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Substance use increases likelihood of psychiatric hold in pregnancy
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
AUSTIN, TEX. – Providers are no more likely to put an involuntary psychiatric hold on someone who is pregnant than not unless she is using substances, recent research shows.
“This raises a question regarding who psychiatrists consider to be their patients: the mother, the unborn child, or both?” Samuel J. House, MD, of the University of Arkansas, Little Rock, said at the annual meeting of the American Academy of Psychiatry and the Law (AAPL).
Dr. House sent out a survey to members of the AAPL to learn their attitudes toward involuntary psychiatric holds on pregnant women, with and without evidence of substance use, and he presented the results at the meeting.
“We know that the rates of involuntary hospitalizations very widely” across different jurisdictions and practice settings, Dr. House said, but research has shown that age, unmarried status, psychotic symptoms, aggression, and a low level of social function are associated with involuntary commitment. He wanted to explore where pregnancy fit.
Dr. House became interested in clinicians’ perspectives on this issue when he realized how few psychiatric holds he saw among pregnant women during the 4 years he spent at a university hospital’s level 1 trauma center. He included questions about substance use in his survey because of the “recent push to criminalize substance use during pregnancy, mainly in response to the significant impact substance use during pregnancy can have on the fetus or developing child,” he said.
Dr. House received 68 survey responses from AAPL members, most of whom were male with an average age of 47 years. The 7-question survey presented various clinical scenarios and asked what the respondent would do.
The first question concerned being called to the emergency department to evaluate a 28-year-old white woman with clinical signs of depression, history of a suicide attempt, and a mother who had committed suicide when the patient was 15. However, she states during evaluation: “I could never actually kill myself. My family would be too upset, and I would go to hell.”
Two-thirds of respondents (67.6%) said they would admit the woman to an inpatient unit for stabilization, and the others would discharge her with close follow-up.
The second question asked what the clinician would do if the patient declined admission: 41.2% would discharge, and 58.8% would place the woman on a psychiatric hold.
The third question introduced a positive pregnancy test for the woman, but none of the respondents said they would cancel the psychiatric hold. Most were split between proceeding with a hold (42.6%) or proceeding with a discharge (47.1%), though 10.3% would cancel the discharge and place the patient on a hold. Ultimately, respondents were no more likely to put the woman on a hold whether she was pregnant or not.
Then the survey repeated the scenario, but instead of a positive pregnancy test, the question asked what clinicians would do if her drug screen were positive after she had refused admission. In that scenario, the woman reported daily methamphetamine use to the emergency physician.
Among respondents, 48.5% would proceed with a psychiatric hold, 42.6% would proceed with a discharge, and 8.8% would cancel the discharge and put the patient on a hold.
The final question asks clinicians’ course of action if the woman’s pregnancy test were positive after the positive drug screen. Now, only a little over a quarter of respondents (26.5%) would proceed with a discharge and follow-up. More than half (57.4%) would proceed with a hold, and 16.2% would cancel the discharge and place a psychiatric hold.
Therefore, 73.6% of clinicians would place a pregnant woman with a history of substance use on a psychiatric hold, compared with 52.9% if the woman were pregnant but not using methamphetamine.
Laws on pregnancy, substance use
Dr. House considered those findings within the context of current laws governing substance use during pregnancy., with prosecution usually requiring detection of the substance at birth or during pregnancy, or evidence of risk to the child’s health.
Tennessee is unique in considering substance abuse in pregnancy assault if the child is born with dependence or other harm from the drug use. Women in Minnesota, South Dakota, and Wisconsin can be subject to civil commitment, including required inpatient drug treatment, for substance abuse during pregnancy (Am J Psychiatry. 2016 Nov 1;173[11]:1077-80).
Mandatory reporting laws for suspected substance abuse during pregnancy exist in 15 states, mostly in the Southwest, northern Midwest, and states around the District of Columbia. And four states – Kentucky, Iowa, Minnesota, and North Dakota – require pregnant women suspected of substance abuse to be tested.
Yet, most major relevant medical associations oppose criminalization of substance use during pregnancy, including the American Psychiatric Association, the American Academy of Addiction Psychiatry, the American Medical Association, and the American College of Obstetricians and Gynecologists.
“They are generally for increasing access for people, like voluntary screening, but against criminalization because it creates a barrier to accessing prenatal care,” Dr. House explained.
Aside from the question of whom psychiatrists consider their patients – the woman, her fetus, or both – the results raise another question, Dr. House said: “While studies have shown that criminalizing substance use during pregnancy discourages mothers from seeking prenatal care, does the threat of an involuntary psychiatric admission have a similar consequence?” That’s a question for further research.
No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
REPORTING FROM THE AAPL ANNUAL MEETING
Key clinical point: Women are more likely to receive a psychiatric hold if they are pregnant and using a substance.
Major finding: Almost 53% of clinicians would place a suicidal pregnant woman on a psychiatric hold, but 73.6% would do so if she were using methamphetamines.
Study details: The findings are based on an Internet survey of 68 members of the American Academy of Psychiatry and the Law.
Disclosures: No external funding was used. Dr. House was a clinical investigator without compensation for Janssen Pharmaceuticals from 2015 to 2017.
Physical activity may count more for women who keep the pounds off
NASHVILLE – , according to new analysis of a small study.
Physical activity is a key component in successful maintenance of weight loss, but differential effects of physical activity between men and women had not been well explored, Ann Caldwell, PhD, said in an interview at Obesity Week 2018, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Dr. Caldwell and her colleagues at the University of Colorado Anschutz Medical Campus, Aurora, conducted a secondary analysis of case-control data of individuals with healthy weight, overweight, or obesity, and those who had successfully maintained weight loss. They compared total daily energy expenditure (TDEE) and physical activity energy expenditure (PAEE), looking at men and women in all three groups separately.
The study included 20 women and 5 men who had successfully maintained a weight loss of at least 13.6 kg for at least 1 year. These were matched with 20 women and 7 men with a body mass index within the healthy range, as controls for the weight loss maintainers at their post–weight loss BMI.
Another group of 22 women and 6 men with BMIs in the overweight or obese category served as controls for the weight loss maintainers at their pre–weight loss BMI.
For all participants, TDEE was measured using the doubly labeled water method for 7 days. This method tracks elimination of a set quantity of ingested water made up of two uncommon isotopes (hydrogen-2 and oxygen-18) to measure energy expenditure. Since the oxygen is lost both as water and carbon dioxide as a result of metabolism, the presence of less oxygen-18 over time indicates a higher total energy expenditure.
Indirect calorimetry was used to measure resting energy expenditure (REE), and energy expenditure related to physical activity was calculated by subtracting REE and a 10% fraction of TDEE (to account for the thermic effect of feeding) from total TDEE.
“There were significant sex-group interactions for TDEE, PAEE, and PAEE/TEE,” said Dr. Caldwell. She explained that the cutoff for statistical significance for the investigators’ analysis was set at P = .1, since sample sizes were so small for men.
For women who were weight-loss maintainers, both PAEE and PAEE/TDEE ratios were higher than for the female healthy-BMI and high-BMI control participants: PAEE was 822 kcal/day for the maintainers, 536 kcal/day for the healthy-BMI, and 669 kcal/day for the high-BMI controls (P less than .01 for both comparisons).
Dr. Caldwell and her colleagues saw no difference when comparing the PAEE/TDEE ratio for women in each of the control groups.
For men, by contrast, PAEE was highest for those with healthy BMIs, at 815 kcal/day, and lowest for those in the high-BMI control group, at 506 kcal/day. Men who were weight loss maintainers fell in the middle, at 772 kcal/day of PAEE. The PAEE/TDEE ratio was significantly higher for both weight loss maintainers and normal-BMI participants than for the high-BMI participants (P less than .07).
“These cross-sectional data suggest potential sex differences in the importance of [physical activity] for successful weight loss maintenance that should be explored further with objective measures,” wrote Dr. Caldwell and her coauthors.
The investigators are planning further work that incorporates objective physical activity data via actigraphy, and that will include a larger sample of men. Through a prospective study that overcomes the limitation of the present study, they hope to develop a clearer picture of sex differences in weight loss maintenance.
The National Institutes of Health supported the study. Dr. Caldwell reported no relevant conflicts of interest.
SOURCE: Caldwell A et al. Obesity Week 2018, Abstract TP-3233.
NASHVILLE – , according to new analysis of a small study.
Physical activity is a key component in successful maintenance of weight loss, but differential effects of physical activity between men and women had not been well explored, Ann Caldwell, PhD, said in an interview at Obesity Week 2018, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Dr. Caldwell and her colleagues at the University of Colorado Anschutz Medical Campus, Aurora, conducted a secondary analysis of case-control data of individuals with healthy weight, overweight, or obesity, and those who had successfully maintained weight loss. They compared total daily energy expenditure (TDEE) and physical activity energy expenditure (PAEE), looking at men and women in all three groups separately.
The study included 20 women and 5 men who had successfully maintained a weight loss of at least 13.6 kg for at least 1 year. These were matched with 20 women and 7 men with a body mass index within the healthy range, as controls for the weight loss maintainers at their post–weight loss BMI.
Another group of 22 women and 6 men with BMIs in the overweight or obese category served as controls for the weight loss maintainers at their pre–weight loss BMI.
For all participants, TDEE was measured using the doubly labeled water method for 7 days. This method tracks elimination of a set quantity of ingested water made up of two uncommon isotopes (hydrogen-2 and oxygen-18) to measure energy expenditure. Since the oxygen is lost both as water and carbon dioxide as a result of metabolism, the presence of less oxygen-18 over time indicates a higher total energy expenditure.
Indirect calorimetry was used to measure resting energy expenditure (REE), and energy expenditure related to physical activity was calculated by subtracting REE and a 10% fraction of TDEE (to account for the thermic effect of feeding) from total TDEE.
“There were significant sex-group interactions for TDEE, PAEE, and PAEE/TEE,” said Dr. Caldwell. She explained that the cutoff for statistical significance for the investigators’ analysis was set at P = .1, since sample sizes were so small for men.
For women who were weight-loss maintainers, both PAEE and PAEE/TDEE ratios were higher than for the female healthy-BMI and high-BMI control participants: PAEE was 822 kcal/day for the maintainers, 536 kcal/day for the healthy-BMI, and 669 kcal/day for the high-BMI controls (P less than .01 for both comparisons).
