Postoperative opioid use for patients with chronic pelvic pain undergoing robotic surgery for resection of endometriosis.

We aimed to identify the amount of opioids used in the postoperative setting for patients with a history of chronic pelvic pain undergoing robotic surgical excision of endometriosis and compare this to patients undergoing benign robotic gynecologic surgery for other indications. We conducted a retrospective cohort study in an urban academic university hospital from January 2019 to March 2020. Data regarding opioid use was collected via a patient-reported survey that was given at the 3 weeks follow-up visit. Data regarding opioid use was compared to patients undergoing robotic surgery for other benign gynecologic indications. Our study included 158 patients, 119 undergoing surgery for endometriosis and 39 patients undergoing robotic surgery for other benign gynecologic indications. Patients undergoing surgery for endometriosis used on average 105.9 morphine milligram equivalents (MME), equivalent to 14 tabs of oxycodone 5 mg. There was no statistically significant difference in the amount of opioids used postoperatively based on stage of endometriosis or need for hysterectomy. Patients undergoing surgery for other benign indications used on average 49.4 MME, equivalent to 6 tabs of oxycodone 5 mg. The difference in amount of opioids used between patients with and without endometriosis was statistically significant. In conclusion, patients undergoing robotic surgery for endometriosis used over two times as many opioids postoperatively as patients without endometriosis and have a higher perceived postoperative pain. Providers should be aware of this difference in order to provide better pain control for this patient population.

Disparities between US Hispanic and non-Hispanic women in obesity-related perinatal outcomes: a prospective cohort study.

BACKGROUND: Mortality figures and national health surveillance data have demonstrated that Hispanics have a 24% lower risk of all-cause mortality compared to their non-Hispanic counterparts despite increased rates of obesity and related illnesses. OBJECTIVE: The aim of this study is to evaluate if this paradox exists for obesity-related perinatal outcomes in otherwise low-risk Hispanic women. MATERIALS AND METHODS: A prospective cohort study of low-risk women across all BMI classes with a singleton, non-anomalous term pregnancy admitted in active labor or undergoing induction of labor between May 2014 and April 2017. All demographic, obstetric, and neonatal outcomes were recorded, and the body mass index (BMI) closest to delivery was used for analysis. Data including composites of adverse maternal and neonatal outcomes were compared across BMI classes and between individuals of Hispanic and non-Hispanic ethnicity. Women with antenatal complications, prior cesarean delivery, and cesarean for non-reassuring fetal status were excluded. RESULTS: Of the 11,369 women who met inclusion criteria, 6303 (55%) were Hispanic. Eight percent of Hispanic women were normal weight (BMI: 18.5-24.9), 34% were overweight (BMI: 25-29.9), and 58% were obese (BMI > 30). Fourteen percent of non-Hispanic women were normal weight, 42% were overweight, and 44% were obese. The majority (65%) of women were multiparous. Rate of induction and birthweight increased across BMI for Hispanic and non-Hispanic groups, however the route of delivery was not significantly different (p = .22, 0.16, respectively). Although the association between BMI and composite perinatal complications did not differ by BMI class and ethnicity, the newborns of non-Hispanic women were more likely to be admitted to the neonatal intensive care unit with increasing maternal weight class (<0.001), even after adjusting for age, parity, marital status, prenatal visits, current tobacco use, type of labor, mode of delivery, and birthweight. CONCLUSION: There were no demonstrable differences in composite adverse maternal or neonatal outcomes between Hispanic and non-Hispanic obese women. However, newborns of non-Hispanic obese women were more likely to be transferred to the neonatal intensive care unit with increasing maternal BMI.

Postoperative Pain and Urinary Retention After Vaginal Reconstructive Surgery.

