Browsing by Subject "Obstetrics"
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Item A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination(Mary Ann Liebert, 2021) Kasting, Monica L.; Head, Katharine J.; DeMaria, Andrea L.; Neuman, Monica K.; Russell, Allissa L.; Robertson, Sharon E.; Rouse, Caroline E.; Zimet, Gregory D.; Communication Studies, School of Liberal ArtsBackground: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.Item Association between patient characteristics and HPV vaccination recommendation for postpartum patients: A national survey of Obstetrician/Gynecologists(Elsevier, 2022-04-20) Lake, Paige W.; Head, Katharine J.; Christy, Shannon M.; DeMaria, Andrea L.; Thompson, Erika L.; Vadaparampil, Susan T.; Zimet, Gregory D.; Kasting, Monica L.; Communication Studies, School of Liberal ArtsHuman papillomavirus (HPV) vaccination rates in the U.S. are relatively low. Provider recommendation rates for HPV vaccination often vary by patient age and relationship status. Obstetrician/gynecologists (OB/GYNs) represent a key provider group that can recommend the HPV vaccine. This study examined differences in OB/GYN recommendation of HPV vaccination for inpatient postpartum patients by age, parity, and marital status. Data were collected from OB/GYNs nationally via a cross-sectional survey. Participants were randomized to two vignette groups (23-year-old patient or 33-year-old patient). Within each group, participants received 4 vignettes that were identical except for patient marital status (married/not in a committed relationship) and number of children (first/third child), and were asked to indicate HPV vaccination recommendation likelihood on a scale of 0 (definitely would not) to 100 (definitely would). A 2 × 2 × 2 general linear model with repeated measures was used to examine main and interaction effects of patient age, relationship status, and parity. 207 OB/GYNs were included in the final analyses. Recommendation was high for 23-year-old patients (range: 64.5-84.6 out of 100). When marital status and parity were held constant, recommendation likelihood was higher for the younger vs. older patient and was also higher for patients not in a committed relationship, compared to married patients (all p-values < 0.001). Differences in recommendation exist when considering age and relationship status, which provides insight into OB/GYN clinical decision-making. Findings highlight the need to address barriers to HPV vaccination recommendation, including awareness of risk factors to consider when recommending the vaccine.Item Can the date of last menstrual period be trusted in the first trimester? Comparisons of gestational age measures from a prospective cohort study in six low-income to middle-income countries(BMJ, 2023-09-20) Patel, Archana; Bann, Carla M.; Thorsten, Vanessa R.; Rao, Sowmya R.; Lokangaka, Adrien; Tshefu Kitoto, Antoinette; Bauserman, Melissa; Figueroa, Lester; Krebs, Nancy F.; Esamai, Fabian; Bucher, Sherri; Saleem, Sarah; Goldenberg, Robert L.; Chomba, Elwyn; Carlo, Waldemar A.; Goudar, Shivaprasad; Derman, Richard; Koso-Thomas, Marion; McClure, Elizabeth; Hibberd, Patricia L.; Pediatrics, School of MedicineObjectives: We examined gestational age (GA) estimates for live and still births, and prematurity rates based on last menstrual period (LMP) compared with ultrasonography (USG) among pregnant women at seven sites in six low-resource countries. Design: Prospective cohort study SETTING AND PARTICIPANTS: This study included data from the Global Network's population-based Maternal and Newborn Health Registry which follows pregnant women in six low-income and middle-income countries (Democratic Republic of the Congo, Guatemala, India, Kenya, Pakistan and Zambia). Participants in this analysis were 42 803 women, including their 43 230 babies, who registered for the study in their first trimester based on GA estimated either by LMP or USG and had a live or stillbirth with an estimated GA of 20-42 weeks. Outcome measures: GA was estimated in weeks and days based on LMP and/or USG. Prematurity was defined as GA of 20 weeks+0 days through 36 weeks+6 days, calculated by both USG and LMP. Results: Overall, average GA varied ≤1 week between LMP and USG. Mean GA for live births by LMP was lower than by USG (adjusted mean difference (95% CI) = -0.23 (-0.29 to -0.17) weeks). Among stillbirths, a higher GA was estimated by LMP than USG (adjusted mean difference (95% CI)= 0.42 (0.11 to 0.72) weeks). Preterm birth rates for live births were significantly higher when dated by LMP (adjusted rate difference (95% CI)= 4.20 (3.56 to 4.85)). There was no significant difference in preterm birth rates for stillbirths. Conclusion: The small differences in GA for LMP versus USG in the Guatemalan and Indian sites suggest that LMP may be a useful alternative to USG for GA dating during the first trimester until availability of USG improves in those areas. Further research is needed to assess LMP for first-trimester GA dating in other regions with limited access to USG.Item Comparing obstetricians' and neonatologists' approaches to periviable counseling(Nature Publishing Group, 2015-05) Tucker Edmonds, B.; McKenzie, F.; Panoch, J. E.; Barnato, A. E.; Frankel, R. M.; Department of Obstetrics and Gynecology, IU School of MedicineOBJECTIVE: To compare the management options, risks and thematic content that obstetricians and neonatologists discuss in periviable counseling. STUDY DESIGN: Sixteen obstetricians and 15 neonatologists counseled simulated patients portraying a pregnant woman with ruptured membranes at 23 weeks of gestation. Transcripts from video-recorded encounters were qualitatively and quantitatively analyzed for informational content and decision-making themes. RESULT: Obstetricians more frequently discussed antibiotics (P=0.005), maternal risks (<0.001) and cesarean risks (<0.005). Neonatologists more frequently discussed neonatal complications (P=0.044), resuscitation (P=0.015) and palliative options (P=0.023). Obstetricians and neonatologists often deferred questions about steroid administration to the other specialty. Both specialties organized decision making around medical information, survival, quality of life, time and support. Neonatologists also introduced themes of values, comfort or suffering, and uncertainty. CONCLUSION: Obstetricians and neonatologists provided complementary counseling content to patients, yet neither specialty took ownership of steroid discussions. Joint counseling and/or family meetings may minimize observed redundancy and inconsistencies in counseling.Item Examining the Impact of the Vaginal Birth After Cesarean Risk Calculator Estimation on Trial of Labor After Cesarean Counseling(Sage, 2019-05-27) Jeffries, Erin; Falcone-Wharton, Amy; Daggy, Joanne; Edmonds, Brownsyne Tucker; Obstetrics and Gynecology, School of MedicineBackground. Because failed trial of labor after cesarean (TOLAC) is associated with greater morbidity than planned cesarean, it is important to distinguish women with a high likelihood of successful vaginal birth after cesarean (VBAC) from those likely to fail. The VBAC Calculator may help make this distinction but little is known about how often providers use it; nor whether use improves risk estimation and/or influences TOLAC counseling. Methods. In a cross-sectional survey, a convenience sample of obstetrical providers reported their likelihood (4-point Likert-type scale) to “Recommend,”“Offer,” or “Agree to” TOLAC for patients presented first through five clinical vignettes; then, in different order, by corresponding VBAC calculator estimates. Results. Of the 85 (of 101, 84% response rate) participants, 88% routinely performed TOLAC, but only 21% used the Calculator. The majority (67.1% to 89.3%) overestimated the likelihood of success for all but one vignette (which had the highest estimate of success). Most providers (42% to 89%) recommended TOLAC for all five vignettes. Given calculated estimates, the majority of providers (67% to 95%) recommended TOLAC for success estimates exceeding 40%. For estimates between 20% and 40%, most providers offered (58%) or agreed (68%) to TOLAC; and even below 20%, over half still agreed to TOLAC. The vignette with the lowest estimate of success (18.7%) had the weakest intraprovider agreement (kappa = 0.116; confidence interval [CI] = 0.045–0.187), whereas the strongest agreement was found in the two vignettes with highest success estimates: 77.9% (kappa = 0.549; CI = 0.382–0.716) and 96.6% (kappa = 0.527; CI = 0.284–0.770). Limitations. Survey responses may not reflect actual practice patterns. Conclusion. Providers