Meredith J. Alston

Intrahepatic fat is increased in the neonatal offspring of obese women with gestational diabetes.

OBJECTIVES To assess precision magnetic resonance imaging in the neonate and determine whether there is an early maternal influence on the pattern of neonatal fat deposition in the offspring of mothers with gestational diabetes mellitus (GDM) and obesity compared with the offspring of normal-weight women. STUDY DESIGN A total of 25 neonates born to normal weight mothers (n = 13) and to obese mothers with GDM (n = 12) underwent magnetic resonance imaging for the measurement of subcutaneous and intra-abdominal fat and magnetic resonance spectroscopy for the measurement of intrahepatocellular lipid (IHCL) fat at 1-3 weeks of age. RESULTS Infants born to obese/GDM mothers had a mean 68% increase in IHCL compared with infants born to normal-weight mothers. For all infants, IHCL correlated with maternal prepregnancy body mass index but not with subcutaneous adiposity. CONCLUSION Deposition of liver fat in the neonate correlates highly with maternal body mass index. This finding may have implications for understanding the developmental origins of childhood nonalcoholic fatty liver disease.

Does the number of forceps deliveries performed in residency predict use in practice

OBJECTIVE We aimed to determine whether a threshold number of forceps deliveries in residency predicts use of forceps in independent practice. STUDY DESIGN We surveyed obstetrics and gynecology residency graduates of 2 academic programs from 2008 through 2012 regarding the use of operative vaginal delivery in practice. At these programs, residents are trained in both forceps and vacuums. Individual case log data were obtained with the number of forceps deliveries performed by each respondent during residency. Respondents were grouped as currently using any forceps or vacuums alone. A logistic regression model estimated the probability of forceps use, predicted by the number of residency forceps deliveries. From the resulting receiver-operating characteristic curve, we assessed sensitivity, specificity, positive predictive value, and area under the curve. RESULTS The response rate was 85% (n = 58) and 90% (n = 52) practice obstetrics. Seventy-nine percent (n = 41) use forceps in practice. The mean number of forceps performed during residency was 22.3 ± 1.3 (mean ± SE) in the any-forceps group and 18.5 ± 2.1 in the vacuums-only group (P = .14). Although the model performed only moderately (area under the curve, 0.61, 95% confidence interval [CI], 0.42-0.81), more than 13 residency forceps deliveries corresponded to a 95% sensitivity (95% CI, 84-99) and a positive predictive value of 83% (95% CI, 69-92) for using forceps in practice. The specificity of this threshold is 27% (95% CI, 6-61). CONCLUSION Although exceeding 13 forceps deliveries made it highly likely that obstetricians would use them in practice, further study is necessary to set goals for a number of resident forceps deliveries that translate into use in practice.

Lack of Agreement Between Endocervical Brush and Endocervical Curettage in Women Undergoing Repeat Endocervical Sampling

Objective To evaluate agreement between an abnormal endocervical brush (ECB) collected at the time of colposcopy and subsequent endocervical curettage (ECC). Methods All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for those who had a colposcopic exam with ECB between April 1, 2013, and June 15, 2015, and who subsequently returned for an ECC to further evaluate eligibility for expectant management or ablative therapy. ECB and ECC results were divided into 2 groups: “low-grade” included low-grade squamous intraepithelial lesions (LSIL) or atypical squamous cells of undetermined significance, and “high-grade” included high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells—cannot exclude high-grade. Women with atypical glandular cells and unsatisfactory ECB results were excluded. Percent agreement between ECB and ECC was calculated based on these categories. Results Seventy-nine women were included: 54 (68%) had a low-grade ECB, and 25 (32%) had a high-grade ECB. Of those who had a low-grade ECB, 4 had a low-grade ECC, 3 had a high-grade ECC, and 47 were negative, resulting in an agreement of 7.4% (4/54). Of those who had a high-grade ECB, 1 had a low-grade ECC, 4 had a high-grade ECC, and 20 were negative, resulting in 16% (4/25) agreement. Conclusions Our data suggest that there is poor agreement between ECC and ECB in our patient population.