OBJECTIVE: The objective of this study was to evaluate the effect of patients' immediate prevoiding pain level after vaginal pelvic reconstructive surgery on their ability to void. METHODS: We conducted a retrospective cohort study of women with and without urinary retention after urogynecologic procedures. Postoperative pain, measured by a visual analog scale, was recorded for each patient before a voiding trial. Demographic, surgical characteristics, prevoiding trial pain, and rate of postoperative urinary retention were compared. Multiple-logistic regression analysis was used with all analyses controlled for univariate variables with a P value of ≤0.1 to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Two-tailed tests were used, with P < 0.05. RESULTS: A total of 458 patients were identified, of which 21% (97/458) failed their voiding trial. In our study, 62% (284/458) of women had a voiding trial on postoperative day 1, and 38% (174/458) underwent a same-day voiding trial. No differences were noted between groups comparing race, ethnicity, hysterectomy, urinary sling, estimated surgical blood loss, utilization of intraoperative or postoperative narcotics, or the proportion of same-day voiding trials. Women with postoperative urinary retention had higher mean prevoiding pain when compared with women without urinary retention (pain visual analog scale, 25 mm vs 12 mm [P < 0.001], respectively). After multiple-logistic regression analysis, a significant association between postoperative urinary retention persisted for prevoiding trial pain score (aOR, 1.02; 95% CI, 1.01-1.03), age (aOR, 1.05; 95% CI, 1.02-1.02), and anterior colporrhaphy (aOR, 2.13; 95% CI, 1.18-3.8). CONCLUSIONS: Prevoiding pain after pelvic surgery is significantly associated with increased rates of postoperative urinary retention.

Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism.

OBJECTIVE: To estimate the rate of readmissions for postpartum venous thromboembolism (VTE) during the first 30 days postdelivery between women with and without the immediate postpartum insertion of the etonogestrel contraceptive implant. METHODS: The Nationwide Readmissions Database from 2016 was used to identify women with a singleton delivery, immediate postpartum insertion of the etonogestrel contraceptive implant, and readmission for VTE within 30 days of discharge. Those with a prior history of VTE or anticoagulant therapy were excluded. These women were compared with the number of women readmitted within 30 days for VTE who did not have the contraceptive implant placed during delivery admission. RESULTS: Of 3,387,120 deliveries, 8,369 women underwent etonogestrel contraceptive implant placement during the delivery admission. There was no difference identified in the rate of readmission for VTE between exposed and unexposed women. Of these, seven had received a postpartum etonogestrel contraceptive implant (0.85/1,000; 95% CI 0.22-1.45/1,000 deliveries), compared with 1,192 without an etonogestrel contraceptive implant (0.35/1,000; 95% CI 0.33-0.37/1,000 deliveries); odds ratio (OR) 2.41; 95% CI 0.58-9.89. The rates of diabetes, thrombophilia, systemic lupus erythematosus, and cesarean birth did not differ between groups. Women who underwent etonogestrel contraceptive implant placement were younger and were more likely to have government-sponsored health insurance, a smoking history, hypertension, peripartum infection, or postpartum hemorrhage than women who did not receive an etonogestrel contraceptive implant (P<.001). After adjusting for these confounders, there remained no difference in rates of VTE, adjusted OR 1.81; 95% CI 0.44-7.45. CONCLUSION: The immediate postpartum placement of the etonogestrel contraceptive implant was not associated with an increased rate of VTE; however, our sample size was underpowered to determine no difference.

Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009).

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.

The Female Genital Self-image Scale in Adult Women With Vulvar Lichen Sclerosus.