Dr. Caldwell and her colleagues saw no difference when comparing the PAEE/TDEE ratio for women in each of the control groups.
For men, by contrast, PAEE was highest for those with healthy BMIs, at 815 kcal/day, and lowest for those in the high-BMI control group, at 506 kcal/day. Men who were weight loss maintainers fell in the middle, at 772 kcal/day of PAEE. The PAEE/TDEE ratio was significantly higher for both weight loss maintainers and normal-BMI participants than for the high-BMI participants (P less than .07).
“These cross-sectional data suggest potential sex differences in the importance of [physical activity] for successful weight loss maintenance that should be explored further with objective measures,” wrote Dr. Caldwell and her coauthors.
The investigators are planning further work that incorporates objective physical activity data via actigraphy, and that will include a larger sample of men. Through a prospective study that overcomes the limitation of the present study, they hope to develop a clearer picture of sex differences in weight loss maintenance.
The National Institutes of Health supported the study. Dr. Caldwell reported no relevant conflicts of interest.
SOURCE: Caldwell A et al. Obesity Week 2018, Abstract TP-3233.
NASHVILLE – , according to new analysis of a small study.
Physical activity is a key component in successful maintenance of weight loss, but differential effects of physical activity between men and women had not been well explored, Ann Caldwell, PhD, said in an interview at Obesity Week 2018, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Dr. Caldwell and her colleagues at the University of Colorado Anschutz Medical Campus, Aurora, conducted a secondary analysis of case-control data of individuals with healthy weight, overweight, or obesity, and those who had successfully maintained weight loss. They compared total daily energy expenditure (TDEE) and physical activity energy expenditure (PAEE), looking at men and women in all three groups separately.
The study included 20 women and 5 men who had successfully maintained a weight loss of at least 13.6 kg for at least 1 year. These were matched with 20 women and 7 men with a body mass index within the healthy range, as controls for the weight loss maintainers at their post–weight loss BMI.
Another group of 22 women and 6 men with BMIs in the overweight or obese category served as controls for the weight loss maintainers at their pre–weight loss BMI.
For all participants, TDEE was measured using the doubly labeled water method for 7 days. This method tracks elimination of a set quantity of ingested water made up of two uncommon isotopes (hydrogen-2 and oxygen-18) to measure energy expenditure. Since the oxygen is lost both as water and carbon dioxide as a result of metabolism, the presence of less oxygen-18 over time indicates a higher total energy expenditure.
Indirect calorimetry was used to measure resting energy expenditure (REE), and energy expenditure related to physical activity was calculated by subtracting REE and a 10% fraction of TDEE (to account for the thermic effect of feeding) from total TDEE.
“There were significant sex-group interactions for TDEE, PAEE, and PAEE/TEE,” said Dr. Caldwell. She explained that the cutoff for statistical significance for the investigators’ analysis was set at P = .1, since sample sizes were so small for men.
For women who were weight-loss maintainers, both PAEE and PAEE/TDEE ratios were higher than for the female healthy-BMI and high-BMI control participants: PAEE was 822 kcal/day for the maintainers, 536 kcal/day for the healthy-BMI, and 669 kcal/day for the high-BMI controls (P less than .01 for both comparisons).
Dr. Caldwell and her colleagues saw no difference when comparing the PAEE/TDEE ratio for women in each of the control groups.
For men, by contrast, PAEE was highest for those with healthy BMIs, at 815 kcal/day, and lowest for those in the high-BMI control group, at 506 kcal/day. Men who were weight loss maintainers fell in the middle, at 772 kcal/day of PAEE. The PAEE/TDEE ratio was significantly higher for both weight loss maintainers and normal-BMI participants than for the high-BMI participants (P less than .07).
“These cross-sectional data suggest potential sex differences in the importance of [physical activity] for successful weight loss maintenance that should be explored further with objective measures,” wrote Dr. Caldwell and her coauthors.
The investigators are planning further work that incorporates objective physical activity data via actigraphy, and that will include a larger sample of men. Through a prospective study that overcomes the limitation of the present study, they hope to develop a clearer picture of sex differences in weight loss maintenance.
The National Institutes of Health supported the study. Dr. Caldwell reported no relevant conflicts of interest.
SOURCE: Caldwell A et al. Obesity Week 2018, Abstract TP-3233.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: Women who kept weight off burned more calories in physical activity than did normal or high-BMI controls.
Major finding: In women, the ratio of physical activity energy expenditure to total daily energy expenditure was higher for successful weight-loss maintainers (P less than .01).
Study details: Secondary analysis of case-control study enrolling 80 individuals.
Disclosures: The National Institutes of Health funded the study. Dr. Caldwell reported no conflicts of interest.
Source: Caldwell A et al. Obesity Week 2018, abstract TP-3233.
Abortion measures continue to fall
Three important national measures of abortion dropped by at least 19% from 2006 to 2015, according to the Centers for Disease Control and Prevention.
Surgical and medical abortions reported to the CDC dropped by 24%, going from almost 843,000 in 2006 to 638,000 in 2015, with declines occurring every year, Tara C. Jatlaoui, MD, and her associates at the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, reported in Morbidity and Mortality Weekly Report Surveillance Summaries.
Over that same time period, the abortion rate fell from 15.9 per 1,000 women aged 15-44 years to 11.8 per 1,000 – a decline of 26%. Abortion ratio – the number of abortions per 1,000 live births within a given population – declined by 19%, dropping from 233 abortions per 1,000 live births in 2006 to 188 abortions per 1,000 live births in 2015, the investigators reported. The findings were based on data from 49 areas that continuously reported over the study period (excludes California, Maryland, and New Hampshire but includes the District of Columbia and New York City).
Abortion rates were highest for women aged 20-29 years for the study period, and this age group accounted for the largest share among the 44 reporting areas that provided data by maternal age each year. Those under age 15 years had the largest drops by age in total number of abortions (40%) and abortion rate (58%) but had the highest, by far, abortion ratio for each year of the study (700 per 1,000 live births in that age group in 2015. The abortion ratio for 15- to 19-year-olds was 289 per 1,000 live births).
The percentage of abortions performed before 14 weeks’ gestation changed little, going from 91.5% in 2006 to 91% in 2015, but “a shift occurred toward earlier gestational ages,” they noted. The percentage of abortions performed before or at 8 weeks increased 3% and those done at 9-13 weeks dropped almost 9% among the 33 areas that reported gestational age every year. Abortions done after 13 weeks gestation represented 9% of all abortions during the study period, with an increase of 7% occurring from 2006 to 2015, Dr. Jatlaoui and her associates said.
Removing barriers such as cost, “insufficient provider reimbursement and training, inadequate client-centered counseling, lack of youth-friendly services, and low client awareness ... might help improve contraceptive use, potentially reducing the number of unintended pregnancies and the number of abortions performed in the United States,” the researchers wrote.
SOURCE: Jatlaoui TC et al. MMWR Surveill Summ. 2018 Nov 23(13):1-45.
Three important national measures of abortion dropped by at least 19% from 2006 to 2015, according to the Centers for Disease Control and Prevention.
Surgical and medical abortions reported to the CDC dropped by 24%, going from almost 843,000 in 2006 to 638,000 in 2015, with declines occurring every year, Tara C. Jatlaoui, MD, and her associates at the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, reported in Morbidity and Mortality Weekly Report Surveillance Summaries.
Over that same time period, the abortion rate fell from 15.9 per 1,000 women aged 15-44 years to 11.8 per 1,000 – a decline of 26%. Abortion ratio – the number of abortions per 1,000 live births within a given population – declined by 19%, dropping from 233 abortions per 1,000 live births in 2006 to 188 abortions per 1,000 live births in 2015, the investigators reported. The findings were based on data from 49 areas that continuously reported over the study period (excludes California, Maryland, and New Hampshire but includes the District of Columbia and New York City).
Abortion rates were highest for women aged 20-29 years for the study period, and this age group accounted for the largest share among the 44 reporting areas that provided data by maternal age each year. Those under age 15 years had the largest drops by age in total number of abortions (40%) and abortion rate (58%) but had the highest, by far, abortion ratio for each year of the study (700 per 1,000 live births in that age group in 2015. The abortion ratio for 15- to 19-year-olds was 289 per 1,000 live births).
The percentage of abortions performed before 14 weeks’ gestation changed little, going from 91.5% in 2006 to 91% in 2015, but “a shift occurred toward earlier gestational ages,” they noted. The percentage of abortions performed before or at 8 weeks increased 3% and those done at 9-13 weeks dropped almost 9% among the 33 areas that reported gestational age every year. Abortions done after 13 weeks gestation represented 9% of all abortions during the study period, with an increase of 7% occurring from 2006 to 2015, Dr. Jatlaoui and her associates said.
Removing barriers such as cost, “insufficient provider reimbursement and training, inadequate client-centered counseling, lack of youth-friendly services, and low client awareness ... might help improve contraceptive use, potentially reducing the number of unintended pregnancies and the number of abortions performed in the United States,” the researchers wrote.
SOURCE: Jatlaoui TC et al. MMWR Surveill Summ. 2018 Nov 23(13):1-45.
Three important national measures of abortion dropped by at least 19% from 2006 to 2015, according to the Centers for Disease Control and Prevention.
Surgical and medical abortions reported to the CDC dropped by 24%, going from almost 843,000 in 2006 to 638,000 in 2015, with declines occurring every year, Tara C. Jatlaoui, MD, and her associates at the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, reported in Morbidity and Mortality Weekly Report Surveillance Summaries.
Over that same time period, the abortion rate fell from 15.9 per 1,000 women aged 15-44 years to 11.8 per 1,000 – a decline of 26%. Abortion ratio – the number of abortions per 1,000 live births within a given population – declined by 19%, dropping from 233 abortions per 1,000 live births in 2006 to 188 abortions per 1,000 live births in 2015, the investigators reported. The findings were based on data from 49 areas that continuously reported over the study period (excludes California, Maryland, and New Hampshire but includes the District of Columbia and New York City).
Abortion rates were highest for women aged 20-29 years for the study period, and this age group accounted for the largest share among the 44 reporting areas that provided data by maternal age each year. Those under age 15 years had the largest drops by age in total number of abortions (40%) and abortion rate (58%) but had the highest, by far, abortion ratio for each year of the study (700 per 1,000 live births in that age group in 2015. The abortion ratio for 15- to 19-year-olds was 289 per 1,000 live births).
