Kate A. Shaw

Posttraumatic stress disorder and risk of spontaneous preterm birth.

OBJECTIVE: To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery. METHODS: We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status. RESULTS: Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14–1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust. CONCLUSION: In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1–4). Posttraumatic stress disorders health effects may extend, through birth outcomes, into the next generation. LEVEL OF EVIDENCE: II

Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review.

OBJECTIVE: To examine the effect of the interval between mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13–24 weeks). DATA SOURCES: We searched MEDLINE (1966–2012), ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, and mifepristone and reviewed reference lists of published reports. METHODS OF STUDY SELECTION: Our search revealed 138 articles of which 29 met inclusion criteria: 20 randomized controlled trials and nine observational studies. Studies were included if, in any study arm, mifepristone and misoprostol were used for medical abortion in the second trimester. TABULATION, INTEGRATION, AND RESULTS: Two authors independently reviewed the articles and abstracted the data using standardized data abstraction templates to summarize data. Discrepancies were resolved by consensus. Three studies directly compared a 1-day to 2-day mifepristone–misoprostol interval; they showed small differences in median induction times (weighted average 7.3 hours, range 7–8.5 for a 1-day interval; weighted average 6.8 hours, range 6.3–7.2 for a 2-day interval) and no significant difference in percent expelled by 12 hours or 24 hours. When all randomized studies using mifepristone and misoprostol were pooled by comparable mifepristone–misoprostol interval and misoprostol dose, induction times (first misoprostol dose to expulsion) were only 1–2 hours longer for a 12- to 24-hour interval compared with a 36–48-hour interval, whereas total abortion times (mifepristone to expulsion) were at least 18 hours longer in the 36- to 48-hour group. Induction times varied by misoprostol dosing, with 400-microgram misoprostol protocols resulting in shorter induction times than 200-microgram protocols. CONCLUSION: Shortening the mifepristone–misoprostol interval, thereby reducing total abortion time, does not compromise the safety or efficacy of second-trimester medication abortion and may be used to accommodate patient or health care provider preference.

Obesity epidemic: how to make a difference in a busy OB/GYN practice.

&NA; At just one-third of the American population, those with a normal body mass index are now in the minority in the United States, whereas 68% are overweight or obese. The key to reducing the prevalence of obesity and improving the health of our population is, of course, screening and prevention. Screening (as simple as a weight and height) is effective, inexpensive, and already part of the routine vital signs taken at every visit. However, providers often avoid tackling the issue of weight due to a misperception that treatment is not effective, or from fear of causing offense or compromising rapport. However, clearly more harm is done by not discussing this important health issue. Cardiovascular disease remains the number 1 killer of women, and obesity is the leading modifiable risk factor. Beyond heart disease, obesity has implications for every visit type seen in the OB/GYN office, from contraception to pregnancy to abnormal bleeding to cancer. In addition, maternal obesity adversely affects future generations, making the impact of obesity a never-ending cycle. OB/GYNs are often the only physicians that reproductive-aged women see, and, thus, OB/GYNs have the opportunity to provide a potentially life-altering intervention. Effective treatment is available and includes lifestyle changes, behavioral counseling, medication, and bariatric surgery. Time is always a limitation in a busy practice but becoming more comfortable with how to approach patients, the language to use and tailoring counseling can save time increase impact. Target Audience: Obstetricians And Gynecologists Learning Objectives: After participating in this activity, physicians should be better able to analyze the obesity epidemic and its implications for our patients and the health care system. Evaluate and use the tools for measuring obesity and incorporate obesity screening and education in a busy practice. Formulate effective therapies and determine when to refer patients for psychological or nutrition counseling, addition of weight loss medication or bariatric surgery.

Immediate postpartum provision of long-acting reversible contraception.

Purpose of review The objective of this review is to describe current literature regarding the role and characteristics of long-acting reversible contraception (LARC) used immediately postpartum. Recent findings Copper and levonorgestrel intrauterine devices (IUDs) inserted immediately postpartum at the time of both vaginal and cesarean deliveries are associated with higher rates of continuation at 6–12 months when compared with IUDs placed at the postpartum visit (4–8 weeks after delivery), despite higher rates of expulsion. IUDs and contraceptive implants are cost-effective when used immediately postpartum, and they are associated with longer interpregnancy intervals. There is limited evidence regarding the effects of immediate postpartum LARC on breastfeeding. Summary Use of LARC methods in the immediate postpartum period is both effective and safe, and could reduce unmet need for contraception during this time. More research is needed to explore various immediate postpartum IUD insertion methods and the effects of immediate postpartum progestin-containing LARC on breastfeeding.

