Multidisciplinary approach to the surgical management of interstitial ectopic pregnancy.

OBJECTIVE: To present a multidisciplinary approach to localize and resect suspected interstitial ectopic pregnancies. Interstitial ectopic pregnancies are distinct from eccentric intracavitary pregnancies and are defined by ultrasound-based criteria, including an empty uterine cavity, gestational sac located >1 cm from the cavity, thin overlying myometrium <5 mm, and the interstitial line sign. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): Here, we present the case of a 28-year-old patient at 6 weeks of gestation by last menstrual period who presented to the emergency department with spotting. Initial pelvic ultrasound findings demonstrated a gestational sac and yolk sac that were believed to be located eccentrically within the uterine cavity. Follow-up imaging was performed 2 weeks later that revealed the pregnancy was located at the uterotubal junction and distinct from the endometrial cavity, consistent with an interstitial ectopic. The patient had ongoing light spotting with mild cramping, a benign clinical exam, and normal laboratory findings. Accurate assessment of pregnancy location is critical given that the mortality rate from interstitial pregnancies is twice that of other ectopics. In contrast, live birth rates for eccentric intracavitary pregnancies may be up to 69%, and some clinicians consider expectant management of asymptomatic patients in the first trimester. INTERVENTION: The patient was recommended for inpatient admission with expedited surgical management of interstitial ectopic pregnancy. On laparoscopic entry, the pregnancy was not well-visualized because it did not deform the uterine serosa. MAIN OUTCOME MEASURES: We present a surgical approach to suspected interstitial ectopic pregnancy that is not well-visualized at the time of laparoscopy. RESULTS: The following principles are explored: the use of multiple minimally invasive modalities (laparoscopy and hysteroscopy) to perform a thorough evaluation of the pregnancy location; incorporation of intraoperative ultrasound; temporary vessel ligation and injection of intramyometrial vasopressin; complete enucleation of the products of conception; and closure of the myometrial defect. CONCLUSION: We emphasize the benefits of a multidisciplinary approach for the localization and resection of interstitial ectopic pregnancy. This patient was discharged home in good condition with no complications.

Affordable Care Act Medicaid Expansion and Racial and Ethnic Disparities in Access to Primary Care.

The Affordable Care Act's (ACA) Medicaid expansions improved access to care for low-income populations, yet evidence is limited on how these gains differed by race/ethnicity. We examined how Medicaid expansions affected access to primary care, and how race/ethnicity moderated these effects. Using 2011-2016 Behavior Risk Factor Surveillance System data, we found that low-income adults in Medicaid expansion states were 13.9 percentage points more likely to have insurance, 5.6 percentage points more likely to have a usual source of care, and 5.0 percentage points less likely to delay care due to cost post-expansion versus in non-expansion states. Insurance gains were 6.4 percentage points lower for Hispanic adults than White adults in expansion states post-expansion; otherwise, gains were similar by race/ethnicity. Baseline access disparities between White and minority adults persisted post-expansion, especially between White and Hispanic adults. Access may decline comparably for White and minority adults if ACA Medicaid expansions are repealed.

Birth weight and body composition of neonates born to Caucasian compared with African-American mothers.

OBJECTIVE: To estimate whether neonates of African-American women have lower birth weights because of either decreased lean body mass or fat mass. METHODS: A secondary analysis of a cohort of 104 African-American and 274 Caucasian term, singleton, healthy pregnancies. Women with existing or gestational diabetes were excluded. Neonatal body composition was estimated using anthropometric measurements. RESULTS: There were significant differences in maternal age (29.5 compared with 25.8, P<.001), prepregnancy body mass index (26.2 compared with 30.9 kg/m, P<.001), and weight gain during pregnancy (15.2 compared with 13.4 kg, P=.03) in Caucasian compared with African-American women, respectively. After adjusting for these factors, African-American women's neonates had significantly lower birth weights (3.20 compared with 3.36 kg, P=.003), less lean body mass (2.80 compared with 2.94 kg, P=.002), but no difference in fat mass (392 compared with 417 g, P=.078). CONCLUSION: Decreased birth weight in African-American neonates is due to lower lean body mass and not a difference in adiposity.