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1.
Am J Perinatol ; 2022 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-35977711

RESUMO

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) contribute significantly to the development of severe maternal morbidities (SMM), particularly among low-income women. The purpose of the study was to explore the relationship between maternal characteristics and SMM, and to investigate if differences in SMM exist among patients with HDP diagnosis. STUDY DESIGN: This study utilized 2017 Alabama Medicaid administrative claims. SMM diagnoses were captured using the Centers for Disease Control and Prevention's classification by International Classification of Diseases codes. Maternal characteristics and frequencies were compared using Chi-square and Cramer's V statistics. Logistic regression analyses were conducted to examine multivariable relationships between maternal characteristics and SMM among patients with HDP diagnosis. Odds ratios and 95% confidence intervals (CIs) were used to estimate risk. RESULTS: A higher proportion of patients experiencing SMM were >34 years old, Black, Medicaid for Low-Income Families eligible, lived in a county with greater Medicaid enrollment, and entered prenatal care (PNC) in the first trimester compared with those without SMM. Almost half of patients (46.2%) with SMM had a HDP diagnosis. After controlling for maternal characteristics, HDP, maternal age, county Medicaid enrollment, and trimester PNC entry were not associated with SMM risk. However, Black patients with HDP were at increased risk for SMM compared with White patients with HDP when other factors were taken into account (adjusted odds ratio [aOR] = 1.37, 95% CI: 1.11-1.69). Patients with HDP and SMM were more likely to have a prenatal hospitalization (aOR = 1.45, 95% CI: 1.20-1.76), emergency visit (aOR = 1.30, 95% CI: 1.07-1.57), and postpartum cardiovascular prescription (aOR = 2.43, 95% CI: 1.95-3.04). CONCLUSION: Rates of SMM differed by age, race, Medicaid income eligibility, and county Medicaid enrollment but were highest among patients with clinical comorbidities, especially HDP. However, among patients with HDP, Black patients had an elevated risk of severe morbidity even after controlling for other characteristics. KEY POINTS: · Patients with SMM were more likely to have a HDP diagnosis.. · Among those with HDP, Black patients had elevated risk of SMM.. · Differences in care delivery did not explain SMM disparities..

2.
Am J Perinatol ; 39(1): 106-112, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-32682328

RESUMO

OBJECTIVE: The study aimed to test the hypothesis that higher Edinburgh Postnatal Depression Scale (EPDS) scores are associated with increased pain scores and opioid use during postpartum hospitalization following cesarean section. STUDY DESIGN: We conducted a retrospective cohort of English or Spanish-speaking women ≥18 years who had prenatal care for a singleton gestation and delivered by cesarean at ≥36 weeks within a tertiary center during 2017. Exclusions included women with fetal anomalies, intrauterine fetal demise, sickle cell disease, previously diagnosed pain disorders (e.g., chronic pain or fibromyalgia), substance use disorder (based on documented prescription or use of methadone or buprenorphine), or reoperation during hospital stay. Women without an EPDS recorded antenatally were also excluded. Major depressive symptoms (MDS) were defined as a documented antenatal EPDS ≥12. Women with and without MDS were compared, and multivariable linear regression models were generated to evaluate associations between MDS status and both pain scores and opioid use. RESULTS: Of the 891 women meeting other inclusion criteria, 676 (76%) had documented antenatal EPDS scores, and 104 (15.4%) of those had MDS. Women with MDS were more likely to be use tobacco and have general anesthesia for cesarean delivery, but groups were otherwise similar. Women with MDS reported higher daily and average pain scores postpartum (2.4 vs. 1.7 average; p < 0.001). Women with MDS used more morphine milligram equivalents (MME) each day during their postpartum hospitalization, leading to a higher total MME use (121 mg [60.5-214.5] vs. 75 mg [28.5-133.5], p < 0.001). CONCLUSION: We found an association between antepartum depressive symptoms and acute pain after cesarean delivery leading to increased opioid use. Given the current focus on opioid stewardship, further research into this association, exploration of tailored pain control, and determining whether treatment of antepartum MDS reduces postpartum pain, and therefore opioid use, will be of the utmost priority. KEY POINTS: · Women with MDS report higher pain scores postcesarean.. · Women with MDS use more opioids postcesarean.. · Future studies are needed for the treatment of MDS..


