Association of intrapartum severe maternal morbidity with receipt of postpartum contraception among Medicaid recipients.

OBJECTIVES: We sought to determine the association between intrapartum severe maternal morbidity and receipt of postpartum contraception within 60 days among Medicaid recipients in Oregon and South Carolina. STUDY DESIGN: We conducted a historical cohort study of all Medicaid births in Oregon and South Carolina from 2011 to April 2018. Intrapartum severe maternal morbidity was measured using diagnosis and procedure codes according to the Center for Disease Control's classifications. Our primary outcome of interest was receipt of postpartum contraception within 60 days of birth. We captured permanent and reversible forms of contraception. We examined the association of intrapartum severe maternal morbidity with receipt of postpartum contraception, and whether this varied by type of Medicaid (Traditional vs Emergency). We used Poisson regression models with robust (sandwich) estimation of variance to calculate relative risk (RR) for each model. RESULTS: Our analytic cohort included 347,032 births. We identified 3079 births with evidence of intrapartum severe maternal morbidity (0.9% of all births). When adjusted for maternal age, rural vs urban status, and state of residence, Medicaid beneficiaries with births complicated by intrapartum severe maternal morbidity are 7% less likely to receive any contraception (RR 0.93, 95% CI (0.91, 0.95)) by 60 days postpartum. Among births complicated by severe maternal morbidity we found that Emergency Medicaid recipients were 92% less likely than Traditional Medicaid recipients to receive any method of contraception (RR 0.08, 95% CI (0.08, 0.08)). CONCLUSIONS: Medicaid recipients experiencing intrapartum severe maternal morbidity are less likely to receive contraception within 60 days than Medicaid beneficiaries with uncomplicated births. IMPLICATIONS: Medicaid recipients with intrapartum severe maternal morbidity are less likely to receive postpartum contraception, than Medicaid beneficiaries without severe maternal morbidity.

Efficacy of Tubal Surgery for Permanent Contraception: Considerations for the Clinician.

Permanent contraception meets the needs of many people certain in their decision to never become pregnant in the future. Female permanent contraception procedures became more common than male procedures during the 1970s and 1980s, when laparoscopic surgery became widely available. To better understand the efficacy of these new procedures, the US Centers for Disease Control and Prevention conducted a prospective cohort study, known as the Collaborative Review of Sterilization (CREST). For decades, results of this study have defined perioperative counseling around failure risks of such surgeries. However, laparoscopic technology and techniques have changed significantly in recent decades and evidence has emerged supporting noncontraceptive benefits of tubal excision. Therefore, we present here a review of updated information regarding permanent contraception failure in the modern context and implications for clinical practice and future research directions.

Risk Factors for Endometrial Cancer or Hyperplasia in Adolescents and Women 25 Years Old or Younger.

STUDY OBJECTIVE: To evaluate characteristics of young women with endometrial hyperplasia or cancer. DESIGN: Retrospective chart review. SETTING: Tertiary care referral center. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We included 10- to 25-year-old young women seen at a single institution between 2006 and 2017 with International Classification of Diseases 9th and 10th revision codes for endometrial cancer or hyperplasia (cases), or who underwent an endometrial biopsy with other benign pathologic diagnoses (controls). Exclusions included a diagnosis of Lynch syndrome. Comparisons were made using χ2, Fisher exact, and nonparametric Wilcoxon rank tests. RESULTS: Sixty-nine patients were identified: 13 cases, 54 controls, and 2 exclusions. Of the 13 cases, 3 had endometrial cancer, 5 had complex atypical hyperplasia (now called endometrioid intraepithelial neoplasia), and 5 had hyperplasia without atypia. A higher proportion of cases had a body mass index (BMI) greater than 30, compared with controls (76.9% vs 40.4%; P < .03). The proportion of patients who had a BMI greater than 30 and were smokers was significantly higher among cases (38.5% vs 9.3%; P < .02). The proportion of patients with a history of polycystic ovary syndrome (PCOS) and smoking was also significantly different between groups (30.8% vs 3.7%; P < .01). CONCLUSION: In women aged 25 years and younger with endometrial sampling, a BMI greater than 30 was statistically more common in patients with endometrioid intraepithelial neoplasia or cancer. Although smoking or PCOS alone was not related to endometrial hyperplasia or cancer in this small cohort study, there might be a relationship between endometrial abnormalities and multiple exposures, including smoking and BMI greater than 30 or smoking and a history of PCOS.

Ovarian Torsion in Premenarchal Girls.

STUDY OBJECTIVE: To investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery. DESIGN: Retrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017. SETTING: Large, tertiary care academic institution. PARTICIPANTS: We included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT. INTERVENTIONS: Records were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann-Whitney U test were used for statistical analysis. MAIN OUTCOME MEASURES: Characteristics predictive of OT in premenarchal girls. RESULTS: Twenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group. CONCLUSION: Patients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses.

Harm Reduction for Abortion in the United States.

Access to abortion in the United States has eroded significantly. Accordingly, there is a growing movement to empower women to self-induce abortion. To date, physicians' roles and responsibilities in this changing environment have not been defined. Here, we consider a harm reduction approach to first-trimester abortion as a way for physicians to honor clinical and moral obligations to care for women, negotiate ever-increasing abortion restrictions, and support women who consider abortion self-induction. Harm reduction approaches to abortion have been successfully implemented in a range of countries around the world and typically take the form of teaching women how to use misoprostol. When women self-administer misoprostol, rather than resort to other means such as self-instrumentation or abdominal trauma, to end a pregnancy, maternal mortality falls. There are clinical and ethical benefits as well as limitations to a harm reduction approach to abortion in U.S. SETTINGS: Its legal implications for patients and physicians are unclear. Ultimately, we suggest that despite its limitations, a harm reduction approach may help both physicians and patients.