Emergency Contraception for Patients Taking Isotretinoin.

This Viewpoint explains the need for emergency contraception as the last chance to avoid pregnancy for patients taking isotretinoin.

Trainee Perspectives Regarding the Effect of the Dobbs v. Jackson Women's Health Organization Supreme Court Decision on Obstetrics and Gynecology Training.

Objectives: We aimed to describe obstetrics and gynecology (OBGYN) trainees' anticipation of how the Dobbs v. Jackson Women's Health Organization (Dobbs) U.S. Supreme Court decision may affect their training. Methods: A REDCap survey of OBGYN residents and fellows in the United States from September 19, 2022, to December 1, 2022, queried trainees' anticipated achievement of relevant Accreditation Council for Graduate Medical Education (ACGME) training milestones, their concerns about the ability to provide care and concern about legal repercussions during training, and the importance of OBGYN competence in managing certain clinical situations for residency graduates. The primary outcome was an ACGME program trainee feeling uncertain or unable to obtain the highest level queried for a relevant ACGME milestone, including experiencing 20 abortion procedures in residency. Results: We received 469 eligible responses; the primary outcome was endorsed by 157 respondents (33.5%). After correction for confounders, significant predictors of the primary outcome were state environment (aOR = 3.94 for pending abortion restrictions; aOR = 2.71 for current abortion restrictions), trainee type (aOR = 0.21 for fellow vs. resident), and a present or past Ryan Training Program in residency (aOR = 0.55). Although the vast majority of trainees believed managing relevant clinical situations are key to OBGYN competence, 10%-30% of trainees believed they would have to stop providing the standard of care in clinical situations during training. Conclusions: This survey of OBGYN trainees indicates higher uncertainty about achieving ACGME milestones and procedural competency in clinical situations potentially affected by the Dobbs decision in states with legal restrictions on abortion.

Examining negative urgency as a predictor of eating disorder maintenance in purging syndromes.

OBJECTIVES: Negative urgency is associated with short-term maintenance of binge eating and purging in unselected samples. The current study used an eating disorder sample to test the hypothesis that negative urgency maintains bulimia nervosa (BN) and purging disorder (PD) at long-term follow-up. It was also hypothesized that baseline differences in negative urgency between BN and PD would remain at follow-up. METHODS: Secondary analyses were conducted on a sample of women who engaged in recurrent self-induced vomiting (n = 68; 52.9% BN; 47.1% PD). Women completed diagnostic interviews and questionnaires at baseline and at a mean (SD) of 5.95 (1.58) years follow-up (range = 2.51-9.62; retention rate = 75%). RESULTS: Negative urgency did not predict eating disorder diagnostic status, recovery status, or global eating pathology at follow-up (p's = .06-.83). There were no significant differences in negative urgency across women with BN and PD at follow-up (p = .16). However, post hoc analyses indicated that negative urgency was not stable across time (ICC = .102). Increases in negative urgency from baseline to follow-up were associated with greater global eating pathology at follow-up (p = .002). CONCLUSION: Results suggest negative urgency does not predict long-term eating disorder maintenance. Negative urgency may not be a stable personality trait but rather an indicator of overall poor emotion regulation. Future research should confirm that changes in negative urgency predict chronic eating pathology over long durations of follow-up in women who have increasing negative urgency across time.

Status of abortion curriculum in genetic counseling: Survey of graduate programs and recent graduates in the United States.

