The impact of genetic counseling on women's grief and coping following termination of pregnancy for fetal anomaly.

Pregnancy termination for fetal anomaly (TFA) is a unique experience that can cause women to develop long-term complicated grief. Although a woman's experience with her healthcare providers has been previously identified as an important factor in coping, studies have shown that many women report their health care as lacking to some extent. Given the overlap in women's needs and the practice scope of a genetic counselor (GC), this study aimed to examine how genetic counseling may impact coping and explore women's expectations of GCs pre- and post-TFA. An online survey, which included the brief COPE and the short version of the Perinatal Grief Scale, was distributed among private online support groups. Appropriate statistical analysis tools, such as the Wilcoxon rank-sum and t test, were utilized for quantitative analysis of the 124 responses, and inductive content analysis was utilized for qualitative analysis. Of those who underwent TFA within the last two years, women who saw a GC utilized active coping, planning, and positive reframing significantly more than women who did not see a GC (p = 0.001, p = 0.031, p = 0.027, respectively). GCs were perceived to have a positive impact on coping when providing information, objective care, emotional support, support resources, and follow-up care; these practices encouraged confidence in their personal decision-making and gave women hope for the future. This study not only identified key counseling roles for GCs prior to a TFA, but also demonstrated that genetic counseling prior to TFA may be beneficial to coping. Further studies are warranted to explore the needs of a more diverse population and to identify appropriate genetic counseling training methods to support women pursuing TFA.

Management and reproductive counseling in cervical, caesarean scar and interstitial ectopic pregnancies over 11 years: identifying the need for a modern management algorithm.

STUDY QUESTION: Do management strategies (treatment type and order), including provision of reproductive counseling, differ in patients with non-tubal pregnancies? SUMMARY ANSWER: Medical and surgical treatment strategies varied widely for each type of non-tubal pregnancy and reproductive counseling in this patient population is lacking. WHAT IS KNOWN ALREADY: Owing to the rarity of non-tubal pregnancies, there is no consensus regarding treatment strategies or protocol. Furthermore, there is limited data on how patients with a non-tubal pregnancy are counseled about future fertility. STUDY DESIGN SIZE DURATION: This is a descriptive retrospective study. Data were collected from January 2006 to December 2017. A total of 50 patients were included in the study. PARTICIPANTS/MATERIALS SETTING METHODS: Patients with an ultrasound diagnosis of a non-tubal ectopic pregnancy (e.g. cervical ectopic pregnancy [CEP], Caesarean scar pregnancy [CSP] or interstitial ectopic pregnancy [IEP]) were included. This study was performed at a university-based institution tertiary referral center. Demographic and clinical characteristics, treatment type and order, reproductive counseling and outcomes were collected. Descriptive statistics were used for analyses. MAIN RESULTS AND THE ROLE OF CHANCE: Of the 50 patients identified, 13 were CEP (26%), 8 were CSP (16%) and 29 were IEP (58%). Patients with a CSP had a higher parity (median = 3, P = 0.02) and number of prior Caesarean deliveries (mean = 2.1, P < 0.001). A total of 66% (23/35) of patients expressed a desire for future fertility prior to treatment and only 56% (28/50) of patients received reproductive counseling according to the electronic medical records. Among all non-tubal pregnancies, there were variations in the type and the order of treatments that patients received. LIMITATIONS REASONS FOR CAUTION: This study was performed in a tertiary referral center therefore the management strategy could have been influenced by the prior interventions and patient response. The descriptive retrospective design precluded any assumption of causation. WIDER IMPLICATIONS OF THE FINDINGS: The management for non-tubal pregnancies has wide variations. Reproductive counseling in this patient population is lacking. The findings highlight the need for the development of a treatment algorithm and a reproductive counseling protocol for each non-tubal pregnancy to better standardize treatment strategy. STUDY FUNDING/COMPETING INTERESTS: There was no funding for this study. The authors have no conflict of interest to report.

Women's Health Care Teams and the Future of Obstetrics and Gynecology.

