Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices.

OBJECTIVE: Studies show immediate postpartum (PP) insertion increases use of contraceptive implants and intrauterine devices (IUDs). Our objective was to compare the satisfaction and continuation rates of the two types of devices at 6 months and 1 year following PP insertion. STUDY DESIGN: We enrolled 133 women in a prospective cohort study following immediate PP insertion of an implant or IUD at two academic hospitals during 8 months of 2011. Subjects completed an enrollment survey during hospital admission and a follow-up phone survey 6 months and 1 year PP. RESULTS: At 6 months PP, 72% of subjects provided follow-up information. Implant users were more likely to be using the originally-placed device (40/41, 98% vs. 45/55, 82%, p=0.02); nine women reported IUD expulsions. When accounting for replacement of expelled IUDs, IUD continuation at 6 months was 89% yielding similar continuation rates between groups (p=0.12). At 1 year PP, 51% provided follow-up. Of those, 82% still had a LARC method in place with similar continuation by device type (84% for implants, 81% for IUDs, p=0.96). Overall, satisfaction was similarly high in both groups. CONCLUSION: Due to IUD expulsion, implants had a higher continuation rate than IUDs six months following immediate PP insertion. After replacement of expelled IUDs, continuation and satisfaction were similar for both devices at 6 months and 1 year. IMPLICATIONS: Placement of implants and IUDs immediately PP can lead to high satisfaction. Despite early IUD expulsions, continuation rates were similar to those placed outside of the immediate PP period.

Immediate placement of intrauterine devices after first and second trimester pregnancy termination.

BACKGROUND: We reviewed our experience with intrauterine device (IUD) placement after surgical abortion up to 20 weeks' gestation. STUDY DESIGN: Women presenting for elective abortion between January 2004 and March 2009 who requested an IUD were included in this retrospective review. RESULTS: Of 308 women requesting postabortion IUD placement, 221 (72%) planned insertion at the time of abortion (immediate group) and 87 (28%) planned insertion at their postoperative visit (interval group). IUDs were placed in 96% of the immediate group and in 23% of the interval group (212/221 vs. 20/87; p<.0001). Failure to return for placement was the most common reason for noninsertion in the interval group (60/87=69%). Follow-up information was obtained for 56% of patients and was documented a median of 137 days postabortion (range 3-1594 days). There was no difference in complication rates between groups. Expulsion rates were 3% and 0% in the immediate and interval groups, respectively (6/212 vs. 0/20; p=.4). Considering only those with documented follow-up after immediate insertion (119), there was a nonsignificant trend towards increased expulsion with placement after second vs. first trimester abortion (4/54=7% vs. 2/65=2%; p=.3). When analyzing the 172 subjects with documented follow-up, those planning immediate insertion were more likely to have an IUD in situ at the last contact than those planning later insertion (84/124=68% vs. 20/48=42%; p=.002). CONCLUSION: Immediate postabortion IUD insertion is safe and effective. Given the low rate of return for interval insertion, immediate placement may be preferable.

Reduced incidence of gestational diabetes with bariatric surgery.

BACKGROUND: Obesity is a risk factor for gestational diabetes mellitus (GDM), and bariatric surgery is an effective treatment for obesity. Our objective was to determine the association of bariatric surgery with the incidence of GDM and related complications. STUDY DESIGN: We performed a retrospective study comparing rates of GDM and related outcomes (including cesarean section, large-for-gestational-age infant, shoulder dystocia, and infection) between a group of women with a delivery before bariatric surgery and a group with a delivery after bariatric surgery. We used a private insurance claims database with information on 23,594 women who had bariatric surgery between 2002 and 2006. The dataset was searched to identify women with codes for bariatric surgery and a pregnancy resulting in a delivery at greater than 22 weeks gestation. Incidences of GDM and selected delivery complications for delivery before versus after bariatric surgery were compared using Fisher exact test and logistic regression. RESULTS: There were 346 women who had a delivery before bariatric surgery, and 354 had a delivery after bariatric surgery. Women with delivery after bariatric surgery had lower incidences of GDM (8% vs 27%, odds ratio (OR) 0.23, (95% CI 0.15 to 0.36) and cesarean section (28% vs 43%, OR0.53, 95% CI 0.39 to 0.72) than those with delivery before bariatric surgery. CONCLUSIONS: Bariatric surgery is associated with a decreased incidence of GDM and cesarean section in subsequent pregnancies. This potential effect of bariatric surgery should be considered in the management of obese women of childbearing age. Prospective studies are needed to confirm these findings.

