Faculty Bibliography

OBJECTIVE:To estimate the association between obstetric forceps volume and severe perineal lacerations or adverse neonatal outcomes. METHODS:This is a retrospective cohort of forceps deliveries performed at a tertiary care hospital. Obstetricians were grouped by quartile of forceps volume over the study time period. Severe (third- or fourth-degree) perineal lacerations and adverse neonatal outcomes were compared across quartiles. Individual patient characteristics were controlled for using multilevel multivariable analysis. This study had 90% power to detect a twofold difference in severe perineal lacerations between the first and fourth quartiles. Additional analyses were performed using physician years in practice or year of residency of the involved resident physicians. RESULTS:One hundred eighteen attending physicians (2,369 forceps deliveries) were included. The median (interquartile range) annual number of forceps per quartile was 1.3 (1.0-1.8), 3.8 (3.0-4.3), 6.3 (5.5-6.8), and 11.5 (9.8-17.3). The frequency of severe perineal lacerations from lowest to highest quartile was 29.9%, 27.5%, 33.3%, and 36.9% (P=.013). After adjusting for confounders, the relationship between volume quartile and severe perineal lacerations became nonsignificant. Although not powered to this outcome, the frequency of composite adverse neonatal outcome was not associated with volume quartile in either bivariate or multivariable analysis. Similarly, neither physician years of practice nor resident year was associated with severe perineal laceration. However, more experience as a resident was associated with a reduced odds of composite adverse neonatal outcomes. CONCLUSIONS:After controlling for patient factors, neither attending forceps volume nor physician years in practice was associated with severe perineal lacerations or composite neonatal injury. LEVEL OF EVIDENCE/METHODS:II.

OBJECTIVES/OBJECTIVE:To describe obstetric outcomes in women with a prior obstetric anal sphincter injury (OASIS) and to identify risk factors for recurrence. METHODS:A retrospective chart review of women who sustained an OASIS between November 2005 and March 2010 at a tertiary care hospital was performed to identify risk factors for recurrence. RESULTS:One thousand six hundred twenty-nine patients had an OASIS. Of these, 758 patients (90%) subsequently delivered during the aforementioned timeframe; 685 patients had a subsequent vaginal delivery. Of the women, 3.2% had a recurrent OASIS. Recurrence was associated with larger birth weight (27% ≥4000 g vs 11.6% <4000 g; P = 0.04) and delivery mode (25.0%, 12.5%, and 2.7% for forceps-assisted, vacuum-assisted, and spontaneous deliveries, respectively (P = 0.0001)), whereas a history of fourth-degree laceration, prior wound complication, or episiotomy at subsequent delivery were not (P = 0.5, P = 0.5, and P = 0.4, respectively). CONCLUSIONS:Recurrent OASIS occurred in a small percentage of women (3.2%) who subsequently delivered vaginally. Recurrent OASIS was associated with operative vaginal delivery and birth weight 4000 g or greater. Neither episiotomy at first delivery nor at subsequent delivery conferred an increased recurrence risk.

Female fertility declines dramatically with age, and childbearing at older maternal ages has significant medical consequences for mother and infant that are well-known to health professionals. Despite this, the average maternal age in the United States continues to rise. Many factors likely contribute to this secular trend; to date, no research has examined whether American women are aware of the complications of deferring conception and how this correlates with health literacy. The purpose of this study was to evaluate women's knowledge of the implications of delaying pregnancy. A structured, in-person interview was administered to 300 women between 20 and 50 years of age attending 1 of 2 gynecologic clinics at a single institution. Demographic information, medical history, and gynecologic history were obtained; and participants answered questions about the implications of aging for fertility and pregnancy outcome. Health literacy and numeracy were assessed. Participants demonstrated knowledge deficits about the implications of aging on fertility and pregnancy, and many were unfamiliar with success rates of infertility treatments. Several demographic factors correlated with knowledge; health literacy and numeracy were both important predictive variables. To the authors' knowledge, this is the first study of women's knowledge about fertility, aging, and their health literacy. Awareness of the importance of health literacy and numeracy should inform future educational efforts about fertility.

OBJECTIVE:To estimate the prevalence of postpartum obsessive-compulsive disorder (OCD) symptoms and to ascertain risk factors for this condition. STUDY DESIGN/METHODS:This is a prospective cohort of postpartum women carried out from June to September 2009. A total of 461 women were recruited after delivery at a tertiary care institution. Demographic, psychiatric, and obstetric information were collected from each participant. Patients were contacted at 2 weeks and at 6 months postpartum and completed screening tests for depression, anxiety, and OCD. RESULTS:Eleven percent of women screened positive for OCD symptoms at 2 weeks postpartum. At 6 months postpartum almost half of those women had persistent symptoms, and an additional 5.4% had developed new OCD symptoms. Concomitant positive screens for anxiety and depression were predictive factors for the development of OCD symptoms. CONCLUSION/CONCLUSIONS:Prior population-based studies estimate the prevalence of OCD to be approximately 2-3%. We found much higher rates among women in the postpartum period. The postpartum period is a high-risk time for the development of OCD symptoms. When such symptoms develop, they have a high likelihood of persisting for at least 6 months.

