Lindsay Zimmerman

Predictors of Persistent or Recurrent Disease After Loop Electrosurgical Excision Procedure.

Objective Follow-up recommendations after an excisional procedure vary depending on whether or not there is a positive ectocervical or endocervical margin or endocervical curettage (ECC). The purpose of this study was to evaluate the importance of these findings in predicting recurrent/persistent (r/p) disease in a sample of human immunodeficiency virus (HIV)-seropositive and -negative patients. Materials and Methods Loop electrosurgical excision procedures with a concurrent ECC performed at the Cook County ambulatory clinic between September 29, 2008, and April 15, 2014 were included in this study. Chart review was performed to collect demographic data, pathology results, and all subsequent cytology or histology. We examined the association of these factors with r/p disease using &khgr;2 and Fisher exact tests as well as log-binomial regression. Results There were 242 women included for analysis. Of these, 9 LEEP specimens showed invasive cancer or adenocarcinoma in situ, and 15.7% were HIV positive. Mean follow-up was 16.4 months. On bivariate analysis, HIV serostatus, LEEP histology, ectocervical margin, endocervical margin, and ECC were all associated with r/p disease. On multivariate regression, only HIV serostatus and ECC were associated with r/p disease. Among women with either a positive endocervical or ectocervical margin or ECC, the prevalence of r/p disease is 29% if they are HIV negative, and 75% if they are positive. Conclusions In our study, ECC seems more predictive of r/p disease than margin status. Most HIV-positive women with positive margins or ECC have r/p disease, whereas most HIV-negative women do not. One should consider HIV serostatus when deciding whether or not to perform repeat excision.

Blood Loss as a Function of Body Surface Area: Redefining Parameters of Obstetric Blood Loss

OBJECTIVE: To identify average blood loss in vaginal and cesarean deliveries in a cohort of women based on body surface area and compare this with the standard definitions. METHODS: In this descriptive study, we analyzed data from 459 deliveries. We identified the median estimated blood loss across the sample. Using body surface area, we calculated the total blood volume for each woman and represented estimated blood loss as a percentage of total blood volume. For each quintile of body surface area, we determined the median estimated blood loss at delivery, the median total blood volume, and the volumes of blood loss that represent 5%, 10% and 15% of total blood volume, respectively. RESULTS: A total of 459 women met inclusion criteria. Median body surface area was 1.9 m2 and median total blood volume was 5,046 mL. Median estimated blood loss was 300 mL and represented 5.9% of total blood volume. For each body surface area quintile, median estimated blood loss and percent total blood volume were: quintile 1, 250 mL, 5.7% total blood volume; quintile 2, 400 mL, 8.5% total blood volume; quintile 3, 300 mL, 5.9% total blood volume, quintile 4, 300 mL, 5.6% total blood volume, and quintile 5, 400 mL, 6.7% total blood volume. CONCLUSION: Redefining obstetric blood loss as a percentage of total blood volume rather than one universal value may help appropriate targeting of interventions.

Pregnancy intention screening tools: a randomized trial to assess perceived helpfulness with communication about reproductive goals

BackgroundFederal and clinical guidelines support integration of reproductive life planning in the care of female patients to aid in the reduction of unplanned pregnancies. A multitude of tools have been created to help in the counseling component, but further research is needed regarding how and whether they facilitate patient-provider communication.ResearchWe performed a randomized controlled trial to evaluate if patients report whether a detailed or simple pregnancy intention screening tool is helpful for communication of reproductive life plans. We compared a novel reproductive counseling aid, the Family Planning Quotient (FPQ), to a simple tool based on the One Key Question® (OKQ). Providers also evaluated whether they thought the tool used at the visit was helpful. We randomized 93 patients to complete a survey including identical demographic questions and either the FPQ or OKQ reproductive counseling tool. We did not provide further instructions to either the patient or provider. Following the visits, we collected 84 subject evaluations and 79 provider evaluations. A similar proportion of subjects using either reproductive counseling tool found it helpful in communicating their reproductive life plans to their providers (approximately 66%), but there was no difference between the two tools studied. Less than half of providers reported that the FPQ tool was helpful (FPQ: 16/43, 37.2% versus OKQ: 18/36, 50%; p = 0.25).ConclusionTwo-thirds of patients reported either a detailed or simple reproductive plan screening tool was helpful to facilitate communication with their provider, but only half of providers found either tool helpful. Use of reproductive screening tools should be followed by patient-centered counseling to help patients meet their reproductive life goals.

