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VIDEO: BMI helps predict bone fragility in obese patients
BOSTON – An index that takes into account the ratio between body mass index (BMI) and bone mineral density (BMD) correlated well with trabecular bone scores, a newer assessment of bone fragility. The index may help predict risk for fragility fractures in individuals with obesity when trabecular bone scores are not available.
“Obesity is traditionally thought to be protective against bone fractures,” said Mikiko Watanabe, MD, an endocrinologist at Sapienza University of Rome. “But recent evidence suggests that this is not entirely true, especially in morbidly obese patients.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Lumbar spine BMD alone may not accurately capture bone fragility in patients with obesity, said Dr. Watanabe in an interview at the annual meeting of the American Association of Clinical Endocrinologists.
Adding the trabecular bone score (TBS) to BMD gives additional information about bone microarchitecture, refining risk assessment for fragility fractures. This newer technology, however, may not be readily available and may be associated with extra cost.
Accordingly, said Dr. Watanabe, the study’s senior investigator, Sapienza University’s Carla Lubrano, MD, had the idea to index bone density to BMI, and then see how well the ratio correlated to TBS; obesity is known to be associated with lower TBS scores, indicating increased bone fragility.
Living in Italy, with relatively fewer medical resources available, “We were trying to find some readily available index that could predict the risk of fracture as well as the indexes that are around right now,” said Dr. Watanabe.
“We did find some very interesting data in our population of over 2,000 obese patients living in Rome,” she said. “We do confirm something from the literature, where BMD tends to go high with increasing BMI.” Further, the relatively weak correlation between TBS and BMI was confirmed in the investigators’ work (r = 0.3).
“If you correct the BMD by BMI – so if you use our index – then the correlation becomes more stringent, and definitely so much better,” she said (r = 0.54).
Dr. Watanabe and her colleagues also conducted an analysis to see if there were differences between participants with and without metabolic syndrome. The 45.7% of participants who had metabolic syndrome had similar lumbar spine BMD scores to the rest of the cohort (1.067 versus 1.063 g/cm2, P = .50754).
However, both the TBS and BMD/BMI ratio were significantly lower for those with metabolic syndrome than for the metabolically healthy participants. The TBS, as expected, was 1.21 in patients with metabolic syndrome, and 1.31 in patients without metabolic syndrome; the BMD/BMI ratio followed the same pattern, with ratios of 0.28 for those with, and 0.30 for those without, metabolic syndrome (P less than .00001 for both).
Dr. Watanabe said that she and her associates are continuing research “to see whether our ratio is actually able to predict the risk of fractures." The hope, she said, is to use the BMD/BMI index together with or instead of TBS to better assess bone strength in patients with obesity.
Dr. Watanabe reported that she had no relevant conflicts of interest.
BOSTON – An index that takes into account the ratio between body mass index (BMI) and bone mineral density (BMD) correlated well with trabecular bone scores, a newer assessment of bone fragility. The index may help predict risk for fragility fractures in individuals with obesity when trabecular bone scores are not available.
“Obesity is traditionally thought to be protective against bone fractures,” said Mikiko Watanabe, MD, an endocrinologist at Sapienza University of Rome. “But recent evidence suggests that this is not entirely true, especially in morbidly obese patients.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Lumbar spine BMD alone may not accurately capture bone fragility in patients with obesity, said Dr. Watanabe in an interview at the annual meeting of the American Association of Clinical Endocrinologists.
Adding the trabecular bone score (TBS) to BMD gives additional information about bone microarchitecture, refining risk assessment for fragility fractures. This newer technology, however, may not be readily available and may be associated with extra cost.
Accordingly, said Dr. Watanabe, the study’s senior investigator, Sapienza University’s Carla Lubrano, MD, had the idea to index bone density to BMI, and then see how well the ratio correlated to TBS; obesity is known to be associated with lower TBS scores, indicating increased bone fragility.
Living in Italy, with relatively fewer medical resources available, “We were trying to find some readily available index that could predict the risk of fracture as well as the indexes that are around right now,” said Dr. Watanabe.
“We did find some very interesting data in our population of over 2,000 obese patients living in Rome,” she said. “We do confirm something from the literature, where BMD tends to go high with increasing BMI.” Further, the relatively weak correlation between TBS and BMI was confirmed in the investigators’ work (r = 0.3).
“If you correct the BMD by BMI – so if you use our index – then the correlation becomes more stringent, and definitely so much better,” she said (r = 0.54).
Dr. Watanabe and her colleagues also conducted an analysis to see if there were differences between participants with and without metabolic syndrome. The 45.7% of participants who had metabolic syndrome had similar lumbar spine BMD scores to the rest of the cohort (1.067 versus 1.063 g/cm2, P = .50754).
However, both the TBS and BMD/BMI ratio were significantly lower for those with metabolic syndrome than for the metabolically healthy participants. The TBS, as expected, was 1.21 in patients with metabolic syndrome, and 1.31 in patients without metabolic syndrome; the BMD/BMI ratio followed the same pattern, with ratios of 0.28 for those with, and 0.30 for those without, metabolic syndrome (P less than .00001 for both).
Dr. Watanabe said that she and her associates are continuing research “to see whether our ratio is actually able to predict the risk of fractures." The hope, she said, is to use the BMD/BMI index together with or instead of TBS to better assess bone strength in patients with obesity.
Dr. Watanabe reported that she had no relevant conflicts of interest.
BOSTON – An index that takes into account the ratio between body mass index (BMI) and bone mineral density (BMD) correlated well with trabecular bone scores, a newer assessment of bone fragility. The index may help predict risk for fragility fractures in individuals with obesity when trabecular bone scores are not available.
“Obesity is traditionally thought to be protective against bone fractures,” said Mikiko Watanabe, MD, an endocrinologist at Sapienza University of Rome. “But recent evidence suggests that this is not entirely true, especially in morbidly obese patients.”
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Lumbar spine BMD alone may not accurately capture bone fragility in patients with obesity, said Dr. Watanabe in an interview at the annual meeting of the American Association of Clinical Endocrinologists.
Adding the trabecular bone score (TBS) to BMD gives additional information about bone microarchitecture, refining risk assessment for fragility fractures. This newer technology, however, may not be readily available and may be associated with extra cost.
Accordingly, said Dr. Watanabe, the study’s senior investigator, Sapienza University’s Carla Lubrano, MD, had the idea to index bone density to BMI, and then see how well the ratio correlated to TBS; obesity is known to be associated with lower TBS scores, indicating increased bone fragility.
Living in Italy, with relatively fewer medical resources available, “We were trying to find some readily available index that could predict the risk of fracture as well as the indexes that are around right now,” said Dr. Watanabe.
“We did find some very interesting data in our population of over 2,000 obese patients living in Rome,” she said. “We do confirm something from the literature, where BMD tends to go high with increasing BMI.” Further, the relatively weak correlation between TBS and BMI was confirmed in the investigators’ work (r = 0.3).
“If you correct the BMD by BMI – so if you use our index – then the correlation becomes more stringent, and definitely so much better,” she said (r = 0.54).
Dr. Watanabe and her colleagues also conducted an analysis to see if there were differences between participants with and without metabolic syndrome. The 45.7% of participants who had metabolic syndrome had similar lumbar spine BMD scores to the rest of the cohort (1.067 versus 1.063 g/cm2, P = .50754).
However, both the TBS and BMD/BMI ratio were significantly lower for those with metabolic syndrome than for the metabolically healthy participants. The TBS, as expected, was 1.21 in patients with metabolic syndrome, and 1.31 in patients without metabolic syndrome; the BMD/BMI ratio followed the same pattern, with ratios of 0.28 for those with, and 0.30 for those without, metabolic syndrome (P less than .00001 for both).
Dr. Watanabe said that she and her associates are continuing research “to see whether our ratio is actually able to predict the risk of fractures." The hope, she said, is to use the BMD/BMI index together with or instead of TBS to better assess bone strength in patients with obesity.
Dr. Watanabe reported that she had no relevant conflicts of interest.
REPORTING FROM AACE 2018
VIDEO: Promoting upright and mobile labor could save over $700 million yearly
AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.
Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.
“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”
The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.
Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.
For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.
The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.
Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”
These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.
Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.
“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”
Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”
Ms. Hersh and her colleagues had no relevant financial disclosures.
SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.
AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.
Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.
“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”
The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.
Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.
For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.
The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.
Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”
These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.
Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.
“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”
Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”
Ms. Hersh and her colleagues had no relevant financial disclosures.
SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.
AUSTIN, TEX. – Encouraging an upright position and allowing mobility during labor is a cost-effective intervention that could save hundreds of millions of dollars while preventing cesarean deliveries, uterine rupture, and maternal deaths, according to a recent cost-effectiveness study.
Alyssa Hersh, a medical student at Oregon Health & Sciences University, Portland, developed the analysis using an innovative model that examines the costs associated not just with the first delivery, but also the probable next delivery.
“Our model was dependent on the ability to reduce cesareans and also reduce labor times,” said Ms. Hersh in a video interview. “So this reduction in cesareans allowed women to avoid having an increased risk of uterine rupture, of emergent hysterectomy, and other downstream consequences.”
The “two-delivery model” takes into account the average number of births per woman in the United States, “such that the risks, benefits, and costs are framed within the public health perspective of the average U.S. childrearing woman’s entire reproductive course,” she and her coauthors wrote in the poster accompanying the presentation at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
This model captures the downstream effects of a first cesarean delivery on the next delivery, for example, providing a more realistic picture of the true costs of cesarean delivery for a nulliparous female.
Some of the known benefits of being upright and mobile during labor, Ms. Hersh said, include shortened labor and reduced risk for cesarean delivery. Cost-effectiveness of this approach for low-risk women, she said, had not been fully explored.
For the analysis, Ms. Hersh and her colleagues used a theoretical cohort of 1.8 million women, approximating the number of nulliparous term deliveries in the United States each year. They used rates of cesarean delivery for women laboring in upright and recumbent positions that were drawn from the literature, but lower than national averages: 7.8% of recumbent women and 5.4% of upright women went on to cesarean delivery in the model used by the investigators.
The outcomes tracked in the analysis included cesarean delivery, uterine rupture, hysterectomy attributed to uterine rupture, costs, and quality-adjusted life years (QALYs). All of the outcomes were tracked for the index pregnancy and the second pregnancy.
Ms. Hersh and her coinvestigators found that in the theoretical cohort, “laboring upright led to 64,890 fewer cesarean deliveries, 15 fewer maternal deaths, 113 fewer uterine ruptures, and 30 fewer hysterectomies.”
These reductions were associated with a savings for this cohort of $785 million, and an increase in QALYs of 2,142.
Using Monte Carlo simulation techniques to ascertain the effect of varying cesarean rates and other components of the model, Ms. Hersh and her colleagues found that the model remained cost-effective even with variation in all of the inputs.
“Laboring upright is a no-cost intervention that leads to improved outcomes, decreased costs, and increased QALYs during a woman’s first and second deliveries,” wrote Ms. Hersh and her associates. “This model argues for increasing systems factors that support women to be upright and mobile during labor, and in doing so, promoting improved health for our patients.”
