Nonadjuvanted Bivalent Respiratory Syncytial Virus Vaccination and Perinatal Outcomes.

Importance: A nonadjuvanted bivalent respiratory syncytial virus (RSV) prefusion F (RSVpreF [Pfizer]) protein subunit vaccine was newly approved and recommended for pregnant individuals at 32 0/7 to 36 6/7 weeks' gestation during the 2023 to 2024 RSV season; however, clinical vaccine data are lacking. Objective: To evaluate the association between prenatal RSV vaccination status and perinatal outcomes among patients who delivered during the vaccination season. Design, Setting, and Participants: This retrospective observational cohort study was conducted at 2 New York City hospitals within 1 health care system among patients who gave birth to singleton gestations at 32 weeks' gestation or later from September 22, 2023, to January 31, 2024. Exposure: Prenatal RSV vaccination with the RSVpreF vaccine captured from the health system's electronic health records. Main Outcome and Measures: The primary outcome is preterm birth (PTB), defined as less than 37 weeks' gestation. Secondary outcomes included hypertensive disorders of pregnancy (HDP), stillbirth, small-for-gestational age birth weight, neonatal intensive care unit (NICU) admission, neonatal respiratory distress with NICU admission, neonatal jaundice or hyperbilirubinemia, neonatal hypoglycemia, and neonatal sepsis. Logistic regression models were used to estimate odds ratios (ORs), and multivariable logistic regression models and time-dependent covariate Cox regression models were performed. Results: Of 2973 pregnant individuals (median [IQR] age, 34.9 [32.4-37.7] years), 1026 (34.5%) received prenatal RSVpreF vaccination. Fifteen patients inappropriately received the vaccine at 37 weeks' gestation or later and were included in the nonvaccinated group. During the study period, 60 patients who had evidence of prenatal vaccination (5.9%) experienced PTB vs 131 of those who did not (6.7%). Prenatal vaccination was not associated with an increased risk for PTB after adjusting for potential confounders (adjusted OR, 0.87; 95% CI, 0.62-1.20) and addressing immortal time bias (hazard ratio [HR], 0.93; 95% CI, 0.64-1.34). There were no significant differences in pregnancy and neonatal outcomes based on vaccination status in the logistic regression models, but an increased risk of HDP in the time-dependent model was seen (HR, 1.43; 95% CI, 1.16-1.77). Conclusions and Relevance: In this cohort study of pregnant individuals who delivered at 32 weeks' gestation or later, the RSVpreF vaccine was not associated with an increased risk of PTB and perinatal outcomes. These data support the safety of prenatal RSVpreF vaccination, but further investigation into the risk of HDP is warranted.

Medication abortion for adolescents in the United States: Strengthening the role of pediatric primary care providers.

BACKGROUND: Recent legal changes have led to mounting abortion restrictions in the United States (US), disproportionately impacting adolescents, who already face multifaceted barriers to abortion care. Informed by the framework of reproductive justice, adolescents who become pregnant deserve comprehensive, unbiased, and non-judgmental pregnancy options counseling, inclusive of all choices for pregnancy continuation and termination. Pediatric primary care providers are at the front lines of caring for adolescent patients' reproductive health needs and frequently diagnose pregnancy, provide pregnancy options counseling, and assist patients in accessing abortion care. They are uniquely poised to provide this care given their trusted, ongoing relationships with adolescent patients and their families, and their values of deep respect for adolescents' individuality and autonomy. METHODS: In this commentary, we aim to describe the medical and legal landscape of adolescent abortion access in the US and provide recommendations to support pediatric primary care providers' involvement in abortion care. We focus on medication abortion, as the provision of medication abortion has the potential to encompass a broad group of clinicians, including pediatric primary care providers. RESULTS: We discuss the importance of providing options counseling to adolescents within the reproductive justice framework, improving abortion education for pediatric providers, and expanding access to abortion care by supporting providers at an institutional level if they opt to provide medication abortions. CONCLUSION: In light of the current legal landscape, the role of pediatric primary care providers in ensuring adolescent access to abortion care is ever more critical. Although many pediatric and adolescent providers already provide this important care, we, a team of obstetricians/gynecologists and adolescent medicine physicians, echo prior calls for improved training and institutional support for pediatric providers to counsel about and provide abortion-related care. We hope that highlighting the role of pediatric providers in this sphere will help center the needs of adolescent patients and help them fulfill their family planning goals.

Approach to intrapartum fever during the COVID-19 pandemic: A New York City Hospital experience.

The yield of repeat severe acute respiratory syndrome coronovirus 2 (SARS-CoV-2) testing for intrapartum fever in patients admitted to labor and delivery negative for SARS-CoV-2 on admission testing is unknown. From October 2020 to June 2022, we performed a retrospective study of 151/3,168 (4.8%) patients who had repeat testing for intrapartum fever. One (0.7%) patient was SARS-CoV-2-positive suggesting repeat SARS-CoV-2 testing for intrapartum fever is generally not warranted nor is separating birthing dyads while awaiting test results.

