The Parental Leave Paradox in Obstetrics and Gynecology.

Medical school, residency, and fellowship occur during peak reproductive years for most trainees. This poses certain challenges for medical trainees as they approach family-building decisions. While the demands of residency have been well-elucidated, attempts at mitigating these demands alongside parenthood have long been neglected across various specialties. These challenges are perhaps most pronounced in Obstetrics and Gynecology residency programs, which are made-up of an 85% female-identifying workforce and whose training focuses on prenatal and postpartum health. Recent literature suggests an improvement in attitudes and policies towards parental leave during medical graduate education, however, there remains a lack of uniformity across specialties and programs. Through a recently developed Parental Leave Task Force made up of Obstetrics and Gynecology Trainees, we sought to conduct a review of the literature examining parental leave policies and their implications across various specialties as a call for uniform parental leave policies for all residents.

Comparing Activity Trackers With vs. Without Alarms to Increase Postoperative Ambulation: A Randomized Control Trial.

Early ambulation is a key component to postoperative recovery; however, measuring steps taken is often inconsistent and nonstandardized. This study aimed to determine whether an activity tracker with alarms would increase postoperative ambulation in patients after elective colorectal procedures. Forty-eight patients were randomly assigned to either trackers with 5 daily alarms or activity trackers alone. Over 223 total patient days, the trackers recorded a complete data set for 216 patient days (96.9%). Increasing the postoperative day significantly affected the number of steps taken, while age, sex, Risk Analysis Index score, and approach (laparoscopic versus open) did not show a significant effect. The mean steps per day in the intervention group were 1468 (median 495; interquartile range (IQR) 1345) and in the control group was 1645 (median 1014; IQR 2498). The use of trackers with alarms did not significantly affect the number of daily steps compared to trackers alone (ANOVA, P = .93). Although activity trackers with alarms did not increase postoperative ambulation compared with trackers with no alarms, we demonstrated a strategy to operationalize the use of trackers into postoperative care to provide a quantitative value for ambulation. This enables quantification of a key component in the Enhanced Recovery After Surgery protocol.

Assessing Influenza Vaccination Behaviors Among Medically Underserved Obstetric Patients.

Background: Despite recommendations, maternal influenza vaccine acceptance has stagnated around 50%. Materials and Methods: A prospective cohort study was conducted of pregnant women seen in the clinic from September 2018 to April 2019. Primary outcomes included influenza vaccine uptake and reasons for vaccine refusal, categorized based on the Health Belief Model. We compared characteristics between three vaccination groups (never refused, refused and vaccinated, and refused and not vaccinated) by using chi-square and one-way analysis of variance. We used multivariate logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between patient characteristics and vaccine acceptance. Mixed-effects logistic regression models were used to explore the impact of provider-patient race concordance on influenza vaccine uptake. Results: Among 1666 women, 902 (54.1%) were vaccinated. Of these, 183 (20.3%) initially refused. Those who refused and were never vaccinated were more likely to be non-Hispanic black (aOR: 1.64, 95% CI: 1.05-2.56) and less likely to be Hispanic (aOR: 0.44, 95% CI: 0.24-0.81). Overall, perceived barriers were the most common reason for refusal (52.4%). Women who refused consistently were more likely to cite reasons related to perceived benefits (38.5% vs. 7.6%). Those who eventually accepted were more likely to cite cue to action (22.4% vs. 12.6%). Women who were race discordant with their provider were more likely to be vaccinated compared with those who were race concordant (57.9% vs. 52.9%, aOR: 1.16, 95% CI: 1.07-1.27). Conclusions: Women who refuse influenza vaccination in pregnancy may later choose to be vaccinated. Continued promotion of vaccination throughout pregnancy is crucial for vaccine uptake.

Trichomonas vaginalis in Pregnancy: Patterns and Predictors of Testing, Infection, and Treatment.

OBJECTIVE: To identify factors associated with testing for and diagnosis of trichomoniasis in pregnancy and to describe patterns of treatment and tests of reinfection or persistence. METHODS: We conducted a retrospective cohort study of women who delivered from July 2016 to June 2018 at one institution. Testing for Trichomonas vaginalis infection was done by wet mount microscopy or by nucleic acid amplification testing for routine prenatal testing or symptomatic visits. Poisson regression was used to identify factors associated with testing for trichomoniasis and testing positive in pregnancy. Treatment and re-testing patterns also were assessed. RESULTS: Among 3,265 pregnant women, 2,489 (76%) were tested for T vaginalis infection. Of the total sample, 1,808 (55%) were tested by wet mount microscopy, 1,661 (51%) by nucleic acid amplification testing, and 980 (30%) by both modalities. The sensitivity for microscopy compared with nucleic acid amplification testing was 26%, with a specificity of 99%. Factors associated with increased likelihood of being tested included younger age (adjusted risk ratio [aRR] 0.99, 95% CI 0.99-1.00) and bacterial vaginosis (aRR 1.17, 95% CI 1.01-1.37). Prevalence of trichomoniasis was 15% among those tested by any modality (wet mount or nucleic acid amplification testing). Risk factors for trichomoniasis included younger age (aRR 0.97, P<.01), being of black race (aRR 2.62, P<.01), abnormal vaginal discharge (aRR 1.45, P<.01), and chlamydia during the current pregnancy (aRR 1.70, P<.01). Women diagnosed by microscopy had a shorter time to treatment compared with those diagnosed by nucleic acid amplification testing. Most (75%) women with positive infections had a test of reinfection; 29% of these were positive. Bacterial vaginosis was associated with decreased risk of a positive test of reinfection. CONCLUSION: Although testing for and treatment of trichomoniasis during pregnancy is not routinely recommended, the high burden of infection among some pregnant women demonstrates a need to further understand patterns of T vaginalis testing and infection. Opportunities exist for improving timely treatment of trichomoniasis and test of reinfection.

