ACOG 2015

SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.

Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.

The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.

Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.

Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.

The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.

“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.

Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.

The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.

Dr. Gunnison reported having no financial disclosures.

SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.

Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.

The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.

Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.

Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.

The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.

“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.

Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.

The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.

Dr. Gunnison reported having no financial disclosures.

SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.

Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.

The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.

Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.

Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.

The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.

“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.

Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.

The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.

Dr. Gunnison reported having no financial disclosures.

SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.

Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.

The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.

Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.

Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.

The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.

“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.

Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.

The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.

Dr. Gunnison reported having no financial disclosures.

[email protected]

SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.

Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.

The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.

Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.

Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.

The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.

“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.

Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.

The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.

Dr. Gunnison reported having no financial disclosures.

[email protected]

SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.

Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.

Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.

The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.

Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.

Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.

The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.

“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.

Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.

The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.

Dr. Gunnison reported having no financial disclosures.

[email protected]

SAN FRANCISCO – A review of 160 mobile applications yielded only a small number with comprehensive and medically accurate birth control information, but these apps could be a useful resource for patients, according to Angel Robinson.

Of the apps reviewed, 16 were targeted toward health care providers and 144 were targeted toward patients. Only 20 of the 144 had comprehensive information about multiple birth control methods, Ms. Robinson, a third-year medical student at the University of California, Los Angeles, reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.

©Yankin Chauvin/Fotolia.com

She and her colleagues featured a few of the better quality apps in their poster, including:

Mayo Clinic About Birth Control: Options for You (cost: $1.99)

Plan A Birth Control (free)

Pregnancy prevention, birth control techniques ($0.99)

My Sex Doctor Plus ($0.99)

Sexual Health Guide (free)

These apps provide information about the various types of birth control available, as well as information about selecting the most appropriate method, Ms. Robinson said. Interactive features allow consumers to input personal health and other information to identify the best options.

Given that 90% of Americans use mobile phones, 58% have a smartphone, and half of those smartphone owners have used their phones to download apps, it follows that health-related apps could have broad appeal and utility; this may be particularly true for younger patients who are tech savvy and comfortable using apps, Ms. Robinson said.

Apps are also an attractive patient resource because they eliminate barriers that can interfere with communication of sexual and reproductive health information, but studies regarding the accuracy of the content of apps related to contraception and family planning have been lacking, she said.

For this study, Ms. Robinson and her colleagues searched the iOS mobile platform using numerous key words related to contraception and family planning between June and July of 2014. Several themes that emerged among the 144 patient-targeted apps were cycle tracking (40 apps), birth control reminders (26 apps), games (16 apps), family planning locators (22 apps), and sexual health information (40 apps).

“Mobile applications may be a powerful untapped patient information and referral resource,” Ms. Robinson and her colleagues wrote. “While mobile applications are an increasingly utilized means of accessing health and medical information, accurate and comprehensive information about contraception and family planning is not easily available for women who seek it through such applications.”

The quality apps that are available, however, could prove to be a useful adjunct to clinical care, she said, adding that additional studies are needed to identify the usefulness of such applications for that purpose.

The investigators reported having no financial disclosures.

[email protected]

SAN FRANCISCO – A review of 160 mobile applications yielded only a small number with comprehensive and medically accurate birth control information, but these apps could be a useful resource for patients, according to Angel Robinson.

Of the apps reviewed, 16 were targeted toward health care providers and 144 were targeted toward patients. Only 20 of the 144 had comprehensive information about multiple birth control methods, Ms. Robinson, a third-year medical student at the University of California, Los Angeles, reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.

©Yankin Chauvin/Fotolia.com

She and her colleagues featured a few of the better quality apps in their poster, including:

Mayo Clinic About Birth Control: Options for You (cost: $1.99)

Plan A Birth Control (free)

Pregnancy prevention, birth control techniques ($0.99)

My Sex Doctor Plus ($0.99)

Sexual Health Guide (free)

These apps provide information about the various types of birth control available, as well as information about selecting the most appropriate method, Ms. Robinson said. Interactive features allow consumers to input personal health and other information to identify the best options.

Given that 90% of Americans use mobile phones, 58% have a smartphone, and half of those smartphone owners have used their phones to download apps, it follows that health-related apps could have broad appeal and utility; this may be particularly true for younger patients who are tech savvy and comfortable using apps, Ms. Robinson said.

Apps are also an attractive patient resource because they eliminate barriers that can interfere with communication of sexual and reproductive health information, but studies regarding the accuracy of the content of apps related to contraception and family planning have been lacking, she said.

For this study, Ms. Robinson and her colleagues searched the iOS mobile platform using numerous key words related to contraception and family planning between June and July of 2014. Several themes that emerged among the 144 patient-targeted apps were cycle tracking (40 apps), birth control reminders (26 apps), games (16 apps), family planning locators (22 apps), and sexual health information (40 apps).

“Mobile applications may be a powerful untapped patient information and referral resource,” Ms. Robinson and her colleagues wrote. “While mobile applications are an increasingly utilized means of accessing health and medical information, accurate and comprehensive information about contraception and family planning is not easily available for women who seek it through such applications.”

The quality apps that are available, however, could prove to be a useful adjunct to clinical care, she said, adding that additional studies are needed to identify the usefulness of such applications for that purpose.

The investigators reported having no financial disclosures.

[email protected]

SAN FRANCISCO – A review of 160 mobile applications yielded only a small number with comprehensive and medically accurate birth control information, but these apps could be a useful resource for patients, according to Angel Robinson.

Of the apps reviewed, 16 were targeted toward health care providers and 144 were targeted toward patients. Only 20 of the 144 had comprehensive information about multiple birth control methods, Ms. Robinson, a third-year medical student at the University of California, Los Angeles, reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.

©Yankin Chauvin/Fotolia.com

She and her colleagues featured a few of the better quality apps in their poster, including:

Mayo Clinic About Birth Control: Options for You (cost: $1.99)

Plan A Birth Control (free)

Pregnancy prevention, birth control techniques ($0.99)

My Sex Doctor Plus ($0.99)

Sexual Health Guide (free)

These apps provide information about the various types of birth control available, as well as information about selecting the most appropriate method, Ms. Robinson said. Interactive features allow consumers to input personal health and other information to identify the best options.

Given that 90% of Americans use mobile phones, 58% have a smartphone, and half of those smartphone owners have used their phones to download apps, it follows that health-related apps could have broad appeal and utility; this may be particularly true for younger patients who are tech savvy and comfortable using apps, Ms. Robinson said.

Apps are also an attractive patient resource because they eliminate barriers that can interfere with communication of sexual and reproductive health information, but studies regarding the accuracy of the content of apps related to contraception and family planning have been lacking, she said.

For this study, Ms. Robinson and her colleagues searched the iOS mobile platform using numerous key words related to contraception and family planning between June and July of 2014. Several themes that emerged among the 144 patient-targeted apps were cycle tracking (40 apps), birth control reminders (26 apps), games (16 apps), family planning locators (22 apps), and sexual health information (40 apps).

“Mobile applications may be a powerful untapped patient information and referral resource,” Ms. Robinson and her colleagues wrote. “While mobile applications are an increasingly utilized means of accessing health and medical information, accurate and comprehensive information about contraception and family planning is not easily available for women who seek it through such applications.”