Genetic counselors (GCs) are trained to help individuals navigate the medical and psychological implications of genetic test results, familial conditions, and ultrasound anomalies. Therefore, familiarity with reproductive options, including abortion, is vital. However, previous studies have found gaps in GCs' knowledge regarding abortion care and there are currently no recommendations regarding abortion curriculum. This study aimed to assess the state of abortion curriculum in genetic counseling graduate programs in the United States and to examine and compare the satisfaction levels of program representatives and recent graduates. Program representatives and recent graduates were invited to complete an anonymous survey evaluating the abortion curriculum, satisfaction with said curriculum, and perceived preparedness to counsel on abortion. Quantitative data from 46 program representatives and 123 recent graduates were analyzed using descriptive statistics and appropriate statistical analyses, including the Mann-Whitney U-test and the Kruskal-Wallis test. Large variability existed in the amount and types of abortion training. Results showed greater satisfaction and feelings of preparation to counsel on abortion in graduates whose program provided a dedicated abortion curriculum (p < 0.001, p = 0.005). In addition, graduates with abortion counseling experience felt less prepared to counsel on abortion than their programs believed them to be (p = 0.04). Graduates perceived procedural timing, facilitation of genetic testing, and resources/support desired by patients before, during, or after an abortion, to be the most important topics, although these were not included in all programs' curriculum. Program representatives and recent graduates alike noted that variability in clinical training is a barrier to abortion education. Our results demonstrate a need for curricular reform to reduce variability in training and ensure that all graduates receive the same foundational abortion education. Further research is needed to determine the scope of GCs in abortion care, as well as which topics and education formats are most helpful in graduate education.

Maternal and child life years gained by transfusing low titer group O whole blood in trauma: A computer simulation.

BACKGROUND: Using low titer group O whole blood (LTOWB) is increasingly popular for resuscitating trauma patients. LTOWB is often RhD-positive, which might cause D-alloimmunization and hemolytic disease of the fetus and newborn (HDFN) if transfused to RhD-negative females of childbearing potential (FCP). This simulation determined the number of life years gained by the FCP and her future children if she was resuscitated with LTOWB compared with conventional component therapy (CCT). METHODS: The model simulated 500,000 injured FCPs of each age between 0 and 49 years with LTOWB mortality relative reductions (MRRs) compared with components between 0.1% and 25%. For each surviving FCP, number of life years gained was calculated using her age at injury and average life expectancy for American women. The number of expected future pregnancies for FCPs that did not survive was also based on her age at injury; each future child was assigned the maximum lifespan unless they suffered perinatal mortality or serious neurological events from HDFN. RESULTS: The LTOWB group with an MRR 25% compared with CCT had the largest total life years gained. The point of equivalence for RhD-positive LTOWB compared to CCT, where life years lost due to severe HDFN was equivalent to life years gained due to FCP survival/future childbearing, occurred at an MRR of approximately 0.1%. CONCLUSION: In this model, RhD-positive LTOWB resulted in substantial gains in maternal and child life years compared with CCT. A >0.1% relative mortality reduction from LTOWB offset the life years lost to HDFN mortality and severe neurological events.

Impact of the Affordable Care Act on Prescription Contraceptive Use and Costs Among Privately Insured Women, 2006-2020.

BACKGROUND: In the years immediately following the Affordable Care Act (ACA)'s contraceptive coverage requirement, out-of-pocket costs fell for all Food and Drug Administration-approved contraceptive methods and use of long-acting reversible contraception (LARC) increased. This analysis examines whether these trends have continued through 2020 for privately insured women. METHODS: Using 2006-2020 MarketScan data, we examined trends in prescription contraceptive use and out-of-pocket costs among women 13 to 49 years old. Multivariable analyses model the likelihood of contraceptive use and paying $0 post-ACA requirement (vs. pre-ACA requirement) for contraception, controlling for age group, U.S. region, urban versus rural, and cohort year. RESULTS: The likelihood of LARC insertion increased post-ACA requirement (adjusted odds ratio [aOR] 1.127, 95% confidence interval [CI] 1.121-1.133), with insertion rates peaking at 3.73% for intrauterine devices (IUDs) and 1.08% for implants in 2019, before declining with the onset of the COVID-19 pandemic in 2020. Although the likelihood of paying $0 for LARC increased after the ACA requirement (IUD: aOR 5.495, 95% CI 5.278-5.716; implant: aOR 7.199, 95% CI 6.992-7.412), the proportion of individuals paying $0 declined to 69% for IUDs and 73% for implants in 2020, after having peaked at 88% in 2014 and 90% in 2016, respectively. For oral contraceptives, both use (aOR 1.028, 95% CI 1.026-1.030) and paying $0 (aOR 20.399, 95% CI 20.301-20.499) increased significantly after the ACA requirement. CONCLUSION: With the exception of oral contraceptives, the proportion of individuals paying $0 for all contraceptive methods declined after peaking in 2014 for IUDs, 2016 for the implant, and 2019 for non-LARC methods. Future monitoring is needed to understand the continuing impact of the ACA requirement on prescription contraceptive use and costs.

