Comparing Effectiveness of Remote-learning Formats for Resident Physician Didactics.

BACKGROUND: It is important to investigate remote- learning options for medical education. We evaluated retention of research-related knowledge after exposure to pre-recorded audio-based didactics (AUDIO) versus video conference-based didactics (ZOOM). METHODS: Obstetrics and Gynecology residents over the 2020-2021 academic year were randomized to didactics delivered in AUDIO versus ZOOM formats. At baseline, immediately post-exposure, and 3-month post-exposure, objective knowledge was assessed through 15 multiple choice questions. Confidence and satisfaction were assessed on a 5-point Likert scale. Median differences and 95% confidence intervals (CI) were applied to identify a 10% non-inferiority margin. RESULTS: Thirty of thirty-one (30/31, 96.8%) eligible residents participated. At 3-month post-exposure, AUDIO was non-inferior to ZOOM (6.3% mean difference in knowledge scores, 95% CI -3.5-16.2). There were no differences in satisfaction or confidence, though a greater proportion of AUDIO participants indicated they would use a similar resource independently (p=0.008). CONCLUSION: AUDIO didactics may be non-inferior to ZOOM.

On the Ethics of Mandatory Reporting of Positive Drug Tests in Newborns and Pregnant Parents at the Time of Delivery.

The opioid epidemic has renewed debate about how to structure laws, agency policies and hospital protocols for mandatory reporting of illicit substances during pregnancy. This paper analyzes the ethics of Rhode Island's approach to mandatory reporting - in particular, reporting of positive maternal and newborn drug tests at time of delivery. Given that state intervention is generally perceived by pregnant people as punitive and threatening to their family, we consider how four elements often used to justify punitive action by the state - retribution, deterrence, rehabilitation, and incapacitation (societal protection) - apply to Rhode Island's policy and approach to prenatal substance use. In addition, the paper considers the equity implications of Rhode Island's approach. It concludes that, given the potential for the policy to do more harm than good, investment of resources would be better spent on clinical and community services that support substance using parents and their newborns.

Comparing perceptions of long-acting reversible contraception among women during periods of incarceration and women attending a local clinic: An exploratory study.

OBJECTIVES: The objective of this study was to understand perceptions of long-acting reversible contraception (LARC) among incarcerated women. We compared survey responses specific to IUDs and implants between a convenience sample of incarcerated women to a sample of women attending a local ob/gyn clinic. STUDY DESIGN: We conducted a cross-sectional survey among two groups: (1) incarcerated women receiving medical care at the state correctional facility, and (2) women receiving care at an ob/gyn clinic in the same community. The anonymous survey included questions about demographic variables, current and past contraceptive use, and perception of IUDs and implants. RESULTS: Almost half of the total sample stated that they might consider an IUD or implant for contraception. Incarcerated women tended to be less likely to give an affirmative answer to current or future use of an IUD or implant (29% vs 39%, p = 0.19). Concerns about pain and side effects were similar between the groups, but more incarcerated women cited concerns about device removal (72% vs 57%, p = 0.02) and the level of training of the provider inserting the device (68% vs 53%, p = 0.02). Incarcerated women interested in using the IUD or implant were more comfortable with device placement in the community than in the correctional setting (42% to 30%, p < 0.001). CONCLUSIONS: Incarcerated women have concerns about LARC that may be specific to their experience of incarceration. Providers working with incarcerated women should consider these when counseling patients on contraceptive choices. Options for post-release follow-up care and device removal should be included in this discussion. IMPLICATIONS: Incarcerated women should receive comprehensive reproductive health care, including contraceptive services if desired. However, incarceration itself may introduce fundamental concerns regarding contraception and these concerns need to be better understood to balance the provision of services with the potential for reproductive coercion.

Enhanced Recovery after Surgery for Cesarean Delivery Decreases Length of Hospital Stay and Opioid Consumption: A Quality Improvement Initiative.

OBJECTIVE: The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption. STUDY DESIGN: This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation. RESULTS: A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05). CONCLUSION: A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective. KEY POINTS: · Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.. · Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.. · Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use)..

Outpatient Opioid Use After Cesarean Delivery.

