Lori M. Gawron

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.

Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study

OBJECTIVES We assessed intrauterine device (IUD) preference among women presenting for emergency contraception (EC) and the probability of pregnancy among concurrent oral levonorgestrel (LNG) plus LNG 52 mg IUD EC users. METHODS We offered women presenting for EC at a single family planning clinic the CuT380A IUD (copper IUD) or oral LNG 1.5 mg plus the LNG 52 mg IUD. Two weeks after IUD insertion, participants reported the results of a self-administered home urine pregnancy test. The primary outcome, EC failure, was defined as pregnancies resulting from intercourse occurring within five days prior to IUD insertion. RESULTS One hundred eighty-eight women enrolled and provided information regarding their current menstrual cycle and recent unprotected intercourse. Sixty-seven (36%) chose the copper IUD and 121 (64%) chose oral LNG plus the LNG IUD. The probability of pregnancy two weeks after oral LNG plus LNG IUD EC use was 0.9% (95% CI 0.0-5.1%). The only positive pregnancy test after treatment occurred in a woman who received oral LNG plus the LNG IUD and who had reported multiple episodes of unprotected intercourse including an episode more than 5 days prior to treatment. CONCLUSIONS Study participants seeking EC who desired an IUD preferentially chose oral LNG 1.5 mg with the LNG 52 mg IUD over the copper IUD. Neither group had EC treatment failures. Including the option of oral LNG 1.5 mg with concomitant insertion of the LNG 52 mg IUD in EC counseling may increase the number of EC users who opt to initiate highly effective reversible contraception. IMPLICATIONS Consideration should be given to LNG IUD insertion with concomitant use of oral LNG 1.5 mg for EC. Use of this combination may increase the number of women initiating highly effective contraception at the time of their EC visit.

The Impact of Hormonal Contraception on Disease-related Cyclical Symptoms in Women with Inflammatory Bowel Diseases.

Background:Women with inflammatory bowel diseases (IBD) commonly report an increase in their IBD symptoms related to their menstrual cycle. Hormonal contraceptives are safe for women with IBD and frequently used for reproductive planning, but data are lacking on their effect on IBD-related symptoms. Methods:We completed a cross-sectional phone survey of 129 women (31% response rate), aged 18 to 45 years, with IBD in an academic practice between March and November 2013. An electronic database query identified eligible women, and we sent an opt-out letter before contact. Questions included demographics, medical and reproductive history, and current/previous contraceptive use. Women were asked if/how their menses affected IBD-related symptoms and if/how their contraceptive affected symptoms. We calculated descriptive statistics and made comparisons by Crohns disease versus ulcerative colitis on Stata V11. Results:Participants were predominately white (85%) and college educated (97%), with a mean age of 34.2 (SD 6.2, range 19–45) years. Sixty percent had Crohns disease, and 30% had IBD-related surgery previously. Half of the participants were parous, and 57% desired future pregnancy. Of the participants, 88% reported current or past hormonal contraceptive use and 60% noted cyclical IBD symptoms. Symptomatic improvement in cyclical IBD symptoms was reported by 19% of estrogen-based contraceptive users and 47% of levonorgestrel intrauterine device users. Only 5% of all hormonal method users reported symptomatic worsening. Conclusions:In a subset of women with IBD, 20% of hormonal contraception users reported improved cyclical menstrual-related IBD symptoms. Health care providers should consider potential noncontraceptive benefits of hormonal contraception in women with cyclical IBD symptoms.

Contraceptive Method Selection by Women with Inflammatory Bowel Diseases: A Cross-sectional Survey

OBJECTIVE Women with inflammatory bowel diseases (IBDs) utilize contraception at a lower rate than the general population. We sought to identify factors associated with contraceptive use and selection of more effective methods in IBD patients at risk for unintended pregnancy. STUDY DESIGN An online survey was distributed to women with IBD in January 2013. Contraceptive methods were categorized by effectiveness and associations with use explored by demographics, disease characteristics and reproductive goals. RESULTS A total of 162 respondents were analyzed: 62% had Crohns disease and 38% ulcerative colitis. Mean age was 31 (range 20-45), 97% identified as White, and 53% were nulliparas. Seventy-four percent were currently using IBD medications. A quarter of participants (23%) used no contraception, 17% used highly effective methods, 41% used short-term hormonal methods, and 19% chose barrier/behavioral methods. Prior IBD-related surgery, biologic therapy use and low education attainment were associated with no contraception use. Of contraceptive users, age, parity, insurance status, IBD surgery and prior immunomodulator use were associated with highly effective method selection. CONCLUSIONS A quarter of women with IBD at risk for pregnancy in this study population reported no contraceptive method use. Higher levels of IBD activity influence contraceptive use and method selection, which could guide future patient and provider educational interventions. IMPLICATIONS Pregnancy planning is important for women with inflammatory bowel diseases to avoid adverse outcomes in a disease-poor state. Use of contraception assists in avoidance of unintended pregnancy. IBD characteristics are targets for educational interventions to improve uptake of highly effective contraceptive methods.

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.