The quality apps that are available, however, could prove to be a useful adjunct to clinical care, she said, adding that additional studies are needed to identify the usefulness of such applications for that purpose.

The investigators reported having no financial disclosures.

[email protected]

Yes: Time to design seamless care

Since the first freestanding birth center opened in the mid-1970s, a demonstration model, designed by Maternity Center Association in New York, the evidence has consistently shown quality and safe care for the mother and newborn in low-risk populations, as well as a reduced cost of care.

The first National Birth Center study published in the New England Journal of Medicine in 1989, as well as the National Birth Center Study II, Outcomes of Care in Birth Centers published in the Journal of Midwifery and Women’s Health in 2013, continue to demonstrate safe outcomes (N. Engl. J. Med. 1989;321:1804-11).

The most recent Birth Center II study collected data from 2007 through 2010 on 15,574 women admitted to 79 midwifery-led freestanding birthing centers (FSBCs) in 33 states. Findings included a rate of 92.8% for normal spontaneous vaginal delivery, 6.1% cesarean delivery, and 84% of women gave birth at the FSBCs, with 12.4% transferred after admission. There were no maternal deaths (J. Midwifery. Womens. Health. 2013;58:3-14).

The most common reason for nonemergent maternal transfer to hospital was prolonged or arrested labor, request for pharmacologic pain relief, and maternal exhaustion. For emergent transfer, the primary reason was nonreassuring fetal heart rate pattern (0.5%) and postpartum hemorrhage (0.2%). Newborn outcomes include transfer of 2.6% and 14 neonatal deaths (7 occurred before admission to the center). The intrapartum fetal mortality rate for admitted mothers was 0.47/1,000 and neonatal mortality rate 0.40/1,000, which is similar to what the United Kingdom found among low-risk women in hospitals, FSBCs, and home births. The primary reason for newborn transfer was respiratory observation.

In 2011, the American College of Obstetricians and Gynecologists Committee Opinion on Planned Home Birth references that hospitals and birthing centers are the safest setting for birth. This was followed up in 2015 with the consensus document on Levels of Maternal Care by ACOG and the Society for Maternal-Fetal Medicine that acknowledges and addresses care provided at birth centers, including the role of caregivers.

The future focus of the FSBCs should include a push to mandate accreditation in all facilities, and ongoing research related to outcomes of: midwifery-led care, provider types, FSBC licensure and/or accreditation status, and types of collegial partnerships. This debate must move from a polarizing discussion of “either/or” to “both/and,” which would expand interprofessional collaborations and design seamless care for the growing number of women choosing out-of-hospital birth.

Dr. Breedlove is president of the American College of Nurse-Midwives.

No: Hospitals are still the safest choice

According to analysis of currently available data, and recognizing that there has not been a randomized controlled trial addressing the site of delivery, hospitals are safer than freestanding birthing centers.

How much safer is a point of contention and depends on several key factors: 1. whether the birthing center is accredited and staffed by certified nurse midwives; 2. how far from the nearest hospital with delivery capability the birthing center is located; and 3. the thoroughness of the selection process in identifying low-risk women who are appropriate candidates to deliver in a birthing center.

Even women correctly classified as low risk may require nonemergent cesarean delivery for failure to progress in labor. Since freestanding birthing centers do not provide cesarean delivery, such women must be transferred to a hospital. If the status of both mother and fetus is reassuring, transfer represents just an inconvenience. Overall, the need for transfer arises fairly often, especially in first pregnancies.

However, unexpected emergencies like cord prolapse can and do occur in the course of labor in low-risk women. Hospitals can respond with immediate cesarean delivery, whereas the only recourse for birthing centers is emergency transfer to a hospital.

The idea of a safety net is the No. 1 reason why women choose to deliver in hospitals and that safety net covers not only their newborns, but women themselves. A second reason is the availability of epidural anesthesia for relief of pain in labor.

In answer to the question of whether birthing centers are a safe alternative to hospitals for delivering babies, I would say it depends on women’s tolerance of risk. Adverse outcomes at freestanding birthing centers are uncommon, but some of those that occur could be prevented in a hospital setting.

One compromise may be to locate birthing centers inside hospitals and this model has been successfully implemented in a number of cities across the United States. This suggestion dates back a quarter of a century but is still meritorious today (N. Engl. J. Med. 1989;321:1824-5). Could it be a way for women to have their cake and eat it too?

Dr. Yeomans is the chair of the department of ob.gyn. at Texas Tech University in Lubbock.

Yes: Time to design seamless care

Since the first freestanding birth center opened in the mid-1970s, a demonstration model, designed by Maternity Center Association in New York, the evidence has consistently shown quality and safe care for the mother and newborn in low-risk populations, as well as a reduced cost of care.

The first National Birth Center study published in the New England Journal of Medicine in 1989, as well as the National Birth Center Study II, Outcomes of Care in Birth Centers published in the Journal of Midwifery and Women’s Health in 2013, continue to demonstrate safe outcomes (N. Engl. J. Med. 1989;321:1804-11).

The most recent Birth Center II study collected data from 2007 through 2010 on 15,574 women admitted to 79 midwifery-led freestanding birthing centers (FSBCs) in 33 states. Findings included a rate of 92.8% for normal spontaneous vaginal delivery, 6.1% cesarean delivery, and 84% of women gave birth at the FSBCs, with 12.4% transferred after admission. There were no maternal deaths (J. Midwifery. Womens. Health. 2013;58:3-14).

The most common reason for nonemergent maternal transfer to hospital was prolonged or arrested labor, request for pharmacologic pain relief, and maternal exhaustion. For emergent transfer, the primary reason was nonreassuring fetal heart rate pattern (0.5%) and postpartum hemorrhage (0.2%). Newborn outcomes include transfer of 2.6% and 14 neonatal deaths (7 occurred before admission to the center). The intrapartum fetal mortality rate for admitted mothers was 0.47/1,000 and neonatal mortality rate 0.40/1,000, which is similar to what the United Kingdom found among low-risk women in hospitals, FSBCs, and home births. The primary reason for newborn transfer was respiratory observation.

In 2011, the American College of Obstetricians and Gynecologists Committee Opinion on Planned Home Birth references that hospitals and birthing centers are the safest setting for birth. This was followed up in 2015 with the consensus document on Levels of Maternal Care by ACOG and the Society for Maternal-Fetal Medicine that acknowledges and addresses care provided at birth centers, including the role of caregivers.

The future focus of the FSBCs should include a push to mandate accreditation in all facilities, and ongoing research related to outcomes of: midwifery-led care, provider types, FSBC licensure and/or accreditation status, and types of collegial partnerships. This debate must move from a polarizing discussion of “either/or” to “both/and,” which would expand interprofessional collaborations and design seamless care for the growing number of women choosing out-of-hospital birth.

Dr. Breedlove is president of the American College of Nurse-Midwives.

No: Hospitals are still the safest choice

According to analysis of currently available data, and recognizing that there has not been a randomized controlled trial addressing the site of delivery, hospitals are safer than freestanding birthing centers.