Assuntos
Dor Aguda/psicologia , Analgésicos Opioides/uso terapêutico , Cesárea/efeitos adversos , Transtorno Depressivo Maior/complicações , Dor Pós-Operatória/tratamento farmacológico , Complicações na Gravidez , Gravidez/psicologia , Dor Aguda/tratamento farmacológico , Dor Aguda/etiologia , Adulto , Estudos de Casos e Controles , Transtorno Depressivo Maior/tratamento farmacológico , Feminino , Humanos , Modelos Lineares , Análise Multivariada , Manejo da Dor , Dor Pós-Operatória/prevenção & controle , Estudos Retrospectivos
3.
Am J Perinatol ; 39(1): 45-53, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-32674202

RESUMO

OBJECTIVE: This study aimed to determine the feasibility and effectiveness of Diabetes Group Prenatal Care to increase patient engagement in diabetes self-care activities. STUDY DESIGN: A pilot randomized controlled trial was conducted at two sites. Inclusion criteria were English or Spanish speaking, type 2 or gestational diabetes, 22 to 34 weeks of gestational age at first study visit, ability to attend group care at specified times, and willingness to be randomized. Exclusion criteria included type 1 diabetes, multiple gestation, major fetal anomaly, serious medical comorbidity, and serious psychiatric illness. Women were randomized to Diabetes Group Prenatal Care or individual prenatal care. The primary outcome was completion of diabetes self-care activities, including diet, exercise, blood sugar testing, and medication adherence. Secondary outcomes included antenatal care characteristics, and maternal, neonatal, and diabetes management outcomes. Analysis followed the intention-to-treat principle. RESULTS: Of 159 eligible women, 84 (53%) consented to participate in the study and were randomized to group (n = 42) or individual (n = 42) prenatal care. Demographic characteristics were similar between study arms. Completion of diabetes self-care activities was similar overall, but women in group care ate the recommended amount of fruits and vegetables on more days per week (5.1 days/week ± 2.0 standard deviation [SD] in group care vs. 3.4 days ± 2.6 SD in individual care; p < 0.01) and gained less weight per week during the study period (0.2 lbs/week [interquartile range: 0-0.7] vs. 0.5 lbs/week [interquartile range: 0.2-0.9]; p = 0.03) than women in individual care. Women with gestational diabetes randomized to group care were 3.5 times more likely to have postpartum glucose tolerance testing than those in individual care (70 vs. 21%; relative risk: 3.5; 95% confidence interval: 1.4-8.8). Other maternal, neonatal, and pregnancy outcomes were similar between study arms. CONCLUSION: Diabetes group care is feasible and shows promise for decreasing gestational weight gain, improving diet, and increasing postpartum diabetes testing among women with pregnancies complicated by diabetes. KEY POINTS: · Women with gestational diabetes in group care were 3.5 times more likely to return for postpartum glucose tolerance testing.. · Women with gestational diabetes in group care had less gestational weight gain during the study period.. · Diabetes Group Prenatal Care is a promising intervention to improve outcomes for women with diabetes in pregnancy..


Assuntos
Diabetes Mellitus Tipo 2/terapia , Diabetes Gestacional/terapia , Gravidez em Diabéticas/terapia , Cuidado Pré-Natal/métodos , Autocuidado , Adulto , Feminino , Ganho de Peso na Gestação , Teste de Tolerância a Glucose , Processos Grupais , Humanos , Projetos Piloto , Gravidez
4.
Fam Process ; 61(3): 1134-1143, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35146754

RESUMO

The field of relationship science has called for more research on the impact of relationship education on child outcomes, yet studies in this area remain sparse, particularly regarding maternal and infant health at birth. Research on group prenatal care demonstrates that individual-oriented group interventions have a positive impact on infant birth outcomes, suggesting the need to consider the impacts of other forms of group programming for women. The current study examined the impact of MotherWise, an individual-oriented relationship education and brief case management/coaching program for minority and low-income pregnant women, on birth outcomes. The study sample included 136 women who enrolled in a larger randomized controlled trial of MotherWise during early pregnancy. Although statistical power was limited due to the sample size and the effects were not outright significant at p < 0.05, results indicated that the effects of MotherWise on birth outcomes were small to moderate in size (0.23 for birthweight, 0.46 for preterm birth) and suggest important avenues for future tests of relationship education programs and their impacts on maternal and infant health. The current study suggests that relationship education during pregnancy could directly impact women's and infant's health.


