Provider Practice Patterns Regarding Over-The-Counter Continence Devices.

INTRODUCTION AND HYPOTHESIS: Vaginal inserts and continence devices are recommended as a conservative treatment option for the management of stress urinary incontinence (SUI); however, practice patterns for recommendation and use of such devices are currently unknown. Our objectives were to better understand counseling patterns relating to over-the-counter (OTC) continence devices, to assess perceived barriers to recommending these devices, and to estimate clinician familiarity with three such devices currently available in the USA. METHODS: In this cross-sectional study, an anonymous electronic survey was distributed to all Accreditation Council for Graduate Medical Education-accredited OB/GYN and Urology residency and Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellowship programs. A total of 326 survey responses were collected. Multivariate logistic regression was used to assess respondent characteristics associated with recommending OTC continence devices to patients. RESULTS: Sixty-four percent of respondents expressed familiarity with any OTC continence device. Of respondents who reported regular evaluation and treatment of women with SUI (n = 269), 60% reported ever recommending OTC devices for SUI. On multivariate regression, being a trainee and general OB/GYN provider were associated with being less likely to recommend OTC devices for SUI. Of respondents who did not regularly recommend OTC continence devices, reported barriers to doing so included a lack of training with these devices, leading to clinician discomfort (70%) and not remembering OTC devices as an option (15%). CONCLUSIONS: Given the low risk associated with patient use of these easily accessible devices, our study highlights barriers to clinician recommendation with the goal of increasing clinician awareness and consideration of OTC continence devices.

Outcomes in Women With Pelvic Organ Prolapse Presenting With Pessary-Related Complications.

IMPORTANCE: There is currently a paucity of data describing the outcomes of women with pelvic organ prolapse (POP) and/or urinary incontinence (UI) who present with pessary-related complications. OBJECTIVE: This study aimed to describe outcomes in women with POP and UI managed with a pessary who present with pessary-related complications. STUDY DESIGN: This was a retrospective cohort study of women with POP and/or UI who elected for management with a pessary from January 1, 2016, to December 31, 2020. Patients were included if they had used a pessary for at least 1 year and had a documented pessary-related complication. Complications were defined a priori, and patient charts were abstracted using International Classification of Diseases, Ninth and Tenth Revisions codes associated with pessary use. RESULTS: Of 2,088 of women receiving pessary care, 444 (21%) experienced a complication. Of 154 of women, 34.6% experienced 2 pessary-related complications during the study period, whereas 12.6% (56) experienced 3, 4.5% (20) experienced 4, and 1.8% (8) experienced 5. One hundred fifty-two patients (34.2%) underwent surgery during the study period to manage their POP and/or UI. Patients who were older were less likely to have surgery (adjusted odds ratio, 0.70 [95% confidence interval, 0.20-0.90]; P = 0.002), and patients who had an indication of pessary use for both POP and UI were more likely to undergo surgery during the study period (adjusted odds ratio, 2.12 [95% confidence interval, 1.29-3.48]; P = 0.003). CONCLUSIONS: Our results suggest that 1 in 5 patients has a documented complication associated with pessary use of greater than 1 year. Of these patients, one third will eventually undergo surgery for management of their POP and/or UI.

Investigating disparities in compliance of nursing pain reassessment for obstetrics and gynecology patients.

