Pregnancy planning, prevention, and risk evaluation clinics: rethinking the traditional preconception consult.

The preconception consultation has traditionally centered pregnancy as desired and preordained. Separating preconception and contraceptive visits burdens patients and further fragments reproductive healthcare. We argue that the creation of a combined preconception and complex contraception clinic for individuals with significant medical and obstetrical comorbidities is one approach to promoting reproductive autonomy. Pregnancy planning, prevention, and risk evaluation clinics are designed to review pregnancy-related risks in the setting of patients' medical and obstetrical comorbidities, recommend strategies to reduce risks, and, if desired, provide contraceptive methods. Consultations for pregnancy risk evaluation and pregnancy prevention should not be considered mutually exclusive. Combining these visits is crucial for obstetrically and/or medically complex patients. Rethinking the traditional preconception consultation is a change in healthcare delivery that centers comprehensive reproductive healthcare.

Contraceptive Risk Events among Family Planning Specialists: a Cross Sectional Study.

Background: Proponents of abortion restriction cite advancements in contraceptive technology as a reason against the need for abortion care today, most recently through oral arguments in the Supreme Court of the United States case, Dobbs v. Jackson Women's Health. However, consistent and correct use of contraception requires reproductive health literacy. Our objectives were to quantify contraceptive risk events and assess contraceptive history and preferences among a population well-equipped to evade contraceptive risks, family planning specialists following initiation of their medical training. "Risk events" are defined as reported episodes of contraceptive failure, emergency contraception use and/or unprotected or underprotected intercourse. Methods: This was a cross-sectional study among current members of a professional organization of family planning specialists. Inclusion criteria included: status as a current or retired clinician, consensual penile-vaginal intercourse since the start of medical training, and personal or partner capacity to become pregnant. Descriptive statistics were performed. This study was IRB exempt. Results: Among 229 respondents, 157 (69%) reported experiencing a contraceptive risk event since training. Twenty-nine (13%) respondents reported an occurrence within the last year. By category, 47% (108/229; 3 reported unknown) reported under- or unprotected intercourse, 35% (81/229) reported emergency contraception use, and 52% of participants (117/227; 2 unknown) reported known or suspected contraceptive failure. The mean number of contraceptive methods used was 3.7 (SD 1.7) out of the 13 methods listed. Almost all (97%) participants reported at least one method was not an acceptable option, with a mean of 5.6 (SD 2.7) of the 13 listed methods. Conclusions: The majority of family planning specialists have experienced contraceptive risk events during times of active pregnancy prevention since their medical training. Contraceptive method change is common and most respondents were limited in the number of methods that were personally acceptable to them. Dialogue idealizing the role of contraception in minimizing or eliminating abortion need is simplistic and inaccurately represents the lived realities of pregnancy-capable individuals and their partners, including among those with exceptional contraceptive literacy and access.

Toxicities of herbal abortifacients.

BACKGROUND: In the post-Roe era, barriers to facility-based abortions may lead to an increased incidence of self-managed abortions. While misoprostol-based medication abortions have significant literature supporting its safety profile, there is a knowledge deficit within the medical community regarding the toxicities of commonly used herbal abortifacients. METHODS: This is a narrative review, based on a MEDLINE and HOLLIS database search, of self-managed abortion methods with herbal abortifacients and their associated toxicities. RESULTS: Common herbal abortifacients with significant morbidity and mortality implications include pennyroyal, blue cohosh, rue, and quinine. Other commonly reported abortifacients considered to be less toxic also are discussed in brief. Special considerations for hepatic, cardiac, renal, and hematologic toxicities are important in patients with significant exposures to these herbal substances. CONCLUSION: There is an anticipated increase in the utility of herbal xenobiotics for self-managed abortions with post-Roe restrictions to standard mifepristone-misoprostol protocols. Frontline providers should be aware of the associated toxicities and have special considerations when treating a poisoned patient in this population.

Switching and discontinuation of participant-masked randomization to a copper or levonorgestrel intrauterine device when presenting for emergency contraception.