A Novel Abdominal Hysterectomy Simulator and Its Impact on Obstetrics and Gynecology Residents’ Surgical Confidence

Introduction The number of abdominal hysterectomies (AHs) performed by OB/GYN residents has decreased dramatically. Thus, there is a need for simulation training to complement operating room experience. Methods A low-fidelity AH simulator was constructed from craft-store supplies costing less than

Advising and Interview Patterns of Medical Students Pursuing Obstetrics and Gynecology Residency

40. OB/GYN residents in a single academic program completed the simulation between July and September of 2015. The 1-hour simulation experience included a pretest, a 5-minute presentation, the simulation, and a posttest. On the pre- and posttests, participants rated their confidence with the steps of AH as not at all, somewhat, or very confident. Results Eighty-six percent (32 of 37) of possible residents completed the session, with even representation from all levels of training (nine PGY 1, seven PGY 2, eight PGY 3, and eight 8 PGY 4 residents). Knowledge of the steps of the procedure and instrumentation improved for all levels of trainees (p < .001). One hundred percent (16 out of 16) of the PGY 1 and PGY 2 residents rated their confidence as increased afterwards, while only 25% (four out of 16) of the PGY 3 and PGY 4 residents did so. Ninety-four percent (30 out of 32) rated the session as very helpful on a scale of not at all, somewhat, or very helpful. Discussion A low-fidelity, low-cost simulator showed an increase in trainee confidence with AH, particularly in the first- and second-year trainees. Nearly all participants found the exercise helpful, suggesting that it may be beneficial to incorporate into OB/GYN training programs nationwide.

Adherence to Management Recommendations in Patients Diagnosed With Cervical Intraepithelial Neoplasia 2 or 3.

OBJECTIVE: To describe the advising practices at medical schools and interview patterns among medical students pursuing obstetrics and gynecology residency training. METHODS: A voluntary, anonymous survey was distributed to all applicants interviewing for obstetrics and gynecology residency during the 2014–2015 cycle at the University of Colorado, University of Washington, University of California, San Francisco, and Loyola University. Demographic data were obtained. The survey explored student advising in the residency application process including number of applications and interviews recommended by advisors. Data are reported as percentage for each survey item and compared by select demographics using an exact &khgr;2. RESULTS: Among 315 unique possible applicants, 73% (n=230) responded. Students were most commonly advised by the obstetrics and gynecology clerkship director (33%) with recommendations to apply to 21–30 programs (48%). Thirty-four percent of students applied to 21–30 programs, 32% to 31–40 programs, and 30% to greater than 40 programs. Students were advised (70%) and planned (55%) to interview at 10–14 programs. Concern over competitiveness of the applicant pool was the most important factor (31%) in determining the number of applications. The number of programs advised to or plan to interview at was greater for those in the couples match (P<.001). CONCLUSION: Medical students pursuing obstetrics and gynecology are most likely to be advised by obstetrics and gynecology clerkship directors and concern over the competitiveness of the applicant pool results in students applying to large numbers of programs. This practice may adversely affect the obstetrics and gynecology match process for both programs and applicants through the requirements of managing additional applications and potentially needing to complete a greater number of interviews.

Adherence to Management Recommendations in Patients Diagnosed With High-Grade Cervical Dysplasia [7]

Objective The aim of the study was to evaluate the rate of patient adherence to provider recommendations for biopsy proven cervical intraepithelial neoplasia (CIN) 2 or 3 in an academic safety-net hospital. Materials and Methods This is a case series of patients with biopsy-proven CIN 2 or 3 identified via pathology records between January 1, 2008 to December 31, 2012 at a single academic safety-net hospital. Patients with human immunodeficiency virus, lupus, or pregnancy were excluded. Patient demographics, recommended management, and patient adherence were extracted from the patient chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariable logistic regression were performed. Results Six hundred eighty-four patients met inclusion and exclusion criteria. The complete adherence rate was 89% (n = 606). In multivariable analyses, those who completed follow-up were older (mean = 31 vs 29 years; p = .031), more likely to use a long-acting reversible contraceptive or sterilization for contraception (92% vs 87%; p = .036) and more likely to have been recommended excision (90% vs 83%; p = .009). In multivariable analysis, using a long-acting reversible contraceptive or sterilization (odds ratio = 1.75; CI = 1.02–3.0) and the recommendation of any kind of treatment as opposed to expectant management (odds ratio = 3.89; CI = 1.96–7.70) remained significantly associated with complete follow-up. Conclusions Patients were overall highly adherent to management recommendations when diagnosed with CIN 2 or 3. Those patients recommended to undergo treatment as opposed to observation were more likely to follow up.