Assuntos
Escolaridade , Cuidado Pré-Natal , Feminino , Humanos , Lactente , Recém-Nascido , Gravidez , Nascimento Prematuro , Cuidado Pré-Natal/métodos
5.
Am J Obstet Gynecol ; 224(4): 359-361, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33306974

RESUMO

Health inequities are not caused by personal failings or shortcomings within disadvantaged groups, which can be erased with behavioral interventions. The scope of the problem is much greater and will only fully be addressed with the examination of the systems, structures, and policies that perpetuate racism, classism, and an economic, class, race, or gender divide between patients and the people who care for them. Solution-oriented strategies to achieve health equity will remain elusive if researchers continue to focus on behavior modification in patients while failing to do harder work that includes focusing on the institutions, community, and societal contexts in which pregnant women are living; addressing social determinants of health; considering racism in study design, analysis, and reporting; valuing the voices of patients, practitioners, and researchers from historically disadvantaged groups; disseminating research findings back to the community; and developing policy and reimbursement structures to support care delivery change that advances equitable outcomes. A case study shows us how group prenatal care may be one viable vehicle through which to affect this change. Group prenatal care is one of the few interventions shown to improve pregnancy outcomes for black women. Studies of group prenatal care have predominantly focused on the patient, but here we propose that the intervention may exert its greatest impact on clinicians and the systems in which they work. The underlying mechanism through which group prenatal care works may be through increased quantity and quality of patient and practitioner time together and communication. We hypothesize that this, in turn, fosters greater opportunity for cross-cultural exposure and decreases clinician implicit bias, explicit bias, and racism, thus increasing the likelihood that practitioners advocate for systems-level changes that directly benefit patients and improve perinatal outcomes.


Assuntos
Equidade em Saúde , Disparidades nos Níveis de Saúde , Assistência Perinatal , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Estudos de Casos Organizacionais , Gravidez
6.
Clin Obstet Gynecol ; 64(1): 174-184, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33346597

RESUMO

Group prenatal care is a health care delivery model that utilizes shared medical appointments to place greater focus on patient education, mutual support, and increased time with the clinician to promote a healthy pregnancy. Several studies suggest that medically low-risk women participating in group prenatal care have improved pregnancy outcomes, but the same tenants can likely be used to help women with diabetes and obesity achieve healthy outcomes during pregnancy and throughout their life course. This chapter will review the background, care model, and evidence regarding group medical visits for pregnant women with diabetes and obesity.


Assuntos
Complicações na Gravidez , Cuidado Pré-Natal , Feminino , Humanos , Obesidade/terapia , Gravidez , Resultado da Gravidez
7.
Am J Perinatol ; 38(S 01): e71-e76, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-32126581

RESUMO

OBJECTIVE: This study aimed to assess whether patient satisfaction differs between women beginning cervical ripening in the outpatient versus inpatient setting. STUDY DESIGN: We performed a planned secondary analysis evaluating patient satisfaction randomized to outpatient versus inpatient cervical ripening. In the original randomized controlled trial, low-risk parous women ≥39 weeks who required cervical ripening for induction and had reassuring fetal heart rate monitoring were included and randomized to inpatient versus outpatient ripening with a transcervical Foley's catheter. All women were then admitted to the labor ward on the following day. Patient satisfaction was evaluated using three separate surveys. The first two surveys, Six Simple Questions and Lady-X, were previously validated. The third survey used visual analog scales to assess overall pain experienced during Foley's placement, overall pain experienced during labor, how likely they would be to choose the same type of care for their next pregnancy, and how likely they would be to recommend their method of cervical ripening to friends/family. RESULTS: From May 2016 to October 2017, 129 women were randomized (outpatient, 65; inpatient, 64). Based on survey results, there was no difference in satisfaction between outpatient and inpatient cervical ripening with transcervical Foley's catheterization, with high satisfaction in both groups. Patients in both the outpatient and inpatient groups would choose the same type of care for their next pregnancy (on a scale of 1-7, median (25th-75th percentile): 7 [7-7] vs. 7 [6-7], respectively, p = 0.75) and would be very likely to recommend their method of induction to a friend or family member (on a scale of 0-100, 99 [80-100] vs. 99 [65-100], respectively, p = 0.60). CONCLUSION: Parous women's satisfaction does not differ between inpatient and outpatient cervical ripening with transcervical Foley's catheterization. KEY POINTS: · Outpatient cervical ripening may allow providers to incorporate the benefits of electively inducing women as well as decrease the time spent in the labor and delivery unit.. · Parous women's satisfaction does not differ between inpatient and outpatient cervical ripening with transcervical Foley.. · Additional prospective evaluation is warranted to further characterize patient preferences in relation to the location of cervical ripening..