The percentage of abortions performed before 14 weeks’ gestation changed little, going from 91.5% in 2006 to 91% in 2015, but “a shift occurred toward earlier gestational ages,” they noted. The percentage of abortions performed before or at 8 weeks increased 3% and those done at 9-13 weeks dropped almost 9% among the 33 areas that reported gestational age every year. Abortions done after 13 weeks gestation represented 9% of all abortions during the study period, with an increase of 7% occurring from 2006 to 2015, Dr. Jatlaoui and her associates said.
Removing barriers such as cost, “insufficient provider reimbursement and training, inadequate client-centered counseling, lack of youth-friendly services, and low client awareness ... might help improve contraceptive use, potentially reducing the number of unintended pregnancies and the number of abortions performed in the United States,” the researchers wrote.
SOURCE: Jatlaoui TC et al. MMWR Surveill Summ. 2018 Nov 23(13):1-45.
FROM MMWR SURVEILLANCE SUMMARIES
Levonorgestrel implant right after delivery does not affect breastfeeding, infant growth
Researchers found no significant differences in infant growth, changes in breastfeeding initiation or breastfeeding continuation at 3-month and 6-month follow-up among women who received a levonorgestrel contraception implant very soon after delivery, compared with women who waited to receive the implant.
“These findings are consistent with the preponderance of literature supporting the hypothesis that progestin-containing contraceptives do not compromise a woman’s ability to initiate or sustain breastfeeding and do not adversely affect infant growth,” Sarah Averbach, MD, of the University of California, San Francisco, and her colleagues wrote in their study published in Contraception.
Dr. Averbach and her colleagues randomized 96 women to receive a two-rod levonorgestrel (LNG)–releasing subdermal contraceptive implant within 5 days of delivery (mean time, 36 hours post delivery) and 87 women to delay the implant to between 6 and 8 weeks at a postpartum follow-up visit (mean time, 68 days). The women were a minimum of 18 years old with a recent vaginal or cesarean section delivery at a Ugandan hospital; 55% of the women had at least three children, and 73% said they had prior experience breastfeeding. The researchers then examined infant weight change and infant head circumference change at 6 months from birth, time to lactogenesis, and whether mothers continued to breastfeed at 3 months and 6 months after birth.
Infant weight was similar in the immediate-implant group (4,632 g), compared with the delayed-implant group (4,407 g; P = .26); infant head circumference was similar between both groups (9.3 cm vs. 9.5 cm; P = .70) at 6 months as well. The time to lactogenesis was not significantly different in the immediate-implant (65 hours) and delayed-implant (63 hours; P = .84) groups. At 3 months, 74% of immediate-implant participants and 71% of delayed-implant participants said they were breastfeeding exclusively (P = .74); at 6 months, 48% of immediate implant participants and 52% of delayed implant participants reported exclusive breastfeeding (P equals .58).
Limitations of the study included follow-up to only 6 months and selection of participants with previous breastfeeding experience. Researchers also noted better measurements of infant and maternal breast milk intake also could be used and limit generalization of the results.
This study was funded by the Society of Family Planning Research Fund. Dr. Averbach is supported by an award from the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The other authors had no relevant financial disclosures.
SOURCE: Averbach S et al. Contraception. 2018. doi: 10.1016/j.contraception.2018.10.008.
Researchers found no significant differences in infant growth, changes in breastfeeding initiation or breastfeeding continuation at 3-month and 6-month follow-up among women who received a levonorgestrel contraception implant very soon after delivery, compared with women who waited to receive the implant.
“These findings are consistent with the preponderance of literature supporting the hypothesis that progestin-containing contraceptives do not compromise a woman’s ability to initiate or sustain breastfeeding and do not adversely affect infant growth,” Sarah Averbach, MD, of the University of California, San Francisco, and her colleagues wrote in their study published in Contraception.
Dr. Averbach and her colleagues randomized 96 women to receive a two-rod levonorgestrel (LNG)–releasing subdermal contraceptive implant within 5 days of delivery (mean time, 36 hours post delivery) and 87 women to delay the implant to between 6 and 8 weeks at a postpartum follow-up visit (mean time, 68 days). The women were a minimum of 18 years old with a recent vaginal or cesarean section delivery at a Ugandan hospital; 55% of the women had at least three children, and 73% said they had prior experience breastfeeding. The researchers then examined infant weight change and infant head circumference change at 6 months from birth, time to lactogenesis, and whether mothers continued to breastfeed at 3 months and 6 months after birth.
Infant weight was similar in the immediate-implant group (4,632 g), compared with the delayed-implant group (4,407 g; P = .26); infant head circumference was similar between both groups (9.3 cm vs. 9.5 cm; P = .70) at 6 months as well. The time to lactogenesis was not significantly different in the immediate-implant (65 hours) and delayed-implant (63 hours; P = .84) groups. At 3 months, 74% of immediate-implant participants and 71% of delayed-implant participants said they were breastfeeding exclusively (P = .74); at 6 months, 48% of immediate implant participants and 52% of delayed implant participants reported exclusive breastfeeding (P equals .58).
Limitations of the study included follow-up to only 6 months and selection of participants with previous breastfeeding experience. Researchers also noted better measurements of infant and maternal breast milk intake also could be used and limit generalization of the results.
This study was funded by the Society of Family Planning Research Fund. Dr. Averbach is supported by an award from the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The other authors had no relevant financial disclosures.
SOURCE: Averbach S et al. Contraception. 2018. doi: 10.1016/j.contraception.2018.10.008.
Researchers found no significant differences in infant growth, changes in breastfeeding initiation or breastfeeding continuation at 3-month and 6-month follow-up among women who received a levonorgestrel contraception implant very soon after delivery, compared with women who waited to receive the implant.
“These findings are consistent with the preponderance of literature supporting the hypothesis that progestin-containing contraceptives do not compromise a woman’s ability to initiate or sustain breastfeeding and do not adversely affect infant growth,” Sarah Averbach, MD, of the University of California, San Francisco, and her colleagues wrote in their study published in Contraception.
Dr. Averbach and her colleagues randomized 96 women to receive a two-rod levonorgestrel (LNG)–releasing subdermal contraceptive implant within 5 days of delivery (mean time, 36 hours post delivery) and 87 women to delay the implant to between 6 and 8 weeks at a postpartum follow-up visit (mean time, 68 days). The women were a minimum of 18 years old with a recent vaginal or cesarean section delivery at a Ugandan hospital; 55% of the women had at least three children, and 73% said they had prior experience breastfeeding. The researchers then examined infant weight change and infant head circumference change at 6 months from birth, time to lactogenesis, and whether mothers continued to breastfeed at 3 months and 6 months after birth.
Infant weight was similar in the immediate-implant group (4,632 g), compared with the delayed-implant group (4,407 g; P = .26); infant head circumference was similar between both groups (9.3 cm vs. 9.5 cm; P = .70) at 6 months as well. The time to lactogenesis was not significantly different in the immediate-implant (65 hours) and delayed-implant (63 hours; P = .84) groups. At 3 months, 74% of immediate-implant participants and 71% of delayed-implant participants said they were breastfeeding exclusively (P = .74); at 6 months, 48% of immediate implant participants and 52% of delayed implant participants reported exclusive breastfeeding (P equals .58).
Limitations of the study included follow-up to only 6 months and selection of participants with previous breastfeeding experience. Researchers also noted better measurements of infant and maternal breast milk intake also could be used and limit generalization of the results.
This study was funded by the Society of Family Planning Research Fund. Dr. Averbach is supported by an award from the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The other authors had no relevant financial disclosures.
SOURCE: Averbach S et al. Contraception. 2018. doi: 10.1016/j.contraception.2018.10.008.
FROM CONTRACEPTION
Key clinical point:
Major finding: Infant weight was similar in the immediate-implant group (4,632 g), compared with the delayed-implant group (4,407 g; P = .26); infant head circumference was similar between both groups (9.3 cm vs. 9.5 cm; P = .70) at 6 months as well.
Study details: A randomized trial of 96 women in Uganda who received a contraceptive implant less than 5 days after delivery and 86 women who received the implant between 6 and 8 weeks post partum.
Disclosures: This study was funded by the Society of Family Planning Research Fund. Dr. Averbach is supported by an award from the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The other authors had no relevant financial disclosures.
Source: Averbach S et al. Contraception. 2018. doi: 10.1016/j.contraception.2018.10.008.
Intimate partner violence and PTSD increase menopausal symptom risk
Intimate partner violence or sexual assault may have a significant effect on menopausal symptoms in women, according to a cohort study published in JAMA Internal Medicine.
Researchers analyzed data from 2,016 women aged 40 years or older who were enrolled in the observational Reproductive Risks of Incontinence Study; 40% were non-Latina white, 21% were black, 20% were Latina or Hispanic, and 19% were Asian. Of this cohort, 21% had experienced emotional intimate partner violence (IPV) – 64 (3.2%) in the past 12 months – 16% had experienced physical IPV, 14% had experienced both, and 19% reported sexual assault. More than one in five women (23%) met the criteria for clinically significant PTSD.
Women who had experienced emotional domestic abuse were 36% more likely to report difficulty sleeping, 50% more like to experience night sweats, and 60% more likely to experience pain with intercourse, compared with women who had not experienced any abuse.
Physical abuse was associated with 33% higher odds of night sweats, and sexual assault was associated with 41% higher odds of vaginal dryness, 42% higher odds of vaginal irritation, and 44% higher odds of pain with intercourse.
Women with clinically significant PTSD symptoms were significantly more likely to experience all the symptoms of menopause, including twofold higher odds of pain with intercourse and threefold higher odds of difficulty sleeping. When authors accounted for the effect of PTSD symptoms in the cohort, they found that only the association between emotional abuse and night sweats or pain with intercourse, and between sexual assault and vaginal dryness, remained independently significant.
Carolyn J. Gibson, PhD, MPH, of the San Francisco Veterans Affairs Health Care System, and coauthors said that the biological and hormonal changes that underpin menopausal symptoms, as well as health risk behaviors, cardiometabolic risk factors, and other chronic health conditions associated with menopause, all are impacted by trauma and its psychological effects.
“Chronic hyperarousal and hypervigilance, common in individuals who have experienced trauma and characteristic symptoms of PTSD, may affect sleep and symptom sensitivity,” they wrote.
The reverse is also true; that the symptoms of menopause can impact the symptoms of PTSD by affecting a woman’s sense of self-efficacy, interpersonal engagements, and heighten the stress associated with this period of transition.