How much safer is a point of contention and depends on several key factors: 1. whether the birthing center is accredited and staffed by certified nurse midwives; 2. how far from the nearest hospital with delivery capability the birthing center is located; and 3. the thoroughness of the selection process in identifying low-risk women who are appropriate candidates to deliver in a birthing center.

Even women correctly classified as low risk may require nonemergent cesarean delivery for failure to progress in labor. Since freestanding birthing centers do not provide cesarean delivery, such women must be transferred to a hospital. If the status of both mother and fetus is reassuring, transfer represents just an inconvenience. Overall, the need for transfer arises fairly often, especially in first pregnancies.

However, unexpected emergencies like cord prolapse can and do occur in the course of labor in low-risk women. Hospitals can respond with immediate cesarean delivery, whereas the only recourse for birthing centers is emergency transfer to a hospital.

The idea of a safety net is the No. 1 reason why women choose to deliver in hospitals and that safety net covers not only their newborns, but women themselves. A second reason is the availability of epidural anesthesia for relief of pain in labor.

In answer to the question of whether birthing centers are a safe alternative to hospitals for delivering babies, I would say it depends on women’s tolerance of risk. Adverse outcomes at freestanding birthing centers are uncommon, but some of those that occur could be prevented in a hospital setting.

One compromise may be to locate birthing centers inside hospitals and this model has been successfully implemented in a number of cities across the United States. This suggestion dates back a quarter of a century but is still meritorious today (N. Engl. J. Med. 1989;321:1824-5). Could it be a way for women to have their cake and eat it too?

Dr. Yeomans is the chair of the department of ob.gyn. at Texas Tech University in Lubbock.

Yes: Time to design seamless care

Since the first freestanding birth center opened in the mid-1970s, a demonstration model, designed by Maternity Center Association in New York, the evidence has consistently shown quality and safe care for the mother and newborn in low-risk populations, as well as a reduced cost of care.

The first National Birth Center study published in the New England Journal of Medicine in 1989, as well as the National Birth Center Study II, Outcomes of Care in Birth Centers published in the Journal of Midwifery and Women’s Health in 2013, continue to demonstrate safe outcomes (N. Engl. J. Med. 1989;321:1804-11).

The most recent Birth Center II study collected data from 2007 through 2010 on 15,574 women admitted to 79 midwifery-led freestanding birthing centers (FSBCs) in 33 states. Findings included a rate of 92.8% for normal spontaneous vaginal delivery, 6.1% cesarean delivery, and 84% of women gave birth at the FSBCs, with 12.4% transferred after admission. There were no maternal deaths (J. Midwifery. Womens. Health. 2013;58:3-14).

The most common reason for nonemergent maternal transfer to hospital was prolonged or arrested labor, request for pharmacologic pain relief, and maternal exhaustion. For emergent transfer, the primary reason was nonreassuring fetal heart rate pattern (0.5%) and postpartum hemorrhage (0.2%). Newborn outcomes include transfer of 2.6% and 14 neonatal deaths (7 occurred before admission to the center). The intrapartum fetal mortality rate for admitted mothers was 0.47/1,000 and neonatal mortality rate 0.40/1,000, which is similar to what the United Kingdom found among low-risk women in hospitals, FSBCs, and home births. The primary reason for newborn transfer was respiratory observation.

In 2011, the American College of Obstetricians and Gynecologists Committee Opinion on Planned Home Birth references that hospitals and birthing centers are the safest setting for birth. This was followed up in 2015 with the consensus document on Levels of Maternal Care by ACOG and the Society for Maternal-Fetal Medicine that acknowledges and addresses care provided at birth centers, including the role of caregivers.

The future focus of the FSBCs should include a push to mandate accreditation in all facilities, and ongoing research related to outcomes of: midwifery-led care, provider types, FSBC licensure and/or accreditation status, and types of collegial partnerships. This debate must move from a polarizing discussion of “either/or” to “both/and,” which would expand interprofessional collaborations and design seamless care for the growing number of women choosing out-of-hospital birth.

Dr. Breedlove is president of the American College of Nurse-Midwives.

No: Hospitals are still the safest choice

According to analysis of currently available data, and recognizing that there has not been a randomized controlled trial addressing the site of delivery, hospitals are safer than freestanding birthing centers.

How much safer is a point of contention and depends on several key factors: 1. whether the birthing center is accredited and staffed by certified nurse midwives; 2. how far from the nearest hospital with delivery capability the birthing center is located; and 3. the thoroughness of the selection process in identifying low-risk women who are appropriate candidates to deliver in a birthing center.

Even women correctly classified as low risk may require nonemergent cesarean delivery for failure to progress in labor. Since freestanding birthing centers do not provide cesarean delivery, such women must be transferred to a hospital. If the status of both mother and fetus is reassuring, transfer represents just an inconvenience. Overall, the need for transfer arises fairly often, especially in first pregnancies.

However, unexpected emergencies like cord prolapse can and do occur in the course of labor in low-risk women. Hospitals can respond with immediate cesarean delivery, whereas the only recourse for birthing centers is emergency transfer to a hospital.

The idea of a safety net is the No. 1 reason why women choose to deliver in hospitals and that safety net covers not only their newborns, but women themselves. A second reason is the availability of epidural anesthesia for relief of pain in labor.

In answer to the question of whether birthing centers are a safe alternative to hospitals for delivering babies, I would say it depends on women’s tolerance of risk. Adverse outcomes at freestanding birthing centers are uncommon, but some of those that occur could be prevented in a hospital setting.

One compromise may be to locate birthing centers inside hospitals and this model has been successfully implemented in a number of cities across the United States. This suggestion dates back a quarter of a century but is still meritorious today (N. Engl. J. Med. 1989;321:1824-5). Could it be a way for women to have their cake and eat it too?

Dr. Yeomans is the chair of the department of ob.gyn. at Texas Tech University in Lubbock.

SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.

Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.

“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.

Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.

If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”

“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.

For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.

Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.

Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.

Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.

“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.

One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.

“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.

Dr. Atrio reported having no financial disclosures.

[email protected]

SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.

Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.

“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.

Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.

If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”

“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.

For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.

Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.

Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.

Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.

“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.

One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.

“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.

Dr. Atrio reported having no financial disclosures.

[email protected]

SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.

Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.

“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.

Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.

If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”

“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.

For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.

Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.

Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.

Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.

“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.

One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.

“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.

Dr. Atrio reported having no financial disclosures.

[email protected]

SAN FRANCISCO – A suitable and effective method for relieving pain among women undergoing intrauterine device insertion has eluded investigators, but the search has not been in vain.

Findings from two studies presented at the annual meeting of the American College of Obstetricians and Gynecologists may have failed to demonstrate clearcut improvements in pain management, but they did show improvement in other aspects of the patient experience.

In one randomized controlled study, use of an Allis clamp to stabilize the uterus during device placement failed to improve pain when compared with the use of a single-tooth tenaculum, but Allis clamp use was associated with a reduced risk of bleeding requiring intervention, Dr. Lee Taylor Johnson reported at the meeting.

Pain scores at the time of placement as measured using a 100-mm visual analog scale were 23.5 mm in 38 patients randomized to undergo placement using an Allis clamp, and 31.5 mm in 40 patients who underwent placement using the tenaculum. The scores at 10 minutes were 4.5 mm and 9 mm, respectively. The scores did not differ significantly between the groups.