Health care delivery is in a stage of transformation and a meaningful change in provision of care must also be accompanied by changes in the educational process of health care professionals. This article lays out a roadmap to better prepare obstetrician-gynecologists (ob-gyns) to succeed in interdisciplinary women's health care teams. Just as our current educational programs emphasize the development of competent surgical skills, our future programs must encourage and support the development of communication, teamwork, and leadership skills for ob-gyns. Formal integration of these fundamentals at all levels of the health care training continuum will create an educational system designed to equip all practitioners with a basic level of knowledge and provide opportunities to acquire additional knowledge and skills as needs and interest dictate. Integral to the implementation will be the evaluation of the effects of the contributions of interprofessional education on patient, practice, and health system outcomes. Successful demonstration of value will lead to the sustainability of the educational programs through recognition by physicians, health care teams, academia, health care systems, and payers.

Utility of Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) score in maternal admissions to the intensive care unit.

OBJECTIVE: A mean Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) score of > 50 is associated with increased intensive care unit mortality rate in nonpregnant cardiac and trauma patients. The objective was to determine the usefulness of the APACHE III score in maternal admissions to an intensive care unit in a tertiary care center in an urban multicultural city. STUDY DESIGN: This was a retrospective review of all maternal admissions (> 20 weeks of gestation or after delivery) to an intensive care unit between January 2002 and May 2004. Demographics, obstetric and medical history, and 20 physiologic variables that comprise the APACHE III were recorded. The minimum APACHE III score (lowest risk of death) is 0; maximum is 299. The association between APACHE III score and maternal death was assessed with Mann Whitney U test. Significance was assumed at a probability value of < .05. RESULTS: Fifty-eight subjects met the study criteria. Thirty percent of these women were admitted antepartum (27 +/- 1.0 weeks of gestation); 31% of the women were admitted on the day of delivery; and 29% of the women were admitted after delivery. Mean maternal age was 27 +/- 6.7 years. Acute conditions that resulted in transfer to the intensive care unit included preeclampsia (24%), cardiorespiratory disease (21%), hemorrhage (16%), infection (12%), trauma (7%), and thromboembolism (3%). Fifty-five percent of the women had no previous underlying obstetric complications, and 98% of the women had no underlying chronic health condition. Fifty-eight percent of the women received care in a medical intensive care unit; 28% of the women received care in a surgical intensive care unit; 10% of the women received care in a cardiac intensive care unit, and 3% of the women received care in a neurologic intensive care unit. The mean intensive care unit stay was 3.7 +/- 4.6 days, and the mean hospital stay was 9.0 +/- 7 days. Three patients died; the rest of the patients went home in good condition. The median APACHE III score was 34 (range, 14-102) and was not correlated with maternal death. CONCLUSION: The APACHE III is not associated with risk of intensive care unit-related maternal death.

Racial bias in patient selection of an obstetrician.

OBJECTIVE: The objective of this study was to determine racial bias in patient selection of an obstetrician. METHODS: Obstetrical patients referred for genetic counseling at a community hospital were included. Self-reported patient race/ethnicity were compared with obstetrician's race/ethnicity. RESULTS: The patient population (n = 1,519) was 27.8% white, 25% Hispanic, 22.5% black, 20.5% Asian, and 4.3% other. Physician race/ethnicity was 47.8% white, 28.8% Asian, 14.4% Hispanic, and 9% black. Patient race/ethnicity and physician race/ethnicity were correlated (contingency coefficient = 0.54, P < 0.001). White and Asian patients were more likely to select obstetricians of their own racial background (72.7% and 66.6%) than were Hispanic or black patients (36% and 24.6%, P < 0.001). Patients of all races were more likely to be under the care of a physician of their own race than of a different race. CONCLUSIONS: In an urban community with a racially diverse population, there is a strong racial bias in patient selection of an obstetrician.

Burnout in residency: a statewide study.

OBJECTIVE: To determine the prevalence of burnout in residents in obstetrics and gynecology through the use of a validated tool. METHODS: The Maslach Burnout Inventory Human Services questionnaire is a previously validated tool that measures burnout. Obstetrics and gynecology residents from Texas were invited to participate in this study in 2002. The Maslach Burnout Inventory Human Services questionnaire and a demographic survey were distributed to each resident. Responses were anonymous and returned by mail. Contingency coefficient and chi2 tests were used for analysis; values of P < 0.05 were significant. RESULTS: Residents (n = 368) from 17 programs in Texas were surveyed. Responses were received from 14 programs (82.4%), with 136 surveys (37%) returned. Overall, 38.2% reported high emotional exhaustion, 47.1% reported high depersonalization, and 19.1% reported reduced personal accomplishment. The number of residents experiencing true burnout (high emotional exhaustion, high depersonalization, and low personal accomplishment) was 17.6% (n = 24). CONCLUSIONS: High levels of emotional exhaustion and depersonalization occur in some residents. Burnout in residents included in this study was approximately 18%.