Said Ms. Hersh, “This is an easy way for hospitals to adopt policies that can enable women to have improved outcomes.”
Ms. Hersh and her colleagues had no relevant financial disclosures.
SOURCE: Hersh A et al. ACOG 2018. Abstract 34C.
REPORTING FROM ACOG 2018
VIDEO: Three questions with Aaron B. Caughey, MD
AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.
OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?
DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.
So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.
If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.
When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?
Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.
OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?
DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.
A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.
So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.
And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.
In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?
Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.
We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.
Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.
I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.
OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?
DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.
But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.
What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.
For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.
So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.
Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.
AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.
OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?
DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.
So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.
If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.
When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?
Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.
OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?
DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.
A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.
So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.
And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.
In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?
Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.
We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.
Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.
I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.
OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?
DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.
But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.
What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.
For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.
So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.
Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.
AUSTIN, TEX. – This interview was conducted at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. It has been edited for length and clarity.
OB.GYN. NEWS: Here at ACOG, there were two studies from your research group at Oregon Health & Sciences University, Portland, that examined the cost-effectiveness of pregnancy interventions using a “two-delivery” model. Could you explain a little more about what that is, and how you arrived at this model?
DR. CAUGHEY: We’ve been working on decision analytics and cost-effectiveness studies of a number of ways to approach pregnancy, whether it be complicated pregnancies or uncomplicated normal pregnancies.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
One of the things that we think is really important to think about is the impact of management and outcomes in the current pregnancy, and how it might affect future pregnancies.
So, for example, if you have a vaginal delivery this time, that makes you multiparous with a prior vaginal delivery next time; that is kind of the goal in pregnancy. It just makes all future labor and delivery experiences so much easier. Whereas, if you have a prior C-section, we all know that now you’re high risk. Everybody gets nervous about you. Are you going to get a trial of labor? Can you find a hospital that will do a trial of labor? And there are all these downstream implications of the delivery in the first pregnancy.
If you think about it, there are a number of ways that we can manage the first pregnancy. There are a number of risk factors for increasing risk for cesarean delivery. And we can include those in models that are considered in downstream pregnancies. And so we’ve been doing that increasingly.
When we think about our vaginal birth after cesarean models, we had two presentations that considered that. One was how we manage the maternal position in labor, and the other was how we use doulas in labor. You think, well gosh, we’re spending money on this doula in this pregnancy – that’s a certain expenditure. Is it worth it?
Part of “Is it worth it?” is not just the current pregnancy, but the downstream pregnancy as well.
OB.GYN. NEWS: What has sparked your interest in looking at obstetric care delivery in this way?
DR. CAUGHEY: I did my PhD in health economics. I began it as a 3rd-year maternal fetal medicine fellow and during my early career as an assistant professor at the University of California, San Francisco.
A lot of people think that economics in general is kind of about finance. Actually, microeconomics in particular is about the allocation of scarce resources to optimize utility – utility as general wellbeing or happiness.
So people will say that this thing, or that intervention, is cost effective, and often what they think they mean is, “It saves money.” But most things don’t save money. Most things in health care cost money. There are a few things in health care that do save money – vaccinations, contraception. Contraception actually saves money – but most things cost money. We have to spend money to get something right.
And the way we do that in health economics is that we think we’re going to get some happiness, some utility, some better outcomes from the money we’re putting in. One of the things that we don’t do very well as a species is think about these downstream outcomes.
In our models, when we think about morbidity and mortality we’re incorporating two and three pregnancy models. Think about what happens in the future, and then think about if we do something – if we spend money on an induction of labor or having a doula or something like that, is it worth it for what we get?
Antenatal testing, for example. Or, is it worth it for you to be testing people with diabetes once a week? Twice a week? More? Less? Part of it is figuring out what you’ll get for it. The measurement of what you get for it is called quality-adjusted life years, and that’s the measure of happiness multiplied times life expectancy.
We incorporate that in standard ways to build these models, to help us make decisions around best practices. Now, the economics piece of it probably matters. We’re the richest country that’s probably ever going to be – not just ever has been but probably ever going to be – the way we’re using up scarce resources to beat the band.
Yet, we still have an issue of allocation. We have people that have less; we have enormous disparities, whether it be racial and ethnic disparities, or socioeconomic disparities. And so we need to figure out ways to be more efficient and allocate those scarce resources properly to the outcomes that will be the best.
I think that’s what we’re working on: creating models to think about how to allocate those scarce resources.
OB.GYN. NEWS: How can a busy obstetrician think about the work you’re doing and incorporate it into her practice on a day-to-day basis?
DR. CAUGHEY: As an economist, I want to step back from time to time and think about public health and allocation of scarce resources.
But as a busy practicing clinician, I don’t necessarily want you consciously to think about cost. There are people who will push back on this and say, “Oh no, we should always be cost conscious.” Actually, what I really want you to do is incorporate best practices into the care of the patient at that moment, and do the thing that improves her outcomes best at that moment.
What we want to do, instead, is design systems that will properly incentivize. Incentivize doesn’t mean you think, “Oh gosh, if I do this thing I’m going to get an extra dollar.” It means subconsciously that those incentives are there, and those incentives don’t have to just be about dollars. Often in our field, they’re about time – what takes less time and more time to do something. So if we provide little extra roadblocks, then you’re more likely to go the other way and do something else.
For example: the hard stop. We did all this research in the 2000s to show that you probably shouldn’t deliver babies just for fun before 39 weeks’ gestational age. There should be an indication. If we don’t allow any hard stop, if we don’t block the pathway, then patients are pushing us, they’re uncomfortable, they’re like, “Just deliver me.” So we said, “No, no, no, we’re going to block this. In fact, we’re actually going to provide a hard stop reimbursement-wise. And medical directors of hospitals are going to have to preapprove.” And so that provides a blockade, and makes it easier just not to do it.
So I think that’s what we want: At the bedside and in your office, we want clinicians to still just be really good doctors. But then, to get involved and help design systems to incentivize us to do the right things.
Aaron B. Caughey, MD, PhD, is professor and chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health & Science University, Portland, and is a member of the U.S. Preventive Services Task Force. He reported that he had no relevant financial disclosures.
REPORTING FROM ACOG 2018
Structured PPH management cuts severe hemorrhage
AUSTIN, TEX. – Taking a page from critical care, an obstetrical team that implemented a checklist-based management protocol for postpartum hemorrhage saw a significant drop in severe obstetric hemorrhage, with numeric reductions in other maternal outcomes.
The protocol, piloted in a single hospital, is now being rolled out in all 28 hospitals of a large, multistate health care system.
“Our medical critical care colleagues long ago abandoned the notion that physician judgment should guide the provision of basic and advanced cardiac life support in favor of highly specific and uniform protocols,” wrote first author Rachael Smith, DO, and her coauthors in the poster accompanying the presentation at the annual clinical and scientific meeting of the American Society of Obstetricians and Gynecologists.
“While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity is necessary to significantly impact morbidity and mortality,” they wrote.
When comparing outcomes for 9 matched months before and after implementation of the protocol, Dr. Smith and her collaborators found that rates of severe postpartum hemorrhage (PPH), defined as estimated blood loss (EBL) of at least 2,500 cc, were halved, dropping from 18% to 9% (P = .035).
“Patients with life-threatening illnesses seem to do better when their providers are following very structured, regimented protocols, and [advanced cardiac life support protocols] is probably the best example of that,” said Ms. Hermann.
They then produced a training video to educate nursing and house staff and attending physicians about the new checklist-based protocol. In this way, each team member would understand the rationale behind the checklist, know the steps in the care pathway, and understand his or her specific role.
The protocol, which begins when uterine atony is suspected, first calls the physician to the patient room, along with a second nurse to be the recorder and timekeeper. Among other duties, this individual tracks blood loss during a maternal bleeding event, weighing linens and sponges, and alerting the team when EBL exceeds 500, 1,000, and 1,500 cc, or when pulse or blood pressure fall outside of designated parameters.
“Having a second nurse in the room who is keeping the team on track, saying ‘Hey, we’re at this much blood loss; these are the next steps,’ and who is recording everything” can avert the sense of chaos that sometimes occurs in critical scenarios, said Ms. Hermann.
When stage 1 PPH (EBL of at least 500 cc) has occurred, a team lead is called. At this point, a PPH cart containing necessary equipment and medication, including uterotonics, is brought to the room.
Having the uterotonic kit in the room, said Ms. Hermann, is a key component of the protocol. “Having a kit you can wheel into the room, and having everything you need to manage PPH” saves critical time, she said. “The nurses aren’t running back and forth to the Pyxis to get the next uterotonic that you need.”
If EBL of at least 1,500 cc is reached, a third nurse is called and the obstetric rapid-response team is activated, meaning that a code cart and additional supportive equipment are also brought to the patient.
The checklist paperwork lays out all interventions, including uterotonic dosing, timing, and contraindications. It also includes differential diagnoses for PPH, and provides directions for visual estimation of blood loss.
Finally, a structured debrief takes place after each PPH, said Ms. Hermann.
The study included women who experienced PPH during matched 9-month periods before and after the PPH protocol implementation. PPH was defined as EBL of at least 500 cc for vaginal delivery, and 1,000 cc for cesarean delivery. Women were excluded if they delivered before 22 weeks’ gestation, or if there was a diagnosis of or suspicion for placenta accreta, increta, or percreta.
A total of 147 women were in the preintervention group; of these, 98 (66%) had vaginal deliveries. In the postintervention group, 110 out of150 women (73%) had vaginal deliveries.
In addition to the significant reduction in severe PPH that followed implementation of the protocol, numeric reductions were also seen in other surrogate measures of maternal morbidity, including stage 1 hemorrhage, the need for transfusion, surgical interventions, intensive care admissions, and length of stay.
“Across all of these surrogates, we saw an improvement in our postprotocol patients,” said Ms. Hermann. “We think that the reason the rest of them weren’t statistically significant was due to lack of power” in the single-center study, she said. “The clinical trend speaks for itself.”
Once the protocol is rolled out in all 28 hospitals, she anticipates seeing statistics that confirm what the investigators are already seeing clinically.
SOURCE: Smith R et al. ACOG 2018, Abstract 26R.
AUSTIN, TEX. – Taking a page from critical care, an obstetrical team that implemented a checklist-based management protocol for postpartum hemorrhage saw a significant drop in severe obstetric hemorrhage, with numeric reductions in other maternal outcomes.
The protocol, piloted in a single hospital, is now being rolled out in all 28 hospitals of a large, multistate health care system.
“Our medical critical care colleagues long ago abandoned the notion that physician judgment should guide the provision of basic and advanced cardiac life support in favor of highly specific and uniform protocols,” wrote first author Rachael Smith, DO, and her coauthors in the poster accompanying the presentation at the annual clinical and scientific meeting of the American Society of Obstetricians and Gynecologists.
“While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity is necessary to significantly impact morbidity and mortality,” they wrote.
When comparing outcomes for 9 matched months before and after implementation of the protocol, Dr. Smith and her collaborators found that rates of severe postpartum hemorrhage (PPH), defined as estimated blood loss (EBL) of at least 2,500 cc, were halved, dropping from 18% to 9% (P = .035).