Assuntos
Assistência Ambulatorial , Maturidade Cervical , Satisfação do Paciente , Adulto , Feminino , Humanos , Pacientes Internados , Trabalho de Parto Induzido/métodos , Pacientes Ambulatoriais , Paridade , Gravidez , Cateterismo Urinário
8.
Arch Womens Ment Health ; 23(4): 565-572, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31720790

RESUMO

Bipolar disorder (BD) during pregnancy is known to be a morbid condition associated with poor outcomes for both the mother and her infant. We aimed to determine if women with BD and their children have higher charges and health service utilization than mother-infant dyads with and without other mental health (MH) diagnoses. The International Classification of Diseases, Ninth Revision (ICD9) codes were used to identify mutually exclusive groups of women who gave birth between January 1, 2011, and December 31, 2012, coding first for BD, then diagnoses that comprised an "other MH diagnoses group" that included post-traumatic stress disorder, anxiety, and depression. Health service utilization and related charges were obtained for the dyad for delivery and for 2 years post-delivery at a single tertiary care center. Analyses included 4440 dyads. A BD diagnosis occurred in 1.8% of medical record codes, other MH diagnoses in 10%, and no known MH diagnosis in 88%. Compared with women with both other MH and no known MH diagnoses, women with BD had higher delivery charges (p < 0.001), higher cumulative charges in the 2 years postpartum (p < 0.001), higher preterm birth and low birthweight rates (15.5% v. 6.9% and 20.8% v. 6.4%, p < 0.001, BD v. no known MH, respectively), and greater utilization of inpatient and emergency psychiatric care services (p < 0.001). Compared with women with and without other mental health diagnoses, women with BD have the highest care utilization and charges. They also have higher preterm birth and low birthweight infant rates, two clinically relevant predictors of long-term health for the child. Given the low prevalence of BD and severity of the disease versus the magnitude of systems costs, women with BD, and their children, deserve the heightened attention afforded to other high-risk perinatal conditions.


Assuntos
Transtorno Bipolar/economia , Honorários e Preços/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Criança , Estudos de Coortes , Colorado , Feminino , Humanos , Lactente , Recém-Nascido , Parto , Período Pós-Parto , Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos
9.
Matern Child Health J ; 24(12): 1429-1437, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32997229

RESUMO

OBJECTIVES: Most research evaluating relationships between social network attributes and loneliness have focused on older adult and adolescent networks. The present study examines the relationships between social network size (number of relationships), social network density (whether named relationships are connected to one another) and maternal loneliness during pregnancy. METHODS: Eligible women were enrolled at the time of their dating ultrasound (between 8 and 12 weeks of gestation). Interested women provided written consent and completed demographic, social network and loneliness measures. Participants completed the same surveys in their third trimester. Mixed-regression models, adjusted for age, race, ethnicity, and insurance type, were used to assess the relationship between social network size, network density, and loneliness. RESULTS: A total of 94 pregnant women (mean age = 23.77, 70.2% Black, 87.2% public insurance) completed baseline study measures, and 60 participants completed both assessment time points. Completers and non-completers did not differ on key characteristics. Social network density, but not social network size, predicted maternal loneliness ([Formula: see text]= - 1.27, 95% CI - 2.53, - 0.01, p = 0.0489) in the first and third trimester. CONCLUSIONS: These findings indicate that pregnant women's social network density may be more intimately related to feelings of loneliness than the objective number of relationships. This knowledge can begin to inform the design of supportive approaches to improve women's health.


Assuntos
Negro ou Afro-Americano/psicologia , Solidão/psicologia , Gestantes/psicologia , Isolamento Social/psicologia , Rede Social , Cônjuges/psicologia , Adolescente , Adulto , Alabama , Feminino , Humanos , Masculino , Gravidez , Gestantes/etnologia , Apoio Social , Saúde da Mulher , Adulto Jovem
10.
Am J Obstet Gynecol ; 216(6): 552-556, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28189608

