The Association between Immediate Postpartum Etonogestrel Implants and Positive Postpartum Depression Screens in Adolescents and Young Adults.

OBJECTIVE: We aimed to compare rates of positive postpartum depression screens at 6 weeks postpartum among adolescents and young adults (AYA) initiating immediate postpartum contraceptive implants and those initiating other methods. DESIGN: Through a retrospective observational design, we collected data on demographics, reproductive history, prenatal and postnatal depression, and postpartum contraception. SETTING: Patients participating in an AYA prenatal-postnatal program were eligible for inclusion. PARTICIPANTS: A total of 497 patients were enrolled between January 2013 and December 2016. The median age was 19 years (range 13-22 years); 86% were primiparous, 50% were Latina, 24% were black, and 16% were white; 34% initiated immediate postpartum implants (n = 169). INTERVENTION: Those initiating a contraceptive implant within the first 14 days postpartum were included in the intervention group. MAIN OUTCOME MEASURE: We compared rates of positive Edinburgh Postpartum Depression Scales (EDPS) (scores ≥10) in AYA initiating immediate postpartum implants and those initiating other contraceptive methods. RESULTS: The AYA initiating immediate postpartum implants were similar to the rest of the cohort in baseline characteristics, aside from an increased rate of preterm births among the intervention group (19.4% vs 12.1%; P = .03). Prenatally, 14% had an elevated Center for Epidemiologic Studies Depression Scale (CES-D) scores (11.5% immediate postpartum implants vs 15.4% comparison, P = .25). At 6 weeks postpartum, 7.6% had a positive postpartum depression screen; this rate was significantly lower for those initiating immediate postpartum implants compared to those choosing other methods (4.1% vs 9.5%, P = .04). CONCLUSIONS: Providers should continue to encourage AYA to choose whichever highly effective contraceptive method they prefer for postpartum use.

A case series of removal of nickel-titanium sterilization microinserts from the uterine cornua using laparoscopic electrocautery for salpingectomy.

Nickel-Titanium sterilization microinserts are surgically removed for various indications, including persistent pain. Previously described removal techniques include salpingostomy and cornuectomy with judicious use of electrocautery to avoid potential injury to adjacent structures or fracturing the micoinsert. This case series presents our technique of laparoscopic salpingectomy, utilizing electrocautery on the microinsert.

Outcomes of Elective Outpatient Hysteroscopic Sterilization in Undocumented Women: A Retrospective Analysis.

OBJECTIVE: To determine the feasibility of hysteroscopic sterilization in low-income and unauthorized immigrant women when financial barriers to care are removed. METHODS: Outpatient hysteroscopic sterilization for low-income women at an urban clinic was made possible by grant funding. All procedures were performed by obstetrician/gynecologist attending physicians or supervised trainees. Electronic records were reviewed for cases performed from June 2010 to December 11, 2013. Outcome incidences and complications were determined. Subgroup analyses using demographic and clinical factors were performed. RESULTS: Hysteroscopic sterilization was attempted in 197 patients. Most were Hispanic (93%) and undocumented immigrants (83%). Bilateral placement was achieved on first attempt in 92% (181/197). Successful placement was ultimately achieved in 96% (190/197), and 88% (168/190) returned for hysterosalpingogram (HSG). Appropriate tubal occlusion was documented on 96% (161/168) of HSGs with mean time of 3.5 ± 1.3 months. Repeat HSG at 6 months showed 100% occlusion (7/7). Of the initial cohort, 85% (168/197) could ultimately rely on Essure for contraception. One pregnancy was self-reported 9 months after the procedure; the patient had not followed up for HSG. There were no pregnancies among those who completed follow-up. There were no cases of procedural complications. Successful Essure placement was not associated with age, parity, immigration status, or clinical characteristics (analgesics administered, history of cesarean section, vaginal delivery, cervical surgery, ectopic, fibroids, or pelvic inflammatory disease). The only factor positively associated with HSG follow-up was age 35 years or younger (53% vs. 47%; p = .03). CONCLUSIONS: Successful hysteroscopic sterilization can be achieved in an undocumented, low-income population. Rates of confirmatory HSG follow-up were found to be higher than in the general population. Public funding of programs could decrease unintended pregnancies and pregnancy-related costs.

