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Roe AH, Wu J, McAllister A, Aragoncillo S, Nunyi E, Voltaire S, Pishko A, Sayani F, Cebert M. Contraceptive Attitudes and Beliefs of Women With Sickle Cell Disease: A Qualitative Study. Womens Health Issues 2024:S1049-3867(24)00027-6. [PMID: 38704343 DOI: 10.1016/j.whi.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES We aimed to qualitatively explore factors influencing contraceptive use in women living with sickle cell disease (SCD). STUDY DESIGN We conducted a semi-structured qualitative study using data from interviews with reproductive-aged women with SCD. The Theory of Planned Behavior, which describes an individual's attitudes, subjective norms, and perceived behavioral control as drivers of a health behavior, served as a framework for data collection and thematic analysis. RESULTS We analyzed interviews from 20 participants. Attitudes toward contraception showed skepticism regarding hormonal contraception and concern about adverse effects of contraception related to SCD. The role of subjective norms in contraceptive choice depended on whether participants possessed trusted sources of information, such as health care providers, family, and friends, or whether they relied on themselves alone in their contraceptive decision-making. The influence of health care providers was complicated by inconsistent and sometimes conflicting counseling. Finally, with regard to participants' perceived control in their contraceptive choices, some were motivated to alleviate menstrual pain or prevent SCD-related pregnancy risks, but many reported feeling disempowered in contraceptive decision-making settings because of their demographic characteristics or pressure from health care providers. CONCLUSIONS Women living with SCD are influenced by many factors similar to those documented for other populations when making decisions about contraception. However, SCD amplifies both the importance and risks of contraception and may also complicate individuals' autonomy and contraceptive access. Hematology and reproductive health providers should recognize the risk of coercion, maximize patients' reproductive agency, and coordinate reproductive health counseling for patients with SCD.
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Affiliation(s)
- Andrea H Roe
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania.
| | - Jessica Wu
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Shelley Aragoncillo
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Esofi Nunyi
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Samuelle Voltaire
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Allyson Pishko
- Department of Hematology, Penn Medicine, Philadelphia, Pennsylvania
| | - Farzana Sayani
- Department of Hematology, Penn Medicine, Philadelphia, Pennsylvania
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Hoffman EA, Kaufman J, Koelper NC, Sonalkar S, Roe AH. Outcomes After Induction of Labor Compared With Dilation and Evacuation for the Management of Rupture of Membranes in the Second Trimester. Obstet Gynecol 2024; 143:550-553. [PMID: 38262065 DOI: 10.1097/aog.0000000000005515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/12/2023] [Indexed: 01/25/2024]
Abstract
Previable and periviable rupture of membranes is associated with significant morbidity for the pregnant patient. For those who have a choice of options and undergo active management, it is not known how the risks of induction of labor compare with those for dilation and evacuation (D&E). We performed a retrospective cohort study of patients with rupture of membranes between 14 0/7 and 23 6/7 weeks of gestation who opted for active management. Adverse events (52.2% vs 16.9%, P <.01) and time to uterine evacuation greater than 24 hours (26.7% vs 9.6%, P =.01) were more common among patients undergoing induction of labor. In a multivariable regression, induction of labor was an independent risk factor for complications (odds ratio 5.70, 95% CI, 2.35-13.82) compared with D&E. Severe complications were rare across both groups (4.4% for patients undergoing induction vs 2.6% for D&E, P =.63). Given the differing risks by termination method, access to D&E is an important treatment option for this patient population.
