Nonurgent and urgent emergency department use during pregnancy: an observational study

Emergency department use is common among pregnant women. Non-urgent emergency department use may represent care that would be better provided by an established obstetric provider in an ambulatory setting

Schedule of Visits and Televisits for Routine Antenatal Care : A Systematic Review

This report is based on research conducted by the Brown Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00001). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.Publisher PD

Tailored intervention to increase dual-contraceptive method use: a randomized trial to reduce unintended pregnancies and sexually transmitted infections

Objective: The objective of the study was to determine whether a transtheoretical model–tailored expert system intervention increases dual-method contraceptive use, compared with a nontailored educational intervention. Study Design: We performed a randomized clinical trial of 542 women at high risk for sexually transmitted infections (STIs) and unintended pregnancy. The intervention group received computer-based tailored feedback using a multimedia program. The control group received general contraceptive information and nontailored advice. Results: Participants in the intervention group were more likely to report use of dual contraceptive methods during follow-up (adjusted hazard rate ratio 1.70, 95% confidence interval 1.09, 2.66), compared with controls. However, there were no differences in the rates of incident STI or unintended pregnancy between the 2 groups. Conclusions: The computer-based transtheoretical model–tailored intervention resulted in a 70% increase in reported dual-method contraceptive use in a group of women at high risk for STIs and unintended pregnancy. Inconsistent use of dual methods may explain the lack of effect on unintended pregnancy rates and incident STIs

Comparison of Vaginal Hysterectomy Techniques and Interventions for Benign Indications: A Systematic Review

OBJECTIVE: To create evidence-based clinical practice guidelines based on a systematic review of published literature regarding the risks and benefits of available preoperative, intraoperative, and postoperative technical steps and interventions at the time of vaginal hysterectomy for benign indications. DATA SOURCES: We systematically searched the literature to identify studies that compared technical steps or interventions during the preoperative, intraoperative, and postoperative periods surrounding vaginal hysterectomy. We searched MEDLINE, Cochrane Central Register of Controlled Trials, Health Technology Assessments, and ClinicalTrials.gov from their inception until April 10, 2016, using the MeSH term "Hysterectomy, Vaginal" and associated text words. We included comparative studies, single-group studies, and systematic reviews published in English. METHODS OF STUDY SELECTION: We double-screened 4,250 abstracts, identifying 60 eligible studies. Discrepancies were adjudicated by a third reviewer. We followed standard systematic review methodology and the Grades for Recommendation, Assessment, Development and Evaluation approach to evaluate the evidence and generate guideline recommendations. TABULATION, INTEGRATION, AND RESULTS: Because of limited literature, only 16 perioperative risks, technical steps, and interventions were identified: obesity, large uteri, prior surgery, gonadotropin-releasing hormone agonists, vaginal antisepsis, bilateral salpingo-oophorectomy, morcellation, apical closure, uterine sealers, hemostatic injectants, hot cone, retractor, cystoscopy, vaginal packing, bladder management, and accustimulation. We organized and reported these as four domains: patient selection, preoperative, intraoperative, and postoperative. We did not identify any patient characteristics precluding a vaginal approach; chlorhexidine or povidone is appropriate for vaginal antisepsis; vasopressin decreases blood loss by 130 cc; tissue-sealing devices decrease blood loss by 44 cc and operative time by 15 minutes with uncertain complication implications; vertical cuff closure results in 1-cm increased vaginal length; either peritoneum or epithelium can be used for colpotomy closure; and routine vaginal packing is not advised. CONCLUSION: Minimal data exist to guide surgeons with respect to planning and performing a vaginal hysterectomy. This study identifies available information and future areas for investigation

