Roxanne Jamshidi

Contraception for the HIV-Positive Woman: A Review of Interactions between Hormonal Contraception and Antiretroviral Therapy

Background. Preventing unintended pregnancy in HIV-positive women can significantly reduce maternal-to-child HIV transmission as well as improve the womans overall health. Hormonal contraceptives are safe and effective means to avoid unintended pregnancy, but there is concern that coadministration of antiretroviral drugs may alter contraceptive efficacy. Materials and Methods. We performed a literature search of PubMed and Ovid databases of articles published between January 1980 and February 2012 to identify English-language reports of drug-drug interactions between hormonal contraceptives (HCs) and antiretroviral drugs (ARVs). We also reviewed the FDA prescribing information of contraceptive hormone preparations and antiretrovirals for additional data and recommendations. Results. Twenty peer-reviewed publications and 42 pharmaceutical package labels were reviewed. Several studies of combined oral contraceptive pills (COCs) identified decreased serum estrogen and progestin levels when coadministered with certain ARVs. The contraceptive efficacy of injectable depot medroxyprogesterone acetate (DMPA) and the levonorgestrel intrauterine system (LNG-IUS) were largely unaffected by ARVs, while data on the contraceptive patch, ring, and implant were lacking. Conclusions. HIV-positive women should be offered a full range of hormonal contraceptive options, with conscientious counseling about possible reduced efficacy of COCs and the contraceptive implant when taken with ARVs. DMPA and the LNG-IUS maintain their contraceptive efficacy when taken with ARVs.

Detection of two biological markers of intercourse: prostate-specific antigen and Y-chromosomal DNA

BACKGROUND Although biological markers of womens exposure to semen from vaginal intercourse have been developed as surrogates for risk of infection or probability of pregnancy, data on their persistence time and clearance are limited. STUDY DESIGN During 2006-2008, 52 couples were enrolled for three 14-day cycles of abstinence from vaginal sex during which women were exposed in the clinic to a specific quantity (10, 100 or 1000 μL) of their partners semen. Vaginal swabs were collected before and at 1, 6, 12, 24, 48, 72 and 144 h after exposure for testing for prostate-specific antigen (PSA) and Y-chromosome DNA (Yc DNA). RESULTS Immediately after exposure to 1000 μL of semen, the predicted sensitivity of being PSA positive was 0.96; this decreased to 0.65, 0.44, 0.21 and 0.07 at 6, 12, 24 and 48 h, respectively. Corresponding predicted sensitivity of being Yc DNA positive was 0.72 immediately postexposure; this increased to 0.76 at 1 h postexposure and then decreased to 0.60 (at 6 h), 0.63 (at 12 h), 0.49 (at 24 h), 0.21 (at 48 h), 0.17 (at 72 h) and 0.12 (at 144 h). CONCLUSIONS Overall findings suggest that PSA may be more consistent as a marker of very recent exposure and that Yc DNA is more likely to be detected in the vagina after 12 h postexposure compared to PSA.

Paracervical Block With Combined Ketorolac and Lidocaine in First-Trimester Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE: To study the effects of a paracervical block with combined ketorolac and lidocaine on perceived pain during first-trimester surgical abortion. METHODS: A double-masked, placebo-controlled, randomized clinical trial of 50 women undergoing first-trimester surgical abortions (before 11 weeks of gestation) received either oral ibuprofen with a lidocaine-alone paracervical block or an oral placebo and paracervical block with combined ketorolac and lidocaine. Women completed a series of 100-mm visual analog scales (anchors: 0=none, 100 mm=worst imaginable) to measure their perceived pain (anticipated pain, pain during and after surgical abortion, and total satisfaction). RESULTS: Twenty-five women received preoperative oral ibuprofen followed by paracervical block with lidocaine alone, and 25 received oral placebo followed by paracervical block with combined ketorolac and lidocaine. Groups were similar with respect to sociodemographic variables. Women who received paracervical block with combined ketorolac and lidocaine reported significantly less pain after cervical dilation (59.8 compared with 74.8 mm, P<.05). The groups did not differ in perceived procedure-related or postoperative pain. There was no difference in overall satisfaction with pain control between the two groups (63.6 compared with 62.9 mm, P=.93). CONCLUSION: Paracervical block with combined ketorolac and lidocaine significantly decreases perceived pain associated with cervical dilation during first-trimester surgical abortion. This analgesic mixture may be offered as an alternative pain regimen to women seeking first-trimester surgical abortion. It may also offer improved pain control in other gynecologic procedures necessitating cervical dilation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00617097. LEVEL OF EVIDENCE: I