OBJECTIVE: There is no agreed upon standard way to measure vulvar lichen sclerosus disease severity. The Female Genital Self-Image Scale (FGSIS) is a validated survey tool assessing female genital self-image and is positively correlated with women's sexual function. A lower score represents a negative genital self-image. We evaluated the FGSIS in women with vulvar lichen sclerosus. METHODS: Women with biopsy-proven lichen sclerosus and women presenting for routine gynecologic care without lichen sclerosus matched by age were surveyed with the 7-item FGSIS. National surveys of healthy women in the United States have shown the mean 7-item FGSIS score is 21. To detect one standard deviation (20% absolute difference) between groups with a power of 80% at p < .05, 15 women would are needed in each group. RESULTS: Sixteen women with lichen sclerosus and 16 matched controls were surveyed between February and July 2018. The mean ± SD age of women with lichen sclerosus was 56.8 ± 13.5 years, 94% were white, 69% married, 81% college educated, 69% postmenopausal, and 18% on hormone replacement therapy. None of these differences were statistically different from control women. Women with vulvar lichen sclerosus had a significantly lower median 7-item FGSIS when compared with control subjects, 18 (interquartile range = 16-21) versus 25 (interquartile range = 23-27), respectively, Mann-Whitney U test, p < .001. CONCLUSIONS: Women with vulvar lichen sclerosus have a lower score on the 7-item Female Genital Self-Image Scale compared with healthy controls.

Efficiency of Screening for the Recurrence of Antenatal Group B Streptococcus Colonization in a Subsequent Pregnancy: A Systematic Review and Meta-analysis with Independent Patient Data.

OBJECTIVE: The objective of this study was to evaluate the risk of recurrent group B streptococcus (GBS) colonization in a subsequent pregnancy and to assess clinical characteristics that influence this risk. STUDY DESIGN: A systematic review and meta-analysis was performed. Databases were searched from inception through June 2015 using PubMed, Embase, Scopus, Central, and ClinicalTrials.gov. Studies were eligible if they assessed antenatal GBS colonization in two successive pregnancies. The quality of included studies was evaluated. Independent patient data was requested from the authors of the included trials. Unadjusted odds ratios (OR) were pooled using the Mantel-Haenszel fixed effect model. RESULTS: In the five studies identified, two studies lacked a nonexposed cohort. GBS colonization in the index pregnancy was associated with a higher risk of recurrence of GBS colonization in a subsequent pregnancy (three studies: 50.2 compared with 14.1%; pooled fixed effects OR, 6.05; 95% confidence interval [CI], 4.84-7.55). When heavy colonization with GBS was compared with colonization by vaginal culture only, an increased risk of recurrence was shown (four studies: 52.0 compared with 45.1%, pooled fixed effects OR, 1.54; 95% CI, 1.02-2.31). CONCLUSION: Women colonized with GBS are at significantly higher odds for recurrent colonization in a subsequent pregnancy when compared with women who were not colonized in an index pregnancy. If the individual is considered heavily colonized with GBS, there appears to be an association with an increased risk compared with conventional culture. Subgroup analysis of the variables time interval ≤ 12 months between subsequent pregnancies, body mass index ≥ 30 kg/m(2), race, ethnicity, and primiparous in the subsequent pregnancy showed no effect.

Screening for group B streptococcus: a private hospital's experience.

OBJECTIVE: To assess the effect of universal screening and administration of intrapartum antibiotic prophylaxis to prevent early-onset neonatal GBS sepsis at a private tertiary care hospital since issuance of the 2002 CDC guidelines for preventing perinatal GBS disease. METHODS: Retrospective analysis of women delivering between January 1, 2003 and December 31, 2004 at a private tertiary care hospital in Houston, Texas. The percentage of women screened, GBS positive women receiving intrapartum antibiotic prophylaxis, and infants developing early-onset GBS sepsis were determined. RESULTS: 2,108 women delivered 2,135 infants with 1,874 (89%) screened for GBS. Of those screened, 1,322 (71%) tested negative and 552 (29%) tested positive for GBS. In this analysis of 2,135 infants, 3 (0.94 cases/1,000 live births) were diagnosed with invasive GBS sepsis. CONCLUSION: High rates of screening of pregnant women for GBS colonization and use of intrapartum antibiotic prophylaxis for GBS carriers can be achieved in a private tertiary care hospital setting. " SYNOPSIS: High screening rates for group B streptococcus in a private tertiary care hospital reduce the incidence of maternal and early onset neonatal GBS infection."

Recurrence of group B streptococci colonization in subsequent pregnancy.

