Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts.

BACKGROUND: Trauma is the leading nonobstetric cause of death in women of reproductive age, and pregnant women in particular may be at increased risk of violent trauma. Management of trauma in pregnancy is complicated by altered maternal physiology, provider expertise, potential disparate imaging, and distorted anatomy. Little is known about the impact of trauma on maternal mortality. OBJECTIVE: We sought to: (1) characterize nonviolent and violent trauma among pregnant women; (2) determine whether pregnancy is associated with increased mortality following traumatic injury; and (3) identify risk factors for trauma-related death in pregnant women. STUDY DESIGN: We studied 1148 trauma events among pregnant girls and women and 43,608 trauma events among nonpregnant girls and women of reproductive age (14-49 years) who presented to any accredited trauma center in Pennsylvania for treatment of trauma-related injuries from 2005 through 2015, as captured in the Pennsylvania Trauma Outcome Study. Traumas were categorized as violent (eg, homicide or assault) or nonviolent (eg, motor vehicle accident or accidental fall). We used modified Poisson regression to estimate relative rate of trauma-related death, adjusting for demographic characteristics and severity of trauma. RESULTS: Compared to nonpregnant women, pregnant women and girls had a lower injury severity score (8.9 vs 10.9, P < .001) and were significantly more likely to experience violent trauma (15.9% vs 9.8%, P < .001). Pregnant trauma victims had a 1.6-fold higher rate of mortality compared to their nonpregnant counterparts (P < .001), and were both more likely to be dead on arrival and to die during their hospital course (adjusted relative risk, 2.33, P < .001, and adjusted relative risk, 1.79, P = .004, respectively). Pregnancy was associated with increased mortality in both victims of nonviolent and violent trauma (adjusted relative risk, 1.69, P = .002, and adjusted relative risk, 1.60, P = .007, respectively). Pregnant trauma victims were less likely to undergo surgery (adjusted relative risk, 0.70, P = .001) and more likely to be transferred to another facility (adjusted relative risk, 1.72, P < .001). Even after adjusting for demographics and injury severity score, violent trauma was associated with 3.14-fold higher mortality in pregnant women and girls compared to nonviolent trauma (adjusted relative risk, 3.14, P = .003). CONCLUSION: Pregnant women and girls are nearly twice as likely to die after trauma and twice as likely to experience violent trauma. Universal screening for violence and trauma during pregnancy may provide an opportunity to identify women at risk for death during pregnancy.

Impact of fertility preservation counseling and treatment on psychological outcomes among women with cancer: A systematic review.

BACKGROUND: For many female cancer survivors, the preservation of reproductive potential is central to quality of life (QOL), and concerns regarding infertility may affect treatment decisions. Despite the existence of several consensus guidelines supporting routine fertility preservation consultation, to the authors' knowledge little is known regarding psychological outcomes in female cancer patients who undergo fertility preservation counseling/consultation (FPC), with or without fertility preservation (FP). METHODS: This literature review examined the effect of FPC alone, or with FP, on psychological outcomes including satisfaction, decisional regret, and QOL. PubMed and PsychINFO were systematically searched for English-language publications from the earliest available publication date of each database through March 2015. Among 111 unique articles concerning oncofertility, 13 met inclusion criteria: peer-reviewed articles reporting primary data regarding satisfaction and psychological outcomes among women who underwent FPC alone or with FP. RESULTS: A majority of women receiving FPC reported that the possibility of FP was instrumental to improved coping. Receiving FPC reduced long-term regret and dissatisfaction concerning fertility, and was associated with improved physical QOL and trends toward improved psychological QOL. Women also desired prompt, standardized, and written information addressing perceived unmet needs specific to oncofertility. Offering FPC was perceived as critical regardless of age or parity. CONCLUSIONS: To the best of the authors' knowledge, little research to date has addressed the impact of FPC alone, or with FP, on QOL in women with cancer. Clinicians should recognize the existing evidence base supporting the psychological benefit of prompt FPC. Future research must be conducted to elucidate the long-term psychosocial effects of FP.

Pregnancy outcomes of liver transplant recipients: a systematic review and meta-analysis.

