Vrishali Lopes

Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse

OBJECTIVE The purpose of this study was to describe patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse symptoms and to describe predictors of preference for uterine preservation. STUDY DESIGN This multicenter, cross-sectional study evaluated patient preferences for uterine preservation vs hysterectomy in women with prolapse symptoms who were being examined for initial urogynecologic evaluation. Before meeting the physician, the women completed a questionnaire that asked them to indicate their prolapse treatment preference (uterine preservation vs hysterectomy) for scenarios in which the efficacy of treatment varied. Patient characteristics that were associated with preferences were determined, and predictors for uterine preservation preference were identified with multivariable logistic regression. RESULTS Two hundred thirteen women participated. Assuming outcomes were equal between hysterectomy and uterine preservation, 36% of the women preferred uterine preservation; 20% of the women preferred hysterectomy, and 44% of the women had no strong preference. If uterine preservation was superior, 46% of the women preferred uterine preservation, and 11% of the women preferred hysterectomy. If hysterectomy was superior, 21% of the women still preferred uterine preservation, despite inferior efficacy. On multivariable logistic regression, women in the South had decreased odds of preferring uterine preservation compared with women in the Northeast (odds ratio [OR], 0.17; 95% CI, 0.05-0.66). Women with at least some college education (OR, 2.87; 95% CI, 1.08-7.62) and those who believed that the uterus is important for their sense of self (OR, 28.2; 95% CI, 5.00-158.7) had increased odds for preferring uterine preservation. CONCLUSION A higher proportion of women with prolapse symptoms who were examined for urogynecologic evaluation preferred uterine preservation, compared with hysterectomy. Geographic region, education level, and belief that the uterus is important for a sense of self were predictors of preference for uterine preservation.

Ambulatory procedures for female pelvic floor disorders in the United States

OBJECTIVE The aim of this study was to estimate the number of women undergoing ambulatory surgical procedures for female pelvic floor disorders (PFDs) in the United States and to compare age-adjusted ambulatory surgical case rates between 1996 and 2006. STUDY DESIGN We analyzed data from the 1996 and 2006 National Survey of Ambulatory Surgery, a federal public access de-identified database. Procedures for PFDs were identified using International Classification of Diseases-9th revision Clinical Modification procedure codes for urinary incontinence, fecal incontinence, and pelvic organ prolapse. RESULTS The number of women undergoing ambulatory surgical procedures for urinary incontinence increased from 34,968 (95% confidence interval, 25,583-44,353) in 1996 to 105,656 (95% confidence interval, 79,033-132,279) in 2006. The age-adjusted ambulatory surgical case rates for all PFDs increased from 7.91 per 10,000 in 1996 to 12.10 per 10,000 in 2006 (P = .0006). CONCLUSION Ambulatory procedures for urinary incontinence increased between 1996 and 2006, as well as the age-adjusted ambulatory case rate for all PFDs.

The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy

OBJECTIVE We sought to design an emergency department sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women. STUDY DESIGN The Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems in accordance with recognized physiologic changes of pregnancy. The S.O.S. was applied to a retrospective cohort of pregnant and postpartum patients from February 2009 through May 2011 with clinical suspicion of sepsis. The primary outcome was ICU admission. Secondary outcomes were telemetry unit admission, length of stay, positive blood cultures, positive influenza swabs, perinatal outcome, and maternal mortality. Receiver operating characteristic curves were constructed to estimate the optimal score for identification of risk of ICU admission. RESULTS In all, 850 eligible women were included. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The S.O.S. had an area under the curve of 0.97 for ICU admission. An S.O.S. ≥6 (maximum score 28) had an area under the curve of 0.92 with sensitivity of 88.9%, specificity of 95.2%, positive predictive value of 16.7%, and negative predictive value of 99.9% for ICU admission, with an adjusted odds ratio of 109 (95% confidence interval, 18-661). An S.O.S. ≥6 was independently associated with increased ICU or telemetry unit admissions, positive blood cultures, and fetal tachycardia. CONCLUSION A sepsis scoring system designed specifically for an obstetric population appears to reliably identify patients at high risk for admission to the ICU. Prospective validation is warranted.

