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Current events in Obstetrics & Gynecology, updates on new web site features and links to other web sites of interest to ObGyns.
Saturday, December 20, 2014

Creanga et al. Pregnancy-related mortality in the United States, 2006-2010

Why should you read about this topic?

Pregnancy-related mortality rates are going the wrong direction in the US

What were the authors trying to do?

Update the US pregnancy-related mortality rates and evaluate characteristics and causes of pregnancy-related deaths

Who participated and in what setting?

Women with live births (N=20,959,533) in the US between 2006 and 2010.

What was the study design?

Population-based retrospective cohort study

What were the main outcome measures?

Pregnancy-related mortality ratio

What were the results?

Derived from 3,358 pregnancy-related deaths, the total pregnancy-related mortality ratio for the 5 years was 16 deaths per 100,000 live births, increased from prior years.  Mortality ratios increased with maternal age.  Non-Hispanic black women had the highest mortality ratio.  Cardiovascular and infectious causes contributed the greatest percent of pregnancy-related deaths.

What is the most interesting image in the paper?

Figure 3

What were the study strengths and weaknesses?

Strengths:  enormous sample; population-based. Weaknesses: change in case ascertainment over time

What does the study contribute for your practice?

Pregnancy-related mortality ratios are rising, possibly due in part to a worsening risk profile of the mothers from chronic disease.


Monday, December 08, 2014
Emily Schneider, MD
Emily N. Schneider
Family Planning Fellow
University of New Mexico
 
In the United States, 21% of all pregnancies end in abortion.1 Access to safe, legal abortion is becoming more difficult with passage of an increasing number of state-level legislative restrictions. Between 2011 and 2013, 205 abortion restrictions were enacted, far greater than the 189 restrictive abortion laws enacted in the entire previous decade (2001-2010). This legislative shift changed the proportion of women living in restrictive states from 31% to 56%.2
 
An article published in the January 2015 issue of Obstetrics & Gynecology by Hutcheon et al highlights the effect of legislation on restricting patients’ access to abortion services. This study demonstrates that states providing Medicaid coverage for pregnancy termination of anomalous fetuses had fewer infant deaths due to anomalies compared to states without Medicaid funding for the same services.3 This disparity, according to the authors, is likely due to the fact that women with anomalous fetuses in states without Medicaid abortion coverage cannot afford to pay for a desired abortion, resulting in a larger percentage of neonatal death due to anomalies.  Facing an abnormal pregnancy is a very difficult time for a woman and her family.  It is concerning that women do not have equal access to quality health care; rather, access depends on one’s state of residence and type of health insurance. Restrictive policies related to abortion, such as this one, place women at higher risk of morbidity and mortality as well as bearing the emotional pain of continuing to carry a pregnancy potentially complicated by lethal anomalies.4
 
As physicians caring for women, we have a vast array of personal beliefs and backgrounds. But we must share one common passion: taking care of women in a comprehensive and nonjudgmental way. It is imperative that we stand up for our patients. Medical evidence should dictate the medical care and counseling we provide, not political agendas. We cannot allow interference with the patient-physician relationship. This relationship is a privilege that was earned through rigorous medical training and ongoing practice. Our patients trust us to care for them during their most intimate moments. We need to respect this privilege by providing patient-centered comprehensive care for the entire spectrum of women’s needs.
 
The American College of Obstetricians and Gynecologists (ACOG) recently published Committee Opinions on “Increasing Access to Abortion” and “Abortion Training and Education.”5,6 These two documents review the latest evidence regarding abortion care in the United States. Both emphasize abortion services as a necessary component of women’s health care and call on us as providers to oppose restrictive legislation targeting access to abortion. Patient advocacy is a new CREOG learning objective for OB/GYN residents. This new objective outlines the important role ob-gyns play as advocates for our patients, women’s health, and the specialty. Integral components of this objective include developing systems of care that are accessible to all women, effectively communicating women’s health concerns to the public, and utilizing ACOG resources for advocacy.
 
For practicing obstetrician-gynecologists, this is an opportune moment to be a patient advocate and role model for our physicians in training as our patients are facing increasingly more restrictions to access to comprehensive reproductive health care. Our patients depend on our leadership and expertise to be a voice in the recent legislative trend regarding women’s health. Clinicians and women together should determine women’s health care and policy. Politicians cannot hear us if we do not speak out.