“The clinical management of menopause symptoms may also be enhanced by trauma-informed care, including recognition of challenges that may impair efforts to address menopause-related concerns among women affected by trauma,” the authors wrote.
Clinicians also could help by providing education about the link between trauma and health, providing their patients with a safe and supportive treatment environment, and facilitating referrals for psychological or trauma-specific services when needed, they said.
The research was supported by the San Francisco Veterans Affairs Medical Center and Kaiser Permanente Northern California, and funded by the University of California San Francisco–Kaiser Permanente Grants Program for Delivery Science, the Office of Research on Women’s Health Specialized Center of Research, and grants from the National Institute of Diabetes and Digestive and Kidney Diseases.
SOURCE: Gibson C et al. JAMA Intern Med. 2018 Nov 19. doi: 10.1001/jamainternmed.2018.5233.
An estimated 33% of women in the United States have been sexually assaulted, and an estimated 25% have experienced IPV, so be aware of how common this “wicked problem” is, the way it impacts health, and what role you can play in educating and helping patients by connecting them to available resources.
But that is not enough. Consider measures such as training yourself and staff in how to assess for IPV and sexual assault and use of EHR to integrate IPV assessment into routine clinical care, as well as developing protocols to be followed when a patient discloses IPV or sexual assault. A multidisciplinary approach also can help, including victim service advocates and behavioral health clinicians to provide care and support.
State requirements for reporting partner and sexual violence differ, so be aware of your state laws.
A strength of this study is that it included emotional as well as physical IPV, which often is left out although it has serious impacts.
Rebecca C. Thurston, PhD, is from the department of psychiatry at the University of Pittsburgh, and Elizabeth Miller, MD, PhD, is from the division of adolescent and young adult medicine at the UPMC Children’s Hospital of Pittsburgh. These comments were taken from an accompanying editorial (JAMA Intern Med. 2018 Nov 19. doi: 10.1001/jamainternmed.2018.5242). Dr. Thurston declared research support from the National Institutes of Health and consultancies for Pfizer, Procter & Gamble, and MAS Innovations.
An estimated 33% of women in the United States have been sexually assaulted, and an estimated 25% have experienced IPV, so be aware of how common this “wicked problem” is, the way it impacts health, and what role you can play in educating and helping patients by connecting them to available resources.
But that is not enough. Consider measures such as training yourself and staff in how to assess for IPV and sexual assault and use of EHR to integrate IPV assessment into routine clinical care, as well as developing protocols to be followed when a patient discloses IPV or sexual assault. A multidisciplinary approach also can help, including victim service advocates and behavioral health clinicians to provide care and support.
State requirements for reporting partner and sexual violence differ, so be aware of your state laws.
A strength of this study is that it included emotional as well as physical IPV, which often is left out although it has serious impacts.
Rebecca C. Thurston, PhD, is from the department of psychiatry at the University of Pittsburgh, and Elizabeth Miller, MD, PhD, is from the division of adolescent and young adult medicine at the UPMC Children’s Hospital of Pittsburgh. These comments were taken from an accompanying editorial (JAMA Intern Med. 2018 Nov 19. doi: 10.1001/jamainternmed.2018.5242). Dr. Thurston declared research support from the National Institutes of Health and consultancies for Pfizer, Procter & Gamble, and MAS Innovations.
An estimated 33% of women in the United States have been sexually assaulted, and an estimated 25% have experienced IPV, so be aware of how common this “wicked problem” is, the way it impacts health, and what role you can play in educating and helping patients by connecting them to available resources.
But that is not enough. Consider measures such as training yourself and staff in how to assess for IPV and sexual assault and use of EHR to integrate IPV assessment into routine clinical care, as well as developing protocols to be followed when a patient discloses IPV or sexual assault. A multidisciplinary approach also can help, including victim service advocates and behavioral health clinicians to provide care and support.
State requirements for reporting partner and sexual violence differ, so be aware of your state laws.
A strength of this study is that it included emotional as well as physical IPV, which often is left out although it has serious impacts.
Rebecca C. Thurston, PhD, is from the department of psychiatry at the University of Pittsburgh, and Elizabeth Miller, MD, PhD, is from the division of adolescent and young adult medicine at the UPMC Children’s Hospital of Pittsburgh. These comments were taken from an accompanying editorial (JAMA Intern Med. 2018 Nov 19. doi: 10.1001/jamainternmed.2018.5242). Dr. Thurston declared research support from the National Institutes of Health and consultancies for Pfizer, Procter & Gamble, and MAS Innovations.
Intimate partner violence or sexual assault may have a significant effect on menopausal symptoms in women, according to a cohort study published in JAMA Internal Medicine.
Researchers analyzed data from 2,016 women aged 40 years or older who were enrolled in the observational Reproductive Risks of Incontinence Study; 40% were non-Latina white, 21% were black, 20% were Latina or Hispanic, and 19% were Asian. Of this cohort, 21% had experienced emotional intimate partner violence (IPV) – 64 (3.2%) in the past 12 months – 16% had experienced physical IPV, 14% had experienced both, and 19% reported sexual assault. More than one in five women (23%) met the criteria for clinically significant PTSD.
Women who had experienced emotional domestic abuse were 36% more likely to report difficulty sleeping, 50% more like to experience night sweats, and 60% more likely to experience pain with intercourse, compared with women who had not experienced any abuse.
Physical abuse was associated with 33% higher odds of night sweats, and sexual assault was associated with 41% higher odds of vaginal dryness, 42% higher odds of vaginal irritation, and 44% higher odds of pain with intercourse.
Women with clinically significant PTSD symptoms were significantly more likely to experience all the symptoms of menopause, including twofold higher odds of pain with intercourse and threefold higher odds of difficulty sleeping. When authors accounted for the effect of PTSD symptoms in the cohort, they found that only the association between emotional abuse and night sweats or pain with intercourse, and between sexual assault and vaginal dryness, remained independently significant.
Carolyn J. Gibson, PhD, MPH, of the San Francisco Veterans Affairs Health Care System, and coauthors said that the biological and hormonal changes that underpin menopausal symptoms, as well as health risk behaviors, cardiometabolic risk factors, and other chronic health conditions associated with menopause, all are impacted by trauma and its psychological effects.
“Chronic hyperarousal and hypervigilance, common in individuals who have experienced trauma and characteristic symptoms of PTSD, may affect sleep and symptom sensitivity,” they wrote.
The reverse is also true; that the symptoms of menopause can impact the symptoms of PTSD by affecting a woman’s sense of self-efficacy, interpersonal engagements, and heighten the stress associated with this period of transition.
“The clinical management of menopause symptoms may also be enhanced by trauma-informed care, including recognition of challenges that may impair efforts to address menopause-related concerns among women affected by trauma,” the authors wrote.
Clinicians also could help by providing education about the link between trauma and health, providing their patients with a safe and supportive treatment environment, and facilitating referrals for psychological or trauma-specific services when needed, they said.
The research was supported by the San Francisco Veterans Affairs Medical Center and Kaiser Permanente Northern California, and funded by the University of California San Francisco–Kaiser Permanente Grants Program for Delivery Science, the Office of Research on Women’s Health Specialized Center of Research, and grants from the National Institute of Diabetes and Digestive and Kidney Diseases.
SOURCE: Gibson C et al. JAMA Intern Med. 2018 Nov 19. doi: 10.1001/jamainternmed.2018.5233.
Intimate partner violence or sexual assault may have a significant effect on menopausal symptoms in women, according to a cohort study published in JAMA Internal Medicine.
Researchers analyzed data from 2,016 women aged 40 years or older who were enrolled in the observational Reproductive Risks of Incontinence Study; 40% were non-Latina white, 21% were black, 20% were Latina or Hispanic, and 19% were Asian. Of this cohort, 21% had experienced emotional intimate partner violence (IPV) – 64 (3.2%) in the past 12 months – 16% had experienced physical IPV, 14% had experienced both, and 19% reported sexual assault. More than one in five women (23%) met the criteria for clinically significant PTSD.
Women who had experienced emotional domestic abuse were 36% more likely to report difficulty sleeping, 50% more like to experience night sweats, and 60% more likely to experience pain with intercourse, compared with women who had not experienced any abuse.
Physical abuse was associated with 33% higher odds of night sweats, and sexual assault was associated with 41% higher odds of vaginal dryness, 42% higher odds of vaginal irritation, and 44% higher odds of pain with intercourse.
Women with clinically significant PTSD symptoms were significantly more likely to experience all the symptoms of menopause, including twofold higher odds of pain with intercourse and threefold higher odds of difficulty sleeping. When authors accounted for the effect of PTSD symptoms in the cohort, they found that only the association between emotional abuse and night sweats or pain with intercourse, and between sexual assault and vaginal dryness, remained independently significant.
Carolyn J. Gibson, PhD, MPH, of the San Francisco Veterans Affairs Health Care System, and coauthors said that the biological and hormonal changes that underpin menopausal symptoms, as well as health risk behaviors, cardiometabolic risk factors, and other chronic health conditions associated with menopause, all are impacted by trauma and its psychological effects.
“Chronic hyperarousal and hypervigilance, common in individuals who have experienced trauma and characteristic symptoms of PTSD, may affect sleep and symptom sensitivity,” they wrote.
The reverse is also true; that the symptoms of menopause can impact the symptoms of PTSD by affecting a woman’s sense of self-efficacy, interpersonal engagements, and heighten the stress associated with this period of transition.
“The clinical management of menopause symptoms may also be enhanced by trauma-informed care, including recognition of challenges that may impair efforts to address menopause-related concerns among women affected by trauma,” the authors wrote.
Clinicians also could help by providing education about the link between trauma and health, providing their patients with a safe and supportive treatment environment, and facilitating referrals for psychological or trauma-specific services when needed, they said.
The research was supported by the San Francisco Veterans Affairs Medical Center and Kaiser Permanente Northern California, and funded by the University of California San Francisco–Kaiser Permanente Grants Program for Delivery Science, the Office of Research on Women’s Health Specialized Center of Research, and grants from the National Institute of Diabetes and Digestive and Kidney Diseases.
SOURCE: Gibson C et al. JAMA Intern Med. 2018 Nov 19. doi: 10.1001/jamainternmed.2018.5233.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Intimate partner violence increases the risk of menopausal symptoms.
Major finding:
Study details: A cohort study in 2,016 women aged 40 years and older.