Adherence patterns to National Comprehensive Cancer Network (NCCN) guidelines for referral to cancer genetic professionals

OBJECTIVE Genetic predisposition is responsible for 5-10% of breast cancer, 10% of ovarian cancer and 2-5% of uterine cancer. The study objective was to compare genetic counseling and testing referral rates among women with breast cancer that met NCCN referral guidelines to the referral rates among women with gynecologic cancers and determine predictors of referral. METHODS Utilizing an institutional tumor registry database, patients from an academic womens oncology program were identified who met a subset of NCCN guidelines for genetic referral between 2004 and 2010. Patients diagnosed with ovarian cancer, breast cancer ≤50years of age, or uterine cancer <50years of age were included. A retrospective electronic chart review was conducted to evaluate for a genetic referral and uptake of genetic testing. RESULTS 820 women were included (216 uterine, 314 breast, and 290 ovarian cancer). The overall genetic referral rate was 21.7%. 34% of eligible breast cancer patients were referred compared to 13.4% of uterine cancer and 14.5% of ovarian cancer patients (p<0.0001). Younger age, breast cancer diagnosis, family history and earlier stage were all significant referral predictors. The odds of being referred increased with the number of affected family members. 70.8% of referred patients, consulted with genetics. Among those who consulted with genetics, 95.2% underwent testing. CONCLUSIONS Although increasing, genetic counseling remains underutilized across cancer diagnosis. Women with breast cancer are more likely to be referred than women with gynecologic cancers. Younger age, earlier stage and positive family history appear to be predictive of referral for genetic evaluation.

Surveying ourselves: examining the use of a web-based approach for a physician survey.

A survey was distributed, using a sequential mixed-mode approach, to a national sample of obstetrician–gynecologists. Differences between responses to the web-based mode and the on-paper mode were compared to determine if there were systematic differences between respondents. Only two differences in respondents between the two modes were identified. University-based physicians were more likely to complete the web-based mode than private practice physicians. Mail respondents reported a greater volume of endometrial ablations compared to online respondents. The web-based mode had better data quality than the paper-based mailed mode in terms of less missing and inappropriate responses. Together, these findings suggest that, although a few differences were identified, the web-based survey mode attained adequate representativeness and improved data quality. Given the metrics examined for this study, exclusive use of web-based data collection may be appropriate for physician surveys with a minimal reduction in sample coverage and without a reduction in data quality.

Evaluation of the clinical use of magnesium sulfate for cerebral palsy prevention.

OBJECTIVE: Clinical trials support the efficacy and safety of magnesium sulfate for cerebral palsy prevention. We evaluated the implementation of a clinical protocol for the use of magnesium for cerebral palsy prevention in our large womens hospital, focusing on uptake, indications, and safety. METHODS: We performed a review of selected gravidas with threatened or planned delivery before 32 weeks of gestation from October 2007 to February 2011. The primary study outcome was the change in the rate of predelivery administration of magnesium sulfate over this time period. RESULTS: Three hundred seventy-three patients were included. In 2007, before guideline implementation, 20% of eligible gravidas (95% confidence interval [CI] 9.1–35.6%) received magnesium before delivery compared with 93.9% (95% CI 79.8–99.3%) in the final 2 months of the study period (P<.001). Dosing did not vary significantly over the 4 study years: the median number of treatments was one, the total predelivery median dose ranged from 15 to 48 g, and the median duration of therapy ranged from 3 to 12 hours. After 3 years, magnesium administration was almost universal among patients diagnosed with preeclampsia, preterm labor, or preterm premature rupture of membranes (95.4%), whereas patients delivered preterm for fetal growth restriction were significantly less likely to receive predelivery magnesium (44%, P<.001). No maternal or perinatal magnesium-attributable morbidity was noted. Among patients eligible for the protocol who received magnesium, 84.2% delivered before 32 weeks of gestation. CONCLUSION: It is feasible to implement a magnesium sulfate cerebral palsy prevention protocol into clinical practice. LEVEL OF EVIDENCE: III

Practice patterns and attitudes about treating abnormal uterine bleeding: a national survey of obstetricians and gynecologists

OBJECTIVE We sought to examine the practice patterns and attitudes of obstetricians and gynecologists surrounding treatment of abnormal uterine bleeding (AUB). STUDY DESIGN We conducted a cross-sectional study of members of the American College of Obstetricians and Gynecologists. Surveys, which were distributed using a sequential mixed method (both web- and mail-based) approach, included questions about practice characteristics, practice patterns, and knowledge about treatment options for AUB. RESULTS Of 802 questionnaires, 417 were returned (52%). The most commonly selected first-line choice for AUB treatment was combined oral contraceptives (97% anovulatory, 98% ovulatory). The levonorgestrel intrauterine system was the next most frequently selected option (63% anovulatory, 53% ovulatory). Respondents did not score high on questions about the effectiveness of treatments for AUB. Only 25% (n = 86) answered at least 2 of the 3 questions correctly. CONCLUSION Continued education is necessary to increase the utilization of the most effective treatment options for AUB.