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Affiliation(s)
- Elizabeth A Hoffman
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Chesnokova AE, Nagendra D, Dixit E, McAllister A, Schachter A, Schreiber CA, Roe AH, Sonalkar S. Trust in provider and stigma during second-trimester abortion. Sex Reprod Healthc 2024; 39:100932. [PMID: 38061314 DOI: 10.1016/j.srhc.2023.100932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 10/31/2023] [Accepted: 11/23/2023] [Indexed: 03/16/2024]
Abstract
OBJECTIVE To determine whether trust in the provider and sociodemographics are associated with individual-level abortion stigma. METHODS We performed a cross sectional and exploratory study design using secondary analysis of a randomized trial that enrolled participants undergoing second trimester abortion. We collected baseline survey data from 70 trial participants to assess stigma (Individual Level of Abortion Stigma scale, ILAS; range 0-4), trust in provider (Trust in Physician scale; range 1-5), anxiety, depression, and sociodemographics. We performed multiple linear regression, for which ILAS score was the outcome of interest. Univariate associations were used to inform the regression model. RESULTS The mean abortion stigma score was at the low end of the ILAS at 1.21 (range 0.2-2.8, SD 0.66). Age, race, income, BMI, parity, gestational age at time of abortion, and reasons for ending the pregnancy were not significantly associated with the ILAS score. Higher trust in provider scores were (m 4.0, SD 0.49) and inversely related to the ILAS score, even after adjustment for confounders (β -0.02, CI -0.03 to -0.004, p = 0.013). Screening positive for anxiety or depression was associated with a higher ILAS score ((β 0.48, CI 0.10, 0.90, p = 0.015); (β = 0.27 CI -0.097, 0.643)), while cohabitation was associated with lower ILAS score (β -0.44, CI -0.82 to -0.57, p = 0.025). CONCLUSIONS Trust in an abortion provider, anxiety, depression, and cohabitation are associated with abortion stigma among people seeking second trimester abortion care. Interventions that improve trust in a provider may be an area of focus for addressing abortion stigma. Future research should confirm these findings in larger populations and across diverse locations and demographics and to conduct qualitative research to understand what patients perceive as trust-promoting behaviors and words during abortion encounters.
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Affiliation(s)
- Arina E Chesnokova
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Divyah Nagendra
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Eshani Dixit
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA; Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854, USA.
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Allison Schachter
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA
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Agarwal S, Stanek JR, Vesely SK, Creary SE, Cronin RM, Roe AH, O’Brien SH. Pregnancy-related thromboembolism in women with sickle cell disease: An analysis of National Medicaid Data. Am J Hematol 2023; 98:1677-1684. [PMID: 37551881 PMCID: PMC10592294 DOI: 10.1002/ajh.27045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/09/2023]
Abstract
Pregnancy and sickle cell disease (SCD) both individually carry a risk of thromboembolism (TE). Pregnancy in people with SCD may further enhance the prothrombotic effect of the underlying disease. The objectives of this study were to determine the rate and risk factors for arterial and venous thrombosis in pregnant people with SCD. Administrative claims data from the United States Centers for Medicare and Medicaid Service Analytic eXtract from 2006 to 2018 were used. The study population included people with SCD from the start of their first identified pregnancy until 1 year postpartum and a control cohort of pregnant people without SCD of similar age and race. Outcomes of interest were identified with ICD-9 or 10 codes. Logistic regression analyses were used to analyze risk factors. We identified infant deliveries in 6388 unique people with SCD and 17 110 controls. A total of 720 venous thromboembolism (11.3%) and 335 arterial TE (5.2%) were observed in people with SCD compared to 202 (1.2%) and 95 (0.6%) in controls. People with SCD had an 8-11 times higher odds of TE compared to controls (p < .001). Within the SCD cohort, age, hemoglobin SS (HbSS) genotype, hypertension, and history of thrombosis were identified as independent risk factors for pregnancy-related TE. Pregnancy-specific factors (pre-eclampsia, eclampsia, multigestational pregnancy) were not associated with TE. In conclusion, the risk of pregnancy-related TE is considerably higher in people with SCD compared with controls without SCD. Hence, people with SCD, particularly those with multiple risk factors may be candidates for thromboprophylaxis during pregnancy and the postpartum period.
