Contraception and sterilization selection at delivery among pregnant patients with malignancy.

INTRODUCTION: Since malignancy during pregnancy is uncommon, information regarding contraception selection or sterilization at delivery is limited. The objective of this study was to examine the type of long-acting reversible contraception or surgical sterilization procedure chosen by pregnant patients with malignancy at delivery. MATERIAL AND METHODS: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample in the USA. The study population was vaginal and cesarean deliveries in a hospital setting from January 2017 to December 2020. Pregnant patients with breast cancer (n = 1605), leukemia (n = 1190), lymphoma (n = 1120), thyroid cancer (n = 715), cervical cancer (n = 425) and melanoma (n = 400) were compared with 14 265 319 pregnant patients without malignancy. The main outcome measures were utilization of long-acting reversible contraception (subdermal implant or intrauterine device) and performance of permanent surgical sterilization (bilateral tubal ligation or bilateral salpingectomy) during the index hospital admission for delivery, assessed with a multinomial regression model controlling for clinical, pregnancy and delivery characteristics. RESULTS: When compared with pregnant patients without malignancy, pregnant patients with breast cancer were more likely to proceed with bilateral salpingectomy (adjusted odds ratio [aOR] 2.30) or intrauterine device (aOR 1.91); none received the subdermal implant. Pregnant patients with leukemia were more likely to choose a subdermal implant (aOR 2.22), whereas those with lymphoma were more likely to proceed with bilateral salpingectomy (aOR 1.93) and bilateral tubal ligation (aOR 1.76). Pregnant patients with thyroid cancer were more likely to proceed with bilateral tubal ligation (aOR 2.21) and none received the subdermal implant. No patients in the cervical cancer group selected long-acting reversible contraception, and they were more likely to proceed with bilateral salpingectomy (aOR 2.08). None in the melanoma group chose long-acting reversible contraception. Among pregnant patients aged <30, the odds of proceeding with bilateral salpingectomy were increased in patients with breast cancer (aOR 3.01), cervical cancer (aOR 2.26) or lymphoma (aOR 2.08). The odds of proceeding with bilateral tubal ligation in pregnant patients aged <30 with melanoma (aOR 5.36) was also increased. CONCLUSIONS: The results of this nationwide assessment in the United States suggest that among pregnant patients with malignancy, the preferred contraceptive option or method of sterilization at time of hospital delivery differs by malignancy type.

Pregnancy following assisted reproductive technology in morbidly obese patients: assessment of feto-maternal outcomes.

PURPOSE: To examine feto-maternal characteristics and outcomes of morbidly obese pregnant patients who conceived with assisted reproductive technology (ART). METHODS: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 48,365 patients with ART pregnancy from January 2012 to September 2015, including non-obesity (n = 45,125, 93.3%), class I-II obesity (n = 2445, 5.1%), and class III obesity (n = 795, 1.6%). Severe maternal morbidity at delivery per the Centers for Disease and Control Prevention definition was assessed with multivariable binary logistic regression model. RESULTS: Patients in the class III obesity group were more likely to have a hypertensive disorder (adjusted-odds ratio (aOR) 3.03, 95% confidence interval (CI) 2.61-3.52), diabetes mellitus (aOR 3.08, 95%CI 2.64-3.60), large for gestational age neonate (aOR 3.57, 95%CI 2.77-4.60), and intrauterine fetal demise (aOR 2.03, 95%CI 1.05-3.94) compared to those in the non-obesity group. Increased risks of hypertensive disease (aOR 1.35, 95%CI 1.14-1.60) and diabetes mellitus (aOR 1.39, 95%CI 1.17-1.66) in the class III obesity group remained robust even compared to the class I-II obesity group. After controlling for priori selected clinical, pregnancy, and delivery factors, patients with class III obesity were 70% more likely to have severe maternal morbidity at delivery compared to non-obese patients (8.2% vs 4.4%, aOR 1.70, 95%CI 1.30-2.22) whereas those with class I-II obesity were not (4.1% vs 4.4%, aOR 0.87, 95%CI 0.70-1.08). CONCLUSIONS: The results of this national-level analysis in the United States suggested that morbidly obese pregnant patients conceived with ART have increased risks of adverse fetal and maternal outcomes.

