Hysteroscopic sterilization in a large group practice: experience and effectiveness.

OBJECTIVE: To estimate device placement and tubal occlusion rates for hysteroscopic sterilization and evaluate risk factors for failure. METHODS: Women undergoing hysteroscopic sterilization at Kaiser Permanente Northern California from January 2004 to December 2006 were identified. Risk factors assessed included age, parity, body mass index (BMI), operative location, and provider experience with the technique. Occlusion was determined by hysterosalpingogram. Univariable analyses were performed to identify factors predictive of successful placement and occlusion. The Cochrane-Armitage test was performed for trend analysis. RESULTS: Hysteroscopic sterilization was attempted in 884 women by 118 physicians at 30 Kaiser Permanente Northern California facilities. The initial placement attempt was successful in 850 patients (96.2%). Patient age, nulliparity, and BMI were not predictive of successful placement. Bilateral occlusion was demonstrated by hysterosalpingogram in 687 of 739 patients (93.0%). There were no significant differences in age, nulliparity, and BMI between those with and without occlusion. Loss to follow-up before a hysterosalpingogram was obtained was 13%. There was no significant increase in occlusion rate with experience (P for trend=.6). CONCLUSION: High placement and occlusion rates were noted from the first insertions, and success was not related to age, parity, BMI, or operator experience. LEVEL OF EVIDENCE: III.

Probability of hysterectomy after endometrial ablation.

OBJECTIVE: To investigate risk factors for hysterectomy after endometrial ablation. METHODS: This was a retrospective cohort analysis of data from Kaiser Permanente Northern California members, aged 25-60 years undergoing endometrial ablation from 1999 to 2004 and collected through 2007. Risk factors assessed included age, presence of leiomyomas, setting of procedure (inpatient or outpatient), and type of endometrial ablation procedure (first generation, radio frequency, hydrothermal, or thermal balloon). Univariable and survival analyses were performed to identify risk factors and estimate probability of hysterectomy. RESULTS: From 1999 to 2004, 3,681 women underwent endometrial ablation at 30 Kaiser Permanente Northern California facilities. Hysterectomy was subsequently performed in 774 women (21%), whereas 143 women (3.9%) had uterine-conserving procedures. Age was a significant predictor of hysterectomy (P<.001). Cox regression analysis found that compared with women aged older than 45 years, women aged 45 years or younger were 2.1 times more likely to have hysterectomy (95% confidence interval 1.8-2.4). Hysterectomy risk increased with each decreasing stratum of age and exceeded 40% in women aged 40 years or younger. Overall, type of endometrial ablation procedure, setting of endometrial ablation procedure, and presence of leiomyomas were not predictors of hysterectomy. In analysis of individual procedure types, concomitant myomectomy was associated with a decreased risk of hysterectomy for patients receiving first-generation endometrial ablation (P=.002), and outpatient location for hydrothermal endometrial ablation increased hysterectomy risk (P<.001). CONCLUSION: Age is more important than type of procedure or presence of leiomyomas in predicting subsequent hysterectomy after endometrial ablation. Women undergoing endometrial ablation at younger than 40 years of age are at elevated risk of hysterectomy, and rather than plateauing within several years of endometrial ablation, hysterectomy risk continues to increase through 8 years of follow-up. LEVEL OF EVIDENCE: II.

Predictors of hysterectomy after uterine artery embolization for leiomyoma.