Findings associated with recurrence of bacterial vaginosis among adolescents attending sexually transmitted diseases clinics.

STUDY OBJECTIVE: Bacterial vaginosis (BV) is a common infection and has been associated with adverse health outcomes, including preterm birth, pelvic inflammatory disease (PID), and acquisition of HIV. There are limited data on recurrent BV in adolescents. A relationship between the frequency of BV recurrence and specific risk factors might shed light on the pathophysiology of BV and lead to targeted interventions. DESIGN: Record-based historical clinic study. SETTING: Adolescent visits to two sexually transmitted disease (STD) clinics between 1990 and 2002. PARTICIPANTS: 254 girls who had >/= 2 episodes of BV and at least 3 clinical visits, matched on clinic attendance frequency to 254 girls with only 1 documented BV episode and 254 girls with no history of BV. MAIN OUTCOME MEASURE: Risk factor differences between groups. ANALYSIS: Multinomial logistic regression with robust estimator of the standard errors, accounting for repeated measures. RESULTS: 5,977 adolescent girls visited the clinics. 1509 (25%) had at least one episode of BV; of those, 303 (19.9%) had 2 or more BV episodes. Girls with a history of 1 BV episode and girls with a history of 2 or more BV episodes were more likely to be infected with Trichomonas vaginalis [OR 1.77, 95% CI: 1.17-2.67, OR 1.56, 95% CI: 1.05-2.34] and be diagnosed with PID [OR 1.50, 95% CI: 1.02-2.22, OR 2.05, 95% CI: 1.41-2.98] compared to girls with no BV history, respectively. Girls with a history of BV were also more likely to report active oral sex and lack of contraceptive use. CONCLUSION: Adolescent girls who attend STD clinics have a high prevalence of BV. Although the association between BV and PID is not clearly causal, when one condition is diagnosed, evaluation and counseling for the other may reduce recurrence and sequelae.

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 chi(2), 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.

Prophylactic antibiotic administration prior to hysterectomy: a quality improvement initiative.

OBJECTIVE: To determine whether institution of a preoperative antibiotic policy could increase the use of prophylactic antibiotics prior to hysterectomy. STUDY DESIGN: A retrospective cohort study of 400 women who underwent abdominal, vaginal or laparoscopic hysterectomy for benign indications at Women and Infants Hospital was performed. Rates and timing of prophylactic preoperative antibiotic administration were determined, as were the rates of postoperative febrile morbidity. These data were compared to data collected in a medical record review of 686 hysterectomies performed prior to institution of the antibiotic policy. RESULTS: Prior to the institution of the antibiotic policy, 50% of patients (342/686, 95% CI 46.0, 53.7) received prophylactic preoperative antibiotics. After introduction of the antibiotic policy, 91.2% (95% CI 88.0, 93.8) of patients received prophylactic preoperative antibiotics. Approximately 66% of the antibiotics were administered within the 60 minutes preceding the surgical incision. Postoperative febrile morbidity was noted in 14% of patients prior to the antibiotic policy as compared to 11% of patients after the policy was instituted. Abdominal surgical approach was found to be a clinically and statistically significant risk factor for febrile morbidity (OR = 7.0; 95% CI 2.3, 20.9). CONCLUSION: Rates of prophylactic preoperative antibiotic administration significantly increased after institution of a hospital policy advocating routine antibiotic prophylaxis prior to hysterectomy. Additional steps must be taken to ensure more routine and appropriately timed administration of antibiotics prior to hysterectomy and to continuously monitor the use of prophylactic antibiotics.