Postpartum Hemorrhage after Vaginal Delivery is Associated with a Decrease in Immediate Breastfeeding Success.

OBJECTIVE: This study aimed to identify the impact of postpartum hemorrhage (PPH) after vaginal delivery on immediate breastfeeding success. STUDY DESIGN: This is a retrospective cohort study examining the impact of PPH on breastfeeding for nulliparous patients after term, singleton, vaginal deliveries at a large academic institution from 2017 to 2018. Indicators of successful breastfeeding in the immediate postpartum period were measured by the presence of breastfeeding, the need for formula supplementation, the average number of breastfeeding sessions per day, the average amount of time spent at each breastfeeding session, the average number of newborn stools and wet diapers produced daily, and the neonatal percentage in weight loss over the first 2 to 3 days of life. RESULTS: A total of 1,904 women met inclusion criteria during the study period, 262 (13.8%) of whom experienced PPH, defined as an estimated blood loss of 500 mL or greater after vaginal delivery. Women who had a PPH had significantly fewer breastfeeding sessions on average (ß = -0.06, p-value 0.01) and required more time at each breastfeeding session (ß = 0.08, p-value <0.002). Neonates of women with PPH had a larger percentage in weight loss over the first 2 to 3 days of life compared with those without PPH (ß = 0.06, p = 0.008). CONCLUSION: Women who experience PPH after vaginal delivery have a decreased number of breastfeeding sessions despite spending more time trying to breastfeed, and an increased percentage in neonatal weight loss over the first 2 to 3 days of life. Further work is needed to elicit the mechanism behind this association; however, it is possible that PPH results in decreased secretion of endogenous oxytocin from the hypothalamic-pituitary axis as a result of hypovolemia. These women may therefore require additional breastfeeding support for successful breastfeeding initiation in the immediate postpartum period. KEY POINTS: · Women who experience PPH after vaginal delivery have decreased breastfeeding success.. · Further work is needed to elicit the mechanism behind this association.. · These women may require additional support for successful breastfeeding initiation postpartum..

Live birth outcomes following single-step blastocyst warming technique - optimizing efficiency without impacting live birth rates.

PURPOSE: To evaluate the impact of a single-step (SS) warming versus standard warming (SW) protocol on the survival/expansion of vitrified blastocysts and their clinical outcomes post-frozen embryo transfer (FET). METHODS: Retrospective analysis was performed on 200 vitrified/warmed research blastocysts equally divided amongst two thawing protocols utilizing the Fujifilm Warming NX kits (Fujifilm, CA). SW utilized the standard 14-minute manufacturer's guidelines. SS protocol required only a one-minute immersion in thaw solution (TS) before the embryos were transferred to culture media. A time-interrupted study was performed evaluating 752 FETs (SW: 376 FETs, SS 376 FETs) between April 2021-December 2022 at a single academic fertility clinic in Boston, Massachusetts. Embryologic, clinical pregnancy, and live birth outcomes were assessed using generalized estimated equation (GEE) models, which accounted for potential confounders. RESULTS: There was 100% survival for all blastocysts (n = 952 embryos) with no differences in blastocyst re-expansion regardless of PGT status. Adjusted analysis showed no differences in implantation, clinical pregnancy, spontaneous abortion, or biochemical pregnancy rate. A higher odds of multiple gestation [AdjOR(95%CI) 1.06 (1.01, 1.11), p = 0.019] were noted, even when adjusting for number of embryos transferred [AdjOR(95%CI) 1.05 (1.01, 1.10)]. Live birth outcomes showed no differences in live birth rates or birthweight at delivery. CONCLUSIONS: The study found equivalent outcomes for SS and SW in all parameters except for a slight rise in the rate of multiple gestations. The results suggest that SS warming is an efficient, viable alternative to SW, reducing thaw times without adverse effects on live birth rates or neonatal birth weights.

Maternal Morbidity with Repeated Cesarean Deliveries.

OBJECTIVE: This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. STUDY DESIGN: Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. RESULTS: A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). CONCLUSION: Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. KEY POINTS: · Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..

Comparison of Breastfeeding Success by Mode of Delivery.