Disclosures: The research was supported by the San Francisco Veterans Affairs Medical Center and Kaiser Permanente Northern California, and funded by the University of California San Francisco–Kaiser Permanente Grants Program for Delivery Science, the Office of Research on Women’s Health Specialized Center of Research, and grants from the National Institute of Diabetes and Digestive and Kidney Diseases.
Source: Gibson C et al. JAMA Intern Med. 2018 Nov 19. doi:10.1001/jamainternmed.2018.5233.
Smaller assistant ports mean less prolapse repair pain
LAS VEGAS – Patients experience less right-sided pain after laparoscopic sacrocolpopexy when surgeons use an 8-mm assistant port instead of a 12-mm port, results from a small trial show.
In the trial, conducted at Loyola University Medical Center in Maywood, Ill.,17 women were randomized to undergo the procedure with an 8-mm assistant port, and 18 with a 12-mm port, both on the right side of the abdomen.
Overall, pain severity was low at 2 weeks postop in both groups at just over 1 point on a 10-point visual analogue scale and not statistically different. However, patients who had a 12-mm assistant port were more likely to report right-sided pain, compared with those who had an 8-mm assistant port (60% vs.18%, P = 0.027).
“I saw a lot of these patients in the clinic at 2 weeks, and even though the overall pain score was low, they kept complaining about a dull, achy pain on the right side. They were using ibuprofen, and some of them had even restricted [their activities] because they were afraid they were going to pop a stitch,” said study lead Yufan B. Chen, MD, a urogynecology fellow at Loyola.
He said the research team thinks the difference in port-site pain “is clinically significant. . Since our study ended, we have stopped using the 12-mm port in most of our cases; we use the 8-mm port for the assistant,” he said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
The tradeoff was that there were more needle struggles with the 8-mm port, 3.1/case vs. 0.6/case (P = .004). Surgeons found inserting and withdrawing the Gore-Tex needle through the smaller port more difficult. But there were no needle losses in either group and no differences in operative time – an average of about 95 minutes.
“The larger port size essentially benefits the surgeon more than the patient. This is kind of a common theme in minimally invasive surgery where less is actually more,” he said. Since the study, “we have identified why we have challenges with the needle transport; it’s usually because the needle gets bent, so we just unbend it a little bit with our needle drivers before we remove it,” Dr. Chen said.
Even so, “there may be a role in using the 12-mm port when you have assistants who are not [that] experienced,” he said.
Laparoscopic sacrocolpopexy is done through four ports at Loyola: a 12-mm umbilical port for the scope; two 5-mm ports on the left for the primary surgeon; and the right side port for the assistant, through which the Gore-Tex needle is passed.
In the study, there were no demographic or preop differences between the two groups of women. About 60% were white, with a mean age of 61 years. About 10% of the women had had prior abdominal surgery.
The study received no industry funding, and the investigators had no disclosures.
SOURCE: Chen YB et al. 2018 AAGL Global Congress, Abstract 197.
LAS VEGAS – Patients experience less right-sided pain after laparoscopic sacrocolpopexy when surgeons use an 8-mm assistant port instead of a 12-mm port, results from a small trial show.
In the trial, conducted at Loyola University Medical Center in Maywood, Ill.,17 women were randomized to undergo the procedure with an 8-mm assistant port, and 18 with a 12-mm port, both on the right side of the abdomen.
Overall, pain severity was low at 2 weeks postop in both groups at just over 1 point on a 10-point visual analogue scale and not statistically different. However, patients who had a 12-mm assistant port were more likely to report right-sided pain, compared with those who had an 8-mm assistant port (60% vs.18%, P = 0.027).
“I saw a lot of these patients in the clinic at 2 weeks, and even though the overall pain score was low, they kept complaining about a dull, achy pain on the right side. They were using ibuprofen, and some of them had even restricted [their activities] because they were afraid they were going to pop a stitch,” said study lead Yufan B. Chen, MD, a urogynecology fellow at Loyola.
He said the research team thinks the difference in port-site pain “is clinically significant. . Since our study ended, we have stopped using the 12-mm port in most of our cases; we use the 8-mm port for the assistant,” he said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
The tradeoff was that there were more needle struggles with the 8-mm port, 3.1/case vs. 0.6/case (P = .004). Surgeons found inserting and withdrawing the Gore-Tex needle through the smaller port more difficult. But there were no needle losses in either group and no differences in operative time – an average of about 95 minutes.
“The larger port size essentially benefits the surgeon more than the patient. This is kind of a common theme in minimally invasive surgery where less is actually more,” he said. Since the study, “we have identified why we have challenges with the needle transport; it’s usually because the needle gets bent, so we just unbend it a little bit with our needle drivers before we remove it,” Dr. Chen said.
Even so, “there may be a role in using the 12-mm port when you have assistants who are not [that] experienced,” he said.
Laparoscopic sacrocolpopexy is done through four ports at Loyola: a 12-mm umbilical port for the scope; two 5-mm ports on the left for the primary surgeon; and the right side port for the assistant, through which the Gore-Tex needle is passed.
In the study, there were no demographic or preop differences between the two groups of women. About 60% were white, with a mean age of 61 years. About 10% of the women had had prior abdominal surgery.
The study received no industry funding, and the investigators had no disclosures.
SOURCE: Chen YB et al. 2018 AAGL Global Congress, Abstract 197.
LAS VEGAS – Patients experience less right-sided pain after laparoscopic sacrocolpopexy when surgeons use an 8-mm assistant port instead of a 12-mm port, results from a small trial show.
In the trial, conducted at Loyola University Medical Center in Maywood, Ill.,17 women were randomized to undergo the procedure with an 8-mm assistant port, and 18 with a 12-mm port, both on the right side of the abdomen.
Overall, pain severity was low at 2 weeks postop in both groups at just over 1 point on a 10-point visual analogue scale and not statistically different. However, patients who had a 12-mm assistant port were more likely to report right-sided pain, compared with those who had an 8-mm assistant port (60% vs.18%, P = 0.027).
“I saw a lot of these patients in the clinic at 2 weeks, and even though the overall pain score was low, they kept complaining about a dull, achy pain on the right side. They were using ibuprofen, and some of them had even restricted [their activities] because they were afraid they were going to pop a stitch,” said study lead Yufan B. Chen, MD, a urogynecology fellow at Loyola.
He said the research team thinks the difference in port-site pain “is clinically significant. . Since our study ended, we have stopped using the 12-mm port in most of our cases; we use the 8-mm port for the assistant,” he said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
The tradeoff was that there were more needle struggles with the 8-mm port, 3.1/case vs. 0.6/case (P = .004). Surgeons found inserting and withdrawing the Gore-Tex needle through the smaller port more difficult. But there were no needle losses in either group and no differences in operative time – an average of about 95 minutes.
“The larger port size essentially benefits the surgeon more than the patient. This is kind of a common theme in minimally invasive surgery where less is actually more,” he said. Since the study, “we have identified why we have challenges with the needle transport; it’s usually because the needle gets bent, so we just unbend it a little bit with our needle drivers before we remove it,” Dr. Chen said.
Even so, “there may be a role in using the 12-mm port when you have assistants who are not [that] experienced,” he said.
Laparoscopic sacrocolpopexy is done through four ports at Loyola: a 12-mm umbilical port for the scope; two 5-mm ports on the left for the primary surgeon; and the right side port for the assistant, through which the Gore-Tex needle is passed.
In the study, there were no demographic or preop differences between the two groups of women. About 60% were white, with a mean age of 61 years. About 10% of the women had had prior abdominal surgery.
The study received no industry funding, and the investigators had no disclosures.
SOURCE: Chen YB et al. 2018 AAGL Global Congress, Abstract 197.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: Patients experienced less pain at 2 weeks with a smaller port; there are also more needle struggles, but that can be easily fixed.
Major finding: Patients who had a 12-mm assistant port were more likely to report right-sided pain, compared with those who received an 8- mm assistant port (60% vs. 18%, P = 0.027).
Study details: Randomized trial with 35 women.
Disclosures: The study received no industry funding, and the investigators had no disclosures.
Source: Chen YB et al. 2018 AAGL Global Congress, Abstract 197.
Try to normalize albumin before laparoscopic hysterectomy
LAS VEGAS – Serum albumin is an everyday health marker commonly used for risk assessment in open abdominal procedures, but it’s often not checked before laparoscopic hysterectomies.
Low levels mean something is off, be it malnutrition, inflammation, chronic disease, or other problems. If it can be normalized before surgery, it should be; women probably will do better, according to investigators from the University of Kentucky, Lexington.
“In minimally invasive gynecologic procedures, we haven’t come to adopt this marker just quite yet. It could be included in the routine battery of tests” at minimal cost. “I think it’s something we should consider,” said ob.gyn. resident Suzanne Lababidi, MD.
The team was curious why serum albumin generally is not a part of routine testing for laparoscopic hysterectomy. The first step was to see if it made a difference, so they reviewed 43,289 cases in the National Surgical Quality Improvement Program database. The women were “par for the course;” 51 years old, on average; and had a mean body mass index of 31.9 kg/m2. More than one-third were hypertensive. Mean albumin was in the normal range at 4.1 g/dL, Dr. Lababidi said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
Her team did not come up with a cut-point to delay surgery – that’s the goal of further research – but they noticed on linear regression that women with lower preop albumin had higher rates of surgical site infections and intraoperative transfusions, plus higher rates of postop pneumonia; renal failure; urinary tract infection; sepsis; and deep vein thrombosis, among other issues – and even after controlling for hypertension, diabetes, and other comorbidities. The findings met statistical significance.
It’s true that patients with low albumin might have gone into the operating room sicker, but no matter; Dr. Lababidi’s point was that preop serum albumin is something to pay attention to and correct whenever possible before laparoscopic hysterectomies.
Preop levels are something to consider for “counseling and optimizing patients to improve surgical outcomes,” she said.
The next step toward an albumin cut-point is to weed out confounders by further stratifying patients based on albumin levels, she said.
The work received no industry funding. Dr. Lababidi had no disclosures.
SOURCE: Lababidi S et al. 2018 AAGL Global Congress, Abstract 199.
LAS VEGAS – Serum albumin is an everyday health marker commonly used for risk assessment in open abdominal procedures, but it’s often not checked before laparoscopic hysterectomies.
Low levels mean something is off, be it malnutrition, inflammation, chronic disease, or other problems. If it can be normalized before surgery, it should be; women probably will do better, according to investigators from the University of Kentucky, Lexington.