“Patients with life-threatening illnesses seem to do better when their providers are following very structured, regimented protocols, and [advanced cardiac life support protocols] is probably the best example of that,” said Ms. Hermann.
They then produced a training video to educate nursing and house staff and attending physicians about the new checklist-based protocol. In this way, each team member would understand the rationale behind the checklist, know the steps in the care pathway, and understand his or her specific role.
The protocol, which begins when uterine atony is suspected, first calls the physician to the patient room, along with a second nurse to be the recorder and timekeeper. Among other duties, this individual tracks blood loss during a maternal bleeding event, weighing linens and sponges, and alerting the team when EBL exceeds 500, 1,000, and 1,500 cc, or when pulse or blood pressure fall outside of designated parameters.
“Having a second nurse in the room who is keeping the team on track, saying ‘Hey, we’re at this much blood loss; these are the next steps,’ and who is recording everything” can avert the sense of chaos that sometimes occurs in critical scenarios, said Ms. Hermann.
When stage 1 PPH (EBL of at least 500 cc) has occurred, a team lead is called. At this point, a PPH cart containing necessary equipment and medication, including uterotonics, is brought to the room.
Having the uterotonic kit in the room, said Ms. Hermann, is a key component of the protocol. “Having a kit you can wheel into the room, and having everything you need to manage PPH” saves critical time, she said. “The nurses aren’t running back and forth to the Pyxis to get the next uterotonic that you need.”
If EBL of at least 1,500 cc is reached, a third nurse is called and the obstetric rapid-response team is activated, meaning that a code cart and additional supportive equipment are also brought to the patient.
The checklist paperwork lays out all interventions, including uterotonic dosing, timing, and contraindications. It also includes differential diagnoses for PPH, and provides directions for visual estimation of blood loss.
Finally, a structured debrief takes place after each PPH, said Ms. Hermann.
The study included women who experienced PPH during matched 9-month periods before and after the PPH protocol implementation. PPH was defined as EBL of at least 500 cc for vaginal delivery, and 1,000 cc for cesarean delivery. Women were excluded if they delivered before 22 weeks’ gestation, or if there was a diagnosis of or suspicion for placenta accreta, increta, or percreta.
A total of 147 women were in the preintervention group; of these, 98 (66%) had vaginal deliveries. In the postintervention group, 110 out of150 women (73%) had vaginal deliveries.
In addition to the significant reduction in severe PPH that followed implementation of the protocol, numeric reductions were also seen in other surrogate measures of maternal morbidity, including stage 1 hemorrhage, the need for transfusion, surgical interventions, intensive care admissions, and length of stay.
“Across all of these surrogates, we saw an improvement in our postprotocol patients,” said Ms. Hermann. “We think that the reason the rest of them weren’t statistically significant was due to lack of power” in the single-center study, she said. “The clinical trend speaks for itself.”
Once the protocol is rolled out in all 28 hospitals, she anticipates seeing statistics that confirm what the investigators are already seeing clinically.
SOURCE: Smith R et al. ACOG 2018, Abstract 26R.
AUSTIN, TEX. – Taking a page from critical care, an obstetrical team that implemented a checklist-based management protocol for postpartum hemorrhage saw a significant drop in severe obstetric hemorrhage, with numeric reductions in other maternal outcomes.
The protocol, piloted in a single hospital, is now being rolled out in all 28 hospitals of a large, multistate health care system.
“Our medical critical care colleagues long ago abandoned the notion that physician judgment should guide the provision of basic and advanced cardiac life support in favor of highly specific and uniform protocols,” wrote first author Rachael Smith, DO, and her coauthors in the poster accompanying the presentation at the annual clinical and scientific meeting of the American Society of Obstetricians and Gynecologists.
“While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity is necessary to significantly impact morbidity and mortality,” they wrote.
When comparing outcomes for 9 matched months before and after implementation of the protocol, Dr. Smith and her collaborators found that rates of severe postpartum hemorrhage (PPH), defined as estimated blood loss (EBL) of at least 2,500 cc, were halved, dropping from 18% to 9% (P = .035).
“Patients with life-threatening illnesses seem to do better when their providers are following very structured, regimented protocols, and [advanced cardiac life support protocols] is probably the best example of that,” said Ms. Hermann.
They then produced a training video to educate nursing and house staff and attending physicians about the new checklist-based protocol. In this way, each team member would understand the rationale behind the checklist, know the steps in the care pathway, and understand his or her specific role.
The protocol, which begins when uterine atony is suspected, first calls the physician to the patient room, along with a second nurse to be the recorder and timekeeper. Among other duties, this individual tracks blood loss during a maternal bleeding event, weighing linens and sponges, and alerting the team when EBL exceeds 500, 1,000, and 1,500 cc, or when pulse or blood pressure fall outside of designated parameters.
“Having a second nurse in the room who is keeping the team on track, saying ‘Hey, we’re at this much blood loss; these are the next steps,’ and who is recording everything” can avert the sense of chaos that sometimes occurs in critical scenarios, said Ms. Hermann.
When stage 1 PPH (EBL of at least 500 cc) has occurred, a team lead is called. At this point, a PPH cart containing necessary equipment and medication, including uterotonics, is brought to the room.
Having the uterotonic kit in the room, said Ms. Hermann, is a key component of the protocol. “Having a kit you can wheel into the room, and having everything you need to manage PPH” saves critical time, she said. “The nurses aren’t running back and forth to the Pyxis to get the next uterotonic that you need.”
If EBL of at least 1,500 cc is reached, a third nurse is called and the obstetric rapid-response team is activated, meaning that a code cart and additional supportive equipment are also brought to the patient.
The checklist paperwork lays out all interventions, including uterotonic dosing, timing, and contraindications. It also includes differential diagnoses for PPH, and provides directions for visual estimation of blood loss.
Finally, a structured debrief takes place after each PPH, said Ms. Hermann.
The study included women who experienced PPH during matched 9-month periods before and after the PPH protocol implementation. PPH was defined as EBL of at least 500 cc for vaginal delivery, and 1,000 cc for cesarean delivery. Women were excluded if they delivered before 22 weeks’ gestation, or if there was a diagnosis of or suspicion for placenta accreta, increta, or percreta.
A total of 147 women were in the preintervention group; of these, 98 (66%) had vaginal deliveries. In the postintervention group, 110 out of150 women (73%) had vaginal deliveries.
In addition to the significant reduction in severe PPH that followed implementation of the protocol, numeric reductions were also seen in other surrogate measures of maternal morbidity, including stage 1 hemorrhage, the need for transfusion, surgical interventions, intensive care admissions, and length of stay.
“Across all of these surrogates, we saw an improvement in our postprotocol patients,” said Ms. Hermann. “We think that the reason the rest of them weren’t statistically significant was due to lack of power” in the single-center study, she said. “The clinical trend speaks for itself.”
Once the protocol is rolled out in all 28 hospitals, she anticipates seeing statistics that confirm what the investigators are already seeing clinically.
SOURCE: Smith R et al. ACOG 2018, Abstract 26R.
REPORTING FROM ACOG 2018
Key clinical point: Indicators of maternal morbidity decreased after a postpartum hemorrhage checklist was implemented.
Major finding: Severe postpartum hemorrhage rates fell from 18% to 9% (P = .035).
Study details: A prospective pre/post implementation study of 297 women experiencing postpartum hemorrhage.
Disclosures: The study authors reported no relevant financial conflicts of interest.
Source: Smith R et al. ACOG 2018, Abstract 26R.
VIDEO: Few ob.gyns. asking in detail about sexual behavior
AUSTIN, TEX. – Patients in an urban practice were comfortable discussing sexual practices, even less traditional behaviors such as use of sex toys and “hook-up” apps, with their providers, according to results of a recent survey. The survey also found that ob.gyns. often weren’t asking about sexual behaviors at all.
“We wanted to find out what sexual behaviors our patients were participating in, and if their providers were asking them about those behaviors,” said Casuarina Hart, MD, chief ob.gyn. resident at Icahn School of Medicine at Mount Sinai, New York.
The survey also sought to determine whether patients were comfortable with being asked detailed questions about their sexual behavior, she said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
A total of 207 anonymous paper-and-pencil surveys were completed by patients who attended Mount Sinai ob.gyn. clinics, as well as private practices where ob.gyns. had Mount Sinai affiliations. “Our patients were very diverse,” Dr. Hart said in a video interview. About a quarter were white, a quarter were African American, and one-third were Hispanic. The average age of respondents was 33 years.
Dr. Hart's interview:
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
In addition to asking about participation in vaginal, oral, and anal sex, Dr. Hart and her coauthors asked about “more interesting sexual behaviors, from the use of sex toys to different ‘hook-up’ apps,” she said.
Among this group of urban respondents, participation in vaginal and oral sex was about at the national average. Anal sex participation, though, was 6%-8% higher than the national average, said Dr. Hart. This difference is important, she said, because there is “different screening and counseling for those patients.”
When Dr. Hart and her colleagues looked at the next phase of the survey, they found that fewer than half of patients said that providers were asking about sexual behaviors – and only about half were asking about condom use. When it came to being asked about participation in anal sex and oral sex, about one in five patients reported that their providers had broached the topics.
The investigators found that age had little to do with reported participation in sexual behaviors – with two exceptions. Patients who reported using sex toys were, on average, older than were those who never used them (34.3 vs. 30.7 years, P = .01). Conversely, those who used ‘hook-up’ apps were younger than were never-users (28.3 vs. 33.7 years, P = .0002).
“I found that less than 60% of my patients were regularly using condoms, and less than 50% of patients were ever asked by their provider about condom use. That was the most shocking finding that I had,” said Dr. Hart.
“The biggest thing is, patients are comfortable,” said Dr. Hart. “Around 90% of patients are comfortable discussing anything from sex toys, vaginal sex, to anal sex – but providers aren’t asking about them. And they really should,” to optimize screening for sexually transmitted diseases and cancer, and to provide thorough counseling about safe sex practices, she said.
What about the physician perspective? Maria Kon, MD, a Mount Sinai ob.gyn., and her collaborators received responses to a survey from 90 physicians, finding that most did not routinely ask about sexual orientation, sexual problems, or satisfaction. Further, one in four respondents reported disapproving of their patients’ sexual practices.
Asking about sexual practices is important not just in the context of reproductive health and disease prevention, but also to the “well-being of a woman in general, which is very important if you want to be a good doctor,” Dr. Kon said in a video interview.
Dr. Kon's interview:
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Links to the online survey were sent to ob.gyn. residents, fellows, and attending physicians in New York. Three-quarters of respondents were female, and almost half (46%) were aged 25-30 years; 59% were in postgraduate year 1-4. Most were white (69%) and heterosexual (87%).
“Years of training improve the level of comfort” in discussing specific sexual practices, Dr. Kon and her colleagues wrote in the poster accompanying their presentation at the meeting. “What we found, actually, is that people who are in practice longer were more comfortable talking about certain topics, but not all of them,” said Dr. Kon.