RESUMO

Patients participating in group prenatal care gather together with women of similar gestational ages and 2 providers who cofacilitate an educational session after a brief medical assessment. The model was first described in the 1990s by a midwife for low-risk patients and is now practiced by midwives and physicians for both low-risk patients and some high-risk patients, such as those with diabetes. The majority of literature on group prenatal care uses CenteringPregnancy, the most popular model. The first randomized controlled trial of CenteringPregnancy showed that it reduced the risk of preterm birth in low-risk women. However, recent meta-analyses have shown similar rates of preterm birth, low birthweight, and neonatal intensive care unit admission between women participating in group prenatal care and individual prenatal care. There may be subgroups, such as African Americans, who benefit from this type of prenatal care with significantly lower rates of preterm birth. Group prenatal care seems to result in increased patient satisfaction and knowledge and use of postpartum family planning as well as improved weight gain parameters. The literature is inconclusive regarding breast-feeding, stress, depression, and positive health behaviors, although it is theorized that group prenatal care positively affects these outcomes. It is unclear whether group prenatal care results in cost savings, although it may in large-volume practices if each group consists of approximately 8-10 women. Group prenatal care requires a significant paradigm shift. It can be difficult to implement and sustain. More randomized trials are needed to ascertain the true benefits of the model, best practices for implementation, and subgroups who may benefit most from this innovative way to provide prenatal care. In short, group prenatal care is an innovative and promising model with comparable pregnancy outcomes to individual prenatal care in the general population and improved outcomes in some demographic groups.


Assuntos
Educação de Pacientes como Assunto/métodos , Cuidado Pré-Natal/métodos , Adolescente , Serviços de Planejamento Familiar , Feminino , Idade Gestacional , Nível de Saúde , Humanos , Recém-Nascido de Baixo Peso , Terapia Intensiva Neonatal/estatística & dados numéricos , Tocologia , Militares , Grupos Minoritários , Obstetrícia/métodos , Médicos , Período Pós-Parto , Gravidez , Resultado da Gravidez , Gravidez na Adolescência , Nascimento Prematuro/epidemiologia , Fatores de Risco
11.
Am J Obstet Gynecol ; 216(1): 69.e1-69.e7, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27687213

RESUMO

BACKGROUND: Many young and middle-aged women receive their primary health care from their obstetrician-gynecologists. A recent change to vaccination recommendations during pregnancy has forced the integration of new clinical processes at obstetrician-gynecology practices. Evidence-based best practices for vaccination delivery include the establishment of vaccination standing orders. OBJECTIVES: As part of an intervention to increase adoption of evidence-based vaccination strategies for women in safety-net and private obstetrician-gynecology settings, we conducted a qualitative study to identify the facilitators and barriers experienced by obstetrician-gynecology sites when establishing vaccination standing orders. STUDY DESIGN: At 6 safety-net and private obstetrician-gynecology practices, 51 semistructured interviews were completed by trained qualitative researchers over 2 years with clinical staff and vaccination program personnel. Standardized qualitative research methods were used during data collection and team-based data analysis to identify major themes and subthemes within the interview data. RESULTS: All study practices achieved partial to full implementation of vaccine standing orders for human papillomavirus, tetanus diphtheria pertussis, and influenza vaccines. Facilitating factors for vaccine standing order adoption included process standardization, acceptance of a continual modification process, and staff training. Barriers to vaccine standing order adoption included practice- and staff-level competing demands, pregnant women's preference for medical providers to discuss vaccine information with them, and staff hesitation in determining HPV vaccine eligibility. CONCLUSIONS: With guidance and commitment to integration of new processes, obstetrician-gynecology practices are able to establish vaccine standing orders for pregnant and nonpregnant women. Attention to certain process barriers can aid the adoption of processes to support the delivery of vaccinations in obstetrician-gynecology practice setting, and provide access to preventive health care for many women.


Assuntos
Atitude do Pessoal de Saúde , Ginecologia , Obstetrícia , Cuidado Pré-Natal , Prescrições Permanentes , Vacinação , Pessoal Administrativo , Pessoal Técnico de Saúde , Difteria/prevenção & controle , Vacinas contra Difteria, Tétano e Coqueluche Acelular/uso terapêutico , Feminino , Humanos , Vacinas contra Influenza/uso terapêutico , Influenza Humana/prevenção & controle , Enfermeiras e Enfermeiros , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/uso terapêutico , Preferência do Paciente , Diretores Médicos , Gravidez , Pesquisa Qualitativa , Tétano/prevenção & controle , Coqueluche/prevenção & controle
12.
J Reprod Med ; 62(1-2): 3-8, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29999273