A Novel Patient Recruitment Strategy: Patient Selection Directly from the Community through Linkage to Clinical Data

OBJECTIVE This article presents and describes our methods in developing a novel strategy for recruitment of underrepresented, community-based participants, for pragmatic research studies leveraging routinely collected electronic health record (EHR) data. METHODS We designed a new approach for recruiting eligible patients from the community, while also leveraging affiliated health systems to extract clinical data for community participants. The strategy involves methods for data collection, linkage, and tracking. In this workflow, potential participants are identified in the community and surveyed regarding eligibility. These data are then encrypted and deidentified via a hashing algorithm for linkage of the community participant back to a record at a clinical site. The linkage allows for eligibility verification and automated follow-up. Longitudinal data are collected by querying the EHR data and surveying the community participant directly. We discuss this strategy within the context of two national research projects, a clinical trial and an observational cohort study. CONCLUSION The community-based recruitment strategy is a novel, low-touch, clinical trial enrollment method to engage a diverse set of participants. Direct outreach to community participants, while utilizing EHR data for clinical information and follow-up, allows for efficient recruitment and follow-up strategies. This new strategy for recruitment links data reported from community participants to clinical data in the EHR and allows for eligibility verification and automated follow-up. The workflow has the potential to improve recruitment efficiency and engage traditionally underrepresented individuals in research.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in an urban public hospital pregnancy termination clinic

This study is a follow-up observational study to assess the prevalence of chlamydia (CT) and gonorrhea (GC) among women who undergo a first-trimester surgical termination in a large public, urban hospital-based termination clinic, and to compare the rates to previously published data. We conducted a retrospective chart review on 4197 patients who underwent CT and GC testing before an elective, first-trimester surgical termination between 1 June 2014 and 31 May 2015. The prevalence rates were calculated and compared by chi square tests to previously published data from 1 January 2006 to 30 June 2006 from the same publicly-funded pregnancy termination clinic. Our study population comprised mostly of African Americans (86.8%), and more than half were aged less than 25 years. The overall prevalence of CT in our population was 9.6%, which was significantly different to the prevalence of 11.4% in 2006 (p value = 0.03). The overall prevalence of GC in our population was 1.9%, which was not significantly different to the prevalence of 2.6% in 2006. To conclude, this study demonstrates the high prevalence rate of CT-positive and GC-positive patients in our publicly-funded pregnancy termination clinic. The prevalence of infection with CT and GC in our study is higher than in other family planning clinics. Regular screening of all patients who undergo induced termination in pregnancy termination clinics can provide a valuable opportunity for physicians to counsel patients about sexually transmitted infection prevention and treatment prior to the procedure or distribution of medications.

Applicability of the modified ACOG/SGO referral criteria for adnexal mass within a limited‐resource setting

To evaluate the performance of the modified American Congress of Obstetricians and Gynecologists (ACOG)/Society of Gynecologic Oncology (SGO) referral guidelines in a high‐risk limited‐resource setting.

Follow-up After Molar Pregnancy: Discussion of Feasibility of Semiquantitative Urine Pregnancy Tests [198]

INTRODUCTION: Regular human chorionic gonadotropin (hCG) monitoring for 1 year after evacuation of a molar pregnancy allows early diagnosis of recurrence or persistence. Compliance can be difficult, especially for a population without established care. Our objective was to evaluate the safety and feasibility of reducing blood draws with home semiquantitative urinary pregnancy tests. METHODS: A retrospective review of all cases of complete moles followed at our gynecologic oncology clinic. Data were extracted from electronic medical records. Serum hCG was compared with a model using semiquantitative urinary pregnancy test cutoffs of 10,000, 2,000, 500, 100, and 25 international units per liter. RESULTS: Sixty-one complete moles were diagnosed. Forty-two (68.9%) were followed to serum hCG less than 5, and 18 (29.5%) completed surveillance. On average, patients underwent 13 blood draws (standard deviation [SD]±8.1) and took 71 days (SD±39) to reach hCG under 5. All hCG drawn within 2 weeks declined to less than 10,000. All compliant patients had hCG less than 2,000 within 64 days, under 500 within 70 days, under 100 within 89 days (90% within 2 months), and under 25 within 152 days (SD±38) (95.2% within 3 months). After reaching hCG less than 25, hCG rose only in cases of new pregnancies. Data from 17 partial moles are also available. CONCLUSION: Our results demonstrated difficulties with compliance to serum hCG monitoring in our patient population. A home urinary semiquantitative urinary pregnancy test could be used to safely document appropriately declining hCG, limiting blood draws to patients with increasing hCG, hCG above 100 at 2 months, or above 25 at 3 months after diagnosis.

Utilization of the Family Planning Quotient in Three Cohorts of Women [250].