OBJECTIVE: This study was undertaken to describe long-term outcomes after uterine artery embolization for leiomyoma. STUDY DESIGN: Data from Kaiser Permanente Northern California members undergoing uterine artery embolization for leiomyoma before July 2001 were collected. Survival analysis was performed to describe hysterectomy rates and identify predictors of hysterectomy. RESULTS: Uterine artery embolization was performed in 562 women from 1997-2001. Thirty-three women (5.9%) had unilateral uterine artery embolization. One hundred women (18%) underwent hysterectomy after uterine artery embolization, and 32 (5.7%) had additional uterine sparing procedures. Only unilateral uterine artery embolization predicted subsequent hysterectomy (relative risk = 2.19; 95% CI 1.34-3.57), whereas age, indication, uterine volume, embolizing particle, and radiologist experience did not. The rate of hysterectomy at 5 years was 19.7%; rates for bilateral and unilateral uterine artery embolizations were 18.5% and 39.2%, respectively. Fifty-four women (9.6%) had emergency room visits and 17 (3%) had unplanned readmissions. CONCLUSIONS: Uterine artery embolization for leiomyoma permits uterine conservation in more than 80% of women monitored long-term. When bilateral procedures cannot be performed, failure rates are considerably higher.

Changes in rates of hysterectomy and uterine conserving procedures for treatment of uterine leiomyoma.

OBJECTIVE: The purpose of this study was to investigate treatment of uterine leiomyoma by hysterectomy and uterine conserving procedures (UCPs). STUDY DESIGN: Data from Kaiser Permanente Northern California members undergoing hysterectomy, myomectomy, uterine artery embolization (UAE) and endometrial ablation (EA) for uterine leiomyoma from 1997-2003 were collected. Statistical analysis included trend tests and survival analysis. RESULTS: Hysterectomy rates for leiomyoma decreased significantly from 2.13 per 1000 to 1.91 (P < .0001). Rates for myomectomy (.4-.37) and EA (.26-.27) remained stable (P = .17 and .26, respectively), whereas rates for UAE increased significantly from < .01-.24 (P < .0001). The combined rates for hysterectomy and UCPs remained stable at 2.79 (P = .95). Rate of hysterectomy after UCP increased over time, and at 6 years reached 11.5%, 17.7%, and 7.9% for EA, UAE, and myomectomy, respectively. CONCLUSION: Whereas rate of hysterectomy for leiomyoma decreased, total rate of invasive treatment remained stable. Increase in rate of UAE had the greatest impact on treatment, possibly replacing hysterectomy.

Hysterectomy rates for benign indications.

OBJECTIVE: To investigate the annual rates, types, and indications for hysterectomies performed for benign disease in Kaiser Permanente Northern California from 1994 to 2003. METHODS: All women, 20 years or age or older, who were undergoing hysterectomy for benign indications in Kaiser Permanente Northern California from 1994 to 2003 were identified. We analyzed hysterectomy rates by type, indication, and age group. Changes over time were analyzed with the Cochran-Armitage test for linear trend. RESULTS: From 1994 to 2003, there were 32,321 hysterectomies performed for benign indications. Hysterectomy rates showed a significant decline, from 4.01 per 1,000 women in 1994 to 3.41 per 1,000 women in 2003 (P for trend < .001). The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13.0% in 1995 and then steadily declined to 3.9% in 2003 (P for trend < .001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (P for trend < .001). Hysterectomy rates declined 11.2% for uterine leiomyoma (relative risk [RR] 0.89, 95% confidence interval [CI] 0.83-0.95), 33.1% for endometriosis (RR 0.67, 95% CI 0.59-0.76), and 18.6% for uterine prolapse (RR 0.81, 95% CI 0.72-0.92). The relative proportion performed for uterine leiomyoma was consistently greater than for all other indications combined. CONCLUSION: The rates of hysterectomy for benign indications are decreasing. The type of hysterectomy changed significantly, with LAVH performed less frequently and subtotal abdominal hysterectomy increasing in popularity. Uterine leiomyoma remains the most common indication for benign hysterectomy. LEVEL OF EVIDENCE: II-2.

Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization.

