Hormone Therapy: Menopausal Hormone Therapy.

The marked decrease in estrogen levels in menopausal women can cause bothersome symptoms that affect daily life. More than 75% of women experience menopausal symptoms, which can include vaginal dryness, itching, discharge, dyspareunia, mood changes, hot flushes, and night sweats. Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms. Benefits include decreased risk of osteoporotic fractures and vaginal atrophy, improved glycemic control, and decreased vasomotor symptoms. However, recent research on risks associated with MHT has shown increased risk of venous thromboembolism and breast cancer. MHT typically is an option for patients younger than 60 years or within 10 years of menopause onset with bothersome vasomotor symptoms. The decision to start MHT should be made on an individual basis after a thorough evaluation and counseling. Oral, intramuscular, transdermal, and intravaginal formulations are available. The goal of therapy is use of the lowest dose for the shortest time that effectively manages symptoms. The patient and physician should regularly assess the risks and benefits associated with MHT and ensure that the benefits of its use continue to outweigh the risks.

The Safety of Low-Dose Aspirin on the Mode of Delivery: Secondary Analysis of the Effect of Aspirin in Gestation and Reproduction Randomized Controlled Trial.

OBJECTIVE: This study aimed to examine whether prenatal low-dose aspirin (LDA) therapy affects risk of cesarean versus vaginal delivery. STUDY DESIGN: This study is a secondary analysis of the randomized clinical effects of aspirin in gestation and reproduction (EAGeR) trial. Women received 81-mg daily aspirin or placebo from preconception to 36 weeks of gestation. Mode of delivery and obstetric complications were abstracted from records. Log-binomial regression models estimated relative risk (RR) of cesarean versus vaginal delivery. Data were analyzed among the total preconception cohort, as well as restricted to women who had a live birth. RESULTS: Among 1,228 women, 597 had a live birth. In the intent-to-treat analysis, preconception-initiated LDA was not associated with risk of cesarean (RR = 1.02; 95% confidence interval [CI]: 0.98-1.07) compared with placebo. Findings were similar in just women with a live birth and when accounting prior cesarean delivery and parity. CONCLUSION: Preconception-initiated daily LDA was not associated with mode of delivery among women with one to two prior losses. KEY POINTS: · Aspirin was not associated with risk of cesarean section.. · Aspirin was not associated with mode of delivery.. · No increased risk of bleeding with use of aspirin..

An alternative to cesarean: a description of external cephalic version in noncephalic presenting twin.

Objective: External cephalic version (ECV) is utilized in breech presenting singleton gestations but ECV of the noncephalic presenting twin has been considered technically unfeasible. We have successfully performed ECVs of the noncephalic presenting twin. Our objective is to describe our experience with this technique.Study design: This is a descriptive case series of our attempted ECVs in twin pregnancies and their outcomes.Results: Of 19 twin A ECV attempts, 10 cases were successful. The overall vaginal delivery rate was 42% (8/19 cases). There were no emergent cesarean deliveries required, and no neonatal injuries were observed.Conclusions: ECV can be achieved in pregnancies complicated by a noncephalic presenting twin. Further study is necessary to assess the safety and generalizability of our finding.

Maternal risk factors and neonatal outcomes in placental abruption among patients with equal access to health care.

INTRODUCTION: Placental abruption complicates 1% of pregnancies, and is associated with significant morbidity and mortality. The objective was to examine risk factors and outcomes in pregnancies complicated by abruption in a health care system with equal access to care. METHODS: This was a retrospective cohort study of all deliveries at Walter Reed National Military Medical Center (WRNMMC) between 1 January 2014 and 1 June 2017. The primary outcome was maternal factors that influenced abruption. The secondary outcome evaluated the neonatal outcomes after abruption. RESULTS: A total of 4351 patients delivered at WRNMMC and met the inclusion criteria. 52 patients (1.2%) had a pathology confirmed abruption. There was an association with smoking (p < .05; OR 4.25) and African American race (p = .005). Neonatal variables demonstrated an association between abruption and gestational age at delivery, low birth weight, Apgar scores, NICU admissions, and fetal demise all with p < .005. CONCLUSIONS: Our results demonstrate an association between both smoking and African American race with placental abruption. Unlike previous studies, there were no barriers to access to care. Further, there was no association with age, hypertension, diabetes, autoimmune disease, or trauma. Results did reaffirm an association between abruption and preterm birth, low birth weight, lower Apgars, NICU admissions, and fetal demise.PrécisIn a medical system with no barriers to access to care, maternal risk factors and neonatal outcomes associated with placental abruptions were investigated in over 4300 deliveries.