Understanding Clinician Knowledge About Race Adjustment in the Vaginal Birth After Cesarean Calculator.

Disparities in maternal health outcomes are striking. Historical and biased clinical support tools have potential to exacerbate inequities. In 2022, NewYork-Presbyterian, with ∼25,000 annual births, and our academic partners, Columbia and Weill Cornell, launched a program to better understand practice patterns and clinician attitudes toward a vaginal birth after cesarean (VBAC) calculator, which predicts VBAC success. This article summarizes the program, focusing on the VBAC calculator utilization survey, which measured provider awareness of the revised calculator and key factors considered in patient counseling. Our preliminary findings warrant future research and education on the calculator's implications for counseling and outcomes.

Reproductive and Fertility Knowledge and Attitudes Among Transgender and Gender-Expansive Youth: A Replication and Extension.

Purpose: This study sought to replicate and expand a previous pilot investigation of reproductive knowledge, attitudes toward fertility and parenthood, and sources of information on these topics among transgender and gender-expansive (TGE) youth. Methods: The Yale Pediatric Gender Program (YPGP) Reproductive Knowledge and Experiences Survey (YPGP-RKES) was administered to 70 TGE adolescents receiving care at an interdisciplinary clinic providing gender-affirming health care at an academic medical center. Data gathered included sources of information on reproduction and fertility, concerns about future parenthood and reproduction, and interest in different types of parenthood. Results: Over a third (39.1%) of participants reported it was important to them to have a child one day, while only a small proportion (23.2%) reported an interest in biological parenthood. A plurality of participants (37.3%) reported at least one concern about future fertility. The number of reproductive concerns did not differ by age or treatment (puberty blockers or gender-affirming hormones vs. no treatment) status. With respect to needs for more information and sources of information, most (56.5%) participants received information about fertility issues before this study, with the most cited source of information being online research. Conclusions: The current study replicated and extended previous findings on the reproductive attitudes and knowledge of TGE adolescents. Understanding the informational needs and priorities of adolescent TGE patients presenting for medical treatment will allow providers to give more robust patient education. This will, in turn, facilitate patients' ability to provide fully informed consent for treatment that aligns with their fertility and reproductive priorities and goals.

Vulvar Aphthous Ulcers in Perimenarchal Adolescents after COVID-19 Vaccination: A Multicenter Case Series.

This case series from 3 academic hospital-based pediatric and adolescent gynecology services outlines the temporal association between vulvar ulcers in female adolescents and COVID-19 vaccination. We identified 8 cases and describe each patient's presentation, differential diagnosis, diagnostic workup, complications, treatment modalities, and overall course of illness. All cases seek to illustrate the clinical experiences of patients and providers interfacing with vulvar aphthous ulcers and contribute to the emerging literature exploring the novel association between vulvar aphthous ulcers and COVID-19 vaccination. To date, this is the largest described case series of this association in the literature. Key Words: COVID-19, Vaccine, Aphthous ulcers, Vulva, Adolescent.

Implementation of simulation-based health systems science modules for resident physicians.

BACKGROUND: Health system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains.  METHODS: Each scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January - March 2021. RESULTS: A total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures. CONCLUSIONS: The simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.

Multifaceted Approach to Evaluation in a Pediatric and Adolescent Gynecology Rotation for Medical Students.

STUDY OBJECTIVE: We evaluated whether and to what extent a novel medical student rotation in pediatric and adolescent gynecology (PAG) increases clinical knowledge and skills and meets student needs and expectations. DESIGN: Constructivist prospective pre-post study and post-rotation student survey SETTING: Academic medical center PARTICIPANTS: Pilot study of 9 medical students, which represents the entire population of those who completed the rotation. INTERVENTIONS: Four-week clinical rotation in PAG MAIN OUTCOME MEASURES: Changes in clinical knowledge were measured by a pre- and post-intervention multiple-choice assessment, and clinical skills were assessed before and after the intervention using entrustable professional activities (EPAs); these data were analyzed with paired Student's t tests. Student evaluations of the rotation were measured through an anonymous, end-of-rotation, closed- and open-ended survey and were analyzed using descriptive statistics. RESULTS: A statistically significant increase in clinical knowledge was observed post-rotation, with a mean pretest score of 67.0% (standard deviation [SD] 1.7%) and a mean posttest score of 75.2% (SD 3.2%, P = 0.02). Statistically significant increases were observed for all EPAs between the first and final day of the rotation. Eight students who completed the post-rotation survey rated the rotation favorably (5 on a scale from 1 to 5). CONCLUSION: A multipronged evaluation showed that a new PAG clinical rotation significantly increased medical students' clinical skills and knowledge. This multifaceted evaluation method provides valuable insights to educators on how best to tailor a rotation to individual learners' levels of clinical skills and knowledge. If comparable rotations could be instituted and similarly evaluated in other medical schools, a noticeable knowledge/skill gap among trainees might be addressed.

Pelvic Examinations in the Adolescent and Young Adult Population: A Commentary on Why and When.

