Colposcopy and Loop Electrosurgical Excision Procedure: A Simulated Exercise.

Introduction: Cervical intraepithelial neoplasia 3 is associated with a high degree of progression to cervical cancer. Its risk is markedly reduced after excisional treatment. Hence, it is critical that providers accurately diagnose and treat this condition. We present a simulation-based module focused on resident mastery of performance of colposcopy and loop electrosurgical excision procedure (LEEP). Methods: Learners were obstetrics and gynecology residents. Guidelines on performance of colposcopy and LEEP were presented prior to module participation. We used pelvic task trainers, kielbasa sausages, and routine equipment for performance of colposcopy and LEEP. Colposcopy and LEEP sessions each lasted 30 minutes. Learners completed questionnaires before and after regarding comfort level on aspects of colposcopy and LEEP performance and level of agreement with statements on performing procedures independently. Comfort levels and degrees of agreement were based on 5-point Likert scales (1 = very uncomfortable/strongly disagree, 3 = neither comfortable nor uncomfortable/neutral, 5 = very comfortable/strongly agree, respectively). Results: Modules were held in November 2021 and May 2022. Thirty-four residents participated. Mean comfort scores significantly increased from 3.1 to 4.3 (p < .001) before and after the module for all steps. There was an increase in level of agreement with statements on being able to independently perform colposcopy (2.2 to 3.5, p < .01) and LEEP (2.9 to 3.6, p = .06). Discussion: Simulation-based modules on performance of colposcopy and LEEP significantly increased resident learner comfort in the performance of these procedures. Comfort in performing these procedures is important in providing comprehensive gynecologic care.

Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids.

Background and Objectives: Since the 2014 Food and Drug Administration communication regarding the use of power morcellation, gynecologists have adopted alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by gynecologic surgeons for tissue extraction following minimally invasive hysterectomy or myomectomy for fibroids. Methods: An online survey was distributed to all AAGL members and responses were collected between March 26, 2019 and April 17, 2019. Results: Four hundred thirty-six respondents completed the survey. For hysterectomy, the most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) or minilaparotomy (66.9%). Nearly one-third (31.7%) endorsed using power morcellation. For myomectomy, manual morcellation via minilaparotomy (71.9%) was the most common approach, followed by power morcellation (35.7%). Use of containment bags was common. Minilaparotomy incisions were typically three cm and most often at the umbilicus.Geographic differences were detected, particularly with power morcellation. During hysterectomy, 18.4% of US-based surgeons reported its use, compared to 56.9% of nonUS-based surgeons. During myomectomy, 20.5% of US-based surgeons reported its use compared to 67.5% of their international counterparts. Age, years in practice, fellowship training, and practice location were all significantly associated with power morcellator use. Conclusion: A large majority of practitioners are performing manual morcellation through the colpotomy or minilaparotomy. Use of containment bags is common with all routes of tissue removal. Power morcellation use is less common in the United States than in other countries.

Prevalence of contraindications to progestin-only contraceptive pills in a multi-institution patient database.

OBJECTIVE: We calculated the prevalence of contraindications to progestin-only pills (POPs) among reproductive age women to evaluate the safety of over the counter provision. STUDY DESIGN: This descriptive study queried a multi-institution US database to identify women ages 10 to 45 presenting for preventive care, and a subset of this initial cohort also presenting for contraceptive services, to estimate the prevalence of contraindications to POPs using diagnosis and procedure codes. RESULTS: Among 813,888 females seeking preventive care between 2009 and 2015, 4.36% had a condition associated with a potential risk or unacceptable risk for initiation of POPs, compared to 2.29% of the 71,216 women seeking both preventive care and contraceptive services. Current breast cancer, the only condition classified as an unacceptable risk for initiation, was listed as a diagnosis for 2.67% and 0.57% in each respective group. CONCLUSION: The prevalence of contraindications to POPs among reproductive age women is low. This finding supports the relative safety of an over the counter progestin-only contraceptive pill. IMPLICATIONS: This analysis provides support for the safety of over the counter access to progestin-only contraceptive pills.

Safety of deep sedation without intubation during surgical abortion in the independent clinic setting.

OBJECTIVE: To establish the safety of deep sedation without intubation delivered by a certified registered nurse anesthetist (CRNA) in an independent outpatient abortion setting. STUDY DESIGN: We performed a review of clinic Quality and Patient Safety Reports, a daily-maintained report of complications at time of all dilation and curettage (D&C) and dilation and evacuation (D&E) procedures performed at an independently operated, urban, high-volume abortion clinic between March 2013 and August 2017. The clinic provided procedures through 23 weeks 6 days gestation to women at low risk for medical or surgical complications, referring high-risk procedures to a nearby hospital. A CRNA provided anesthesia for all deep sedation procedures. We extracted information on gestational age, risk factors, and clinical course for all patients who experienced any anesthesia-related complication. RESULTS: During the study period, the clinic evaluated 10,297 women for surgical abortion, referring 292 high-risk cases and performing 10,005 procedures (9004 D&C and 1001 D&E), most (9405 [94%]) with deep sedation. We documented six anesthesia-related complications; three (0.03%) in D&C procedures (laryngospasm not requiring intubation [n = 2] and respiratory stridor) and three (0.30%) in D&E procedures (laryngospasm requiring intubation, seizure, and hypotension/bradycardia). Only one patient (0.01%) required intubation. CONCLUSIONS: Anesthesia-related complications in the setting of deep sedation without intubation during surgical abortion were exceedingly rare, supporting the safety of this form of anesthesia for low-risk patients in an independent community clinic setting. IMPLICATIONS: Independent community clinics, where the majority of abortion procedures are performed within the U.S., can provide safe anesthesia care using deep sedation provided by CRNA professionals. This care delivery model, which includes triaging patient eligibility, reassuringly provides anesthesia as safely as other greater resourced care delivery settings.

