Blood type and postpartum hemorrhage by mode of delivery: A retrospective cohort study.

OBJECTIVE: To assess the relationship between postpartum hemorrhage and ABO blood type for vaginal delivery and cesarean delivery. STUDY DESIGN: This is a retrospective cohort study of data abstracted from the PeriBank database regarding demographics and delivery outcomes. All live singleton deliveries from January 2011 until March 2018 were included in this study. Exclusion criteria were sickle cell disease and multiple gestations. Analyses were conducted separately for cesarean delivery and vaginal delivery. Quantitative variables were analyzed with analysis of variance testing and categorical variables with chi square testing. Significant demographic differences between groups were controlled for using multivariate logistical regression. The primary outcome was the rate of postpartum hemorrhage by blood type (A, B, AB, and O), defined as blood loss >500 mL in vaginal delivery and >1000 mL in cesarean delivery. 43,437 patients were screened and 32,023 women met inclusion criteria (22,484 vaginal deliveries (70.2%) and 9539 cesarean deliveries (29.8%)). RESULTS: In the vaginal delivery group there were differences in age, parity, race, use of regional anesthesia, rate of induction of labor, and thrombocytopenia between blood types. In the cesarean delivery group, age, parity, and race were significantly different between blood types. There was no observed difference in the rate of postpartum hemorrhage by blood type for those who delivered via vaginal delivery when controlling for demographic differences (p = 0.2). In the cesarean delivery group, there was a significantly higher rate of postpartum hemorrhage in women with type O blood (5.2% type O vs 3.8% type A vs 4.4% type B vs 4.2% type AB, p = 0.035), including when controlling for demographic differences (p = 0.02). In both vaginal and cesarean delivery groups, there was no difference in rates of any of the secondary outcomes, including blood transfusion, hysterectomy, intrapartum dilation and curettage, and intensive care unit admission. CONCLUSION: Although this study found no statistically significant difference in clinical outcomes between blood types, type O blood may be an additional risk factor to consider for postpartum hemorrhage at the time of cesarean delivery.

Chromopertubation of an Ectopic Pregnancy.

BACKGROUND: An ectopic pregnancy is a nonviable pregnancy located outside of the endometrial cavity of the uterus, which can be managed medically or surgically. CASE: A 35-year-old woman with a prior ectopic pregnancy, who reported tubal surgery of unknown location and extent, presented with a recurrent ectopic pregnancy. Ultrasound imaging showed a complex cystic lesion adjacent to the ovary, moderate complex free fluid, and no intrauterine pregnancy. She underwent an urgent diagnostic laparoscopy. Chromopertubation was performed to demonstrate absence of the left fallopian tube. The ectopic pregnancy was incidentally noted to be mobile and was expelled from the right fallopian tube. CONCLUSION: Chromopertubation offers a minimally invasive technique for management of ectopic pregnancy that may reduce injury as a result of less surgical manipulation of the fallopian tube.

Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism.

OBJECTIVE: To estimate the rate of readmissions for postpartum venous thromboembolism (VTE) during the first 30 days postdelivery between women with and without the immediate postpartum insertion of the etonogestrel contraceptive implant. METHODS: The Nationwide Readmissions Database from 2016 was used to identify women with a singleton delivery, immediate postpartum insertion of the etonogestrel contraceptive implant, and readmission for VTE within 30 days of discharge. Those with a prior history of VTE or anticoagulant therapy were excluded. These women were compared with the number of women readmitted within 30 days for VTE who did not have the contraceptive implant placed during delivery admission. RESULTS: Of 3,387,120 deliveries, 8,369 women underwent etonogestrel contraceptive implant placement during the delivery admission. There was no difference identified in the rate of readmission for VTE between exposed and unexposed women. Of these, seven had received a postpartum etonogestrel contraceptive implant (0.85/1,000; 95% CI 0.22-1.45/1,000 deliveries), compared with 1,192 without an etonogestrel contraceptive implant (0.35/1,000; 95% CI 0.33-0.37/1,000 deliveries); odds ratio (OR) 2.41; 95% CI 0.58-9.89. The rates of diabetes, thrombophilia, systemic lupus erythematosus, and cesarean birth did not differ between groups. Women who underwent etonogestrel contraceptive implant placement were younger and were more likely to have government-sponsored health insurance, a smoking history, hypertension, peripartum infection, or postpartum hemorrhage than women who did not receive an etonogestrel contraceptive implant (P<.001). After adjusting for these confounders, there remained no difference in rates of VTE, adjusted OR 1.81; 95% CI 0.44-7.45. CONCLUSION: The immediate postpartum placement of the etonogestrel contraceptive implant was not associated with an increased rate of VTE; however, our sample size was underpowered to determine no difference.