RESUMO

OBJECTIVE: To examine women�s perceptions of their obstetrician/gynecologist (ob-gyn) as primary care provider (PCP) and comfort in receiving primary care services in an ob-gyn setting. STUDY DESIGN: Survey regarding women�s use of their ob-gyn provider as a PCP, their desire and comfort in receiving primary care services from them, and their perceptions of their ob-gyn�s delivery of primary care. Associations were assessed between use of an ob-gyn as PCP and various demographic and attitudinal factors, as well as patients� perceptions of primary care performance RESULTS: The response rate was 48% (1,404/2,916). Overall, the majority of participants responded that routine primary care services are available at their ob-gyn office and that they were comfortable receiving those services from their ob-gyn. Twenty percent of respondents considered their ob-gyn as their PCP, 52% considered another provider their PCP, and 28% of women did not identify a PCP. Women who were pregnant, mothers of newborns, and patients without a chronic health condition were more likely to identify their ob-gyn as their PCP. CONCLUSION: A substantial proportion of women consider their ob-gyn their primary care provider and do not visit another provider regularly. While ob-gyns may not consider themselves as PCPs, they are often perceived as such by patients.


Assuntos
Ginecologia , Obstetrícia , Preferência do Paciente , Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Demografia , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Inquéritos e Questionários , Adulto Jovem
13.
J Low Genit Tract Dis ; 21(1): 64-66, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27906805

RESUMO

OBJECTIVE: The aim of the study was to identify factors associated with the presence of high-grade squamous intraepithelial lesion (HSIL) at surgical margins of loop electrosurgical excision procedure (LEEP) pathology specimens. MATERIALS AND METHODS: All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for all women who had a LEEP performed for indications within contemporary American Society of Colposcopy and Cervical Pathology guidelines between April 1, 2013, and April 30, 2015. Factors extracted from the database included demographics, contraception, weight, tobacco use, provider volume, resident participation, history of cervical procedure, and pathology features including preceding Pap test category. A positive margin was defined as HSIL on either the endocervical or ectocervical margin of the LEEP specimen or in endocervical curettage specimen after LEEP. We performed univariable statistics to identify factors associated with positive margins and then logistic regression modeling on significant factors for the outcome of positive margins. RESULTS: Two hundred sixty-nine women were identified. Seventy five (27.8%) of these women had positive margins. Only tobacco use, gravity, parity, and preceding Pap category were significant on univariable analysis. After multivariable analysis, smokers remained more likely to have positive margins (odds ratio = 2.01; CI = 1.12-3.6; p < .01) as did those with preceding HSIL Pap tests (odds ratio = 1.96; CI = 1.13-3.41; p < .01). CONCLUSIONS: In our population, of all the factors assessed, only tobacco use and preceding high-grade Pap tests were associated with positive margins at time of LEEP. This information may be helpful in preprocedural planning to optimize treatment.


Assuntos
Curetagem , Eletrocirurgia , Lesões Intraepiteliais Escamosas Cervicais/diagnóstico , Lesões Intraepiteliais Escamosas Cervicais/cirurgia , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/cirurgia , Adulto , Idoso , Feminino , Histocitoquímica , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
14.
J Low Genit Tract Dis ; 21(4): 258-260, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28953115

RESUMO

OBJECTIVE: The aim of the study was to determine the frequency that endometrial biopsies (EMBs) performed on postmenopausal (PMP) women with benign endometrial cells (BECs) on Pap test are adequate for assessing malignancy or hyperplasia. METHODS: This is a case series including all PMP women older than 55 years at a single academic institution between January 2008 and September 2015 with a Pap test result including BEC. Patients were identified via an internal cytology database. Patient data, the ability to obtain an EMB, and the result of the EMB were collected. An adequate EMB was defined as the presence of glands and stroma sufficient to assess for endometrial hyperplasia and/or malignancy. Descriptive statistics were performed, and then univariable and logistic regression analyses were used to evaluate associations of patient factors and adequacy of EMB. RESULTS: One hundred sixteen women met inclusion criteria. One hundred seven had an EMB scheduled (92%) and of those 91 EMBs were obtained (85%). Of the obtained biopsies, 63 were inadequate to rule out the diagnosis of hyperplasia and/or malignancy (69%). Of these, 19 patients underwent pelvic ultrasound (30%), 12 followed up with repeat Pap test (19%), and 4 underwent dilation and curettage (6%). Of the adequate biopsies, 5 had a diagnosis of hyperplasia (18%) and 5 with malignancy (18%). CONCLUSIONS: In PMP women with BEC on Pap test, adequate EMB was only obtained in 31% of patients. Most patients without an adequate biopsy had no further workup of their abnormal Pap test.