Diagnosing and managing adrenal crisis in pregnancy: A case report.

BACKGROUND: The diagnosis of adrenal insufficiency in pregnancy is relatively rare. Further, making this diagnosis can be challenging as many of the symptoms overlap with normal symptoms of pregnancy. Given the potential for severe maternal and fetal morbidity and mortality, early recognition and prompt comprehensive treatment are critical. CASE: A 24-year-old woman, G3 P2002, at 17 + 1 weeks of gestation with unremarkable prenatal course was admitted to hospital for hyperemesis gravidarum in the setting of parainfluenza with a notable blood glucose of 20 mg/dL. On hospital day two, she was transferred to intensive care after developing significant hypotension, hyponatremia, and a new finding of hypothyroidism. During her evaluation in the ICU, she was diagnosed with adrenal crisis and she showed significant improvement with glucocorticoid therapy. CONCLUSIONS: There is a paucity of literature regarding diagnosing adrenal insufficiency in pregnancy. Adrenal crisis in pregnancy can present with symptoms similar to severe nausea and vomiting of pregnancy or hyperemesis gravidarum. Additionally, several critical laboratory tests to support the proper diagnosis require time that acute patients cannot always afford. In this patient's case, the diagnosis was made empirically with improvement after glucocorticoid administration, and was later confirmed by laboratory testing. This case highlights the importance of including adrenal insufficiency in the differential diagnosis of hyperemesis patients in order to quickly manage and treat these often acutely and severely ill patients.

Speed Mentoring: An Effective & Efficient Path to Development of Mentor Relationships in a Military Obstetrics & Gynecology Residency.

INTRODUCTION: With a deficit of effective military residency mentorships, a paucity of research on successful mentorship programs, and growing reports on innovative mentoring programs, we developed a "Speed Mentoring" event for the National Capital Consortium OBGYN Residency. MATERIALS AND METHODS: The development, implementation, and follow-up responses through participant surveys were designed as an institutional review board (IRB)-approved evidence-based quality improvement project at our institution. Our event coordinated mentorship opportunities between residents and faculty from a wide range of specialties, leadership roles, and research experiences. Residents were matched with faculty that aligned with self-identified goals. Surveys were distributed prior to the event and at follow-up intervals to demonstrate the lasting impact and areas for improvement. RESULTS: Prior to our first event, every resident reported by survey that they desired more mentorship opportunities. However, only 55% could identify a specific mentor, citing limited time and difficulty establishing a relationship. Immediately following the event, 90% of residents scheduled a follow-up with at least one mentor. Forty-seven percent of residents reported inspiration to initiate a new research project. Meanwhile, faculty felt valued and gained satisfaction by "giving back" to their profession. After 1 month, half of the residents and faculty had already conducted at least one meeting. At 3 months, 76% of meetings centered on research and 23% on quality improvement projects. Fifty-seven percent of participants reported future scheduled meetings. At 6 months, 75% of residents reported meaningful mentorship relationships. CONCLUSIONS: After demonstrating a need for improved mentorship opportunities, we implemented an efficient way to foster mentorship while expanding resident involvement in research, QI projects, and fellowship applications. This "Speed Mentorship" program can be easily adapted to all residency programs.

Donor oocyte recipients do not benefit from preimplantation genetic testing for aneuploidy to improve pregnancy outcomes.

