Menstrual bleeding and spotting with the Levonorgestrel Intrauterine System (52 mg) during the first-year post-insertion: a systematic review and meta-analysis.

Abstract: Changes in menstrual bleeding concern many users of the 52 mg Levonorgestrel Intrauterine System (LNG-IUS). Prescribing information for LNG-IUS devices describe an overall decrease in bleeding and spotting days […]

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Prophylactic antibiotics in caesarean delivery before or after cord clamping – Protecting the mother at the expense of the infant’s microbiota?

Abstract: To prevent postoperative infections after caesarean deliveries, most obstetric guidelines recommend intravenous antibiotic prophylaxis before skin incision as opposed to after cord clamping (1). However, the clinical reality may […]

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Undetectable Equals Untransmittable (U=U): Implications for Preconception Counseling for Human Immunodeficiency Virus Serodiscordant Couples.

Abstract: Although limited by society guidelines from the American Society for Reproductive Medicine and the Centers for Disease Control in the past, many human immunodeficiency virus serodiscordant American couples who […]

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Geographic variation in the use of lymphadenectomy and external-beam radiotherapy for endometrial cancer: a cross-sectional analysis of population-based data.

Abstract: To quantify geographic variation in the use of lymphadenectomy and/ or external beam radiotherapy (EBRT) for endometrial cancer in England.Cross-sectional analysis of population-based data.English cancer registry data, linked to […]

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Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting.

Abstract: We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were […]

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Methodological decisions influence the identification of potential core outcomes in pre-eclampsia related studies: a sensitivity analysis informing the development of guidelines for future core outcome set developers.

To quantify the effect of different methodological decisions on the identification of potential core outcomes to inform the development of recommendations.Mixed methods study.A core outcome set for pre-eclampsia was used as an exemplar.A long list of potential core outcomes was developed by undertaking a systematic review of pre-eclampsia trials and performing a thematic analysis of in-depth patient interviews.Specific methods used to generate long lists of potential core outcomes were evaluated, including limitations placed within the search strategy and varied approaches in the extraction of outcomes from published trial reports.Different methodological decisions had a substantial impact on the identification of potential core outcomes. Extracting outcomes from published pre-eclampsia trials was an effective way of identifying 48 maternal, eight fetal, 25 neonatal outcomes, and eight patient-reported outcomes. Limiting the extraction of outcomes to primary outcomes or outcomes commonly reported in pre-eclampsia trials reduced the number and diversity of potential core outcomes identified. Thematic analysis of in-depth patient interviews ensured an additional five patient reported outcomes and six outcomes related to future child health were identified.Future core outcome set developers should use quantitative and qualitative methods when developing a long list of potential core outcomes. This article is protected by copyright. All rights reserved.

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Obstetric Care Consensus, Number 9: Levels of Maternal Care: (Replaces Obstetric Care Consensus Number 2, February 2015).

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

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Levels of Maternal Care: Obstetric Care Consensus No, 9.

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage, and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

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Levels of Maternal Care: Obstetric Care Consensus No, 9 Summary.

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage, and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

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“New or not-so-new” labor management practices and cesarean delivery for arrest of progress.

Because nearly one-third of births in the United States are now delivered by cesarean-more than 1.27 million women each year-national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ? 6 cm cervical dilatation had been reached or labor had been stimulated for at least 6 hours.To determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation.Between 1 January 1999 and 31 December 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all liveborn, singleton, non-anomalous, cephalic gestations delivered by primary cesarean at ? 37 weeks. A cesarean was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ? 4 cm in the presence of uterine contractions.A total of 13,269 primary cesareans were available for analysis and 8,546 (65%) were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean. Of these cesareans for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ? 4 cm (active phase). Approximately two-thirds (N=5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached 6 cm or more cervical dilatation before cesarean was performed. Moreover, a total of 7440 (95%) of the 7827 women in active labor were ? 6 cm dilatation or had received labor stimulation ? 6 hours prior to cesarean for arrest of dilatation.Women undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women were ? 6 cm dilatation or had received labor stimulation ? 6 hours prior to cesarean for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates.

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Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease.