OBJECTIVE: This article identifies how mode of delivery and the presence of labor affect the initiation and effectiveness of breastfeeding. STUDY DESIGN: This is a retrospective cohort study of breastfeeding success after vaginal delivery, cesarean section after labor, and scheduled cesarean section in term, singleton deliveries in nulliparous patients at a large academic institution from 2017 to 2018. Exclusion criteria included major postpartum complications requiring admission to the surgical intensive care unit or neonatal intensive care unit, general anesthesia, and major fetal anomalies. Breastfeeding success in the immediate postpartum period, defined as the first 2 to 3 days postpartum prior to hospital discharge, was measured by the presence of breastfeeding, the need for formula supplementation, the average number of breastfeeding sessions per day, the average amount of time spent at each breastfeeding session, the average number of newborn stools and wet diapers produced daily, and the neonatal percentage in weight loss over the first 2 to 3 days of life. Multivariable linear and logistic regression were used to assess the association between mode of delivery and markers of breastfeeding success after adjusting for potential confounders. A Tukey's post hoc analysis with pairwise comparisons was performed to assess differences in breastfeeding outcomes between vaginal delivery, scheduled cesarean section, and cesarean section after labor. RESULTS: A total of 2,966 women met inclusion criteria during the study period, 1,936 (65.3%) of whom underwent spontaneous vaginal delivery, 415 (14.0%) of whom delivered by scheduled cesarean section, and 615 (20.7%) of whom underwent cesarean section after labor. There were significant differences in maternal age, obesity, race/ethnicity, insurance status, gestational age at delivery, birth weight, and 1-minute Apgar's score less than 7 between vaginal delivery, scheduled cesarean section, and cesarean section after labor. There were also significant differences between indication for oxytocin, type of anesthesia, and postpartum hemorrhage between the three groups. After controlling for these factors, women who underwent vaginal delivery were more likely to have infants with decreased need for formula supplementation (adjusted odds ratio [aOR] = 1.71, 95% confidence interval [CI]: 1.52-1.93) and were less likely to switch from breast to formula feeding (aOR = 1.71, 95% CI: 1.04-1.31) in comparison to women who delivered via cesarean section in labor or scheduled cesarean section. The infants of these women also had an increased number of breastfeeding sessions on average (ß = 0.06, p = 0.002), required fewer number of daily formula feedings (ß = 0.14, p < 0.001), and experienced a smaller percentage in neonatal weight loss over the first 2 to 3 days of life (ß = 0.18, p < 0.001) compared to those born after cesarean section and cesarean section after labor. These women comparatively required less time at each breastfeeding session (ß = 0.06, p = 0.005), and produced fewer wet diapers and stools on average (ß = 0.12, p < 0.001 and ß = 0.12, p < 0.001, respectively). On post hoc analysis with pairwise comparisons, and on separate sensitivity analysis of only women who underwent cesarean delivery, there was no difference in breastfeeding outcome measures between scheduled cesarean section and cesarean section in labor. CONCLUSION: Women who deliver by cesarean section, despite the presence or absence of labor, are less likely to maintain exclusive breastfeeding postpartum and are more likely to require formula supplementation. These women may need more support with breastfeeding after surgery in order to experience similar benefits for neonatal growth and weight gain. KEY POINTS: · Women who deliver by cesarean section are less likely to maintain exclusive breastfeeding.. · Women who deliver by cesarean section are more likely to require formula supplementation.. · Women may need more support with breastfeeding after cesarean delivery..

Subchorionic Hematomas and Adverse Pregnancy Outcomes among Twin Pregnancies.