However, the tenaculum group required more interventions to stop bleeding with pressure or cauterization (15 patients vs. 1 patient in the Allis clamp group), said Dr. Johnson, who conducted the research with colleagues at the Carilion Clinic Residency Gynecology Clinic in Roanoke, Va. She is now at the Tuba City Healthcare Corporation in Tuba City, Ariz.

Patients included in the study were at least 18 years old and were enrolled between September 2012 and November 2013. The study is the first to compare the effects of different instruments on pain during IUD placement, although multiple studies have looked at other ways to reduce pain, she noted.

“They have looked at NSAIDs, paracervical blocks, lidocaine gel, misoprostol, and nitroglycerin. In 2009 a Cochrane Database Review noted that no interventions that have been properly evaluated reduce pain during or after IUD insertion,” Dr. Johnson said.

Based on the current findings, providers should consider using an Allis clamp during IUD placement to decrease the risk of cervical bleeding following the procedure, she said.

In another study, Dr. Lauren D. Thaxton, of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, found that the use of nitrous oxide improved satisfaction with pain management.

The mean pain score among 40 women in the randomized double-blind study who were treated with 50/50 nitrous oxide and oxygen at the time of IUD insertion was 54 mm on a 100 mm visual analog scale, which was not significantly different from the mean of 55 mm in women who received only oxygen. However, satisfaction with pain management, as measured on a 5-point Likert scale, was significantly greater in the nitrous oxide group, she said.

The study included nulliparous women aged 13-45 years.

Nitrous oxide is relatively inexpensive and has few side effects, which are rapidly reversible with 100% oxygen, making it a feasible approach to improving the experience of IUD insertion for many women, according to Dr. Thaxton.

In fact, women in the study reported being willing to pay $20 to $50 out of pocket for nitrous oxide administration at the time of IUD insertion, Dr. Thaxton said.

In a video interview, she speculated that the amnestic and anxiolytic effects of nitrous oxide may play a role in the higher satisfaction scores, and that higher dosing could contribute to better pain relief.

Dr. Rameet H. Singh, also of the University of New Mexico and the principle investigator for the study, said that it only takes about 1 minute to administer 50/50 nitrous oxide and oxygen, and about 90 seconds to achieve 70/30 concentration, so the process doesn’t substantially prolong the insertion process.

Both Dr. Johnson and Dr. Thaxton reported having no financial disclosures. Dr. Singh reported receiving an honorarium for authoring an article on long-acting reversible contraception.

[email protected]

SAN FRANCISCO – A suitable and effective method for relieving pain among women undergoing intrauterine device insertion has eluded investigators, but the search has not been in vain.

Findings from two studies presented at the annual meeting of the American College of Obstetricians and Gynecologists may have failed to demonstrate clearcut improvements in pain management, but they did show improvement in other aspects of the patient experience.

In one randomized controlled study, use of an Allis clamp to stabilize the uterus during device placement failed to improve pain when compared with the use of a single-tooth tenaculum, but Allis clamp use was associated with a reduced risk of bleeding requiring intervention, Dr. Lee Taylor Johnson reported at the meeting.

Pain scores at the time of placement as measured using a 100-mm visual analog scale were 23.5 mm in 38 patients randomized to undergo placement using an Allis clamp, and 31.5 mm in 40 patients who underwent placement using the tenaculum. The scores at 10 minutes were 4.5 mm and 9 mm, respectively. The scores did not differ significantly between the groups.

However, the tenaculum group required more interventions to stop bleeding with pressure or cauterization (15 patients vs. 1 patient in the Allis clamp group), said Dr. Johnson, who conducted the research with colleagues at the Carilion Clinic Residency Gynecology Clinic in Roanoke, Va. She is now at the Tuba City Healthcare Corporation in Tuba City, Ariz.

Patients included in the study were at least 18 years old and were enrolled between September 2012 and November 2013. The study is the first to compare the effects of different instruments on pain during IUD placement, although multiple studies have looked at other ways to reduce pain, she noted.

“They have looked at NSAIDs, paracervical blocks, lidocaine gel, misoprostol, and nitroglycerin. In 2009 a Cochrane Database Review noted that no interventions that have been properly evaluated reduce pain during or after IUD insertion,” Dr. Johnson said.

Based on the current findings, providers should consider using an Allis clamp during IUD placement to decrease the risk of cervical bleeding following the procedure, she said.

In another study, Dr. Lauren D. Thaxton, of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, found that the use of nitrous oxide improved satisfaction with pain management.

The mean pain score among 40 women in the randomized double-blind study who were treated with 50/50 nitrous oxide and oxygen at the time of IUD insertion was 54 mm on a 100 mm visual analog scale, which was not significantly different from the mean of 55 mm in women who received only oxygen. However, satisfaction with pain management, as measured on a 5-point Likert scale, was significantly greater in the nitrous oxide group, she said.

The study included nulliparous women aged 13-45 years.

Nitrous oxide is relatively inexpensive and has few side effects, which are rapidly reversible with 100% oxygen, making it a feasible approach to improving the experience of IUD insertion for many women, according to Dr. Thaxton.

In fact, women in the study reported being willing to pay $20 to $50 out of pocket for nitrous oxide administration at the time of IUD insertion, Dr. Thaxton said.

In a video interview, she speculated that the amnestic and anxiolytic effects of nitrous oxide may play a role in the higher satisfaction scores, and that higher dosing could contribute to better pain relief.

Dr. Rameet H. Singh, also of the University of New Mexico and the principle investigator for the study, said that it only takes about 1 minute to administer 50/50 nitrous oxide and oxygen, and about 90 seconds to achieve 70/30 concentration, so the process doesn’t substantially prolong the insertion process.

Both Dr. Johnson and Dr. Thaxton reported having no financial disclosures. Dr. Singh reported receiving an honorarium for authoring an article on long-acting reversible contraception.

[email protected]

SAN FRANCISCO – A suitable and effective method for relieving pain among women undergoing intrauterine device insertion has eluded investigators, but the search has not been in vain.

Findings from two studies presented at the annual meeting of the American College of Obstetricians and Gynecologists may have failed to demonstrate clearcut improvements in pain management, but they did show improvement in other aspects of the patient experience.

In one randomized controlled study, use of an Allis clamp to stabilize the uterus during device placement failed to improve pain when compared with the use of a single-tooth tenaculum, but Allis clamp use was associated with a reduced risk of bleeding requiring intervention, Dr. Lee Taylor Johnson reported at the meeting.

Pain scores at the time of placement as measured using a 100-mm visual analog scale were 23.5 mm in 38 patients randomized to undergo placement using an Allis clamp, and 31.5 mm in 40 patients who underwent placement using the tenaculum. The scores at 10 minutes were 4.5 mm and 9 mm, respectively. The scores did not differ significantly between the groups.

However, the tenaculum group required more interventions to stop bleeding with pressure or cauterization (15 patients vs. 1 patient in the Allis clamp group), said Dr. Johnson, who conducted the research with colleagues at the Carilion Clinic Residency Gynecology Clinic in Roanoke, Va. She is now at the Tuba City Healthcare Corporation in Tuba City, Ariz.