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Affiliation(s)
- Shreya Agarwal
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
| | - Joseph R Stanek
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Biostatistics Resource at Nationwide Children’s Hospital, Columbus, OH
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, OK
| | - Susan E. Creary
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Andrea H. Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Sarah H. O’Brien
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
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Bala NS, Stanek JR, Vesely SK, Cronin RM, Creary SE, Roe AH, Xu W, O’Brien SH. Comparison of thromboembolism outcomes in patients with sickle cell disease prescribed hormonal contraception. Blood Adv 2023; 7:6140-6150. [PMID: 37585480 PMCID: PMC10582388 DOI: 10.1182/bloodadvances.2023010204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 08/18/2023] Open
Abstract
Patients with sickle cell disease (SCD) are at a risk of thromboembolism (TE), and use of hormonal contraception can further increase that risk. This study aims to assess patterns of hormonal contraceptive use and compare risk of contraception-related TE between combined hormonal contraceptives (CHCs) and progestin-only contraceptives (POCs). Patients with SCD aged between 12 and 44 years with a new prescription of a hormonal contraceptive in the Centers for Medicare and Medicaid Services Medicaid Analytic eXtract database (2006-2018) were followed up to 1 year. We identified 7173 new users: 44.6% initiated CHC and 55.4% initiated POC. Combined oral contraceptive pills (OCPs; 36.5%) and progestin-only depot medroxyprogesterone acetate (33.9%) were the most frequently prescribed agents. A total of 1.8% of contraception users had a new diagnosis of TE within 1 year of the first identified contraception prescription. There were no significant differences in TE event rates between CHC and POC users (17.2 and 24.7 events per 1000 person-years, respectively). In patients prescribed OCP, there were no differences in TE event rates based on estrogen dose or progestin generation. Transdermal patch had a 2.4-fold increased risk of TE as compared with that of OCP. Although limited by the retrospective study design and use of administrative claims data, this study found no significant differences in TE rates between new users of CHC and POC in patients with SCD. Careful evaluation of underlying TE risk factors should be considered for each patient with SCD before initiation of hormonal contraception.
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Affiliation(s)
- Natasha S. Bala
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
| | - Joseph R. Stanek
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, The University of Oklahoma, Oklahoma City, OK
| | - Robert M. Cronin
- Department of Internal Medicine, The Ohio State University, College of Medicine, Columbus, OH
| | - Susan E. Creary
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Andrea H. Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Wendy Xu
- Division of Health Services Management and Policy, The Ohio State University, College of Public Health, Columbus, OH
| | - Sarah H. O’Brien
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
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Gutman S, Connor H, Mumford SL, Gilmore E, Roe AH, Schreiber CA. Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care. Contraception 2023; 126:110114. [PMID: 37467921 DOI: 10.1016/j.contraception.2023.110114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES This study aimed to evaluate the feasibility and acceptability of virtual group contraceptive counseling in the abortion care setting. STUDY DESIGN Patients seeking abortion care at an urban university hospital were invited to participate in this cohort study. Prior to their clinical appointments, groups of two to six patients participated in 45-minute virtual contraceptive counseling visits facilitated by study staff. Contraceptive method use, effectiveness, and side effects were reviewed according to group interest. Participant satisfaction scores were collected immediately following the sessions. After their appointments, providers estimated the time spent on contraceptive counseling during the clinical visit. RESULTS Of 195 patients approached, 86 (44%) were enrolled. Fifty-seven (66%) enrolled patients completed a session. The most common reason for declining enrollment was concern about the time commitment. Most (93%) participants reported being "satisfied" or "very satisfied" overall, and 96% would recommend group contraceptive counseling to a friend. Providers reported that compared to typical counseling, participants required a shorter amount of time during the clinical visit than nonparticipants (time spent <5 minutes: 74% vs 54%). CONCLUSIONS Virtual group contraceptive counseling for patients seeking abortion was feasible and acceptable in this study. Group virtual visits may reduce provider time burden, add value when virtual care delivery is desired or required, and deserve further study. IMPLICATIONS Family planning clinics can consider incorporating virtual group counseling as a person-centered and efficient approach to contraceptive counseling at the time of abortion care.