The investigators found that respondents who were in their 5th postgraduate year and beyond were significantly more comfortable discussing sex with elderly patients, talking about masturbation and sex toys, and talking about dyspareunia or libido problems (P value for being either “comfortable” or “very comfortable,” .0104, .0422, and .003, respectively). On the other hand, experience didn’t make a difference in the level of comfort with addressing a transgender person.
“Gender has no effect on the level of comfort,” the investigators wrote. They found no significant differences in any of these domains between male and female respondents.
The survey also asked ob.gyns. whether they would like more education about sexual behavior, and the answer was “yes.” About four in five respondents wanted to know more about the topics raised in the survey, which also asked about comfort in talking about sexual orientation and gender identity. About the same number think that their sexual history taking could be more detailed.
In terms of how ob.gyns. responding to the survey would like to receive more information and education, almost all (94%) said they would appreciate receiving more formal lectures about sexual practices. One third said they would like to educate themselves about trends in sexual behavior.
“Based on the survey responses, it seems that people would prefer for official lectures to be included in the curriculum,” said Dr. Kon, noting that required medical school sexual education is currently brief, with a focus on pregnancy and disease prevention and abortion. “In residency, we really don’t have much education either,” she said, adding that more formal education, as in grand rounds, “would highly benefit us as doctors who can relate to patients, who are comfortable talking to women about their health and well-being.”
Dr. Kon and Dr. Hart reported no relevant disclosures.
SOURCE: Hart C et al. and Kon M et al. ACOG 2018. Abstracts 26Q and 11M.
AUSTIN, TEX. – Patients in an urban practice were comfortable discussing sexual practices, even less traditional behaviors such as use of sex toys and “hook-up” apps, with their providers, according to results of a recent survey. The survey also found that ob.gyns. often weren’t asking about sexual behaviors at all.
“We wanted to find out what sexual behaviors our patients were participating in, and if their providers were asking them about those behaviors,” said Casuarina Hart, MD, chief ob.gyn. resident at Icahn School of Medicine at Mount Sinai, New York.
The survey also sought to determine whether patients were comfortable with being asked detailed questions about their sexual behavior, she said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
A total of 207 anonymous paper-and-pencil surveys were completed by patients who attended Mount Sinai ob.gyn. clinics, as well as private practices where ob.gyns. had Mount Sinai affiliations. “Our patients were very diverse,” Dr. Hart said in a video interview. About a quarter were white, a quarter were African American, and one-third were Hispanic. The average age of respondents was 33 years.
Dr. Hart's interview:
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
In addition to asking about participation in vaginal, oral, and anal sex, Dr. Hart and her coauthors asked about “more interesting sexual behaviors, from the use of sex toys to different ‘hook-up’ apps,” she said.
Among this group of urban respondents, participation in vaginal and oral sex was about at the national average. Anal sex participation, though, was 6%-8% higher than the national average, said Dr. Hart. This difference is important, she said, because there is “different screening and counseling for those patients.”
When Dr. Hart and her colleagues looked at the next phase of the survey, they found that fewer than half of patients said that providers were asking about sexual behaviors – and only about half were asking about condom use. When it came to being asked about participation in anal sex and oral sex, about one in five patients reported that their providers had broached the topics.
The investigators found that age had little to do with reported participation in sexual behaviors – with two exceptions. Patients who reported using sex toys were, on average, older than were those who never used them (34.3 vs. 30.7 years, P = .01). Conversely, those who used ‘hook-up’ apps were younger than were never-users (28.3 vs. 33.7 years, P = .0002).
“I found that less than 60% of my patients were regularly using condoms, and less than 50% of patients were ever asked by their provider about condom use. That was the most shocking finding that I had,” said Dr. Hart.
“The biggest thing is, patients are comfortable,” said Dr. Hart. “Around 90% of patients are comfortable discussing anything from sex toys, vaginal sex, to anal sex – but providers aren’t asking about them. And they really should,” to optimize screening for sexually transmitted diseases and cancer, and to provide thorough counseling about safe sex practices, she said.
What about the physician perspective? Maria Kon, MD, a Mount Sinai ob.gyn., and her collaborators received responses to a survey from 90 physicians, finding that most did not routinely ask about sexual orientation, sexual problems, or satisfaction. Further, one in four respondents reported disapproving of their patients’ sexual practices.
Asking about sexual practices is important not just in the context of reproductive health and disease prevention, but also to the “well-being of a woman in general, which is very important if you want to be a good doctor,” Dr. Kon said in a video interview.
Dr. Kon's interview:
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Links to the online survey were sent to ob.gyn. residents, fellows, and attending physicians in New York. Three-quarters of respondents were female, and almost half (46%) were aged 25-30 years; 59% were in postgraduate year 1-4. Most were white (69%) and heterosexual (87%).
“Years of training improve the level of comfort” in discussing specific sexual practices, Dr. Kon and her colleagues wrote in the poster accompanying their presentation at the meeting. “What we found, actually, is that people who are in practice longer were more comfortable talking about certain topics, but not all of them,” said Dr. Kon.
The investigators found that respondents who were in their 5th postgraduate year and beyond were significantly more comfortable discussing sex with elderly patients, talking about masturbation and sex toys, and talking about dyspareunia or libido problems (P value for being either “comfortable” or “very comfortable,” .0104, .0422, and .003, respectively). On the other hand, experience didn’t make a difference in the level of comfort with addressing a transgender person.
“Gender has no effect on the level of comfort,” the investigators wrote. They found no significant differences in any of these domains between male and female respondents.
The survey also asked ob.gyns. whether they would like more education about sexual behavior, and the answer was “yes.” About four in five respondents wanted to know more about the topics raised in the survey, which also asked about comfort in talking about sexual orientation and gender identity. About the same number think that their sexual history taking could be more detailed.
In terms of how ob.gyns. responding to the survey would like to receive more information and education, almost all (94%) said they would appreciate receiving more formal lectures about sexual practices. One third said they would like to educate themselves about trends in sexual behavior.
“Based on the survey responses, it seems that people would prefer for official lectures to be included in the curriculum,” said Dr. Kon, noting that required medical school sexual education is currently brief, with a focus on pregnancy and disease prevention and abortion. “In residency, we really don’t have much education either,” she said, adding that more formal education, as in grand rounds, “would highly benefit us as doctors who can relate to patients, who are comfortable talking to women about their health and well-being.”
Dr. Kon and Dr. Hart reported no relevant disclosures.
SOURCE: Hart C et al. and Kon M et al. ACOG 2018. Abstracts 26Q and 11M.
AUSTIN, TEX. – Patients in an urban practice were comfortable discussing sexual practices, even less traditional behaviors such as use of sex toys and “hook-up” apps, with their providers, according to results of a recent survey. The survey also found that ob.gyns. often weren’t asking about sexual behaviors at all.
“We wanted to find out what sexual behaviors our patients were participating in, and if their providers were asking them about those behaviors,” said Casuarina Hart, MD, chief ob.gyn. resident at Icahn School of Medicine at Mount Sinai, New York.
The survey also sought to determine whether patients were comfortable with being asked detailed questions about their sexual behavior, she said at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
A total of 207 anonymous paper-and-pencil surveys were completed by patients who attended Mount Sinai ob.gyn. clinics, as well as private practices where ob.gyns. had Mount Sinai affiliations. “Our patients were very diverse,” Dr. Hart said in a video interview. About a quarter were white, a quarter were African American, and one-third were Hispanic. The average age of respondents was 33 years.
Dr. Hart's interview:
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
In addition to asking about participation in vaginal, oral, and anal sex, Dr. Hart and her coauthors asked about “more interesting sexual behaviors, from the use of sex toys to different ‘hook-up’ apps,” she said.
Among this group of urban respondents, participation in vaginal and oral sex was about at the national average. Anal sex participation, though, was 6%-8% higher than the national average, said Dr. Hart. This difference is important, she said, because there is “different screening and counseling for those patients.”
When Dr. Hart and her colleagues looked at the next phase of the survey, they found that fewer than half of patients said that providers were asking about sexual behaviors – and only about half were asking about condom use. When it came to being asked about participation in anal sex and oral sex, about one in five patients reported that their providers had broached the topics.
The investigators found that age had little to do with reported participation in sexual behaviors – with two exceptions. Patients who reported using sex toys were, on average, older than were those who never used them (34.3 vs. 30.7 years, P = .01). Conversely, those who used ‘hook-up’ apps were younger than were never-users (28.3 vs. 33.7 years, P = .0002).
“I found that less than 60% of my patients were regularly using condoms, and less than 50% of patients were ever asked by their provider about condom use. That was the most shocking finding that I had,” said Dr. Hart.
“The biggest thing is, patients are comfortable,” said Dr. Hart. “Around 90% of patients are comfortable discussing anything from sex toys, vaginal sex, to anal sex – but providers aren’t asking about them. And they really should,” to optimize screening for sexually transmitted diseases and cancer, and to provide thorough counseling about safe sex practices, she said.
What about the physician perspective? Maria Kon, MD, a Mount Sinai ob.gyn., and her collaborators received responses to a survey from 90 physicians, finding that most did not routinely ask about sexual orientation, sexual problems, or satisfaction. Further, one in four respondents reported disapproving of their patients’ sexual practices.
Asking about sexual practices is important not just in the context of reproductive health and disease prevention, but also to the “well-being of a woman in general, which is very important if you want to be a good doctor,” Dr. Kon said in a video interview.
Dr. Kon's interview:
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Links to the online survey were sent to ob.gyn. residents, fellows, and attending physicians in New York. Three-quarters of respondents were female, and almost half (46%) were aged 25-30 years; 59% were in postgraduate year 1-4. Most were white (69%) and heterosexual (87%).
“Years of training improve the level of comfort” in discussing specific sexual practices, Dr. Kon and her colleagues wrote in the poster accompanying their presentation at the meeting. “What we found, actually, is that people who are in practice longer were more comfortable talking about certain topics, but not all of them,” said Dr. Kon.
The investigators found that respondents who were in their 5th postgraduate year and beyond were significantly more comfortable discussing sex with elderly patients, talking about masturbation and sex toys, and talking about dyspareunia or libido problems (P value for being either “comfortable” or “very comfortable,” .0104, .0422, and .003, respectively). On the other hand, experience didn’t make a difference in the level of comfort with addressing a transgender person.
“Gender has no effect on the level of comfort,” the investigators wrote. They found no significant differences in any of these domains between male and female respondents.
The survey also asked ob.gyns. whether they would like more education about sexual behavior, and the answer was “yes.” About four in five respondents wanted to know more about the topics raised in the survey, which also asked about comfort in talking about sexual orientation and gender identity. About the same number think that their sexual history taking could be more detailed.
In terms of how ob.gyns. responding to the survey would like to receive more information and education, almost all (94%) said they would appreciate receiving more formal lectures about sexual practices. One third said they would like to educate themselves about trends in sexual behavior.
“Based on the survey responses, it seems that people would prefer for official lectures to be included in the curriculum,” said Dr. Kon, noting that required medical school sexual education is currently brief, with a focus on pregnancy and disease prevention and abortion. “In residency, we really don’t have much education either,” she said, adding that more formal education, as in grand rounds, “would highly benefit us as doctors who can relate to patients, who are comfortable talking to women about their health and well-being.”