Though consensus guidelines on the management of cardiovascular disease (CVD) in pregnancy reserve cesarean delivery for obstetric indications, there is a paucity of data to support this approach.To compare cardiovascular and obstetric morbidity in women with cardiovascular disease (CVD) according to plan for vaginal birth or cesarean delivery.We assembled a prospective cohort of women delivering at an academic tertiary care center with a protocolized multidisciplinary approach to management of CVD between September 2011 and December 2016. Our practice is to encourage vaginal birth in women with CVD unless there is an obstetric indication for cesarean delivery. We allow women attempting vaginal birth a trial of Valsalva in the second stage with the ability to provide operative vaginal delivery if pushing leads to changes in hemodynamics or symptoms. Women were classified according to planned mode of delivery-either vaginal birth or cesarean delivery. We then used univariate analysis to compare adverse outcomes according to planned mode of delivery. The primary composite cardiac outcome of interest included sustained arrhythmia, heart failure, cardiac arrest, cerebral vascular accident, need for cardiac surgery or intervention, or death. Secondary obstetric and neonatal outcomes were also considered.We included 276 consenting women with congenital heart disease (68.5%), arrhythmias (11.2%), connective tissue disease (9.1%), cardiomyopathy (8.0%), valvular disease (1.4%) or vascular heart disease (1.8%) at or beyond 24 weeks gestation. Seventy-six percent (n=210) planned vaginal birth and 24% (n=66) planned cesarean delivery. Women planning vaginal birth had lower rates of left ventricular outflow tract obstruction, multiparity, and preterm delivery. All women attempting vaginal birth were allowed to Valsalva. Among planned vaginal deliveries 86.2% (n=181) were successful with a 9.5% operative vaginal delivery rate. Five women underwent operative vaginal delivery for the indication of cardiovascular disease without another obstetric indication at the discretion of the delivering provider. Four of these patients tolerated trials of Valsalva ranging from 15 to 75 minutes prior to delivery. Adverse cardiac outcomes were similar between planned vaginal birth and cesarean delivery groups (4.3% v. 3.0%, p=1). Rates of postpartum hemorrhage (1.9% v. 10.6%, p<0.01) and transfusion (1.9% v. 9.1%, p=0.01) were lower in the planned vaginal birth group. There were no differences in adverse cardiac, obstetric or neonatal outcomes in the cohort overall or the subset of women with high-risk CVD or a high burden of obstetric comorbidity.These findings suggest that cesarean delivery does not reduce adverse cardiovascular outcomes and lend support to a planned vaginal birth for the majority of women with CVD including those with high-risk disease.

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National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder.

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women’s Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

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Referral Patterns for the Evaluation of Asymptomatic Microscopic Hematuria in Women in a Single Health Care System: Room for Improvement.

To identify patterns of care for women referred for asymptomatic microhematuria in a single, hospital-based health care system and estimate the cost of unindicated evaluation.We conducted a retrospective study of 100 women with a diagnosis of asymptomatic microhematuria referred to a tertiary female pelvic medicine and reconstructive surgery practice. Our analysis focused on referral patterns by obstetrician-gynecologists and primary care physicians. Data analyzed included whether asymptomatic microhematuria was documented using urine microscopy (vs urine dipstick) and whether the urine microscopy correctly identified asymptomatic microhematuria with three red blood cells (RBCs).Forty-six patients were referred who met the American Urological Association’s guidelines for asymptomatic microhematuria with a workup estimated at $8,298 per patient. Fifty-four were referred to a female pelvic medicine and reconstructive surgery specialist despite clearly not meeting the American Urological Association’s definition of asymptomatic microhematuria. Of these, 33 patients were referred based on dipstick-positive results only, 11 were referred based on microscopic urinalysis demonstrating fewer than three RBCs per high-power field (HPF), and the remaining 10 patients were referred with urine microscopy demonstrating at least 3 RBC/HPF but in the setting of a clearly benign cause, such as infection or menstruation. The total estimated cost of the unnecessary asymptomatic microhematuria workup in patients who did not meet American Urological Association criteria for referral was $1,213 per patient.Fewer than half of the referrals for asymptomatic microhematuria were appropriate, leading to wasted and entirely preventable health care expenditures. This study highlights the need for education of health care providers making these referrals.

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