Considerations for management of interstitial ectopic pregnancies: two case reports.

BACKGROUND: Conventional treatment of interstitial pregnancies includes systemic methotrexate, direct methotrexate injection, wedge resection, or hysterectomy. We present two cases of interstitial pregnancies that were successfully managed by different minimally invasive surgical techniques. We also report the novel use of hysteroscopic urologic stone retrieval forceps in the transvaginal removal of persistent products of conception after systemic methotrexate for an interstitial pregnancy. CASE PRESENTATION: Case 1 was a 28-year-old gravida 1 white woman at 8 weeks gestation; she was diagnosed with a left interstitial pregnancy. After laparoscopic confirmation of the interstitial pregnancy, successful ultrasound-guided suction dilation and curettage was performed. Case 2 was a 33-year-old gravida 3 para 1021 (one term pregnancy, no preterm pregnancies, one ectopic pregnancy and one spontaneous miscarriage, and one living child) Hispanic woman with persistent products of conception after systemic methotrexate for a left interstitial pregnancy. She underwent hysteroscopic-guided removal of the persistent products of conception, which was possible due to novel use of urologic stone retrieval forceps. CONCLUSIONS: Successful minimally invasive treatment of interstitial pregnancies may be possible in certain cases. Collaboration between different specialties continues to be important for improving minimally invasive options.

Hysteroscopic sterilization in immunocompromised patients who have intrauterine devices in place: two case reports.

INTRODUCTION: The micro-inserts used in the hysteroscopic sterilization procedure elicit a benign occlusive tissue response leading to permanent tubal occlusion. Little is known about whether immunosuppressed patients mount the immunological response necessary to ensure tubal occlusion. Theoretical concern for non-occlusion has limited the use of hysteroscopic sterilization in patients on immunosuppressive therapies. In all patient populations, if an intrauterine device is in place, it is usually removed at the time of hysteroscopic sterilization. Little is known about maintaining intrauterine devices during the 3-month period to tubal occlusion. CASE PRESENTATION: Our patient in case 1 was a 35-year-old Hispanic woman, gravida 2, para 2002, with a history of a living donor kidney transplant. Our patient in case 2 was a 32-year-old Hispanic woman, gravida 3, para 2103, diagnosed with undifferentiated autoimmune disease. Both patients underwent hysteroscopic sterilization. In both cases, a levonorgestrel intrauterine device was in place for contraception. At the time of micro-insert placement, our patients were both on daily immunosuppressive medications, including long-term glucocorticoids. Three months after the hysteroscopic procedure, both patients had successful tubal occlusion, demonstrated by a hysterosalpingogram. CONCLUSION: Hysteroscopic sterilization in an outpatient setting is a reasonable option for sterilization in immunocompromised patients on immunosuppressive therapies. Intrauterine devices can be maintained during the procedure and during the 3-month period to tubal occlusion.

Early hysteroscopic removal of intratubal microinserts with urologic stone retrieval forceps.

BACKGROUND: Nickel hypersensitivity reactions can be an indication for the removal of intratubal microinserts used for hysteroscopic sterilization. Although early removal can be attempted hysteroscopically, hysteroscopic grasping forceps may be inadequate to grasp deeply positioned inserts. CASE: Three days after hysteroscopic sterilization, the patient presented with a rash consistent with a nickel hypersensitivity reaction. Ten days after placement, we successfully performed hysteroscopic removal of an intratubal microinsert with tri-prong urologic stone retrieval forceps after standard hysteroscopic grasping forceps was unable to reach the deeply positioned device. Within 36 hours of bilateral microinsert removal, all symptoms resolved. CONCLUSION: In difficult cases, 1-mm tri-prong urologic stone retrieval forceps can be useful for early hysteroscopic removal of intratubal microinserts.