Patients included in the study were at least 18 years old and were enrolled between September 2012 and November 2013. The study is the first to compare the effects of different instruments on pain during IUD placement, although multiple studies have looked at other ways to reduce pain, she noted.

“They have looked at NSAIDs, paracervical blocks, lidocaine gel, misoprostol, and nitroglycerin. In 2009 a Cochrane Database Review noted that no interventions that have been properly evaluated reduce pain during or after IUD insertion,” Dr. Johnson said.

Based on the current findings, providers should consider using an Allis clamp during IUD placement to decrease the risk of cervical bleeding following the procedure, she said.

In another study, Dr. Lauren D. Thaxton, of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, found that the use of nitrous oxide improved satisfaction with pain management.

The mean pain score among 40 women in the randomized double-blind study who were treated with 50/50 nitrous oxide and oxygen at the time of IUD insertion was 54 mm on a 100 mm visual analog scale, which was not significantly different from the mean of 55 mm in women who received only oxygen. However, satisfaction with pain management, as measured on a 5-point Likert scale, was significantly greater in the nitrous oxide group, she said.

The study included nulliparous women aged 13-45 years.

Nitrous oxide is relatively inexpensive and has few side effects, which are rapidly reversible with 100% oxygen, making it a feasible approach to improving the experience of IUD insertion for many women, according to Dr. Thaxton.

In fact, women in the study reported being willing to pay $20 to $50 out of pocket for nitrous oxide administration at the time of IUD insertion, Dr. Thaxton said.

In a video interview, she speculated that the amnestic and anxiolytic effects of nitrous oxide may play a role in the higher satisfaction scores, and that higher dosing could contribute to better pain relief.

Dr. Rameet H. Singh, also of the University of New Mexico and the principle investigator for the study, said that it only takes about 1 minute to administer 50/50 nitrous oxide and oxygen, and about 90 seconds to achieve 70/30 concentration, so the process doesn’t substantially prolong the insertion process.

Both Dr. Johnson and Dr. Thaxton reported having no financial disclosures. Dr. Singh reported receiving an honorarium for authoring an article on long-acting reversible contraception.

[email protected]

SAN FRANCISCO – Occult uterine sarcoma occurred in less than 0.1% of more than 10,000 hysterectomies performed at a large hospital system between 2000 and 2014 for presumed benign gynecologic indications.

Of 10,083 patients who underwent such hysterectomies at University of Texas Southwestern Medical Center hospitals during the study period, 9 were found to have uterine sarcoma (overall rate of 8.9 per 10,000), including 5 with leiomyosarcoma (rate of 4.96 per 10,000) and 2 each with endometrial stromal sarcoma and uterine adenosarcoma (rate of 1.98 per 10,000 for each) Dr. Ken Yu Lin reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The patients’ median age at diagnosis was 39 years, and their median body mass index was 27 kg/m^2. Six had prior hormonal therapy, and three reported responding to leuprolide, including two who experienced decreased bleeding, and one who experienced uterine mass size reduction. None had a history of tamoxifen use or pelvic radiation exposure, and one had rapid uterine enlargement and was found to have leiomyosarcoma.

At a median follow-up of 48 months, one had died, one had a recurrence of endometrial stromal sarcoma, and seven were alive with no evidence of disease, Dr. Lin said.

Leiomyomas were associated with significantly larger uterine size (mean weight of 3,500 g), compared with endometrial stromal sarcoma and adenosarcoma, he noted.

Four of five patients with leiomyoma underwent a biopsy prior to surgery, and the results were normal. One underwent manual morcellation during abdominal hysterectomy because of large mass size, but power morcellation was not used in any patient.

The 0.1% frequency of uterine sarcoma in patients undergoing hysterectomy for a benign condition was lower than the frequency in previously reported studies and pooled analyses, Dr. Lin said.

The patients were women who underwent hysterectomy for benign conditions – abnormal bleeding in 78% of cases and leiomyoma in 56% of cases. Five underwent total abdominal hysterectomy, three had a total vaginal hysterectomy, and one had a supracervical hysterectomy.

Occult uterine sarcoma was defined as uterine sarcoma on pathology postoperatively in those with no preoperative suspicion of malignancy, Dr. Lin said.

Hysterectomy is one of the most common surgical procedures in the United States, and outcomes have improved thanks to minimally invasive procedures that require only small incisions.

However, small incisions lead to challenges with respect to the removal of large specimens, Dr. Lin said, adding that morcellation, which has been used to facilitate the removal of tissue in cases involving minimally invasive surgery, has come under scrutiny because of concerns about its role in the dissemination of occult gynecologic malignancies, and particularly uterine sarcoma.

Central to this discussion is the question of the prevalence of occult sarcoma in the setting of hysterectomy for benign indications, he said, noting that the prevalence of occult sarcoma in women undergoing surgery for presumed uterine fibroids has been reported to be as high as 1 in 350 by some authors.

The findings suggest that “clinical practices and regional referral patterns may impact local rates of occult uterine sarcoma and should be considered during patient counseling and when developing clinical recommendations,” Dr Lin concluded.

Dr. Lin reported having no relevant disclosures.

[email protected]

SAN FRANCISCO – Occult uterine sarcoma occurred in less than 0.1% of more than 10,000 hysterectomies performed at a large hospital system between 2000 and 2014 for presumed benign gynecologic indications.

Of 10,083 patients who underwent such hysterectomies at University of Texas Southwestern Medical Center hospitals during the study period, 9 were found to have uterine sarcoma (overall rate of 8.9 per 10,000), including 5 with leiomyosarcoma (rate of 4.96 per 10,000) and 2 each with endometrial stromal sarcoma and uterine adenosarcoma (rate of 1.98 per 10,000 for each) Dr. Ken Yu Lin reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The patients’ median age at diagnosis was 39 years, and their median body mass index was 27 kg/m^2. Six had prior hormonal therapy, and three reported responding to leuprolide, including two who experienced decreased bleeding, and one who experienced uterine mass size reduction. None had a history of tamoxifen use or pelvic radiation exposure, and one had rapid uterine enlargement and was found to have leiomyosarcoma.

At a median follow-up of 48 months, one had died, one had a recurrence of endometrial stromal sarcoma, and seven were alive with no evidence of disease, Dr. Lin said.

Leiomyomas were associated with significantly larger uterine size (mean weight of 3,500 g), compared with endometrial stromal sarcoma and adenosarcoma, he noted.

Four of five patients with leiomyoma underwent a biopsy prior to surgery, and the results were normal. One underwent manual morcellation during abdominal hysterectomy because of large mass size, but power morcellation was not used in any patient.

The 0.1% frequency of uterine sarcoma in patients undergoing hysterectomy for a benign condition was lower than the frequency in previously reported studies and pooled analyses, Dr. Lin said.

The patients were women who underwent hysterectomy for benign conditions – abnormal bleeding in 78% of cases and leiomyoma in 56% of cases. Five underwent total abdominal hysterectomy, three had a total vaginal hysterectomy, and one had a supracervical hysterectomy.

Occult uterine sarcoma was defined as uterine sarcoma on pathology postoperatively in those with no preoperative suspicion of malignancy, Dr. Lin said.

