Jennifer H. Tang

WHO recommendations for misoprostol use for obstetric and gynecologic indications

Misoprostol, a prostaglandin E1 analog, stimulates uterine contractility and cervical ripening. A number of randomized trials and systematic reviews have evaluated its use in obstetric and gynecologic conditions. Misoprostol is inexpensive, stable at room temperature, and available in more than 80 countries, making it particularly useful in resource‐poor settings. WHO recognizes the crucial role of misoprostol in reproductive health and has incorporated recommendations for its use into 4 reproductive health guidelines focused on induction of labor, prevention and treatment of postpartum hemorrhage, and management of spontaneous and induced abortion.

Effect of protease inhibitor therapy on glucose intolerance in pregnancy.

OBJECTIVE: To determine if protease inhibitor use was associated with increased glucose intolerance in our population of pregnant women infected with the human immunodeficiency virus (HIV). METHODS: Women who were infected with HIV from January 1, 1998, to January 8, 2004, and who had a 1-hour and 3-hour glucola test were identified. Medical records were reviewed to obtain demographic characteristics and obstetric and laboratory data. Drug regimens at the time of glucola testing were determined. Human immunodeficiency virus–infected women were then matched 1:3 to HIV-noninfected gravidas by race, age, and year of delivery. RESULTS: One hundred seventy-one HIV-infected women had glucola results available. Twelve percent had an abnormal 1-hour glucola result and 3% had an abnormal 3-hour result. This was similar to the HIV-noninfected population. Forty-five percent of the HIV-infected cohort was on a protease inhibitor at the time of glucola testing. Protease inhibitor exposure had no effect on glucola test results. HIV infection itself also did not increase abnormal glucola test results. CONCLUSION: Glucose intolerance in this obstetric population was not associated with the diagnosis of HIV or with the use of protease inhibitors. Protease inhibitors should continue to be an option for the treatment of HIV in pregnancy. LEVEL OF EVIDENCE: II-2

Characteristics associated with interest in long-acting reversible contraception in a postpartum population.

BACKGROUND Short interpregnancy intervals lead to adverse perinatal outcomes and could be prevented with increased use of long-acting reversible contraception (LARC) in the postpartum period. The primary objective of this study was to assess which baseline characteristics are associated with the intent to use LARC among postpartum women. STUDY DESIGN This study was a substudy of baseline data from a randomized controlled trial. Eight hundred women completed a pre-intervention survey of demographics and reproductive health history and intentions. We estimated adjusted relative risks (RRs) of intent to use LARC for baseline characteristics of interest. RESULTS Three hundred three postpartum women (38%) intended to use LARC. Two out of 10 baseline characteristics were significantly associated with intent to use LARC: not trying for pregnancy at time of conception [adjusted RR, 1.6; 95% confidence interval (CI), 1.2-2.1] and no desire for another pregnancy within 2 years (adjusted RR, 1.9; 95% CI, 1.2-2.8). CONCLUSIONS High interest in LARC exists among postpartum women, particularly among women with a recent unintended pregnancy and women who do not desire pregnancy for at least 2 years. Past and future pregnancy intentions should be incorporated into future models and frameworks that evaluate postpartum contraceptive choice. Educational intervention studies are also needed to assess if LARC interest can be increased among postpartum women who are less likely to intend to use LARC but at risk for future adverse perinatal outcomes.

Barriers to Receiving Long-acting Reversible Contraception in the Postpartum Period.

OBJECTIVE To assess why postpartum women who desired long-acting reversible contraception (LARC) did not receive it in the postpartum period and to assess which contraceptive methods they were using instead. STUDY DESIGN This was a subgroup analysis of 324 women enrolled in a randomized, controlled trial to receive or not receive an educational LARC script during their postpartum hospitalization. Participants in this subgroup analysis stated that they were either using LARC (n = 114) or interested in using LARC (n = 210) during a follow-up survey completed after their scheduled 6-week postpartum visit. Modified Poisson regression analysis was used to assess for characteristics associated with using LARC by the time of the follow-up survey. RESULTS Women who were interested in LARC but not using it were more likely to be multiparous (relative risk [RR], 1.59; 95% CI, 1.19-2.11) and to have missed their postpartum visit (RR, 25.88; 95% CI, 3.75-178.44) compared with those using LARC. Among the interested 210 who were not using LARC, the most common reasons provided for non-use were that they were told to come back for another insertion visit (45%), missed the postpartum visit (26%), and could not afford LARC (11%). The most common contraceptive methods used instead of LARC were barrier methods (42%) and abstinence (19%); 18% used no contraceptive method. CONCLUSION Two-thirds (65%) of postpartum women who desired to use LARC did not receive it in the postpartum period and used less effective contraceptive methods. Increasing access to immediate postpartum LARC and eliminating two-visit protocols for LARC insertion may increase postpartum LARC use. As the Affordable Care Act moves toward full implementation, it is necessary to understand the barriers that prevent interested patients from receiving LARC.