Approximately 14,000 women of reproductive age are currently living in the United States after liver transplantation (LT), and another 500 undergo LT each year. Although LT improves reproductive function in women with advanced liver disease, the associated pregnancy outcomes and maternal-fetal risks have not been quantified in a broad manner. To obtain more generalizable inferences, we performed a systematic review and meta-analysis of articles that were published between 2000 and 2011 and reported pregnancy-related outcomes for LT recipients. Eight of 578 unique studies met the inclusion criteria, and these studies represented 450 pregnancies in 306 LT recipients. The post-LT live birth rate [76.9%, 95% confidence interval (CI) = 72.7%-80.7%] was higher than the live birth rate for the US general population (66.7%) but was similar to the post-kidney transplantation (KT) live birth rate (73.5%). The post-LT miscarriage rate (15.6%, 95% CI = 12.3%-19.2%) was lower than the miscarriage rate for the general population (17.1%) but was similar to the post-KT miscarriage rate (14.0%). The rates of pre-eclampsia (21.9%, 95% CI = 17.7%-26.4%), cesarean section delivery (44.6%, 95% CI = 39.2%-50.1%), and preterm delivery (39.4%, 95% CI = 33.1%-46.0%) were higher than the rates for the US general population (3.8%, 31.9%, and 12.5%, respectively) but lower than the post-KT rates (27.0%, 56.9%, and 45.6%, respectively). Both the mean gestational age and the mean birth weight were significantly greater (P < 0.001) for LT recipients versus KT recipients (36.5 versus 35.6 weeks and 2866 versus 2420 g). Although pregnancy after LT is feasible, the complication rates are relatively high and should be considered during patient counseling and clinical decision making. More case and center reports are necessary so that information on post-LT pregnancy outcomes and complications can be gathered to improve the clinical management of pregnant LT recipients. Continued reporting to active registries is highly encouraged at the center level.

Relationship between body mass index and operative time in women receiving immediate postpartum tubal ligation.

OBJECTIVES: The aim of the study was to (1) assess the relationship between body mass index (BMI) and operative time during immediate postpartum tubal ligation procedures and to (2) determine whether operative time is non-inferior in women with BMI ≥30 versus women with BMI <30 and in women with BMI ≥40 versus women with BMI <40. STUDY DESIGN: We conducted a retrospective cohort study of women who received immediate postpartum tubal ligations following vaginal delivery from 2013 to 2017 at a university hospital. We abstracted demographic information, patient and procedural characteristics, and clinical outcomes. We assessed the relationship between BMI and operative time via linear regression. We also conducted non-inferiority analysis to determine whether the mean operative time in women with BMI ≥30 was non-inferior to the mean operative time in women with BMI <30, within a non-inferiority margin of 10 min. We compared intraoperative and postoperative complications in the two groups. RESULTS: A total of 279 women were included for analysis, among whom N=79 (28%) had a BMI of 25-29.9 and N=171 (61%) had a BMI ≥30. Demographic characteristics were similar in both groups. We found that operative time increased by 35 s for each one-point increase in BMI (p<.01). Although mean operative time was 46.1 min (n=171; 95% CI 43.7, 48.6 min) for women with BMI ≥30 and 40.6 min (n=108; 95% CI 37.9 min, 43.4 min) for women with BMI <30, (p<.01), it was non-inferior within a 10-min margin. There was no difference in rates of intraoperative or postoperative complications, incision length, total anesthesia time, and median length of stay between women with BMI ≥30 and BMI <30. CONCLUSION: There is a small increase in postpartum tubal ligation operative time with increasing BMI. However, among women who received immediate postpartum tubal ligations at our institution, women with BMI ≥30 versus BMI <30 had operative times that were non-inferior within a 10-min margin. IMPLICATIONS: While increasing body mass index slightly increases the operative time for immediate postpartum tubal ligations, this increase in time does not appear to be clinically significant.

A Clinical Reference Guide on Sexual Devices for Obstetrician-Gynecologists.

In the United States, more than half of all women have used a vibrator, nearly one third of women have used a dildo, and more than three quarters of women who have sex with women have used a vibrator. Sexual devices can be used by patients with decreased libido, anorgasmia, conditions inhibiting vaginal penetration, partner erectile dysfunction, and motor or sensory disabilities. Basic knowledge of sexual devices can help obstetrician-gynecologists counsel patients about device safety, sharing, cleaning, disinfection, and material selection. Common sexual devices include vibrators, penetrative devices, anal-specific devices, and air pulsation devices. Collision dyspareunia aids can assist patients who experience difficulty with deep penetration owing to pain and structural limitations. Although rare, the most common risks of sexual devices are traumatic injury and infection. Barrier use over sexual devices and proper disinfection can help reduce, but not eliminate, the risk of transmission of common viral and bacterial sexually transmitted infections. Sexual devices made of nonporous materials are the safest and easiest to clean and disinfect. Porous materials should be avoided given inability to disinfect and risk of material breakdown. Sexual devices can benefit specific patient populations, including women who are pregnant or postpartum, those with disorders of sexual function or pelvic floor, menopausal patients, cancer patients undergoing treatment, and women with disability and chronic illness.

Cross-Cultural Obstetric and Gynecologic Care of Muslim Patients.

