Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana.

STUDY OBJECTIVE: Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana. DESIGN: Cross-sectional mixed methods. SETTING: Gaborone, Botswana. PARTICIPANTS: Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders. INTERVENTIONS: Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research. MAIN OUTCOME MEASURES: Themes reflecting barriers and facilitators of LARC implementation. RESULTS: The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics' inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs. CONCLUSION: We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

Preconception and Interconception Pediatric Primary Care Utilization of Pregnant and Parenting Teens.

PURPOSE: Gaps in preventive care may contribute to adverse outcomes among pregnant teens. This study quantified teen preventive care utilization before and after pregnancy. METHODS: A continuous retrospective cohort identified 150 teens with a positive pregnancy test (July 2015 to May 2017) at two pediatric primary care sites. Chart review assessed office visits for 18 months before and after the pregnancy test. We also assessed contraceptive counseling, pregnancy outcomes (live birth, miscarriage, termination), and continuity with a single clinician. Demographic factors included age, race, ethnicity, primary insurance, and residential zip code. Logistic regression identified factors associated with visits after pregnancy. Separately, for a cohort of 47 parenting teens who received primary care at the same site as their infants, we assessed teen-infant care after birth. RESULTS: Teens were predominantly non-Latina black (91%) and Medicaid insured (71%). Before pregnancy, most teens had preventive visits (66%) and reported contraceptive use (65%). After pregnancy, 52% discussed pregnancy decisions within a month, 55% reported contraceptive use, and 64% had any primary care visit. Postpregnancy visits were associated with teen age (<18 vs. ≥18 years odds ratio 2.84, 95% confidence interval 1.17-6.90) and pregnancy outcome (termination vs. live birth odds ratio 4.02, 95% confidence interval 1.47-11.01). Among parenting teens, there were more infant visits than teen visits, and continuity was higher for infants. CONCLUSION: In a primary care cohort of pregnant teens, gaps persisted in pediatric clinical follow-up after pregnancy. Particularly in situations where pregnancy led to a birth, pregnancy frequently prompted a transition away from pediatric care.

Clinical, Hormonal, and Metabolic Parameters in Women with Subclinical Hypothyroidism and Polycystic Ovary Syndrome: A Cross-Sectional Study.

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive age women, yet its clinical presentation shares similarities with several other endocrine disorders such as thyroid disease. Hence, the objective of this study was to further evaluate this association by investigating the clinical, hormonal, and metabolic parameters between subclinical hypothyroidism (SCH) and PCOS. METHODS: This is a cross-sectional study conducted in a tertiary care clinic at Cleveland, Ohio, USA. A total of 137 women diagnosed with PCOS by Rotterdam criteria were examined. SCH was defined as thyroid-stimulating hormone >2.5 mIU/L in the absence of symptoms of overt hypothyroidism. The mean age, body mass index (BMI), fasting plasma glucose (FPG), glucose tolerance test, hemoglobin A1c, fasting insulin, a 2 hours insulin level after 75 g glucose load, cholesterol, LDL, HDL, and homeostatic model assessment (HOMA) were compared between women with and without SCH. Logistic regression was used to adjust for age and BMI. RESULTS: Among 137 women with PCOS, 21.9% had SCH. Comparison groups were similar in both age and BMI and there was no difference in the mean values of all endocrine and metabolic parameters tested. However, abnormal FPG levels (OR 3.01; CI: 1.12-8.07. p = 0.03) and abnormal HOMA (OR 3.7; CI: 1.14-12.00. p = 0.03) were more likely in women who had SCH than in women without SCH independent of age and BMI. CONCLUSIONS: Women with PCOS and SCH are more likely to have impaired FPG values and impaired insulin sensitivity even after adjusting for age and BMI. Hence, close monitoring of PCOS patients for SCH may be beneficial.

Surgical anatomy of supraumbilical port placement: implications for robotic and advanced laparoscopic surgery.

OBJECTIVE: To describe the surgical anatomy of the supraumbilical region and to provide guidelines for insertion technique. DESIGN: Educational video. SETTING: Tertiary university hospital. PATIENT(S): A study population of 92 women. INTERVENTION(S): Abdominal thickness was measured from the skin to the anterior peritoneum. Distance to the aorta and the IVC was measured from the anterior peritoneum to the most superficial border of the vessel. Mean values are presented for the distances from the umbilicus to the aorta and the IVC and at 1-cm increments cephalad to the umbilicus. Pearson correlation coefficients and 95% confidence intervals were calculated to describe the association between BMI and the distance and thickness measurements. MAIN OUTCOME MEASURE(S): Abdominal wall thickness, distance to the aorta and inferior vena cava. RESULT(S): Abdominal wall thickness increases the more cephalad above the umbilicus. The distance to the great vessels decreases at 1-cm increments above the umbilicus until 2 cm. The greatest distance from the entry point to the aorta and the IVC is at 5 cm above the umbilicus. However, the abdominal wall is also the thickest at this point, particularly in obese patients. Thus, the overall distance from the skin to the great vessels is reduced as BMI increases. The distal end of the falciform ligament, which is a fold of the peritoneal ligament, is on average 6.5 cm from the umbilicus. CONCLUSION(S): It is prudent for the surgeon to be cognizant of distance variations and risk of vessel injury with obese patients. If the supraumbilical entry is necessary, it is recommended to do so at 5 cm cephalad to the umbilicus. These anatomical relationships should be considered to avoid injury to the aorta and the IVC as well as intraligamentary preperitoneal insufflation.