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Affiliation(s)
- Sarah Gutman
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Hannah Connor
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Sunni L Mumford
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Emma Gilmore
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Andrea H Roe
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Courtney A Schreiber
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
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Peng G, Taylor-Cousar JL, Lee M, Keller A, West NE, Kazmerski TM, Goralski JL, Aitken ML, Roe AH, Hadjiliadis D, Uluer A, Flume PA, Mody S, Bray LA, Jain R. Association between unplanned pregnancies and maternal exacerbations in cystic fibrosis. J Cyst Fibros 2023; 22:796-803. [PMID: 37029015 DOI: 10.1016/j.jcf.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION Following availability of the highly effective cystic fibrosis (CF) transmembrane conductance regulator modulator, elexacaftor/tezacaftor/ivacaftor, there was a near doubling of pregnancies reported in the United States (US) in people with CF. We sought to determine health impacts of planned (PP) versus unplanned pregnancies (UP). METHODS We collected retrospective pregnancy data from January 2010-December 2020 from 11 US CF centers. After adjusting for potential confounding effects, we conducted multivariable, multilevel longitudinal regression analysis using mixed effect modeling to assess whether changes in percent predicted forced expiratory volume in one second (ppFEV1), body mass index (BMI), and pulmonary exacerbations (PEx) 1-year-pre- to 1-year-post-pregnancy were associated with pregnancy planning. RESULTS Our analysis included 163 people with 226 pregnancies; the cohort had a mean age at conception of 29.6 years, mean pre-pregnancy ppFEV1 of 75.4 and BMI of 22.5 kg/m2. PpFEV1 declined in both PP (adjusted decline of -2.5 (95% CI: -3.8, -1.2)) and UP (adjusted decline of -3.0 (95% CI: -4.6, -1.4)) groups, they did not differ from each other (p = 0.625). We observed a difference in change in the annual number of PEx pre- to post-pregnancy (PP: 0.8 (0.7, 1.1); UP: 1.3 (1.0, 1.7); interaction effect p = 0.029). In a subset of people with available infant data, infants resulting from UP had more preterm births, lower APGAR scores, and more intensive care unit stays. CONCLUSIONS Following UP, there is an increased trajectory for PEx and potentially for infant complications compared to PP. Clinicians should consider increased surveillance in the setting of UP.
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Affiliation(s)
- Giselle Peng
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | | | - MinJae Lee
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | - Ashley Keller
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | | | | | | | | | - Andrea H Roe
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Denis Hadjiliadis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Ahmet Uluer
- Harvard/Boston Children's Hospital and Brigham & Women's Hospital, Boston, MA, United States
| | - Patrick A Flume
- Medical University of South Carolina, Charleston, SC, United States
| | - Sheila Mody
- University of California San Diego, San Diego, CA, United States
| | - Leigh Ann Bray
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Raksha Jain
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States.
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Roe AH, Koelper N, McAllister A, Barnhart KT, Schreiber CA, Hadjiliadis D. Cervical mucus quality in females with and without cystic fibrosis. J Cyst Fibros 2023; 22:804-805. [PMID: 36966038 DOI: 10.1016/j.jcf.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/13/2023] [Accepted: 03/18/2023] [Indexed: 03/27/2023]
Affiliation(s)
- Andrea H Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Arden McAllister
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Denis Hadjiliadis
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Roe AH, McAllister A, Kete C, Pishko A, Whitworth H, Schreiber CA, Sayani FA. Sex as an Independent Risk Factor for Venous Thromboembolism in Sickle Cell Disease: A Cross-Sectional Study. J Womens Health (Larchmt) 2022; 31:1467-1471. [PMID: 35675680 PMCID: PMC9836659 DOI: 10.1089/jwh.2022.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Venous thromboembolism (VTE) affects up to 25% of individuals with sickle cell disease (SCD), but risk factors are not well characterized. We sought to measure the prevalence of VTE among SCD patients in our health system and to describe the relationship between medical history, biological sex, and VTE. We performed a retrospective chart review of SCD patients who visited an outpatient hematology clinic within Penn Medicine between June 2014 and June 2019. Demographics and medical history were compared across those with and without a history of VTE. We developed a logistic regression model to describe factors independently associated with VTE. Of 597 patients with SCD who were identified, 147 (24.6%) had a history of VTE; 100 were female and 47 were male. In the regression model, female sex was independently associated with history of VTE (odds ratio 1.91, 95% confidence interval 1.26-2.91), as were pulmonary hypertension, hydroxyurea use, and history of stroke. Among females only, 49.7% were parous and 18.8% had used oral contraceptives, and these proportions did not differ by history of VTE. One-quarter of the SCD patients in our health system had a history of VTE, confirming significantly higher rates than in the general population. Females had twice the odds of VTE compared to males, highlighting an important sex disparity in SCD disease outcomes and raising questions regarding optimal pregnancy and contraceptive care for females with SCD.