“In minimally invasive gynecologic procedures, we haven’t come to adopt this marker just quite yet. It could be included in the routine battery of tests” at minimal cost. “I think it’s something we should consider,” said ob.gyn. resident Suzanne Lababidi, MD.
The team was curious why serum albumin generally is not a part of routine testing for laparoscopic hysterectomy. The first step was to see if it made a difference, so they reviewed 43,289 cases in the National Surgical Quality Improvement Program database. The women were “par for the course;” 51 years old, on average; and had a mean body mass index of 31.9 kg/m2. More than one-third were hypertensive. Mean albumin was in the normal range at 4.1 g/dL, Dr. Lababidi said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
Her team did not come up with a cut-point to delay surgery – that’s the goal of further research – but they noticed on linear regression that women with lower preop albumin had higher rates of surgical site infections and intraoperative transfusions, plus higher rates of postop pneumonia; renal failure; urinary tract infection; sepsis; and deep vein thrombosis, among other issues – and even after controlling for hypertension, diabetes, and other comorbidities. The findings met statistical significance.
It’s true that patients with low albumin might have gone into the operating room sicker, but no matter; Dr. Lababidi’s point was that preop serum albumin is something to pay attention to and correct whenever possible before laparoscopic hysterectomies.
Preop levels are something to consider for “counseling and optimizing patients to improve surgical outcomes,” she said.
The next step toward an albumin cut-point is to weed out confounders by further stratifying patients based on albumin levels, she said.
The work received no industry funding. Dr. Lababidi had no disclosures.
SOURCE: Lababidi S et al. 2018 AAGL Global Congress, Abstract 199.
LAS VEGAS – Serum albumin is an everyday health marker commonly used for risk assessment in open abdominal procedures, but it’s often not checked before laparoscopic hysterectomies.
Low levels mean something is off, be it malnutrition, inflammation, chronic disease, or other problems. If it can be normalized before surgery, it should be; women probably will do better, according to investigators from the University of Kentucky, Lexington.
“In minimally invasive gynecologic procedures, we haven’t come to adopt this marker just quite yet. It could be included in the routine battery of tests” at minimal cost. “I think it’s something we should consider,” said ob.gyn. resident Suzanne Lababidi, MD.
The team was curious why serum albumin generally is not a part of routine testing for laparoscopic hysterectomy. The first step was to see if it made a difference, so they reviewed 43,289 cases in the National Surgical Quality Improvement Program database. The women were “par for the course;” 51 years old, on average; and had a mean body mass index of 31.9 kg/m2. More than one-third were hypertensive. Mean albumin was in the normal range at 4.1 g/dL, Dr. Lababidi said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
Her team did not come up with a cut-point to delay surgery – that’s the goal of further research – but they noticed on linear regression that women with lower preop albumin had higher rates of surgical site infections and intraoperative transfusions, plus higher rates of postop pneumonia; renal failure; urinary tract infection; sepsis; and deep vein thrombosis, among other issues – and even after controlling for hypertension, diabetes, and other comorbidities. The findings met statistical significance.
It’s true that patients with low albumin might have gone into the operating room sicker, but no matter; Dr. Lababidi’s point was that preop serum albumin is something to pay attention to and correct whenever possible before laparoscopic hysterectomies.
Preop levels are something to consider for “counseling and optimizing patients to improve surgical outcomes,” she said.
The next step toward an albumin cut-point is to weed out confounders by further stratifying patients based on albumin levels, she said.
The work received no industry funding. Dr. Lababidi had no disclosures.
SOURCE: Lababidi S et al. 2018 AAGL Global Congress, Abstract 199.
REPORTING FROM THE AAGL GLOBAL CONGRESS
Antibiotics backed as standard of care for myomectomies
LAS VEGAS – The surgical site infection rate was 2.9% among women who received perioperative antibiotics for fibroid surgery, but 7.8% among those who did not, in a review of 1,433 cases at Massachusetts General Hospital and Brigham and Women’s Hospital, Boston.
That is despite the fact that antibiotic cases were longer – 155 minutes vs. 89 minutes – and had more blood loss, 200 ml vs. 117 ml. Antibiotic cases also had larger specimen weights – 346 g vs. 176 g – and were more likely to have the uterine cavity entered, 30.2% vs. 14.4%.
“Surgical site infections were more common in the no-antibiotics group despite these being less complex cases.” There was “nearly a fivefold increased odds of surgical site infection or any infectious complication when no antibiotics were given,” after controlling for infection risk factors, including smoking and diabetes, said investigator Nisse V. Clark, MD, a minimally invasive gynecologic surgeon affiliated with Massachusetts General Hospital.
There are no perioperative antibiotic guidelines for myomectomies; maybe there should be. Almost 94% of the women in the review did receive antibiotics at the Harvard-affiliated hospitals, but the nationwide average has been pegged at about two-thirds, she said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
The antibiotic cases usually received a cephalosporin before surgery, and were about evenly about evenly split between abdominal, robotic, and laparoscopic approaches.
About one-third of the 90 women (6.3%) who did not get antibiotics had hysteroscopic procedures in which antibiotics usually are not given because the peritoneal cavity is not breeched. Most of the rest, however, were laparoscopic cases. It’s unknown why they weren’t given antibiotics. In her own practice, Dr. Clark said preop antibiotics are the rule for laparoscopic myomectomies.
The surgical site infection difference was driven largely by higher incidences of pelvic abscesses and other organ space infections in the no-antibiotic group.
The only significant demographic difference between the two groups was that women who received antibiotics were slightly younger (mean 38 versus 39.7 years).
In addition to diabetes and smoking, the team adjusted for age, surgery route, body mass index, uterine entry, intraoperative complications, and myoma weight in their multivariate analysis. Still, women in the no-antibiotic group were 4.59 times more likely to have a surgical site infection, 4.76 more likely to have any infectious complication, and almost 8 times more likely to have a major infectious complication. All of the findings were statistically significant.
The study had no industry funding, and Dr. Clark had no disclosures.
LAS VEGAS – The surgical site infection rate was 2.9% among women who received perioperative antibiotics for fibroid surgery, but 7.8% among those who did not, in a review of 1,433 cases at Massachusetts General Hospital and Brigham and Women’s Hospital, Boston.
That is despite the fact that antibiotic cases were longer – 155 minutes vs. 89 minutes – and had more blood loss, 200 ml vs. 117 ml. Antibiotic cases also had larger specimen weights – 346 g vs. 176 g – and were more likely to have the uterine cavity entered, 30.2% vs. 14.4%.
“Surgical site infections were more common in the no-antibiotics group despite these being less complex cases.” There was “nearly a fivefold increased odds of surgical site infection or any infectious complication when no antibiotics were given,” after controlling for infection risk factors, including smoking and diabetes, said investigator Nisse V. Clark, MD, a minimally invasive gynecologic surgeon affiliated with Massachusetts General Hospital.
There are no perioperative antibiotic guidelines for myomectomies; maybe there should be. Almost 94% of the women in the review did receive antibiotics at the Harvard-affiliated hospitals, but the nationwide average has been pegged at about two-thirds, she said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
The antibiotic cases usually received a cephalosporin before surgery, and were about evenly about evenly split between abdominal, robotic, and laparoscopic approaches.
About one-third of the 90 women (6.3%) who did not get antibiotics had hysteroscopic procedures in which antibiotics usually are not given because the peritoneal cavity is not breeched. Most of the rest, however, were laparoscopic cases. It’s unknown why they weren’t given antibiotics. In her own practice, Dr. Clark said preop antibiotics are the rule for laparoscopic myomectomies.
The surgical site infection difference was driven largely by higher incidences of pelvic abscesses and other organ space infections in the no-antibiotic group.
The only significant demographic difference between the two groups was that women who received antibiotics were slightly younger (mean 38 versus 39.7 years).
In addition to diabetes and smoking, the team adjusted for age, surgery route, body mass index, uterine entry, intraoperative complications, and myoma weight in their multivariate analysis. Still, women in the no-antibiotic group were 4.59 times more likely to have a surgical site infection, 4.76 more likely to have any infectious complication, and almost 8 times more likely to have a major infectious complication. All of the findings were statistically significant.
The study had no industry funding, and Dr. Clark had no disclosures.
LAS VEGAS – The surgical site infection rate was 2.9% among women who received perioperative antibiotics for fibroid surgery, but 7.8% among those who did not, in a review of 1,433 cases at Massachusetts General Hospital and Brigham and Women’s Hospital, Boston.
That is despite the fact that antibiotic cases were longer – 155 minutes vs. 89 minutes – and had more blood loss, 200 ml vs. 117 ml. Antibiotic cases also had larger specimen weights – 346 g vs. 176 g – and were more likely to have the uterine cavity entered, 30.2% vs. 14.4%.
“Surgical site infections were more common in the no-antibiotics group despite these being less complex cases.” There was “nearly a fivefold increased odds of surgical site infection or any infectious complication when no antibiotics were given,” after controlling for infection risk factors, including smoking and diabetes, said investigator Nisse V. Clark, MD, a minimally invasive gynecologic surgeon affiliated with Massachusetts General Hospital.
There are no perioperative antibiotic guidelines for myomectomies; maybe there should be. Almost 94% of the women in the review did receive antibiotics at the Harvard-affiliated hospitals, but the nationwide average has been pegged at about two-thirds, she said at the meeting, sponsored by the American Association of Gynecologic Laparoscopists.
The antibiotic cases usually received a cephalosporin before surgery, and were about evenly about evenly split between abdominal, robotic, and laparoscopic approaches.
About one-third of the 90 women (6.3%) who did not get antibiotics had hysteroscopic procedures in which antibiotics usually are not given because the peritoneal cavity is not breeched. Most of the rest, however, were laparoscopic cases. It’s unknown why they weren’t given antibiotics. In her own practice, Dr. Clark said preop antibiotics are the rule for laparoscopic myomectomies.
The surgical site infection difference was driven largely by higher incidences of pelvic abscesses and other organ space infections in the no-antibiotic group.
The only significant demographic difference between the two groups was that women who received antibiotics were slightly younger (mean 38 versus 39.7 years).
In addition to diabetes and smoking, the team adjusted for age, surgery route, body mass index, uterine entry, intraoperative complications, and myoma weight in their multivariate analysis. Still, women in the no-antibiotic group were 4.59 times more likely to have a surgical site infection, 4.76 more likely to have any infectious complication, and almost 8 times more likely to have a major infectious complication. All of the findings were statistically significant.
