Jessica Kiley

Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block

BACKGROUND This study was conducted to investigate the effects of a 1% lidocaine paracervical block on perceived patient pain during intrauterine device (IUD) insertion. STUDY DESIGN We randomized 50 women undergoing IUD insertion to receive either a 10-mL 1% lidocaine paracervical block or no local anesthetic before IUD insertion. Women marked their pain on a 100-mm visual analogue scale (VAS) (0 mm = no pain, 100 mm = worst pain possible) at various points of the procedure (speculum insertion, tenaculum placement, paracervical block administration, IUD insertion and 5 min postprocedure). RESULTS Twenty-six women received the paracervical block before IUD insertion, and 24 received no local anesthesia. Groups were similar in age, parity, ethnicity, education and complications. Women who received the paracervical block reported a median VAS score of 24.0 mm with IUD insertion, and women who did not receive local anesthetic reported a median VAS score of 62.0 mm with IUD insertion; p=.09. CONCLUSION Compared with no anesthetic, a 1% lidocaine paracervical block did not result in a statistically significant decrease in perceived pain with IUD insertion.

Delays in request for pregnancy termination: comparison of patients in the first and second trimesters

BACKGROUND Despite the availability of first trimester abortion services in urban settings, many women request abortion in the second trimester. We identified protective and risk factors associated with women who delay requesting abortions until the second trimester. STUDY DESIGN The study was a cross-sectional survey of 247 patients requesting surgical abortion at an urban family planning clinic. Survey and medical records data were analyzed for associations between 18 risk factors and incidence of second trimester request. RESULTS Thirty-two percent of subjects presented in the second trimester. Chi-square analyses revealed that first trimester participants were more often employed (p<.0001), privately insured (p=.01), or had previous abortions (p=.04). Second trimester patients were younger (p<.0001), more often primigravid (p=.04), experienced more difficulty financing the procedure (p<.0001) and finding a surgeon (p<.0001), traveled longer distances (p=.005), and more often feared the procedure (p=.03). Using multiple logistic regression, women requesting second trimester abortions were more likely to report: obstacles financing the abortion (OR 2.34, 95% CI 1.28-4.28); traveling long distances (OR 2.88, 95% CI 1.31-6.31); and fear (OR 2.45, 95% CI 1.17-5.17). These women were less often employed outside the home (OR 0.35, 95% CI 0.19-0.64). CONCLUSIONS Physicians and advocates must strive to reduce abortion costs, increase access to trained surgeons, and allay womens fears of abortion procedures.

estradiol valerate and dienogest: a new approach to oral contraception

Most combination oral contraceptives contain ethinyl estradiol and a progestin. A new and novel oral contraceptive formulation combines estradiol valerate (E2V) with dienogest (DNG) in a four-phase dosing regimen. 17β-estradiol is a naturally-occurring estrogen, and a contraceptive pill containing such an estrogen offers potential benefits with regard to metabolic side effects and adverse events. Dienogest is derived from 19-nortestosterone and exerts profound progestational effects on the endometrium, but it differs from other progestins in its class by its antiandrogenic activity. Estradiol valerate plus dienogest (E2V/DNG) is now available in a four-phasic regimen that integrates an estrogen stepdown and progestin stepup dosing approach along with a short two-day hormone-free interval. This regimen offers safe, reliable contraception and has been shown to be an effective treatment for heavy menstrual bleeding. Metabolic effects and adverse events appear similar to those reported with oral contraceptives containing ethinyl estradiol.

The lowest-dose, extended-cycle combined oral contraceptive pill with continuous ethinyl estradiol in the United States: a review of the literature on ethinyl estradiol 20 μg/levonorgestrel 100 μg + ethinyl estradiol 10 μg

Extended-cycle oral contraceptives (OCs) are increasing in popularity in the United States. A new extended-cycle OC that contains the lowest doses of ethinyl estradiol (EE) and levonorgestrel (LNG) + continuous EE throughout the cycle is now available. It provides 84 days of a low-dose, combined active pill containing levonorgestrel 100 μg and ethinyl estradiol 20 μg. Instead of 7 days of placebo following the active pills, the regimen delivers 7 days of ethinyl estradiol 10 μg. Existing studies reveal a similar efficacy and adverse effect profile compared with other extended-regimen OCs. Specifically, the unscheduled bleeding profile is similar to other extended-cycle OCs and improves with the increase in the duration of use. Although lower daily doses of hormonal exposure have potential benefit, to our knowledge, there are no published studies indicating that this specific regimen offers a lower incidence of hormone-related side effects or adverse events. In summary, this new extended-cycle OC provides patients a low-dose, extended-regimen OC option without sacrificing efficacy or tolerability.