Dr. Kon and Dr. Hart reported no relevant disclosures.
SOURCE: Hart C et al. and Kon M et al. ACOG 2018. Abstracts 26Q and 11M.
REPORTING FROM ACOG 2018
VIDEO: Anemia more than doubles risk of postpartum depression
AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.
“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”
The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.
To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.
Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).
Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.
Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m2; P = .025).
Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.
Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.
Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”
“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.
Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.
SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.
AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.
“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”
The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.
To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.
Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).
Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.
Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m2; P = .025).
Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.
Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.
Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”
“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.
Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.
SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.
AUSTIN, TEX. – The risk of depression was more than doubled in women who were anemic during pregnancy, according to a recent retrospective cohort study of nearly 1,000 women. Among patients who had anemia at any point, the relative risk of screening positive for postpartum depression was 2.25 (95% confidence interval, 1.22-4.16).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
“This was an unexpected finding,” said Shannon Sutherland, MD, of the University of Connecticut, Farmington, in an interview after she presented the findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
“Maternal suicide exceeds hemorrhage and hypertensive disease as a cause of U.S. maternal mortality,” wrote Dr. Sutherland and her collaborators in the poster accompanying the presentation. And anemia is common: “Anemia in pregnancy can be as high as 27.4% in low-income minority pregnant women in the third trimester,” they wrote.
“If we can find something like this that affects depression, and screen for it and correct for it, we can make a real big difference in patients’ lives,” said Dr. Sutherland in a video interview. “Screening for anemia ... is such a simple thing for us to do, and I also think it’s very easy for us to correct, and very cheap for us to correct.”
The 922 study participants were at least 16 years old and receiving postpartum care at an outpatient women’s health clinic. Patients who had diseases that disrupted iron metabolism or were tobacco users, and those on antidepressants, anxiolytics, or antipsychotics were excluded from the study. Other exclusion criteria included anemia that required transfusion, and intrauterine fetal demise or neonatal mortality.
To assess depression, Dr. Sutherland and her colleagues administered the Edinburgh Postnatal Depression Scale at routine postpartum visits. Dr. Sutherland and her coinvestigators calculated the numbers of respondents who fell above and below the cutoff for potential depression on the 10-item self-report scale. They then looked at the proportion of women who scored positive for depression among those who were, and those who were not, anemic.
Possible depression was indicated by depression scale scores of 9.2% of participants, while three quarters (75.2%) were anemic either during pregnancy or in the immediate postpartum period. Among anemic patients, 10.8% screened positive for depression, while 4.8% of those without anemia met positive screening criteria for postpartum depression (P = .007).
Dr. Sutherland and her collaborators noted that fewer women in their cohort had postpartum depression than the national average of 19%. They may have missed some patients who would later develop depression since the screening occurred at the first postpartum visit; also, “it is possible that women deeply affected by [postpartum depression] may have been lost to follow-up,” they wrote.
Participants had a mean age of about 26 years, and body mass index was slightly higher for those with anemia than without (mean, 32.2 vs 31.2 kg/m2; P = .025).
Postpartum depression was not associated with marital status, substance use, ethnicity, parity, or the occurrence of postpartum hemorrhage, in the investigators’ analysis.
Dr. Sutherland said that, in their analysis, she and her coinvestigators did not find an association between degree of anemia and the likelihood, or severity, of postpartum depression. However, they did find that anemia of any degree in the immediate peripartum period was most strongly associated with postpartum depression.
Though the exact mechanism of the anemia-depression link isn’t known, the fatigue associated with anemia may help predispose women to postpartum depression, said Dr. Sutherland. Also, she said, “iron can make a difference in synthesizing neurotransmitters” such as serotonin, “so it may follow that you might have some depressive symptoms.”
“The next step after this study, which was a launching point, is to see if we correct the degree of anemia and bring them to normal levels, if that can help decrease the risk of postpartum depression,” said Dr. Sutherland.
Dr. Sutherland and her coinvestigators reported that they had no relevant financial disclosures.
SOURCE: Sutherland S et al. ACOG 2018. Abstract 35C.
REPORTING FROM ACOG 2018
VIDEO: Doula care could avert over 200,000 cesareans annually
AUSTIN, TEX. – Having a trained doula in attendance at labor and delivery for nulliparous women could be a cost-effective strategy to prevent hundreds of thousands of cesarean deliveries yearly, according to a new analysis of the practice.
“We were interested in looking at the cost-effectiveness of having a professional doula at labor and delivery,” said Karen Greiner, a medical student at Oregon Health and Sciences University, Portland. She and her colleagues had their interest sparked after reading a Cochrane review that found reduced rates of cesarean delivery and shortened labor times with continuous support during labor, she said in an interview.
The cost-effectiveness analysis, presented during a poster session of the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, used a two-delivery model to track the effect of doula attendance at a nulliparous term labor and delivery. Since most women in the United States have two deliveries, the researchers analyzed what effect having a doula attend the first delivery would have on the subsequent pregnancy as well.
Ms. Greiner and her colleagues used a theoretical cohort of 1.8 million women, about the number of nulliparous women with term deliveries in the United States annually, to see what effect doula care would have on cost and maternal outcomes. “We found that there was a significant reduction in cesarean deliveries – almost 220,000 – when a woman had a professional doula with her during labor and delivery, versus not having that doula support,” Ms. Greiner said in a video interview. “We also found a reduction in maternal deaths ... a reduction in uterine rupture, also in hysterectomies.”
The 51 maternal deaths, 382 uterine ruptures, and 100 subsequent hysterectomies averted by use of doulas would result in an increase of 7,227 quality-adjusted life years, the effectiveness metric chosen for the analysis. However, this benefit would come at an increased cost of $207 million for the theoretical cohort.
“We did find that doulas are expensive, that they do cost money,” acknowledged Ms. Greiner. She and her coauthors allocated $1,000 per doula – the median cost for doula attendance at labor and delivery in Portland, Ore. – in the model used for cost-effectiveness analysis.
“Overall, we found that having a doula during a woman’s labor and delivery is cost-effective up to $1,286 for the cost of the doula” when quality-adjusted life years are taken into account, said Ms. Greiner.
She reported having no relevant financial disclosures.
SOURCE: Greiner K et al. ACOG 2018. Abstract 25C.
AUSTIN, TEX. – Having a trained doula in attendance at labor and delivery for nulliparous women could be a cost-effective strategy to prevent hundreds of thousands of cesarean deliveries yearly, according to a new analysis of the practice.
“We were interested in looking at the cost-effectiveness of having a professional doula at labor and delivery,” said Karen Greiner, a medical student at Oregon Health and Sciences University, Portland. She and her colleagues had their interest sparked after reading a Cochrane review that found reduced rates of cesarean delivery and shortened labor times with continuous support during labor, she said in an interview.
The cost-effectiveness analysis, presented during a poster session of the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, used a two-delivery model to track the effect of doula attendance at a nulliparous term labor and delivery. Since most women in the United States have two deliveries, the researchers analyzed what effect having a doula attend the first delivery would have on the subsequent pregnancy as well.
Ms. Greiner and her colleagues used a theoretical cohort of 1.8 million women, about the number of nulliparous women with term deliveries in the United States annually, to see what effect doula care would have on cost and maternal outcomes. “We found that there was a significant reduction in cesarean deliveries – almost 220,000 – when a woman had a professional doula with her during labor and delivery, versus not having that doula support,” Ms. Greiner said in a video interview. “We also found a reduction in maternal deaths ... a reduction in uterine rupture, also in hysterectomies.”
The 51 maternal deaths, 382 uterine ruptures, and 100 subsequent hysterectomies averted by use of doulas would result in an increase of 7,227 quality-adjusted life years, the effectiveness metric chosen for the analysis. However, this benefit would come at an increased cost of $207 million for the theoretical cohort.
“We did find that doulas are expensive, that they do cost money,” acknowledged Ms. Greiner. She and her coauthors allocated $1,000 per doula – the median cost for doula attendance at labor and delivery in Portland, Ore. – in the model used for cost-effectiveness analysis.
“Overall, we found that having a doula during a woman’s labor and delivery is cost-effective up to $1,286 for the cost of the doula” when quality-adjusted life years are taken into account, said Ms. Greiner.
She reported having no relevant financial disclosures.
SOURCE: Greiner K et al. ACOG 2018. Abstract 25C.
AUSTIN, TEX. – Having a trained doula in attendance at labor and delivery for nulliparous women could be a cost-effective strategy to prevent hundreds of thousands of cesarean deliveries yearly, according to a new analysis of the practice.
“We were interested in looking at the cost-effectiveness of having a professional doula at labor and delivery,” said Karen Greiner, a medical student at Oregon Health and Sciences University, Portland. She and her colleagues had their interest sparked after reading a Cochrane review that found reduced rates of cesarean delivery and shortened labor times with continuous support during labor, she said in an interview.
The cost-effectiveness analysis, presented during a poster session of the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, used a two-delivery model to track the effect of doula attendance at a nulliparous term labor and delivery. Since most women in the United States have two deliveries, the researchers analyzed what effect having a doula attend the first delivery would have on the subsequent pregnancy as well.
Ms. Greiner and her colleagues used a theoretical cohort of 1.8 million women, about the number of nulliparous women with term deliveries in the United States annually, to see what effect doula care would have on cost and maternal outcomes. “We found that there was a significant reduction in cesarean deliveries – almost 220,000 – when a woman had a professional doula with her during labor and delivery, versus not having that doula support,” Ms. Greiner said in a video interview. “We also found a reduction in maternal deaths ... a reduction in uterine rupture, also in hysterectomies.”
The 51 maternal deaths, 382 uterine ruptures, and 100 subsequent hysterectomies averted by use of doulas would result in an increase of 7,227 quality-adjusted life years, the effectiveness metric chosen for the analysis. However, this benefit would come at an increased cost of $207 million for the theoretical cohort.
“We did find that doulas are expensive, that they do cost money,” acknowledged Ms. Greiner. She and her coauthors allocated $1,000 per doula – the median cost for doula attendance at labor and delivery in Portland, Ore. – in the model used for cost-effectiveness analysis.
“Overall, we found that having a doula during a woman’s labor and delivery is cost-effective up to $1,286 for the cost of the doula” when quality-adjusted life years are taken into account, said Ms. Greiner.
She reported having no relevant financial disclosures.
SOURCE: Greiner K et al. ACOG 2018. Abstract 25C.
REPORTING FROM ACOG 2018
ACOG, ACP voice ‘deep concern’ over potential Title X changes
The American College of Physicians and the American College of Obstetricians and Gynecologists expressed concern over possible significant changes to Title X, a long-standing federal program that provides gynecologic care and family planning information and services, primarily to low-income and uninsured Americans.
“An announcement is expected any day that the Trump administration is going to make dramatic changes to Title X funding,” said Shari M. Erickson, vice president of governmental affairs and medical practice at the American College of Physicians, during a joint telebriefing May 4.
Hal Lawrence, MD, executive vice president and chief executive officer of the American College of Obstetricians and Gynecologists, echoed ACP’s concerns.
“When we talk about changes to limit or restructure Title X, we’re talking about changes to basic family planning options for American women,” he said during the telebriefing.
