Characteristics associated with trial of labor among patients with twin pregnancies.

OBJECTIVE: This study aimed to identify patient and provider factors associated with undergoing trial of labor among eligible patients with twin gestations. STUDY DESIGN: This retrospective cohort study of patients with twin gestations who received care at a large tertiary care center from 2000-2016 included individuals with live pregnancies greater than twenty-three weeks of gestation and cephalic-presenting twin. Patients with a prior uterine scar or contraindication to vaginal delivery were excluded from analyses. Maternal and clinical characteristics were compared among patients who did and did not undergo trial of labor. Multivariable logistic regression models included characteristics chosen a priori and those with bivariable associations with p <0.1. Interactions between parity and other significant variables in the primary models were also investigated. RESULTS: Among 1888 eligible patients, 80.7% (N=1524) underwent trial of labor. Those undergoing trial of labor were more likely to be younger, multiparous, and have a maternal-fetal medicine physician as the delivering provider (p<0.01). Hypertensive disorders of pregnancy were less prevalent among patients undergoing trial of labor (20.2% vs. 27.8%, p<0.01). In multivariable analysis, advanced maternal age (aOR 0.55, 95% CI 0.40-0.74) and nulliparity (aOR 0.36, 95% CI 0.25-0.52) conferred a lower odds of trial of labor, while having a maternal-fetal medicine provider (aOR 2.74, 95% CI 1.55-4.83) was associated with higher odds. Interaction analyses demonstrated no significant interaction effects between parity and other characteristics. Among those undergoing trial of labor, 76.0% (1158/1524) had a successful vaginal delivery of both twins, with 48.1% (557/1158) having breech extraction of the second twin. CONCLUSION: In this cohort of twin gestations with a high frequency of trial of labor, patient and provider characteristics are associated with attempting vaginal delivery. Variation in provider practices suggests differing skills and comfort with twin vaginal delivery may influence route of delivery decision-making in patients with twins.

The Association of Twin Chorionicity with Maternal Outcomes.

OBJECTIVE: Our objective was to investigate the association between maternal outcomes and twin chorionicity in a large, contemporary obstetric population. STUDY DESIGN: Retrospective cohort study was conducted at a single, large tertiary care center. Prenatal and inpatient records for all individuals with twin gestations were reviewed from 2000 to 2016. Patients with monoamniotic twins, higher-order multiples reduced to twins, multiple sets of twins in the study period, or undetermined chorionicity were excluded. Patients with monochorionic twins were compared with those with dichorionic twins. The co-primary outcomes were gestational diabetes mellitus and hypertensive disorders of pregnancy. Secondary outcomes included cesarean delivery, preterm delivery, postpartum hemorrhage, and other maternal outcomes. Bivariate and multivariate analyses were performed to assess associations of chorionicity with maternal outcomes. RESULTS: Of the 2,979 patients eligible for inclusion, 2,627 (88.2%) had dichorionic twin gestations and 352 (11.8%) had monochorionic twin gestations. Patients with monochorionic twins were less likely to self-identify as non-Hispanic White and to have conceived via assisted reproductive technology but were more likely to be publicly insured, multiparous and have prenatal care with a maternal-fetal medicine provider. Neither gestational diabetes mellitus (6.8% monochorionic vs. 6.2% dichorionic, p = 0.74; adjusted odds ratio [OR] 1.06, 95% confidence interval (CI) 0.60-1.86) nor hypertensive disorders of pregnancy (21.9% monochorionic vs. 26.3% dichorionic, p = 0.09; adjusted OR 0.99, 95% CI, 0.71-1.38) differed by chorionicity. Of the secondary maternal outcomes, patients with monochorionic twins experienced a lower frequency of cesarean delivery (46.0 vs. 61.8%, p < 0.001), which persisted after multivariate analyses (adjusted OR 0.60, 95% CI 0.46-0.80). There were no differences in preterm delivery, preterm premature rupture of membranes, hemorrhage, hysterectomy, or intrahepatic cholestasis of pregnancy. CONCLUSION: The odds of gestational diabetes mellitus and hypertensive disorders of pregnancy do not appear to differ by twin chorionicity. KEY POINTS: · Hypertensive disorders of pregnancy do not differ by twin chorionicity.. · Gestational diabetes mellitus does not differ by twin chorionicity.. · Maternal outcomes are similar for individuals with monochorionic and dichorionic twin gestations..

Case Series of Reproductive Outcomes after Surgical Correction of Obstructed Hemivagina in OHVIRA.

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) is a rare congenital developmental syndrome manifested by uterine duplication, lower genital tract obstruction, and unilateral renal anomaly. Literature on reproductive outcomes in this patient population is limited. The aim of this study is to describe obstetric outcomes after surgical correction of obstructed hemivagina in a longitudinal cohort of patients with a diagnosis of OHVIRA. All cases of OHVIRA presenting to a single tertiary care children's hospital from 1990 to 2021 were retrospectively reviewed. Three cases demonstrating a variety of clinically important reproductive outcomes are described in detail including risks such as retained products, endometritis, preterm labor, and malpresentation. Understanding the reproductive outcomes associated with this diagnosis is important for practitioners seeking to counsel and care for patients with this diagnosis. This case series demonstrates a wide array of potential gynecologic and obstetric risks, though ultimately with successful term and near-term pregnancies.

Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone.

