Kristina Tocce

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

OBJECTIVE The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion. STUDY DESIGN Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined. RESULTS Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9-12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8-23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1-4.3; P = .03). CONCLUSION IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.

Effect of Body Mass Index and Excessive Weight Gain on Success of Vaginal Birth After Cesarean Delivery

OBJECTIVE: To estimate whether excessive weight gain or obesity are risk factors affecting success for vaginal birth after cesarean (VBAC). METHODS: Patients attempting VBAC were identified by the International Classification of Diseases, 9th Revision, codes “VBAC” and “non-primary C-section” and by reviewing logbooks on labor and delivery. A chart review identified patients attempting VBAC who were eligible for inclusion. Exclusion criteria included multiple gestation, more than one previous cesarean delivery, previous classical uterine scar, delivery at less than 36 weeks of gestation, and incomplete information. Patients were divided into the following categories: underweight (body mass index [BMI] < 19.8), normal weight (BMI 19.8–26), overweight (BMI 26.1–29), and obese (BMI > 29). Excessive weight gain was defined as a weight gain of more than 40 lb. Variables of interest included diabetes, previous successful vaginal delivery or VBAC, and presence of recurrent indication for cesarean delivery. RESULTS: We identified 1,213 patients who met inclusion criteria. Overall, the VBAC success rate was 77.2%. The success rates for BMI less than 19.8, 19.8–26, 26.1–29, and greater than 29 were 83.1%, 79.9%, 69.3%, and 68.2%, respectively, P < .001. Obese patients were almost 50% less likely to have a successful VBAC when compared to underweight patients, odds ratio 0.53, 95% confidence interval 0.29–0.98, P = .043. Similarly, patients who gained more than 40 lb were almost 40% less likely to be successful at VBAC than those who gained less than that amount, odds ratio 0.63, 95% confidence interval 0.42–0.97, P = .034. They had a VBAC success rate of 66.8%, whereas patients who gained less than 40 lb were successful 79.1% of the time, P < .001. CONCLUSION: Excessive weight gain during pregnancy and obesity both decrease VBAC success. Proper patient selection will help increase the likelihood of successful VBAC. LEVEL OF EVIDENCE: II-2

Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost-effective?

OBJECTIVE The objective of the study was to determine the cost-effectiveness of a hypothetical state-funded program offering immediate postpartum implant (IPI) insertion for adolescent mothers. STUDY DESIGN Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, n = 171) vs standard contraceptive initiation (comparison group, n = 225). Implant discontinuation, repeat pregnancies and pregnancy outcomes were determined. We compared the anticipated public expenditures for IPI recipients and comparisons at 6, 12, 24, and 36 months postpartum using the actual outcomes of this cohort and Colorado Medicaid reimbursement estimates. Costs were normalized to 1000 adolescents in each arm and included 1 year of well-baby care for delivered pregnancies. RESULTS At 6 months, the expenditures of the IPI group exceed the comparison group by

Postplacental intrauterine device expulsion by 12 weeks: A prospective cohort study

73,000. However, at 12, 24, and 36 months, publicly funded IPIs would result in a savings of more than

First trimester myomectomy as an alternative to termination of pregnancy in a woman with a symptomatic uterine leiomyoma: a case report

550,000,

Reasons for Ineffective Contraceptive Use Antedating Adolescent Pregnancies: Part 2: A Proxy for Childbearing Intentions

2.5 million, and

Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation.

4.5 million, respectively. For every dollar spent on the IPI program,

Scheduled hysterectomy for second-trimester abortion in a patient with placenta accreta.

0.79,

Comfort With Skills and Knowledge After Immediate Postpartum Intrauterine Device Training.

3.54, and

Umbilical cord transection to induce fetal demise prior to second-trimester D&E abortion: in reply

6.50 would be saved at 12, 24, and 36 months. Expenditures between the IPI and comparison groups would be equal if the comparison group pregnancy rate was 13.8%, 18.6%, and 30.5% at 12, 24, and 36 months. Actual rates were 20.1%, 46.5%, and 83.7%. CONCLUSION Offering IPIs to adolescent mothers is cost effective. Payors that do not currently cover IPI should integrate these data into policy considerations.