The study had no industry funding, and Dr. Clark had no disclosures.
REPORTING FROM THE AAGL GLOBAL CONGRESS
Key clinical point: A Boston study suggests that even low-risk cases benefit from antibiotics.
Major finding: The surgical site infection rate was 2.9% among women who received perioperative antibiotics for fibroid surgery, but 7.8% among those who did not.
Study details: Review of 1,433 myomectomies at two academic medical centers.
Disclosures: The study had no industry funding, and Dr. Clark had no disclosures.
Two-stage preeclampsia screening cuts cost, preserves effectiveness
Using maternal characteristics to identify high-risk pregnant women for second-stage preeclampsia screening achieved similar detection rates as screening all pregnant women, based on data from a prospective study of 61,174 singleton pregnancies.
About 90% of preeclampsia cases can be predicted using the “triple test” of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF) plus a combination of maternal factors at 11 to 13 weeks’ gestation, wrote Alan Wright, PhD, of the University of Exeter, United Kingdom, and colleagues. The need for detection of preeclampsia is important, as high-risk pregnant women who take aspirin before 16 weeks’ gestation can reduce early preeclampsia by 90% and preterm preeclampsia by 60%, they said.
However, “measurements of serum PlGF and UtA-PI are not part of routine care and would be associated with an additional cost,” Dr. Wright and his colleagues noted in the American Journal of Obstetrics & Gynecology.
In the study, the researchers used a competing risks model to combine MAP, UtA-PI, and PlGF and maternal factors to compare detection rates if the triple test were used for a subset of high-risk women. Most of the women in the study were white.
Overall, Dr. Wright and his colleagues found, if first-stage screening method is maternal factors, then measurements of MAP, UtA-PI, and PlGF can be reserved for 70% of the pregnant population.
When the researchers compared various components of the triple test, they found that, if the first stage of screening included maternal factors along with MAP and UtA-PI, measurement of PlGF could be saved for 30%-40% of pregnant women. Similarly, if first-stage screening included maternal factors, MAP, and PlGF, measurement of UtA-PI can be saved for 20%-30% of the population, they said.
The study findings were limited by several factors, including the homogeneity of the population studied, the researchers noted. “The risk for development of [preeclampsia] is higher in women of black or South Asian racial origin than in white women,” Dr. Wright and his colleagues wrote. “Consequently, in screening in a population of mixed racial origins, for a given risk cut-off, the [detection rate] and [screen positive rate] would be higher in black and South Asian than white women and the overall performance would be dependent on the proportion of the various racial groups within that population.”
However, the results support the effectiveness of using only certain tests paired with maternal factors to identify high-risk patients for further screening.
“Inevitably, ,” the researchers said.
Dr. Wright and his colleagues reported no conflicts of interest. The study was supported in part by the Fetal Medicine Foundation, and the reagents and equipment used for the measurement of serum placental growth factor were provided by PerkinElmer Life and Analytical Sciences.
SOURCE: Wright A et al. Am J Obstet Gynecol. 2018. doi: 10.1016/j.ajog.2018.10.092.
Using maternal characteristics to identify high-risk pregnant women for second-stage preeclampsia screening achieved similar detection rates as screening all pregnant women, based on data from a prospective study of 61,174 singleton pregnancies.
About 90% of preeclampsia cases can be predicted using the “triple test” of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF) plus a combination of maternal factors at 11 to 13 weeks’ gestation, wrote Alan Wright, PhD, of the University of Exeter, United Kingdom, and colleagues. The need for detection of preeclampsia is important, as high-risk pregnant women who take aspirin before 16 weeks’ gestation can reduce early preeclampsia by 90% and preterm preeclampsia by 60%, they said.
However, “measurements of serum PlGF and UtA-PI are not part of routine care and would be associated with an additional cost,” Dr. Wright and his colleagues noted in the American Journal of Obstetrics & Gynecology.
In the study, the researchers used a competing risks model to combine MAP, UtA-PI, and PlGF and maternal factors to compare detection rates if the triple test were used for a subset of high-risk women. Most of the women in the study were white.
Overall, Dr. Wright and his colleagues found, if first-stage screening method is maternal factors, then measurements of MAP, UtA-PI, and PlGF can be reserved for 70% of the pregnant population.
When the researchers compared various components of the triple test, they found that, if the first stage of screening included maternal factors along with MAP and UtA-PI, measurement of PlGF could be saved for 30%-40% of pregnant women. Similarly, if first-stage screening included maternal factors, MAP, and PlGF, measurement of UtA-PI can be saved for 20%-30% of the population, they said.
The study findings were limited by several factors, including the homogeneity of the population studied, the researchers noted. “The risk for development of [preeclampsia] is higher in women of black or South Asian racial origin than in white women,” Dr. Wright and his colleagues wrote. “Consequently, in screening in a population of mixed racial origins, for a given risk cut-off, the [detection rate] and [screen positive rate] would be higher in black and South Asian than white women and the overall performance would be dependent on the proportion of the various racial groups within that population.”
However, the results support the effectiveness of using only certain tests paired with maternal factors to identify high-risk patients for further screening.
“Inevitably, ,” the researchers said.
Dr. Wright and his colleagues reported no conflicts of interest. The study was supported in part by the Fetal Medicine Foundation, and the reagents and equipment used for the measurement of serum placental growth factor were provided by PerkinElmer Life and Analytical Sciences.
SOURCE: Wright A et al. Am J Obstet Gynecol. 2018. doi: 10.1016/j.ajog.2018.10.092.
Using maternal characteristics to identify high-risk pregnant women for second-stage preeclampsia screening achieved similar detection rates as screening all pregnant women, based on data from a prospective study of 61,174 singleton pregnancies.
About 90% of preeclampsia cases can be predicted using the “triple test” of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF) plus a combination of maternal factors at 11 to 13 weeks’ gestation, wrote Alan Wright, PhD, of the University of Exeter, United Kingdom, and colleagues. The need for detection of preeclampsia is important, as high-risk pregnant women who take aspirin before 16 weeks’ gestation can reduce early preeclampsia by 90% and preterm preeclampsia by 60%, they said.
However, “measurements of serum PlGF and UtA-PI are not part of routine care and would be associated with an additional cost,” Dr. Wright and his colleagues noted in the American Journal of Obstetrics & Gynecology.
In the study, the researchers used a competing risks model to combine MAP, UtA-PI, and PlGF and maternal factors to compare detection rates if the triple test were used for a subset of high-risk women. Most of the women in the study were white.
Overall, Dr. Wright and his colleagues found, if first-stage screening method is maternal factors, then measurements of MAP, UtA-PI, and PlGF can be reserved for 70% of the pregnant population.
When the researchers compared various components of the triple test, they found that, if the first stage of screening included maternal factors along with MAP and UtA-PI, measurement of PlGF could be saved for 30%-40% of pregnant women. Similarly, if first-stage screening included maternal factors, MAP, and PlGF, measurement of UtA-PI can be saved for 20%-30% of the population, they said.
The study findings were limited by several factors, including the homogeneity of the population studied, the researchers noted. “The risk for development of [preeclampsia] is higher in women of black or South Asian racial origin than in white women,” Dr. Wright and his colleagues wrote. “Consequently, in screening in a population of mixed racial origins, for a given risk cut-off, the [detection rate] and [screen positive rate] would be higher in black and South Asian than white women and the overall performance would be dependent on the proportion of the various racial groups within that population.”
However, the results support the effectiveness of using only certain tests paired with maternal factors to identify high-risk patients for further screening.
“Inevitably, ,” the researchers said.
Dr. Wright and his colleagues reported no conflicts of interest. The study was supported in part by the Fetal Medicine Foundation, and the reagents and equipment used for the measurement of serum placental growth factor were provided by PerkinElmer Life and Analytical Sciences.
SOURCE: Wright A et al. Am J Obstet Gynecol. 2018. doi: 10.1016/j.ajog.2018.10.092.
FROM THE AMERICAN JOURNAL OF OBSTETRICS & GYNECOLOGY
Key clinical point: Reserving two-stage testing for preeclampsia to high-risk subgroups can cut costs without cutting effectiveness.
Major finding: The more costly measurements of MAP, UtA-PI, and PlGF can be reserved for 70% of pregnant women with similar preeclampsia detection rates as testing the entire population.
Study details: The data come from a prospective study of 61,174 singleton pregnancies.
Disclosures: The researchers reported no conflicts of interest. The study was supported in part by the Fetal Medicine Foundation; the reagents and equipment used for the measurement of serum placental growth factor were provided by PerkinElmer Life and Analytical Sciences.
Source: Wright A et al. Am J Obstet Gynecol. 2018. doi: 10.1016/j.ajog.2018.10.092.
CKD, and even dialysis, may not be barriers to pregnancy
SAN DIEGO – Nephrologists are often uncomfortable with the idea of advising women with chronic kidney disease (CKD) about pregnancy, a physician told colleagues. They must do better, she said, with sensitivity and insight into once-extreme possibilities like pregnancy during dialysis.
“For many women, having a child is a life goal, and our women with chronic kidney disease are not different,” said Michelle Hladunewich, MD, of Toronto’s Sunnybrook Health Sciences Center. “When we don’t know what we should do, we tend to over-aggressively counsel our women, and that can traumatize them. It’s our role as nephrologists to help them find the safest window to have their pregnancy,” she said at the meeting sponsored by the American Society of Nephrology.
According to Dr. Hladunewich, there are tens of thousands of women of child-bearing age in the United States who have CKD, end-stage renal disease (ESRD), and kidney transplants. However, she said, research presented at Kidney Week 2018 suggested that many nephrologists do not feel confident about counseling patients regarding issues such as pregnancy outcomes in CKD. “We are not that comfortable with it, but we have to become more comfortable,” she said. “We need to be prepared to talk about contraception if they don’t want to have a child or the plan about how to have a child if they do.”
It’s especially important to understand that while women can fear birth defects and the exacerbation of their disease, they may also feel “they’re not fulfilling a societal norm to have a child like everyone else,” she said.
The risks of pregnancy in CKD can affect the mother (via worse kidney function) and/or the fetus (preeclampsia, poor fetal growth, preterm delivery).
In a 2015 study, Italian researchers compared 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. They found that the risks of adverse outcomes increased in women at higher stages of CKD, compared with those at lower stages: “Renal function matters, and a stepwise increase in the risk of adverse maternal-fetal outcomes is observed from stage 1 to stages 4-5.”
