Obstetrical & Gynecological Survey最新文献

{"title":"Medication Abortion and Uterine Aspiration for Undesired Pregnancy of Unknown Location: A Retrospective Cohort Study","authors":"Karen Borchert, Chelsea Thibodeau, Paige Varin, Heidi Wipf, Sarah Traxler, Christy M. Boraas","doi":"10.1097/01.ogx.0000979672.75675.3d","DOIUrl":"https://doi.org/10.1097/01.ogx.0000979672.75675.3d","url":null,"abstract":"ABSTRACT Uncertain diagnosis can complicate the evaluation and treatment of patients presenting for undesired pregnancy termination at early gestational ages. Pregnant patients with no ultrasonography-identifiable pregnancy location receive classification of pregnancy of unknown location (PUL). Until receiving a definitive intrauterine pregnancy (IUP), ectopic pregnancy, or early pregnancy loss diagnosis, these patients are often managed expectantly with serial serum human chorionic gonadotropin (hCG) measurements and ultrasonography. Immediate treatment of undesired PUL with low-risk for ectopic pregnancy can be performed in ways that minimize the risk. This retrospective cohort study reviewed outcomes of pregnancies for PUL-diagnosed patients presenting at Planned Parenthood in Minnesota, North Dakota, and South Dakota to receive induced abortions between July 1, 2016, and December 31, 2019. Care of patients with PUL included assessment of health history, counseling, and ectopic pregnancy precaution reviews. Clinicians then proceeded to triage patients into low- and high-risk groups based on transvaginal ultrasonography findings and patient symptoms. For PUL patients deemed low risk for ectopic pregnancy, the choices of expectant management or induced abortion were given. Patients proceeding with induced abortions then proceeded with uterine aspiration or medication abortion. The primary objective compared the diagnosis of pregnancy location to time for 3 groups, which included the groups of patients choosing immediate treatment (via uterine aspiration or medical management), and the group of patients who initially chose expectant management (delay for diagnosis). Time to diagnosis, as measured in days, was recorded from initial PUL diagnosis until final pregnancy location diagnosis. A spontaneous decline of serum hCG after 48–72 hours in the delay-for-diagnosis group was recorded as a spontaneously resolved PUL consistent with spontaneous abortion. Incidence of ectopic pregnancies, complications such as transfusion-requiring hemorrhages, and failure to adhere with follow-up guidelines (greater than 60 days from PUL diagnosis without clinical contact and/or a pregnancy diagnosis) were also recorded. From a total of 19,151 abortion counters across the study period, 2.9% of patients (553) were diagnosed with PUL. High-risk diagnoses were given to 9.4% of patients (52), based on concerns from symptoms and ultrasounds (27 of these had ectopic pregnancies [51.9%]). Low-risk diagnoses were given to 90.6% of the remaining patients (501), who were given a choice of management. When compared with expectant management, results indicated that low-risk patients with undesired PUL experienced fewer days to diagnosis with immediate treatment by uterine aspiration (and a similar time frame to diagnosis with abortion via medication). For uterine aspiration, abortion treatment using simultaneous serial hCG trending was effective. Although this study lacked stat","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388701","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between Marked Fetal Heart Rate Variability and Neonatal Acidosis: A Prospective Cohort Study","authors":"Lola Loussert, Paul Berveiller, Alexia Magadoux, Michael Allouche, Christophe Vayssiere, Charles Garabedian, Paul Guerby","doi":"10.1097/01.ogx.0000979656.52076.a2","DOIUrl":"https://doi.org/10.1097/01.ogx.0000979656.52076.a2","url":null,"abstract":"ABSTRACT Monitoring of fetal heart rate (FHR) is an important indicator of fetal well-being during labor, but it is subject to low specificity and interpretation variability; this causes the clinical effectiveness for preventing adverse outcomes to remain controversial. Fetal heart rate has inherent variability, but reduced or marked variability can reflect poor autonomic activity, indicating conditions such as fetal acidosis. Recent research has highlighted that marked variability can indicate fetal distress; more research is needed to validate and investigate this claim. This study aimed to understand the association between marked FHR variability during labor and subsequent neonatal acidosis. Data were collected from 2 French maternity units; inclusion criteria extended to women at 37 weeks' gestation or greater, with continuous FHR monitoring during labor. Exclusion criteria were intrauterine fetal death, medical termination, multiple pregnancies, noncephalic presentation, and cesarean delivery. The primary outcome for this study was neonatal acidosis, or an umbilical artery pH of less than or equal to 7.10. Secondary outcomes included severe acidosis (pH ≤7.0), a 5-minute Apgar score of less than 7, respiratory distress, neonatal intensive care unit admission, neonatal infection, and neonatal death. Final analysis included 4394 women who gave birth between January 1 and December 31, 2019. Of this population, 177 