Impact of telehealth implementation on diagnosis of hypertensive disorders of pregnancy.

BACKGROUND: COVID-19 caused a rapid integration of telehealth into prenatal care. This raises questions about the ability to screen for hypertensive disorders of pregnancy when caring for patients remotely. OBJECTIVE: This study aimed to assess the effect of telehealth adaptation on the timing and severity of diagnosis of hypertensive disorders of pregnancy. STUDY DESIGN: This was a retrospective study of patients with hypertensive disorders of pregnancy who delivered from April 2019 to October 2019 (before the pandemic) and April 2020 to October 2020 (during the pandemic) at 1 urban tertiary care center. The primary outcome was mean gestational age at diagnosis of a hypertensive disorder of pregnancy. The secondary outcomes included severity of diagnosis, both initially and at the time of delivery. The results were adjusted for baseline characteristic difference at P<.10, using multivariable logistic regression and analysis of covariance, as appropriate. The sample size was calculated based on a previous cohort study of patients who developed preeclampsia, with a mean gestational age at delivery of 36.3 weeks and a standard deviation of 2.8 weeks. A sample size of 124 patients would be needed per group to detect a gestational age difference of 1 week with 80% power and a 95% confidence interval. RESULTS: Overall, 498 patients were included, with 231 from 2019 and 267 from 2020. Of note, 17.1% of patients had preeclampsia with severe features initially, and 29.3% of patients met the criteria at delivery. In 2020, 80.5% of patients used telehealth (vs 0.9% of patients in 2019), doing so for a mean of 29.0% of prenatal appointments. Unadjusted and adjusted analyses showed no significant difference in gestational age at diagnosis or diagnosis severity between cohorts. In the adjusted analysis, cohort year was not significantly associated with severity of initial diagnosis (adjusted odds ratio, 0.86; 95% confidence interval, 0.53-1.39; P=.53) or severity of diagnosis at delivery (adjusted odds ratio, 0.97; 95% confidence interval, 0.64-1.46; P=.87). However, Black race was significantly associated with increased risk of having severe preeclampsia at initial diagnosis (adjusted odds ratio, 1.70; 95% confidence interval, 1.01-2.85; P=.046). In addition, Black race (adjusted odds ratio, 2.62; 95% confidence interval, 1.60-4.28; P<.001), Hispanic ethnicity (adjusted odds ratio for non-Hispanic, 0.40; 95% confidence interval, 0.19-0.82; P=.01), and initial body mass index (adjusted odds ratio, 1.04; 95% confidence interval, 1.01-1.06; P=.005) were significantly associated with a diagnosis of severe preeclampsia at delivery. CONCLUSION: The adaptation of telehealth was not associated with delays in the diagnosis of hypertensive disorders of pregnancy or with increased severity of diagnoses.

Incarcerated Gravid Uterus Liberated by Placement of a Vaginal Balloon.

BACKGROUND: Incarceration of the gravid uterus is an infrequent obstetric complication that can cause severe complications. CASE: A 37-year-old woman, G3P2002, at 14 weeks of gestation presented with vomiting, back pain, and urinary retention. She was noted to be in acute renal failure, with a creatinine level of 9.24 mg/dL, and results of her physical examination were concerning for uterine incarceration. Passive maneuvers and manual pressure failed to resolve the incarceration. Under spinal anesthesia, a Bakri balloon was inflated in the posterior vagina, elevating the fundus and relieving the incarcerated uterus. CONCLUSION: An intravaginal balloon may aid in the alleviation of uterine incarceration.

Contraception Counseling and Use Among Adolescent and Young Adult Female Patients Undergoing Cancer Treatment: A Retrospective Analysis.

STUDY OBJECTIVE: Adolescent and young adult (AYA) women undergoing cancer treatment face unique reproductive health risks. This study aimed to assess the prevalence of sexual health counseling and contraception use in the oncology setting, and to identify patient factors associated with these outcomes. DESIGN: Retrospective chart review. SETTING: Yale New Haven Hospital from 2013 to 2018. PARTICIPANTS: Female patients 15-25 years of age receiving cancer treatment, excluding those treated with surgery only. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Outcomes of documented sexual health counseling and contraception use were assessed for frequency. Associations between patient factors and these outcomes were assessed using Pearson χ2 and Fisher exact tests, and multivariate logistic regression was used to identify predictors of these outcomes. RESULTS: In this cohort (n = 157), the median age was 20.5 years, and the most common diagnoses were hematologic (40.8%) and thyroid (31.2%) malignancies. Of the patients, 33.1% were documented as receiving sexual health counseling, and 48.4% used contraception. Younger patients (15-20 years of age) were less likely to receive counseling (OR 0.31, 95% CI 0.14-0.70, P = .005). Receiving counseling (OR 3.36, 95% CI 1.35-8.34, P = .009) and sexual activity (OR 4.18, 95% CI 1.80-9.68, P = .001) were significantly associated with contraception use. CONCLUSIONS: Sexual health counseling was documented infrequently during oncologic care for AYA women, especially for younger patients. However, such conversations were associated with a higher likelihood of contraception use. There is a need to improve rates of counseling in this high-risk setting, in which adolescents may be more vulnerable with regard to sexual health.

Tetrathiomolybdate inhibits mitochondrial complex IV and mediates degradation of hypoxia-inducible factor-1α in cancer cells.

Hypoxia-inducible factor-1α (HIF-1α) is a transcription factor that triggers adaptive responses upon low oxygen conditions and plays a crucial role in cancer metabolism and therapy resistance. Tetrathiomolybdate (TM), a therapy option for copper overload disorder, has also been shown to be capable of limiting tumor angiogenesis, although its underlying mechanism remains unclear. Using ovarian and endometrial cancer cell lines, we observed that TM downregulates HIF-1α protein levels and HIF-transcriptional targets involved in tumor angiogenesis and glycolysis, but did not affect HIF-1α protein synthesis. TM-mediated HIF-1α downregulation was suppressed when HIF-prolyl hydroxylase activity was pharmacologically inhibited using deferoxamine or dimethyloxaloylglycine, and also when the oxygen-dependent degradation domains of HIF-1α, which are responsible for the interaction with HIF-prolyl hydroxylase, were deleted. These findings suggest that TM causes HIF-1α downregulation in a HIF-prolyl hydroxylase-dependent manner. Our studies showed that TM inhibits the activity of the copper-dependent mitochondrial complex IV and reduces mitochondrial respiration, thereby possibly increasing oxygen availability, which is crucial for HIF-prolyl hydroxylase activity. Pimonidazole staining also showed that TM elevates oxygen tension in hypoxic cells. Our studies provide mechanistic evidence for TM-mediated HIF-1α regulation and suggest its therapeutic potential as a method of blocking angiogenesis in ovarian and endometrial tumors.