Racial and ethnic disparities in access to gynecologic care.

PURPOSE OF REVIEW: Despite efforts to minimize patient barriers to equitable care, health disparities persist in gynecology. This paper seeks to highlight racial and ethnic disparities in gynecologic care as represented by recent literature. RECENT FINDINGS: Disparities exist among many areas including preventive screenings, vaccination rates, contraception use, infertility, and oncologic care. These can be identified at the patient, physician, and institutional levels. SUMMARY: As we identify these social disparities in healthcare, we gain valuable knowledge of where our efforts are lacking and where we can further improve the health of women. Future research should focus on identifying and combating such disparities with measurable changes in health outcomes.

Secondary Postpartum Hemorrhage Due to Retained Placenta Accreta Spectrum: A Case Report.

Background: Retained products of conception and placenta accreta spectrum are causes of postpartum hemorrhage. Placenta accreta spectrum is frequently managed with cesarean hysterectomy, but conservative approaches are emerging. We present a case of delayed postpartum hemorrhage secondary to a retained placenta increta. Case: A 29-year-old G3P2 presented with heavy vaginal bleeding 20 days postoperatively following an uncomplicated classical cesarean delivery at 27 5/7 weeks' gestation for preterm labor in the setting of a vasa previa. On workup, imaging showed retained products of conception and concern for placenta accreta. A hypervascular area in the lower uterine segment was identified at the time of postpartum laparotomy. Total abdominal hysterectomy was performed due to postpartum hemorrhage and clinical suspicion for placenta accreta spectrum disorder. Pathology confirmed a placenta increta. Conclusion: Diagnosis of placenta accreta spectrum in the remote postpartum period is uncommon but should be a considered etiology in delayed postpartum hemorrhage. Careful inspection and documentation of the placenta implantation site should occur in cesarean sections because placenta accreta spectrum disorders can remain unnoticed during delivery.

Spontaneous Uterine Vessel Rupture During Pregnancy or in the Puerperium: A Review of the Literature.

Importance: Spontaneous perinatal rupture of a uterine vessel is a rare occurrence that may lead to severe hemorrhage and requires prompt identification and management. Objective: The aim of this study was to examine the etiologies, locations, diagnostic tools, treatment options, and risks in subsequent pregnancies when spontaneous rupture of a uterine vessel occurs in pregnancy. Evidence Acquisition: A literature search was performed by university research librarians using the PubMed, CINAHL, and Web of Science search engines. Identified were 78 cases of perinatal spontaneous uterine vessel rupture and formed the basis for this review. Results: Increased uterine blood flow during pregnancy may alter the integrity of pelvic vessels leading to increased risk of spontaneous rupture. The uterine artery is the most common site of vessel rupture; the second most common site is the uterine-ovarian plexus. The most common presentation is abdominal or pelvic pain, maternal vital sign abnormalities, and an absence of vaginal bleeding. Exploratory laparotomy and embolization (interventional radiology) have been reported as management options. Conclusions: Spontaneous rupture of uterine vessels is a rare but potentially life-threatening complication of pregnancy that should be included in the differential diagnosis of pregnant patients presenting with an acute abdomen. Relevance: Our aim is to increase the awareness of spontaneous vessel rupture during pregnancy to improve detection, management, and perinatal outcomes.

July Effect in Obstetric Outcomes.

OBJECTIVE: The July effect represents the month when interns begin residency and residents advance with increased responsibility. This has not been well studied in Obstetrics and Gynecology residencies and no study has been conducted evaluating obstetric outcomes. The purpose of this study was to evaluate the July effect on obstetric outcomes. Women who delivered between July and September (quarter 1) were compared to those delivering between April and June (quarter 4). METHODS: This retrospective cohort study compared outcomes of deliveries between quarter 1 and quarter 4 from 2017 to 2020. Outcomes evaluated were postpartum length of stay (LOS), postpartum readmission, wound complication, wound infection, blood transfusion, estimated blood loss, 3rd and 4th degree lacerations, 5 min APGAR scores, and cesarean delivery rates. RESULTS: There were 3693 deliveries in quarter 1 and 3107 deliveries in quarter 4. There was a higher incidence Of wound infection during the April-June period (N = 21; 0.68%) compared to July-September (N = 10; 0.27%; p = 0.0135). Although LOS for both periods were the same, the average postpartum LOS during July-September was slightly longer than April-June (1.7 days; SD = 1.1 vs 1.6 days; SD = 1.2; p = 0.0026). All other pregnancy outcomes were similar between the two groups. CONCLUSION: Overall, the July effect is minimal on obstetric complications. However, LOS between July and September may differ because all residents are less experienced in quarter 1. Wound infection rates were higher in April-June, perhaps because new PGY-1s went from assisting to primary on cesarean surgeries starting in the 4th quarter of the year.