STUDY QUESTION: Do donor oocyte recipients benefit from preimplantation genetic testing for aneuploidy (PGT-A)? SUMMARY ANSWER: PGT-A did not improve the likelihood of live birth for recipients of vitrified donor oocytes, but it did avoid embryo transfer in cycles with no euploid embryos. WHAT IS KNOWN ALREADY: Relative to slow freeze, oocyte vitrification has led to increased live birth from cryopreserved oocytes and has led to widespread use of this technology in donor egg IVF programs. However, oocyte cryopreservation has the potential to disrupt the meiotic spindle leading to abnormal segregation of chromosome during meiosis II and ultimately increased aneuploidy in resultant embryos. Therefore, PGT-A might have benefits in vitrified donor egg cycles. In contrast, embryos derived from young donor oocytes are expected to be predominantly euploid, and trophectoderm biopsy may have a negative effect relative to transfer without biopsy. STUDY DESIGN, SIZE, DURATION: This is a paired cohort study analyzing donor oocyte-recipient cycles with or without PGT-A performed from 2012 to 2018 at 47 US IVF centers. PARTICIPANTS/MATERIALS, SETTING, METHODS: Vitrified donor oocyte cycles were analyzed for live birth as the main outcome measure. Outcomes from donors whose oocytes were used by at least two separate recipient couples, one couple using PGT-A (study group) and one using embryos without PGT-A (control group), were compared. Generalized estimating equation models controlled for confounders and nested for individual donors contributing to both PGT-A and non-PGT-A cohorts, enabling a single donor to serve as her own control. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 1291 initiated recipient cycles from 223 donors were analyzed, including 262 cycles with and 1029 without PGT-A. The median aneuploidy rate per recipient was 25%. Forty-three percent of PGT-A cycles had only euploid embryos, whereas only 12.7% of cycles had no euploid embryos. On average 1.09 embryos were transferred in the PGT-A group compared to 1.38 in the group without PGT-A (P < 0.01). Live birth occurred in 53.8% of cycles with PGT-A versus 55.8% without PGT-A (P = 0.44). Similar findings persisted in cumulative live birth from per recipient cycle. LIMITATIONS, REASONS FOR CAUTION: Pooled clinical data from 47 IVF clinics introduced PGT-A heterogeneity as genetic testing were performed using different embryology laboratories, PGT-A companies and testing platforms. WIDER IMPLICATIONS OF THE FINDINGS: PGT-A testing in donor oocyte-recipient cycles does not improve the chance for live birth nor decrease the risk for miscarriage in the first transfer cycle but does increase cost and time for the patient. Further studies are required to test if our findings can be applied to the young infertility patient population using autologous oocytes. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used for this study. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons.

BACKGROUND: We evaluated a novel simulation-based cesarean section training program to teach critical techniques for cesarean section and hemorrhage management.  Methods: This was a prospective educational intervention. After Institutional Review Board approval, we recruited Obstetrics and Gynecology, Family Medicine, and General Surgery residents at three hospitals. All participants received didactic education. Participants were then randomized into two arms with one group to receive task-trainer based training and the other no training. Afterwards, all residents had their performance of a complete cesarean section and management of a post-partum hemorrhage evaluated on a high-fidelity simulator. Evaluators were blinded to randomization. EXPERIENCE: Thirty-three participants were recruited between July 2017 and January 2019. There were 19 trainees in the control group and 14 in the intervention group. The intervention group scored significantly higher on performance of the cesarean delivery (p-value 0.007), hemorrhage management (p-value 0.0002), and overall skill (p-value 0.008). There were no differences in the other categories. CONCLUSION: Participants trained with a combination of didactic education and task-trainers versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.

Recalled maternal lifestyle behaviors associated with anti-müllerian hormone of adult female offspring.

Anti-müllerian hormone (AMH) is an established marker of ovarian reserve that decreases with age. Though the pool of ovarian follicles is established during fetal development, impacts of in utero exposures on AMH are uncertain. Thus, we sought to evaluate associations of in utero exposures with AMH of adult daughters with a prospective cohort study of adult daughters at university medical centers. Women noted their mother's reported use of diethylstilbestrol (DES), vitamins, tobacco, alcohol, and caffeine during pregnancy, and their mother's occupation during pregnancy. All participants were reproductive age women (18-40 years) enrolled in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial. Serum AMH concentrations were measured at baseline prior to conception and categorized using clinical guidelines. Multinomial regression models estimated associations between each exposure and high (>3.5 ng/mL) and low (<1.0 ng/mL) versus normal AMH (1.0-3.5 ng/mL), adjusting for participant's age, mother's age, mother's history of fertility treatment, and mother's use of vitamins. In 1202 women with available data, maternal caffeine use was associated with an increased risk of low AMH, compared to normal (relative risk [RR] 1.90, 95 % confidence interval [CI] 1.09, 3.30). Vitamins were associated with an increased risk of high AMH compared to normal (RR 1.93, 95 % CI 1.24, 3.00). Other exposures were not associated with AMH concentrations in offspring. Maternal caffeine and vitamin use during pregnancy may be associated with ovarian reserve in adult offspring, highlighting the potential importance of pregnancy lifestyle on the reproductive health of daughters.