Fetal fibronectin, cervical length, and the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage.

OBJECTIVE: The objective of this study is to estimate the risk of preterm birth in patients with an ultrasound or physical exam indicated cervical cerclage based on the results of fetal fibronectin (fFN) and cervical length (CL) screening. METHODS: Retrospective cohort of patients with a singleton pregnancy and an ultrasound or physical exam indicated Shirodkar cerclage placed by one maternal-fetal medicine practice from November 2005 to January 2015. Patients routinely underwent serial CL and fFN testing from 22 to 32 weeks. Based on ROC curve analysis, a short CL was defined as ≤15 mm. All fFN and CL results included are from after the cerclage placement. RESULTS: One hundred and four patients were included. Seventy eight (75%) patients had an ultrasound-indicated cerclage and 26 (25%) patients had a physical exam-indicated cerclage. A positive fFN was associate with preterm birth <32 weeks (15.6% versus 4.2%, p = 0.043), <35 weeks (37.5% versus 11.1%, p = 0.002), <37 weeks (65.6% versus 20.8%, p < 0.001), and earlier gestational ages at delivery (35.2 ± 3.9 versus 37.4 ± 2.9, p = 0.001). A short CL was also associated with preterm birth <35 weeks (50.0% versus 11.9%, p < 0.01), preterm birth <37 weeks (55.0% versus 29.8%, p = 0.033), and earlier gestational ages at delivery (34.8 ± 4.1 versus 37.2 ± 3.0, p = 0.004). The risk of preterm birth <32, <35, and <37 weeks increased significantly with the number of abnormal markers. CONCLUSION: In patients with an ultrasound or physical exam indicated cerclage, a positive fFN and a short CL are both associated with preterm birth. The risk of preterm birth increases with the number of abnormal biomarkers.

The association between second trimester estimated fetal weight and small for gestational age at birth.

OBJECTIVE: To analyze diagnostic accuracy of second trimester ultrasound fetal growth parameters as predictors of small for gestational age (SGA) birth weight. METHODS: We reviewed the fetal biometry from 714 consecutive patients with second trimester ultrasounds. The estimated fetal weight (EFW) and abdominal circumference (AC) percentiles were tested as predictors of SGA at birth (<10‰). RESULTS: 87 (12.2%) patients had an SGA baby. Patients with a second trimester EFW ≤25‰ were significantly more likely to have SGA at birth (24.2% versus 10.3%, p < 0.001). Similar results were seen for women with second trimester AC ≤25‰ (likelihood of SGA 21.9% versus 11.2%, p = 0.013). A second trimester EFW ≤25‰ was a better predictor of SGA at birth than a second trimester EFW ≤ 10‰ (Positive likelihood ratio 2.30 versus 2.09). In the second trimester, only 9 (1.3%) patients had an EFW 0-10‰, only 43 (6%) patients had an EFW 11-20‰, and only 46 (6.4%) patients had an EFW 91-99‰. Each other EFW centile had more than 10% of the patients. CONCLUSIONS: The incidence of second trimester EFW or AC ≤10‰ is less common than expected from standard tables. An EFW ≤25‰ and an AC ≤25‰ should be considered the second trimester marker for risk of SGA at birth. However, due to the low likelihood ratio of, it is not clear if second trimester ultrasound should be used as a predictor of SGA at birth.

Infection and extramural delivery with use of digoxin as a feticidal agent.

BACKGROUND: Many abortion providers use digoxin to induce fetal demise prior to dilation and evacuation (D&E). Our primary objective was to examine the frequency of infection and extramural delivery following digoxin use. STUDY DESIGN: We conducted a retrospective single-cohort study. Inclusion criteria were all women between 18 and 24 weeks of estimated gestational age who received digoxin in preparation for D&E at our outpatient facility. We queried two electronic databases to collect data on the frequency of extramural delivery and the rate of perioperative infection. RESULTS: From January 1, 2000, to December 31, 2008, 4906 abortions were performed between 18 and 24 weeks of estimated gestation with digoxin injection administered as feticidal agent 1 day prior to D&E. Extramural delivery frequency was 0.30%, and infection frequency was 0.04%. There were no significant differences in the frequency of extramural deliveries across procedure year (p = .2), estimated gestational age (p = .3), race/ethnicity (p = .2) or maternal age (p = .3). CONCLUSION: Rates of extramural delivery and infection are acceptably low following digoxin use prior to scheduled D&E.