Occupational stress among obstetrician/gynecologists.

OBJECTIVE: Our objective was to assess occupational stress in obstetrician/gynecologists using a standardized, validated tool. METHODS: The Osipow Occupational Stress Inventory, which measures occupational stress (occupational roles questionnaire [ORQ]), psychological strain (personal strain questionnaire), and coping resources (personal resources questionnaire), was distributed to 277 obstetrician/gynecologists in Houston. The chi2 or Fisher's exact test was used where appropriate. RESULTS: Sixty-nine surveys were analyzed. Median T scores for all subscales were within the normal range. Abnormal scores were recorded by 22 physicians (31%) on at least one subscale of the ORQ, by 5 physicians (7%) on at least one subscale of the personal strain questionnaire, and by 6 physicians (9%) on at least one subscale of the personal resources questionnaire (P < 0.05). Abnormal scores occurred more frequently in the ORQ domain. Generalists had significantly more abnormal scores than did subspecialists (P < 0.05). CONCLUSION: Occupational stress is common among obstetrician/gynecologists. This appears to be balanced by good coping skills.

Job satisfaction among program directors in obstetrics and gynecology: a national portrait.

OBJECTIVES: The purpose of this study was to determine job satisfaction among program directors in obstetrics and gynecology with the use of a validated tool and to identify specific sources of dissatisfaction that might lead to job change. STUDY DESIGN: The program director satisfaction and a global job satisfaction survey were sent to all program directors in the United States. Motivators for seeking a job change were assessed. The chi(2) test, Kruskal-Wallis test, correlation analysis, and multiple linear regression were used. RESULTS: Seventy percent of 254 surveys were completed. Global job satisfaction (minimum, 4; maximum, 16) was 11.9+/-2.9; mean program director satisfaction score was 135+/-25.8 (minimum, 54; maximum, 200). Job satisfaction was highest in chairs, full professors, those whose age was >50 years, and those with >5 years of experience (P=.02) and in facets that were related to work with residents, colleagues, and patients. Dissatisfaction was highest with regard to salary, promotion opportunities, and resources. Forty-six percent of those who responded were considering a job change in 3 years; the most common reason for a job change that was cited was administrative hassles. CONCLUSION: Although job satisfaction is high among program directors, administrative hassles may lead to high rate of rapid turnover.

Work hours for practicing obstetrician-gynecologists: the reality of life after residency.

OBJECTIVE: Recently the Accreditation Council for Graduate Medical Education placed restrictions on all residency programs that limited work hours to 80 hours per week. The objective of this study was to determine the work hours for practicing obstetrician-gynecologists in an urban center. STUDY DESIGN: A questionnaire about physician demographics and work hours was mailed to all obstetrician-gynecologists in Houston in June 2002. Chi(2) testing was used for statistical analysis. RESULTS: One hundred eighty-nine surveys were mailed. One hundred surveys (56%) were returned complete and analyzed. Sixty-two physicians reported working >80 hours per week. Physicians were more likely to work >80 hours per week if they were men or if they were >50 years old. Marital status and having children living at home did not affect work hours. CONCLUSION: Most obstetrician-gynecologists in Houston work longer hours than the number of hours that is imposed by the Accreditation Council for Graduate Medical Education resident work hour guidelines.

Laparoscopy in gynecologic emergencies.

Laparoscopy is ideal for the diagnosis of acute pelvic pain and the treatment of gynecologic emergencies. It is as safe and effective as laparotomy for the treatment of ectopic pregnancy, ovarian cysts, dermoid cysts, and adnexal torsion. Treatment with laparoscopy results in shorter hospital stay and faster recovery. Future fertility is not compromised and in some cases may be improved with laparoscopic treatment. There are also studies suggesting that laparoscopy can be used safely for the diagnosis and treatment of gynecologic emergencies in the first and second trimester of pregnancy.