BACKGROUND: Racial and socioeconomic disparities, exacerbated during the COVID-19 pandemic and surrounding socio-political polarization, affect access to, delivery of, and patient perception of healthcare. Perioperatively, the bedside nurse carries the greatest responsibility of direct care, which includes pain reassessment, a metric tracked for compliance. OBJECTIVE: This study aimed to critically assess disparities in obstetrics and gynecology perioperative care and how these have changed since March 2020 using nursing pain reassessment compliance within a quality improvement framework. STUDY DESIGN: A retrospective cohort of 76,984 pain reassessment encounters from 10,774 obstetrics and gynecology patients at a large, academic hospital from September 2017 to March 2021 was obtained from Tableau: Quality, Safety and Risk Prevention platform. Noncompliance proportions were analyzed by patient race across service lines; a sensitivity analysis was performed excluding patients who were of neither Black nor White race. Secondary outcomes included analysis by patient ethnicity, body mass index, age, language, procedure, and insurance. Additional analyses were performed by temporally stratifying patients into pre- and post-March 2020 cohorts to investigate potential pandemic and sociopolitical effects on healthcare disparities. Continuous variables were assessed with Wilcoxon rank test, categorical variables were assessed with chi-squared test, and multivariable logistic regression analyses were performed (P<.05). RESULTS: Noncompliance proportions of pain reassessment did not differ significantly between Black and White patients as an aggregate of all obstetrics and gynecology patients (8.1% vs 8.2%), but greater differences were found within the divisions of Benign Subspecialty Gynecologic Surgery (Minimally Invasive Gynecologic Surgery + Urogynecology) (14.9% vs 10.70%; P=.03) and Maternal Fetal Medicine (9.5% vs 8.3%; P=.04). Black patients admitted to Gynecologic Oncology experienced lower noncompliance proportions than White patients (5.6% vs 10.4%; P<.01). These differences persisted after adjustment for body mass index, age, insurance, timeline, procedure type, and number of nurses attending to each patient with multivariable analyses. Noncompliance proportions were higher for patients with body mass index ≥35 kg/m2 within Benign Subspecialty Gynecology (17.9% vs 10.4%; P<.01). Non-Hispanic/Latino patients (P=.03), those ≥65 years (P<.01), those with Medicare (P<.01), and those who underwent hysterectomy (P<.01) also experienced greater noncompliance proportions. Aggregate noncompliance proportions differed slightly pre- and post-March 2020; this trend was seen across all service lines except Midwifery and was significant for Benign Subspecialty Gynecology after multivariable analysis (odds ratio, 1.41; 95% confidence interval, 1.02-1.93; P=.04). Though increases in noncompliance proportions were seen for non-White patients after March 2020, this was not statistically significant. CONCLUSION: Significant race, ethnicity, age, procedure, and body mass index-based disparities were identified in the delivery of perioperative bedside care, especially for those admitted to Benign Subspecialty Gynecologic Services. Conversely, Black patients admitted to Gynecologic Oncology experienced lower levels of nursing noncompliance. This may be in part be related to the actions of a Gynecologic Oncology nurse practioner at our institution who helps coordinate care for the division's postoperative patients. Noncompliance proportions increased after March 2020 within Benign Subspecialty Gynecologic Services. Although this study was not designed to establish causation, possible contributing factors include implicit or explicit biases regarding pain experience across race, body mass index, age, or surgical indication, discrepancies in pain management across hospital units, and downstream effects of healthcare worker burnout, understaffing, increased use of travelers, or sociopolitical polarization since March 2020. This study demonstrates the need for ongoing investigation of healthcare disparities at all interfaces of patient care and provides a way forward for tangible improvement of patient-directed outcomes by utilizing an actionable metric within a quality improvement framework.

The Impact of Fertility Goals on Long-term Quality of Life in Reproductive-aged Women Who Underwent Myomectomy versus Hysterectomy for Uterine Fibroids.

STUDY OBJECTIVE: The objective of this study is to compare quality of life (QOL) for myomectomy with hysterectomy 1 to 5 years after surgical management for fibroids. This study evaluated the difference in QOL in a population of women of reproductive age, including those who desire fertility. DESIGN: A retrospective cohort study. INTERVENTIONS: Not applicable. SETTING: A large academic hospital. PATIENTS: A total of 142 women who underwent hysterectomy or myomectomy in 2015 to 2020. Included patients were women aged 18 years or older who underwent surgical intervention owing to uterine fibroids. MEASUREMENTS AND MAIN RESULTS: The 36-Item Short Form Health Survey (SF-36) provides a total score as a single measure of health-related QOL. The Uterine Fibroid Symptom Quality of Life Questionnaire for Hysterectomy and Myomectomy (UFS-QOL) is a patient-reported outcome measure of fibroid symptoms and health-related QOL after hysterectomy and myomectomy. There was no significant difference in SF-36 QOL scores in women after myomectomy who desired fertility compared with those who did not desire fertility, except in the social functioning domain (p = .025). UFS-QOL scores in women after myomectomy who desired fertility were not significantly different compared with women after myomectomy who did not desire fertility (p = .37). There were no significant differences between women who underwent myomectomy and hysterectomy in overall QOL scores on the SF-36 (p = .13) and UFS-QOL scores (p = .16). CONCLUSION: Myomectomy is not associated with significant differences in measures of general health and QOL compared with hysterectomy, making it a viable fibroid management option for women who desire fertility. Our study highlights the importance of discussing fertility goals and QOL when counseling patients for surgical fibroid treatment.

Revision sacrocolpopexy: tips and tricks for optimal outcomes.

INTRODUCTION AND HYPOTHESIS: The aim of this video is to highlight important considerations and techniques for revision sacrocolpopexy in women with symptomatic recurrence of pelvic organ prolapse after sacrocolpopexy. METHODS: In this video, we show five patients who presented with recurrent symptomatic pelvic organ prolapse after prior sacrocolpopexy. We demonstrate techniques for robotic-assisted laparoscopic sacrocolpopexy revision including surgical dissection, revision of existing mesh, and/or addition of new mesh. CONCLUSIONS: Overall, revision sacrocolpopexy requires an individualized approach. These surgeries are often challenging because of adhesions and altered anatomy from the prior sacrocolpopexy. The reviewed considerations and techniques can be useful for ensuring a safe and effective outcome.

Associations Between Preconception Plasma Fatty Acids and Pregnancy Outcomes.

