Results of Immediate Postpartum Long Acting Reversible Contraception Provision After Expanded Reimbursement Policy Implementation at an Academic Medical Institution.

INTRODUCTION: Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients. METHODS: Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer's exact tests, based on cell sizes, were calculated using SAS (version9.4). RESULTS: Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%). DISCUSSION: Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice.

Assessing Women's Health Needs in the Underserved Island Communities of Vanuatu.

INTRODUCTION: Vanuatu is a South Pacific island nation with limited resources and dispersed communities. Healthcare provision and population health data is lacking; and women have been an historically undervalued, underserved group. This needs assessment was completed by mothers in the area surrounding a health clinic in Vanuatu to better inform the clinic's service expansion. METHODS: In a period of six weeks, 60 parous women, between 17 and 66 years old, were interviewed in their native language (Bislama). Participants provided verbal responses to 29 questions targeting family health needs and pregnancy experiences. The questionnaire was constructed from WHO and UNICEF surveys. Descriptive statistics were calculated. RESULTS: Primary care complaints were the most common health concerns reported by participants. Few women (43.3%, 26/60) knew what a sexually transmitted infection was, and 38.3% (23/60) knew a place offering HIV testing. Thirty percent (18/60) never had a pelvic exam. During their last pregnancies, 98.3% (59/60) received prenatal care with a median of five visits and variable health education. Injectable (65.2%, 15/23) and oral contraception (21.7%, 5/23) were the most utilized family planning methods; one person used condoms (4.3%, 1/23). Eighty-seven percent (52/60) felt unsafe walking through their neighborhoods at night. DISCUSSION: General knowledge and utilization of women's health resources were limited in this group. The community-based primary care setting could be an important site for future provision of women's health services. Future studies and interventions in family planning, sexual health, and prenatal care could aid this community.

Intubation and intensive care after laminaria anaphylaxis in second-trimester abortion.

Laminaria are cervical dilators inserted for several days preceding second-trimester abortions and other uterine procedures. Our patient was intubated after a life-threatening anaphylactic reaction to laminaria prior to her surgical abortion. Abortions with laminaria dilators are frequently performed outpatient across the United States. Due to stigma, increasing restrictions, and forced closure of family planning clinics, these procedures are often obtained covertly and remotely. Patients may present obtunded, in shock, without records or proxy, and with no external evidence of the allergen's location or continued presence. Emergency and critical care physicians may consider this etiology in obtunded women with anaphylaxis who are responding poorly to standard care.

Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery.

OBJECTIVES: To identify barriers to postpartum permanent contraception procedures after vaginal delivery and to explore contraceptive and reproductive outcomes of women who experience unfulfilled requests. STUDY DESIGN: We performed a retrospective cohort study of women requesting postpartum permanent contraception after vaginal delivery from 7/1/11 to 6/30/14 at Strong Memorial Hospital in Rochester, NY. We ascertained patient characteristics and outcomes through electronic medical records and birth certificate data search. RESULTS: Of 189 women in our sample, 78 (41.3%) had a postpartum permanent contraception procedure. Factors associated with unfulfilled requests in adjusted analysis included BMI ≥40 (OR 3.71, 95% CI 1.46-9.48 compared to BMI <35), federal sterilization consent signed ≥36 weeks (OR 5.10, 95% CI 1.64-15.86 compared to <36 weeks) and delivery in the latter half of the week (Wednesday-Saturday) (OR 2.02, 95% CI 1.08-3.79). Documented reasons for unfulfilled permanent contraception requests included patient changing her mind related to procedural issues (21, 18.9%), invalid consent (20, 18.0%), maternal obesity (17, 15.3%), lack of operating room availability (14, 12.6%) and ambivalence about permanent contraception (5, 4.5%). Of 57 women who planned for interval permanent contraception and had institutional follow-up over the subsequent year, 14 (24.6%) had a procedure, 8 (14.0%) initiated long-acting reversible contraception, and 13 (22.8%) became pregnant. CONCLUSIONS: Fewer than half of women obtained desired postpartum permanent contraception after vaginal delivery, with logistical issues and obesity being the most common reported barriers. Health care providers should advocate for access to postpartum permanent contraception, as well as discuss prenatally the individualized probability of nonfulfillment and importance of alternative contraceptive plans. IMPLICATIONS: Logistical barriers and inappropriate antenatal preparation contribute to the fact that over half of women do not obtain desired postpartum permanent contraception after vaginal delivery. To respect reproductive autonomy and improve care, clinicians and other health officials should eliminate barriers to immediate postpartum permanent contraception while increasing access to alternative options.