Accessory and cavitated uterine mass with functional endometrium in an adolescent: diagnosis and laparoscopic excision technique.

STUDY OBJECTIVE: Accessory and cavitated uterine masses (ACUM) with functional endometrium can be treated successfully with laparoscopic excision. The objectives of this report are to illustrate the surgical technique used for the removal of this uterine wall mass and to discuss the patient's clinical course and outcomes. DESIGN: Surgical technique and description of 1 case. SETTING: Department of Obstetrics and Gynecology, University Hospitals Case Medical Center. PARTICIPANT(S): A 16-year-old adolescent presented with severe dysmenorrhea and pelvic pain. Ultrasonographic examination and MRI demonstrated a cystic uterine wall mass distinct from the endometrial cavity. INTERVENTION(S): Laparoscopic excision of uterine mass. RESULTS: Pathologic examination of the mass was consistent with an accessory and cavitated uterine mass. A 9-month follow-up after surgical excision of the mass confirmed complete symptom resolution. CONCLUSIONS: ACUM is a unique and not uncommon pathologic category in the adolescent and young adult population. It is associated with severe and intractable dysmenorrhea and pelvic pain. Laparoscopic excision of these masses is justifiable, safe and feasible.

Standardization of laparoscopic pelvic examination.

OBJECTIVE: To propose a novel standardized and reproducible system to be used for reporting positive and negative findings during diagnostic and operative laparoscopy based on anatomical landmarks. DESIGN: Video presentation of clinical article. The video uses animation and surgical cases to demonstrate a systematic examination of the female pelvis based on anatomical landmarks to establish a standardized way of reporting. SETTING: Tertiary care referral center. PATIENT(S): Not applicable. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): This video demonstrates a proposal to standardize laparoscopic pelvic examinations. The pelvis is topographically divided into two midline zones (zone I and II) and two paired (right and left) lateral zones (zone III and IV). Zone I is the area between the two round ligaments from their origin at the uterine cornua to their insertion in the deep inguinal rings. Zone II is the area between the two uterosacral ligaments from their origin from the back of the uterus to their insertions in the sacrum posteriorly. Zone III is the area between the uterosacral ligament inferiorly and the entire length of the fallopian tube and the infundibulo pelvic ligament superiorly. Zone III contains the tubes and the ovaries. Zone IV is the triangular area lateral to the fallopian tube and the infundibulo pelvic ligament and medial to the external iliac vessels up to the round ligament. CONCLUSION(S): This system is based on standardized anatomical landmarks. It is user friendly, reproducible and allows systemic search of the pelvis to document the presence or absence of any pathology. It could improve diagnostic accuracy, help diagnose lesions in anatomically challenging locations, and provide the required standardization with its clinical and academic advantages. Video is available at http://fertstertforum.com/bedaiwym-standardization-laparoscopic-pelvic-examination/.

Standardization of laparoscopic pelvic examination: a proposal of a novel system.

Objective. Laparoscopic pelvic assessment is often performed in a nonstandardized fashion depending on the surgeon's discretion. Reporting anatomic findings is inconsistent and lesions in atypical locations may be missed. We propose a method for systematic pelvic assessment based on anatomical landmarks. Design. Retrospective analysis. Setting. Tertiary care academic medical center. Intervention. We applied this system to operative reports of 540 patients who underwent diagnostic or operative laparoscopy for unexplained infertility between 2006 and 2012. The pelvis was divided into 2 midline zones (zone I and II) and right and left lateral zones (zone III and IV). All reports were evaluated for the comprehensiveness of description with respect to normal findings or pathology for each zone. Results. Of 540 surgeries, all reports commented on the uterus, tubes, and ovaries (100%), but only 17% (n = 93, 95% CI: 13.8-20.2) commented on the dome of the bladder and the anterior cul-de-sac. 24% (n = 130, 95% CI: 20.4-27.6) commented on the posterior cul-de-sac, and 5% (n = 29, 95% CI: 3.2-6.8) commented on the pelvic sidewall. Overall, 6% (n = 34, 95% CI: 4-8) reported near complete documentation of the pelvic zones. Conclusion. Implementation of a systematic approach for laparoscopic pelvic examination will enhance the diagnostic accuracy and provide better communication between care providers. In the absence of pelvic pathology, we recommend a minimum of 6 photographs of the 6 pelvic zones.