Various professional organizations have weighed in on the practice utility of speculum examinations. The US Preventive Services Task Force (USPSTF), American Academy of Pediatrics (AAP), and American College of Physicians (ACP) have recommended against internal pelvic examinations in asymptomatic patients, whereas the American College of Obstetricians and Gynecologists (ACOG) has encouraged shared decision making. Although a pelvic examination can be a stressful event for adolescents, studies have shown that early discussions and performing the examination in a trusting environment can mitigate the worries and improve the patient-provider relationship. In this commentary, we discuss the literature and conclude that performing a pelvic examination in the asymptomatic adolescent and young adult patient is ultimately a matter of shared decision making. The benefits of conducting the examination in a nonthreatening environment, minimizing "exceptionalization" of the female genitalia, and strengthening the patient-provider relationship should be highlighted during the discussions.

Contraception Counseling and Use Among Adolescent and Young Adult Female Patients Undergoing Cancer Treatment: A Retrospective Analysis.

STUDY OBJECTIVE: Adolescent and young adult (AYA) women undergoing cancer treatment face unique reproductive health risks. This study aimed to assess the prevalence of sexual health counseling and contraception use in the oncology setting, and to identify patient factors associated with these outcomes. DESIGN: Retrospective chart review. SETTING: Yale New Haven Hospital from 2013 to 2018. PARTICIPANTS: Female patients 15-25 years of age receiving cancer treatment, excluding those treated with surgery only. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Outcomes of documented sexual health counseling and contraception use were assessed for frequency. Associations between patient factors and these outcomes were assessed using Pearson χ2 and Fisher exact tests, and multivariate logistic regression was used to identify predictors of these outcomes. RESULTS: In this cohort (n = 157), the median age was 20.5 years, and the most common diagnoses were hematologic (40.8%) and thyroid (31.2%) malignancies. Of the patients, 33.1% were documented as receiving sexual health counseling, and 48.4% used contraception. Younger patients (15-20 years of age) were less likely to receive counseling (OR 0.31, 95% CI 0.14-0.70, P = .005). Receiving counseling (OR 3.36, 95% CI 1.35-8.34, P = .009) and sexual activity (OR 4.18, 95% CI 1.80-9.68, P = .001) were significantly associated with contraception use. CONCLUSIONS: Sexual health counseling was documented infrequently during oncologic care for AYA women, especially for younger patients. However, such conversations were associated with a higher likelihood of contraception use. There is a need to improve rates of counseling in this high-risk setting, in which adolescents may be more vulnerable with regard to sexual health.

Exploring crowdfunding campaigns for abortion services.

OBJECTIVES: To examine the use of crowdfunding to pay for abortion services for individuals in the United States. STUDY DESIGN: Cross-sectional analysis of data abstracted from publicly available campaigns for abortion services on four major crowdfunding sites. RESULTS: Among 92 crowdfunding campaigns, the median amount requested was $610 (IQR $500-$1000), the median raised was $0 (IQR $0-$444), and 19 (21%) campaigns successfully reached their fundraising goal. Campaign success did not differ by state abortion policy, but campaigns written in third person or describing maternal/fetal diagnoses raised significantly more money. CONCLUSIONS: Although individuals use crowdfunding to finance abortion services, the success rate is low.

Low-Grade Astrocytoma within a Mature Cystic Teratoma in an Adolescent Patient.

BACKGROUND: Mature cystic teratomas are the most common ovarian neoplasm in adolescents. They are typically benign, however, malignant transformation rarely occurs. We report a low-grade astrocytoma arising from a mature cystic teratoma in an adolescent patient. CASE: The patient was a 12-year-old girl with an asymptomatic ovarian cyst and subsequent cystectomy. Final pathology identified a solid tumor with glial tissue within the cyst, reported as low-grade astrocytoma arising in a mature cystic teratoma. SUMMARY AND CONCLUSION: There are few data on astrocytomas in the gynecologic tract. Risk factors for malignant transformation in a mature cystic teratoma include increased age, postmenopausal status, elevated carcinoma antigen 125, and large tumor size. Interestingly, this patient had a history of partial trisomy 20, which has been associated with teratoma formation in a mouse model.

Vulvar Lesions in an 8-Year-Old Girl: Cutaneous Manifestations of Multisystem Langerhans Cell Histiocytosis.

BACKGROUND: Langerhans cell histiocytosis (LCH) is a rare localized or systemic disease characterized by proliferation of myeloid-derived dendritic cells. Vulvar lesions might be the herald symptom of LCH and might mimic other cutaneous lesions. Prognosis varies widely on the basis of the extent and spread of disease. CASE: An 8-year-old girl with a 4-month history of vulvar lesions resistant to topical steroids was referred by her pediatrician. Vulvar biopsy was diagnostic for LCH. Imaging studies revealed a left hip lesion consistent with LCH. The patient was subsequently treated for multisystem LCH with vinblastine and prednisone. SUMMARY AND CONCLUSION: Although rare, LCH might be diagnosed by gynecologic providers and should be included in the differential diagnosis of genital lesions. We recommend having a low threshold for performing biopsy of vulvar lesions.