OBJECTIVE: This study estimates the association of a first trimester finding of subchorionic hematoma (SCH) with third trimester adverse pregnancy outcomes in women with twin pregnancies. STUDY DESIGN: Retrospective cohort study of twin pregnancies prior to 14 weeks at a single institution from 2005 to 2019, all of whom had a first trimester ultrasound. We excluded monoamniotic twins, fetal anomalies, history of fetal reduction or spontaneous reduction, and twin-to-twin transfusion syndrome. Ultrasound data were reviewed, and we compared pregnancy outcomes after 24 weeks in women with and without a SCH at their initial ultrasound 60/7 to 136/7 weeks. Regression analysis was used to control for any differences in baseline characteristics. RESULTS: A total of 760 women with twin pregnancies met inclusion criteria for the study, 68 (8.9%) of whom had a SCH. Women with SCH were more likely to have vaginal bleeding and had their initial ultrasound at earlier gestational ages. On univariate analysis, SCH was not significantly associated with gestational age at delivery, preterm birth, birthweight of either twin, low birthweight percentiles of either twin, fetal demise, or preeclampsia. SCH was associated with placental abruption on univariate analysis, but not after controlling for vaginal bleeding and gestational age at the time of the initial ultrasound (adjusted odds ratio: 2.00, 95% confidence interval: 0.63-6.42). Among women with SCH, SCH size was not associated with adverse pregnancy outcomes. CONCLUSION: In women with twin pregnancies, the finding of a first trimester SCH is not associated with adverse pregnancy outcomes >24 weeks.

Correction to: Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya.

An amendment to this paper has been published and can be accessed via the original article.

Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya.

BACKGROUND: Non-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs. METHODS: We created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members. RESULTS: Using human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context. CONCLUSIONS: Contextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015.

Predictors of Early Preterm Birth Despite Vaginal Progesterone Therapy in Singletons with Short Cervix.

OBJECTIVE: This study aimed to identify the incidence of and risk factors for early preterm birth (PTB) (delivery <34 weeks) in women without prior PTB and current short cervix (≤20 mm) prescribed vaginal progesterone. STUDY DESIGN: Retrospective cohort study of singletons without prior PTB diagnosed with short cervix (≤20 mm) between 180/7 and 236/7 weeks. Women who accepted vaginal progesterone and had delivery outcomes available were included. Demographic/obstetric history, cervical length, and pregnancy characteristics compared between women with early PTB versus delivery ≥34 weeks. Multiple logistic regression analysis used to identify predictors; odds ratio for significant factors used to generate a risk score. Risk score and risk of early PTB assessed with receiver operating characteristic curve (ROCC). Perinatal outcomes compared by risk score. RESULTS: Among 109 patients included, 29 (27%) had a spontaneous PTB <34 weeks. In univariate analysis, only gestational age at ultrasound, presence funneling, and mean cervical length were significantly different between those with and without early sPTB. With multiple logistic regression analysis, only gestational age at diagnosis (odds ratio [OR]: 0.66; 95% confidence interval [CI]: 0.46-0.96; p = 0.028) and index cervical length (OR: 0.84; 95% CI: 0.76-0.93; p = 0.001) remained significantly associated with early PTB. ROCC for the risk score incorporating cervical length and gestational age was predictive of early PTB with an AUC of 0.76 (95% CI: 0.67-0.86; p < 0.001). A high-risk score was predictive of early PTB with a sensitivity of 79%, specificity of 75%, positive predictive value of 54%, and negative predictive value of 91%. Women with a high-risk score had worse perinatal outcomes compared with those with low-risk score. CONCLUSION: A total of 27% of patients with short cervix prescribed vaginal progesterone will have a sPTB < 34 weeks. Patients at high risk for early PTB despite vaginal progesterone therapy may be identified using gestational age and cervical length at diagnosis of short cervix. Given the narrow window for intervention after diagnosis of short cervix, this has important implications for clinical care.

A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in maternal-fetal medicine physicians in the United States.