Pathologic Examination of Fetal and Placental Tissue Obtained by Dilation and Evacuation

CONTEXT Dilation and evacuation (D&E) is an alternative method to induction of labor for pregnancy termination and intrauterine fetal demise, and it is the most common mode of second-trimester uterine evacuation in the United States. Many D&E specimens are examined in surgical pathology, and there is little information available in surgical pathology textbooks or the literature to assist pathologists in these examinations. OBJECTIVE To provide an overview of the D&E procedure, discuss related legal issues, provide guidelines for routine pathologic examination of D&E specimens, and demonstrate the importance of careful pathologic examination of D&E specimens. DATA SOURCES Case-derived material and literature review. CONCLUSIONS Pathologic examination of D&E specimens has been understudied. However, the available literature and our experience support the fact that careful pathologic examination of D&E specimens can identify significant fetal and placental changes that can confirm clinical diagnoses or provide definitive diagnosis, assist in explaining the cause of intrauterine fetal demise, and identify unexpected anomalies that may provide further clues to a diagnostic syndrome or mechanism of anomaly formation.

Perinatal pathologic examination of nonintact, second-trimester fetal demise specimens: The value of standardization

CONTEXT Management of second-trimester intrauterine fetal demise via dilation and evacuation results in nonintact specimens for pathologic examination. Surgical pathology examination is often mandated; however, evidence on expected findings and specimen evaluation guidelines are lacking. OBJECTIVES To assess pathologic findings of nonintact, second-trimester fetal demise specimens, through comparison of anatomic abnormalities identified on standardized perinatal examination to individualized general pathology examinations. DESIGN Single institution, retrospective chart review of 14- to 24-week gestational size fetal demise cases was conducted from May 2006 to October 2010. Suspected abnormalities, chromosomal and pathologic diagnoses were collected. A general surgical pathology examination occurred between May 2006 and October 2008, while a perinatal pathologist examined specimens between October 2008 and October 2010. Statistical analysis consisted of t tests and χ(2) tests by Stata/SE 12.1. RESULTS One hundred eighteen specimens were included and mean gestational size was 16.0 weeks (standard deviation, 1.6 weeks). Perinatal pathologic evaluation diagnosed significantly more abnormalities than did general pathologic examination (77.3% [34 of 44] versus 9.5% [7 of 75], P < .001). Forty-eight abnormalities were identified: 77.0% (n = 37) were placental and 23.0% (n = 11) were fetal. Chromosomal analysis was done on 73.7% (n = 87 of 118) with 12.6% (n = 11 of 87) showing abnormalities. Among aneuploid specimens, the perinatal pathologist confirmed abnormalities in 66.7% (n = 4 of 6) of cases while general pathologists confirmed abnormalities in 0% (n = 0 of 5) (P = .02). CONCLUSIONS Systematic surgical pathology examination of nonintact, second-trimester fetal demise specimens yields increased information on fetal or placental abnormalities, which may be clinically useful. Institutions with high-risk obstetrical practices and dilation and evacuation providers should consider integrating a standardized perinatal checklist into educational and practice guidelines.

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.

Two-year continuation of intrauterine devices and contraceptive implants in a mixed-payer setting: A retrospective review.

BACKGROUND: As the popularity of long‐acting reversible contraception increases, so does the need for accurate data on method continuation in diverse clinical settings. We determined 2‐year continuation rates for the levonorgestrel 52‐mg intrauterine device, the copper T380A intrauterine device, and the 68‐mg etonogestrel contraceptive implant in an academic healthcare system with mixed‐payer reimbursement. OBJECTIVE: The purpose of this study was to examine the proportion and characteristics of women who continue intrauterine device and implant use to 2 years and to relate continuation to device type when controlling for patient characteristics. STUDY DESIGN: This retrospective chart review assessed University of Utah Healthcare System patients who had an intrauterine device or contraceptive implant inserted between January 1, 2004, and December 31, 2012. We identified users and dates of insertions and removals by querying billing, medication, and procedural data in the Electronic Data Warehouse. Multivariable Poisson regression was conducted to estimate incidence risk ratios and to relate the probability of 2‐year continuous use to device type. RESULTS: Data on 8603 device insertions were obtained with the following distribution: levonorgestrel 52‐mg intrauterine devices (6459; 75.1%), copper T380A intrauterine devices (1136; 13.2%), and 68‐mg etonogestrel implant (1008; 11.7%). Two‐year continuation rates were 77.8%, 73.1%, and 75.9%, respectively. There was no statistical difference in 2‐year continuation between levonorgestrel 52‐mg intrauterine device users (adjusted risk ratio, 1.1; 95% confidence interval, 1.0–1.1) and 68‐mg etonogestrel implant users (adjusted risk ratio, 1.1; 95% confidence interval, 1.0–1.1) compared with copper device users, after we controlled for age, Hispanic ethnicity, payer type, and year of insertion. Older‐age, self‐pay, or public payer insurance (reference commercial payer) and Hispanic ethnicity were associated with 2‐year continuation. CONCLUSION: Three‐quarters of women with an intrauterine device or implant continue using it for 2 years. In this cohort, the 2‐year continuation rates were 77.8%, 73.1%, and 75.9% for the levonorgestrel 52‐mg intrauterine device, copper T380A intrauterine device, and 68‐mg etonogestrel implant, respectively.

New developments in long-acting reversible contraception: the promise of intrauterine devices and implants to improve family planning services

After decades of having the developed worlds highest rates of unintended pregnancy, the United States finally shows signs of improvement. This progress is likely due in large part to increased use of highly effective long-acting reversible methods of contraception. These methods can be placed and do not require any maintenance to provide years of contraception as effective as sterilization. Upon removal, fertility returns to baseline rates. This article addresses advances in both software-improved use and elimination of barriers to provide these methods; and hardware-novel delivery systems and devices.