Peripartum Hypertensive Crisis Simulation and Education Initiative among Rural Emergency Departments.

OBJECTIVE: To determine whether the introduction of hypertensive bundles through simulation and education would result in the timely assessment and treatment of a simulated patient in a peripartum hypertensive crisis. METHODS: This prospective observational pilot study evaluates the use of simulation and education on hypertension bundled care for peripartum patients in eight rural hospitals. Unannounced simulation exercises were conducted at each hospital. Emergency department staff response was assessed with a checklist. Primary outcomes included time to first antihypertensive medication administered, time to registered nurse assessment, and time to physician assessment. After the initial simulation, nurse educators conducted an in-person didactic on the management of peripartum hypertensive crisis, providing each hospital with materials for local bundle initiation and implementation for hypertensive emergency. The nurse educators conducted the same simulation at the individual sites 3 to 4 months later. Time of intervention improvement pre- and posteducation training scores were analyzed for each of these using a paired t test followed by a Wilcoxon signed-rank test. The average time of intervention improvement among delivering hospitals versus nondelivering hospitals was compared. RESULTS: Eight training simulation and training sessions were conducted at four delivering and four nondelivering hospitals. Seventy-three healthcare workers attended training. The average time decreased from pre- to postsimulation at all of the hospitals (this was not statistically significant, however). The average reduction in time for first nurse assessment was 1.25 ± 10.05 minutes (P = 0.99). The average reduction in time to physician assessment was 4.88 ± 14.74 minutes (P = 0.45). The average reduction of time to administration of first hypertensive medication was 12.0 ± 25.79 minutes (P = 0.15). The average times for nurse or physician assessment and time to first hypertension medication administration were similar between delivering and nondelivering hospitals. CONCLUSIONS: Our study demonstrates a trend toward improved treatment of a peripartum hypertensive emergency through bundled care and simulation. The training reduced the time to first medication given and improved the selection process for the preferred hypertensive medication. The time from nurse care to physician assessment also was reduced. Education in bundled peripartum hypertension care may improve patient outcomes by decreasing hypertension-related maternal morbidity and mortality.

Recurrent gynandroblastoma of the ovary with germline DICER1 mutation: A case report and review of the literature.

Sex cord-stromal tumors (SCSTs) are ovarian tumors that generally present with an adnexal mass and signs/symptoms of hormone excess. Gynandroblastoma is a rare subtype of SCST with a combination of female and male sex cord differentiation. These tumors typically present in premenopausal women and are diagnosed at early stages with benign clinical courses. Here, we present a rare case of recurrent gynandroblastoma in a premenopausal woman with a DICER1 germline mutation. The patient was referred to our clinic for new symptoms of hormonal imbalance with a history of ovarian juvenile granulosa cell tumor (JGCT). Evaluation revealed a 5x5cm complex right adnexal mass and rising inhibin B. Patient underwent total abdominal hysterectomy with right salpingo-oophorectomy, omentectomy and right pelvic and para-aortic lymphadenectomy. Pathology showed a right ovarian gynandroblastoma. Somatic biallelic mutations in the RNase IIIb domain of DICER1 were identified; a 23-gene germline panel confirmed a germline DICER1 pathogenic variant. Cascade testing of her children documented that both daughters inherited the pathogenic variant. Testing for DICER1 mutations has important implications for individual and familial tumor risk assessment given what we know about DICER1 mutation and increased childhood cancer risk.