BACKGROUND: Compassion fatigue is secondary traumatic distress experienced by providers from ongoing contact with patients who are suffering. Compassion satisfaction is emotional fulfillment from caring for others. Burnout is distress related to dissonance between job demands and available resources. Although burnout is well-studied, compassion satisfaction and compassion fatigue are neglected components of physician well-being. Because of recurrent exposure to adverse outcomes, maternal-fetal medicine providers may be at particular risk for compassion fatigue. OBJECTIVE: This study aimed to better characterize both clinical and nonclinical drivers of work-related distress vs satisfaction. STUDY DESIGN: The modified Compassion Fatigue and Satisfaction Self-Test and a questionnaire of professional and personal characteristics were distributed electronically to maternal-fetal medicine providers nationally. Multivariable regression models were constructed for compassion fatigue, burnout, and compassion satisfaction as a function of potential predictors. RESULTS: The survey response rate was 24% (n=366), primarily consisting of White physicians working in academic medical centers. Significant predictors of lower burnout scores included employment at 1 institution for >20 years, discussing work-related distress with friends, and having one's most recent involvement in decision-making for a periviable fetus >6 months ago; distress because of coworkers and personal factors predicted higher scores. Female sex, self-report of significant emotional depletion, use of mental health services, and having other maternal-fetal medicine physicians as part of the care team for a fetus with severe anomalies were significant predictors of higher compassion fatigue scores, whereas White race and having social work as part of the care team for a maternal mortality predicted lower scores. Personal spiritual practice was a significant predictor of higher compassion satisfaction score, whereas employment at current institution for <5 years predicted lower scores. CONCLUSION: Compassion fatigue, compassion satisfaction, and burnout are associated with several modifiable risk factors, such as practice type, having a multidisciplinary team, and emotional support outside of the workplace; these are potential targets for intervention.

Ovarian torsion during ovarian stimulation prior to trigger followed by successful oocyte retrieval: A case report.

Objective: To report a case of ovarian torsion during ovarian stimulation prior to trigger followed by laparoscopic detorsion, trigger, and subsequent successful oocyte retrieval, as well as to review outcomes from the cycle. Case Presentation: A 32-year-old woman with a history of recurrent ovarian torsion presented with ovarian torsion during ovarian stimulation for in vitro fertilization prior to trigger injection. She underwent laparoscopic ovarian detorsion followed by trigger and oocyte retrieval.The rate of fertilization and blastocyst conversion of oocytes retrieved from the ovary affected by torsion was lower than from the contralateral ovary. Viable oocytes and an embryo were produced by the affected ovary. Conclusion: Ovarian torsion during ovarian hyperstimulation for in vitro fertilization is a rare occurrence, particularly prior to trigger. Clinicians can consider proceeding with trigger and oocyte retrieval after treating ovarian torsion in appropriately counseled patients.

External Validation of a Prediction Model for External Cephalic Version Success.

External cephalic version (ECV) success correlates with numerous maternal and pregnancy factors. A prior study developed an ECV success prediction model based on body mass index, parity, placental location, and fetal presentation. We performed external validation of this model using a retrospective cohort of ECV procedures from a separate institution between July 2016 and December 2021. Four hundred thirty-four ECV procedures were performed, with a 44.4% success rate (95% CI 39.8-49.2%), which was similar to the derivation cohort (40.6%, 95% CI 37.7-43.5%, P =.16). There were significant differences in patients and practices between cohorts, including the rate of neuraxial anesthesia (83.5% derivation cohort vs 10.4% our cohort, P <.001). The area under the receiver operating characteristic curve (AUROC) was 0.70 (95% CI 0.65-0.75), which was similar to that in the derivation cohort (AUROC 0.67, 95% CI 0.63-0.70). These results suggest the published ECV prediction model's performance is generalizable outside the original study institution.

Utility of Office Hysteroscopy in Diagnosing Retained Products of Conception Following Early Pregnancy Loss After In Vitro Fertilization.