The Rise of Female Sterilization: A Closer Look at Colombia.

Objective In the 1970s, OCPs and IUDs were the most popular contraceptive methods in Colombia. According to data from the most recent Demographic and Health Survey (DHS), sterilization has become the most common form of birth control in Colombia. This study aims to examine the characteristics of Colombian women desiring long-acting contraception. Methods This study uses the 2005 and 2010 Colombian DHS dataset. Women who choose long-acting contraception were divided into those using female sterilization and those using long-acting reversible contraception (LARC). A multivariate logistic regression model was used to compare demographic and social determinants of contraceptive choice among reproductive age women seeking long-acting contraception between the years 2005 and 2010. Results Among women using a long-acting contraceptive method in 2010, compared to 2005, women were significantly more likely to be sterilized (1.14 OR, 95% CI 1.09-1.18) and less likely to use LARC (0.88 OR, 95% CI 0.85-0.92). Of women seeking long-acting contraception, those exposed to a family planning provider were less likely to undergo sterilization (0.54 OR, 95% CI 0.51-0.58) and more likely to use LARC (1.84 OR, 95% CI 1.73-1.96). When compared to all contraceptive users, younger women and women with less than two children were more likely to use LARC than sterilization. Conclusion Between 2005 and 2010, an increase in the proportion of contracepting women being sterilized in Colombia occurred. Our findings suggest that exposure to a family planning provider and appropriate contraceptive counseling appears to be key determinants of long-acting contraceptive choice. To improve use of long-acting, effective contraception, efforts should be made to increase access to family planning providers.

Human glial chimeric mice reveal astrocytic dependence of JC virus infection.

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease triggered by infection with the human gliotropic JC virus (JCV). Due to the human-selective nature of the virus, there are no animal models available to investigate JCV pathogenesis. To address this issue, we developed mice with humanized white matter by engrafting human glial progenitor cells (GPCs) into neonatal immunodeficient and myelin-deficient mice. Intracerebral delivery of JCV resulted in infection and subsequent demyelination of these chimeric mice. Human GPCs and astrocytes were infected more readily than oligodendrocytes, and viral replication was noted primarily in human astrocytes and GPCs rather than oligodendrocytes, which instead expressed early viral T antigens and exhibited apoptotic death. Engraftment of human GPCs in normally myelinated and immunodeficient mice resulted in humanized white matter that was chimeric for human astrocytes and GPCs. JCV effectively propagated in these mice, which indicates that astroglial infection is sufficient for JCV spread. Sequencing revealed progressive mutation of the JCV capsid protein VP1 after infection, suggesting that PML may evolve with active infection. These results indicate that the principal CNS targets for JCV infection are astrocytes and GPCs and that infection is associated with progressive mutation, while demyelination is a secondary occurrence, following T antigen-triggered oligodendroglial apoptosis. More broadly, this study provides a model by which to further assess the biology and treatment of human-specific gliotropic viruses.

Forebrain engraftment by human glial progenitor cells enhances synaptic plasticity and learning in adult mice.

Human astrocytes are larger and more complex than those of infraprimate mammals, suggesting that their role in neural processing has expanded with evolution. To assess the cell-autonomous and species-selective properties of human glia, we engrafted human glial progenitor cells (GPCs) into neonatal immunodeficient mice. Upon maturation, the recipient brains exhibited large numbers and high proportions of both human glial progenitors and astrocytes. The engrafted human glia were gap-junction-coupled to host astroglia, yet retained the size and pleomorphism of hominid astroglia, and propagated Ca2+ signals 3-fold faster than their hosts. Long-term potentiation (LTP) was sharply enhanced in the human glial chimeric mice, as was their learning, as assessed by Barnes maze navigation, object-location memory, and both contextual and tone fear conditioning. Mice allografted with murine GPCs showed no enhancement of either LTP or learning. These findings indicate that human glia differentially enhance both activity-dependent plasticity and learning in mice.