OBJECTIVES: With a goal of informing opioid prescribing after cesarean delivery, we compared inpatient, prescribed, and outpatient Morphine Equivalent Doses (MED) and patient characteristics. METHODS: Patients were enrolled after cesarean delivery and followed for 2-5 weeks with demographic, opioid use, and clinical characteristics collected from participants and the medical record. T-test, ANOVA, linear regression, and Pearson correlation coefficients were used in analyses. RESULTS: Among 76 women, 21% used all opioids prescribed and 20% used none. History of psychiatric comorbidities was associated with higher outpatient opiate use (172 MED vs 103 MED; p = 0.046). There was no difference in opiates consumed inpatient and amount prescribed at discharge (p = 0.502). However, low, medium, and high inpatient consumers used 53 (SD 76), 111 (SD 96), and 195 (SD 132) MEDs outpatient, respectively (p < 0.001). CONCLUSIONS: Outpatient opioid prescribing based on inpatient needs may facilitate judicious opioid use after cesarean delivery. Significance What Is Already Known: Opioid abuse is a growing problem in this country, and excess prescribing contributes to the availability of opioids. Limited data exist regarding the amount of opioids patients need after cesarean delivery, or what factors are predictive of an individual patient's opioid needs. WHAT THIS STUDY ADDS: This study further supports the growing literature demonstrating that providers frequently over-prescribe opioids following cesarean delivery. It uniquely adds associations of patient-specific factors and outpatient opioid needs.

Characteristics of women without a postpartum checkup among PRAMS participants, 2009-2011.

Introduction For uncomplicated pregnancies in the United States, a healthcare visit 4 to 6 weeks postpartum is recommended to assess a woman's mental, social, and physical health. We studied whether sociodemographic characteristics and pregnancy and delivery factors were related to the likelihood of missing a postpartum checkup. Methods We conducted a cross-sectional analysis of 64,952 women who completed the United States Centers for Disease Control Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 6 survey in 2009-2011 from 17 states and New York City that included a Yes/No question about receiving a maternal postpartum checkup. We calculated risk ratios (RR) with 95% confidence intervals (CI) to assess the association between maternal factors and lack of a postpartum checkup. Results Compared to women who attended a postpartum checkup (89.4%), women who missed the visit (10.6%) were younger, unmarried, less educated, with lower income, without insurance, and smokers (all p < 0.05). Compared to women with adequate prenatal care, women with intermediate (RR 1.79 (95% CI 1.70-1.88)) or inadequate (RR 2.71 (95% CI 2.53-2.91)) care were more likely to miss the checkup. Women were more likely to miss this checkup if their infant was born at a residence compared to a hospital (RR 2.27 (95% CI 1.71-3.01)), and were less likely to miss the checkup if their newborn had a 1-week well visit (RR 0.70 (95% CI 0.61-0.81)). Discussion Sociodemographic factors and noncompliance with other medical care were associated with missing a postpartum checkup. Women with a high-risk of not attending a postpartum visit should be targeted for interventions to increase their accessibility to care.

The Effect of Gestational Weight Gain on Persistent Increase in Body Mass Index in Adolescents: A Longitudinal Study.

Background: Weight retention after pregnancy is a concern for adolescents who may be entering adulthood at unhealthy weights. Methods: We studied associations between each of three measures: prepregnancy body mass index (BMI), gestational weight gain (GWG), and postpregnancy BMI in a longitudinal follow-up of an adolescent pregnancy study cohort. BMI and GWG were compared using t-tests and linear regression. Results: Among 91 adolescents, mean prepregnancy BMI was 24.6 [standard deviation (SD) 5.7] and mean GWG was 15.5 kg [SD 6.3]. Overall, prepregnancy BMI was not significantly related to GWG (p = 0.145). Among 42 teens with postpregnancy weight data, within 4 years of their first delivery, mean postpregnancy BMI was 26.3 [SD 5.0] with an average BMI increase of 2.0 points [SD 5.1] (p = 0.013) from prepregnancy. Within 4 years of their first delivery, 45% of teens moved to a higher BMI category. For every 4.5 kg (10 lb) increase in GWG, BMI within 4 years increased on average by 1.6 points (p = 0.006). The association persisted (1.0 points, p = 0.049) after controlling for prepregnancy BMI. Conclusions: Teens experienced an increase in BMI from prepregnancy to within 4 years after their first delivery, and this increase was related to GWG. Adolescent mothers are at risk for developing and maintaining unhealthy BMI after pregnancy, which may be amplified by GWG.

Emergency department visits for postpartum hypertension.