Hysterectomy is one of the most common surgical procedures in the United States, and outcomes have improved thanks to minimally invasive procedures that require only small incisions.

However, small incisions lead to challenges with respect to the removal of large specimens, Dr. Lin said, adding that morcellation, which has been used to facilitate the removal of tissue in cases involving minimally invasive surgery, has come under scrutiny because of concerns about its role in the dissemination of occult gynecologic malignancies, and particularly uterine sarcoma.

Central to this discussion is the question of the prevalence of occult sarcoma in the setting of hysterectomy for benign indications, he said, noting that the prevalence of occult sarcoma in women undergoing surgery for presumed uterine fibroids has been reported to be as high as 1 in 350 by some authors.

The findings suggest that “clinical practices and regional referral patterns may impact local rates of occult uterine sarcoma and should be considered during patient counseling and when developing clinical recommendations,” Dr Lin concluded.

Dr. Lin reported having no relevant disclosures.

[email protected]

SAN FRANCISCO – Occult uterine sarcoma occurred in less than 0.1% of more than 10,000 hysterectomies performed at a large hospital system between 2000 and 2014 for presumed benign gynecologic indications.

Of 10,083 patients who underwent such hysterectomies at University of Texas Southwestern Medical Center hospitals during the study period, 9 were found to have uterine sarcoma (overall rate of 8.9 per 10,000), including 5 with leiomyosarcoma (rate of 4.96 per 10,000) and 2 each with endometrial stromal sarcoma and uterine adenosarcoma (rate of 1.98 per 10,000 for each) Dr. Ken Yu Lin reported at the annual meeting of the American College of Obstetricians and Gynecologists.

The patients’ median age at diagnosis was 39 years, and their median body mass index was 27 kg/m^2. Six had prior hormonal therapy, and three reported responding to leuprolide, including two who experienced decreased bleeding, and one who experienced uterine mass size reduction. None had a history of tamoxifen use or pelvic radiation exposure, and one had rapid uterine enlargement and was found to have leiomyosarcoma.

At a median follow-up of 48 months, one had died, one had a recurrence of endometrial stromal sarcoma, and seven were alive with no evidence of disease, Dr. Lin said.

Leiomyomas were associated with significantly larger uterine size (mean weight of 3,500 g), compared with endometrial stromal sarcoma and adenosarcoma, he noted.

Four of five patients with leiomyoma underwent a biopsy prior to surgery, and the results were normal. One underwent manual morcellation during abdominal hysterectomy because of large mass size, but power morcellation was not used in any patient.

The 0.1% frequency of uterine sarcoma in patients undergoing hysterectomy for a benign condition was lower than the frequency in previously reported studies and pooled analyses, Dr. Lin said.

The patients were women who underwent hysterectomy for benign conditions – abnormal bleeding in 78% of cases and leiomyoma in 56% of cases. Five underwent total abdominal hysterectomy, three had a total vaginal hysterectomy, and one had a supracervical hysterectomy.

Occult uterine sarcoma was defined as uterine sarcoma on pathology postoperatively in those with no preoperative suspicion of malignancy, Dr. Lin said.

Hysterectomy is one of the most common surgical procedures in the United States, and outcomes have improved thanks to minimally invasive procedures that require only small incisions.

However, small incisions lead to challenges with respect to the removal of large specimens, Dr. Lin said, adding that morcellation, which has been used to facilitate the removal of tissue in cases involving minimally invasive surgery, has come under scrutiny because of concerns about its role in the dissemination of occult gynecologic malignancies, and particularly uterine sarcoma.

Central to this discussion is the question of the prevalence of occult sarcoma in the setting of hysterectomy for benign indications, he said, noting that the prevalence of occult sarcoma in women undergoing surgery for presumed uterine fibroids has been reported to be as high as 1 in 350 by some authors.

The findings suggest that “clinical practices and regional referral patterns may impact local rates of occult uterine sarcoma and should be considered during patient counseling and when developing clinical recommendations,” Dr Lin concluded.

Dr. Lin reported having no relevant disclosures.

[email protected]

SAN FRANCISCO – The majority of pregnant teens who smoked in a large population-based cohort study continued smoking throughout pregnancy, and those teens had a higher rate of preterm birth than did those who quit at any time during pregnancy.

Those who quit in the first trimester, however, had the greatest reduction in the risk of preterm birth, Dr. Beth Moore reported during a poster session at the annual meeting of the American College of Obstetricians and Gynecologists.

Sharon Worcester/Frontline Medical News

The findings underscore the need to counsel teen mothers that smoking cessation at any point in pregnancy will reduce the risk for preterm birth, Dr. Moore said. “Targeted counseling and interventions should focus on early smoking cessation in this group of mothers who are at an inherently high risk of preterm birth, as it results in the most substantial risk reduction for delivering prior to 37 weeks.”

Of 96,599 teens who were included in the analysis, 31% smoked during the 3 months prior to conception. Of those, 6,508 (22%) quit during the first trimester, and 17,804 (about 60%) smoked throughout pregnancy. The remainder quit smoking during the second or third trimester, according to Dr. Moore, of the department of maternal-fetal medicine at the University of Cincinnati.

The baseline rate of preterm birth in the study cohort was 11%; the rate among those who smoked throughout pregnancy was 13%.

The risk of preterm birth was reduced by about 24% (odds ratio, 0.76) among those who quit smoking during the first trimester, and was reduced by about 12% (OR, 0.88) among those who quit at any point during pregnancy, she said.

Compared with older women, teens are already at increased risk of preterm birth, and smoking further increases that risk, Dr. Moore said.

To assess the effects of smoking cessation on preterm birth risk in teens, she and her colleagues retrospectively reviewed all non-anomalous singleton birth records in Ohio during the study period. Of the 1,003,532 eligible births recorded during that time, the 96,599 included in the current analysis were to those under age 20 years for whom smoking data were available.

The association between smoking cessation and preterm birth risk was assessed by logistic regression after adjusting for maternal race, Medicaid enrollment, and marital status.

The authors reported having no disclosures.

[email protected]

SAN FRANCISCO – The majority of pregnant teens who smoked in a large population-based cohort study continued smoking throughout pregnancy, and those teens had a higher rate of preterm birth than did those who quit at any time during pregnancy.

Those who quit in the first trimester, however, had the greatest reduction in the risk of preterm birth, Dr. Beth Moore reported during a poster session at the annual meeting of the American College of Obstetricians and Gynecologists.

Sharon Worcester/Frontline Medical News

The findings underscore the need to counsel teen mothers that smoking cessation at any point in pregnancy will reduce the risk for preterm birth, Dr. Moore said. “Targeted counseling and interventions should focus on early smoking cessation in this group of mothers who are at an inherently high risk of preterm birth, as it results in the most substantial risk reduction for delivering prior to 37 weeks.”

Of 96,599 teens who were included in the analysis, 31% smoked during the 3 months prior to conception. Of those, 6,508 (22%) quit during the first trimester, and 17,804 (about 60%) smoked throughout pregnancy. The remainder quit smoking during the second or third trimester, according to Dr. Moore, of the department of maternal-fetal medicine at the University of Cincinnati.