Menstruation: science and society

© 2020 The Authors Women's health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Menstrual health is an integral part of overall health because between menarche and menopause, most women menstruate. Yet for tens of millions of women around the world, menstruation regularly and often catastrophically disrupts their physical, mental, and social well-being. Enhancing our understanding of the underlying phenomena involved in menstruation, abnormal uterine bleeding, and other menstruation-related disorders will move us closer to the goal of personalized care. Furthermore, a deeper mechanistic understanding of menstruation—a fast, scarless healing process in healthy individuals—will likely yield insights into a myriad of other diseases involving regulation of vascular function locally and systemically. We also recognize that many women now delay pregnancy and that there is an increasing desire for fertility and uterine preservation. In September 2018, the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a 2-day meeting, “Menstruation: Science and Society” with an aim to “identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field.” Experts in fields ranging from the evolutionary role of menstruation to basic endometrial biology (including omic analysis of the endometrium, stem cells and tissue engineering of the endometrium, endometrial microbiome, and abnormal uterine bleeding and fibroids) and translational medicine (imaging and sampling modalities, patient-focused analysis of menstrual disorders including abnormal uterine bleeding, smart technologies or applications and mobile health platforms) to societal challenges in health literacy and dissemination frameworks across different economic and cultural landscapes shared current state-of-the-art and future vision, incorporating the patient voice at the launch of the meeting. Here, we provide an enhanced meeting report with extensive up-to-date (as of submission) context, capturing the spectrum from how the basic processes of menstruation commence in response to progesterone withdrawal, through the role of tissue-resident and circulating stem and progenitor cells in monthly regeneration—and current gaps in knowledge on how dysregulation leads to abnormal uterine bleeding and other menstruation-related disorders such as adenomyosis, endometriosis, and fibroids—to the clinical challenges in diagnostics, treatment, and patient and societal education. We conclude with an overview of how the global agenda concerning menstruation, and specifically menstrual health and hygiene, are gaining momentum, ranging from increasing investment in addressing menstruation-related barriers facing girls in schools in low- to middle-income countries to the more recent “menstrual equity” and “period poverty” movements spreading across high-income countries

Factors associated with increased charges for hysterectomy

OBJECTIVE: To evaluate factors associated with increased hospital charges for hysterectomy with specific attention to differences based on surgical approach. METHODS: We performed a retrospective cohort study of 686 patients who underwent hysterectomy between January 1997 and September 1997 using medical chart review and hospital financial information. Demographic information, surgical approach (abdominal, vaginal, or laparoscopic), and surgical and postoperative factors were extracted from the medical record. Hospital charges were obtained from the hospital billing database. Relationships between charges and various clinical and demographic variables were examined using χ2, Fisher exact test, t tests, or analysis of variance, where appropriate. Logistic regression was used to estimate odds ratios while controlling for important confounding variables. RESULTS: In our logistic regression model, blood loss greater than 1,000 mL (odds ratio [OR] 11.8, 95% confidence interval [CI] 4.2-33.2) and operative time 105 minutes or more (OR 14.2, CI 5.8-34.5) were strongly associated with higher charges for hysterectomy. Other factors associated with higher charges included: postoperative fever (OR 2.2, CI 1.1-4.5), increasing length of hospitalization (OR 5.3, CI 3.7-7.7), the use of prophylactic antibiotics (OR 3.0, CI 1.3-6.6), and the laparoscopic surgical approach compared with vaginal hysterectomy (OR 2.7, CI 1.0-7.0). CONCLUSION: Surgical factors such as operative time and blood loss were strongly associated with increased hospital charges for hysterectomy. © 2006 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins

Nonurgent and urgent emergency department use during pregnancy: an observational study

BACKGROUND: Emergency department use is common among pregnant women. Non-urgent emergency department use may represent care that would be better provided by an established obstetric provider in an ambulatory setting. OBJECTIVE: To identify socio-demographic factors associated with non-urgent emergency department use in pregnancy. STUDY DESIGN: This is a cross-sectional study of women recruited during their postpartum hospitalization. Data regarding prenatal care and emergency department visits was collected from medical records; participants completed a survey with questions regarding demographics and emergency department use. Urgency of an emergency department visit was pre-specified based on a-priori criteria abstracted from medical record review. Women with any non-urgent emergency department use were compared with women without non-urgent emergency department use. Logistic regression was performed to identify factors associated with non-urgent emergency department use. RESULTS: Two hundred and thirty-three women participated in this study; 197 (84%) received care in the emergency department during pregnancy. Eighty-three (35.6%) women had at least one visit to the emergency department that was non-urgent. In regression analysis, increased odds of non-urgent emergency department use was associated with a preferred language other than English (OR 2.02, 95% CI 1.01-4.05) and lack of private insurance (OR 5.55, 95% CI 2.54-12.12). The two most common reasons for presentation to the emergency department were concern that there was an emergency (45%) or being referred by a healthcare provider (36%). CONCLUSION: Women frequently use the emergency department during pregnancy, including visits for non-urgent indications. Identifying risk factors for non-urgent emergency department use in pregnancy is important for identifying women likely to use the emergency department, including for non-urgent visits, and the development of strategies to decrease non-urgent emergency department utilization in pregnancy