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Affiliation(s)
- Andrea H. Roe
- Department of Obstetrics and Gynecology, and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Arden McAllister
- Department of Obstetrics and Gynecology, and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Corinne Kete
- Department of Obstetrics and Gynecology, and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allyson Pishko
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hilary Whitworth
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Courtney A. Schreiber
- Department of Obstetrics and Gynecology, and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Farzana A. Sayani
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Flynn AN, Hoffman E, Murphy C, Jen A, Schreiber CA, Roe AH. Fetomaternal hemorrhage assessment in Rh-negative patients undergoing dilation and evacuation between 20 and 24 weeks' gestational age: A retrospective cohort study. Contraception 2022; 110:27-29. [PMID: 35192809 DOI: 10.1016/j.contraception.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the rate of requiring more than one 300-mcg Rh D immune globulin dose for fetomaternal hemorrhage (FMH) at the time of second-trimester dilation and evacuation (D + E). STUDY DESIGN We performed a retrospective cohort analysis of patients at greater than 20 weeks' gestation who underwent D + E, had Rh D-negative blood type, and received FMH quantification testing. RESULTS Of 25 eligible patients, 24 had negative quantification of FMH; one had positive quantification that did not meet the clinical threshold for additional dosing. CONCLUSIONS The absolute risk of requiring additional Rh D immune globulin after D+E for pregnancies greater than 20 weeks' gestation was 0%.
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Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia PA, United States.
| | - Elizabeth Hoffman
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, PA, United States
| | - Christina Murphy
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia PA, United States
| | - Alicia Jen
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia PA, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia PA, United States
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia PA, United States
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Oxman R, Roe AH, Ullal J, Putman MS. Gestational and pregestational diabetes in pregnant women with cystic fibrosis. J Clin Transl Endocrinol 2022; 27:100289. [PMID: 34984172 PMCID: PMC8693285 DOI: 10.1016/j.jcte.2021.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/04/2022] Open
Abstract
As cystic fibrosis transmembrane regulator (CFTR) modulator therapies offer greater longevity and improved health quality, women living with cystic fibrosis (CF) are increasingly pursuing pregnancy. Maternal risks for pregnant women with CF largely depend on a woman's baseline pulmonary and pancreatic function, and the majority of CF pregnancies will successfully end in live births. Diabetes, either gestational or pre-existing cystic fibrosis-related diabetes (CFRD), is highly prevalent in women with CF, affecting 18 to 62% of pregnancies in recent CF center reports. In addition to the rising incidence of CFRD with age, gestational diabetes is also more common in women with CF due to lower insulin secretion, higher insulin resistance, and increased hepatic glucose production as compared to pregnant women without CF. Diabetes occurring during pregnancy has important implications for maternal and fetal health. It is well established in women without CF that glycemic control is directly associated with risks of fetal malformation, neonatal-perinatal mortality, cesarean delivery and need for neonatal intensive care. Small studies in women with CF suggest that pregnancies affected by diabetes have an increased risk of preterm delivery, lower gestational age, and lower fetal birth weight compared to those without diabetes. Women with CF preparing for pregnancy should be counseled on the risks of diabetes and should undergo routine screening for CFRD with oral glucose tolerance testing (OGTT) if not already completed in the past six months. Glycemic control in those with pre-gestational CFRD should be optimized prior to conception. Insulin is preferred for the management of diabetes in pregnant women with CF via multiple daily injections or insulin pump therapy, and continuous glucose monitors (CGM) can be useful in mitigating hypoglycemia risks. Women with CF face many unique challenges impacting diabetes care during pregnancy and would benefit from support by a multidisciplinary care team, including nutrition and endocrinology, to ensure healthy pregnancies.