Obstetric simulation for a pandemic.

OBJECTIVE: In the middle of the COVID-19 pandemic, guidelines and recommendations are rapidly evolving. Providers strive to provide safe high-quality care for their patients in the already high-risk specialty of Obstetrics while also considering the risk that this virus adds to their patients and themselves. From other pandemics, evidence exists that simulation is the most effective way to prepare teams, build understanding and confidence, and increase patient and provider safety. FINDING: Practicing in-situ multidisciplinary simulations in the hospital setting has illustrated key opportunities for improvement that should be considered when caring for a patient with possible COVID-19. CONCLUSION: In the current COVID-19 pandemic, simulating obstetrical patient care from presentation to the hospital triage through postpartum care can prepare teams for even the most complicated patients while increasing their ability to protect themselves and their patients.

Is transferring a lower-quality embryo with a good-quality blastocyst detrimental to the likelihood of live birth?

OBJECTIVE: To determine if transferring a lower-quality embryo with a good-quality blastocyst is detrimental, given that evidence suggests that embryos can signal the endometrium and that embryo quality may affect negatively endometrial receptivity. DESIGN: Retrospective cohort study. SETTING: In vitro fertilization center. INTERVENTION(S): Single- versus double-embryo transfer. PATIENT(S): Patients with a double-embryo transfer of a good-quality blastocyst plus a lower-quality blastocyst, early blastocyst, or morula were compared with patients receiving a single good-quality blastocyst. MAIN OUTCOME MEASURE(S): Live birth, multiple gestation. RESULT(S): In this study, 4,640 in vitro fertilization cycles were analyzed. In none of the analyses did transferring a second lower-quality embryo negatively affect birth rate. In the primary analysis, transferring a second lower-quality embryo increased live birth by 10% and the multiple birth rate by 15%. The addition of a fair- or poor-quality blastocyst or early blastocyst markedly increased the twin birth rate by 22%-27% with an 8%-12% increase in live birth. The addition of a morula did not increase live birth but resulted in 12% more multiples. In women younger than 38 years, adding a lower-quality embryo increased the birth rate by 7% but resulted in 18% increase in multiples. In women 38 years or older, adding a lower-quality embryo increased the live birth rate by 9% with a 15% increase in multiples. CONCLUSION(S): Addition of a lower-quality embryo does not have a detrimental effect on a good-quality blastocyst and results in a small increase in live births. However, this is at the expense of a marked increase in the likelihood of multiple gestations.

Intravesicular Onabotulinumtoxin A Hemorrhage on Rivaroxaban.

Overactive bladder (OAB) is urgency, with or without urgency incontinence. For OAB, an injection of onabotulinumtoxin A (BOTOX®) can be a low-risk outpatient procedure. We present a patient on a novel anticoagulant that experienced excessive bleeding after this procedure. This 80-year-old G2P2002 Caucasian female had a history of urge urinary incontinence. She presented for intravesicular onabotulinumtoxin A injection (150 units) after recent initiation of rivaroxaban (Xarelto®) for her atrial fibrillation. Several hours after an uncomplicated procedure, she presented with anuria and pain after gross hematuria earlier in the day. Her pain was immediately alleviated with bladder irrigation. She was discharged home and remained asymptomatic. With the popularity of the novel anticoagulants, new guidance on management of these medications during procedures is limited. When managing a patient on a novel anticoagulant before any procedure, even a low risk procedure, several factors should be considered to determine if the medication should be held, bridged, or continued. In sum, each patient on anticoagulation undergoing any procedure should be assessed individually for thrombotic risk, bleeding risk, and the procedural risk to best avoid postprocedural hemorrhage.