Assuntos
Biópsia/métodos , Neoplasias do Endométrio/diagnóstico , Neoplasias/diagnóstico , Pós-Menopausa , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Teste de Papanicolaou
17.
Am J Obstet Gynecol ; 214(5): 617.e1-7, 2016 05.
Artigo em Inglês | MEDLINE | ID: mdl-26627727

RESUMO

BACKGROUND: There is increasing attention on immunizations by obstetrician-gynecologists and a need to improve vaccination rates for all women. OBJECTIVE: To evaluate the effect of a multimodal intervention on rates of immunization with tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza in outpatient obstetrics and gynecology clinics. STUDY DESIGN: Immunization rates at 2 clinics were compared pre- and post-implementation of multiple interventions at a public integrated health-care system. Study interventions began on June 6, 2012 and concluded on May 31, 2014; the preimplementation time period used was June 6, 2010 to June 5, 2012. Interventions included stocking of immunizations in clinics, revision and expansion of standing orders, creation of a reminder/recall program, identification of an immunization champion to give direct provider feedback, expansion of a payment assistance program, and staff education. All women aged 15 and older who made a clinic visit during influenza season were included in the influenza cohort; women who delivered an infant during the study time period and had at least 1 prenatal visit within 9 months preceding delivery were included in the Tdap cohort; each clinic visit by a nonpregnant woman aged 15-26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series. The primary outcome was receipt of influenza and Tdap vaccine per current American College of Obstetricians and Gynecologists guidelines and receipt of HPV vaccine during eligible visits. Influenza and Tdap were assessed with overall coverage rates at the institutional level, and HPV was assessed at the visit level by captured opportunities. All analyses included generalized estimating equations and the primary outcome was assessed with time as a covariate in all models. RESULTS: A total of 19,409 observations were included in the influenza cohort (10,231 pre- and 9178 post-intervention), 2741 in the Tdap cohort (1248 pre- and 1493 post-intervention), and 12,443 in the HPV cohort (7966 pre- and 4477 post-intervention). Our population was largely Hispanic, English-speaking, and publicly insured. The rate of influenza vaccination increased from 35.4% pre-intervention to 46.0% post-intervention (P < .001). The overall rate for Tdap vaccination increased from 87.6% pre-intervention to 94.5% post-intervention until the recommendation to vaccinate during each pregnancy was implemented (z = 4.58, P < .0001). The average Tdap up-to-date rate after that recommendation was 75.0% (z = -5.77, P < .0001). The overall rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention. CONCLUSION: Using evidence-based practices largely established in other settings, our intervention was associated with increased rates of influenza, Tdap, and HPV vaccination in outpatient underserved obstetrics and gynecology clinics. Integrating such evidence-based practices into routine obstetrics and gynecology care could positively impact preventive health for many women.


Assuntos
Promoção da Saúde/organização & administração , Vacinação/estatística & dados numéricos , Adulto , Instituições de Assistência Ambulatorial , Colorado , Toxoide Diftérico , Prática Clínica Baseada em Evidências , Feminino , Ginecologia , Humanos , Vacinas contra Influenza , Obstetrícia , Vacinas contra Papillomavirus , Vacina contra Coqueluche , Toxoide Tetânico , Adulto Jovem
18.
J Low Genit Tract Dis ; 20(4): 296-9, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27518843

RESUMO

OBJECTIVE: To evaluate agreement between an abnormal endocervical brush (ECB) collected at the time of colposcopy and subsequent endocervical curettage (ECC). METHODS: All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for those who had a colposcopic exam with ECB between April 1, 2013, and June 15, 2015, and who subsequently returned for an ECC to further evaluate eligibility for expectant management or ablative therapy. ECB and ECC results were divided into 2 groups: "low-grade" included low-grade squamous intraepithelial lesions (LSIL) or atypical squamous cells of undetermined significance, and "high-grade" included high-grade squamous intraepithelial lesions (HSIL) or atypical squamous cells-cannot exclude high-grade. Women with atypical glandular cells and unsatisfactory ECB results were excluded. Percent agreement between ECB and ECC was calculated based on these categories. RESULTS: Seventy-nine women were included: 54 (68%) had a low-grade ECB, and 25 (32%) had a high-grade ECB. Of those who had a low-grade ECB, 4 had a low-grade ECC, 3 had a high-grade ECC, and 47 were negative, resulting in an agreement of 7.4% (4/54). Of those who had a high-grade ECB, 1 had a low-grade ECC, 4 had a high-grade ECC, and 20 were negative, resulting in 16% (4/25) agreement. CONCLUSIONS: Our data suggest that there is poor agreement between ECC and ECB in our patient population.