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Affiliation(s)
- Rachael Oxman
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Andrea H. Roe
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jagdeesh Ullal
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa S. Putman
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
- Departments of Pediatrics and Medicine, Harvard Medical School, Boston, MA, USA
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12
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Naz Khan F, Mason K, Roe AH, Tangpricha V. CF and male health: Sexual and reproductive health, hypogonadism, and fertility. J Clin Transl Endocrinol 2022; 27:100288. [PMID: 34987977 PMCID: PMC8695349 DOI: 10.1016/j.jcte.2021.100288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/28/2022] Open
Abstract
Over 30,000 people in the United States are diagnosed with cystic fibrosis (CF), and over 50% of those with CF are male. Men with CF face specific and sometimes difficult sexual and reproductive health (SRH) issues, including infertility and hypogonadism. Male infertility affects over 95% of men with CF, with obstructive azoospermia resulting from congenital bilateral absence of the vas deferens being the primary cause of infertility. SRH education for males with CF represents an important opportunity for clinical improvement, as the majority of men with CF know that their disease impacts their fertility, however the depth of this understanding varies significantly. Hypogonadism is a clinical syndrome that affects men with low testosterone level, a common finding among men with CF that has clinical implications and can significantly affect quality of life. Better understanding of SRH attitudes, the prevalence of hypogonadism, and management of infertility in men with CF should remain future research priorities.
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Affiliation(s)
- Farah Naz Khan
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, United States
| | - Kelly Mason
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA and the Atlanta VA Medical Center, Atlanta, GA, United States
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13
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Stransky OM, Pam M, Ladores SL, Birru Talabi M, Borrero S, Godfrey EM, Roe AH, Sawicki GS, Zuckerwise LC, Mody S, Mentch L, Deal A, O’Leary R, Taylor-Cousar JL, Jain R, Kazmerski TM. Engaging Stakeholders in the Development of a Reproductive Goals Decision AID for Women with Cystic Fibrosis. J Patient Exp 2022; 9:23743735221077527. [PMID: 35128042 PMCID: PMC8814976 DOI: 10.1177/23743735221077527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective: More people with cystic fibrosis (pwCF) are reaching adulthood and considering their reproductive futures. Unfortunately, many pwCF report gaps in their reproductive healthcare. We describe measures of stakeholder engagement in developing a reproductive goals decision aid for women with CF called MyVoice:CF. Methods: Stakeholders reviewed the content, design, and usability of the tool, which was informed by prior research related to CF family planning experiences and preferences as well as a conceptual understanding of reproductive decision making. We evaluated stakeholder engagement via process measures and outcomes of stakeholder involvement. We collected data via recorded stakeholder recommendations and surveys. Results: Fourteen stakeholders participated and the majority described their role on the project as "collaborator", "advisor", or "expert." Most felt their expectations for the project were met or exceeded, that they had contributed significantly, and that they received sufficient and frequent information about the process. All stakeholders provided recommen-dations and clarified aims for a CF-specific family planning tool, including its content and focus on facilitating shared decision making. Discussion: Utilizing meaningful stakeholder contributions, we developed MyVoice:CF, a novel web-based decision aid to help women with CF engage in shared decision-making regarding their reproductive goals. Practical Value: Our findings from working with stakeholders for MyVoice:CF indicate that disease-specific reproductive health resources can and should be designed with input from individuals in the relevant communities.