INTRODUCTION: In response to the Centers for Disease Control and Preventions reproductive life plan, we developed the Reproductive Life Index and its unit of measure, the Family Planning Quotient to visually present and quantitatively assess reproductive health goals and outcomes. The objective of this study is to present utilization of Family Planning Quotient in three populations. METHODS: The Family Planning Quotient is a ratio of the number of children a woman has divided by the number she wants at one time point. A Family Planning Quotient less than 1 indicates a woman wants more children and a Family Planning Quotient greater than 1 indicates a woman has achieved or exceeded her family plans. The Family Planning Quotient can be used on a population level to capture overall reproductive health status. The Family Planning Quotient was sampled in three populations: 468 family planning providers in a national survey of family planning providers, 1,780 patients presenting for first-trimester abortion, and 124 patients in the Title X program. RESULTS: Among family planning providers, 59.2% had a quotient less than 1, 39.3% equal to 1, and 1.5% greater than 1. Among first-trimester abortions, 35.9% had a quotient less than 1, 58.9% equal to 1, and 5.2% greater than 1. Among Title X programs, 44.4% had a quotient less than 1, 49.2% equal to 1, and 6.5% greater than 1. Family Planning Quotients were significantly different when stratified by age among the family planning providers (P<.001), patients presenting for first-trimester abortion (P<.001), and Title X programs (P=.004). CONCLUSION: The Reproductive Life Index/Family Planning Quotient is an innovative tool to assist patients and health care providers in the discussion of reproductive health plans and should be further implemented to demonstrate its effect on reproductive planning.

Prevalence of rape-related pregnancy as an indication for abortion at two urban family planning clinics ☆ ☆☆

OBJECTIVE We sought to estimate the prevalence of rape-related pregnancy as an indication for abortion at two public Chicago facilities and to describe demographic and clinical correlates of women who terminated rape-related pregnancies. METHODS We performed a cross-sectional study of women obtaining abortion at the Center for Reproductive Health (CRH) at University of Illinois Health Sciences Center and Reproductive Health Services (RHS) at John H. Stroger, Jr. Hospital between August 2009 and August 2013. Gestational age limits at CRH and RHS were 23+6 and 13+6weeks, respectively. We estimated the prevalence of rape-related pregnancy based on billing code (CRH) or data from an administrative database (RHS), and examined relationships between rape-related pregnancy and demographic and clinical variables. RESULTS Included were 19,465 visits for abortion. The majority of patients were Black (85.6%). Prevalence of abortion for rape-related pregnancy was 1.9%, and was higher at CRH (6.9%) than RHS (1.5%). Later gestational age was associated with abortion for rape-related pregnancy (median 12days, p<.001). Younger age and Black race were associated with abortion for rape-related pregnancy at CRH only (p<.001 for both). Chlamydia and gonorrhea infection were no more prevalent among women terminating rape-related pregnancy than among those terminating for other indications. CONCLUSION Rape-related pregnancy as an indication for abortion had a low, but clinically significant prevalence at two urban Chicago family planning centers. Later gestational age was associated with abortion for rape-related pregnancy. IMPLICATIONS Rape-related pregnancy may occur with higher prevalence among some subgroups of women seeking abortion than others. Efforts to address rape-related pregnancy in the abortion care setting are needed.

One-Hour Buccal Misoprostol Compared With Osmotic Dilators for Cervical Preparation in Early Surgical Abortion

INTRODUCTION: We sought to compare the effectiveness of 1 hour of 400 micrograms buccal misoprostol with overnight osmotic dilators in early second-trimester surgical abortion. METHODS: We conducted a retrospective cohort study reviewing 170 charts from Family Planning Associates in Chicago, Illinois, to compare procedure times for women who received 400 micrograms of buccal misoprostol 1 hour preprocedure compared with overnight osmotic dilators before dilation and evacuation between 14 and 15 6/7 weeks of gestation. Primary outcome was procedure time and secondary outcomes included suction curette size, estimated blood loss, vaginal bleeding, pain, and nausea or vomiting. RESULTS: Eighty-one women (47.65%) received overnight osmotic dilators and 89 (52.35%) received buccal misoprostol. Groups did not differ regarding gestational age, demographic factors, or gynecologic history (Tables 1 and 2). All procedures in both groups were completed. Procedure time was not different between the osmotic dilator and misoprostol groups (10.62 compared with 11.45 minutes, P=.185), even after multivariable linear regression (P=.133; Table 3). Secondary outcomes did not differ between the groups (Table 4). On multivariable linear regression, women with one or more previous abortion, previous cesarean delivery, or gestational age 15 0/7—6/7 weeks had statistically longer procedure times (P=.031, P=.029, and P=.039, respectively). Women with three or more previous pregnancies had shorter procedure times (P=.032; Table 5). Table 1 Demographic Factors Table 2 Medical History Table 3 Procedure Data Table 4 Postoperative Data Table 5 Multivariable Linear Regression CONCLUSIONS: We found no statistical difference in procedure time between 1 hour preprocedure buccal misoprostol compared with overnight osmotic dilators before early second-trimester abortion. One hour preprocedure misoprostol allows for 1-day procedures and decreased time from cervical preparation initiation to procedure completion, likely increasing accessibility and acceptability of early second-trimester abortion.