N.R. Patel

Bed Rest and Gestational Diabetes: More Reasons to Get Out of Bed in the Morning

INTRODUCTION: Activity restriction or “bed rest” is a commonly prescribed obstetric intervention, which lacks data demonstrating efficacy. Complications including bone demineralization, pulmonary atelectasis, venous thromboembolism, and muscle deconditioning have been attributed to bed rest. Exercise has a known beneficial effect toward achieving good glycemic control in women with gestational diabetes mellitus (GDM). We sought to quantitate the effect that bed rest has on GDM. METHODS: We performed a retrospective cohort study from 2007 to 2012 at a large tertiary hospital. Charts for women with singleton pregnancies who were admitted for 7 days or longer with diagnosis codes for preterm labor, cervical shortening, preterm premature rupture of membranes, advanced cervical dilation, and preeclampsia were identified. Those who had their 1-hour screening Glucola test during admission were included. Logistic regression analysis was done to determine the effect of bed rest on GDM. RESULTS: Five hundred nine women were available for inclusion. Fifty-four were diagnosed with gestational diabetes during a prolonged hospital stay (10.6%). Patient characteristics between the two groups were similar. Maternal age (relative risk 2.66, P=.008) and maternal length of stay (relative risk 6.13, P=0.00) were associated with the development of GDM. For every day a patient was admitted to the hospital on bed rest, their risk of GDM increased 1.04 times. CONCLUSION: Antenatal bed rest increases the risk of acquiring GDM. The association between bed rest and GDM is biologically plausible because skeletal muscle is the primary site of maternal insulin resistance. Activation of these muscles has been shown to increase insulin sensitivity and decrease blood glucose levels. This finding supports the mounting evidence that bed rest does more harm than good.

Utility of anesthetic block for endometrial ablation pain: a randomized controlled trial

Background Second‐generation endometrial ablation has been demonstrated safe for abnormal uterine bleeding treatment, in premenopausal women who have completed childbearing, in short‐stay surgical centers and in physicians’ offices. However, no standard regarding anesthesia exists, and practice varies depending on physician or patient preference and hospital policy and setting. Objective The aim of this study was to evaluate whether local anesthetic, in combination with general anesthesia, affects postoperative pain and associated narcotic use following endometrial ablation. Materials and Methods This was a single‐center single‐blind randomized controlled trial conducted in an academic‐affiliated community hospital. A total of 84 English‐speaking premenopausal women, aged 30 to 55 years, who were undergoing outpatient endometrial ablation for benign disease were randomized to receive standardized paracervical injection of 20 mL 0.25% bupivacaine (treatment group) or 20 mL normal saline solution (control group) upon completion of ablation. The study was designed to test a 40% 1‐hour mean visual analog scale (VAS) pain score difference with an average standard deviation of 75% of both groups’ mean VAS scores, using a 2‐tailed test, a type I error of 5%, and statistical power of 80%. A sample of 36 patients per study group was required. Assuming a 15% attrition rate, the study enrolled 42 patients per study arm randomized in blocks of 2 (84 total). Two‐tailed cross‐tabulations with Fisher exact significance values where appropriate and Student t tests were used to compare patient characteristics. Backward stepwise regressions were conducted to control for confounding. Results Between April 2016 and February 2017, a total of 108 women scheduled for endometrial ablation were screened (refusals, n = 21; ineligible, n = 3) to determine whether there were meaningful differences in postoperative VAS pain scores and postoperative narcotic use. Of the 84 randomized women, 2 age‐ineligible women were excluded. Intent‐to‐treat analyses included 1 incorrect randomization (in which the provider consciously decided to provide analgesia regardless of the protocol, after which the provider was excluded from further study participation) and 3 women having no ablation because of operative difficulties. Three were lost to second‐day follow‐up. Treatment group patients (n = 41) experienced 1.3 points lower 1‐hour postoperative VAS pain scores than the control group (n = 41, P = .02). The difference diminished by 4 hours (P = .31) and was negligible by 8 hours (P = .62). Treatment group patients used 3.6 less morphine equivalents of postoperative pain medication (P = .05). Regression analyses controlled for confounding reduced the 1‐hour postoperative treatment group pain score difference to 0.8 (confidence interval [CI], −0.6 to 0.1) but slightly increased the average postoperative morphine equivalents to 3.7 (CI, −6.8 to −0.7). Conclusion This randomized controlled trial found that local anesthetic with low risk for complications, used in conjunction with general anesthesia, decreased postoperative pain at 1 hour and significantly reduced postoperative narcotic use following endometrial ablation. Further research is needed to determine whether the study results are generalizable and whether post procedure is the best time to administer the paracervical block to decrease endometrial ablation pain.

Effect of Unplanned Pregnancy on Contraceptive Method Selection: Are Long-Acting Reversible Contraceptives Underutilized? [207].

OBJECTIVE: Approximately 3.1 million pregnancies are considered unplanned in the United States, annually; approximately half are a result of contraceptive failure. We sought to determine whether having an unplanned pregnancy correlated with choosing a long-acting reversible contraceptive (LARC). METHODS: The Pregnancy Risk Assessment Monitoring System (PRAMS) database was used to assess antepartum contraceptive method and postpartum contraceptive method in women who experienced an unplanned pregnancy. Data collected between 2004 and 2009 from participating states, comprising Phases 5 and 6 of the PRAMS survey tool, were analyzed by univariable modeling to assess linkages between unplanned or planned pregnancy, method of contraception before pregnancy, and method of contraception postdelivery. Long-acting reversible contraception compared with non-LARC methods were compared in aggregate. RESULTS: Postpartum LARC was selected by 28.5% of participants in the unplanned pregnancy group (n=49,907); non-LARC, no contraception, or both was selected by 51.7%; and permanent sterilization was selected by 19.8%. In the planned pregnancy group (n=42,040), 18.4% selected LARC postpartum; 68.9% selected non-LARC, no contraception, or both; and permanent sterilization was selected by 12.7%. Our analysis showed a significant increase in postpartum LARC selection after unplanned pregnancy. Specifically, we found a 47.3% rate of change to postpartum LARC selection. Notably, 51.1% of women with an unplanned pregnancy reported no change in contraceptive method after delivery. CONCLUSION: The results of this study support current estimates of contraceptive failure and resultant unplanned pregnancies. The subsequent rate of change to LARC postpartum, although showing potential, reveals a gap between documented contraceptive failure rates and the uptake of reliable, reversible contraception.