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Affiliation(s)
- Olivia M. Stransky
- Center for Women's Health Research and Innovation, 230 McKee Place, Pittsburgh, PA 15213, USA
| | - Molly Pam
- Cystic Fibrosis Reproductive and Sexual Health Collaborative, Seattle, WA, USA
| | - Sigrid L. Ladores
- University of Alabama at Birmingham, School of Nursing, 1701 University Blvd, THT 422, Birmingham, AL 35294, USA
| | - Mehret Birru Talabi
- Center for Women's Health Research and Innovation, 230 McKee Place, Pittsburgh, PA 15213, USA
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Sonya Borrero
- Center for Women's Health Research and Innovation, 230 McKee Place, Pittsburgh, PA 15213, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA
| | - Emily M. Godfrey
- Department of Family Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Andrea H. Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | | | - Lisa C. Zuckerwise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, 1161 21 Avenue South, B-1100 Medical Center North, Nashville, TN 37232, USA
| | - Sheila Mody
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego
| | - Laura Mentch
- Cystic Fibrosis Reproductive and Sexual Health Collaborative, Seattle, WA, USA
| | - Ashley Deal
- School of Design, Carnegie Mellon University, 5130 Margaret Morrison St, Pittsburgh, PA 15213, USA
| | - Raelynn O’Leary
- School of Design, Carnegie Mellon University, 5130 Margaret Morrison St, Pittsburgh, PA 15213, USA
| | - Jennifer L. Taylor-Cousar
- Divisions of Pulmonary, Critical Care and Sleep Medicine and Pediatric Pulmonary Medicine, National Jewish Health, 1400 Jackson Street, Denver, Colorado 80206, USA
| | - Raksha Jain
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Traci M. Kazmerski
- Center for Women's Health Research and Innovation, 230 McKee Place, Pittsburgh, PA 15213, USA
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, University Center, 120 Lytton Ave., Mezzanine Floor Suite M060, Pittsburgh, PA, 15213, USA
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14
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Rubin ES, Huttler A, Mainigi M, Roe AH. Cervix Surgical uterine evacuation in patients with two cervices: a case series. Contraception 2022; 108:73-77. [PMID: 35031305 DOI: 10.1016/j.contraception.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe the clinical circumstances, surgical approach, intraoperative challenges, and outcomes of patients with two cervices undergoing uterine evacuation for spontaneous, incomplete, or induced abortion at our institution. STUDY DESIGN We used diagnostic and procedure codes related to uterine anomalies and uterine evacuation to identify patients with cervical duplication who underwent uterine evacuation at Penn Medicine from January 2008 to December 2020. RESULTS We identified fifteen patients with cervical duplication in whom we performed uterine evacuations during nineteen pregnancies. We describe in detail each patient's first pregnancy with uterine evacuation at our institution, of which providers performed eleven in the first trimester and four in the second trimester. Ten patients had a known diagnosis of cervical duplication prior to pregnancy. Five patients did not have a diagnosis of cervical duplication prior to pregnancy and providers newly made this diagnosis intraoperatively either at our institution or referring clinics. Providers at outside institutions referred three patients to our institution for incomplete procedures. At our institution, one patient had a procedure notable for a major complication. Eight other cases were notable for surgical challenges including difficulty placing osmotic dilators, difficulty identifying the correct cervix for local anesthesia, and contralateral cervical and uterine horn instrumentation. CONCLUSIONS This case series suggests surgical abortion in patients with two cervices is rare, but generally safe. The majority of patients did not have major complications, despite presenting a variety of unique procedural challenges. Surgical providers were sometimes the first to make the diagnosis of a second cervix.
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Affiliation(s)
- Elizabeth S Rubin
- Perelman School of Medicine at the University of Pennsylvania, Department of Obstetrics and Gynecology, Philadelphia, PA 19104, United States.
| | - Alexandra Huttler
- Perelman School of Medicine at the University of Pennsylvania, Department of Obstetrics and Gynecology, Philadelphia, PA 19104, United States
| | - Monica Mainigi
- Perelman School of Medicine at the University of Pennsylvania, Department of Obstetrics and Gynecology, Philadelphia, PA 19104, United States
| | - Andrea H Roe
- Perelman School of Medicine at the University of Pennsylvania, Department of Obstetrics and Gynecology, Philadelphia, PA 19104, United States
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15
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Roe AH, Merjaneh L, Oxman R, Hughan KS. Gynecologic health care for females with cystic fibrosis. J Clin Transl Endocrinol 2021; 26:100277. [PMID: 34849351 PMCID: PMC8607192 DOI: 10.1016/j.jcte.2021.100277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/03/2021] [Accepted: 11/12/2021] [Indexed: 11/19/2022] Open
Abstract
Females with CF may have cyclic lung symptoms, yeast infections, and urinary incontinence. Contraception is safe, but comorbidities should be considered in method selection. Females with CF have reduced fertility, though the etiology is unknown. Females with CF underutilize basic preventive gynecologic services.