OBJECTIVES: Examine intrauterine device (IUD) switching or discontinuation up to 6 months after participant-masked randomization to different IUDs. STUDY DESIGN: Participants were randomized 1:1 to the copper T380A or levonorgestrel 52 mg IUD for emergency contraception and informed they could switch IUD type without cost at any time. RESULTS: Of the 327 subjects allocated to the levonorgestrel IUD, 7 (2.1%) switched their IUD type by 6 months versus 18 (5.5%) of the 328 copper IUD users (RR: 0.4 [95% CI: 0.2, 0.9], p = 0.03). Six-month IUD discontinuation occurred in 34 (10.4%) levonorgestrel and 35 (10.7%) copper IUD users. CONCLUSION: Individuals randomly assigned to IUD type at presentation for emergency contraception continue their assigned IUDs at high rates over 6 months. IMPLICATIONS: While many recruited individuals declined enrollment, those who accepted randomization had high continuation rates; the high continuation and low cross-over supports using IUD randomization as a tool for future investigation. Participants' similar rates of and reasons for switching and discontinuation by IUD type over the study period may impact clinical counseling.

Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics.

OBJECTIVES: To explore the prevalence of intrauterine device self-removal practices before and during the COVID-19 pandemic among family planning clinics. STUDY DESIGN: This is a secondary analysis of data from a descriptive, longitudinal study using a clinic-based convenience sample from the Abortion Clinical Research Network assessing baseline and pandemic-adaptive family planning practices. RESULTS: Of the 63 sites that provided contraception, 5 (7.9%) reported providing guidance on intrauterine device self-removal at baseline. Sixteen sites (25.4%) provided guidance on self-removal by the end of the study period. Self-removal counseling was associated with being an academic center and reporting a median lower number of monthly contraceptive encounters. CONCLUSIONS: Endorsement of IUD self-removal increased to one-quarter of sites by the final timepoint. IMPLICATIONS: Twenty-five percent of family planning clinics reported provision of intrauterine device self-removal guidance by eight months into the COVID-19 pandemic, a three-fold increase from baseline; these findings suggest clinician support for patient autonomy in contraceptive self-management and limited concern for safety issues with self-removal during a public health emergency.

Abortion as Essential Health Care and the Critical Role Your Practice Can Play in Protecting Abortion Access.

Few obstetrician-gynecologists (ob-gyns) provide abortion care, resulting in abortion being separated from other reproductive health care. This segregation of services disrupts the ob-gyn patient-clinician relationship, generates needless costs, delays access to abortion care, and contributes to stigma. General ob-gyns have both the skills and the knowledge to incorporate abortion into their clinical practices. In this way, they can actively contribute to the protection of abortion access now with the loss of federal protection for abortion under Roe v Wade . For those who live where abortion remains legal, now is the time to start providing abortions and enhancing your abortion-referral process. For all, regardless of state legislation, ob-gyns must be leaders in advocacy by facilitating abortion care-across state lines, using telehealth, or with self-managed abortion-and avoiding any contribution to the criminalization of those who seek or obtain essential abortion care. Our patients deserve a specialty-wide concerted effort to deliver comprehensive reproductive health care to the fullest extent.

Coerced Choice: Resigned Contraceptive Usership Among Individuals Affected by Reproductive Coercion.

INTRODUCTION: Partner-mediated reproductive coercion is a common form of violence that affects individuals' sexual and reproductive health goals. Clinicians' understanding of the scope of reproductive coercion continues to grow with direct implications for clinical interventions. The purpose of this study was to generate a more comprehensive set of reproductive coercion tactics used by intimate partners for recognition in a clinical setting. METHODS: This was a qualitative study using grounded theory. Individuals were recruited through an established statewide community network to participate in videoconferencing focus groups regarding reproductive coercion. Discussions were moderated and recorded. Data were coded and then subjected to qualitative content analysis. RESULTS: Twenty community members participated. Participants described partner interference with reproductive and sexual health goals, including limitation of their contraceptive options. Although participants were able to access health care and use contraception as part of a goal to avoid pregnancy, they also reported dissatisfaction with their methods. Some participants described being forced to use an undesired form of contraception in the setting of reproductive coercion from abusive partners. DISCUSSION: Individuals affected by reproductive coercion may be able to access and exercise limited choice over their contraceptive options, but some may be unable to use the preferred method because of partners' behavior. Clinician awareness of the diversity of presentations of reproductive coercion, including individuals using long-acting reversible contraceptives, may facilitate individualized counseling and realignment of care with patient preferences.

Disparities in state-mandated third-trimester testing for syphilis.