Obesity and oral contraceptives: A clinician's guide

Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinicians greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.

Effect of a combined estrogen and progesterone oral contraceptive on circulating adipocytokines adiponectin, resistin and DLK-1 in normal and obese female rhesus monkeys

BACKGROUND Hormonal contraception is the most common medication used by reproductive aged women but there is little understanding of the impact of hormonal contraception on obesity and metabolism. Adipokine levels (adiponectin, resistin) and markers of adipocyte development (DLK-1) are altered in obese animals and humans and are associated with increased cardiovascular risk. We sought to determine the effect of combined hormonal oral contraceptive pills (COCs) on circulating adiponectin, resistin and DLK-1 levels in obese and normal-weight rhesus macaque monkeys. METHODS Serum adiponectin, resistin and DLK-1 levels in reproductive-age female rhesus macaques of normal (n = 5, mean = 5.76 kg) and inherently obese (n = 5, mean = 8.11 kg) weight were determined before, during and 2 months after cessation of 8 months of continuous treatment with COCs. RESULTS The obese group alone showed a significant decrease (p<.01) in weight with COC use, which returned to baseline after COC cessation. Baseline adiponectin levels prior to COC treatment were lower in the obese group (p<.05). Adiponectin levels increased from baseline in both groups, but more so in the obese group (p<.05). Resistin levels were similar at baseline, with an increase in both groups following treatment. Circulating resistin remained elevated above baseline levels after COC cessation, particularly in the obese group (p<.05). While DLK-1 levels did not change significantly in either group, a trend for higher levels in obese animals was observed. CONCLUSIONS COC use may alter metabolic processes via direct (resistin) or indirect (adiponectin) means, while unchanging DLK1 levels suggest they do not affect adipocyte development. COCs may directly increase resistin levels, as observed in both groups. As adiponectin is inversely related to adipocyte mass, increased levels in the obese group are likely attributed to weight loss.

Post‐traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia

BACKGROUND Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSDs pathophysiology impacts pregnancy. METHODS This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery). RESULTS Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery. CONCLUSIONS The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

Update on long-acting reversible methods.

Purpose of review The last several years have seen a number of important clinical and academic advances in long-acting reversible contraceptive (LARC) methods, such that many professional medical organizations now recommend these methods as first-line contraception for all women. Recent findings Recent data support the use of LARC in a variety of special circumstances including adolescents, nulliparous women and immediately postpartum and postabortion. Evidence also shows that traditional methods of pain control with intrauterine device (IUD) insertion and cervical preparation prior to insertion may not be warranted. Further, the extended use of IUDs is safer and more effective than previously realized. Summary The rising uptake of LARC methods in the United States has the potential to dramatically decrease undesired pregnancies and abortion rates, and should be considered an effective option in the majority of women.

Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen

OBJECTIVE To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake. METHODS This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression. RESULTS Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, β=0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, β=0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001). CONCLUSION Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.

Self-Administered Lidocaine Gel for Pain Control With First-Trimester Surgical Abortion: A Randomized Controlled Trial.

OBJECTIVE: To compare pain control at various time points during first-trimester surgical abortion using a patient-administered lidocaine gel compared with a traditional lidocaine paracervical block. METHODS: We conducted a randomized controlled trial of women undergoing surgical abortion at less than 12 weeks of gestation in an outpatient setting. The primary outcome was pain at cervical dilation as measured on a 100-mm visual analog scale. A sample size of 142 participants was planned to detect a 15-mm or greater difference on the 100-mm visual analog scale with 90% power and a significance level of .025, adding 10% for participant dropout and protocol violations. Participants received either 12 mL of a 1% lidocaine paracervical block or 20 mL of a self-administered, 2% lidocaine gel 20–30 minutes before procedure initiation. Secondary outcomes included anticipated pain, baseline pain, pain with speculum and tenaculum placement, pain after suction aspiration, and pain 30–45 minutes postoperatively. RESULTS: From April to October 2015, a total of 142 women were enrolled (68 in the paracervical block group, 69 in the gel group, and five not analyzed as a result of participant withdrawal). Sociodemographic characteristics were similar between groups. The mean pain score with cervical dilation was 60 mm (95% confidence interval [CI] 54–66) in the paracervical block group and 64 mm (95% CI 59–69) in the gel group (P=.3). There was no significant difference between mean pain scores at any time points measured. CONCLUSION: Self-administration of lidocaine gel before first-trimester surgical abortion is noninferior to a traditional paracervical lidocaine block and should be considered as an alternative, noninvasive approach to pain control for first-trimester surgical abortion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02447029.