Adverse Perinatal Outcomes Associated with Increasing Maternal Obesity.

OBJECTIVE: The aim of this study was to determine adverse perinatal outcomes related to maternal preconception body mass index (BMI). STUDY DESIGN: This is a retrospective observational cohort study at a single institution of 500 consecutive mothers of normal weight with a preconception BMI of 18.5 to less than 25 and 500 additional obese mothers with a preconception BMI more than or equal to 30. Maternal/newborn metrics were stratified by maternal preconception BMI and trend analysis was performed both by simple univariable and multivariable logistic regression analysis. RESULTS: The study included 858 mother/baby dyads after 142 were excluded. Trend analysis demonstrated higher preconception BMI was significantly associated with progressively higher rates of cesarean section (p < 0.001), preeclampsia p < 0.001), gestational diabetes (p < 0.001), preterm birth (p = 0.001), lower 1- and 5 minutes Apgar scores (p < 0.001), and neonatal intensive care unit admission (p = 0.002). These associations remained significant in both simple univariable and multivariable logistic regression models. CONCLUSION: We demonstrated obese women are more likely to have maternal complications and neonatal morbidity when compared with normal weight mothers. Maternal and fetal complications increase with increasing obesity with superobese mothers (BMI ≥ 50) having more perinatal adverse outcomes when compared with other classes of obesity. It is reasonable to counsel weight loss prior to conception of women with BMI more than or equal to 30 in an effort to reduce maternal complications and neonatal morbidity related to pregnancy. KEY POINTS: · Maternal obesity is associated with adverse outcomes.. · Complications increase with increasing obesity.. · Superobese mothers have the most adverse outcomes..

Diagnostic Value of Bile Acids and Fibroblast Growth Factor 21 in Women with Polycystic Ovary Syndrome.

Objective: Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by a reduction in fertility and metabolic dysfunction. Unfortunately, due to a lack of clear presentation, it is often a long process of diagnosis. In this study, we investigated bile acids as potential biomarkers. Materials and Methods: Subjects were recruited and stratified into groups based on body mass index and PCOS status. Biometric data and plasma were acquired to understand bile acid profiles and related markers. Results: Taurocholic acid (TCA) and taurodeoxycholic acid were elevated in PCOS subjects with obesity in comparison to controls without PCOS. Fibroblast growth factor 21 (FGF-21), a metabolic regulator implemented in bile acid metabolism, was elevated in PCOS patients and was positively correlated with TCA changes. Conclusions: We present evidence suggesting that bile acids may be novel diagnostic targets in obese patients with PCOS while further studies need to delineate the interplay between FGF-21, bile acids, and testosterone in the early detection of PCOS.

Teaching Pediatric Straddle Injury Repair with Use of a 3D Printed Model.

STUDY OBJECTIVE: To determine the utility of a 3D vulvar model for teaching pediatric straddle injury repair. DESIGN: Prospective study. SETTING: Two academic hospitals. PARTICIPANTS: Twenty obstetrics and gynecology residents INTERVENTIONS AND MAIN OUTCOME MEASURES: Knowledge score on the basis of a 7-question pre/post test. Likert scale questions evaluated the 3D model as a teaching tool. RESULTS: Twenty residents participated; 2 (10%) had ever repaired a straddle injury. Knowledge scores increased after model use and didactic session from 3.05 of possible 7 to 6.35; P = .001. Only 2/20 (10%) residents "agreed" or "strongly agreed" with the statement, "I am comfortable repairing a straddle injury" before the intervention, compared with 19/20 (95%) afterward (P < .001). Of 20 residents, 19 (95%) believed that it simulated surgical experience "very well" or "well." CONCLUSION: The use of a 3D pediatric vulvar model can simulate surgical experience and can be an effective teaching tool when combined with a didactic session on pediatric straddle injury.