neonates experienced marked variability in FHR within 1 hour before delivery, with a median duration of marked variability of 2 minutes. Prevalence of neonatal acidosis was 15.3% in neonates who experienced marked FHR variability and 5.6% in those who did not (aRR, 2.30; 95% confidence interval [CI], 1.53–3.44). In addition, those with marked FHR variability more often experienced respiratory distress (aRR, 1.73; 95% CI, 1.15–2.58). Analysis was subsequently performed according to the National Institute of Child Health and Human Development category of FHR; the association between FHR variability and neonatal acidosis was significant in category I (aRR, 5.48; 95% CI, 1.88–15.96) and category II (aRR, 2.29; 95% CI, 1.40–3.74) groups. Category III FHR, however, had no significant association. Strengths of this study include the prospective cohort design, as well as generalizability. Subcategory assessment of the FHR patterns allowed for more accurate examination of the risk of neonatal acidosis. Limitations include an observational design and the strict exclusion criteria required to minimize bias, which reduces generalizability to low-risk groups. The findings of this study are consistent with previous literature in that FHR variability can be a significant marker for fetal outcomes. Clinically, these results can help providers recognize the risk of fetal and neonatal acidosis. Further research is needed to delineate further associations and assess interpretations of pattern variability.","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"2011 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Low-Dose Aspirin Use in Pregnancy and the Risk of Preterm Birth: A Swedish Register-Based Cohort Study","authors":"Ellen Kupka, Susanne Hesselman, Roxanne Hastie, Riccardo Lomartire, Anna Karin Wikström, Lina Bergman","doi":"10.1097/ogx.0000000000001197","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001197","url":null,"abstract":"ABSTRACT Evidence has shown that low-dose aspirin can reduce the risk of preeclampsia in women with risk factors; more recent evidence has shown that aspirin may also be useful for the prevention of spontaneous preterm birth, even among women without risk factors for preeclampsia. However, there are fewer studies examining the effectiveness of low-dose aspirin in this population, and the studies that have been done have generally been statistically underpowered. This study was meant to address this limitation in a large population of women who had previously experienced preterm birth, assessing whether low-dose aspirin treatment was associated with a lower risk for preterm birth. This study was a register-based cohort study performed using several different Swedish registries. The sample included all women with a first and second singleton birth between 2006 and 2019 and with a preterm birth in the first pregnancy. The primary outcome assessed was preterm birth during the second pregnancy, and secondary outcomes included assessment of preterm birth by severity (moderate preterm was between 32 and 36 weeks' gestation, and severe preterm was less than 32 weeks' gestation) and onset (spontaneous or medically indicated). The variable of interest was low-dose aspirin exposure or at least 1 dispensed prescription of 75 to 160 mg aspirin. The analysis included 22,127 women with a preterm birth in their first pregnancy followed by a second recorded pregnancy. Of this sample, 3057 (14%) were prescribed low-dose aspirin during their second pregnancy. Recurrent preterm birth occurred in 3703 individuals, of whom 547 (15%) had used low-dose aspirin. After adjusting for confounding variables, the incidence of preterm birth was lower in those using low-dose aspirin, with a marginal relative risk (mRR) of 0.87 (95% confidence interval [CI], 0.77–0.99). However, there was no difference in risk for moderate or severe preterm birth (moderate group: mRR, 0.90 [95% CI, 0.78–1.03]; severe group: mRR, 0.75 [95% CI, 0.54–1.04]). In adjusted analyses, there were no statistically significant differences for either medically indicated or spontaneous preterm birth between individuals who used low-dose aspirin and those who did not. The study was limited by its retrospective nature. In addition, the authors acknowledge that a dispensed prescription for aspirin does not necessarily equate to consistent intake of low-dose aspirin throughout a pregnancy. In addition, the population for this study was limited to those who had already experienced a preterm birth, which could affect the generalizability of the results. Although limited differences were found, a small protective effect could not be ruled out, and randomized controlled trials to understand more fully the effect low-dose aspirin might have on preterm birth would be helpful. Further research should also focus on whether the benefits of aspirin use during pregnancy outweigh the potential risks, as well as what the low","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"2011 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135388924","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of Medicaid Expansion With Postpartum Depression Treatment in Arkansas","authors":"Maria W. Steenland, Amal