Maternal and child life years gained by transfusing low titer group O whole blood in trauma: A computer simulation.

BACKGROUND: Using low titer group O whole blood (LTOWB) is increasingly popular for resuscitating trauma patients. LTOWB is often RhD-positive, which might cause D-alloimmunization and hemolytic disease of the fetus and newborn (HDFN) if transfused to RhD-negative females of childbearing potential (FCP). This simulation determined the number of life years gained by the FCP and her future children if she was resuscitated with LTOWB compared with conventional component therapy (CCT). METHODS: The model simulated 500,000 injured FCPs of each age between 0 and 49 years with LTOWB mortality relative reductions (MRRs) compared with components between 0.1% and 25%. For each surviving FCP, number of life years gained was calculated using her age at injury and average life expectancy for American women. The number of expected future pregnancies for FCPs that did not survive was also based on her age at injury; each future child was assigned the maximum lifespan unless they suffered perinatal mortality or serious neurological events from HDFN. RESULTS: The LTOWB group with an MRR 25% compared with CCT had the largest total life years gained. The point of equivalence for RhD-positive LTOWB compared to CCT, where life years lost due to severe HDFN was equivalent to life years gained due to FCP survival/future childbearing, occurred at an MRR of approximately 0.1%. CONCLUSION: In this model, RhD-positive LTOWB resulted in substantial gains in maternal and child life years compared with CCT. A >0.1% relative mortality reduction from LTOWB offset the life years lost to HDFN mortality and severe neurological events.

Status of abortion curriculum in genetic counseling: Survey of graduate programs and recent graduates in the United States.

Genetic counselors (GCs) are trained to help individuals navigate the medical and psychological implications of genetic test results, familial conditions, and ultrasound anomalies. Therefore, familiarity with reproductive options, including abortion, is vital. However, previous studies have found gaps in GCs' knowledge regarding abortion care and there are currently no recommendations regarding abortion curriculum. This study aimed to assess the state of abortion curriculum in genetic counseling graduate programs in the United States and to examine and compare the satisfaction levels of program representatives and recent graduates. Program representatives and recent graduates were invited to complete an anonymous survey evaluating the abortion curriculum, satisfaction with said curriculum, and perceived preparedness to counsel on abortion. Quantitative data from 46 program representatives and 123 recent graduates were analyzed using descriptive statistics and appropriate statistical analyses, including the Mann-Whitney U-test and the Kruskal-Wallis test. Large variability existed in the amount and types of abortion training. Results showed greater satisfaction and feelings of preparation to counsel on abortion in graduates whose program provided a dedicated abortion curriculum (p < 0.001, p = 0.005). In addition, graduates with abortion counseling experience felt less prepared to counsel on abortion than their programs believed them to be (p = 0.04). Graduates perceived procedural timing, facilitation of genetic testing, and resources/support desired by patients before, during, or after an abortion, to be the most important topics, although these were not included in all programs' curriculum. Program representatives and recent graduates alike noted that variability in clinical training is a barrier to abortion education. Our results demonstrate a need for curricular reform to reduce variability in training and ensure that all graduates receive the same foundational abortion education. Further research is needed to determine the scope of GCs in abortion care, as well as which topics and education formats are most helpful in graduate education.

Examining negative urgency as a predictor of eating disorder maintenance in purging syndromes.