Acceptability of a Comprehensive Sex Education Self-Study Website for Teaching Reproductive Health: A Pilot Study Among College Students and Obstetrics and Gynecology Resident Physicians.

INTRODUCTION: There is a growing interest among adolescents to obtain sexual health information online, which could be helpful in rural areas where adolescents face unique obstacles to contraception access, and medically accurate sex education is not mandated. AIM: This study piloted a comprehensive sex education self-study website among undergraduate students and resident physicians to assess the accuracy and feasibility for future use in younger adolescents. METHODS: A sex education website developed by a board-certified obstetrician-gynecologist (OBGYN) was piloted among a group of OBGYN resident physicians and undergraduates from West Virginia. Groups were chosen to assess the accuracy of information and acceptability for use in younger adolescents. The 30-minute curriculum was a series of short videos (2-4 minutes each) covering anatomy, physiology, sexuality, gender identity, relationship health, contraception, and sexually transmitted infection prevention. Data were obtained on subjects' past experience and perception of sex education. Subjects also evaluated the website for usefulness and accuracy. OUTCOMES: Main outcomes included a Likert scale assessment of each curriculum session's usefulness, accuracy, and how easy it was to follow. RESULTS: 24 subjects (14 undergraduates and 10 physicians) participated during September and October of 2019. All except for 1 subject had sex education taught in school; 11 (45.8%) reported it to be "low quality"; 23 (95.8%) reported being taught in a classroom. Individual website video sessions were reported to be highly accurate, very easy to follow, and very useful. All subjects (100%) felt that high school adolescents would be interested in the self-study website. CONCLUSIONS: A self-study website was successfully tested and found to be a well-accepted way to teach sex education among this pilot group. Future work involves testing this tool among younger adolescent subjects. Yoost J, Ruley M, Durfee L. Acceptability of a Comprehensive Sex Education Self-Study Website for Teaching Reproductive Health: A Pilot Study Among College Students and Obstetrics and Gynecology Resident Physicians. Sex Med 2021;9:100302.

The Impact of an Adolescent Gynecology Provider on Intrauterine Device and Subdermal Contraceptive Implant Use Among Adolescent Patients.

STUDY OBJECTIVE: To assess how the addition of a pediatric and adolescent gynecologist (PAG) in an area where one has not previously been available affects the use of long-acting reversible contraception (LARC) among adolescent and adult women 13-24 years of age. DESIGN: Retrospective chart review. SETTING: Academic practice including 12 general practice obstetric/gynecologists (GP) and 1 PAG, and Title X clinics in 3 neighboring counties in West Virginia. PARTICIPANTS: Patients receiving an intrauterine device (IUD) or implant during 2010-2016. INTERVENTIONS: Subject charts were reviewed for age and date at insertion, provider (GP, PAG, and Title X), device type, parity, discontinuation, and sequential LARC placement. MAIN OUTCOME MEASURES: Frequencies of LARC and relative risks (RR) with 95% confidence intervals were calculated for the 13- to 17-year and 18- to 24-year age groups and compared between provider type. RESULTS: The frequency of LARC increased over time for all providers for participants age 13-24; the PAG had the highest frequency of LARC among participants aged 13-17 years. The RR for IUD provision for the PAG provider among those aged 13-17 years was 3.1 and 32.5 times greater compared to GP and Title X (P < .001). Title X providers were 2.9 (2.27, 3.79) and 2.8 (2.06, 3.81) times more likely to provide implants to patients aged 13-17 years compared to PAG and GP, respectively (P < .001). CONCLUSIONS: A PAG provider can have a positive impact on LARC uptake among adolescents in a community where this specialist has not previously been available. This is most noted among 13- to 17-year-old patients receiving IUDs.

Clinical research with adolescents: barriers and how to overcome them.