The baseline rate of preterm birth in the study cohort was 11%; the rate among those who smoked throughout pregnancy was 13%.

The risk of preterm birth was reduced by about 24% (odds ratio, 0.76) among those who quit smoking during the first trimester, and was reduced by about 12% (OR, 0.88) among those who quit at any point during pregnancy, she said.

Compared with older women, teens are already at increased risk of preterm birth, and smoking further increases that risk, Dr. Moore said.

To assess the effects of smoking cessation on preterm birth risk in teens, she and her colleagues retrospectively reviewed all non-anomalous singleton birth records in Ohio during the study period. Of the 1,003,532 eligible births recorded during that time, the 96,599 included in the current analysis were to those under age 20 years for whom smoking data were available.

The association between smoking cessation and preterm birth risk was assessed by logistic regression after adjusting for maternal race, Medicaid enrollment, and marital status.

The authors reported having no disclosures.

[email protected]

SAN FRANCISCO – The majority of pregnant teens who smoked in a large population-based cohort study continued smoking throughout pregnancy, and those teens had a higher rate of preterm birth than did those who quit at any time during pregnancy.

Those who quit in the first trimester, however, had the greatest reduction in the risk of preterm birth, Dr. Beth Moore reported during a poster session at the annual meeting of the American College of Obstetricians and Gynecologists.

Sharon Worcester/Frontline Medical News

The findings underscore the need to counsel teen mothers that smoking cessation at any point in pregnancy will reduce the risk for preterm birth, Dr. Moore said. “Targeted counseling and interventions should focus on early smoking cessation in this group of mothers who are at an inherently high risk of preterm birth, as it results in the most substantial risk reduction for delivering prior to 37 weeks.”

Of 96,599 teens who were included in the analysis, 31% smoked during the 3 months prior to conception. Of those, 6,508 (22%) quit during the first trimester, and 17,804 (about 60%) smoked throughout pregnancy. The remainder quit smoking during the second or third trimester, according to Dr. Moore, of the department of maternal-fetal medicine at the University of Cincinnati.

The baseline rate of preterm birth in the study cohort was 11%; the rate among those who smoked throughout pregnancy was 13%.

The risk of preterm birth was reduced by about 24% (odds ratio, 0.76) among those who quit smoking during the first trimester, and was reduced by about 12% (OR, 0.88) among those who quit at any point during pregnancy, she said.

Compared with older women, teens are already at increased risk of preterm birth, and smoking further increases that risk, Dr. Moore said.

To assess the effects of smoking cessation on preterm birth risk in teens, she and her colleagues retrospectively reviewed all non-anomalous singleton birth records in Ohio during the study period. Of the 1,003,532 eligible births recorded during that time, the 96,599 included in the current analysis were to those under age 20 years for whom smoking data were available.

The association between smoking cessation and preterm birth risk was assessed by logistic regression after adjusting for maternal race, Medicaid enrollment, and marital status.

The authors reported having no disclosures.

[email protected]

SAN FRANCISCO – Few physicians in a recent survey regarding levonorgestrel intrauterine device placement follow the manufacturer’s placement instructions provided on the product insert.

Only 7.5% of 132 respondents said they always perform every recommended placement technique, Dr. Todd R. Jenkins of the University of Alabama at Birmingham (UAB), reported at the annual meeting of the American College of Obstetricians and Gynecologists.

During a brief introduction of the study, Dr. Jenkins, who presented the findings on behalf of his colleague and lead investigator, Dr. Sabrina N. Wyatt, also of UAB, explained that the study was initiated as a result of a system-wide standardization effort.

“We tried to standardize all our residents’ and faculty members’ intrauterine device insertion technique and placement. That resulted in quite the debacle and debate,” he said, adding that a subsequent search of the literature revealed that “there are no studies on the best ways to place an IUD.”

A proposal to conduct a study to determine the best approach to IUD placement was denied by the university’s institutional review board, which deemed such a study unethical because the product insert provides detailed placement instructions.

Robert Boston/Washington University

“So therefore, we decided to survey obstetrician-gynecologists to see how many people actually follow those guidelines,” Dr. Jenkins said.

Members of the Society for Academic Specialists in General Obstetrics and Gynecology and directors of Ryan Residency Training Program were invited to participate. Respondents practiced throughout the United States, and their length of experience ranged from 0-5 years to 21 years or more. Most respondents (81%) were women.

The respondents were divided with respect to premedication of women undergoing IUD placement, with 67% saying they rarely or never premedicate patients, and 33% reporting that they always or frequently premedicate.

Tenaculum use and use of uterine sound for cavity depth were recommended steps eliminated by 30% and 20% of respondents, respectively. Further, 64% of respondents reported eliminating the step of changing from non-sterile to sterile gloves prior to device handling. Few respondents used ultrasound in any capacity, including during, immediately after, or at a later date; 98% said they rarely or never used ultrasound.

No significant relationships were found between the number of years in practice and any of the responses, but there was a significant relationship between practice region and changing into sterile gloves prior to device handling, and having the patient return to the clinic for a string check, the investigators said.

For example, about 70% of those practicing in the Southeast reported changing into sterile gloves, compared with about 20% of those practicing in the Northeast. And about 80% of those practicing in the Midwest reported having patients return for a string check, compared with about 25% of those in the West.

Long-acting reversible contraception (LARC) methods, such as the levonorgestrel IUD, have higher continuation and efficacy rates than do other reversible methods, but barriers to use remain, including cost, patient anticipation of discomfort, and concern for complications, the investigators explained.

Prior studies have demonstrated that variations in practice exist, they said, noting that it is possible that variations and/or reductions in instrumentation could result in decreased discomfort for patients, as well as in decreased time and cost – all of which could increase LARC uptake.

“Our survey confirmed that variations in practice patterns exist among obstetrician-gynecologists in the United States. While some of these variations may be attributed to not practicing in an evidence-based fashion, other variations exist in the absence of evidence,” they wrote, noting that further investigation to determine best practices among these variations is warranted.

Based on the findings of the current study, the UAB’s institutional review board has relented and agreed to allow studies comparing different practice patterns to help determine the most effective and comfortable experience for patients, Dr. Jenkins said.

The researchers reported having no financial disclosures.

[email protected]

SAN FRANCISCO – Few physicians in a recent survey regarding levonorgestrel intrauterine device placement follow the manufacturer’s placement instructions provided on the product insert.

Only 7.5% of 132 respondents said they always perform every recommended placement technique, Dr. Todd R. Jenkins of the University of Alabama at Birmingham (UAB), reported at the annual meeting of the American College of Obstetricians and Gynecologists.

During a brief introduction of the study, Dr. Jenkins, who presented the findings on behalf of his colleague and lead investigator, Dr. Sabrina N. Wyatt, also of UAB, explained that the study was initiated as a result of a system-wide standardization effort.

“We tried to standardize all our residents’ and faculty members’ intrauterine device insertion technique and placement. That resulted in quite the debacle and debate,” he said, adding that a subsequent search of the literature revealed that “there are no studies on the best ways to place an IUD.”

A proposal to conduct a study to determine the best approach to IUD placement was denied by the university’s institutional review board, which deemed such a study unethical because the product insert provides detailed placement instructions.