With the growing number of Muslim patients in the United States, there is a greater need for obstetrician-gynecologists (ob-gyns) to understand the health care needs and values of this population to optimize patient rapport, provide high-quality reproductive care, and minimize health care disparities. The few studies that have explored Muslim women's health needs in the United States show that among the barriers Muslim women face in accessing health care services is the failure of health care providers to understand and accommodate their beliefs and customs. This article outlines health care practices and cultural competency tools relevant to modern obstetric and gynecologic care of Muslim patients, incorporating emerging data. There is an exploration of the diversity of opinion, practice, and cultural traditions among Muslims, which can be challenging for the ob-gyn who seeks to provide culturally competent care while attempting to avoid relying on cultural or religious stereotypes. This commentary also focuses on issues that might arise in the obstetric and gynecologic care of Muslim women, including the patient-physician relationship, modesty and interactions with male health care providers, sexual health, contraception, abortion, infertility, and intrapartum and postpartum care. Understanding the health care needs and values of Muslims in the United States may give physicians the tools necessary to better deliver high-quality care to this minority population.

Perioperative complications after live-donor hepatectomy.

Current studies of complications following donor hepatectomy may not be generalizable to all hospitals performing this procedure. To address this, live liver donors were identified in the Nationwide Inpatient Sample (2000-2008). Complications after donor hepatectomy were categorized using International Classification of Diseases, Ninth Revision codes and risk factors for complications were tested using logistic regression. Negative binomial regression models were used to estimate the increase in length of stay and hospital charge associated with complications. Among 555 donors (representing 2783 donors nationwide), 23% had 1 or more complications and 5% had a major complication. The most common complications were ileus (27%) and atelectasis (26%). No patient or hospital factors were associated with complications. Having any complication was associated with increased length of stay (incidence rate ratio, 1.36; 95% CI, 1.16-1.58; P < .001) and hospital charge (incidence rate ratio, 1.25; 95% CI, 1.09-1.44; P = .002). Approximately 25% of liver donors have complications immediately postoperatively but most are minor, lending support to current practices in live liver donation and donor selection.

Sex trafficking of women and girls.

Sex trafficking involves some form of forced or coerced sexual exploitation that is not limited to prostitution, and has become a significant and growing problem in both the United States and the larger global community. The costs to society include the degradation of human and women's rights, poor public health, disrupted communities, and diminished social development. Victims of sex trafficking acquire adverse physical and psychological health conditions and social disadvantages. Thus, sex trafficking is a critical health issue with broader social implications that requires both medical and legal attention. Healthcare professionals can work to improve the screening, identification, and assistance of victims of sex trafficking in a clinical setting and help these women and girls access legal and social services.

Uterine rupture after prior conservative management of placenta accreta.

BACKGROUND: There is little evidence for counseling patients who seek uterine conservation in the setting of placenta accreta. CASE: We report the case of a 37-year-old woman with retained placenta accreta after vaginal delivery. Attempts at transvaginal removal failed, and the placenta was removed through a fundal hysterotomy with bilateral uterine artery ligations performed to control blood loss. She conceived a second pregnancy 11 months later and sustained spontaneous fundal uterine rupture at 26.5 weeks of gestation with a recurrent accreta found at the rupture site. The newborn survived but has residual musculoskeletal morbidity and developmental delay at 1 year of age. CONCLUSION: Patients undergoing conservative treatment of placenta accreta in the setting of a fundal hysterotomy should be cautioned about recurrent accreta and uterine rupture.

Screening for intimate partner violence during pregnancy.

Intimate partner violence (IPV) is defined as an actual or threatened abuse by an intimate partner that may be physical, sexual, psychological, or emotional in nature. Each year approximately 1.5 million women in the United States report some form of sexual or physical assault by an intimate partner; it is estimated that approximately 324,000 women are pregnant when violence occurs. Pregnancy may present a unique opportunity to identify and screen for patients experiencing IPV. This article provides health care practitioners and clinicians with the most current valid assessment and screening tools for evaluating pregnant women for IPV.

Pregnancy after solid organ transplantation: a guide for obstetric management.

Successful pregnancy outcomes are possible among all solid organ transplant recipients. Patients should be fully counseled regarding the potential adverse fetal outcomes, including prematurity and low birth weight. Transplant recipients are at an increased risk for both maternal and neonatal complications and should be seen by a high-risk obstetrician in conjunction with their transplant teams. Ideally, preconception counseling begins during the pretransplantation evaluation process. Initiating contraception early after transplantation is ideal, and long-acting reversible methods such as intrauterine devices and subdermal implants may be preferred. Pregnancy should be avoided for at least 1 year after transplantation to limit the potential risks of early pregnancy that may adversely affect both allograft function and fetal well-being. Hypertension, diabetes, and infection should be monitored and treated to minimize fetal risks during pregnancy. Maintenance of current immunosuppression is usually recommended, with the exception of mycophenolic acid products, which (when possible) should be discontinued before conception and replaced with an alternative medication. Throughout pregnancy, immunosuppression must be maintained at appropriate dosing to avoid graft rejection. During labor and delivery, cesarean delivery should be performed for obstetric reasons only. A multidisciplinary team should manage pregnant transplant recipients before, during, and following pregnancy. Breastfeeding and long-term in utero exposure to immunosuppressants for offspring of transplant recipients continue to require further investigation but have been encouraged by recent reports. Continued reporting of post-transplantation pregnancy outcomes to the National Transplantation Pregnancy Registry is highly encouraged.

