Economic Evaluation of Prenatal and Postpartum Care in Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review.

OBJECTIVES: This study aimed to summarize evidence on the economic outcomes of prenatal and postpartum interventions for the management of gestational diabetes mellitus and hypertensive disorders of pregnancy (HDP), assess the quality of each study, and identify research gaps that may inform future research. METHODS: Electronic databases including PubMed/MEDLINE, Embase, the Cochrane Library, and Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to October 1, 2021. Selected studies were included in narrative synthesis and extracted data were presented in narrative and tabular forms. The quality of each study was assessed using the Consolidated Health Economic Evaluation Reporting Standards and Consensus on Health Economic Criteria list. RESULTS: Among the 22 studies identified through the systematic review, 19 reported favorable cost-effectiveness of the intervention. For prenatal management of HDP, home blood pressure monitoring was found to be cost-effective compared with in-person visits in improving maternal and neonatal outcomes. For postpartum care, regular screening for hypertension or metabolic syndrome followed by subsequent treatment was found to be cost-effective compared with no screening in women with a history of gestational diabetes mellitus or HDP. CONCLUSIONS: Existing economic evaluation studies showed that prenatal home blood pressure monitoring and postpartum screening for hypertension or metabolic syndrome were cost-effective. Nevertheless, limitations in the approach of the current economic evaluations may dampen the quality of the evidence and warrant further investigation.

Evaluating unplanned readmission and prolonged length of stay following minimally invasive surgery for endometrial cancer.

OBJECTIVE: To evaluate risk factors for 30-day unplanned readmission and increased length of stay (LOS) following minimally invasive surgery (MIS) for endometrial cancer. METHODS: This was a retrospective, case-control study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Multivariable logistic regression was used to assess perioperative variables associated with readmission and increased LOS after MIS for endometrial cancer. RESULTS: The study population included 10,840 patients who met the criteria of having undergone MIS with a resultant endometrial malignancy confirmed on postoperative pathology. Common reasons for readmission included organ/space surgical site infection (65 cases), sepsis/septic shock (19 cases), and venous thromboembolism (20 cases). Notable risk factors for readmission included (Odds Ratio, Confidence Interval, p-value): dialysis dependence (6.77, 2.51-17.80, <0.01), increased length of stay (3.00, 2.10-4.10, <0.01), and preoperative weight loss (2.80, 1.06-7.17, 0.03); notable risk factors for increased LOS: ascites (8.51, 2.00-36.33, <0.01), operation duration >5 h (6.93, 5.29-9.25, <0.01), and preoperative blood transfusion (5.37, 2.05-14.04, <0.01). CONCLUSIONS: Identification of risk factors for adverse postoperative outcomes is necessary to inform and improve standards of care in MIS for endometrial cancer. Using nationally reported data from the ACS NSQIP, this study identifies independent risk factors for unplanned readmission and prolonged LOS, and in doing so, highlights potential avenues for quality improvement.

Sonographically guided insertion of intrauterine device: Indications and results.

From 2011 to 2015, a total of 67 patients were referred for IUD insertion guided with transabdominal sonography (TAS). Fifty-six of the 67 patients had successful IUD insertion under TAS guidance. The clinical indications for referral included fibroids, uterine position, previous history of IUD expulsion, and limited tolerance of pelvic examination. Reasons for failed TAS-guided IUD insertion included patient discomfort, cervical stenosis, and inability to remove and replace an existing device. Ultrasound guidance could help broaden the patient population that may benefit from the therapeutic value of an IUD.

Same-Day Compared With Overnight Cervical Preparation Before Dilation and Evacuation Between 16 and 19 6/7 Weeks of Gestation: A Randomized Controlled Trial.

We performed a double-blind, placebo-controlled, randomized noninferiority trial to compare same-day osmotic dilators plus misoprostol with overnight osmotic dilators alone for cervical preparation before dilation and evacuation (D&E) between 16 0/7 and 19 6/7 weeks of gestation. The primary outcome was procedure time. The study was halted early owing to poor accrual. However, the median procedure time was 5.7 minutes in the same-day group compared with 4.2 minutes in the overnight group. The median absolute difference in procedure time was 1.5 minutes, which corresponded to a 35% increase in procedure time (relative difference 35%, one-sided 95% CI -Inf to 52%). Same-day cervical preparation with osmotic dilators plus buccal misoprostol before D&E may be a timely option. Clinical Trial Registration: ClinicalTrials.gov, NCT03002441.