References
  1. Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspect Sex Reprod Health, 2014, 46(1):3-14.
  2. Nash E, Gold RB, Rowan A, Rathburn G, Vierboom Y. Laws affecting reproductive health and rights: 2013 state policy review. New York: Guttmacher Institute, 2014. Available at: http://www.guttmacher.org/statecenter/updates/2013/statetrends42013.html. Retrieved Nov. 20, 2014.
  3. Hutcheon JA, Bodnar LM, Simhan HN. Medicaid pregnancy termination funding and racial disparities in congenital anomaly-related infant deaths. Obstet Gynecol 2015;125:163–9.
  4. Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol 2012;119:215-9.
  5. Increasing access to abortion. Committee Opinion No. 613. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:1060-5.
  6. Abortion training and education. Committee Opinion No. 612. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:1055-9.

Saturday, November 29, 2014

Shaw et al. Posttraumatic stress disorder and risk of spontaneous preterm birth

Why should you read about this topic?

It’s not only veterans who have PTSD.

What were the authors trying to do?

Determine if there is an association between PTSD and spontaneous preterm delivery

Who participated and in what setting?

Deliveries (N=16,334) covered by the Veterans Health Administration from 2000-2012

What was the study design?

Retrospective cohort study using national clinical and administrative databases

What were the main outcome measures?

Spontaneous delivery before 37 weeks

What were the results?

Mothers with active PTSD had a higher rate of spontaneous preterm delivery (aOR 1.35), with an attributable 2 extra preterm births per 100 affected deliveries.

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths:  large number of deliveries; distinction between active and historical PTSD; numerous sensitivity analyses demonstrating the robustness of the conclusion. Weaknesses: administrative database

What does the study contribute for your practice?

The Precis says it all: women with antenatal PTSD are at increased risk of spontaneous preterm delivery


Saturday, November 15, 2014

Gyamfi-Bannerman and Ananth. Trends in spontaneous and indicated preterm delivery among singleton gestations in the United States, 2005-2012

Why should you read about this topic?

The preterm delivery rate in the US is too high.  The more we know about its trends the better we will be able to direct research to reduce the rate.

What were the authors trying to do?

To determine whether the recent decline in preterm delivery rate was due to a decrease in spontaneous or indicated preterm delivery across all races and ethnicities.

Who participated and in what setting?

Women with singleton deliveries (N=19,984,436) in the US between 2005 and 2012

What was the study design?

Population-based cross-sectional retrospective analysis of the2003 revision birth certificate data

What were the main outcome measures?

Preterm delivery (24-36 weeks) rates—overall, spontaneous, and indicated

What were the results?

Both spontaneous preterm delivery and indicated preterm delivery rates declined (spontaneous—15.4%; indicated—12.9%) similarly across all race/ethnicity groups.  The largest relative decline occurred in the early preterm delivery rate (24-31 weeks).

What is the most interesting image in the paper?

Figure 3

What were the study strengths and weaknesses?

Strengths: population-based; huge sample size. Weaknesses: birth certificate data; significant potential for misclassification of indicated/spontaneous preterm delivery.

What does the study contribute for your practice?

Progress in reducing preterm delivery is being made across all fronts, probably due to a collection of factors including protocols for elective delivery and progesterone therapy.


Saturday, November 08, 2014

Nyirjesy. Management of persistent vaginitis

Why should you read about this topic?

No matter what your patient population is—young, old, pregnant—you’re going to be faced with persistent vaginitis at one point or another

What were the authors trying to do?

Provide a framework for evaluating and treating persistent vaginitis.

What was the study design?

Expert review

What were the results?

Key diagnostic tests are pH, amine test, saline/10% KOH microscopy, and yeast culture with speciation.

What is the most interesting image in the paper?

Table 1

What does the study contribute for your practice?

Systematic evaluation and testing are critical to effective treatment of persistent vaginitis

About the Author

William C. Dodson, MD
William C. Dodson, MD, is Professor of Obstetrics and Gynecology and Director of the Division of Reproductive Endocrinology and Infertility at Penn State College of Medicine. He completed his fellowship in reproductive endocrinology at Duke University. His research and clinical areas of focus include treatment of infertility, especially ovulation induction. He was previously on the Editorial Board of Obstetrics & Gynecology and has served as the Consultant Web Editor for Obstetrics & Gynecology since 2008.