A review of evidence for safe abortion care

BACKGROUND The provision of safe abortion services to women who need them has the potential to drastically reduce or eliminate maternal deaths due to unsafe abortion. The World Health Organization recently updated its evidence-based guidance for safe and effective clinical practices using data from systematic reviews of the literature. MATERIALS AND METHODS Systematic reviews pertaining to the evidence for safe abortion services, from pre-abortion care, medical and surgical methods of abortion and post-abortion care were evaluated for relevant outcomes, primarily those relating to safety, effectiveness and womens preference. RESULTS Sixteen systematic reviews were identified and evaluated. The available evidence does not support the use of pre-abortion ultrasound to increase safety. Routine use of cervical preparation with osmotic dilators, mifepristone or misoprostol after 14 weeks gestation reduces complications; at early gestational ages, surgical abortions have very few complications. Prophylactic antibiotics result in lower rates of post-surgical abortion infection. Pain medication such as non-steroidal anti-inflammatories should be offered to women undergoing abortion procedures; acetaminophen, however, is not effective in reducing pain. Women who are eligible should be offered a choice between surgical (vacuum aspiration or dilation and evacuation) and medical methods (mifepristone and misoprostol) of abortion when possible. Modern methods of contraception can be safely initiated immediately following abortion procedures. CONCLUSIONS Evidence-based guidelines assist health care providers and policymakers to utilize the best data available to provide safe abortion care and prevent the millions of deaths and disabilities that result from unsafe abortion.

Efficacy of an accelerated hepatitis B vaccination program during pregnancy.

OBJECTIVE: To estimate the feasibility and immunogenicity of an accelerated hepatitis B vaccination schedule of 0, 1, and 4 months in high-risk pregnant women. METHODS: We conducted a prospective clinical trial of high-risk pregnant women who were hepatitis B surface antigen-negative at presentation for prenatal care. A detailed questionnaire was administered and eligible women received a hepatitis B vaccine intramuscularly on a 0-, 1-, and 4-month schedule. Adverse reactions and hepatitis B surface antigen seroconversion rates were documented. Factors influencing seroconversion were determined. RESULTS: Two hundred high-risk pregnant women were enrolled; 84% completed the three-dose vaccine series. Seroconversion (hepatitis B surface antigen 10 milli-international units/mL or greater) after one dose was 56% (95% confidence interval [CI], 49–63%), 77% (95% CI, 71–83%) after two doses, and 90% (95% CI, 85–94%) after completing three doses. Body mass index was inversely associated with seroconversion rates (P<.001). There was no single body mass index above which seroconversion did not occur. There were no serious adverse events; injection site discomfort was the most prevalent complaint (10.5%). CONCLUSION: An accelerated hepatitis B vaccination schedule at 0, 1, and 4 months in high-risk pregnant women is effective, practical, and well tolerated. This accelerated vaccine strategy can be completed during the course of pregnancy and provides another means of decreasing hepatitis B virus disease and transmission. LEVEL OF EVIDENCE: II

Effect of an educational script on postpartum contraceptive use: a randomized controlled trial

OBJECTIVES Short interpregnancy intervals are associated with adverse perinatal outcomes. Increased postpartum use of long-acting reversible contraception (LARC) could reduce short interpregnancy intervals. Therefore, the primary objective of our study was to evaluate if a postpartum educational script about LARC (LARC script) could increase postpartum LARC utilization at the 6-week postpartum visit. STUDY DESIGN We completed a randomized controlled trial (1:1) of 800 postpartum women in Raleigh, North Carolina. Women were recruited from the postpartum unit and randomized to receive (intervention) or not receive (control) the LARC script prior to hospital discharge. We conducted follow-up phone interviews to assess LARC use after their 6-week postpartum visit. We used Pearsons chi-squared test to compare LARC use between arms. RESULTS Between May 2011 and January 2012, 400 women were randomized to each arm. Three hundred sixty-nine women (92.3%) in each arm were successfully contacted after their 6-week postpartum visit. LARC use was reported by 17.6% and 13.3% of women in the intervention and control arms, respectively (p=.103). CONCLUSIONS The LARC script did not increase LARC utilization at the 6-week postpartum visit. Future studies should evaluate interventions that address both educational and systematic barriers to postpartum LARC uptake. IMPLICATIONS Use of a postpartum educational script focused on the intrauterine device and contraceptive implant did not increase their utilization after the 6-week postpartum visit. Future studies should evaluate interventions that address both educational and systematic barriers to postpartum contraceptive uptake.