The association between abortion training and obstetrics and gynecology resident competence and intention to provide abortion care before Dobbs.

OBJECTIVE: To assess the role of abortion training in fourth-year obstetrics and gynecology (OBGYN) residents' abortion care competence and practice intentions before the Dobbs decision. STUDY DESIGN: This is a planned secondary analysis of survey data of fourth-year U.S. OBGYN residents. Abortion training was defined as 'routine' if automatically included in schedules, ''optional'' if not scheduled but available, and ''not available''. Self-assessed competence was defined as feeling prepared to independently provide care. Participants were asked about their competence and post-residency intentions to provide specific aspects of pregnancy loss and induced abortion care. RESULTS: Of 1241 fourth-year residents, 885 (71%) completed the questions of interest. For each skill, more residents with routine training reported competence compared to those with less comprehensive training. More residents with routine training reported intentions to include abortion care in practice (422, 79%) compared to residents with optional (171, 66%) or no training (51, 55%), p < 0.001). Residents with routine training were nearly six times more likely to intend to provide medication abortion post-residency compared to residents without training; more residents in all groups reported intentions to provide care for pregnancy loss compared to abortion. CONCLUSIONS: Pre-Dobbs, residents with routine abortion training had greater self-assessed competence in abortion care than those with optional or no training and were more likely to intend to provide this after residency. Given the evolving impacts of the 2022 reversal of Roe v Wade, residency training programs must work to ensure routine access to legally permissible abortion training as routine training is associated with intention to provide fundamental, reproductive healthcare. IMPLICATIONS: Routine training in abortion care during OBGYN residency is associated with higher competence and intention to provide post-residency - availability of this training Is severely compromised in restricted states post-Dobbs.

Judicial bypass for minors post-Dobbs.

State laws that require minors seeking abortion care to notify or obtain consent from a parent or other legal guardian are broadly referred to as parental involvement laws. Judicial bypass allows a minor to petition the court to bypass parental involvement. Even before the Dobbs v Jackson Women's Health Organization decision overturned Roe v Wade on 24 June 2022, 36 states had at least one parental involvement law, making minor access to abortion care even more complex than adult access. Since the Dobbs decision, at least 15 states have completely banned abortion, adding further complexity, geographic barriers, and inequities to the pursuit of reproductive healthcare. In this narrative review and commentary, we explain parental involvement laws and judicial bypass from both a legal and medical perspective, exploring the evolving challenges created by this system in the year post-Dobbs.

Induced Abortion and the Risk of Rh Sensitization.