Effect of Immediate Compared With Delayed Insertion of Etonogestrel Implants on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effect of insertion of etonogestrel implants with mifepristone compared with after the abortion on the risks of medical abortion failure and repeat pregnancy over the subsequent 6 months. METHODS: In a randomized trial, we assigned patients undergoing medical abortion to receive etonogestrel implants either with the mifepristone (Quickstart group) or after the abortion (Afterstart group). We followed them for 7 months to ascertain abortion outcome, pregnancies, and contraception use. RESULTS: Between September 2013 and August 2014, we enrolled 236 participants in the Quickstart group and 240 in the Afterstart group. To examine abortion failure, we conducted a noninferiority analysis from which we excluded nine participants who had missing outcome data and four with specified protocol violations. Of the rest, 9 of 229 (3.9%) and 9 of 234 (3.8%) in the Quickstart and Afterstart groups, respectively, had surgery to complete the abortion; the difference of 0.08% (90% confidence interval −3.1% to 3.3%) excluded our prestipulated noninferiority margin of 5 percentage points. Among participants with pregnancy follow-up through 6 months, 1 of 213 (0.5%) and 3 of 208 (1.4%) in the Quickstart and Afterstart groups, respectively, became pregnant within that time; 6-month pregnancy rates did not differ significantly by group (exact log-rank test, P=.28). At enrollment, significantly more participants in the Quickstart group than in the Afterstart group were satisfied with their group assignments (187/236 [79%] compared with 129/240 [54%], respectively; P<.001). CONCLUSION: Insertion of etonogestrel implants with mifepristone did not appreciably increase medical abortion failure risk and it enhanced patient satisfaction, but we found no evidence that it decreased repeat pregnancy rates. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01902485.

Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices.

OBJECTIVE Studies show immediate postpartum (PP) insertion increases use of contraceptive implants and intrauterine devices (IUDs). Our objective was to compare the satisfaction and continuation rates of the two types of devices at 6 months and 1 year following PP insertion. STUDY DESIGN We enrolled 133 women in a prospective cohort study following immediate PP insertion of an implant or IUD at two academic hospitals during 8 months of 2011. Subjects completed an enrollment survey during hospital admission and a follow-up phone survey 6 months and 1 year PP. RESULTS At 6 months PP, 72% of subjects provided follow-up information. Implant users were more likely to be using the originally-placed device (40/41, 98% vs. 45/55, 82%, p=0.02); nine women reported IUD expulsions. When accounting for replacement of expelled IUDs, IUD continuation at 6 months was 89% yielding similar continuation rates between groups (p=0.12). At 1 year PP, 51% provided follow-up. Of those, 82% still had a LARC method in place with similar continuation by device type (84% for implants, 81% for IUDs, p=0.96). Overall, satisfaction was similarly high in both groups. CONCLUSION Due to IUD expulsion, implants had a higher continuation rate than IUDs six months following immediate PP insertion. After replacement of expelled IUDs, continuation and satisfaction were similar for both devices at 6 months and 1 year. IMPLICATIONS Placement of implants and IUDs immediately PP can lead to high satisfaction. Despite early IUD expulsions, continuation rates were similar to those placed outside of the immediate PP period.

Factors associated with increased charges for hysterectomy

OBJECTIVE: To evaluate factors associated with increased hospital charges for hysterectomy with specific attention to differences based on surgical approach. METHODS: We performed a retrospective cohort study of 686 patients who underwent hysterectomy between January 1997 and September 1997 using medical chart review and hospital financial information. Demographic information, surgical approach (abdominal, vaginal, or laparoscopic), and surgical and postoperative factors were extracted from the medical record. Hospital charges were obtained from the hospital billing database. Relationships between charges and various clinical and demographic variables were examined using &khgr;2, Fisher exact test, t tests, or analysis of variance, where appropriate. Logistic regression was used to estimate odds ratios while controlling for important confounding variables. RESULTS: In our logistic regression model, blood loss greater than 1,000 mL (odds ratio [OR] 11.8, 95% confidence interval [CI] 4.2–33.2) and operative time 105 minutes or more (OR 14.2, CI 5.8–34.5) were strongly associated with higher charges for hysterectomy. Other factors associated with higher charges included: postoperative fever (OR 2.2, CI 1.1–4.5), increasing length of hospitalization (OR 5.3, CI 3.7–7.7), the use of prophylactic antibiotics (OR 3.0, CI 1.3–6.6), and the laparoscopic surgical approach compared with vaginal hysterectomy (OR 2.7, CI 1.0–7.0). CONCLUSION: Surgical factors such as operative time and blood loss were strongly associated with increased hospital charges for hysterectomy. LEVEL OF EVIDENCE: II-2