OBJECTIVE: To describe the characteristics of women diagnosed with postpartum hypertension in an emergency department (ED) to better inform postpartum care. METHODS: Women with an ED diagnosis of hypertension were compared to women with all other ED diagnoses. RESULTS: Among 252 postpartum women who presented for ED care, 52 were given a diagnosis of hypertension. Women with hypertension had some recognizable risk factors and presented on average within one week of delivery. Readmission rate was high, and many women seemed aware of their hypertension. CONCLUSION: Postpartum surveillance may not prevent readmission for hypertension; future focus should be in prevention interventions.

Over-the-counter treatments and perineal hygiene in postmenopausal women.

OBJECTIVE: The objective of this descriptive study was to quantify the personal hygiene habits/practices of, as well as the over-the-counter (OTC) products used by, postmenopausal women. Specifically, we were interested in any product that would contact the vulva or vagina. METHODS: We performed a cross-sectional study of postmenopausal women seeking routine gynecologic care. We developed a questionnaire on their personal hygiene habits/practices and the OTC products that they use that would contact the vulva or vagina. We recruited postmenopausal women seeking gynecologic care from two separate gynecology practices. Descriptive statistics were performed as appropriate to characterize the frequency of reported treatments and practices. RESULTS: The questionnaire on OTC treatments and perineal hygiene was completed by 114 postmenopausal women. Fifty-eight women (50.9%) reported using at least one OTC vulvovaginal treatment in the last 3 months, including barrier treatments, topical anesthetics, powders, and antifungals. Women often used more than one OTC product. Thirty-seven women (32.5%) reported the use of two or more OTC products. Powders were used by 34 women (29.8%). Talcum powder was the most commonly used powder (26 of 34; 76.5%). Nine postmenopausal women (7.9%) reported douching in the last 3 months. CONCLUSIONS: We found that more than half of postmenopausal women seeking gynecologic care have used an OTC product for vulvovaginal symptoms in the last 3 months and that one third of women use two or more products. Because the use of OTC products is very common, our study highlights the need for a detailed history inquiry about OTC product use and perineal hygiene practices.

Maternal postoperative complications after nonobstetric antenatal surgery.

OBJECTIVE: Our primary objective is to estimate the occurrence of major maternal 30 day postoperative complications after nonobstetric antenatal surgery. METHODS: We analyzed the 2005-2009 data files from the American College of Surgeons National Surgical Quality Improvement Program to assess outcomes for pregnant women undergoing nonobstetric antenatal surgery during any trimester of pregnancy as classified by CPT-4 codes. t Tests, χ(2), logistic regression and other tests were used to calculate composite 30-day major postoperative complications and associations of preoperative predictors with 30 day postoperative morbidity. RESULTS: The most common nonobstetric antenatal surgical procedure among the 1969 included women was appendectomy (44.0%). The prevalence of composite 30-day major postoperative complications was 5.8% (n = 115). This included (not exclusive categories): return to the surgical operating room within 30 days of surgery 3.6%, infectious morbidity 2.0%, wound morbidity 1.4%, 30 day respiratory morbidity 2.0%, venous thromboembolic event morbidity 0.5%, postoperative blood transfusion 0.2%, and maternal mortality 0.25%. CONCLUSION: Major maternal postoperative complications following nonobstetric antenatal surgery were low (5.8%). Maternal postoperative mortality was rare (0.25%).

Morbidity of appendectomy and cholecystectomy in pregnant and nonpregnant women.

OBJECTIVE: To use the data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program to estimate major postoperative morbidity after 1) appendectomy in pregnant compared with nonpregnant women; and 2) cholecystectomy in pregnant compared with nonpregnant women. METHODS: We selected a cohort of reproductive-aged women undergoing appendectomy and cholecystectomy between 2005 and 2009 from the data files of the ACS National Surgical Quality Improvement Program. Outcomes in pregnant women were compared with those in nonpregnant women. The primary outcome was composite 30-day major postoperative complications. Pregnancy-specific complications were not assessed and thus not addressed. RESULTS: Pregnant and nonpregnant women had similar composite 30-day major morbidity after appendectomy (3.9% [33 of 857] compared with 3.1% [593 of 19,172], P=.212) and cholecystectomy (1.8% [eight of 436] compared with 1.8% [584 of 32,479], P=.954). Pregnant women were more likely to have preoperative systemic infections before each procedure. In logistic regression analysis, pregnancy status was not predictive of increased postoperative morbidity for appendectomy (adjusted odds ratio 1.26, 95% confidence interval 0.87-1.82). CONCLUSION: Pregnancy does not increase the occurrence of postoperative maternal morbidity related to appendectomy and cholecystectomy. LEVEL OF EVIDENCE: II.