Patterns of Screening, Infection, and Treatment of Chlamydia trachomatis and Neisseria gonorrhea in Pregnancy.

OBJECTIVE: To describe factors associated with not being tested for Chlamydia trachomatis and Neisseria gonorrhea infection during pregnancy and for testing positive and to describe patterns of treatment and tests of reinfection. METHODS: We conducted a retrospective cohort study of women who delivered at an urban teaching hospital from July 1, 2016 to June 30, 2018. Women with at least one prenatal care or triage visit were included. The index delivery was included for women with multiple deliveries. We used logistic regression to analyze factors associated with not being tested and for testing positive for these infections in pregnancy. Cox proportional hazards models were used to examine factors associated with time to treatment and tests of reinfection. We reviewed medical records to determine reasons for delays in treatment longer than 1 week. RESULTS: Among 3,265 eligible deliveries, 3,177 (97%) women were tested during pregnancy. Of these, 370 (12%) tested positive (287 chlamydia, 35 gonorrhea, 48 both), and 15% had repeat infections. Prenatal care adequacy and insurance status were risk factors for not being tested. Age, race and ethnicity, alcohol use, and sexually transmitted infection history were associated with testing positive. Time to treatment ranged from 0 to 221 days, with the majority (55%) of patients experiencing delays of more than 1 week. Common reasons for delays included lack of clinician recognition and follow-up of abnormal results (65%) and difficulty contacting the patient (33%). CONCLUSION: Traditional risk factors are associated with increased risk of infection during pregnancy. Prenatal care adequacy and insurance status were associated with the likelihood of being tested. Delays in treatment and tests of reinfection were common. Point-of-care testing and expedited partner therapy should be explored as ways to improve the management of these infections in pregnancy.

National mosaic embryo transfer practices: a survey.

BACKGROUND: The growing use of preimplantation genetic testing with in vitro fertilization has provided clinicians with more information about the genetics of embryos. Embryos, however, sometimes result with a mixed composition of both aneuploid and euploid cells, called mosaic embryos. The interpretation of these results has varied, leading some clinicians to transfer mosaic embryos and some opt not to. In addition, laboratories providing preimplantation genetic testing for aneuploidy have differing thresholds for determining an embryo aneuploid, mosaic, or euploid. Overall practice patterns for mosaic embryo transfer practices in the United States are unknown. OBJECTIVE(S): The objectives of the study were to characterize national mosaic embryo transfer practices, including the use of preimplantation genetic testing for aneuploidy, prior history of transferring mosaic embryos, thresholds for determining mosaicism, and willingness to transfer mosaic embryos among assisted reproductive technology clinics in the United States. STUDY DESIGN: A 14 question online survey assessing current use of preimplantation genetic testing for aneuploidy, thresholds for determining mosaicism, and clinic experience and willingness to transfer mosaic embryos was e-mailed to 405 assisted reproductive technology clinics across the United States. Descriptive statistics and logistic regression were used to analyze survey responses and identify clinical factors associated with reporting having ever transferred a mosaic embryo. RESULTS: Of the 405 US assisted reproductive technology clinics contacted, 252 (62.2%) completed a survey, including 157 private (62.3%), 55 academic (21.8%), and 40 hybrid (15.9%) clinics. Most clinics (168, 66.7%) reported conducting preimplantation genetic testing for aneuploidy on less than 50% of all in vitro fertilization cycles. The most common type of preimplantation genetic testing for aneuploidy technology used was next-generation sequencing at 88.9%. Ninety-one clinics (36.1%) receive mosaicism data on their preimplantation genetic testing for aneuploidy report; the most common thresholds for determining embryo aneuploidy and euploidy by clinics' primary genetics laboratories were <20% normal (36.3%) and >80% normal (46.2%), respectively. Thirty-nine (42.9%) of the 91 have transferred and 57 (62.6%) would transfer a mosaic embryo. Nearly 40% of clinics were unsure about their thresholds for mosaic transfer and one fourth of clinics reported they had no threshold. Private (odds ratio, 1.0, 95% confidence interval, 0.5-1.8) and hybrid (odds ratio, 0.9, 95% confidence interval, 0.4-2.1) clinics were just as likely as academic clinics to report having transferred a mosaic embryo. Clinics in the northeastern United States were more likely to have transferred a mosaic embryo than clinics in other regions (odds ratio, 1.5, 95% confidence interval, 0.9-2.7). Most clinics (72.6%) report they do not have a unique consent for transfer of mosaic embryos. CONCLUSION: There is uncertainty and variability in the transfer practices of mosaic embryos and classification of mosaicism among US assisted reproductive technology clinics. These findings provide an opportunity to establish mosaicism thresholds and create standardized guidelines for transferring mosaic embryos.