Utilization of instruments in the chairman's curio cabinet: a case report.

BACKGROUND: The use of fetal destructive instruments found in curio cabinets may be unfathomable; however, these instruments continue to have a role in select cases. CASE: A 30-year-old multigravida at 40 weeks' gestation had 3 prior normal vaginal deliveries in Africa followed by a cesarean delivery with a complicated postoperative course in the United States. She was intent on having a vaginal delivery, despite repeated recommendations for surgery due to nonreassuring fetal status. After fetal demise and subsequent arrest of labor, vaginal cephalocentesis and fetal extraction were used to achieve delivery. CONCLUSION Fetal destructive procedures, such as the one described here, have a role in modern obstetrics in select cases. In addition, despite an unfortunate fetal outcome, respect for patient autonomy is paramount and is consistent with the recommendations of the American Congress of Obstetricians and Gynecologists. (J Reprod

First trimester myomectomy as an alternative to termination of pregnancy in a woman with a symptomatic uterine leiomyoma: a case report.

INTRODUCTION: Performing a myomectomy during pregnancy is extremely rare due to the risk of pregnancy loss, hemorrhage and hysterectomy. Favorable outcomes have been demonstrated with select second trimester gravid myomectomies. Literature documenting first trimester surgical management of myomas during pregnancy is scant. Patients with symptomatic myomas failing conservative management in the first trimester may be counseled to abort the pregnancy and then undergo myomectomy. Reports focusing on myomectomy in the first trimester are needed to permit more thorough options counseling for patients failing conservative management in the first trimester. CASE PRESENTATION: A 30-year-old Caucasian primagravid (G1P0) was referred for termination of her pregnancy at 10 weeks due to a 14 cm myoma causing severe pain, constipation and urine retention. Her referring physician planned an interval myomectomy following the abortion. Instead, our patient underwent myomectomy at 11 weeks. Two leiomyomas were successfully removed; she delivered a healthy infant at term. CONCLUSION: Patients in the first trimester should not be counseled that termination followed by myomectomy is the best option for symptomatic myomas, failing conservative treatment. Management should be individualized after taking into account the patient's symptoms, gestational age and the location of the myomas in relation to the placenta. Any field providing women's health services will be impacted by the ability to offer more thorough options counseling for women with refractory myomas in the first trimester.

Reasons for ineffective contraceptive use antedating adolescent pregnancies: part 2: a proxy for childbearing intentions.

PURPOSE: Compare the relationship between childbearing intentions, maternal behaviors, and pregnancy outcomes in a group of early/middle adolescents versus a group of late adolescents (specifically high school seniors, high school graduates, and GED certificate recipients). METHODS: The reasons given by a racially/ethnically diverse group of 1,568 pregnant 13-18 year olds for not using contraception were used to classify their pregnancies as intended or unintended. Proportion comparison tests and stepwise logistic regression analyses were used to study the relationship between childbearing intentions, maternal behaviors, and pregnancy outcomes. RESULTS: Regardless of age, adolescents who intended to become pregnant conceived in an objectively more hospitable and supportive childbearing milieu than those who conceived unintentionally. This is evidenced by their greater likelihood of having goals compatible with adolescent childbearing, cohabitation with the father of the child, and living in a non-chaotic environment. However, pregnancy planning was not associated with improved compliance with preventive health care recommendations during gestation nor with infant outcomes. As such, the consequences among adolescents with intended pregnancies were negative, as evidenced by a higher rate of smoking, STDs late in gestation, school dropout, and repeat conception. CONCLUSIONS: Like adults, adolescents with intended pregnancies conceived in an objectively more supportive environment than their counterparts with unintended pregnancies. However, this advantage did not translate into better support, healthier maternal behavior during gestation, or improved pregnancy outcomes.