OBJECTIVE: To evaluate the utility of office hysteroscopy in diagnosing and treating retained products of conception in patients with infertility who experience early pregnancy loss (EPL) after in vitro fertilization (IVF). METHODS: We evaluated a retrospective cohort of 597 pregnancies that ended in EPL in patients aged 18-45 years who conceived through fresh or frozen embryo transfer at an academic fertility practice between January 2016 and December 2021. All patients underwent office hysteroscopy after expectant, medical, or surgical management of the EPL. The primary outcome was presence of retained products of conception at the time of office hysteroscopy. Secondary outcomes included incidence of vaginal bleeding, presence of intrauterine adhesions, treatment for retained products of conception, and duration of time from EPL diagnosis to resolution. Log-binomial regression and Poisson regression were performed, adjusting for potential confounders including oocyte age, patient age, body mass index, prior EPL count, number of prior dilation and curettage procedures, leiomyomas, uterine anomalies, and vaginal bleeding. RESULTS: Of the 597 EPLs included, 129 patients (21.6%) had retained products of conception diagnosed at the time of office hysteroscopy. The majority of individuals with EPL were managed surgically (n=427, 71.5%), in lieu of expectant management (n=140, 23.5%) or medical management (n=30, 5.0%). The presence of retained products of conception was significantly associated with vaginal bleeding (relative risk [RR] 1.72, 95% CI 1.34-2.21). Of the 41 patients with normal pelvic ultrasonogram results before office hysteroscopy, 10 (24.4%) had retained products of conception detected at the time of office hysteroscopy. When stratified by EPL management method, retained products of conception were significantly more likely to be present in individuals with EPL who were managed medically (adjusted RR 2.66, 95% CI 1.90-3.73) when compared with those managed surgically. Intrauterine adhesions were significantly less likely to be detected in individuals with EPL who underwent expectant management when compared with those managed surgically (RR 0.14, 95% CI 0.04-0.44). Of the 127 individuals with EPL who were diagnosed with retained products of conception at the time of office hysteroscopy, 30 (23.6%) had retained products of conception dislodged during the office hysteroscopy, 34 (26.8%) chose expectant or medical management, and 63 (49.6%) chose surgical management. The mean number of days from EPL diagnosis to resolution of pregnancy was significantly higher in patients who elected for expectant management (31 days; RR 1.18, 95% CI 1.02-1.37) or medical management (41 days; RR 1.54, 95% CI 1.25-1.90) when compared with surgical management (27 days). CONCLUSION: In patients with EPL after IVF, office hysteroscopy detected retained products of conception in 24.4% of those with normal pelvic ultrasonogram results. Due to the efficacy of office hysteroscopy in diagnosing and treating retained products of conception, these data support considering office hysteroscopy as an adjunct to ultrasonography in patients with infertility who experience EPL after IVF.

Stratified risk of pregnancy loss for women with a viable singleton pregnancy in the first trimester.

OBJECTIVE: Calculate the risk of miscarriage in women with a viable (defined as presence of fetal heart rate on ultrasound) first trimester singleton pregnancy and to create a model for stratified risk-assessment for pregnancy loss based on significant risk factors. STUDY DESIGN: Retrospective cohort study of unselected women with singleton pregnancies in a large obstetrical practice who presented for prenatal care prior to 14 weeks over a three-year period. All women underwent a formal first-trimester ultrasound, and we only included women with viable pregnancies with fetal heart activity seen on that ultrasound. Our primary outcome was pregnancy loss prior to 20 weeks. Statistical modeling was used to create a risk-assessment tool from adjusted likelihood ratios of pregnancy loss based on risk factors independently associated with this outcome. RESULTS: From January 2015-December 2017, 2,446 women met the inclusion criteria for the study and 132 (5.4%) had a pregnancy loss <20 weeks. On regression analysis, the independent risk factors for pregnancy loss were earlier gestational age (aOR 0.72, 95% CI 0.65-0.80) and increasing number of prior miscarriages (aOR 1.56, 95% CI 1.32-1.83). Using these risk factors, we calculated the stratified risk of pregnancy loss, which ranged from 0.8% in women at 13 weeks of gestation with no prior miscarriages to 33.7% in women at six weeks of gestation with three or more prior miscarriages. CONCLUSION: In first trimester singleton pregnancies, the overall risk of pregnancy loss <20 weeks after confirmation of fetal heart activity is 5.4%, but can be stratified for each woman and ranges from 0.8% to 33.7% based on the gestational age and number of prior pregnancy losses.

The association between sonographic cervical length components and preterm birth in women with ultrasound- or exam-indicated cerclage.