Practice patterns and outcomes in retransplantation among pediatric kidney transplant recipients.

BACKGROUND: More than 25% of pediatric kidney transplants are lost within 7 years, necessitating dialysis or retransplantation. Retransplantation practices and the outcomes of repeat transplantations, particularly among those with early graft loss, are not clear. METHODS: We examined retransplantation practice patterns and outcomes in 14,799 pediatric (ages <18 years) patients between 1987 and 2010. Death-censored graft survival was analyzed using extended Cox models and retransplantation using competing risks regression. RESULTS: After the first graft failure, 50.4% underwent retransplantation and 12.1% died within 5 years; after the second graft failure, 36.1% underwent retransplantation and 15.4% died within 5 years. Prior preemptive transplantation and graft loss after 5 years were associated with increased rates of retransplantation. Graft loss before 5 years, older age, non-Caucasian race, public insurance, and increased panel-reactive antibody were associated with decreased rates of retransplantation. First transplants had lower risk of graft loss compared with second (adjusted hazard ratio [aHR], 0.72; 95% confidence interval [CI], 0.64-0.80; P<0.001), third (aHR, 0.62; 95% CI, 0.49-0.78; P<0.001), and fourth (aHR, 0.44; 95% CI, 0.24-0.78; P=0.005) transplants. However, among patients receiving two or more transplants (conditioned on having lost a first transplant), second graft median survival was 8.5 years despite a median survival of 4.5 years for the first transplant. Among patients receiving three or more transplants, third graft median survival was 7.7 years despite median survivals of 2.1 and 3.1 years for the first and second transplants. CONCLUSIONS: Among pediatric kidney transplant recipients who experience graft loss, racial and socioeconomic disparities exist with regard to retransplantation, and excellent graft survival can be achieved with retransplantation despite poor survival of previous grafts.

Management of pregnant patients who refuse medically indicated cesarean delivery.

The doctrine of informed refusal may become difficult to adhere to in obstetric practice, especially in situations in which the fetus's life is at risk. One rare yet potentially problematic situation of informed refusal is the case of a pregnant woman who refuses to undergo a medically indicated cesarean delivery that would ensure the well-being of her fetus. Although some would argue that patient autonomy takes precedence and the woman's informed refusal should be respected, others would argue that beneficence, justice, and doing no harm to the viable fetus should ethically overrule the refusal of a surgery. This article explores the profound conflict between maternal autonomy and the rights of the fetus, provides a framework to address when the two diverge, and poses suggestions for how providers can better navigate this dilemma.

Potential limitations of presumed consent legislation.

A causal link has been proposed between presumed consent (PC) and increased donation; we hypothesized that too much heterogeneity exists in transplantation systems to support this inference. We explored variations in PC implementation and other potential factors affecting donation rates. In-depth interviews were performed with senior transplant physicians from 13 European PC countries. Donation was always discussed with family and would not proceed against objections. Country-specific, nonconsent factors were identified that could explain differences in donation rates. Because the process of donation in PC countries does not differ dramatically from the process in non-PC countries, it seems unlikely that PC alone increases donation rates.

Live donor champion: finding live kidney donors by separating the advocate from the patient.

BACKGROUND: Lack of education and reluctance to initiate a conversation about live donor kidney transplantation is a common barrier to finding a donor. Although transplant candidates are often hesitant to discuss their illness, friends or family members are often eager to spread awareness and are empowered by advocating for the candidates. We hypothesized that separating the advocate from the patient is important in identifying live donors. METHODS: We developed an intervention to train a live donor champion (LDC; a friend, family member, or community member willing to advocate for the candidate) for this advocacy role. We compared outcomes of 15 adult kidney transplant candidates who had no prospective donors and underwent the LDC intervention with 15 matched controls from our waiting list. RESULTS: Comfort in initiating a conversation about transplantation increased over time for LDCs. Twenty-five potential donors contacted our center on behalf of LDC participants; four participants achieved live donor kidney transplantation and three additional participants have donors in evaluation, compared with zero among matched controls (P < 0.001). CONCLUSIONS: Transplant candidates are ill equipped to seek live donors; by separating the advocate from the patient, understandable concerns about initiating conversations are reduced.