Risk Assessment and Treatment Guide for Obstetric Thromboprophylaxis: Comprehensive Review of Current Guidelines.

OBJECTIVE: Currently, there are numerous recommendations and often conflicting guidance provided for venous thromboembolism (VTE) prophylaxis in pregnancy. Our objective was to create a one-page risk assessment and treatment guide based on a review of the most recent and evidence-based publications on this subject to simplify the approach and allow all obstetric patients to be properly assessed for risk of VTE and treated if indicated. STUDY DESIGN: We identified studies by completing a PubMed and MEDLINE search from January of 1980 through March 2017 with articles utilizing a specific combination of the selected general keywords (thrombophilia, pregnancy, VTE, prophylaxis, hypercoagulability, antepartum, postpartum, risk, etc.). We completed the search at the saturation point, meaning that all combinations of the relevant words were directing us to the same articles. After collecting the relevant sources and reviewing them, a total of 10 articles/guidelines were selected for inclusion in the analysis. RESULTS: We outlined every recommendation in the identified articles and guidelines and included any recommendation that was cited in at least three different sources in the final guide. We used American College of Obstetrics and Gynecology recommendations as the base for screening and dosing guidelines and utilized known and published absolute risk values and odds ratios to stratify risk factors. This stratification was used for both antepartum and postpartum recommendations and a single-page guideline was created. CONCLUSION: This compilation of guidelines integrates the complicated topic into a simple comprehensive guide where women can be identified early and accurately for appropriate VTE prophylaxis to protect them during and after pregnancy.

Visual Estimation of Force Applied During Simulated Deliveries Complicated by Shoulder Dystocia.

Background Shoulder dystocia occurs when the fetal head delivers, but the shoulder is lodged behind the pubic symphysis. Training for these emergency deliveries is not optimized, and litigation can occur around a shoulder dystocia delivery. Objective Evaluate the ability of an outside observer to visually estimate the amount of traction applied to the fetal head during simulated deliveries complicated by shoulder dystocia. Study Design Simulated deliveries with an objective measurement of traction were randomly organized for estimation of traction applied. Videos show providers applying a "normal" (75 N) and "excessive" (150 N) amount of force in both a "calm" and "stressed" delivery. Results Fifty participants rated the amount of force applied. Observers estimated traction, on a scale from 1 to 5, higher in the 150-N deliveries as compared with 75-N deliveries ("calm" environment: 3.1 vs. 2.8, p < 0.001; and "stressed" environment: 3.2 vs. 2.8, p < 0.001). Only 15% of observers rated force "above average" or "excessive" in a "calm" environment, as opposed to 30% of observers in the "stressed" environment. Conclusion Observers are not able to determine when "excessive force" is used and are twice as likely to overestimate the force applied to a fetal head when an average amount of force is used and the delivery environment is stressful. Precis Observers are unable to determine when excessive traction is applied to the fetal head during simulated deliveries complicated by shoulder dystocia.

Postpartum Management After Obstetric Anal Sphincter Injuries.

A 26-year-old woman, gravida 1 para 1, experiences a severe perineal laceration that extends through the rectal mucosa after a vaginal delivery. She asks you, "What can be done to optimize my recovery?"

Congenital Megaureter Presenting in an Adult as a Vaginal Wall Cyst.

BACKGROUND: Vaginal cysts are a common finding. The differential diagnosis includes epidermal inclusion, Bartholin gland, Gartner duct, and Skene gland cysts and Müllerian anomalies. Rarely, leiomyomas, cancers, or ectopic ureters or megaureters are found. CASE: A 31-year-old woman, gravida 3 para 3, presented with a 12-year history of intermittent abdominal pain and involuntary loss of urine. She was diagnosed with ectopic vaginal megaureter after evaluation and subsequently underwent a nephroureterectomy with a marsupialized distal ureter. She remains asymptomatic. CONCLUSION: Consideration of a rare diagnosis such as an ectopic ureter is important when patients repeatedly present with involuntary urinary incontinence in conjunction with a vaginal cyst and an otherwise negative evaluation. Using magnetic resonance imaging can be useful to assess urinary tract involvement, particularly in patients with known urinary tract malformations.