OBJECTIVES: Negative urgency is associated with short-term maintenance of binge eating and purging in unselected samples. The current study used an eating disorder sample to test the hypothesis that negative urgency maintains bulimia nervosa (BN) and purging disorder (PD) at long-term follow-up. It was also hypothesized that baseline differences in negative urgency between BN and PD would remain at follow-up. METHODS: Secondary analyses were conducted on a sample of women who engaged in recurrent self-induced vomiting (n = 68; 52.9% BN; 47.1% PD). Women completed diagnostic interviews and questionnaires at baseline and at a mean (SD) of 5.95 (1.58) years follow-up (range = 2.51-9.62; retention rate = 75%). RESULTS: Negative urgency did not predict eating disorder diagnostic status, recovery status, or global eating pathology at follow-up (p's = .06-.83). There were no significant differences in negative urgency across women with BN and PD at follow-up (p = .16). However, post hoc analyses indicated that negative urgency was not stable across time (ICC = .102). Increases in negative urgency from baseline to follow-up were associated with greater global eating pathology at follow-up (p = .002). CONCLUSION: Results suggest negative urgency does not predict long-term eating disorder maintenance. Negative urgency may not be a stable personality trait but rather an indicator of overall poor emotion regulation. Future research should confirm that changes in negative urgency predict chronic eating pathology over long durations of follow-up in women who have increasing negative urgency across time.

Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care.

Legal, institutional, and payer policies regulating reproductive health care lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may affect the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive health care including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive health care.

Induced Abortion and the Risk of Rh Sensitization.

Importance: While population-level data suggest Rh immunoglobulin is unnecessary before 12 weeks' gestation, clinical evidence is limited. Thus, guidelines vary, creating confusion surrounding risks and benefits of Rh testing and treatment. As abortion care in traditional clinical settings becomes harder to access, many people are choosing to self-manage and need to know if ancillary blood type testing is necessary. Objective: To determine how frequently maternal exposure to fetal red blood cells (fRBCs) exceeds the most conservative published threshold for Rh sensitization in induced first-trimester abortion. Design, Setting, and Participants: Multicenter, observational, prospective cohort study using high-throughput flow cytometry to detect circulating fRBCs in paired maternal blood samples before and after induced first-trimester abortion (medication or procedural). Individuals undergoing induced first-trimester abortion before 12 weeks 0 days' gestation were included. Paired blood samples were available from 506 participants who underwent either medical (n = 319 [63.0%]) or procedural (n = 187 [37.0%]) abortion. Exposure: Induced first-trimester abortion. Main Outcomes and Measures: The primary outcome was the proportion of participants with fRBC counts above the sensitization threshold (125 fRBCs/5 million total RBCs) after induced first-trimester abortion. Results: Among the 506 participants, the mean (SD) age was 27.4 (5.5) years, 313 (61.9%) were Black, and 123 (24.3%) were White. Three of the 506 participants had elevated fRBC counts at baseline; 1 of these patients had an elevated fRBC count following the abortion (0.2% [95% CI, 0%-0.93%]). No other participants had elevated fRBC counts above the sensitization threshold after induced first-trimester abortion. The median change from baseline was 0 fRBCs, with upper 95th and 99th percentiles of 24 and 35.6 fRBCs, respectively. Although there was a strong association between the preabortion and postabortion fRBC counts, no other baseline characteristic was significantly associated with postabortion fRBC count. Conclusions and Relevance: Induced first-trimester abortion is not a risk factor for Rh sensitization, indicating that Rh testing and treatment are unnecessary before 12 weeks' gestation. This evidence may be used to inform international guidelines for Rh immunoglobulin administration following first-trimester induced abortion.

Elevated fullness and bloating as correlates of eating pathology: Implications for screening.

A minority of individuals with eating disorders report being asked about their eating by health care professionals; delayed detection of eating disorders may contribute to poorer outcomes. The current study investigated common meal-related gastrointestinal symptoms (i.e., elevated fullness and bloating) as correlates of eating pathology that may be more readily disclosed to health professionals and indicate the need to assess for eating pathology. The current study also tested the hypothesis that elevated fullness and bloating are more strongly linked to eating pathology among those with higher body dissatisfaction. 281 university students (70.1% female, 84.3% white) completed gastrointestinal symptom and eating pathology assessments. Elevated fullness and bloating were each associated with increased purging, restrictive eating behaviors, and likelihood of having an eating disorder. Elevated fullness and bloating were more strongly linked to purging and probable eating disorder diagnosis with higher, relative to lower, body dissatisfaction. However, body dissatisfaction did not moderate the relationship between gastrointestinal symptoms and restrictive eating behaviors. Results indicate that elevated fullness and bloating are correlates of eating pathology. Healthcare professionals should consider and/or assess for eating pathology when elevated fullness and bloating are reported; further assessment of body dissatisfaction may be helpful in identifying purging behaviors.