are overly optimistic in their clinical estimation of VBAC success. Wider use of decision support could aid in risk stratification and TOLAC counseling to reduce patient morbidity.Item Exposed: The Hidden History of the Pelvic Exam(2024-02-20) Kline, WendyPresentation slides for lecture delivered by Wendy Kline, PhD (Dema G. Seelye Chair in the History of Medicine and Director of Medical Humanities Program, Purdue University) on February 20, 2024. Ever since the introduction of the pelvic exam as a gynecological procedure in the late nineteenth century, consumers and doctors have struggled to define the boundaries between preventive health and sexual impropriety. This talk suggests that the pelvic exam is more than just a medical procedure; it is a window into a deeper, more meaningful set of questions about gender, medicine, and power. From gynecological research on enslaved women’s bodies to practice on anesthetized patients, the pelvic exam as we know it today carries the burden of its history. By looking through that window, we can begin to understand why the pelvic exam remains both mysterious and contentious. Presentation recording available online: https://purl.dlib.indiana.edu/iudl/media/m80h83t87dItem Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation(Frontiers Media, 2022-05-04) Bunch, Connor M.; Moore, Ernest E.; Moore, Hunter B.; Neal, Matthew D.; Thomas, Anthony V.; Zackariya, Nuha; Zhao, Jonathan; Zackariya, Sufyan; Brenner, Toby J.; Berquist, Margaret; Buckner, Hallie; Wiarda, Grant; Fulkerson, Daniel; Huff, Wei; Kwaan, Hau C.; Lankowicz, Genevieve; Laubscher, Gert J.; Lourens, Petrus J.; Pretorius, Etheresia; Kotze, Maritha J.; Moolla, Muhammad S.; Sithole, Sithembiso; Maponga, Tongai G.; Kell, Douglas B.; Fox, Mark D.; Gillespie, Laura; Khan, Rashid Z.; Mamczak, Christiaan N.; March, Robert; Macias, Rachel; Bull, Brian S.; Walsh, Mark M.; Surgery, School of MedicineEarly in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.Item Is personalized medicine achievable in obstetrics?(Elsevier - WB Saunders, 2014-12) Quinney, Sara K.; Patil, Avinash S.; Flockhart, David A.; Department of Obstetrics and Gynecology, IU School of MedicinePersonalized medicine seeks to identify the right dose of the right drug for the right patient at the right time. Typically, individualization of therapy is based on the pharmacogenomic makeup of the individual and environmental factors that alter drug disposition and response. In addition to these factors, during pregnancy, a woman's body undergoes many changes that can impact the therapeutic efficacy of medications. Yet, there is minimal research regarding personalized medicine in obstetrics. Adoption of pharmacogenetic testing into the obstetrical care is dependent on evidence of analytical validity, clinical validity, and clinical utility. Here, we briefly present information regarding the potential utility of personalized medicine for treating the obstetric patient for pain with narcotics, hypertension, and preterm labor, and discuss the impediments of bringing personalized medicine to the obstetrical clinic.Item Pharmacokinetics of Antidepressants in Pregnancy(Wiley, 2023) Yue, Min; Kus, Lauren; Katta, Shilpa; Su, Isaac; Li, Lang; Haas, David M.; Quinney, Sara K.; Obstetrics and Gynecology, School of MedicineDepression is common in pregnant women. However, the rate of antidepressant treatment in pregnancy is significantly lower than in nonpregnant women. Although some antidepressants may cause potential risks to the fetus, not treating or withdrawing the treatment is associated with relapsing and adverse pregnancy outcomes such as preterm birth. Pregnancy-associated physiologic changes can alter pharmacokinetics (PK) and may impact dosing requirements during pregnancy. However, pregnant women are largely excluded from PK studies. Dose extrapolation from the nonpregnant population could lead to ineffective doses or increased risk of adverse events. To better understand PK changes during pregnancy and guide dosing decisions, we conducted a literature review to catalog PK studies of antidepressants in pregnancy, with a focus on maternal PK differences from the nonpregnant population and fetal exposure. We identified 40 studies on 15 drugs, with most data from patients taking selective serotonin reuptake