Effects of Depot Medroxyprogesterone Acetate Injection Timing on Medical Abortion Efficacy and Repeat Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of timing of depot medroxyprogesterone acetate injection on medical abortion outcome and risk of repeat pregnancy within the subsequent 6 months. METHODS: In a multinational randomized trial, we assigned women undergoing medical abortion who wanted depot medroxyprogesterone acetate to administration either with mifepristone (Quickstart group) or after the abortion (Afterstart group). We ascertained abortion outcome, pregnancies, and contraception use over 7 months. RESULTS: From August 2013 to March 2015, we enrolled 461 participants with pregnancy durations of 75 days or less. Of participants included in the abortion outcome analyses, 14 of 220 (6.4%) and 12 of 226 (5.3%) in the Quickstart and Afterstart groups, respectively, had surgery to complete the abortion; the upper 90% confidence limit on this difference was 4.9%, within our prestipulated 5% noninferiority margin. Ongoing pregnancy after initial abortion treatment was significantly more common in the Quickstart group (8/220 [3.6%]) than in the Afterstart group (2/226 [0.9%]); the difference was 2.7% (90% confidence interval 0.4–5.6%). By 6 months, 5 of 213 (2.3%) and 7 of 217 (3.2%) in the Quickstart and Afterstart groups, respectively, became pregnant (exact log-rank test, P=.64). Use of highly effective contraceptives was significantly more common in the Quickstart group at 31 days (P<.001), but no difference was apparent at 6 months. The Quickstart group was significantly more satisfied with group assignment. CONCLUSION: Depot medroxyprogesterone acetate administration with mifepristone did not appreciably increase the risk of surgery after medical abortion but did increase the risk of ongoing pregnancy. It enhanced patient satisfaction, but we found no evidence that it decreased 6-month risk of repeat pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT01902485.

Safety Culture and Surgical Site Infection Outcomes After Abdominal Hysterectomy [342]

INTRODUCTION: Previous studies demonstrate that hospital workplace culture may affect surgical outcomes. We designed a study evaluating the role of culture on surgical site infection after abdominal hysterectomy. METHODS: Data were collected from eight Minnesota community hospitals participating in a quality measurement collaborative from January 1 to December 31, 2012. Safety culture was measured using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture instrument; surgical site infection was measured using National Healthcare Safety Network definitions. RESULTS: Median hospital size was 93 beds (range 57–426 beds) and mean survey response rate of staff was 44%. Rates of surgical site infection after abdominal hysterectomy ranged from 0% to 5.26%; median abdominal hysterectomy performed was 33 (range 10–276). Safety culture scores ranged from 16 to 92 on a scale of 0–100. Eight dimensions of safety culture were inversely associated with abdominal hysterectomy SSI rates: supervisor expectations and actions (r=−0.93; 95% CI [−0.66, −0.99]), teamwork across units (r=−0.87; 95% CI [−0.43, −0.98]), organizational learning (r=−0.87; 95% CI [−0.43, −0.98]), feedback and communication about error (r=−0.87; 95% CI [−0.41, −0.98]), overall perception of safety (r=−0.84; 95% CI [−0.34, −0.97]), management support for patient safety (r=−0.82; 95% CI [−0.27, −0.97]), frequency of event reporting (r=−0.77; 95% CI [−0.15, −0.96]), and teamwork within the unit (r=−0.77; 95% CI [−0.14, −0.96]). CONCLUSION: In a cohort of community hospitals, there was a strong association between safety culture and risk of abdominal hysterectomy surgical site infection. These data suggest a strong role for safety culture, teamwork culture, and engaged hospital management in creating high-quality surgical outcomes.

Contraceptive needs of human immunodeficiency virus-infected adolescent women: a qualitative analysis.

INTRODUCTION: Adolescents and young adults represent approximately 40% of new human immunodeficiency virus (HIV) infections in the United States. Although knowledge and attitudes regarding family planning methods and use have been described in adult women living with HIV, limited work has focused on adolescents and young adults. METHODS: We conducted semistructured interviews with 10 HIV-positive women aged 13–21 years. The interviews addressed contraceptive knowledge, preferences, experiences, and pregnancy intentions. Qualitative analysis of the interviews was performed using a grounded theory approach. RESULTS: The majority (n=9) of interview participants were perinatally infected with HIV. Five respondents reported ever having been sexually active with three reporting use of hormonal contraception (all used injectable progestin). Only three women were aware of the intrauterine device, and one was aware of the implant as contraceptive options. All expressed a desire for future fertility, and none wanted to conceive right now. Major themes included concerns regarding hormonal contraceptive side effects, the importance of avoiding HIV transmission to a partner or child, and the desire to delay childbearing. Participants frequently identified their HIV care provider as their preferred source of information regarding contraception. CONCLUSIONS: This research demonstrates that young women with HIV have unmet needs for family planning services, and they rely on their HIV care providers for these services. Clinicians specializing in HIV management need to be comfortable providing contraceptive counseling for highly effective methods. Collaboration between HIV care providers and adolescent-friendly family planning service providers is important to prevent unintended pregnancy in this vulnerable group of youth.