Iatrogenic Preterm Premature Rupture of Membranes after Fetoscopic Laser Ablative Surgery

Introduction: To describe the incidence and risk factors for iatrogenic premature preterm rupture of membranes (iPPROM) after fetoscopic laser surgery for the twin-to-twin-transfusion syndrome. Materials and Methods: This is a retrospective review of all patients who have undergone fetoscopic laser surgery at a single fetal treatment center since 2000. We defined iPPROM as spontaneous rupture of membranes before the onset of labor prior to 34 weeks of gestation. The iPPROM cohort was compared to the cohort without iPPROM for several preoperative, operative, and delivery characteristics. Results: Ninety-two consecutive patients were reviewed. The overall rate of iPPROM was 18.5% (n = 17). The rates of iPPROM within 1 and 4 weeks were 5.4 and 10.9%, respectively. The median interval from surgery to delivery was significantly shorter in the iPPROM group (21 vs. 62 days, p = 0.01). The mean gestational age at delivery (27.0 vs. 31.1 weeks, p = 0.02) was lower in the iPPROM group. No other characteristics studied differed significantly between the groups. Discussion: The incidence of iPPROM was substantially lower than in recent multicenter reports; however, no risk factors of iPPROM could be identified. Whether this is related to variations in surgical or anesthetic management will require further investigation.

Comparing daily versus less frequent blood glucose monitoring in patients with mild gestational diabetes.

Abstract Objective: The prevalence of gestational diabetes mellitus (GDM) is increasing. This study was designed to determine if different frequencies in blood glucose (BG) monitoring, without regard to other variables, would allow timely detection of hyperglycemia requiring pharmacologic treatment in mild GDMs. Methods: Retrospective chart review, limited to self-glucose monitoring values, of 120 mild GDM patients who required pharmacologic therapy. Three data sets were constructed from each patient’s BG log: (1) all available BG; (2) every other day’s BG blocked; (3) only every third day’s BG available for review. The blocked BG datasets were compared with daily values. Results: 95% and 97% of subjects were started on pharmacologic therapy before or within 7 d of the reference date using every other day and every third day BG logs, respectively. Conclusions: Based exclusively on BG values, without regard to other clinical information, every other day or every third day BG monitoring in mild GDM does not delay the initiation of pharmacologic therapy.

Can hemoglobin A1c in early pregnancy predict adverse pregnancy outcomes in diabetic patients

OBJECTIVE To examine the association of elevated early pregnancy hemoglobin A1c (HbA1c) levels with adverse pregnancy outcomes in women with preexisting diabetes mellitus. STUDY DESIGN Retrospective cohort study of 330 women with preexisting diabetes enrolled in a Diabetes in Pregnancy Program at an academic institution between 2003 and 2011 who had an early HbA1c determination. The frequencies of composite maternal adverse pregnancy outcomes (birth at<37 weeks, preeclampsia, and medically indicated birth <39 weeks), and composite fetal adverse pregnancy outcomes [shoulder dystocia, Apgar scores<7 at 5 minutes, small for gestational age (SGA), large for gestational age (LGA), and stillbirth] were compared between HbA1c categories (<6.5, 6.5-7.4, 7.5-8.4 and ≥ 8.5%). RESULTS There was no statistically significant difference between composite adverse maternal pregnancy outcomes and composite adverse fetal pregnancy outcomes as well as other individual outcomes between different HbA1c categories. Of the vaginally delivered women in our cohort, the 37 patients with HbA1c levels of ≥ 8.5% had a significantly higher frequency of fetal shoulder dystocia than the 62 with HbA1c levels of < 8.5% (24.2 vs. 1.6%, P = 0.002). Neonates of patients with HbA1c ≥ 8.5% were more likely to have low five minute Apgar scores than neonates of patients with HbA1c < 8.5%, but this was of borderline statistical significance (7.4% vs. 0.5%, P = 0.05). CONCLUSION In patients with preexisting diabetes mellitus, HbA1c levels of ≥ 8.5% during early pregnancy are not useful in predicting most adverse outcomes, although there may be an increased risk for shoulder dystocia.