“As the largest organization of women’s health care providers, ACOG is deeply concerned about anticipated changes to Title X to limit the services that qualify for program funding and picking and choosing among qualified providers. These changes move away from science-based principles,” Dr. Lawrence said.
Title X provides federal funding for family planning and related preventive health services, primarily serving low-income individuals and those without health insurance.
Agencies receiving Title X money currently provide gynecologic exams, contraceptive and family planning counseling, contraceptive services, and pregnancy testing and related information, explained Ms. Erickson.
“The expected changes from the administration would prevent any Title X funds from going to an entity that provides even basic information about all of the legal and evidence-based options available for pregnant women,” said Ms. Erickson, referring to the possibility of a “gag rule” that would prevent those receiving Title X monies from discussing abortion.
These changes, if implemented, would echo policies implemented in the 1980s by the Reagan administration, a shift that Ms. Erickson termed “outdated and out of touch.” Millions of individuals could have access to care affected, she said, “with a disproportionate number of those impacted being women who are seeking access to contraception and reproductive health care, as well as general preventive services.”
If patients lose access to such services through Title X–funded facilities, they may not have another option within reasonable proximity, said Ms. Erickson. She added that options that exist for the population likely to be affected are often community health centers already operating under significant resource constraints.
Title X does not currently fund any abortion services.
Ms. Erickson said that it’s not currently clear whether any proposed changes or limitations would include proscriptions on discussing contraceptive methods. She and Dr. Lawrence said that neither ACP nor ACOG would anticipate initiating or joining litigation against the U.S. Department of Health & Human Services or the administration. On the telebriefing, each representative said that their organizations would need to know what form Title X changes might take, and then see what the nature of any lawsuits would be, before endorsing litigation.
The American College of Physicians and the American College of Obstetricians and Gynecologists expressed concern over possible significant changes to Title X, a long-standing federal program that provides gynecologic care and family planning information and services, primarily to low-income and uninsured Americans.
“An announcement is expected any day that the Trump administration is going to make dramatic changes to Title X funding,” said Shari M. Erickson, vice president of governmental affairs and medical practice at the American College of Physicians, during a joint telebriefing May 4.
Hal Lawrence, MD, executive vice president and chief executive officer of the American College of Obstetricians and Gynecologists, echoed ACP’s concerns.
“When we talk about changes to limit or restructure Title X, we’re talking about changes to basic family planning options for American women,” he said during the telebriefing.
“As the largest organization of women’s health care providers, ACOG is deeply concerned about anticipated changes to Title X to limit the services that qualify for program funding and picking and choosing among qualified providers. These changes move away from science-based principles,” Dr. Lawrence said.
Title X provides federal funding for family planning and related preventive health services, primarily serving low-income individuals and those without health insurance.
Agencies receiving Title X money currently provide gynecologic exams, contraceptive and family planning counseling, contraceptive services, and pregnancy testing and related information, explained Ms. Erickson.
“The expected changes from the administration would prevent any Title X funds from going to an entity that provides even basic information about all of the legal and evidence-based options available for pregnant women,” said Ms. Erickson, referring to the possibility of a “gag rule” that would prevent those receiving Title X monies from discussing abortion.
These changes, if implemented, would echo policies implemented in the 1980s by the Reagan administration, a shift that Ms. Erickson termed “outdated and out of touch.” Millions of individuals could have access to care affected, she said, “with a disproportionate number of those impacted being women who are seeking access to contraception and reproductive health care, as well as general preventive services.”
If patients lose access to such services through Title X–funded facilities, they may not have another option within reasonable proximity, said Ms. Erickson. She added that options that exist for the population likely to be affected are often community health centers already operating under significant resource constraints.
Title X does not currently fund any abortion services.
Ms. Erickson said that it’s not currently clear whether any proposed changes or limitations would include proscriptions on discussing contraceptive methods. She and Dr. Lawrence said that neither ACP nor ACOG would anticipate initiating or joining litigation against the U.S. Department of Health & Human Services or the administration. On the telebriefing, each representative said that their organizations would need to know what form Title X changes might take, and then see what the nature of any lawsuits would be, before endorsing litigation.
The American College of Physicians and the American College of Obstetricians and Gynecologists expressed concern over possible significant changes to Title X, a long-standing federal program that provides gynecologic care and family planning information and services, primarily to low-income and uninsured Americans.
“An announcement is expected any day that the Trump administration is going to make dramatic changes to Title X funding,” said Shari M. Erickson, vice president of governmental affairs and medical practice at the American College of Physicians, during a joint telebriefing May 4.
Hal Lawrence, MD, executive vice president and chief executive officer of the American College of Obstetricians and Gynecologists, echoed ACP’s concerns.
“When we talk about changes to limit or restructure Title X, we’re talking about changes to basic family planning options for American women,” he said during the telebriefing.
“As the largest organization of women’s health care providers, ACOG is deeply concerned about anticipated changes to Title X to limit the services that qualify for program funding and picking and choosing among qualified providers. These changes move away from science-based principles,” Dr. Lawrence said.
Title X provides federal funding for family planning and related preventive health services, primarily serving low-income individuals and those without health insurance.
Agencies receiving Title X money currently provide gynecologic exams, contraceptive and family planning counseling, contraceptive services, and pregnancy testing and related information, explained Ms. Erickson.
“The expected changes from the administration would prevent any Title X funds from going to an entity that provides even basic information about all of the legal and evidence-based options available for pregnant women,” said Ms. Erickson, referring to the possibility of a “gag rule” that would prevent those receiving Title X monies from discussing abortion.
These changes, if implemented, would echo policies implemented in the 1980s by the Reagan administration, a shift that Ms. Erickson termed “outdated and out of touch.” Millions of individuals could have access to care affected, she said, “with a disproportionate number of those impacted being women who are seeking access to contraception and reproductive health care, as well as general preventive services.”
If patients lose access to such services through Title X–funded facilities, they may not have another option within reasonable proximity, said Ms. Erickson. She added that options that exist for the population likely to be affected are often community health centers already operating under significant resource constraints.
Title X does not currently fund any abortion services.
Ms. Erickson said that it’s not currently clear whether any proposed changes or limitations would include proscriptions on discussing contraceptive methods. She and Dr. Lawrence said that neither ACP nor ACOG would anticipate initiating or joining litigation against the U.S. Department of Health & Human Services or the administration. On the telebriefing, each representative said that their organizations would need to know what form Title X changes might take, and then see what the nature of any lawsuits would be, before endorsing litigation.
Maternal morbidity and BMI: A dose-response relationship
AUSTIN, TEX. – Women with the highest levels of obesity were at higher odds of experiencing a composite serious maternal morbidity outcome, while women at all levels of obesity experienced elevated risks of some serious complications of pregnancy, compared with women with a body mass index (BMI) in the normal range, according to a recent study.
Looking at individual indicators of severe maternal morbidity, Marissa Platner, MD, and her study coauthors saw that women who fell into the higher levels of obesity had significantly elevated odds of some complications.
“Those risks are really impressive, with odds ratios of two and three times that of a normal-weight patient,” said Dr. Platner in a video interview.
The adjusted odds ratio of acute renal failure for women with superobesity (BMI of 50 kg/m2 or more) was 3.62 (95% confidence interval, 1.75-7.52); odds ratios for renal failure were not significantly elevated for less-obese women.
Women with all levels of obesity had elevated risks of experiencing heart failure during a procedure or surgery, with adjusted odds ratios ranging from 1.68 (95% CI, 1.48-1.93) for women with class I obesity (BMI, 30-34.9 kg/m2) to 2.23 for women with superobesity (95% CI, 1.15-4.33).
Results from the retrospective cohort study were presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
Dr. Platner and her colleagues examined 4 years of New York City delivery data that were linked to birth certificates, identifying those singleton live births for whom maternal prepregnancy BMI data were available.
From this group, they included women aged 15-50 years who delivered at 20-45 weeks’ gestational age. Women with prepregnancy BMIs less than 18.5 kg/m2 – those who were underweight – were excluded.
Dr. Platner and her coinvestigators used multivariable analysis to see what association the full range of obesity classes had with severe maternal morbidity, adjusting for many socioeconomic and demographic factors.
Of the 539,870 women included in the study, 3.3% experienced severe maternal morbidity, and 17.4% of patients met criteria for obesity. “Across all classes of obesity, there was a significantly greater risk of severe maternal morbidity, compared to nonobese women,” wrote Dr. Platner and her colleagues in the poster accompanying the presentation.
These risks climbed for women with the highest BMIs, however. “Women with higher levels of obesity, not surprisingly, are at increased risk” of severe maternal morbidity, said Dr. Platner. She and her colleagues noted in the poster that, “There is a significant dose-response relationship between increasing obesity class and risk of [severe maternal morbidity] at delivery hospitalization.”
It had been known that women with obesity are at increased risk of some serious complications of pregnancy, including severe maternal morbidity and mortality, and that those considered morbidly obese – with BMIs of 40 and above – are most likely to experience these complications, Dr. Platner said. However, she added, there’s a paucity of data to inform maternal risk stratification by level of obesity.
“We included the group of superobese women, which is significant in the surgical literature, and that’s a BMI of 50 and above ... we thought that would be an important subgroup to analyze in this population,” she said.
Dr. Platner said that she and her colleagues already had the clinical impressions that women with the highest BMIs were most likely to have serious complications. “I don’t think that these findings are particularly surprising,” she said. “This is what our hypothesis was in terms of why we did this study.”
The greater surprise, she said, was the magnitude of increased risk seen for serious morbidity with higher levels of obesity.
“Really, the risk is truly increased for those women with class III or superobesity, and when we start to stratify ... those are the women we need to be concerned about in terms of our prenatal counseling,” said Dr. Platner, a maternal-fetal medicine fellow at Yale University, New Haven, Conn.
“What can we do to intervene before we get there?” asked Dr. Platner. Although data are lacking about what specific interventions might be able to reduce the risk of these serious complications, she said she could envision such steps as acquiring predelivery baseline ECGs and cardiac ultrasounds in women with higher levels of obesity and being sure to follow renal function closely as well.
The findings also may help physicians provide more evidence-based preconception advice to women who are among the 35% of American adults who have obesity.
Dr. Platner reported no relevant financial disclosures.
SOURCE: Platner M et al. ACOG 2018, Abstract 39I.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AUSTIN, TEX. – Women with the highest levels of obesity were at higher odds of experiencing a composite serious maternal morbidity outcome, while women at all levels of obesity experienced elevated risks of some serious complications of pregnancy, compared with women with a body mass index (BMI) in the normal range, according to a recent study.
Looking at individual indicators of severe maternal morbidity, Marissa Platner, MD, and her study coauthors saw that women who fell into the higher levels of obesity had significantly elevated odds of some complications.
“Those risks are really impressive, with odds ratios of two and three times that of a normal-weight patient,” said Dr. Platner in a video interview.
The adjusted odds ratio of acute renal failure for women with superobesity (BMI of 50 kg/m2 or more) was 3.62 (95% confidence interval, 1.75-7.52); odds ratios for renal failure were not significantly elevated for less-obese women.