PURPOSE OF REVIEW: This review aims to emphasize the importance of including adolescents in research, outline current standards and evaluate barriers that prevent adolescent research. We also hope to provide some guidance and call for much needed additional direction in the field. RECENT FINDINGS: The absolute necessity for including adolescents in research has been an area of focus within the community of adolescent providers and care takers. Recent policy and support from major organizations has emphasized the importance of including this population in research but also pointed out many of the complexities. SUMMARY: Adolescent research is imperative to guiding policy and promoting evidence-based care. Current standards provide both guidance and barriers, yet more research is needed to further guide conduct of ethical research in this population.

The Management of an Ectopic Ovary in an Adolescent Patient with Gastroschisis.

BACKGROUND: Gastroschisis is an abdominal wall defect through which the bowel herniates into the amniotic cavity. Surgical correction of gastroschisis is performed during infancy. Gynecologic concerns have not been described in this population as either an associated anomaly or complication of surgical repair. CASE: A 15-year-old nulliparous female patient presented with abdominal pain with a history of gastroschisis requiring 4 surgeries in infancy. Computed tomography scan showed an ovary located in the right upper quadrant, which was concerning for torsion. She was taken for a laparotomy with right oophorectomy after conservative management had failed. SUMMARY AND CONCLUSION: Long-term gynecologic outcomes of patients with gastroschisis are not well documented. Because gastroschisis patients are known to have abdominal pain later in life, this case shows that the differential diagnosis should include etiologies beyond the gastrointestinal tract.

The Use of Telehealth to Teach Reproductive Health to Female Rural High School Students.

STUDY OBJECTIVE: To evaluate the use of telehealth to teach reproductive health to rural areas with high rates of teen pregnancy. DESIGN: Prospective cohort study. SETTING: Two high schools in rural West Virginia. PARTICIPANTS: High school female students who attended telehealth sessions. INTERVENTIONS: Teleconferencing equipment connected rural high schools to a distal academic institution. Telehealth sessions included reproductive health and life skills topics. Demographic information, session pre- and post-tests, and 6- month assessment was obtained. MAIN OUTCOME MEASURES: Reproductive health knowledge, behavior, and self-efficacy were assessed at intervention and at 6 months, along with Likert scale evaluation of telehealth as an educational tool. RESULTS: Fifty-five students participated in the program with an average age of 16.14 (SD 1.24) years. Only 20% (10/50) of subjects' mothers and 12% (6/50) of subjects' fathers had achieved education beyond high school, and 20% (10/50) of subject's mothers had experienced teen pregnancies (age 18 or younger). Sexual activity was reported among 52% (26/50) of subjects, 4/50 (8%) reported desire to become pregnant within the next year, and 4/50 (8%) reported already pregnant. Thirty-seven students completed the 6-month follow-up survey. Reported condom use increased from 20% (10/50) at baseline to 40% (15/37) at 6 months (P = .04) and hormonal contraception use increased from 22% (11/50) to 38% (14/37) (P = .12). Report of human papillomavirus vaccination increased from 38% (10/26) to 70% (26/37) (P = .001) among all subjects. At 6 months, 91.8% (34/37) reported the use of telehealth was "very effective" as a means to teach the material. CONCLUSIONS: Telehealth is an effective tool to teach reproductive health to rural areas.

Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States.

Three intrauterine devices (IUDs), one copper and two containing the progestin levonorgestrel, are available for use in the United States. IUDs offer higher rates of contraceptive efficacy than nonlong-acting methods, and several studies have demonstrated higher satisfaction rates and continuation rates of any birth control method. This efficacy is not affected by age or parity. The safety of IUDs is well studied, and the risks of pelvic inflammatory disease, perforation, expulsion, and ectopic pregnancy are all of very low incidence. Noncontraceptive benefits include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia. The use of IUDs is accepted in patients with multiple medical problems who may have contraindications to other birth control methods. Yet despite well-published data, concerns and misperceptions still persist, especially among younger populations and nulliparous women. Medical governing bodies advocate for use of IUDs in these populations, as safety and efficacy is unchanged, and IUDs have been shown to decrease unintended pregnancies. Dispersion of accurate information among patients and practitioners is needed to further increase the acceptability and use of IUDs.