Importance: While population-level data suggest Rh immunoglobulin is unnecessary before 12 weeks' gestation, clinical evidence is limited. Thus, guidelines vary, creating confusion surrounding risks and benefits of Rh testing and treatment. As abortion care in traditional clinical settings becomes harder to access, many people are choosing to self-manage and need to know if ancillary blood type testing is necessary. Objective: To determine how frequently maternal exposure to fetal red blood cells (fRBCs) exceeds the most conservative published threshold for Rh sensitization in induced first-trimester abortion. Design, Setting, and Participants: Multicenter, observational, prospective cohort study using high-throughput flow cytometry to detect circulating fRBCs in paired maternal blood samples before and after induced first-trimester abortion (medication or procedural). Individuals undergoing induced first-trimester abortion before 12 weeks 0 days' gestation were included. Paired blood samples were available from 506 participants who underwent either medical (n = 319 [63.0%]) or procedural (n = 187 [37.0%]) abortion. Exposure: Induced first-trimester abortion. Main Outcomes and Measures: The primary outcome was the proportion of participants with fRBC counts above the sensitization threshold (125 fRBCs/5 million total RBCs) after induced first-trimester abortion. Results: Among the 506 participants, the mean (SD) age was 27.4 (5.5) years, 313 (61.9%) were Black, and 123 (24.3%) were White. Three of the 506 participants had elevated fRBC counts at baseline; 1 of these patients had an elevated fRBC count following the abortion (0.2% [95% CI, 0%-0.93%]). No other participants had elevated fRBC counts above the sensitization threshold after induced first-trimester abortion. The median change from baseline was 0 fRBCs, with upper 95th and 99th percentiles of 24 and 35.6 fRBCs, respectively. Although there was a strong association between the preabortion and postabortion fRBC counts, no other baseline characteristic was significantly associated with postabortion fRBC count. Conclusions and Relevance: Induced first-trimester abortion is not a risk factor for Rh sensitization, indicating that Rh testing and treatment are unnecessary before 12 weeks' gestation. This evidence may be used to inform international guidelines for Rh immunoglobulin administration following first-trimester induced abortion.

Elevated fullness and bloating as correlates of eating pathology: Implications for screening.

A minority of individuals with eating disorders report being asked about their eating by health care professionals; delayed detection of eating disorders may contribute to poorer outcomes. The current study investigated common meal-related gastrointestinal symptoms (i.e., elevated fullness and bloating) as correlates of eating pathology that may be more readily disclosed to health professionals and indicate the need to assess for eating pathology. The current study also tested the hypothesis that elevated fullness and bloating are more strongly linked to eating pathology among those with higher body dissatisfaction. 281 university students (70.1% female, 84.3% white) completed gastrointestinal symptom and eating pathology assessments. Elevated fullness and bloating were each associated with increased purging, restrictive eating behaviors, and likelihood of having an eating disorder. Elevated fullness and bloating were more strongly linked to purging and probable eating disorder diagnosis with higher, relative to lower, body dissatisfaction. However, body dissatisfaction did not moderate the relationship between gastrointestinal symptoms and restrictive eating behaviors. Results indicate that elevated fullness and bloating are correlates of eating pathology. Healthcare professionals should consider and/or assess for eating pathology when elevated fullness and bloating are reported; further assessment of body dissatisfaction may be helpful in identifying purging behaviors.

Binge eating in patients pursuing bariatric surgery: understanding relationships with food insecurity and adverse childhood experiences.

BACKGROUND: Positive relationships exist between adult food insecurity and binge eating, and between adverse childhood experiences and binge eating. However, the nature of these relationships remains to be determined. OBJECTIVES: The current study sought to examine the association between binge eating and childhood abuse and/or neglect and household dysfunction and to explore whether the strength of the relationship between adverse childhood experiences and binge eating differs across levels of food insecurity in patients seeking bariatric surgery. SETTING: University Hospital in the Appalachian region of United States. METHODS: A total of 366 adults seeking bariatric surgery completed validated questionnaires as a component of a routine psychological evaluation prior to surgery. RESULTS: Only childhood experiences of abuse and/or neglect were positively related to adult binge eating, r(363) = .13, P = .011. Food insecurity moderated the relationship between adverse childhood experiences and binge eating, F(4, 358) = 242.98, P < .001, such that the relationship was stronger for individuals who endorsed the presence of both food insecurity and adverse childhood experiences (M = 15.90; standard deviation [SD] = 8.38), relative to individuals who endorsed the absence of both food insecurity and adverse childhood experiences (M = 11.19; SD = 7.91; Tukey P = .005; d = .58). CONCLUSIONS: Food insecurity strengthens the relationship between adverse childhood experiences and adult binge eating. Results suggest that healthcare providers should include assessments of both adverse childhood experiences and food insecurity to identify patients who may be at risk for disordered eating prior to surgery, as these individuals may require additional interventions to address binge eating and related factors.

Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care.

Legal, institutional, and payer policies regulating reproductive health care lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may affect the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive health care including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive health care.

Managing Undesired Pregnancy After Dobbs.

Although both medication abortion (MAB) and aspiration procedures are safe and effective, the Supreme Court decision in Dobbs v. Jackson Women's Health Organization removed federal protection of access to abortion services. Abortion access is now illegal or severely limited in many states, leading to delays in abortion care for patients in all states. In this rapidly evolving landscape, primary care physicians (PCPs) must be familiar with laws surrounding abortion care in their own and neighboring states. PCPs must also be prepared to expedite abortion care by sharing resources, obtaining testing when needed, and counseling patients about expected outcomes following abortion.

Society of Family Planning committee consensus on Rh testing in early pregnancy.

Historical evidence that fetal red blood cell (RBC) exposure during early spontaneous or induced abortion can cause maternal Rh sensitization is limited. A close reading of these studies indicates that forgoing Rh immunoglobulin administration before 12weeks gestation is highly unlikely to increase risk of Rh (D) antibody development, and recent studies indicate that fetal RBC exposure during aspiration abortion <12 weeks gestation is below the calculated threshold to cause maternal Rh sensitization, and the amount of fetomaternal hemorrhage during dilation and evacuation procedures up to 18weeks gestation is adequately treated with 100mcg of Rh immunoglobulin. We provide updated recommendations for Rh immunoglobulin administration based on this new evidence.

Association of Provider Specialty With Abortion-Related Morbidity and Adverse Events Among Patients Having Procedural and Medication Abortions.

OBJECTIVE: Since abortion was legalized throughout the United States in 1973, states have passed restrictive abortion policies, including permitting only obstetrician-gynecologist physicians (OBGYNs) to provide abortions. We are unaware of any research that directly compares patient safety-related outcomes by physician specialty. In this study, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus OBGYNs. STUDY DESIGN: Using the IBM Watson Health MarketScan claims database, we identified privately insured individuals who had an induced abortion between January 1, 2011, and December 31, 2014. The primary outcome was major abortion-related morbidity or adverse events, and the secondary outcome was any abortion-related morbidity or adverse events occurring within 6 weeks of the abortion. RESULTS: The study cohort included 34,764 patients who had 35,407 abortions-4,843 (13.7%) abortions provided by physicians of other specialties and 30,564 (86.3%) abortions provided by OBGYNs. Major and any abortion-related morbidity or adverse event occurred in 115 (0.3%) and 1,271 (3.6%) of 35,407 of abortions, respectively. In adjusted analyses, there was no statistically significant difference in major abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 1.02; 95% confidence interval, 0.59-1.75), and no statistically significant difference in any abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 0.91; 95% confidence interval, 0.77-1.09). CONCLUSIONS: There were no differences in abortion-related morbidity or adverse events by physician specialty. Our findings do not support state laws limiting abortion care to OBGYN physicians.

Trauma and Alcohol Use Among Transgender and Gender Diverse Women: An Examination of the Stress-Buffering Hypothesis of Social Support.

Transgender and gender diverse (TGD) women (i.e., individuals who were assigned male at birth and identify as women or trans women) experience trauma at disproportionate rates compared to cisgender populations. While trauma is associated with increased alcohol use among TGD women, research regarding factors that are protective of this association is scant. The stress-buffering hypothesis of social support suggests that perceived social support, defined as the judgment that social network members will be helpful when individuals experience stress, may buffer and reduce the association between trauma symptoms and alcohol use. However, this relationship has not been examined among TGD women. We examined whether perceived social support moderates the association between trauma and alcohol use among 89 TGD women. Exploratory multiple regression analyses provided support for this hypothesis, insofar as trauma symptoms were related to alcohol use by individuals with low, relative to high levels of perceived social support. Exploratory analyses demonstrated that this finding was driven by perceived social support from friends and family. Our results are the first to suggest that social support reduces alcohol use among TGD women and add to the literature on their trauma and alcohol use.