Women with all levels of obesity had elevated risks of experiencing heart failure during a procedure or surgery, with adjusted odds ratios ranging from 1.68 (95% CI, 1.48-1.93) for women with class I obesity (BMI, 30-34.9 kg/m2) to 2.23 for women with superobesity (95% CI, 1.15-4.33).
Results from the retrospective cohort study were presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
Dr. Platner and her colleagues examined 4 years of New York City delivery data that were linked to birth certificates, identifying those singleton live births for whom maternal prepregnancy BMI data were available.
From this group, they included women aged 15-50 years who delivered at 20-45 weeks’ gestational age. Women with prepregnancy BMIs less than 18.5 kg/m2 – those who were underweight – were excluded.
Dr. Platner and her coinvestigators used multivariable analysis to see what association the full range of obesity classes had with severe maternal morbidity, adjusting for many socioeconomic and demographic factors.
Of the 539,870 women included in the study, 3.3% experienced severe maternal morbidity, and 17.4% of patients met criteria for obesity. “Across all classes of obesity, there was a significantly greater risk of severe maternal morbidity, compared to nonobese women,” wrote Dr. Platner and her colleagues in the poster accompanying the presentation.
These risks climbed for women with the highest BMIs, however. “Women with higher levels of obesity, not surprisingly, are at increased risk” of severe maternal morbidity, said Dr. Platner. She and her colleagues noted in the poster that, “There is a significant dose-response relationship between increasing obesity class and risk of [severe maternal morbidity] at delivery hospitalization.”
It had been known that women with obesity are at increased risk of some serious complications of pregnancy, including severe maternal morbidity and mortality, and that those considered morbidly obese – with BMIs of 40 and above – are most likely to experience these complications, Dr. Platner said. However, she added, there’s a paucity of data to inform maternal risk stratification by level of obesity.
“We included the group of superobese women, which is significant in the surgical literature, and that’s a BMI of 50 and above ... we thought that would be an important subgroup to analyze in this population,” she said.
Dr. Platner said that she and her colleagues already had the clinical impressions that women with the highest BMIs were most likely to have serious complications. “I don’t think that these findings are particularly surprising,” she said. “This is what our hypothesis was in terms of why we did this study.”
The greater surprise, she said, was the magnitude of increased risk seen for serious morbidity with higher levels of obesity.
“Really, the risk is truly increased for those women with class III or superobesity, and when we start to stratify ... those are the women we need to be concerned about in terms of our prenatal counseling,” said Dr. Platner, a maternal-fetal medicine fellow at Yale University, New Haven, Conn.
“What can we do to intervene before we get there?” asked Dr. Platner. Although data are lacking about what specific interventions might be able to reduce the risk of these serious complications, she said she could envision such steps as acquiring predelivery baseline ECGs and cardiac ultrasounds in women with higher levels of obesity and being sure to follow renal function closely as well.
The findings also may help physicians provide more evidence-based preconception advice to women who are among the 35% of American adults who have obesity.
Dr. Platner reported no relevant financial disclosures.
SOURCE: Platner M et al. ACOG 2018, Abstract 39I.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AUSTIN, TEX. – Women with the highest levels of obesity were at higher odds of experiencing a composite serious maternal morbidity outcome, while women at all levels of obesity experienced elevated risks of some serious complications of pregnancy, compared with women with a body mass index (BMI) in the normal range, according to a recent study.
Looking at individual indicators of severe maternal morbidity, Marissa Platner, MD, and her study coauthors saw that women who fell into the higher levels of obesity had significantly elevated odds of some complications.
“Those risks are really impressive, with odds ratios of two and three times that of a normal-weight patient,” said Dr. Platner in a video interview.
The adjusted odds ratio of acute renal failure for women with superobesity (BMI of 50 kg/m2 or more) was 3.62 (95% confidence interval, 1.75-7.52); odds ratios for renal failure were not significantly elevated for less-obese women.
Women with all levels of obesity had elevated risks of experiencing heart failure during a procedure or surgery, with adjusted odds ratios ranging from 1.68 (95% CI, 1.48-1.93) for women with class I obesity (BMI, 30-34.9 kg/m2) to 2.23 for women with superobesity (95% CI, 1.15-4.33).
Results from the retrospective cohort study were presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.
Dr. Platner and her colleagues examined 4 years of New York City delivery data that were linked to birth certificates, identifying those singleton live births for whom maternal prepregnancy BMI data were available.
From this group, they included women aged 15-50 years who delivered at 20-45 weeks’ gestational age. Women with prepregnancy BMIs less than 18.5 kg/m2 – those who were underweight – were excluded.
Dr. Platner and her coinvestigators used multivariable analysis to see what association the full range of obesity classes had with severe maternal morbidity, adjusting for many socioeconomic and demographic factors.
Of the 539,870 women included in the study, 3.3% experienced severe maternal morbidity, and 17.4% of patients met criteria for obesity. “Across all classes of obesity, there was a significantly greater risk of severe maternal morbidity, compared to nonobese women,” wrote Dr. Platner and her colleagues in the poster accompanying the presentation.
These risks climbed for women with the highest BMIs, however. “Women with higher levels of obesity, not surprisingly, are at increased risk” of severe maternal morbidity, said Dr. Platner. She and her colleagues noted in the poster that, “There is a significant dose-response relationship between increasing obesity class and risk of [severe maternal morbidity] at delivery hospitalization.”
It had been known that women with obesity are at increased risk of some serious complications of pregnancy, including severe maternal morbidity and mortality, and that those considered morbidly obese – with BMIs of 40 and above – are most likely to experience these complications, Dr. Platner said. However, she added, there’s a paucity of data to inform maternal risk stratification by level of obesity.
“We included the group of superobese women, which is significant in the surgical literature, and that’s a BMI of 50 and above ... we thought that would be an important subgroup to analyze in this population,” she said.
Dr. Platner said that she and her colleagues already had the clinical impressions that women with the highest BMIs were most likely to have serious complications. “I don’t think that these findings are particularly surprising,” she said. “This is what our hypothesis was in terms of why we did this study.”
The greater surprise, she said, was the magnitude of increased risk seen for serious morbidity with higher levels of obesity.
“Really, the risk is truly increased for those women with class III or superobesity, and when we start to stratify ... those are the women we need to be concerned about in terms of our prenatal counseling,” said Dr. Platner, a maternal-fetal medicine fellow at Yale University, New Haven, Conn.
“What can we do to intervene before we get there?” asked Dr. Platner. Although data are lacking about what specific interventions might be able to reduce the risk of these serious complications, she said she could envision such steps as acquiring predelivery baseline ECGs and cardiac ultrasounds in women with higher levels of obesity and being sure to follow renal function closely as well.
The findings also may help physicians provide more evidence-based preconception advice to women who are among the 35% of American adults who have obesity.
Dr. Platner reported no relevant financial disclosures.
SOURCE: Platner M et al. ACOG 2018, Abstract 39I.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
REPORTING FROM ACOG 2018
Reduced intensity conditioning doesn’t protect fertility
SALT LAKE CITY – Both male and female recipients of childhood hematopoietic stem cell transplantation (HSCT) were very likely to have severely decreased fertility potential, even in the setting of preserved puberty, according to a recent study of adolescent and young adult HSCT recipients.
A reduced intensity conditioning regimen did not protect this cohort from decreased fertility, a finding that surprised the study’s lead author.
“We had hypothesized that, as compared to myeloablative conditioning, reduced intensity conditioning in children who received HSCT would lower the risk of infertility and lessen gonadal failure,” said Helen Oquendo del Toro, MD. In fact, Dr. Oquendo del Toro and her collaborators found that more than 90% of semen samples available for analysis had results that indicated infertility or severely impaired fertility, regardless of the type of pretransplant conditioning the patient had received.
The study highlights the need for fertility preservation when possible before HSCT, and makes clear that “normal puberty does not equate to normal fertility,” said Dr. Oquendo del Toro, of Cincinnati Children’s Hospital Medical Center.
Dr. Oquendo del Toro presented results of an observational cohort study of late effects of HSCT that included individuals aged 1-40 years old who received a single HSCT at, or after, 1 year of age.
Twenty-one males in the study had semen available for analysis. Of the 10 males who received myeloablative conditioning (MAC), 8 had azoospermia, and 2 more had oligoteratospermia (low sperm count with abnormal morphology). For the 11 males who received reduced intensity conditioning (RIC), eight had azoospermia, two had semen samples that showed oligoteratospermia, and one had a normal semen analysis.
The median age at transplant for these males was 14.5 years, and patients were a median of 19 years old at follow-up, Dr. Oquendo del Toro said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
For females in the study, low levels of anti-Müllerian hormone (AMH) – generally considered the best surrogate lab value for ovarian reserve – were nearly as common. Of 14 females receiving MAC, 13 (93%) had low AMH, as did 6 of 8 (75%) female patients who received RIC.
Individuals with more than one HSCT were excluded, as were those with Fanconi anemia, which itself carries a risk of gonadal failure. The study’s two aims were to investigate gonadal function as well as fertility potential after receipt of either RIC or MAC for HSCT.
Patients were seen by an endocrinologist who assessed testicular volume and assigned a Tanner stage. At age 11 and older, patients’ gonadal function was assessed on an annual basis by obtaining levels of luteinizing hormone and follicle stimulating hormone for all patients; female estradiol levels were tracked, as were male testosterone levels.
Assessment of fertility potential required additional laboratory testing: For females, the investigators obtained AMH levels, while for males, semen analysis was coupled with serum levels of inhibin B, an indicator of Sertoli cell function.
A total of 72 males were more than 1 year post-HSCT in the cohort, and of these, 41 were at least 11 years old and had achieved pubertal status according to laboratory evaluation. In all, 22 of the male patients received RIC, and 19 received MAC.
Males receiving MAC were a median 20 years old at their follow-up evaluation, and a median 6 years post-HSCT, while the RIC group were a median of 18.5 years old and 5.5 years out from their transplant.
Of the 50 females who were more than 1 year post-HSCT, 25 were pubertal and 11 years old or older. Nine of the female patients received RIC, and 16 received MAC.
Females who received MAC were a median 12.1 years old and 4.1 years post-HSCT at their follow-up evaluation. Females receiving RIC were a median 16 years old, and 6.5 years post-HSCT at the time of evaluation.
Patients received their transplants for a variety of malignant and nonmalignant conditions.
“We saw relatively normal gonadotropins after both reduced intensity and myeloablative conditioning in males,” Dr. Oquendo del Toro said. Of the MAC group, 4 of 15 (27%) had elevated follicle stimulating hormone levels, as did 2 of 17 (12%) of the RIC group. Elevated luteinizing hormone levels were seen in 2 of 15 (13%) of the MAC group and 1 of 17 (6%) of the RIC group. Four patients in each group had abnormally low testosterone levels.
However, when the investigators looked at inhibin B levels in males, they found abnormally low levels in 9 of 15 (60%) of those who received MAC, and in 6 of 15 (40%) of those who received RIC. These results meshed with the severely abnormal semen analyses investigators found from those participants for whom a sample was available, Dr. Oquendo del Toro said.