Fertility-Sparing Surgery for Stage I Epithelial Ovarian Cancer.

OBJECTIVE: To describe population-level utilization of fertility-sparing surgery and outcome of reproductive-aged patients with early epithelial ovarian cancer who underwent fertility-sparing surgery in the United States. METHODS: This retrospective study queried the National Cancer Institute's Surveillance, Epidemiology, and End Result Program. The study included 3,027 patients younger than age 50 years with stage I epithelial ovarian cancer receiving primary surgical therapy from 2007 to 2020. Fertility-sparing surgery was defined as preservation of one ovary and the uterus for unilateral lesion and preservation of the uterus for bilateral lesions. Temporal trend of fertility-sparing surgery was assessed with linear segmented regression with log-transformation. Overall survival associated with fertility-sparing surgery was assessed with Cox proportional hazard regression model. RESULTS: A total of 534 patients (17.6%) underwent fertility-sparing surgery. At the cohort level, the utilization of fertility-sparing surgery was 13.4% in 2007 and 21.8% in 2020 ( P for trend=.009). Non-Hispanic White individuals (2.8-fold), those with high-grade serous histology (2.2-fold), and individuals with stage IC disease (2.3-fold) had a more than twofold increase in fertility-sparing surgery utilization during the study period (all P for trend<.05). After controlling for the measured clinicopathologic characteristics, patients who received fertility-sparing surgery had overall survival comparable with that of patients who had nonsparing surgery (5-year rates 93.6% vs 92.1%, adjusted hazard ratio 0.87, 95% CI, 0.57-1.35). This survival association was consistent in high-grade serous (5-year rates 92.9% vs 92.4%), low-grade serous (100% vs 92.2%), clear cell (97.5% vs 86.1%), mucinous (92.1% vs 86.6%), low-grade endometrioid (95.7% vs 97.7%), and mixed (93.3% vs 83.7%) histology (all P >.05). In high-grade endometrioid tumor, fertility-sparing surgery was associated with decreased overall survival (5-year rates 71.9% vs 93.8%, adjusted hazard ratio 2.90, 95% CI, 1.09-7.67). Among bilateral ovarian lesions, fertility-sparing surgery was not associated with overall survival (5-year rates 95.8% vs 92.5%, P =.364). Among 41,914 patients who had epithelial ovarian cancer with any age and stage, those younger than age 50 years with stage I disease increased from 8.6% to 10.9% during the study period ( P for trend=.002). CONCLUSION: Nearly one in five reproductive-aged patients with stage I epithelial ovarian cancer underwent fertility-sparing surgery in recent years in the United States. More than 90% of reproductive-aged patients with stage I epithelial ovarian cancer who underwent fertility-sparing surgery were alive at the 5-year timepoint, except for those with high-grade endometrioid tumors.

Pregnancy with endometriosis: Assessment of national-level trends, characteristics, and maternal morbidity at delivery.