Intrauterine Device Knowledge and Practices: A National Survey of Obstetrics and Gynecology Residents

Objectives The primary objective of this study was to assess the current intrauterine device (IUD) knowledge and counseling practices of US obstetrics and gynecology chief residents. The secondary objective was to evaluate the current IUD experience of obstetrics and gynecology residents. Methods A Web-based survey about IUD knowledge and practices was sent to US obstetrics and gynecology residents in January 2010. An analysis of responses by postgraduate year was completed using descriptive statistics. Results We received 699 surveys (36%) from a pool of 1922 residents in 96 different residency programs. A total of 654 respondents (94%) had placed an IUD during residency and 88% had received formal teaching about IUDs during residency. Only 53% of respondents knew that the copper IUD could be used for emergency contraception. Less than 65% of respondents would routinely recommend the IUD to adolescents or immediately after first trimester abortion. Conclusions Many US obstetrics and gynecology residents lack knowledge about IUD benefits and do not counsel all eligible women to use IUDs. We should continue to evaluate our training and educational programs to ensure that women’s health providers do not act as a barrier to IUD use.

Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women

The objectives of this study were to describe the most recent pregnancy intentions and family planning preferences of HIV-infected and HIV-uninfected postpartum Malawian women, and to assess whether HIV status is associated with fertility desire and knowledge of intrauterine contraception (IUC) and the subdermal contraceptive implant. We conducted a cross-sectional analysis of the baseline characteristics of Malawian women enrolled in a prospective cohort study assessing postpartum contraceptive uptake and continuation. Women at a government hospital completed a baseline survey assessing reproductive history, family planning preferences, and knowledge of IUC and the implant. We used Pearsons chi-square tests to compare these parameters between HIV-infected and HIV-uninfected women. Modified Poisson regression was performed to assess the association between HIV status and fertility desire and knowledge about IUC and the implant. Of 634 postpartum women surveyed, HIV-infected women were more likely to report their most recent pregnancy was unintended (49% vs. 37%, p = 0.004). Nearly all women (97%) did not want a child in the next 2 years, but HIV-infected women were more likely to desire no more children (adjusted prevalence ratio [PR]: 1.59; 95% confidence interval [CI]: 1.33, 1.89). HIV-infected women were also less likely to know that IUC (adjusted PR: 0.72; 95% CI: 0.61, 0.84) and the implant (adjusted PR: 0.83; 95% CI: 0.75, 0.92) are safe during breast-feeding. Postpartum women strongly desire family spacing and many HIV-infected postpartum women desire no more children, suggesting an important role for these long-acting methods. Education about the efficacy and safety of IUC and the implant particularly during breast-feeding may facilitate postpartum use.

Patterns of contraceptive adoption, continuation, and switching after delivery among Malawian women

Women who report use of postpartum family planning may not continue their initial method or use it consistently. Understanding the patterns of method uptake, discontinuation, and switching among women after delivery is important to promote uptake and continuation of effective methods of contraception. This is a secondary analysis of 634 Malawian women enrolled into a prospective cohort study after delivery. They completed baseline surveys upon enrollment and follow-up telephone surveys 3, 6, and 12 months post-delivery. Women were included in this analysis if they had completed at least the 3- and 6-month post-delivery surveys. Descriptive statistics were used to assess contraceptive method mix and patterns of switching, whereas Pearson’s χ2 tests were used for bivariable analyses to compare characteristics of women who continued and discontinued their initial post-delivery contraceptive method. Among the 479 women included in this analysis, the use of abstinence/traditional methods decreased and the use of long-acting and permanent methods (LAPM) increased over time. Almost half (47%) discontinued the contraceptive method reported at 3-months post-delivery; women using injectables or LAPM at 3-months post-delivery were significantly more likely to continue their method than those using non-modern methods (p<0.001). Of the 216 women who switched methods, 82% switched to a more or equally effective method. The change in contraceptive method mix and high rate of contraceptive switching in the first 12 months postpartum highlights a need to assist women in accessing effective contraceptives soon after delivery.