Adherence to the American Society for Colposcopy and Cervical Pathology guidelines: an observational study.

OBJECTIVE: The 2012 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines were developed to provide guidance regarding cervical pathology and to minimize overtreatment of lesions that may resolve spontaneously. We aimed to evaluate the adherence to these guidelines with referrals for colposcopy at a large academic center and to understand the factors associated with incorrect referrals. METHODS: This retrospective observational study involved women referred to the Virginia Commonwealth University for colposcopy or loop electrosurgical excision procedure from January 2015 to December 2016. RESULTS: Referral requests from 430 women were reviewed. Among these, 17.4% were discordant with the ASCCP guidelines. The most common discordant colposcopy referrals were low-grade squamous intraepithelial lesions (48%) and atypical squamous cells of undetermined significance (29%). The possibility of incorrect referrals was decreased among highgrade lesions (odds ratio [OR], 0.03), while it was increased in women aged <25 years (OR, 31.6) and in those referred by family medicine (OR, 3.6) or internal medicine (OR, 4.4). Ten patients were referred for cervical cytology results of samples collected from the vaginal cuffs despite hysterectomies performed for benign lesions. CONCLUSION: Patients referred outside of the guidelines were most often women aged <25 years with low-grade lesions. Referrals outside evidence-based guidelines may lead to unnecessary procedures and additional healthcare expenses. Our results help identify the areas for provider education and potential areas of concern regarding the implementation of the 2019 ASCCP guideline updates.

Single-Dose Levonorgestrel Emergency Contraception and Silent Barriers to Its Access: Is It Really Just One Step?

BACKGROUND: Single-dose levonorgestrel has been legally available over the counter in the United States without age restriction since 2013. The objective of this study was to discover if there are barriers to access and to determine if such barriers vary based on the gender of the person making the purchase. MATERIALS AND METHODS: A male and female caller contacted 146 Richmond, Virginia pharmacies listed on the Plan B One Step® website. Ultimately, these callers interviewed 90 pharmacies via phone and used a rehearsed standardized script to ask eight questions regarding emergency contraception (EC) in relation to availability, age restrictions, parental consent, counseling requirements, and a male's ability to purchase the product. The statistical data were analyzed using Fisher's exact test. RESULTS: Pharmacy employees provided incorrect information to both men and women regarding age restrictions for purchasing Plan B One Step 51% of the time. However, only seven of the pharmacy employees counseled that males were unable to purchase the medication. Both callers received correct information regarding parental consent and in-store counseling at the time of purchase. Pharmacy technicians provided the majority of information, and the male caller was more likely to be transferred to another person when requesting the medication (9 vs. 0 transfers for the male and female callers, respectively). CONCLUSION: Given the inconsistent data provided to the public regarding the purchase of EC, clinicians are obligated to convey accurate up-to-date information to patients about emergency contraceptive products as part of their counseling and should not assume that consumers receive accurate information when inquiring about over-the-counter EC.

Implementation of a Hydrotherapy Protocol to Improve Postpartum Pain Management.

INTRODUCTION: A growing number of women are seeking alternatives to traditional pharmacologic pain management during birth. While there has been an extensive array of nonpharmacologic options developed for labor, there are limited offerings in the postpartum period. The purpose of this quality improvement project was to implement a hydrotherapy protocol in the early postpartum period to improve pain management for women choosing a nonmedicated birth. PROCESS: The postpartum hydrotherapy protocol was initiated in a certified nurse-midwife (CNM) practice in an urban academic medical center. All women who met criteria were offered a 30-minute warm water immersion bath at one hour postpartum. Pain scores were assessed prior to the bath, at 15 minutes after onset, and again at the conclusion (30 minutes). Women who completed the bath were also asked to complete a brief survey on their experience with postpartum hydrotherapy. OUTCOMES: In women who used the bath (N = 45), there was a significant reduction in pain scores (P < .001) between the onset of the bath and scores at both 15 minutes and 30 minutes. There was no significant difference between pain scores at 15 minutes and 30 minutes (P = .97). Of those women who completed a survey (n = 43), 97.7% reported both that the bath reduced their pain and improved their birth experience. One hundred percent reported they would use it again in another birth. DISCUSSION: This project demonstrated successful implementation of a hydrotherapy protocol as an alternative or adjunct to medication for early postpartum pain management that significantly reduced pain and improved the birth experience for those who used it. It offers a nonpharmacologic alternative where there have traditionally been limited options.

Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources.

At our university-affiliated medical center, a major renovation of the women's health and birthing unit resulted in the temporary loss of the permanent tub used for water immersion therapy during labor. Because 40 percent of the women in the nurse-midwifery practice utilize hydrotherapy, we undertook a rigorous search for an interim solution. We developed a safe and cost-effective strategy that can be easily replicated and utilized by others to provide hydrotherapy for laboring women.

Obstetric-gynecology resident education regarding barrier and over-the-counter contraceptives: a national study.

BACKGROUND: The study was conducted to assess obstetrics-gynecology resident knowledge about barrier and over-the-counter (OTC) contraceptives and identify strengths and weaknesses in resident education. METHODS: We developed a survey for distribution among 50 randomly selected U.S. obstetrics-gynecology residency programs. RESULTS: Of 202 respondents, only 57% and 36% of residents reported adequate knowledge to counsel patients regarding latex vs. nonlatex condom use, respectively. Ninety-six percent knew spermicides were nonprotective against sexually transmitted diseases (STDs); however, there was limited knowledge about delivery options. Only 17% had ever fit or prescribed a diaphragm, and 30% reported knowledge in performing a fitting. Greater than 80% of residents stated they received no formal didactics addressing the use of condoms, spermicides, or diaphragms. Limited experience regarding Cycle Beads and natural family planning was expressed. CONCLUSIONS: Obstetrics-gynecology residents receive little formal training about barrier and OTC contraceptive options and seek more education because of their awareness of inadequate knowledge.

DNA methylation is altered in maternal blood vessels of women with preeclampsia.

We analyzed 27,578 CpG sites that map to 14,495 genes in omental arteries of normal pregnant and preeclamptic women for DNA methylation status using the Illumina platform. We found 1685 genes with a significant difference in DNA methylation at a false discovery rate of <10% with many inflammatory genes having reduced methylation. Unsupervised hierarchical clustering revealed natural clustering by diagnosis and methylation status. Of the genes with significant methylation differences, 236 were significant at a false discovery rate of <5%. When data were analyzed more stringently to a false discovery rate of <5% and difference in methylation of >0.10, 65 genes were identified, all of which showed reduced methylation in preeclampsia. When these genes were mapped to gene ontology for molecular functions and biological processes, 75 molecular functions and 149 biological processes were overrepresented in the preeclamptic vessels. These included smooth muscle contraction, thrombosis, inflammation, redox homeostasis, sugar metabolism, and amino acid metabolism. We speculate that reduced methylation may contribute to the pathogenesis of preeclampsia and that alterations in DNA methylation resulting from preeclampsia may increase maternal risk of cardiovascular disease later in life.

Intra-abdominal irrigation at cesarean delivery: a randomized controlled trial.

OBJECTIVE: To determine whether avoiding intra-abdominal irrigation at cesarean delivery will decrease rates of intraoperative and postoperative gastrointestinal disturbance without increasing postoperative morbidity. METHODS: This was a randomized controlled trial of patients undergoing cesarean delivery. Patients were randomized to irrigation after closure of the hysterotomy compared with no irrigation. The cesarean delivery was otherwise performed in the usual fashion. The patient was blinded to treatment once assigned. The primary outcome was maternal intraoperative nausea. The secondary outcomes were postoperative maternal gastrointestinal disturbance and incidence of maternal infectious morbidity. RESULTS: Two hundred thirty-six patients were randomized; 126 were randomized to no irrigation and 110 were randomized to irrigation. Both were similar with respect to age, body mass index, operative time, blood loss, uterine incision, tubal ligation, exteriorization of the uterus, packing of bowel, lysis of adhesions and bladder flap, and peritoneal or rectus muscle closure. Intraoperative nausea was significantly more frequent with irrigation compared with no irrigation (51 of 110 [46.4%] compared with 36 of 126 [28.26%]; relative risk 1.62, 95% confidence interval 1.15-2.28). We noted no statistically significant differences for intraoperative emesis, preoperative chorioamnionitis, postoperative nausea, postoperative emesis, postoperative antiemetic administration, endometritis, or postoperative febrile morbidity. There was an increased trend of postoperative nausea and antiemetic use with irrigation. CONCLUSION: Irrigation at cesarean delivery increases intraoperative nausea without decreasing postoperative infectious morbidity. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01479712. LEVEL OF EVIDENCE: I.