OBJECTIVE: This study was undertaken to compare the use of glyburide with insulin for the treatment of gestational diabetes mellitus (GDM) unresponsive to diet therapy. STUDY DESIGN: A retrospective study was performed among women with singleton pregnancies who had GDM diagnosed, with fasting plasma glucose 140 mg/dL or less on glucose tolerance testing, between 12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified 584 women and compared those treated with insulin between 1999 and 2000 with women treated with glyburide between 2001 and 2002. Maternal and neonatal outcomes and complications were assessed. Statistical methods included univariate analyses and multivariable logistic regression. RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide. The 2 groups were similar with regard to age, nulliparity, and historical GDM risk factors; however, women in the insulin group had a higher mean body mass index (31.9 vs 30.6 kg/m 2 , P=.04), a greater proportion identified themselves as white (43%, 28%, P<.001) and fewer as Asian (24%, 37%, P=.001), and they had a significantly higher mean fasting on glucose tolerance test (105.4 vs 102.4 mg/dL , P=.005) compared with the glyburide group. There were no significant differences in birth weight (3599+/-650 g vs 3661+/-629 g, P=.3), macrosomia (24%, 25%, P=.7), or cesarean delivery (35%, 39 %, P=.4). Women in the glyburide group had a higher incidence of preeclampsia (12%, 6%, P=.02), and neonates in the glyburide group were more likely to receive phototherapy (9%, 5%, P<.05), and less likely to be admitted to the neonatal intensive care unit (NICU) (15%, 24%, P=.008) though they had a longer NICU length of stay (4.3+/-9.6 vs 8.0+/-10.1, P=.002). Posttreatment glycemic control data were available for 122 women treated with insulin and 137 women treated with glyburide. More women in the glyburide group achieved mean fasting and postprandial goals (86%, 63%, P<.001). These findings remained significant in logistic regression analysis. CONCLUSION: In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study.

Helicobacter pylori seropositivity and hyperemesis gravidarum.

OBJECTIVE: To investigate the possible association between Helicobacter pylori seropositivity and hyperemesis gravidarum. STUDY DESIGN: We designed a case-control study to compare the prevalence of H pylori seropositivity in women diagnosed with hyperemesis gravidarum to that in a control population recruited from 2 university-based clinics, 1 inner city and 1 suburban. Results were tested for statistical significance by chi 2, Student t test and unconditional logistic regression analysis. RESULTS: Fifty-three subjects (30 inner city, 23 suburban) and 153 controls (75 inner city, 78 suburban) were enrolled. There was no significant difference in the prevalence of H pylori seropositivity between subjects and controls at either site (50% vs. 47%, P = .8 inner city; 17% vs. 13%, P = .6 suburban) or overall (36% vs. 29%, P = .39). In logistic regression analysis only race (African American) and age remained significantly associated with hyperemesis gravidarum, with adjusted odds ratios of 2.45 (95% CI 1.03-5.83) and .91 (95% CI .85-.98), respectively. CONCLUSION: This study found no association between hyperemesis gravidarum and H pylori seropositivity in 2 populations with disparate H pylori seroprevalence.

A comparison of medical induction and dilation and evacuation for second-trimester abortion.

OBJECTIVE: The purpose of this study was to compare complication rates of patients who undergo dilation and evacuation or medical abortion between 14 and 24 weeks of gestation. STUDY DESIGN: We present a retrospective cohort study of 297 women who underwent either dilation and evacuation or medical abortion. Statistical methods included the Student t test, the chi(2) test, the Fisher exact test (where appropriate), and logistic regression. RESULTS: The overall complication rate was significantly lower in patients who underwent dilation and evacuation than in patients who underwent medical abortion (4% vs 29%; P <.001). Medical abortions with misoprostol resulted in a lower complication rate than abortions with other medications (odds ratio, 0.2; 95% CI, 0.1-0.4). More Laminaria was associated with a decreased risk of complications with surgical abortions (odds ratio, 0.9; 95% CI, 0.7-1.0). CONCLUSION: Dilation evacuation is the safest method of second-trimester abortion. Misoprostol is safer than other methods for medical abortion. Maximal use of Laminaria will decrease complication rates in surgical abortion.