N. Trivedi","doi":"10.1097/01.ogx.0000967008.55178.da","DOIUrl":"https://doi.org/10.1097/01.ogx.0000967008.55178.da","url":null,"abstract":"ABSTRACT Approximately 1 in 8 individuals experience postpartum depression in the United States. Among them, 17% had their care covered by Medicaid and 10% had their care covered by a commercial payer. Postpartum depression is also more common among American Indian/Alaska Native (22%), Asian/Pacific Islander (19%), and Black (18%) individuals than White individuals (11%). Adverse postpartum health outcomes include reduced maternal quality of life, greater difficulty with social and partner relationships, increased odds of unemployment, and adverse child health outcomes. Effective treatments for postpartum depression include antidepressant medications and psychotherapy. Yet, these therapies are often underused, particularly among Medicaid enrollees and Black individuals, due to systemic racism and lack of access to health care, childcare, and transportation. One solution that has been suggested includes expanding Medicaid coverage to a year postpartum. One study in Oregon found that Medicaid expansion increased screening for and treatment of postpartum depression. The aim of this study was to compare the differences in treatment for postpartum depression among individuals whose births were covered by Medicaid versus commercial payers. This was a cohort study conducted in Arkansas with a difference-in-differences regression design. Data were collected from the state’s birth certificate records and all-payer claims database. Included were all births between January and June 2013, when Medicaid postpartum coverage ended 60 days after childbirth, and between January 2014 and December 2015, after the state expanded Medicaid postpartum coverage beyond 60 days if the individual’s income was below 138% of the federal poverty level. The primary outcomes were the filling of ≥1 antidepressant prescriptions and the number of days supplied in the first 60 days (early postpartum period) and 61 days to 6 months after childbirth (later postpartum period). The secondary outcomes were psychotherapy visits and a diagnosis of depression in the 6 months after childbirth. A total of 60,990 individuals gave birth in Arkansas between 2013 and 2015. Of these births, 71.7% were covered by Medicaid and 28.3% by commercial payers. Compared with individuals with commercially paid births, individuals who had a Medicaid-covered birth were younger (mean age, 25.5 vs 29.4 years), more likely to identify as Hispanic (10.8% vs 3.0%), and less likely to have a college or higher level of education (5.1% vs 55.5%). In the later postpartum period, 4.2% of those with Medicaid coverage filled a prescription for antidepressants before the expansion of Medicaid. In 2015, with Medicaid expansion, the likelihood of filling an antidepressant prescription in the later postpartum period increased by 110% (adjusted difference-in-differences, 4.6; 95% confidence interval [CI], 2.9–6.3). Similarly, in the early postpartum period, the likelihood of individuals with Medicaid filling an antidepressan","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"55 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136106146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost Effectiveness of Concurrent Midurethral Sling at the Time of Prolapse Repair: Results From a Randomized Controlled Trial","authors":"Rui Wang, Paul Tulikangas, Elisabeth C. Sappenfield","doi":"10.1097/ogx.0000000000001180","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001180","url":null,"abstract":"ABSTRACT After pelvic reconstructive surgery for pelvic organ prolapse, postoperative stress urinary incontinence (SUI) commonly occurs, which leads many women to choose to have a midurethral sling placed at the time of surgery, even in cases without symptomatic preoperative urinary incontinence. Approximately 27.3% of women with a sling had de novo SUI despite this intervention. Full evaluation of the societal and economic implications brought by a midurethral sling placement attempting to prevent postoperative de novo SUI at the time of a pelvic reconstructive surgery have yet to be evaluated. This study aimed to evaluate the 1-year cost-effectiveness of a midurethral sling in the prevention of SUI at the time of prolapse surgery. This assessment was a randomized controlled trial based on patient resource utilization and patient-reported effectiveness. Study data were obtained via the OPUS randomized clinical trial, which was performed through the Pelvic Floor Disorders Network (a cooperative agreement network sponsored through the National Institute of Child Health and Human Development). A total of 337 women with anterior vaginal prolapse and without SUI symptoms set to undergo treatment from May 2007 to January 2011 were included in the study. Patients were randomly assigned to receive either sham incisions or a midurethral sling during vaginal prolapse surgery. Follow-up occurred at 3, 6, and 12 months postsurgery, with surveys, physical examinations, and medical history. Cost data were collected, and overall health utility in quality-adjusted life-years (QALYs) was calculated. Secondary outcomes were urinary incontinence-specific quality of life and cases of urinary incontinence, as defined by bothersome incontinence