BACKGROUND: Although fatty acids are involved in critical reproductive processes, the relationship between specific fatty acids and fertility is uncertain. We investigated the relationship between preconception plasma fatty acids and pregnancy outcomes. METHODS: We included 1,228 women attempting pregnancy with one to two previous pregnancy losses from the EAGeR trial (2007-2011). Plasma fatty acids were measured at baseline. We used log-binomial regression to assess associations between fatty acids and pregnancy, pregnancy loss, and live birth, adjusting for age, race, smoking, BMI, physical activity, income, parity, treatment arm, and cholesterol. RESULTS: Although total saturated fatty acids (SFAs) were not associated with pregnancy outcomes, 14:0 (myristic acid; relative risk [RR] = 1.10, 95% confidence interval [CI] = 1.02, 1.19, per 0.1% increase) and 20:0 (arachidic acid; RR = 1.05, 95% CI = 1.01, 1.08, per 0.1% increase) were positively associated with live birth. Findings suggested a positive association between total monounsaturated fatty acids (MUFAs) and pregnancy and live birth and an inverse association with loss. Total polyunsaturated fatty acids (PUFAs) were associated with lower probability of pregnancy (RR = 0.97, 95% CI = 0.95, 1.00) and live birth (RR = 0.96, 95% CI = 0.94, 0.99), and increased risk of loss (RR = 1.10, 95% CI = 1.00, 1.20), per 1% increase. Trans fatty acids and n-3 fatty acids were not associated with pregnancy outcomes. CONCLUSIONS: Preconception total plasma MUFAs were positively associated with pregnancy and live birth. PUFAs were inversely associated with pregnancy outcomes. Specific SFAs were associated with a higher probability of live birth. Our results suggest that fatty acids may influence pregnancy outcomes.

Pilot study of placental tissue collection, processing, and measurement procedures for large scale assessment of placental inflammation.

BACKGROUND: Placental dysfunction is related to many pregnancy complications, but collecting placental specimens for investigation in large scale epidemiologic studies is often infeasible. Standard procedures involving immediate collection after birth and snap freezing are often cost prohibitive. We aimed to collect pilot data regarding the feasibility and precision of a simpler approach, the collection of tissue samples following 24 hours of refrigeration of whole placentae at 4°C, as compared to the "gold standard" of snap freezing excised tissue within 40 minutes of delivery for the assessment of inflammatory cytokines. METHODS: Placentae were collected from 12 women after delivering live-born singleton babies via uncomplicated vaginal delivery. Two placentae were utilized to establish laboratory tissue processing and assay protocols. The other 10 placentae were utilized in a comparison of three tissue collection conditions. Specifically, key inflammatory cytokines were measured in 3 sections, representing three collection conditions. Sections 1 (full thickness) and 2 (excised prior to freezing) were obtained within 40 minutes of delivery and snap frozen in liquid nitrogen, and section 3 (full thickness) was obtained after refrigerating the placenta at 4°C for 24 hours. RESULTS: IL-6, IL-10, and IL-8 all had comparable concentrations and variability overall in all three section types. Levels of tumor necrosis factor alpha (TNF-α) were too low among samples to reliably measure using immunoassay. CONCLUSIONS: Refrigeration of placentae prior to processing does not appear to compromise detection of these cytokines for purposes of large scale studies. These findings provide a framework and preliminary data for the study of inflammatory cytokines within the placenta in large scale and/or resource-limited settings.

Vitamin D is associated with bioavailability of androgens in eumenorrheic women with prior pregnancy loss.

BACKGROUND: Prior studies have reported mixed results regarding relationships between vitamin D, androgens, and sex hormone-binding globulin in patients with polycystic ovary syndrome. However, less is known regarding these associations in eumenorrheic, premenopausal women. OBJECTIVE: Our objective was to study the relationships between serum vitamin D and androgen biomarkers in eumenorrheic women with a history of pregnancy loss who were attempting pregnancy. STUDY DESIGN: This was an analysis of a cohort of 1191 participants from the Effects of Aspirin in Gestation and Reproduction trial (2006-2012). Participants were attempting to conceive, aged 18-40 years, with 1-2 documented prior pregnancy losses and no history of infertility, and recruited from 4 academic medical centers in the United States. Serum vitamin D (25-hydroxyvitamin D) and hormone concentrations were measured at baseline. RESULTS: Vitamin D concentration was negatively associated with free androgen index (percentage change [95% confidence interval, -5% (-8% to -2%)] per 10 ng/mL increase) and positively associated with sex hormone-binding globulin (95% confidence interval, 4% [2-7%]), although not with total testosterone, free testosterone, or dehydroepiandrosterone sulfate after adjusting for age, body mass index, smoking status, race, income, education, physical activity, and season of blood draw. CONCLUSION: Overall, vitamin D was associated with sex hormone-binding globulin and free androgen index in eumenorrheic women with prior pregnancy loss, suggesting that vitamin D may play a role in the bioavailability of androgens in eumenorrheic women. We are limited in making assessments regarding directionality, given the cross-sectional nature of our study.