Assuntos
Colo do Útero/patologia , Patologia Clínica/métodos , Manejo de Espécimes/métodos , Neoplasias do Colo do Útero/diagnóstico , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos
19.
J Low Genit Tract Dis ; 20(1): 44-6, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26461230

RESUMO

OBJECTIVE: The aim of the study was to evaluate the rate of patient adherence to provider recommendations for biopsy proven cervical intraepithelial neoplasia (CIN) 2 or 3 in an academic safety-net hospital. MATERIALS AND METHODS: This is a case series of patients with biopsy-proven CIN 2 or 3 identified via pathology records between January 1, 2008 to December 31, 2012 at a single academic safety-net hospital. Patients with human immunodeficiency virus, lupus, or pregnancy were excluded. Patient demographics, recommended management, and patient adherence were extracted from the patient chart. Complete adherence was defined as completion of follow-up recommendations within 6 months of the recommended follow-up date. The primary outcome was rate of complete adherence to management recommendations. Descriptive statistics, univariate analysis, and multivariable logistic regression were performed. RESULTS: Six hundred eighty-four patients met inclusion and exclusion criteria. The complete adherence rate was 89% (n = 606). In multivariable analyses, those who completed follow-up were older (mean = 31 vs 29 years; p = .031), more likely to use a long-acting reversible contraceptive or sterilization for contraception (92% vs 87%; p = .036) and more likely to have been recommended excision (90% vs 83%; p = .009). In multivariable analysis, using a long-acting reversible contraceptive or sterilization (odds ratio = 1.75; CI = 1.02-3.0) and the recommendation of any kind of treatment as opposed to expectant management (odds ratio = 3.89; CI = 1.96-7.70) remained significantly associated with complete follow-up. CONCLUSIONS: Patients were overall highly adherent to management recommendations when diagnosed with CIN 2 or 3. Those patients recommended to undergo treatment as opposed to observation were more likely to follow up.


Assuntos
Adesão à Medicação , Displasia do Colo do Útero/diagnóstico , Displasia do Colo do Útero/terapia , Adolescente , Adulto , Idoso , Feminino , Hospitais Universitários , Humanos , Pessoa de Meia-Idade , Adulto Jovem
20.
J Low Genit Tract Dis ; 19(4): 329-32, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26247258

RESUMO

OBJECTIVE: To describe the outcomes of women with high-grade cervical cytology in pregnancy and to identify factors that predict completion of appropriate postpartum follow-up. METHODS: We describe a case series of all patients with high-grade cervical cytology collected during pregnancy between 2007 and 2011 at a single institution. Patients were considered adherent with follow-up if they received any kind of postpartum evaluation or treatment for their cervical dysplasia at our institution within 9 months of delivery. RESULTS: Of 138 women with high-grade cervical cytology in pregnancy, 87 (63%) had high-grade squamous intraepithelial lesion, 47 (34%) had atypical squamous cells that cannot rule out high-grade (ASC-H), and 4 (3%) had atypical glandular cells (AGC). Most patients (81%) underwent colposcopy during pregnancy. A total of 48 patients (43%) had biopsies performed, 26 (54%) were CIN 2 or 3, and one (2%) was adenocarcinoma in situ (AIS). A total of 97 (70%) of 138 patients completed recommended postpartum follow-up, resulting in the detection of one additional case of AIS and one case of invasive adenocarcinoma. Hispanic ethnicity (odds ratio [OR], 3.6; confidence interval [CI], 1.4-9.1), being married (OR, 4.5; CI, 1.6-12.4), being employed (OR, 3.7; CI, 1.3-10.5), and CIN2 or 3 on antenatal biopsy (OR, 9.8; CI, 2.0-47.9) were all significantly associated with completion of postpartum follow-up. CONCLUSION: Colposcopy during pregnancy resulted in the detection of one case of AIS. Postpartum evaluation and treatment detected an additional case of AIS as well as one case of invasive cervical adenocarcinoma. Whereas certain demographic characteristics were associated with completion of recommended follow-up, the strongest association is with a high-grade biopsy during pregnancy.


Assuntos
Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Adesão à Medicação , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/patologia , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/patologia , Adolescente , Adulto , Feminino , Humanos , Assistência Perinatal , Gravidez , Resultado do Tratamento , Adulto Jovem
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