BACKGROUND: Since 1999, Illinois has had a legal statute mandating both first-visit and third-trimester syphilis testing in all pregnancies. However, the incidence of syphilis infection is increasing at the national and state level, including among individuals of reproductive age, conferring risk of congenital syphilis. Although state-mandated infectious disease screening is purported to be a strategy to improve equity and quality of care, adherence to such mandates and disparities in adherence are unknown. OBJECTIVE: We sought to evaluate compliance with state-mandated third-trimester syphilis testing at a single tertiary hospital in Illinois and to identify disparities in testing. STUDY DESIGN: This is a retrospective cohort study of all pregnant individuals who delivered between January 1, 2015 and February 28, 2018 at a large-volume academic center. Patients who delivered after 28 weeks of gestation were included. Frequency of state-mandated first-visit (<28 weeks) and third-trimester (≥28 weeks) syphilis screening was evaluated over the study period. The primary outcome was completion of any third-trimester screening (ie, performed as an initial or repeat test in the third trimester) in accordance with state law. Demographic and clinical factors associated with the primary outcome and with completion of both first-visit and third-trimester screening were evaluated with multivariable logistic regression. RESULTS: Of the 9048 eligible deliveries, 96.9% (N=8766) of patients had first-visit syphilis screening, whereas only 27.3% (N=2469) had third-trimester screening. Performance of third-trimester syphilis testing increased over time from an average of 5.8% of deliveries during the first 6 months of the study period to 59.8% over the last 6 months of the study period. Non-Hispanic Black or Hispanic race or ethnicity, non-English primary language, public insurance, age <25, multiparity, and greater body mass index were independently associated with increased odds of third-trimester screening. CONCLUSION: Despite a decades-old state mandate for third-trimester syphilis screening in this high-prevalence region, third-trimester screening performance was suboptimal. Several demographic characteristics were associated with adherence to screening, suggesting inequity and bias exist in testing practices. It is important to acknowledge that legal statutes do not fully eliminate bias and health disparities.

United States' Obstetrician/Gynecologists' Readiness to Care for Women Affected by Female Genital Cutting.

Background: Female genital cutting (FGC) is a form of gender-based violence with obstetrical and gynecological complications that require recognition and care. Data suggest that United States' physicians are not prepared to care for those who have been affected by this practice. This study evaluated the knowledge and practices of United States' obstetricians and gynecologists to care for patients who have undergone FGC. Materials and Methods: This was a cross-sectional confidential survey distributed electronically to a sample of clinically active members of the American College of Obstetricians and Gynecologists. The survey consisted of questions characterizing care of patients who had undergone FGC and barriers to optimal support. Results: Five hundred forty-eight participants representing a wide range of years in practice, geographical locations, subspecializations, and patient demographics participated. Sixty-six percent of participants had cared for patients who had undergone FGC. Participants' description of their patient population racial/ethnic composition did not correlate with likelihood of treating this patient population. Forty percent of participants reported some form of education about FGC, more often among women, younger physicians, and those in practice for fewer years. Thirty-one percent of participants were comfortable counseling about and 20% were comfortable performing deinfibulation; these percentages were higher among those who had received education or had recently cared for an affected patient. Participants reported insufficient training as the largest barrier to providing care to women. Conclusions: While most physicians in this national cohort had cared for women who had undergone cutting, a minority had any form of education. However, prior education correlated with indicators of improved care. Physicians require additional guidance in treating this important and growing patient population.

Rates of pregnancy among levonorgestrel and copper intrauterine emergency contraception initiators: Implications for backup contraception recommendations.