For females, estradiol levels were significantly lower for those who had received MAC, with 7 of 11 (64%) of that group having abnormally low estradiol levels. The levels approached 0 pg/mL for many, said Dr. Oquendo del Toro. None of the eight patients who had received RIC had abnormally low estradiol levels (P = .0008).
“Male puberty is relatively well preserved after both myeloablative and reduced intensity conditioning, but there is a greater than 90% risk of male infertility associated with both reduced intensity and myeloablative conditioning for HSCT,” Dr. Oquendo del Toro said.
For females, the study paints a different picture. “We saw decreased premature ovarian failure after reduced intensity conditioning … but the fertility potential as assessed by anti-Müllerian hormone was decreased” after both conditioning regimens, she said.
Dr. Oquendo del Toro reported having no conflicts of interest.
SOURCE: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.
SALT LAKE CITY – Both male and female recipients of childhood hematopoietic stem cell transplantation (HSCT) were very likely to have severely decreased fertility potential, even in the setting of preserved puberty, according to a recent study of adolescent and young adult HSCT recipients.
A reduced intensity conditioning regimen did not protect this cohort from decreased fertility, a finding that surprised the study’s lead author.
“We had hypothesized that, as compared to myeloablative conditioning, reduced intensity conditioning in children who received HSCT would lower the risk of infertility and lessen gonadal failure,” said Helen Oquendo del Toro, MD. In fact, Dr. Oquendo del Toro and her collaborators found that more than 90% of semen samples available for analysis had results that indicated infertility or severely impaired fertility, regardless of the type of pretransplant conditioning the patient had received.
The study highlights the need for fertility preservation when possible before HSCT, and makes clear that “normal puberty does not equate to normal fertility,” said Dr. Oquendo del Toro, of Cincinnati Children’s Hospital Medical Center.
Dr. Oquendo del Toro presented results of an observational cohort study of late effects of HSCT that included individuals aged 1-40 years old who received a single HSCT at, or after, 1 year of age.
Twenty-one males in the study had semen available for analysis. Of the 10 males who received myeloablative conditioning (MAC), 8 had azoospermia, and 2 more had oligoteratospermia (low sperm count with abnormal morphology). For the 11 males who received reduced intensity conditioning (RIC), eight had azoospermia, two had semen samples that showed oligoteratospermia, and one had a normal semen analysis.
The median age at transplant for these males was 14.5 years, and patients were a median of 19 years old at follow-up, Dr. Oquendo del Toro said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
For females in the study, low levels of anti-Müllerian hormone (AMH) – generally considered the best surrogate lab value for ovarian reserve – were nearly as common. Of 14 females receiving MAC, 13 (93%) had low AMH, as did 6 of 8 (75%) female patients who received RIC.
Individuals with more than one HSCT were excluded, as were those with Fanconi anemia, which itself carries a risk of gonadal failure. The study’s two aims were to investigate gonadal function as well as fertility potential after receipt of either RIC or MAC for HSCT.
Patients were seen by an endocrinologist who assessed testicular volume and assigned a Tanner stage. At age 11 and older, patients’ gonadal function was assessed on an annual basis by obtaining levels of luteinizing hormone and follicle stimulating hormone for all patients; female estradiol levels were tracked, as were male testosterone levels.
Assessment of fertility potential required additional laboratory testing: For females, the investigators obtained AMH levels, while for males, semen analysis was coupled with serum levels of inhibin B, an indicator of Sertoli cell function.
A total of 72 males were more than 1 year post-HSCT in the cohort, and of these, 41 were at least 11 years old and had achieved pubertal status according to laboratory evaluation. In all, 22 of the male patients received RIC, and 19 received MAC.
Males receiving MAC were a median 20 years old at their follow-up evaluation, and a median 6 years post-HSCT, while the RIC group were a median of 18.5 years old and 5.5 years out from their transplant.
Of the 50 females who were more than 1 year post-HSCT, 25 were pubertal and 11 years old or older. Nine of the female patients received RIC, and 16 received MAC.
Females who received MAC were a median 12.1 years old and 4.1 years post-HSCT at their follow-up evaluation. Females receiving RIC were a median 16 years old, and 6.5 years post-HSCT at the time of evaluation.
Patients received their transplants for a variety of malignant and nonmalignant conditions.
“We saw relatively normal gonadotropins after both reduced intensity and myeloablative conditioning in males,” Dr. Oquendo del Toro said. Of the MAC group, 4 of 15 (27%) had elevated follicle stimulating hormone levels, as did 2 of 17 (12%) of the RIC group. Elevated luteinizing hormone levels were seen in 2 of 15 (13%) of the MAC group and 1 of 17 (6%) of the RIC group. Four patients in each group had abnormally low testosterone levels.
However, when the investigators looked at inhibin B levels in males, they found abnormally low levels in 9 of 15 (60%) of those who received MAC, and in 6 of 15 (40%) of those who received RIC. These results meshed with the severely abnormal semen analyses investigators found from those participants for whom a sample was available, Dr. Oquendo del Toro said.
For females, estradiol levels were significantly lower for those who had received MAC, with 7 of 11 (64%) of that group having abnormally low estradiol levels. The levels approached 0 pg/mL for many, said Dr. Oquendo del Toro. None of the eight patients who had received RIC had abnormally low estradiol levels (P = .0008).
“Male puberty is relatively well preserved after both myeloablative and reduced intensity conditioning, but there is a greater than 90% risk of male infertility associated with both reduced intensity and myeloablative conditioning for HSCT,” Dr. Oquendo del Toro said.
For females, the study paints a different picture. “We saw decreased premature ovarian failure after reduced intensity conditioning … but the fertility potential as assessed by anti-Müllerian hormone was decreased” after both conditioning regimens, she said.
Dr. Oquendo del Toro reported having no conflicts of interest.
SOURCE: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.
SALT LAKE CITY – Both male and female recipients of childhood hematopoietic stem cell transplantation (HSCT) were very likely to have severely decreased fertility potential, even in the setting of preserved puberty, according to a recent study of adolescent and young adult HSCT recipients.
A reduced intensity conditioning regimen did not protect this cohort from decreased fertility, a finding that surprised the study’s lead author.
“We had hypothesized that, as compared to myeloablative conditioning, reduced intensity conditioning in children who received HSCT would lower the risk of infertility and lessen gonadal failure,” said Helen Oquendo del Toro, MD. In fact, Dr. Oquendo del Toro and her collaborators found that more than 90% of semen samples available for analysis had results that indicated infertility or severely impaired fertility, regardless of the type of pretransplant conditioning the patient had received.
The study highlights the need for fertility preservation when possible before HSCT, and makes clear that “normal puberty does not equate to normal fertility,” said Dr. Oquendo del Toro, of Cincinnati Children’s Hospital Medical Center.
Dr. Oquendo del Toro presented results of an observational cohort study of late effects of HSCT that included individuals aged 1-40 years old who received a single HSCT at, or after, 1 year of age.
Twenty-one males in the study had semen available for analysis. Of the 10 males who received myeloablative conditioning (MAC), 8 had azoospermia, and 2 more had oligoteratospermia (low sperm count with abnormal morphology). For the 11 males who received reduced intensity conditioning (RIC), eight had azoospermia, two had semen samples that showed oligoteratospermia, and one had a normal semen analysis.
The median age at transplant for these males was 14.5 years, and patients were a median of 19 years old at follow-up, Dr. Oquendo del Toro said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
For females in the study, low levels of anti-Müllerian hormone (AMH) – generally considered the best surrogate lab value for ovarian reserve – were nearly as common. Of 14 females receiving MAC, 13 (93%) had low AMH, as did 6 of 8 (75%) female patients who received RIC.
Individuals with more than one HSCT were excluded, as were those with Fanconi anemia, which itself carries a risk of gonadal failure. The study’s two aims were to investigate gonadal function as well as fertility potential after receipt of either RIC or MAC for HSCT.
Patients were seen by an endocrinologist who assessed testicular volume and assigned a Tanner stage. At age 11 and older, patients’ gonadal function was assessed on an annual basis by obtaining levels of luteinizing hormone and follicle stimulating hormone for all patients; female estradiol levels were tracked, as were male testosterone levels.
Assessment of fertility potential required additional laboratory testing: For females, the investigators obtained AMH levels, while for males, semen analysis was coupled with serum levels of inhibin B, an indicator of Sertoli cell function.
A total of 72 males were more than 1 year post-HSCT in the cohort, and of these, 41 were at least 11 years old and had achieved pubertal status according to laboratory evaluation. In all, 22 of the male patients received RIC, and 19 received MAC.
Males receiving MAC were a median 20 years old at their follow-up evaluation, and a median 6 years post-HSCT, while the RIC group were a median of 18.5 years old and 5.5 years out from their transplant.
Of the 50 females who were more than 1 year post-HSCT, 25 were pubertal and 11 years old or older. Nine of the female patients received RIC, and 16 received MAC.
Females who received MAC were a median 12.1 years old and 4.1 years post-HSCT at their follow-up evaluation. Females receiving RIC were a median 16 years old, and 6.5 years post-HSCT at the time of evaluation.
Patients received their transplants for a variety of malignant and nonmalignant conditions.
“We saw relatively normal gonadotropins after both reduced intensity and myeloablative conditioning in males,” Dr. Oquendo del Toro said. Of the MAC group, 4 of 15 (27%) had elevated follicle stimulating hormone levels, as did 2 of 17 (12%) of the RIC group. Elevated luteinizing hormone levels were seen in 2 of 15 (13%) of the MAC group and 1 of 17 (6%) of the RIC group. Four patients in each group had abnormally low testosterone levels.
However, when the investigators looked at inhibin B levels in males, they found abnormally low levels in 9 of 15 (60%) of those who received MAC, and in 6 of 15 (40%) of those who received RIC. These results meshed with the severely abnormal semen analyses investigators found from those participants for whom a sample was available, Dr. Oquendo del Toro said.
For females, estradiol levels were significantly lower for those who had received MAC, with 7 of 11 (64%) of that group having abnormally low estradiol levels. The levels approached 0 pg/mL for many, said Dr. Oquendo del Toro. None of the eight patients who had received RIC had abnormally low estradiol levels (P = .0008).
“Male puberty is relatively well preserved after both myeloablative and reduced intensity conditioning, but there is a greater than 90% risk of male infertility associated with both reduced intensity and myeloablative conditioning for HSCT,” Dr. Oquendo del Toro said.
For females, the study paints a different picture. “We saw decreased premature ovarian failure after reduced intensity conditioning … but the fertility potential as assessed by anti-Müllerian hormone was decreased” after both conditioning regimens, she said.
Dr. Oquendo del Toro reported having no conflicts of interest.
SOURCE: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.
REPORTING FROM THE 2018 BMT TANDEM MEETINGS
Key clinical point:
Major finding: Of 21 males receiving reduced intensity conditioning or myeloablative conditioning, all but one had azoospermia or oligoteratospermia.
Study details: Observational cohort study of 41 males and 25 females receiving pediatric HSCT.
Disclosures: Dr. Oquendo del Toro reported having no conflicts of interest.
Source: Oquendo del Toro H et al. The 2018 BMT Tandem Meetings, Abstract 88.