Robert Boston/Washington University

“So therefore, we decided to survey obstetrician-gynecologists to see how many people actually follow those guidelines,” Dr. Jenkins said.

Members of the Society for Academic Specialists in General Obstetrics and Gynecology and directors of Ryan Residency Training Program were invited to participate. Respondents practiced throughout the United States, and their length of experience ranged from 0-5 years to 21 years or more. Most respondents (81%) were women.

The respondents were divided with respect to premedication of women undergoing IUD placement, with 67% saying they rarely or never premedicate patients, and 33% reporting that they always or frequently premedicate.

Tenaculum use and use of uterine sound for cavity depth were recommended steps eliminated by 30% and 20% of respondents, respectively. Further, 64% of respondents reported eliminating the step of changing from non-sterile to sterile gloves prior to device handling. Few respondents used ultrasound in any capacity, including during, immediately after, or at a later date; 98% said they rarely or never used ultrasound.

No significant relationships were found between the number of years in practice and any of the responses, but there was a significant relationship between practice region and changing into sterile gloves prior to device handling, and having the patient return to the clinic for a string check, the investigators said.

For example, about 70% of those practicing in the Southeast reported changing into sterile gloves, compared with about 20% of those practicing in the Northeast. And about 80% of those practicing in the Midwest reported having patients return for a string check, compared with about 25% of those in the West.

Long-acting reversible contraception (LARC) methods, such as the levonorgestrel IUD, have higher continuation and efficacy rates than do other reversible methods, but barriers to use remain, including cost, patient anticipation of discomfort, and concern for complications, the investigators explained.

Prior studies have demonstrated that variations in practice exist, they said, noting that it is possible that variations and/or reductions in instrumentation could result in decreased discomfort for patients, as well as in decreased time and cost – all of which could increase LARC uptake.

“Our survey confirmed that variations in practice patterns exist among obstetrician-gynecologists in the United States. While some of these variations may be attributed to not practicing in an evidence-based fashion, other variations exist in the absence of evidence,” they wrote, noting that further investigation to determine best practices among these variations is warranted.

Based on the findings of the current study, the UAB’s institutional review board has relented and agreed to allow studies comparing different practice patterns to help determine the most effective and comfortable experience for patients, Dr. Jenkins said.

The researchers reported having no financial disclosures.

[email protected]

SAN FRANCISCO – Few physicians in a recent survey regarding levonorgestrel intrauterine device placement follow the manufacturer’s placement instructions provided on the product insert.

Only 7.5% of 132 respondents said they always perform every recommended placement technique, Dr. Todd R. Jenkins of the University of Alabama at Birmingham (UAB), reported at the annual meeting of the American College of Obstetricians and Gynecologists.

During a brief introduction of the study, Dr. Jenkins, who presented the findings on behalf of his colleague and lead investigator, Dr. Sabrina N. Wyatt, also of UAB, explained that the study was initiated as a result of a system-wide standardization effort.

“We tried to standardize all our residents’ and faculty members’ intrauterine device insertion technique and placement. That resulted in quite the debacle and debate,” he said, adding that a subsequent search of the literature revealed that “there are no studies on the best ways to place an IUD.”

A proposal to conduct a study to determine the best approach to IUD placement was denied by the university’s institutional review board, which deemed such a study unethical because the product insert provides detailed placement instructions.

Robert Boston/Washington University

“So therefore, we decided to survey obstetrician-gynecologists to see how many people actually follow those guidelines,” Dr. Jenkins said.

Members of the Society for Academic Specialists in General Obstetrics and Gynecology and directors of Ryan Residency Training Program were invited to participate. Respondents practiced throughout the United States, and their length of experience ranged from 0-5 years to 21 years or more. Most respondents (81%) were women.

The respondents were divided with respect to premedication of women undergoing IUD placement, with 67% saying they rarely or never premedicate patients, and 33% reporting that they always or frequently premedicate.

Tenaculum use and use of uterine sound for cavity depth were recommended steps eliminated by 30% and 20% of respondents, respectively. Further, 64% of respondents reported eliminating the step of changing from non-sterile to sterile gloves prior to device handling. Few respondents used ultrasound in any capacity, including during, immediately after, or at a later date; 98% said they rarely or never used ultrasound.

No significant relationships were found between the number of years in practice and any of the responses, but there was a significant relationship between practice region and changing into sterile gloves prior to device handling, and having the patient return to the clinic for a string check, the investigators said.

For example, about 70% of those practicing in the Southeast reported changing into sterile gloves, compared with about 20% of those practicing in the Northeast. And about 80% of those practicing in the Midwest reported having patients return for a string check, compared with about 25% of those in the West.

Long-acting reversible contraception (LARC) methods, such as the levonorgestrel IUD, have higher continuation and efficacy rates than do other reversible methods, but barriers to use remain, including cost, patient anticipation of discomfort, and concern for complications, the investigators explained.

Prior studies have demonstrated that variations in practice exist, they said, noting that it is possible that variations and/or reductions in instrumentation could result in decreased discomfort for patients, as well as in decreased time and cost – all of which could increase LARC uptake.

“Our survey confirmed that variations in practice patterns exist among obstetrician-gynecologists in the United States. While some of these variations may be attributed to not practicing in an evidence-based fashion, other variations exist in the absence of evidence,” they wrote, noting that further investigation to determine best practices among these variations is warranted.

Based on the findings of the current study, the UAB’s institutional review board has relented and agreed to allow studies comparing different practice patterns to help determine the most effective and comfortable experience for patients, Dr. Jenkins said.

The researchers reported having no financial disclosures.

[email protected]

SAN FRANCISCO – During an update on contraception at the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Eve Espey touched on topics ranging from the latest in long-acting reversible contraception methods and the use of those methods in teens, to the “next big thing,” which she said is postpartum intrauterine device placement.

Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, also discussed the latest from the CHOICE project, talked about current controversies in contraception, and offered practical clinical tips for physicians to take back to their practices.

In this video, Dr. Espey summed up some of the latest evidence on contraception choices, including findings among obese patients.

Dr. Espey reported having no financial disclosures.

[email protected]

SAN FRANCISCO – During an update on contraception at the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Eve Espey touched on topics ranging from the latest in long-acting reversible contraception methods and the use of those methods in teens, to the “next big thing,” which she said is postpartum intrauterine device placement.

Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, also discussed the latest from the CHOICE project, talked about current controversies in contraception, and offered practical clinical tips for physicians to take back to their practices.

In this video, Dr. Espey summed up some of the latest evidence on contraception choices, including findings among obese patients.

Dr. Espey reported having no financial disclosures.

[email protected]

SAN FRANCISCO – During an update on contraception at the annual meeting of the American College of Obstetricians and Gynecologists, Dr. Eve Espey touched on topics ranging from the latest in long-acting reversible contraception methods and the use of those methods in teens, to the “next big thing,” which she said is postpartum intrauterine device placement.

Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, also discussed the latest from the CHOICE project, talked about current controversies in contraception, and offered practical clinical tips for physicians to take back to their practices.

In this video, Dr. Espey summed up some of the latest evidence on contraception choices, including findings among obese patients.

Dr. Espey reported having no financial disclosures.

[email protected]