symptoms and positive cough stress tests. Initial surgical procedures and subsequent urinary incontinence-related health care were all used for recording health care sector costs. Total costs for study participants were collected via health care resource utilization data, including office visits, additional surgical procedures, and related procedures. The incremental cost-effectiveness ratio was the difference between the sham incision and midurethral sling groups in mean cost, divided by difference in mean QALYs. Data for health care resource utilization were collected during the trial period. Questionnaires at baseline, 3, 6, 9, and 12 months were used to collect other costs. At 1 year, one-way sensitivity analysis was performed for assessing the varying effectiveness of midurethral slings at 1 year, by noting the urinary incontinence-associated patient costs and by using varied QALY for the sling group. Results were taken from a study population of 337 women who underwent randomization to be included in the analysis of cost-effectiveness. No great variance of characteristics existed between groups. One year after surgery, a lower rate of urinary incontinence existed for those in the midurethral sling group. Notably, QALYs w","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"59 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136107083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Utility of sFlt-1 and PlGF in Screening, Prediction, Diagnosis and Monitoring of Pre-eclampsia and Fetal Growth Restriction","authors":"H. Stepan, A. Galindo, M. Hund, D. Schlembach, J. Sillman, D. Surbek, M. Vatish","doi":"10.1097/ogx.0000000000001185","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001185","url":null,"abstract":"ABSTRACT Preeclampsia is a serious hypertensive disorder of pregnancy that can deteriorate into eclampsia or HELLP syndrome and ultimately result in severe maternal morbidity or mortality. In addition to possible complications for the mother, preeclampsia and its additional complications can lead to adverse outcomes for infants, both before and after birth. Because of the serious consequences associated with preeclampsia, current practice guidelines recommend the screening of all pregnant patients for risk of preeclampsia in the first trimester and consistent monitoring for the development of preeclampsia later in pregnancy. Recommendations also include that women who are diagnosed with preeclampsia are closely monitored to prevent further complications such as preterm birth, as well as monitoring for fetal growth restriction (FGR). There are serum markers that are known to be related to preeclampsia, such as proangiogenic placental growth factor (PlGF) and antiangiogenic soluble fms-like tyrosine kinase-1 (sFlt-1). This article is a review aiming to summarize current knowledge about PlGF and sFlt-1, their performance, and potential alteration in diagnosis and monitoring of preeclampsia. Factors such as these have trends that occur in normal pregnancy and different trends that tend to occur in a pregnancy that is abnormal. In a healthy pregnancy, sFlt-1 increases in the third trimester, but in patients who later develop preeclampsia or FGR, it tends to increase sooner. Recent studies have shown that the interaction between sFlt-1 and PlGF reduces the amount of PlGF in circulating in the blood, causing a cascade of other effects. In addition, a decrease in PlGF is known to be associated with the development of preeclampsia. Because of this interaction, the ratio of sFlt-1 to PlGF can be used as a diagnostic tool; an increasing ratio can indicate development of preeclampsia. In addition to predicting preeclampsia, sFlt-1 and PlGF have been shown to be helpful in managing preeclampsia that has already been diagnosed. Monitoring the ratio of sFlt-1 to PlGF has shown a correlation between a higher ratio and imminent preterm delivery due to preeclampsia. It has also proven to be a predictor of other adverse outcomes such as preterm delivery and FGR, as well as stillbirth and complications of multiple pregnancies. Recent data show robust enough associations between sFlt-1 and PlGF that it can reasonably be used for predicting short-term development of preeclampsia, monitoring preeclampsia that has been previously diagnosed and predicting other disorders of the placenta. These factors can be particularly useful in guiding treatment of those whose symptoms are not a clear enough indicator on their own for preeclampsia, but who may be in danger of complications if left untreated. In particular, the most impactful clinical outcome comes when both sFlt-1 and PlGF levels are monitored, as the interaction between the 2 gives the most relevant information, wher","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135222838","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CME PROGRAM EXAM AND ANSWER SHEET","authors":"","doi":"10.1097/ogx.0000000000001193","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001193","url":null,"abstract":"","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"96 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136106144","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Enhanced Recovery After Surgery (ERAS®) Society Guidelines for Gynecologic Oncology: Addressing Implementation Challenges - 2023 Update","authors":"G. Nelson, C. Fotopoulou, J. Taylor, G. Glaser, J. Bakkum-Gamez, L. A. Meyer, R. Stone, G. Mena, K. M. Elias, A. D. Altman, S. P. Bisch, P. T. Ramirez, S. C. Dowdy","doi":"10.1097/01.ogx.0000967024.88312.e0","DOIUrl":"https://doi.org/10.1097/01.ogx.0000967024.88312.e0","url":null,"abstract":"ABSTRACT Implementation of the Enhanced Recovery after Surgery (ERAS) Society Guidelines in 2016 has resulted in an approximate decrease in hospital length of stay (LOS), reduction in complications and readmission, and cost saving. Recent publications however have demonstrated that barriers and gaps in understanding may result in many ERAS recommendations being poorly adhered to in gynecologic oncology patients. The aims of this second update to the ERAS Society Guidelines for gynecologic oncology is to summarize and update the evidence investigating specific implementation challenges to increase ERAS uptake and improve clinical outcomes for patients. A literature search was conducted for topics specified to 9 ERAS implementation challenges identified: perioperative oral intake safety, preoperative medication importance, penicillin allergies, intraoperative analgesia, how to manage urinary drainage, venous thromboembolism prophylaxis, postoperative opioid prescription practices, same-day discharge programs, and how can I overcome barriers to ERAS implementation. The quality of evidence and recommendations was evaluated, and recommendations graded as strong or weak based on quality, balance between desirable and undesirable effects on holistic clinical outcomes, and on values and preferences of practitioners. Regarding perioperative oral intake safety, patients should be encouraged to consume clear liquids in 2 hours before surgery and preoperative carbohydrate loading improves satisfaction and comfort. Optimal preoperative medications include nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids. Patients with penicillin allergies should receive standard surgical antibiotic prophylaxis. For intraoperative analgesia, wound infiltration with local anesthetic and TAP block are preferred over thoracic epidural analgesia. Indwelling bladder catheters should be removed as early as possible in the postoperative period such as on the day of surgery for minimally invasive procedures and no later than postoperative day 1 for laparotomy. Patients at increased risk of venous thromboembolism should receive dual prophylaxis with compression and medications, and extended chemoprophylaxis should be prescribed to those with high-risk criteria or after laparotomy. Multimodal opioid-reduction is critical for all patients, and decreased postdischarge opioid proscribing is improved with a team approach and does not affect pain control or patient satisfaction. Patient controlled analgesia is a last resort for those requiring repeated treatment with intravenous opioids. Multidisciplinary same-day discharge programs should be considered in minimally invasive surgeries, and implementation requires a multidisciplinary team approach with patient education, case selection, and ERAS principles. Overcoming barriers to ERAS principles is more successful with changes at the management level and education. Communication of the economic benefits of ERAS to admin","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136107080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Disease-Free Survival Does Not Differ According to Fertility Preservation Technique for Young Women With Breast Cancer","authors":"Charlotte Sonigo, Noémi Amsellem, Anne Mayeur, Laetitia Laup, Barbara Pistilli, Suzette Delaloge, Florence Eustache, Christophe Sifer, Sophia Rakrouki, Alexandra Benoit, Maeliss Peigné, Michael Grynberg","doi":"10.1097/01.ogx.0000967028.09669.ba","DOIUrl":"https://doi.org/10.1097/01.ogx.0000967028.09669.ba","url":null,"abstract":"ABSTRACT Approximately 5% of breast cancer cases occur in women younger than 40 years, and the 5-year overall survival for women between the ages of 15 and 44 years is 90%. As the childbearing age increases, so too does the proportion of women who wish to achieve pregnancy after breast cancer. The conception rate among these women is 40% lower than the general population, as a result of advanced age and the gonadal toxicity of chemotherapy. Fertility preservation (FP) techniques enable young patients to freeze gametes before treatment; however, the most recommended method of FP is oocyte or embryo vitrification after controlled ovarian hyperstimulation (COH), which has limited safety data in breast cancer patients. This retrospective cohort study aimed to evaluate disease-free survival (DFS) in a large cohort of women with breast cancer who underwent FP techniques with or without COH. Patients with breast cancer between 18 and 43 years old referred for FP to 2 university hospitals between July 2013 and July 2019 were included. Women not included in the FP program after oncofertility counseling, those with stage 4 disease at diagnosis or history of other invasive cancer, or those with gonadotoxic treatment have been excluded. Patients were split into 2 groups, with the STIM group receiving at least 1 COH protocol using a gonadotropin-releasing hormone antagonist with or