Assessing the accuracy and quality of YouTube videos on early pregnancy loss.

Objective: To assess the accuracy and quality of YouTube videos pertaining to early pregnancy loss for use as a patient education tool. Methods: A cross-sectional study was conducted via YouTube search using the keywords "miscarriage," "spontaneous abortion," "pregnancy loss," and "pregnancy failure." The first 20 results for each keyword search, sorted by both relevance and view count, were compiled into a list. Descriptive characteristics, including the numbers of views, likes, dislikes, video length, and duration of upload were collected. All videos were independently evaluated by two physician researchers using two unique assessment tools. The Currency, Relevance, Authority, Accuracy, and Purpose (CRAAP) test was used to measure the reliability of video content. The Miscarriage-Specific Question Score (MSQS) criterion was used to objectively assess video content specific to miscarriage. Inter-rater agreement was analyzed via kappa coefficient and Pearson correlation. Results: 160 videos were screened, among which 74 videos were included for analysis. The mean CRAAP score was 8.3 out of a total possible score of 15, demonstrating good quality sources, though not of academic level. Mean MSQS score was 8.1 out of a total possible score of 24, demonstrating "fair" accuracy and comprehensiveness. Pearson correlations were 0.87 and 0.86 for CRAAP and MSQS total scores, respectively, demonstrating excellent inter-rater reliability. Conclusion: YouTube videos related to early pregnancy loss span a wide range of quality, accuracy, and purpose. While some videos provide effective content, mean rater scores demonstrate that YouTube is not a reliable source for patient education on early pregnancy loss.

Modeling the impact of a health coaching intervention to prevent teen pregnancy.

Teenage pregnancy is an important public health issue in the United States, presenting significant health and economic risks to adolescents and the society. Health coaching is a potentially effective intervention in preventing teen pregnancy. In 2017, the Children's Hospital of Philadelphia implemented a health coaching program among sexually active teenage girls, which improved their contraceptive continuation rates. However, the cost-effectiveness of the health coaching program is not clear. We developed a microsimulation model of teen pregnancy that can predict the number of teen pregnancies and related birth outcomes. Model parameters were estimated from the literature and the health coaching program. The teen pregnancy model was used to assess how the program could influence direct health care costs and pregnancy outcomes. Our model projected that the health coaching program could prevent 15 teen pregnancies per 1000 adolescents compared to no intervention. The incremental cost-effectiveness ratio (ICER) for the intervention was $309 per pregnancy prevented, which was less than the willingness-to-pay threshold of $4,206 per pregnancy. Thus, the health coaching intervention was cost-effective. Our study provides promising data on the effectiveness and cost-effectiveness of a health coaching intervention to reduce the burden of teen pregnancies. Health practitioners should consider implementing the program for a longer term and at a larger scale.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City. STUDY DESIGN: We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only. RESULTS: The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs. CONCLUSION: Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

Contraception pathway: application for midlife women.

OBJECTIVE: To create a system where evidence based medicine can be applied to accommodate every woman's needs by designing a contraceptive pathway that can be utilized by any healthcare provider, regardless of the patient's age, and to offer appropriate counseling in order to maximize patient outcomes, especially for the midlife woman. METHODS: United States Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC) was used as the framework for these recommendations for a contraceptive care pathway that can be incorporated into care for midlife women. DISCUSSION: By utilizing a total office approach that includes the scheduler, receptionist, medical assistant, nurse and health care provider as members of a team, the entire spectrum of the patient population in need of contraception from teenagers to midlife can be captured. Specifically for midlife women the need for an effective form of contraception may be overlooked as fecundity declines in this age group. This paper will highlight the use of this pathway for midlife women.

A Case Report of Aggressive Angiomyxoma in Pregnancy: Do Hormones Play a Role?

Aggressive angiomyxoma is a rare, locally invasive tumor that generally affects the perineum and pelvis of reproductive age females. Aggressive angiomyxoma is often misdiagnosed, resulting in the delay of the treatment. Case reports show increased growth of the tumor during pregnancy, thus suggesting a hormonal dependency. We report this rare condition in a 29-year-old primigravid female with a growing mass on the right labium majus at 20 weeks' gestation. The patient also developed a smaller mass on the left labium majus at 37 weeks' gestation. The patient underwent a primary cesarean section with resection of the right labial mass, with a final diagnosis of aggressive angiomyxoma. The lesion on her left labium majus resolved spontaneously postpartum. This case report supports a hormonal involvement in this tumor.