The effect of an educational approach to pregnancy prevention among high-risk early and late adolescents.

PURPOSE: To evaluate a novel approach to adolescent pregnancy prevention through scheduled educational clinic visits, focusing to retain patients within the clinic system. METHODS: This is a retrospective chart review conducted at the Center for Adolescent Pregnancy Prevention, a privately funded clinic located in an urban setting serving only adolescents and young adults. Subjects included adolescent patients aged 11-18 years who were seen between January 2007 and December 2010. The primary outcomes studied were 12- and 24-month continuation rates of birth control options, total length of follow-up, time until gaps in follow-up, and any incident pregnancies. Results were stratified based on age at initial visit: early adolescents (aged 11-15 years) or late adolescents (aged 16-18 years). RESULTS: There were 121 patients who met inclusion and had more than one visit. There were seven incident pregnancies over the study period, all in the late adolescent group. The relative risk of pregnancy among those with a gap in follow-up of >12 months compared with those without a gap was 4.63 (95% confidence interval [CI] 1.1-19.4). The early adolescents had a greater rate of continuation of birth control at 12 months compared with late adolescents (66.6% vs. 42.2%, relative risk [RR] 1.57, 95% CI 1.12-2.20) and had higher rates of continuation at 24 months (41.6% vs. 18.3%, RR 2.27, 95% CI 1.25-4.11). CONCLUSIONS: The educational approach at Center for Adolescent Pregnancy Prevention may decrease adolescent pregnancy among high-risk adolescents that stay within the clinic system. This educational model may be more effective for early adolescents than late adolescent patients.

A multicenter survey of contraceptive knowledge among adolescents in North America.

STUDY OBJECTIVE: To assess knowledge about contraceptive efficacy and side effects in an adolescent population seen in Pediatric and Adolescent Gynecology referral centers. DESIGN: This is a multisite cross-sectional survey study. A 23-question survey assessing knowledge of contraception and demographic information was administered. Data analysis was performed using descriptive statistics, simple paired t tests, and chi-square analyses using SAS 9.3. SETTING: Pediatric and Adolescent Gynecology clinics in 4 tertiary care centers. The study was conducted in 3 institutions in the United States and 1 institution in Canada. PARTICIPANTS: A convenience sample of 354 female patients aged 10-24 y seeking reproductive healthcare at participating institutions. INTERVENTIONS: None MAIN OUTCOME MEASURES: The percentage of correct answers to questions assessing general knowledge about contraception, familiarity with different contraceptive methods, and comparison of results between study sites. RESULTS: The mean percentage of correct answers among all participants was 55.8% ± 17%. Younger participants (age 10-13 years) scored significantly lower than their older counterparts (49%, 55%, and 60% respectively, P < .05). There was no correlation between score and ethnicity or location of the participating site. Subjects reporting the internet as a source of information, those who were sexually active, and those familiar with long acting reversible contraceptives scored significantly higher. Of all contraceptive methods, participants were least likely to have heard of etonogestrel implants (18%), rhythm method/natural family planning (28%), and IUDs (32%). CONCLUSION: Adolescents and young adults performed poorly overall demonstrating both the lack of overall knowledge regarding methods of contraception and misinformation about side effects.

Use of the levonorgestrel intrauterine system in adolescents with endometriosis.