OBJECTIVE: To examine pregnancy characteristics and maternal morbidity at delivery among pregnant patients with a diagnosis of endometriosis. STUDY DESIGN: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population was 17,796,365 hospital deliveries from 2016 to 2020, excluded adenomyosis and uterine myoma. The exposure was endometriosis diagnosis. Main outcome measures were clinical and pregnancy characteristics and severe maternal morbidity at delivery related to endometriosis, assessed with multivariable regression model. RESULTS: Endometriosis was diagnosed in 17,590 patients. The prevalence of endometriosis increased by 24 % from one in 1,191 patients in 2016 to one in 853 patients in 2020 (adjusted-odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.19-1.30). Clinical and pregnancy characteristics that had greater than two-fold association to endometriosis included polycystic ovary syndrome, placenta previa, cesarean delivery, maternal age of ≥30 years, prior pregnancy loss, and anxiety disorder. Pregnant patients with endometriosis were more likely to have the diagnosis of measured severe maternal morbidity during the index hospitalization for delivery (47.8 vs 17.3 per 1,000 deliveries, aOR 1.91, 95%CI 1.78-2.06); these associations were more prominent following vaginal (aOR 2.82, 95%CI 2.41-3.30) compared to cesarean (aOR 1.85, 95%CI 1.71-2.00) deliveries. Among the individual morbidity indicators, endometriosis was most strongly associated with thromboembolism (aOR 5.05, 95%CI 3.70-6.91), followed by sepsis (aOR 2.39, 95%CI 1.85-3.09) and hysterectomy (aOR 2.18, 95%CI 1.85-2.56). When stratified for endometriosis anatomical site, odds of thromboembolism was increased in endometriosis at distant site (aOR 9.10, 95%CI 3.76-22.02) and adnexa (aOR 7.37, 95%CI 4.43-12.28); odds of sepsis was most increased in endometriosis at multi-classifier locations (aOR 7.33, 95%CI 2.93-18.31) followed by pelvic peritoneum (aOR 5.54, 95%CI 2.95-10.40); and odds of hysterectomy exceeded three-fold in endometriosis at adnexa (aOR 3.00, 95%CI 2.30-3.90), distant site (aOR 5.36, 95%CI 3.48-8.24), and multi-classifier location (aOR 4.46, 95%CI 2.11-9.41). CONCLUSION: The results of this nationwide analysis suggest that pregnancy with endometriosis is uncommon but gradually increasing over time in the United States. The data also suggest that endometriosis during pregnancy is associated with increased risk of severe maternal morbidity at delivery, especially for thromboembolism, sepsis, and hysterectomy. These morbidity risks differed by the anatomical location of endometriosis.

Planned Oocyte Cryopreservation: A Review of Current Evidence on Outcomes, Safety and Risks.

Although oocyte cryopreservation was initially used as a fertility preservation strategy for medical indications, it is now is increasingly used to circumvent age-related infertility. Outcomes following planned oocyte vitrification, also known as elective egg freezing, are limited. Current studies show higher success rates for individuals undergoing fertility preservation treatment under age 35. Additionally, while freezing 20 oocytes is optimal to achieve pregnancy, freezing at least 8-10 oocytes is recommended. While fertility is not guaranteed, current evidence demonstrates that planned oocyte vitrification is an overall safe, low risk method of fertility preservation to reduce the risk for age-related infertility.

Facilitators of and Barriers to Successful Implementation of the One Key Question® Pregnancy Intention Screening Tool.

Background: One Key Question® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings. Methods: We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR). Main Findings: Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments. Conclusions: The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788.

"This has definitely opened the doors": Provider perceptions of patient experiences with telemedicine for contraception in Illinois.

CONTEXT: The COVID-19 pandemic increased the provision of contraception through telemedicine. This qualitative study describes provider perceptions of how telemedicine provision of contraception has impacted patient care. METHODS: We interviewed 40 obstetrics-gynecology and family medicine physicians, midwives, nurse practitioners, and support staff providing contraception via telemedicine in practices across Illinois, including Planned Parenthood of Illinois (PPIL) health centers. We analyzed interview content to identify themes around the perceived impact of telemedicine implementation on contraception access, contraceptive counseling, patient privacy, and provision of long-acting reversible contraception (LARC). RESULTS: Participants perceived that telemedicine implementation improved care by increasing contraception access, increasing focus on counseling while reducing bias, and allowing easier method switching. Participants thought disparities in telemedicine usage and limitations to the technological interface presented barriers to patient care. Participants' perceptions of how telemedicine implementation impacts patient privacy and LARC provision were mixed. Some participants found telemedicine implementation enhanced privacy, while others felt unable to ensure privacy in a virtual space. Participants found telemedicine modalities useful for counseling patients considering methods of LARC, but they sometimes presented an unnecessary extra step for those sure about receiving one at a practice offering same day insertion. CONCLUSION: Providers felt telemedicine provision of contraception positively impacted patient care. Improvements to counseling and easier access to method switching suggest that telemedicine implementation may help reduce contraceptive coercion. Our findings highlight the need to integrate LARC care with telemedicine workflows, improve patient privacy protections, and promote equitable access to all telemedicine modalities.