Complications of surgical termination of second-trimester pregnancy in obese versus nonobese women.

BACKGROUND: Obesity is becoming increasingly common in obstetric and gynecologic populations, which may affect the safety of surgical termination of pregnancy. STUDY DESIGN: We performed a retrospective review of all patients undergoing second-trimester surgical termination of pregnancy by under ultrasound guidance termination between 13 0/7 and 24 0/7 weeks of gestational age (GA) to compare perioperative risks in obese and nonobese women. Complication rates, operative times and anesthesia times were compared between obese [body mass index (BMI) ≥30 kg/m²] and nonobese women (BMI <30). RESULTS: Of 1044 women, 29.0% were obese. The mean complication rate was 6.1% and similar between groups (5.5% nonobese, 7.6% obese, p=.20). Operative times were 4.4 min longer and mean anesthesia times were 5 min longer in obese patients (p<.001 for each). There was a nonsignificant trend toward more complications with gestational ages above 18 weeks (5.5% vs. 7.7%, p=.20). A history of one or more cesarean sections had an independent association with major complications after adjustment for confounders (adjusted odds ratio 4.2, p=.001). CONCLUSIONS: Both anesthesia and operative times were modestly increased in obese women versus nonobese women undergoing second-trimester surgical termination, without significant differences in complication rates. For patients at advanced GA with prior cesarean delivery, clinicians should be aware of the potential increase in complications as well as increased operative time in obese women, and counsel appropriately.

Intrauterine device insertion after medical abortion.

BACKGROUND: Studies comparing immediate intrauterine device (IUD) insertion after first-trimester surgical abortion with interval insertion show similar efficacy and expulsion rates. However, women randomized to interval insertion of an IUD are less likely to return for device placement. An ideal time to insert intrauterine contraception may be the day a woman presents for verification of a completed medical abortion. We examined immediate insertion of IUDs after completed first-trimester medical abortion. STUDY DESIGN: This is a prospective, observational clinical study to determine expulsion rates of intrauterine contraception placed immediately after confirmed, completed first-trimester medical abortion. RESULTS: Of 118 subjects, 78 women had levonorgestrel IUDs placed, whereas 41 women received copper IUDs. Of 97 subjects who completed the study, there were 4 clinical expulsions (4.1%) during 3 months of follow-up. There were no diagnosed pelvic infections, pregnancies, or uterine perforations. The continuation rate at 3 months was 80%. CONCLUSION: Intrauterine devices inserted at the time of completed, confirmed first-trimester medical abortion have low rates of expulsion.

Relationship of intraamniotic digoxin to fetal demise.

BACKGROUND: Induced fetal demise by intraamniotic injection of digoxin is an alternative to methods using intracardiac or umbilical vein injection. This study was designed to evaluate the effectiveness of intraamniotic injection and the timing of fetal demise after injection. STUDY DESIGN: Twenty-two women had ultrasonic fetal cardiac assessments 1, 2, 4 and 20 to 24 h after intraamniotic injection of 1.5 mg digoxin. RESULTS: Fetal cardiac activity was absent in 21/21 women assessed at least 20 h after injection. One woman had agonal (40 bpm) fetal cardiac activity at 14 h. Most women had fetal cardiac activity 4 h after injection. Signs of toxicity were not seen. CONCLUSION: Intraamniotic injection of digoxin 1.5 mg is effective at causing fetal demise by 20 to 24 h. However, for most women, fetal demise is not obtained within 4 h.

Cervical obstruction complicating second-trimester abortion: treatment with misoprostol.

BACKGROUND: Cervical cone biopsy or loop electrosurgical excision procedures (LEEP) may lead to cervical scarring, agglutination, or stenosis. Leiomyomas may also obstruct the lower uterine segment such that instruments cannot be passed from the vagina to the gestation. CASE: Two women requested second trimester abortion. Both women had undergone cervical LEEP. In addition, one woman had a 10-cm leiomyoma, which seemed to be obstructing the lower segment. In both, the external cervical os was essentially obliterated. After administration of misoprostol, the cervix softened markedly in 18-24 hours. In both women, the cervix dilated readily and allowed dilation and evacuation of the uterus. CONCLUSION: Misoprostol resulted in the ability to evacuate the uterus vaginally, in a situation that might have otherwise resulted in hysterotomy.