OBJECTIVE: To estimate the prevalence of group B streptococci (GBS) colonization in a subsequent pregnancy in women with and without GBS colonization in an index pregnancy. METHODS: A retrospective cohort study of women who had two consecutive deliveries with the availability of GBS culture result at 35 to 37 weeks of gestation or the diagnosis of GBS colonization by urine culture for both pregnancies was undertaken. Women in the index pregnancy with GBS genitourinary tract colonization were compared by culture date with the next woman that screened negative for GBS colonization. To detect a doubling of GBS colonization from 20% to 40% would require 91 women in each arm at P<.05 with a power of 80%. Risk factors for GBS colonization were ascertained. Univariable and conditional logistic regression analyses were performed. P<.05 was considered statistically significant. RESULTS: A total of 102 women positive for GBS genitourinary colonization were compared with controls. The rate of recurrence for GBS colonization (53%) was significantly higher when judged against women GBS negative in their index pregnancy (15%) (adjusted odds ratio 11.7, 95% confidence interval 3.5-38.9, P<.01). Women who were GBS positive in the index pregnancy were more often of African-American race and less likely to be nulliparous or smoke tobacco. CONCLUSION: Women with GBS colonization are at increased risk of GBS colonization in a subsequent pregnancy. Prior GBS colonization should be considered in the algorithm to treat unknown GBS status during term labor.

Diagnosis of short cervix in a community hospital prior to placement of a therapeutic cerclage.

The purpose of this study was to describe how obstetricians in the community define a short cervix prior to cerclage placement. A secondary analysis of cerclages placed for the diagnosis of short cervix, defined by either digital or ultrasound examination, were identified from a cohort of 1076 cerclages placed at a community hospital from January 1, 2000, through December 31, 2004. Two hundred twenty-six cerclages were placed for the diagnosis of short cervix. Fifty-eight women (25.7%) were nulliparous. The mean estimated gestational age at placement was 15.4 +/- 3.8 weeks. More than half of the cerclages (n = 125; 55.3%) were placed prior to 15 weeks estimated gestational age. Of those cases with documented cervical length by ultrasound (n = 171), 36 of these patients (21.1%) had a cervical length of > or = 25 mm. The most common indications for cerclage placement were short cervix only (40.3%), previous cone biopsy/loop electrocautery excision procedure (28.8%), and multiple gestation (9.7%). In a community hospital, cerclages for short cervix are often performed in nulliparous women without antecedent risk factors at a gestational age when cervical length is not a reliable tool for predicting adverse pregnancy outcome.

Use of the cervical cerclage: comparison of a community and university hospital setting.

OBJECTIVE: To compare the use of cervical cerclage between a community hospital and a university teaching hospital to estimate if the rate of cervical cerclage placement differs and if indications selected for cervical cerclage placement vary by institution type. METHODS: A review of medical records from January 1, 2000, through December 31, 2004, of women undergoing cervical cerclage was performed at a community hospital and a university teaching hospital. The rate of cerclage and indications for placement were estimated. A multivariate logistic regression model examined the likelihood that women with a specific indication for cerclage would be more likely found in a university hospital or in a community hospital. The analysis was adjusted for confounding variables. RESULTS: During the 5-year period, 41,458 and 17,153 deliveries occurred at the community hospital and the university teaching hospital, respectively. Rate of cerclage placement was higher at the community hospital 2.6% (n=1,076) than at the university hospital 0.57% (n=98), P<.01. The community hospital had more elective (94.6% versus 83.7%) and fewer emergency cerclages (5.4% versus 16.3%) than the university hospital, P<.01. More cerclages were placed at the community hospital for the diagnosis of cervical cone biopsy/loop electrocautery excision procedure (LEEP), short cervix, or multiple gestations, P<.05. Multivariate logistic regression confirmed that patients with an indication of cone biopsy/LEEP, short cervix, or multiple gestations were more likely to be found in a community hospital setting, P<.01. CONCLUSION: Obstetricians in private practice use cervical cerclage more frequently than their colleagues in a university hospital setting. LEVEL OF EVIDENCE: II.