inhibitors and venlafaxine. Most of the studies have relatively poor quality, with small sample sizes, reporting concentrations at delivery only, a large amount of missing data, and not including times and adequate dose information. Only four studies collected multiple samples following a dose and reported PK parameters. In general, there are limited data available regarding PK of antidepressants in pregnancy and deficiencies in data reporting. Future studies should provide accurate information on drug dosing and timing of dose, PK sample collection, and individual-level PK data.Item Segregation by Payer in Obstetrics and Gynecology Residency Ambulatory Care Sites(American Medical Association, 2024-09-03) Vinekar, Kavita; Qasba, Neena; Reiser, Hannah; Banks, Erika; Arora, Kavita S.; Tucker Edmonds, Brownsyne; George, Karen; Obstetrics and Gynecology, School of MedicineImportance: Many teaching hospitals in the US segregate patients by insurance status, with resident clinics primarily composed of publicly insured or uninsured patients and faculty practices seeing privately insured patients. The prevalence of this model in obstetrics and gynecology residencies is unknown. Objectives: To examine the prevalence of payer-based segregation in obstetrics and gynecology residency ambulatory care sites nationally and to compare residents' and program directors' perceptions of differences in quality of care between payer-segregated and integrated sites. Design, setting, and participants: This national survey study included all 6060 obstetrics and gynecology residents and 293 obstetrics and gynecology residency program directors in the US as of January 2023. The proportion of program directors reporting payer segregation was calculated to characterize the national prevalence of this model in obstetrics and gynecology. Perceived differences in care quality were compared between residents and program directors at payer-segregated sites. Main outcome and measures: The primary measure was prevalence of payer-based segregation in obstetrics and gynecology residency programs in the US as reported by residency program directors. The secondary measure was resident and program director perceptions of care quality in these ambulatory care settings. Before study initiation, the study hypothesis was that residents and program directors at ambulatory sites with payer-based segregation would report more disparity in perceived health care quality between resident and faculty practices compared with those from integrated sites. Results: A total of 251 residency program directors (response rate, 85.7%) and 3471 residents (response rate, 57.3%) were included in the study. Resident respondent demographics reflected demographics of obstetrics and gynecology residents nationally in terms of racial and ethnic distribution (6 [0.2%] American Indian or Alaska Native; 425 [13.0%] Asian; 239 [7.3%] Black or African American; 290 [8.9%] Hispanic, Latinx, or Spanish; 7 [0.2%] Native Hawaiian or Other Pacific Islander; 2052 [62.7%] non-Hispanic White; 49 [1.5%] multiracial; 56 [1.7%] other [any race not listed]; and 137 [4.2%] preferred not to say) and geographic distribution (regional prevalence of payer-based segregation: 36 of 53 [67.9%] in the Northeast, 35 of 44 [79.5%] in the Midwest, 43 of 67 [64.2%] in the South, and 13 of 22 [59.1%] in the West), with 2837 respondents (86.9%) identifying as female. Among program directors, 127 (68.3%) reported payer-based segregation in ambulatory care. University programs were more likely to report payer-based segregation compared with community, hybrid, and military programs (63 of 85 [74.1%] vs 31 of 46 [67.4%], 32 of 51 [62.7%], and 0, respectively; P = .04). Residents at payer-segregated programs were less likely than their counterparts at integrated programs to report equal or higher care quality from residents compared with faculty (1662 [68.7%] vs 692 [81.6%] at segregated and integrated programs, respectively; P < .001). Conclusions and relevance: In this survey study of residents and residency program directors, payer-based segregation was prevalent in obstetrics and gynecology residency programs, particularly at university programs. These findings reveal an opportunity for structural reform to promote more equitable care in residency training programs.