Perinatal High-Grade Cervical Cytology: A Case Series From a Safety Net Institution.

INTRODUCTION: The management of high-grade cervical dysplasia includes multiple options: observation, ablation, or excision. We evaluated patient adherence to health care provider management recommendations for high-grade cervical lesions in an academic safety net hospital. METHODS: This was a retrospective cohort study identifying patients with biopsy-proven high-grade cervical dysplasia (cervical intraepithelial neoplasia 2 or 3) through pathology records between January 1, 2008, and December 31, 2012. Patients with human immunodeficiency virus or lupus or who were pregnant were excluded. Patient demographics, recommended management, and patient adherence were extracted from the chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariate logistic regression were performed. RESULTS: A total of 684 patients met the inclusion criteria. The complete adherence rate was 89% (n=606). Those who completed follow-up were older (31 compared with 29 years old, P=.031), more likely to use long-acting reversible contraception or sterilization for contraception (92% compared with 87%, P=.036), and more likely to have had excision recommended (90% compared with 83%, P=.009). In multivariate analysis, those patients who had observation recommended (n=46) were less likely to complete follow-up (70%, odds ratio 0.26, confidence interval 0.13–0.51). The observation group was noted to be younger (23 compared with 32 years, P<.001), with lower parity (1.4 compared with 2.1, P<.001). No variables were associated with complete adherence in the observation group. CONCLUSION: Patients were overall highly adherent with management recommendations in the setting of high-grade cervical dysplasia. Those patients recommended to undergo observation were least likely to be adherent.

Evaluation of the utility of baseline serum hepatic and renal testing in pregnant patients with chronic hypertension.

Objective To describe the outcomes of women with high-grade cervical cytology in pregnancy and to identify factors that predict completion of appropriate postpartum follow-up. Methods We describe a case series of all patients with high-grade cervical cytology collected during pregnancy between 2007 and 2011 at a single institution. Patients were considered adherent with follow-up if they received any kind of postpartum evaluation or treatment for their cervical dysplasia at our institution within 9 months of delivery. Results Of 138 women with high-grade cervical cytology in pregnancy, 87 (63%) had high-grade squamous intraepithelial lesion, 47 (34%) had atypical squamous cells that cannot rule out high-grade (ASC-H), and 4 (3%) had atypical glandular cells (AGC). Most patients (81%) underwent colposcopy during pregnancy. A total of 48 patients (43%) had biopsies performed, 26 (54%) were CIN 2 or 3, and one (2%) was adenocarcinoma in situ (AIS). A total of 97 (70%) of 138 patients completed recommended postpartum follow-up, resulting in the detection of one additional case of AIS and one case of invasive adenocarcinoma. Hispanic ethnicity (odds ratio [OR], 3.6; confidence interval [CI], 1.4–9.1), being married (OR, 4.5; CI, 1.6–12.4), being employed (OR, 3.7; CI, 1.3–10.5), and CIN2 or 3 on antenatal biopsy (OR, 9.8; CI, 2.0–47.9) were all significantly associated with completion of postpartum follow-up. Conclusion Colposcopy during pregnancy resulted in the detection of one case of AIS. Postpartum evaluation and treatment detected an additional case of AIS as well as one case of invasive cervical adenocarcinoma. Whereas certain demographic characteristics were associated with completion of recommended follow-up, the strongest association is with a high-grade biopsy during pregnancy.