Minimally Invasive Surgery in Pregnancy.

If it is medically necessary to perform nonobstetrical abdominal surgery in pregnancy, a minimally invasive approach should be considered. The benefits of laparoscopy are well known and current studies promote the safety of laparoscopy in pregnancy, when certain guidelines are followed. This article will review the safety of surgery in pregnancy, maternal physiology, fetal considerations, maternal obesity, laparoscopic cerclage, large adnexal mass, and complications. Guidelines for surgery will be reviewed as well.

A Call to Action to Address Gender Equity Within Our Specialty: Time's Up on Waiting for Change.

Although national attention has been focused on sexual harassment and gender inequity in the United States, leaders within the obstetrics and gynecology community have remained relatively silent. Sexual harassment and gender inequity remain pervasive in our specialty. This article serves as a call to action for leadership as well as physicians within obstetrics and gynecology to implement ethical and evidence-based approaches to reduce gender inequity and improve workplace culture within our specialty.

A Randomized Controlled Trial for Abdominal Binder Use after Laparoendoscopic Single-Site Surgery.

STUDY OBJECTIVE: To compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery. DESIGN: A randomized controlled trial (Canadian Task Force classification level 1). SETTING: An academic gynecologic surgeon's practice. PATIENTS: Private patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017. INTERVENTIONS: Ninety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder. MEASUREMENTS AND MAIN RESULTS: Using a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p < .001). After adjusting for time, the overall pain score differed significantly by binder status (p = .04). Those without a binder reported an average pain score that was 1.13 (standard deviation = 0.55) points higher than those with a binder across the first week. CONCLUSION: The results suggest that abdominal binder use after LESS surgery may be beneficial in reducing postoperative pain in the first week. Results from this study can provide feasibility data for future studies.

Postoperative Pain After Single-Site Versus Multiport Hysterectomy.

BACKGROUND AND OBJECTIVES: With advances in laparoscopic surgery, the goal of surgeons and patients is to minimize pain to allow for faster recovery and return to normal daily activities. One of these advances is single-site surgery. In this study, we compared postoperative pain in laparoendoscopic single-site surgery (LESS) to that in traditional multiple-incision hysterectomy. METHODS: Seventy patients were selected for this prospective cohort study, with 35 undergoing multiple-incision and 35 undergoing LESS hysterectomy. All patients were included who were undergoing hysterectomy with the primary surgeon. All multiport hysterectomies were performed laparoscopically. Six patients underwent LESS hysterectomy and 29 underwent robotic single-site surgery (rLESS). Patients recorded pain levels for 3 weeks after surgery on a variety of measures, including overall and incisional pain. Linear mixed effects models for repeated measures were used for all multivariate analyses, with an unstructured covariance matrix accounting for correlation between time points. RESULTS: Overall, across all time points, there was an average reduction in pain by 1.26 (SD 0.69) points in the single-site group (P = .06). Days 3 and 14 had a marginally significant reduction in pain (P = .06 and 0.058, respectively). On days 4 and 7 there was a significant reduction in overall pain (P = .04 and .04, respectively). CONCLUSION: Based on the results, it is likely that single-site hysterectomy leads to less postoperative pain and achieves a lower pain score faster than multiport surgery. A randomized control trial is necessary to confirm these results before accepting them in clinical practice.