Effects of clinic-level implementation of One Key Question® on reproductive health counseling and patient satisfaction.

OBJECTIVE: We evaluated the effect of clinic level implementation of the One Key Question (OKQ) intervention, including physician and staff training and workflow adjustments, on reproductive counseling and patient satisfaction in primary care and ob/gyn. STUDY DESIGN: We implemented the OKQ intervention in one primary care and one ob/gyn practice, while observing another primary care and ob/gyn practice that each provided usual care (control practices). We surveyed separate patient cohorts at two time points: 26 before and 33 after the primary care practice implemented OKQ, 38 before and 36 after the ob/gyn practice implemented OKQ, 26 and 37 at the primary care control practice, and 31 and 37 at the ob/gyn control practice. We used chi square tests to assess OKQ's effects on counseling rates and patient satisfaction, comparing intervention to control practices across time points. RESULTS: In primary care, from before to after implementation, the intervention practice did not significantly increase reproductive counseling (69-76%, p = 0.58), but increased patient satisfaction (81-97%, p = 0.04) while the control practice demonstrated a decrease in patient satisfaction over the same time periods. In the ob/gyn clinics, no significant change in reproductive counseling or patient satisfaction was seen in the intervention practice, while the control practice demonstrated a decrease in patient satisfaction. CONCLUSIONS: Implementing OKQ appears to increase patient satisfaction. Larger studies are needed to assess whether this clinic-level intervention may increase reproductive counseling. IMPLICATIONS: Further studies of the impact of clinic-level implementation of OKQ are needed.

Where Do I Fit In? A Perspective on Challenges Faced by Asian American Medical Students.

Asian American medical students (AAMSs) face significant bias in the medical learning environment and are more likely than White students to perceive their school climate negatively. Little is known about the factors that contribute to AAMSs' negative experiences. This perspective aims to describe AAMSs' experiences with diversity and inclusion efforts using survey data from a midwest regional conference, Asians in Medicine: A Conference on Advocacy and Allyship. AAMS respondents reported feeling excluded from diversity and inclusion efforts and conference participants advocated for institutional culture and climate assessments stratified by race and disaggregated into Asian subgroups.

Variation in outcome reporting and measurement tools in clinical trials of treatments for genitourinary symptoms in peri- and postmenopausal women: a systematic review.

IMPORTANCE: Genitourinary symptoms affect 40% to 60% of postmenopausal women. Evidence-based approaches to diagnosing and managing these symptoms are limited by inconsistencies in outcomes and measures used in clinical trials. OBJECTIVE: The aim of the study was to systematically review all outcomes and measurement tools reported in randomized clinical trials of interventions for genitourinary symptoms associated with menopause. EVIDENCE REVIEW: We searched PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to December 2018. Randomized controlled trials with a primary or secondary outcome of genitourinary symptoms associated with menopause, English language, and sample size of 20 or more women per study arm were included. Study characteristics, outcomes, and measurement methods were collected. FINDINGS: The search yielded 3,478 articles of which 109 met inclusion criteria. Forty-eight different outcomes were reported with "atrophy" as the most common (56/109, 51%) followed by measures of sexual function (19/109, 17%). Almost all (108/109, 99%) trials included patient-reported measures, with 21 different measures and 39 symptom combinations. Clinician-reported scales of vulvovaginal appearance were used in 36 of 109 (33%) trials, with extensive variation in what was measured and reported. Cytological measures from the vaginal epithelium were the most commonly used objective tools (76/109, 70%). CONCLUSIONS AND RELEVANCE: There is heterogeneity in reported outcomes and measures used in clinical trials of treatments for genitourinary symptoms at menopause and uncertainty as to which outcomes best reflect patient priorities and symptoms. The findings from this systematic review have informed an international survey of stakeholders to determine priorities for outcome selection and reporting. This survey will then inform the development of a Core Outcome Set for use in future clinical trials by the COMMA (Core OutcoMes in MenopAuse) consortium. : Video Summary:http://links.lww.com/MENO/A599.