OBJECTIVE: This study assessed the timing, frequency, use of backup method and 1-month pregnancy rates among individuals who had an intrauterine device (IUD) placed as emergency contraception and reported intercourse within 7 days post-placement. STUDY DESIGN: In this secondary analysis of a randomized control trial of IUDs for emergency contraception, 518 individuals reporting unprotected intercourse in the preceding 5 days had a 52 mg levonorgestrel intrauterine system (IUS) or 380 mm2 copper IUD placed outside the first week of their menstrual cycle. All participants were advised to use backup contraception for 7 days. We assessed pregnancy status 1 month after placement by urine testing or, when not available, by survey responses and electronic health record review.  Participants reported whether their first sexual activity after device placement occurred within 7 days of their placement, the frequency of intercourse and whether they used backup contraception. RESULTS: Rapid return to sexual activity was common and use of backup contraception was rare, regardless of type of IUD placed. Of participants who resumed penile-vaginal intercourse in the first month, most (286/446, 64.1%) participants reported intercourse within 7 days of IUD placement; only 16.4% (74/446) used condoms or withdrawal. No pregnancies occurred among users of the levonorgestrel IUS who reported intercourse within 7 days of placement (0/138, 0.0%, 95% CI 0.0%, 2.6%) nor among users of the 380mm2 copper IUD (0/148, 0.0%, 95% CI 0.0%, 2.5%). CONCLUSION: Pregnancy rates are low after placement of an IUD for emergency contraception, even among the many who resume intercourse within days following IUD placement without use of backup contraception. IMPLICATIONS: Clinical guidelines should facilitate access to contraception, including elimination of unnecessary recommendations for backup contraception or abstinence in the 7 days following 52 mg levonorgestrel intrauterine system.

Ugandan Health Care Professionals' Response to Sexual Violence Survivors: Exploring Local Strategy and International Guidelines.

This survey-based study gathered information on health professionals' attitudes and behaviors regarding victims of sexual assault, focusing on the applicability and utility of best practices put forth by the World Health Organization and the United Nations. This cross-sectional study involved a self-administered, 84-question survey to health care professionals affiliated with Mulago National Referral and Kayunga Hospitals in Uganda. The survey included demographic questions as well as questions about participants' attitudes toward sexual violence and the role of HPs in addressing sexual violence. The remainder of the survey transformed two sets of international guidelines into a series of statements with which participants could agree or disagree using a Likert-type scale. In total, 75 partially or fully completed surveys were collected, 45 from Mulago, and 30 from Kayunga. A minority of participants indicated that the guidelines were unrealistic (4.1%) or culturally inappropriate (14.1%). Most HPs agreed (91.8%) with the key components of recommended care. However, many respondents highlighted the need for additional training (68%). Nearly half of participants were uncertain or disagreed that there was a clear protocol for care of survivors of sexual violence (48%). Targets for improvement identified by participants included enhanced support of staff, access to resources, and relationships with community partners. Ugandan HPs have been receptive to the World Health Organization and United Nations guidelines. The majority of participants felt that the guidelines were realistic and culturally appropriate. Furthermore, many of these guidelines have been implemented. However, additional steps identified by Ugandan health workers could be undertaken to further improve the care received by survivors of sexual violence.

Birth Outcomes Among Women Affected by Reproductive Coercion.

INTRODUCTION: Reproductive coercion is a form of intimate partner violence that includes behaviors that interfere with autonomous decision-making over reproductive outcomes. Unintended pregnancy is associated with exposure to reproductive coercion; however, little is known about the outcomes of continued pregnancies. The purpose of this study is to assess whether women who reported reproductive coercion during their last pregnancy experienced differences in birth outcomes compared with women without contemporaneous reproductive coercion. METHODS: This was a cross-sectional survey study administered in obstetric and gynecologic offices. A survey comprised of standardized reproductive coercion, birth outcome, and intimate partner violence questions was given to English- or Spanish-speaking women with at least one prior pregnancy. Self-reported birth outcomes of interest included late or no prenatal care, low birth weight, prolonged neonatal hospitalization, preterm birth, and intrauterine fetal demise or neonatal death. Descriptive and bivariable comparisons were performed. RESULTS: Of 202 participants, 8.6% of women reported reproductive coercion during their last pregnancy. Women with a reported reproductive coercion history were younger, more likely to be a student, more likely to have anemia and anxiety at the time, and less likely to be married to the father of the incident pregnancy. Women with this history were more likely to express that they never wanted to be pregnant (29.4% vs 6.2%, P = .04), report other forms of intimate partner violence (35.3% vs 11.9%, P = .02), and have low-birth-weight neonates (17.6% vs 3.1%, P = .03). There were no observed differences in other birth outcomes. The response rate was 68%. DISCUSSION: In this exploratory study, women who reported reproductive coercion during their most recent completed pregnancy were more likely to report pregnancy ambivalence, other tactics of intimate partner violence, and low-birth-weight neonates. These data provide insight into the impact of violence on women's reproductive outcomes.

Perivascular epithelioid cell tumors (PEComa) in pregnancy with uterine rupture and ongoing abdominal gestation: A case report.