without an aromatase inhibitor and the no STIM group not undergoing ovarian stimulation. Patient characteristics, obstetric variables, and oncology characteristics were collected from medical records. Disease-free survival and overall survival were estimated using Kaplan-Meier plots and compared between the 2 groups by log-rank test. A total of 740 women (76.7%) who attended oncofertility consultations for breast cancer were included. Of these, 328 (44.3%) underwent at least 1 ovarian stimulation cycle, and 412 (55.7%) had an FP technique without exogenous FSH administration. The STIM group was significantly older and had lower values in ovarian reserve tests, and more women in the no STIM group underwent a mastectomy and neoadjuvant chemotherapy. The proportion of patients with hormone receptor-positive tumors was equal in both groups. Letrozole was coadministered with exogenous gonadotropin in 39.3% of women in the STIM group (Let-COH). Overall, 16.8% of patients had a tumor still present on oocyte retrieval after COH, of which 55% received a Let-COH protocol. Follow-up data were available for 80.9% (559/740) of patients. Cancer recurrence was documented in 87 patients (27 in STIM, 60 in no STIM), and DFS was not statistically different between the groups (log-rank test P = 0.09). Neither difference in DFS nor overall survival was observed in the Let-COH group compared with those undergoing COH after breast surgery. Kaplan-Meier estimates of overall survival at 4 years were 97.6% in the STIM and 93.6% in the no STIM groups, and after adjusting for prognostic parameters, the risk ","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136106140","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Utilisation of Hospital-Based Specialist Palliative Care in Patients With Gynaecological Cancer: Temporal Trends, Predictors and Association With High-Intensity End-of-Life Care","authors":"Anne Høy Seemann Vestergaard, Mette Asbjoern Neergaard, Lars Ulrik Fokdal, Christian Fynbo Christiansen, Jan Brink Valentin, Søren Paaske Johnsen","doi":"10.1097/01.ogx.0000967020.48960.63","DOIUrl":"https://doi.org/10.1097/01.ogx.0000967020.48960.63","url":null,"abstract":"ABSTRACT Although chemotherapy and short-course radiotherapy play important roles in the palliative management of gynecological cancers, these may be associated with significant discomfort and minimal symptom control in advanced disease. Terminally ill patients approaching death may have complex palliative care needs that cannot be resolved in general care practices and require multidisciplinary specialist palliative care services (SPC). Timely access to SPCs is associated with improved quality of life and reduced high-intensity care during the end-of-life phase; however, the role of palliative care on high-intensity interventions at the end of life in patients with gynecological cancers has not been examined in large-scale studies. This nationwide registry-based study aimed to examine the temporal trends, predictors of use, and relationship with high-intensity treatments in hospital-based SPC utilization among patients with gynecological malignancies. All adults in Denmark who died of gynecological cancer between 2010 and 2016 were included. Demographic, financial, and oncological data were obtained for each patient. Utilization of SPC included care provided during hospital admissions, in outpatient clinics, or in the patients' own home. High-intensity end of life care included invasive treatments (chemotherapy, surgery, and radiation), use of services such as emergency department visits, intensive care unit admissions, or more than 1 hospital admission within 30 days, as well as no hospice admissions in the prior year or a patient death in the hospital. Binary regression was used to estimate the chance of receiving hospital-based SPC and the adjusted relative risk of high-intensity end of life care by potential predictors including cancer type, age at death, comorbidity score, region of residence, marital status, income level, migrant status, and FIGO cancer stage. A total of 4502 patients with cervical cancer (n = 708), ovarian cancer (n = 2595), and endometrial cancer (n = 1199) were identified, of whom 179 (40.0%) accessed SPC. The proportion of patients dying of gynecological cancer and receiving SPC increased from 24.2% in 2010 to 50.7% in 2016. Each potential predictor studied was associated with receiving SPC at the end of life, with the strongest associations after adjustment for year of death between 2014 and 2016, younger age, 3 or more comorbidities, residence in Danish regions other than the Capital region, and being an immigrant or descendant. Patients aged 60 to 69 had a 24% decreased chance of receiving SPC compared with those aged 18 to 59 (adjusted relative risk [aRR], 0.76; 95% confidence interval [CI], 0.69–0.83), and as age increased, the proportion of those that received SPC decreased further. Those with 3 or more comorbidities had a 23% higher chance of receiving SPC (aRR 1.23; 95% CI, 1.13–1.34). Compared with nonimmigrants, immigrants and descendants were 29% more likely to receive SPC (aRR, 1.29; 95% CI, 1.14–1.96). Hos","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136107081","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}