Managing Undesired Pregnancy After Dobbs.

Although both medication abortion (MAB) and aspiration procedures are safe and effective, the Supreme Court decision in Dobbs v. Jackson Women's Health Organization removed federal protection of access to abortion services. Abortion access is now illegal or severely limited in many states, leading to delays in abortion care for patients in all states. In this rapidly evolving landscape, primary care physicians (PCPs) must be familiar with laws surrounding abortion care in their own and neighboring states. PCPs must also be prepared to expedite abortion care by sharing resources, obtaining testing when needed, and counseling patients about expected outcomes following abortion.

Society for Maternal-Fetal Medicine Special Statement: Maternal-fetal medicine subspecialist survey on abortion training and service provision.

Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess the attitudes of maternal-fetal medicine subspecialists about abortion services and the available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to associate and regular members of the Society for Maternal-Fetal Medicine to assess their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses were conducted on the survey responses. Of the 2751 members contacted, 546 Society for Maternal-Fetal Medicine members completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. More than 80% of the respondents reported availability of abortion services in their state, 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors contributing to the respondents' limited scope of abortion services or lack of any abortion services offered. In the univariable analysis, exposure to formal family planning training programs, fewer years since the completion of residency, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were factors associated with abortion provision (all P values <.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85-2.10), whereas a favorable state policy environment and fewer years since the completion of residency remained associated with abortion provision. The results of this survey suggest that factors at the individual, institutional, and state levels affect the provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare services.

Emotion dysregulation moderates the relationship between alcohol use and eating pathology among heavy-drinking college men.

OBJECTIVES: There is limited research examining the relationship between alcohol use and eating pathology in men or factors that may moderate this association. The current study investigated the relationship between alcohol use and eating pathology, and examined emotion dysregulation as a moderator of this association, among heavy-drinking college men. METHOD: Men mandated to receive an alcohol intervention (N = 88; average age = 19 years) completed questionnaires related to alcohol use, emotion dysregulation, and eating pathology. RESULTS: Results demonstrated positive relationships between alcohol use and some eating pathology, and a significant interaction between alcohol use and emotion dysregulation. However, results were contrary to hypotheses, such that there was a positive relationship between alcohol use and eating pathology at low levels of emotion dysregulation. CONCLUSION: Future studies should continue to examine the overall presentation of eating pathology in men and investigate factors that may impact the relationship between alcohol use and eating pathology.

Trauma and Alcohol Use Among Transgender and Gender Diverse Women: An Examination of the Stress-Buffering Hypothesis of Social Support.

Transgender and gender diverse (TGD) women (i.e., individuals who were assigned male at birth and identify as women or trans women) experience trauma at disproportionate rates compared to cisgender populations. While trauma is associated with increased alcohol use among TGD women, research regarding factors that are protective of this association is scant. The stress-buffering hypothesis of social support suggests that perceived social support, defined as the judgment that social network members will be helpful when individuals experience stress, may buffer and reduce the association between trauma symptoms and alcohol use. However, this relationship has not been examined among TGD women. We examined whether perceived social support moderates the association between trauma and alcohol use among 89 TGD women. Exploratory multiple regression analyses provided support for this hypothesis, insofar as trauma symptoms were related to alcohol use by individuals with low, relative to high levels of perceived social support. Exploratory analyses demonstrated that this finding was driven by perceived social support from friends and family. Our results are the first to suggest that social support reduces alcohol use among TGD women and add to the literature on their trauma and alcohol use.

From uptake to access: a decade of learning from the ACOG LARC program.