Team-based learning: a novel approach to medical student education in family planning

BACKGROUND Medical schools are increasingly using team-based learning (TBL). We compared medical student satisfaction and understanding of key concepts in family planning following TBL and traditional lectures. STUDY DESIGN During the OB/GYN clinical rotation orientation, third year medical students completed a pretest in family planning. Students in the odd-numbered clerkships participated in TBL, and students in the even-numbered clerkships participated in lectures. Both groups of students completed a posttest and satisfaction survey. RESULTS A total of 130 students participated in this study. Sixty-nine students were in the TBL group, and 61 students were in the lecture group. The TBL group reported higher scores when asked if the learning style was a valuable experience (p=.045), helped them learn the course material (p=.01) and improved problem-solving skills (p=.04). Both groups gained significant amount of knowledge (p<.001) as calculated by the Students paired t test. The change in scores was not significantly different between the groups (p=.73), as calculated using the Students unpaired t test. CONCLUSION As a learning strategy for family planning, TBL resulted in high student satisfaction. This is the first study to evaluate this innovative teaching style for medical student education in family planning.

Recurrent massive perivillous fibrin deposition in the placenta associated with fetal renal tubular dysgenesis: case report and literature review.

Massive perivillous fibrin deposition (MPVFD) of the placenta and renal tubular dysgenesis (RTD) are relatively rare diseases with potential recurrent risks that have not previously associated in the literature. Herein, we report the clinical course, autopsy findings, and placental pathologic features from 3 consecutive pregnancies delivered in 1 woman, all showing recurrent MPVFD in the placenta and RTD in the bilateral fetal kidneys.

Contraception Is a Fundamental Primary Care Service

The Affordable Care Act (ACA) requires health care plans after August 1, 2012, to cover preventive health services recommended by the Institute of Medicine and endorsed by the Department of Health and Human Services. Covered services promote development of a health care system that sustains health rather than merely treats illness. Many services, such as cervical cancer screening, sexually transmitted infection (STI) screening, and contraceptive services, promote the health and well-being of women.1 Some religious organizations and private employers, however, have demanded exemption from providing contraception, arguing that it violates their religious beliefs. We believe that allowing such an exception is at odds with evidence-based preventive care, inconsistent with actual patterns of contraceptive use among women who are religious, and a sectarian incursion into private health care decisions that is without parallel in the US health care system.

Postpartum glucose tolerance in women with gestational diabetes using levonorgestrel intrauterine contraception.

OBJECTIVE Postpartum contraception is critical in women with gestational diabetes mellitus (GDM). We evaluated the effect of the levonorgestrel intrauterine system (LNG-IUS) on glucose tolerance in postpartum women with GDM. STUDY DESIGN The study is a descriptive analysis of 12-month glucose tolerance in women with recent GDM who used the LNG-IUS, the copper IUD or postpartum sterilization. RESULTS Twelve months postpartum, 3 of 13 LNG-IUS users (23.1%) and 1 of 6 nonhormonal contraceptive users (16.6%) had prediabetes. No woman developed overt diabetes. CONCLUSIONS This study is the first and only to measure the metabolic effects of the LNG-IUS women with GDM. Larger trials are necessary. IMPLICATIONS Use of levonorgestrel intrauterine contraception does not appear to negatively affect glucose tolerance in postpartum women with a history of gestational diabetes. Additional appropriately powered clinical studies are needed to confirm these results.

Labor induction outcomes in third-trimester stillbirths

To describe the management of third‐trimester stillbirth at a single institution, stratifying induction intervals and adverse outcomes by method.

Assessment of contraceptive needs in women undergoing bariatric surgery

OBJECTIVE To evaluate documentation of contraception and counseling in women planning to undergo bariatric surgery. STUDY DESIGN Chart review of 1012 women ages 18-45years presenting for bariatric surgery evaluation. Data on socio-demographic variables, documented contraceptive method, preconception counseling, gynecology referrals and postoperative pregnancies were collected. RESULTS The charts of only 272 women (26.9%) contained documentation of a contraceptive method; the most common was oral contraceptives (n=132, 48.5%). Sixteen pregnancies were identified in the first 18months postoperatively. CONCLUSIONS Currently, the documentation of contraceptive counseling is lacking in clinical practice. Measures to enhance provider and patient awareness of these issues will improve patient care. IMPLICATIONS Pregnancy planning and documentation of perioperative contraceptive use in women undergoing bariatric surgery are suboptimal, placing these women at risk of unintended pregnancies. Future research should delineate the best practices in contraceptive provision in this high-risk population of women.