OBJECTIVE: To evaluate which parameters of a sonographic cervical length measurement are associated with preterm birth in women with ultrasound- or exam-indicated cerclage. METHODS: This was a retrospective cohort study of women with singleton pregnancies who underwent ultrasound- or exam-indicated Shirodkar cerclage by a single maternal-fetal medicine practice between 2011 and 2019. All patients underwent sonographic cervical length measurement 2-3 weeks after cerclage placement, and then every 2-4 weeks up to 32 weeks. The images from the first and second post-cerclage cervical lengths were reviewed. Total cervical length, upper cervical length (from the internal cervical os to the cerclage), and lower cervical length (from the cerclage to the external os) were measured. The primary outcome for this study was gestational age at delivery. RESULTS: A total of 114 women with cerclage were included (85 (74.6%) ultrasound-indicated and 29 (25.4%) exam-indicated). The first and second total cervical lengths correlated with gestational age at delivery (r = 0.26, p=.005; r = 0.33, p<.001, respectively), and the change from first to second was inversely correlated with gestational age at delivery (r = -0.20, p=.032). The first and second upper cervical lengths also correlated with gestational age at delivery (r = 0.22, p = .019; r = 0.33, p<.001, respectively), and the change from first to second upper cervical length was inversely correlated with gestational age at delivery (r= -0.20, r = 0.029). Neither the first nor the second lower cervical lengths were significantly associated with gestational age at delivery. On regression analysis, total cervical length and upper cervical length were not independently associated with gestational age at delivery (p = .108 and p=.806, respectively, for the first scan; p = .153 and p=.166, respectively, for the second scan). CONCLUSIONS: Postcerclage total cervical length and upper cervical length are both associated with gestational age at delivery and risk of preterm birth, but not independently. After ultrasound- or exam-indicated cerclage, sonographic monitoring of either the total cervical length or the upper cervical length might be predictive of gestational age at delivery and the risk of preterm birth.

Association of Myomectomy With Anti-Müllerian Hormone Levels and Ovarian Reserve.

OBJECTIVE: To assess whether open and minimally invasive myomectomy are associated with changes in postoperative ovarian reserve as measured by serum anti-müllerian hormone (AMH) level. METHODS: This prospective cohort study included patients who were undergoing open abdominal myomectomy that used a tourniquet or minimally invasive (robot-assisted or laparoscopic) myomectomy that used vasopressin. Serum AMH levels were collected before the procedure and at 2 weeks, 3 months, and 6 months after surgery. The mean change in AMH level at each postsurgery timepoint was compared with baseline. The effect of surgical route on the change in AMH level at each timepoint was assessed by using multivariable linear regression. A subanalysis evaluated postoperative changes in AMH levels among the open myomectomy and minimally invasive myomectomy groups individually. RESULTS: The study included 111 patients (mean age 37.9±4.7 years), of whom 65 underwent open myomectomy and 46 underwent minimally invasive myomectomy. Eighty-seven patients contributed follow-up data. Serum AMH levels declined significantly at 2 weeks postsurgery (mean change -0.30 ng/mL, 95% CI -0.48 to -0.120 ng/mL, P=.002). No difference was observed at 3 months or 6 months postsurgery. On multiple linear regression, open myomectomy was significantly associated with a decline in AMH level at 2 weeks postsurgery (open myomectomy vs minimally invasive myomectomy: ß=-0.63±0.22 ng/mL, P=.007) but not at 3 months or 6 months. Subanalysis revealed a significant decline in mean serum AMH levels in the open myomectomy group at 2 weeks (mean change -0.46 ng/mL, 95% CI -0.69 to -0.25 ng/mL, P<.001) postsurgery but not at three or 6 months. In the minimally invasive myomectomy group, no significant differences in mean AMH levels were detected between baseline and any postoperative timepoint. CONCLUSION: Myomectomy is associated with a transient decline in AMH levels in the immediate postoperative period, particularly after open surgery in which a tourniquet is used. Anti-müllerian hormone levels returned to baseline by 3 months after surgery, indicating that myomectomy is not associated with a long-term effect on ovarian reserve, even with the use of a tourniquet to decrease blood loss. FUNDING SOURCE: This study was funded in part by a Roche Diagnostics Investigator-Initiated Study Grant.

Popliteal Entrapment Syndrome as a Cause of Chronic Lower Extremity Pain in a 16-Year Old.