The Long-Acting Reversible Contraception (LARC) Program at the American College of Obstetricians and Gynecologists (ACOG) celebrated its 10th anniversary in 2018. This Viewpoint article reviews opportunities, challenges, and lessons learned by the ACOG LARC Program throughout the last decade. Housed within the largest medical organization representing women's health providers, the LARC Program supports change by developing resources for clinicians, healthcare systems, healthcare organizations, and policy makers. The Program's Postpartum Contraceptive Access Initiative (PCAI) meets specific needs identified by an Expert Work Group using implementation science principles, including improved contraceptive counseling and clinician training, and institution-wide sustainable systems change in billing, coding, pharmacy, and electronic medical record integration. Key lessons learned include the importance of centering patient preferences and autonomy, developing foundational evidence-based guidance, supporting practice change through implementation tools and collaboration with local champions, advocating for insurance and payment policy, and partnering with other health care organizations to develop robust resources to improve patient access to the full range of contraceptive methods.

Gender minority stress, sleep disturbance, and sexual victimization in transgender and gender nonconforming adults.

OBJECTIVE: The current study examined facets of gender minority stress (nonaffirmation, internalized transphobia) and protective factors (community connectedness, transgender identity pride) as potential moderators of the relationship between sexual victimization and sleep disturbances among transgender and gender nonconforming (TGNC) adults. METHODS: TGNC adults (n = 191) were recruited through Amazon's Mechanical Turk. The average age was 30.28 years old (SD = 7.09; range 18-71) and the majority (55%) identified in the transfemale spectrum. RESULTS: Results demonstrated a significant two-way interaction between sexual victimization and internalized transphobia, such that sexual victimization was more strongly related to sleep disturbances when internalized transphobia was low (ß = .14, p = .017) relative to high (ß = -0.09, p = .221). CONCLUSIONS: This study is the first to establish the relationship between sexual victimization and sleep disturbances in TGNC individuals. Additional research is needed to replicate these findings longitudinally.

Effort expenditure for rewards task modified for food: A novel behavioral measure of willingness to work for food.

OBJECTIVE: Binge eating and associated eating disorders are characterized by abnormalities in reward processing. One component of reward is willingness to expend effort to obtain a reinforcer. The Effort Expenditure for Rewards Task (EEfRT) is a widely used behavioral measure of willingness to work for money. We sought to modify the EEfRT to examine willingness to work for food reward and to preliminarily examine the association between binge eating and effort expenditure for food. METHOD: Participants were 63 females recruited to span the spectrum of binge-eating severity. The modified EEfRT required participants to make a series of choices between an easier, low-reward option (one portion of food) and a harder, high-reward option (between two to five portions of food). Each trial also varied on probability of winning. RESULTS: Participants self-reported engagement in the task, working hard at easy and hard tasks, and making choices based on reward probability and magnitude. As with the original EEfRT, probability, reward magnitude, and their interaction predicted the likelihood of choosing the hard task. Across two different measures, binge-eating symptoms interacted with reward magnitude, such that those with high binge eating used reward magnitude more to make trial choices than those with low binge eating. DISCUSSION: These data provide initial support for the validity of the EEfRT modified for food as a behavioral measure of willingness to work for food reward. The impact of binge eating on effort expenditure must be replicated in samples of patients with eating disorders.

Emotion dysregulation across the spectrum of pathological eating: Comparisons among women with binge eating, overeating, and loss of control eating.

Emotion regulation difficulties influence the etiology and maintenance of binge eating and eating disorders, but differential associations between emotion dysregulation and objective binge eating (OBE) components have not been examined. We compared emotion dysregulation dimensions in women with OBEs (n = 27), overeating only (n = 25), loss of control (LOC) only (n = 32), or no pathological eating (n = 137). Women with OBEs had significantly more difficulty with overall emotion dysregulation, access to strategies, and impulse control when upset than other groups. Women with OBEs and women with overeating did not differ on poor emotional clarity, whereas women with OBEs and women with LOC did not differ on non-acceptance of emotions. The combination of overeating and LOC eating is associated with the greatest emotion dysregulation, but certain emotion regulation facets may differentially relate to overeating and LOC. Identifying emotion-related treatment targets for core eating disorder symptoms is important.