Annual surgeon case volume has been linked to patient outcome in a variety of surgical fields, although limited data focus on gynecologic surgery performed by general gynecologists. Herein we review the literature addressing the associations between intraoperative injury, postoperative morbidity, and resource use among surgeons performing a low vs high volume of hysterectomies. Although study design and populations differ, individual and composite morbidity outcomes consistently favored high-volume surgeons. Given the growing emphasis on competency-based evaluation in surgery, gynecology departments may soon consider volume requirements a component of privileging.

CONTEXT/BACKGROUND:Postpartum, diabetes insipidus (DI) can be part of Sheehan's syndrome or lymphocytic hypophysitis in combination with anterior pituitary hormone deficiencies. In contrast, acute onset of isolated DI in the postpartum period is unusual. CASE PRESENTATION/METHODS:This patient presented at 33 weeks gestation with placental abruption, prompting a cesarean delivery of twins. Immediately after delivery, she developed severe DI. The DI could be controlled with the vasopressinase-resistant 1-deamino-8-D-arginine vasopressin (DDAVP), but not with arginine vasopressin (AVP), and it resolved within a few weeks. OBJECTIVE:The aim of this study was to demonstrate that the postpartum DI in this patient was caused by the release of placental vasopressinase into the maternal bloodstream. METHODS AND RESULTS/RESULTS:Cells were transiently transfected with the AVP receptor 2 (AVPR2) and treated with either AVP or DDAVP in the presence of the patient's serum collected postpartum or 10 weeks after delivery. The response to the different treatments was evaluated by measuring the activity of a cAMP-responsive firefly luciferase reporter construct. The in vitro studies demonstrate that the patient's postpartum serum disrupts activation of the AVPR2 by AVP, but not by the vasopressinase-resistant DDAVP. CONCLUSIONS:Placental abruption can rarely be associated with acute postpartum DI caused by release of placental vasopressinase into the bloodstream. This clinical entity must be considered in patients with placental abruption and when evaluating patients presenting with DI after delivery.

OBJECTIVE:We sought to determine factors associated with perineal wound complications in women with obstetric anal sphincter injuries (OASIS). STUDY DESIGN/METHODS:A retrospective chart review of women who sustained an OASIS from Nov. 2, 2005, through March 1, 2010, was performed. RESULTS:In all, 1629 women sustained an OASIS; 909 had follow-up data. Wound complications (infection, breakdown, packing, operative intervention, secondary repair) occurred in 7.3% (n = 66) of patients. Smoking (odds ratio [OR], 4.04; 95% confidence interval [CI], 1.4-12.2; P = .01), increasing body mass index (OR, 1.06; 95% CI, 1.01-1.12; P = .04), fourth-degree laceration (OR, 1.89; 95% CI, 0.99-3.61; P = .05), operative vaginal delivery (OR, 1.76; 95% CI, 1.15-2.68; P = .009), and use of postpartum antibiotics (OR, 2.46; 95% CI, 1.11-5.63; P = .03) were associated with complications; intrapartum antibiotics were protective (OR, 0.29; 95% CI, 0.14-0.59; P = .001). In all, 44% of patients with a complication (n = 29) required hospital readmission; most (72%) were in the first 2 postpartum weeks. CONCLUSION/CONCLUSIONS:Wound complications after OASIS are associated with modifiable factors and often require hospital readmission.

BACKGROUND:National organizations historically focused on increasing use of effective services are now attempting to identify and discourage use of low-value services. Electronic health records (EHRs) could be used to measure use of low-value services, but few studies have examined this. The aim of the study was to: (1) determine if EHR data can be used to identify women eligible for an extended Pap testing interval; (2) determine the proportion of these women who received a Pap test sooner than recommended; and (3) assess the consequences of these low-value Pap tests. METHODS:Electronic query of EHR data identified women aged 30-65 years old who were at low-risk of cervical cancer and therefore eligible for an extended Pap testing interval of 3 years (as per professional society guidelines). Manual chart review assessed query accuracy. The use of low-value Pap tests (ie, those performed sooner than recommended) was measured, and adverse consequences of low-value Pap tests (ie, colposcopies performed as a result of low-value Pap tests) were identified. RESULTS:Manual chart review confirmed query accuracy. Two-thirds (1120/1705) of low-risk women received a Pap test sooner than recommended, and 21 colposcopies were performed as a result of this low-value Pap testing. CONCLUSION/CONCLUSIONS:Secondary analysis of EHR data can accurately measure the use of low-value services such as Pap testing performed sooner than recommended in women at low risk of cervical cancer. Similar application of our methodology could facilitate efforts to simultaneously improve quality and decrease costs, maximizing value in the US healthcare system.