In addition, the researchers noted that their research suggests “the presence of a baseline risk linked to CKD per se” (J Am Soc Nephrol. 2015 Aug; 26[8]:2011-22).
Dr. Hladunewich recommended focusing on “the safest window of opportunity.” Some patients will progress to end-stage renal disease, and an earlier pregnancy during CKD is a better option, she said. As a result, encouraging an earlier pregnancy can be a wise idea.
In some cases, though, a patient may be far into the stages of CKD. Dr. Hladunewich spoke about the case of a 31-year-old patient with a 29-year history of type 1 diabetes mellitus. She’d had one miscarriage, one preterm birth, and one twin pregnancy that was terminated because of safety concerns including rapid loss of kidney function.
The patient saw Dr. Hladunewich when she had a glomerular filtration rate of 25 mL/min, 3.5 g per 24 hour of proteinuria, and hypertension. The patient had a question: “Dr. Michelle, when can I try again?”
Dr. Hladunewich joked that “I had a small stroke.” But then, she said, “I got to the business of pregnancy counseling.”
She told the woman that her progression to end-stage renal disease was likely inevitable, and “adverse pregnancy outcomes were almost guaranteed.”
The woman responded: “Not now? When?” That, Dr. Hladunewich said, “was when I had my second stroke.”
But there is a possible solution: Pregnancy during dialysis. “Historically, we’ve said absolutely no pregnancy on dialysis,” she said, “but times are changing. We believe aggressive dialysis improves fetal maternal and fetal outcomes.”
Indeed, Dr. Hladunewich led a 2014 study that linked extensive dialysis during pregnancy (compared with less dialysis) to a better likelihood of outcomes such as live birth rate and normal birth weight (JASN May 2014;25[5]:1103-9).
As she noted, “we do offer it as a reproductive option” to patients like the one she mentioned – those who are in ESRD, approaching it, or are nearing the end of their child-bearing years with no transplant in sight. In transplant cases, she said, adequate graft function is linked to good pregnancy outcomes.
Dr. Hladunewich added that it’s important to monitor and adjust treatment of patients during the postpartum period. She said it’s especially important to understand the risks of drugs during breastfeeding. Both dialysis and transplant patients can breastfeed, she said.
Dr. Hladunewich reports no disclosures.
SOURCE: Kidney Week 2018, Abstract FR-OR078.
SAN DIEGO – Nephrologists are often uncomfortable with the idea of advising women with chronic kidney disease (CKD) about pregnancy, a physician told colleagues. They must do better, she said, with sensitivity and insight into once-extreme possibilities like pregnancy during dialysis.
“For many women, having a child is a life goal, and our women with chronic kidney disease are not different,” said Michelle Hladunewich, MD, of Toronto’s Sunnybrook Health Sciences Center. “When we don’t know what we should do, we tend to over-aggressively counsel our women, and that can traumatize them. It’s our role as nephrologists to help them find the safest window to have their pregnancy,” she said at the meeting sponsored by the American Society of Nephrology.
According to Dr. Hladunewich, there are tens of thousands of women of child-bearing age in the United States who have CKD, end-stage renal disease (ESRD), and kidney transplants. However, she said, research presented at Kidney Week 2018 suggested that many nephrologists do not feel confident about counseling patients regarding issues such as pregnancy outcomes in CKD. “We are not that comfortable with it, but we have to become more comfortable,” she said. “We need to be prepared to talk about contraception if they don’t want to have a child or the plan about how to have a child if they do.”
It’s especially important to understand that while women can fear birth defects and the exacerbation of their disease, they may also feel “they’re not fulfilling a societal norm to have a child like everyone else,” she said.
The risks of pregnancy in CKD can affect the mother (via worse kidney function) and/or the fetus (preeclampsia, poor fetal growth, preterm delivery).
In a 2015 study, Italian researchers compared 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. They found that the risks of adverse outcomes increased in women at higher stages of CKD, compared with those at lower stages: “Renal function matters, and a stepwise increase in the risk of adverse maternal-fetal outcomes is observed from stage 1 to stages 4-5.”
In addition, the researchers noted that their research suggests “the presence of a baseline risk linked to CKD per se” (J Am Soc Nephrol. 2015 Aug; 26[8]:2011-22).
Dr. Hladunewich recommended focusing on “the safest window of opportunity.” Some patients will progress to end-stage renal disease, and an earlier pregnancy during CKD is a better option, she said. As a result, encouraging an earlier pregnancy can be a wise idea.
In some cases, though, a patient may be far into the stages of CKD. Dr. Hladunewich spoke about the case of a 31-year-old patient with a 29-year history of type 1 diabetes mellitus. She’d had one miscarriage, one preterm birth, and one twin pregnancy that was terminated because of safety concerns including rapid loss of kidney function.
The patient saw Dr. Hladunewich when she had a glomerular filtration rate of 25 mL/min, 3.5 g per 24 hour of proteinuria, and hypertension. The patient had a question: “Dr. Michelle, when can I try again?”
Dr. Hladunewich joked that “I had a small stroke.” But then, she said, “I got to the business of pregnancy counseling.”
She told the woman that her progression to end-stage renal disease was likely inevitable, and “adverse pregnancy outcomes were almost guaranteed.”
The woman responded: “Not now? When?” That, Dr. Hladunewich said, “was when I had my second stroke.”
But there is a possible solution: Pregnancy during dialysis. “Historically, we’ve said absolutely no pregnancy on dialysis,” she said, “but times are changing. We believe aggressive dialysis improves fetal maternal and fetal outcomes.”
Indeed, Dr. Hladunewich led a 2014 study that linked extensive dialysis during pregnancy (compared with less dialysis) to a better likelihood of outcomes such as live birth rate and normal birth weight (JASN May 2014;25[5]:1103-9).
As she noted, “we do offer it as a reproductive option” to patients like the one she mentioned – those who are in ESRD, approaching it, or are nearing the end of their child-bearing years with no transplant in sight. In transplant cases, she said, adequate graft function is linked to good pregnancy outcomes.
Dr. Hladunewich added that it’s important to monitor and adjust treatment of patients during the postpartum period. She said it’s especially important to understand the risks of drugs during breastfeeding. Both dialysis and transplant patients can breastfeed, she said.
Dr. Hladunewich reports no disclosures.
SOURCE: Kidney Week 2018, Abstract FR-OR078.
SAN DIEGO – Nephrologists are often uncomfortable with the idea of advising women with chronic kidney disease (CKD) about pregnancy, a physician told colleagues. They must do better, she said, with sensitivity and insight into once-extreme possibilities like pregnancy during dialysis.
“For many women, having a child is a life goal, and our women with chronic kidney disease are not different,” said Michelle Hladunewich, MD, of Toronto’s Sunnybrook Health Sciences Center. “When we don’t know what we should do, we tend to over-aggressively counsel our women, and that can traumatize them. It’s our role as nephrologists to help them find the safest window to have their pregnancy,” she said at the meeting sponsored by the American Society of Nephrology.
According to Dr. Hladunewich, there are tens of thousands of women of child-bearing age in the United States who have CKD, end-stage renal disease (ESRD), and kidney transplants. However, she said, research presented at Kidney Week 2018 suggested that many nephrologists do not feel confident about counseling patients regarding issues such as pregnancy outcomes in CKD. “We are not that comfortable with it, but we have to become more comfortable,” she said. “We need to be prepared to talk about contraception if they don’t want to have a child or the plan about how to have a child if they do.”
It’s especially important to understand that while women can fear birth defects and the exacerbation of their disease, they may also feel “they’re not fulfilling a societal norm to have a child like everyone else,” she said.
The risks of pregnancy in CKD can affect the mother (via worse kidney function) and/or the fetus (preeclampsia, poor fetal growth, preterm delivery).
In a 2015 study, Italian researchers compared 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. They found that the risks of adverse outcomes increased in women at higher stages of CKD, compared with those at lower stages: “Renal function matters, and a stepwise increase in the risk of adverse maternal-fetal outcomes is observed from stage 1 to stages 4-5.”
In addition, the researchers noted that their research suggests “the presence of a baseline risk linked to CKD per se” (J Am Soc Nephrol. 2015 Aug; 26[8]:2011-22).
Dr. Hladunewich recommended focusing on “the safest window of opportunity.” Some patients will progress to end-stage renal disease, and an earlier pregnancy during CKD is a better option, she said. As a result, encouraging an earlier pregnancy can be a wise idea.
In some cases, though, a patient may be far into the stages of CKD. Dr. Hladunewich spoke about the case of a 31-year-old patient with a 29-year history of type 1 diabetes mellitus. She’d had one miscarriage, one preterm birth, and one twin pregnancy that was terminated because of safety concerns including rapid loss of kidney function.
The patient saw Dr. Hladunewich when she had a glomerular filtration rate of 25 mL/min, 3.5 g per 24 hour of proteinuria, and hypertension. The patient had a question: “Dr. Michelle, when can I try again?”
Dr. Hladunewich joked that “I had a small stroke.” But then, she said, “I got to the business of pregnancy counseling.”
She told the woman that her progression to end-stage renal disease was likely inevitable, and “adverse pregnancy outcomes were almost guaranteed.”
The woman responded: “Not now? When?” That, Dr. Hladunewich said, “was when I had my second stroke.”
But there is a possible solution: Pregnancy during dialysis. “Historically, we’ve said absolutely no pregnancy on dialysis,” she said, “but times are changing. We believe aggressive dialysis improves fetal maternal and fetal outcomes.”
Indeed, Dr. Hladunewich led a 2014 study that linked extensive dialysis during pregnancy (compared with less dialysis) to a better likelihood of outcomes such as live birth rate and normal birth weight (JASN May 2014;25[5]:1103-9).
As she noted, “we do offer it as a reproductive option” to patients like the one she mentioned – those who are in ESRD, approaching it, or are nearing the end of their child-bearing years with no transplant in sight. In transplant cases, she said, adequate graft function is linked to good pregnancy outcomes.
Dr. Hladunewich added that it’s important to monitor and adjust treatment of patients during the postpartum period. She said it’s especially important to understand the risks of drugs during breastfeeding. Both dialysis and transplant patients can breastfeed, she said.
Dr. Hladunewich reports no disclosures.
SOURCE: Kidney Week 2018, Abstract FR-OR078.
REPORTING FROM KIDNEY WEEK 2018