Popliteal entrapment syndrome is an uncommon cause of intermittent claudication in young patients lacking atherosclerotic risk factors. ZS is a 16-year-old cisgender female with type 1 diabetes complicated by microalbuminuria, obesity (body mass index (BMI) = 45.86 kg/m²), and a history of perinatal stroke with residual right-sided hemiparesis, who presented with six months of worsening bilateral, exertional lower extremity pain. Common causes of chronic bilateral lower extremity pain include peripheral vascular disease and diabetic neuropathy. Less common etiologies include trauma, infection, or juvenile idiopathic arthritis. Given her risk factors, the patient's pain was initially managed as a diabetic neuropathy with pregabalin. Symptoms failed to improve, and she re-presented with positional coolness of the right lower extremity, diminished pulses of the bilateral lower extremities, and weakness in her toes. CT angiography demonstrated occlusion of the right distal superficial femoral and popliteal arteries and diffused tibial disease. Ultimately, the patient was discovered to have right-sided femoral-popliteal occlusion, and she required urgent femoral-tibial bypass. Despite an initial improvement in symptoms postoperatively, she continued to have lower extremity pain and recurrent arterial thrombi, even with antiplatelet and anticoagulation therapy. Eventually, the patient required a right-sided below the knee amputation. This case highlights the high index of suspicion that clinicians must have in young patients with lower extremity pain, both with and without atherosclerotic risk factors, as early intervention facilitates better outcomes. Introduction.

Chronic disease stigma, skepticism of the health system, and socio-economic fragility: Qualitative assessment of factors impacting receptiveness to group medical visits and microfinance for non-communicable disease care in rural Kenya.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of mortality in the world, and innovative approaches to NCD care delivery are being actively developed and evaluated. Combining the group-based experience of microfinance and group medical visits is a novel approach to NCD care delivery. However, the contextual factors, facilitators, and barriers impacting wide-scale implementation of these approaches within a low- and middle-income country setting are not well known. METHODS: Two types of qualitative group discussion were conducted: 1) mabaraza (singular, baraza), a traditional East African community gathering used to discuss and exchange information in large group settings; and 2) focus group discussions (FGDs) among rural clinicians, community health workers, microfinance group members, and patients with NCDs. Trained research staff members led the discussions using structured question guides. Content analysis was performed with NVivo using deductive and inductive codes that were then grouped into themes. RESULTS: We conducted 5 mabaraza and 16 FGDs. A total of 205 individuals (113 men and 92 women) participated in the mabaraza, while 162 individuals (57 men and 105 women) participated in the FGDs. In the context of poverty and previous experiences with the health system, participants described challenges to NCD care across three themes: 1) stigma of chronic disease, 2) earned skepticism of the health system, and 3) socio-economic fragility. However, they also outlined windows of opportunity and facilitators of group medical visits and microfinance to address those challenges. DISCUSSION: Our qualitative study revealed actionable factors that could impact the success of implementation of group medical visits and microfinance initiatives for NCD care. While several challenges were highlighted, participants also described opportunities to address and mitigate the impact of these factors. We anticipate that our approach and analysis provides new insights and methodological techniques that will be relevant to other low-resource settings worldwide.

An Innovative Consulting Group for Sharing Expertise on Launching and Sustaining Student-Run Free Clinics: A Model for Building Student-Run Endeavors.

Student-run, physician-supervised free clinics (SRFCs) provide essential healthcare services for many uninsured and underinsured patients in the USA. While SRFCs serve diverse populations and offer distinct services, they face many similar barriers to successful clinic operation. Historically, the sharing of best practices and development strategies across SRFCs has been limited and insufficient for both new and emerging free clinics. To address these challenges, in 2015, the East Harlem Health Outreach Program (EHHOP) at the Icahn School of Medicine at Mount Sinai formed the EHHOP Consulting Group (ECG), with the goal of providing client SRFCs individualized support from medical students. ECG draws from the experience of EHHOP and other veteran SRFCs to provide customized solutions to best address client SRFC needs. Here, we describe ECG's inception, structure, and consulting work with client SRFCs. We propose that this interactive, longitudinal model can be adapted to other healthcare trainee initiatives where cross-institutional collaboration could prove beneficial.