STUDY OBJECTIVE: This study aimed to characterize the incidence and management of postoperative vaginal bleeding concerns experienced by transgender adolescents and young adults (AYA) on testosterone hormone therapy after gender-affirming hysterectomy (GAH). METHODS: This was a retrospective cohort of transgender AYA, 18 years and older, using testosterone therapy who underwent a GAH between July 2020 and September 2021 at a tertiary care children's hospital. The incidence of patient-reported postoperative vaginal bleeding concerns and management of bleeding are described. RESULTS: Patient ages ranged between 18 and 33 years. Among 25 patients who met the inclusion criteria, 13 (52.0%) reported vaginal bleeding concerns. No modifiable patient or operative characteristics reached statistical significance in association with postoperative bleeding concerns. Among patients with bleeding concerns, 10 (76.9%) experienced such concerns during the first 2 weeks after surgery, and 6 (46.2%) had resolution of bleeding without intervention. Among 11 patients who underwent an exam for evaluation of bleeding, findings included granulation tissue (n = 5, 45.5%), vaginal atrophy (n = 4, 36.4%), bleeding vessel (n = 1, 9.1%), mucosal separation (n = 1, 9.1%), or no cause of bleeding identified (n = 4, 36.4%). CONCLUSIONS: Over half of transgender AYA on testosterone therapy in this cohort reported postoperative vaginal bleeding concerns that were most often secondary to atrophy and granulation tissue, suggesting possible susceptibility to vaginal tissue trauma at the time of GAH and granulation-susceptible healing in patients on testosterone. As vaginal bleeding could worsen gender dysphoria, these findings support the need for patient counseling on postoperative bleeding expectations and identification of interventions to reduce vaginal bleeding after GAH.

A 13-Year-Old Girl with Primary Amenorrhea.

A 13-Year-Old Girl with Primary AmenorrheaA 13-year-old girl presented for evaluation of intermittent lower abdominal pain and absence of menarche. How do you approach the evaluation, and what is the diagnosis?

Do Adolescent Women's Contraceptive Preferences Predict Method Use and Satisfaction? A Survey of Northern California Family Planning Clients.

PURPOSE: Contraceptive satisfaction may influence not only contraceptive use but also long-term engagement in care. We investigated the extent to which adolescent and young women's desired contraceptive features are associated with their current contraceptive method and if the presence of preferred features in their current method is associated with satisfaction. METHODS: We performed a secondary analysis of a cross-sectional survey at five Northern California family planning clinics, including women aged 13-24 years. Descriptive statistics and multivariate logistic regression identified associations between desired features and sociodemographic characteristics. Multivariate logistic regression was used to examine associations between desired features and current contraceptive method, as well as the presence of desired features and satisfaction with current method. RESULTS: Among 814 participants, the features most frequently rated "very important" included effectiveness (87%, n = 685), safety (85%, n = 664), and side effects (72%, n = 562). Contraceptive feature preferences varied by age, race/ethnicity, intimate partner violence history, and sexually transmitted infection history. Having a preference for a specific contraceptive feature was not associated with using a method with that feature, except for sexually transmitted infection prevention (adjusted odds ratio [aOR]: 1.59, confidence interval [CI; 1.18-2.16]). However, respondents with preferences for effectiveness, partner independence, or privacy who used methods that were congruent with their preferences were more likely to express satisfaction (aOReffectiveness: 1.57, CI [1.03-2.37], aORpartner independent: 1.75 [1.03-2.96], and aORprivacy: 1.81 [1.01-3.23]). CONCLUSION: Adolescent and young women have varied contraceptive preferences that are associated with demographics and reproductive health experiences. Adolescent and young women's use of contraceptive methods that matched their preferences may improve satisfaction and engagement in care.

Racial/Ethnic Differences in Young Women's Health-Promoting Strategies to Reduce Vulnerability to Sexually Transmitted Infections.

PURPOSE: Young women of color in the United States are disproportionately affected by sexually transmitted infections (STIs). We characterize the protective behaviors used by young women to reduce their vulnerability to STI acquisition and examine how STI prevention strategies differ by race/ethnicity. METHODS: From 2015 to 2016, women aged 13-24 years presenting to five Northern California family planning clinics were surveyed about their STI prevention strategies. The chi-squared tests and multivariable logistic regression identified associations between race/ethnicity and use of sexual health-promoting strategies. RESULTS: Among 790 women, the most common strategies included condom use (67%), asking partners about STIs (47%), limiting sexual partners (35%), frequent STI screening (35%), and asking partners about other sexual partners (33%). Black, Hispanic, and Asian women had decreased odds of utilizing strategies before intercourse compared with white women (adjusted odds ratio [aOR]black: .25, confidence interval [.14-.47]; aORHispanic: .36, CI [.20-.65]; aORAsian: .44, CI [.23-.84]). Black women had decreased odds of using strategies requiring partner involvement (aORblack: .35, CI [.13-.92]). White women were more likely to report that providers discussed condoms (aOR: 2.53, CI [1.04-6.15]) and talked to partners about STIs (aOR: 2.56, CI [1.52-4.32]) compared with nonwhite women. Black and Hispanic women were more likely to feel very uncomfortable discussing lifetime sexual partners (aORblack: 4.26, CI [1.36-13.30] and aORHispanic: 5.35, CI [1.79-15.99]) and condom use (aORblack: 3.05, CI [1.14-8.15] and aORHispanic: 2.86, CI [1.11-7.35]) with providers. CONCLUSIONS: Young women use diverse strategies to prevent STIs that vary by race/ethnicity. Providers can use these findings to improve sexual health counseling and promote equitable education and services.

Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.

PURPOSE: Although many transgender men may be able to conceive, their reproductive health needs are understudied. METHODS: We retrospectively reviewed charts of transgender men presenting to a clinic for sex workers to describe the proportion at risk for pregnancy, pregnancy intentions, and contraceptive use. RESULTS: Of 26 transgender men identified, half were at risk for pregnancy. Most desired to avoid pregnancy but used only condoms or no contraception. Two individuals desired pregnancy, were taking testosterone (a teratogen), and not using contraception. CONCLUSION: Further research is needed to explore how to best provide family planning services including preconception and contraception care to transgender men.