STUDY OBJECTIVE: The purpose of this study was to evaluate our adolescent patient population who had received a levonorgestrel intrauterine system (LNG-IUS) at or after the time of endometriosis diagnosis, and determine efficacy of the LNG-IUS in regards to pain and bleeding on follow-up exam. DESIGN: Retrospective cohort study. SETTING: Pediatric Adolescent Gynecology Clinic and Children's Hospital in a metropolitan area. PARTICIPANTS: Adolescent patients age 14-22 with pathology-proven endometriosis who had the LNG-IUS placed during the course of their treatment for this disease. Patients were divided into LNG-IUS placement at the time of surgical diagnosis versus placement some time after diagnosis. MAIN OUTCOME MEASURES: Pain and bleeding were assessed by follow-up exam. Pain was classified at each follow-up visit as either none, minimal, moderate, or severe. Bleeding was classified as none, irregular spotting, irregular bleeding, or daily bleeding. RESULTS: The majority of patients (67%) required additional hormonal therapy for pain and bleeding suppression. Time to bleeding suppression and pain suppression was sooner in the group with interval time between surgical diagnosis and LNG-IUS placement, compared to LNG-IUS placement at the time of surgery (2.4 months vs 5.3 months until bleeding suppression, and 3.8 months vs 4.8 months until pain suppression), although statistical significance was not achieved. CONCLUSIONS: The LNG-IUS is an option for treatment of endometriosis in adolescents. As pain is the main problem associated with endometriosis, LNG-IUS placement is beneficial at the time of surgery when it is diagnosed. A prospective study is needed for further assessment of outcomes.

Laparoscopy in pregnancy and the pediatric patient.

Minimally invasive surgery is now standard of care for many procedures in pediatric gynecology. Laparoscopy has been well documented to produce faster recovery,decreased postoperative pain, and because of smaller incisions, a better cosmetic result. These are important when considering an active pediatric patient. Although a laparoscopic approach to endometriosis, adnexal masses, and ovarian torsion are well supported in the literature in the pediatric patient, more data are needed with regard to SILS in younger patients. Laparoscopy seems to be a better approach to oopheropexy in children undergoing radiation, and in resection of certain mullerian anomalies; however, the numbers are low.Similarly in pregnant patients, laparoscopy provides for shorter recovery times,decrease analgesic use and shorter hospital stays. Concerns about poor fetal outcomes in surgery during pregnancy for non gynecologic problems have been brought to light; however, the evidence indicates that these outcomes can be attributed to the nature of the underlying disease and not the surgical approach. With regard to pneumoperitoneum the effect of CO2 insufflation on fetal physiology and long-term outcomes remains unclear, and will continue to be an issue of controversy until larger studies are published.With both the pediatric and pregnant populations, laparoscopic complications can be diminished when performed by skilled surgeons with strict adherence to good technical principles. The advantages of laparoscopy are great, and this approach should be considered in pediatric and pregnant patients.

Management of the low grade squamous intraepithelial lesion Pap smear in a cross-sectional, observational cohort.

OBJECTIVE: To evaluate the practice of delaying colposcopy until repeat cytology demonstrates persistent low grade squamous intraepithelial lesion (LSIL). STUDY DESIGN: A retrospective cross-sectional analysis was performed on patients diagnosed with LSIL in a high-risk urban population. Primary outcomes were defined as regression, persistence, progression and lost to follow-up. RESULTS: A total of 624 patients received an initial cytologic diagnosis of LSIL. Of these, 260 (42%) were lost to follow-up despite multiple contact attempts. Of the 364 patients available for full analysis, 168 (26%) regressed to negative cytology, 93 (15%) had persistent LSIL/cervical intraepithelial neoplasia (CIN) 1, and 103 (17%) progressed to high grade cervical intraepithelial neoplasia (HSIL)/CIN 2/3. Higher rates of LSIL regression were observed in teenagers (< or = 20) compared to women aged 21-30 or > 30 (51% vs. 43% vs. 45%), although this was not statistically significant (p = 0.29). CONCLUSION: Delaying colposcopy to repeat cytology resulted in a significant loss to follow-up in a population at high risk for poor compliance. In women with LSIL over 20 years of age, immediate colposcopy is recommended when optimal patient compliance cannot be ensured. Only 25% of patients avoided eventual colposcopy by regression to normal cytology.