Perivascular epithelioid cell tumors (PEComa) represent a rare family of tumors characterized by distinct histology and immunohistochemistry characteristics. Approximately one-quarter of reported cases are gynecologic in origin and associated pregnancies are rare. We report a case of PEComa in pregnancy with initial undiagnosed presentation at 18 weeks of gestation and subsequent presentation and diagnosis at 30 weeks of gestation. Abdominal pain led to the use of magnetic resonance imaging, which raised concerns about placentation abnormality and abdominal pregnancy. Exploratory laparotomy was notable for a 10 cm by 15 cm posterior uterine defect through which the placenta and amniotic sac containing the fetus were extruded. Placenta-like tissue was noted to be invading through the anterior wall of the uterus, which led to concern regarding placenta percreta. A total abdominal hysterectomy and bilateral salpingectomy were then performed, given the complete loss of normal uterine architecture. Pathology returned with findings of placenta accreta and PEComa. Indolent uterine rupture in the setting of PEComa led to an ongoing viable abdominal pregnancy. Uterine PEComa can masquerade as a placenta and lead to obstetrical complications.

Lipids and Women's Health: Recent Updates and Implications for Practice.

The obstetrician/gynecologist frequently serves as the primary care physician for women. Specialty-specific guidelines vary in screening recommendations for lipid disorders; women's health practitioners often follow recommendations to screen at age 45 in the absence of other risk factors. However, 2013 American College of Cardiology/American Heart Association cholesterol guidelines recommend screening at age 21 to capture those at risk of cardiovascular disease and allow for early intervention with lifestyle and, in the most severe cases, evidence-based statins. We discuss the care of women who primarily benefit from screening: those with familial hypercholesterolemia (FH), those with the metabolic syndrome (MetS) or polycystic ovary syndrome, and those with hypertriglyceridemia. Those with FH have elevated low-density lipoprotein cholesterol from birth and a propensity for premature coronary heart disease. Early recognition of FH can allow risk-reducing interventions, as well as identification of additional affected relatives. Early detection of metabolic variables, such as in the MetS and hypertriglyceridemia, can lead to an enhanced focus on physical activity and heart-healthy diet. Finally, we discuss a practical approach to lipid management and review concerns regarding drug safety. Our objective is to provide a current overview of cardiovascular risk factor optimization that women's health practitioners can use in identifying and/or treating patients at risk for cardiovascular disease and diabetes.

Applying surgical antimicrobial standards in cesarean deliveries.

Antimicrobial prophylaxis practices are critical to surgical site infection risk-reduction strategies. Included in these practices is antibiotic redosing following prolonged procedures or after large blood losses. Guidelines have been published by several professional associations, with most endorsing repeat antibiotic administration after an estimated blood loss of 1500 mL or following 2 half-lives of the select agent. These conventions have been widely adopted by surgeons with the exception of obstetricians at the time of cesarean delivery. This Viewpoint explores existing guidelines, reviews the data for these recommendations, and questions the tradition of abstinence from redosing in cesarean deliveries despite the burden of infection in this cohort.

Update on childhood and adolescent immunizations: selected review of US recommendations and literature: part 2.

PURPOSE OF REVIEW: To provide a clinically relevant synopsis of research findings regarding childhood and adolescent vaccines. RECENT FINDINGS: Vaccine coverage is relatively static or improving for the vaccines included in the 2010 annual harmonized immunization schedules. Providers should be reviewing patients' immunization records at each visit to take advantage of any opportunity to administer indicated, age-appropriate vaccines. There have been infectious disease outbreaks among highly immunized populations, although unvaccinated or undervaccinated individuals continue to play large roles in the spread of disease. Infants, many of whom are too young to be vaccinated, continue to bear a large disease burden, which underscores the importance of cocooning and, in some cases, vaccination of pregnant women. Influenza, measles, mumps, and rubella, varicella, hepatitis A, meningococcal conjugate, human papillomavirus, diphtheria and tetanus toxoids and acellular pertussis, and tetanus and diphtheria toxoids and acellular pertussis vaccines are reviewed in this second of two articles. SUMMARY: New research on childhood and adolescent vaccines is anticipated to shape the practice of pediatric providers. Research will continue to provide the science to optimize protection and to promote the health and well being of all children and adolescents.