42.0 months and overall survival (OS) was 54.7, 44.7, 44.8 and 49.7 months, among the respective groups. There was no association between BMI and PFS (p=0.71), OS (p=0.72), or time to recurrence (p=0.71). There were no differences among the increasing BMI groups compared to normal weight women for the risk of death. CONCLUSIONS Our analysis did not reveal any differences in outcomes by BMI group. Our data reveals that obesity is highly prevalent in type II ECs, though obesity has not historically been described as a risk factor. While BMI as a single variable may not be prognostic for survival outcomes, the role of obesity as a risk factor for type II EC should be further investigated, given the increasing prevalence of obesity in type II ECs.

Comparing office and telephone follow-up after medical abortion ☆ ☆☆

OBJECTIVES Compare proportion lost to follow-up, successful abortion, and staff effort in women who choose office or telephone-based follow-up evaluation for medical abortion at a teaching institution. STUDY DESIGN We performed a chart review of all medical abortions provided in the first three years of service provision. Women receiving mifepristone and misoprostol could choose office follow-up with an ultrasound evaluation one to two weeks after mifepristone or telephone follow-up with a scheduled telephone interview at one week post abortion and a second telephone call at four weeks to review the results of a home urine pregnancy test. RESULTS Of the 176 medical abortion patients, 105 (59.7%) chose office follow-up and 71 (40.3%) chose telephone follow-up. Office evaluation patients had higher rates of completing all required follow-up compared to telephone follow-up patients (94.3% vs 84.5%, respectively, p=.04), but proportion lost to follow-up was similar in both groups (4.8% vs 5.6%, respectively, p=1.0). Medical abortion efficacy was 94.0% and 92.5% in women who chose office and telephone follow-up, respectively. We detected two (1.2%) ongoing pregnancies, both in the office group. Staff rescheduled 15.0% of appointments in the office group. For the telephone follow-up cohort, staff made more than one phone call to 43.9% and 69.4% of women at one week and four weeks, respectively. CONCLUSIONS Proportion lost to follow-up is low in women who have the option of office or telephone follow-up after medical abortion. Women who choose telephone-based evaluation compared to office follow-up may require more staff effort for rescheduling of contact, but overall outcomes are similar. IMPLICATIONS Although women who choose telephone evaluation may require more rescheduling of contact as compared to office follow-up, having alternative follow-up options may decrease the proportion of women who are lost to follow-up.

Physicians' approaches to post-abortion care in Manila, Philippines.

To assess the knowledge and practice of health professionals in Manila, Philippines, regarding methods used for uterine evacuation in post‐abortion care (PAC), including the use of misoprostol.