Trends in gestational age at time of surgical abortion for fetal aneuploidy and structural abnormalities.

BACKGROUND: Screening for fetal aneuploidy has evolved over the past 2 decades. Whether these advances impact gestational age at abortion has received little study. OBJECTIVE: We sought to describe trends in the gestational age at the time of abortion by fetal diagnosis over an 11-year study period. We hypothesized that gestational age at time of abortion would decrease for fetal aneuploidy but remain unchanged for structural abnormalities. STUDY DESIGN: We conducted a retrospective case series of all women undergoing surgical abortion for fetal aneuploidy or structural abnormalities up to 24 weeks' gestation from 2004 through 2014 in a hospital operating room setting at a single, urban medical center. We excluded labor induction abortions (<1% of abortions at our medical center) and suction aspirations performed in the office practice. We performed suction aspiration up to 14 weeks and dilation and evacuation after that gestational age. We describe the median gestational age at abortion by fetal indication and year. RESULTS: For women undergoing abortion for fetal aneuploidy (n = 392), the median gestational age at time of abortion decreased from 19.0 weeks (interquartile range 18.0-21.0) in 2004 to 14.0 weeks (interquartile range 13.0-17.0) in 2014 (Kruskal-Wallis P < .0001). For women undergoing abortion for fetal structural abnormalities (n = 586), the median gestational age was ≥20 weeks for each year during the study interval (P = .1). As gestational age decreased in the fetal aneuploidy group, fewer women underwent dilation and evacuation and more became eligible for suction aspiration (<14 weeks). In 2004, >90% of women underwent dilation and evacuation for either indication. By 2014, 31% of women with fetal aneuploidy were eligible for suction aspiration compared to 11% of those with structural anomalies. CONCLUSION: Gestational age at the time of abortion for fetal aneuploidy decreased substantially from 2004 through 2014; earlier abortion is safer for women. In contrast, women seeking abortion for fetal structural abnormalities did not experience a change in timing. Legislation restricting gestational age at the time of abortion could disproportionately affect women with fetal structural abnormalities.

Unintended Pregnancy, Induced Abortion, and Mental Health.

PURPOSE OF REVIEW: The early medical literature on mental health outcomes following abortion is fraught with methodological flaws that can improperly influence clinical practice. Our goal is to review the current medical literature on depression and other mental health outcomes for women obtaining abortions. RECENT FINDINGS: The Turnaway Study prospectively enrolled 956 women seeking abortion in the USA and followed their mental health outcomes for 5 years. The control group was comprised of women denied abortions based on gestational age limits, thereby circumventing the major methodological flaw that had plagued earlier studies on the topic. Rates of depression are not significantly different between women obtaining abortion and those denied abortion. Rates of anxiety are initially higher in women denied abortion care. Counseling on decision-making for women with unintended pregnancies should reflect these findings.

Economic analysis of foregoing Rh immunoglobulin for bleeding in pregnancy <12 weeks gestation.

OBJECTIVES: To perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States. STUDY DESIGN: We created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from the current literature and calculated the number needed to treat (NNT) and number needed to screen to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44% to 100%. RESULTS: The annual savings to health care payers in the United States of foregoing RhD testing and RhIg administration with bleeding events at <12 weeks are $5.5 million/100,000 total pregnancies, assuming the sensitization risk is 0%. In sensitivity analyses with a sensitization risk of 1.5% and subsequent pregnancy rate of 84.3% foregoing Rh testing and RhIg administration would save $2.8 million/100,000 pregnancies, with a NNT of 7322 and a number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is most economical. CONCLUSIONS: There is an opportunity to save as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy. IMPLICATIONS: Cost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By deimplementing this low-value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.