As females with cystic fibrosis (CF) increasingly reach their reproductive years, gynecologic issues have become an important area of clinical care and research. First, females with CF may have disease-specific gynecologic problems, including cyclic pulmonary symptoms, vaginal yeast infections, and urinary incontinence. Next, contraceptive methods are thought to be overall safe and effective, however further research is needed to confirm this and to understand the lower rates of uptake among females with CF compared to the general population. Further, females with CF have reduced fertility, although the etiology of this is unknown and under investigation. While assisted reproductive technologies may help achieve pregnancy, decision-making around parenthood remains complex. Finally, while patients and providers agree on the importance of sexual and reproductive health care, females with CF underutilize basic preventive services such as cervical cancer screening, and better approaches are needed to bridge the gap with gynecology. In this review, we discuss the current state of gynecologic care for females with CF, as well as clinical and research opportunities for improvement.
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Affiliation(s)
- Andrea H. Roe
- Division of Family Planning, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
- Corresponding author.
| | - Lina Merjaneh
- Division of Endocrinology, Department of Pediatrics, University of Washington, Seattle, WA 98115, United States
| | - Rachael Oxman
- Division of Endocrinology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, United States
| | - Kara S. Hughan
- Division of Pediatric Endocriology and Metabolism, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, United States
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16
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Burlando AM, Flynn AN, Gutman S, McAllister A, Roe AH, Schreiber CA, Sonalkar S. The Role of Subcutaneous Depot Medroxyprogesterone Acetate in Equitable Contraceptive Care: A Lesson From the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol 2021; 138:574-577. [PMID: 34623069 PMCID: PMC8454279 DOI: 10.1097/aog.0000000000004524] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, health care professionals have made swift accommodations to provide consistent and safe care, including emphasizing remote access to allow physical distancing. Depot medroxyprogesterone acetate intramuscular injection (DMPA-IM) prescription is typically administered by a health care professional, whereas DMPA-subcutaneous has the potential to be safely self-injected by patients, avoiding contact with a health care professional. However, DMPA-subcutaneous is rarely prescribed despite its U.S. Food and Drug Administration approval in 2004 and widespread coverage by both state Medicaid providers and many private insurers. Depot medroxyprogesterone acetate users are disproportionately non-White, and thus the restriction in DMPA-subcutaneous prescribing may both stem from and contribute to systemic racial health disparities. We review evidence on acceptability, safety, and continuation rates of DMPA-subcutaneous, consider sources of implicit bias that may impede prescription of this contraceptive method, and provide recommendations for implementing DMPA-subcutaneous prescribing.
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Affiliation(s)
- Audrey M Burlando
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Jain R, Kazmerski TM, Zuckerwise LC, West NE, Montemayor K, Aitken ML, Cheng E, Roe AH, Wilson A, Mann C, Ladores S, Sjoberg J, Poranski M, Taylor-Cousar JL. Pregnancy in cystic fibrosis: Review of the literature and expert recommendations. J Cyst Fibros 2021; 21:387-395. [PMID: 34456158 DOI: 10.1016/j.jcf.2021.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis (CF) was historically a disease largely afflicting children. Due to therapeutic advancements, there are now more adults with CF than children. In the past decade, medications including Cystic Fibrosis Transmembrane conductance Regulator (CFTR) modulators became available that treat the underlying cause of CF and are dramatically improving lung function as well as quality and quantity of life for people with CF. As a result, more women with CF are becoming pregnant. We gathered a panel of experts in CF care, family planning, high risk obstetrics, nutrition, genetics and women with CF to review current literature on pregnancies and to provide care recommendations for this unique population.
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Affiliation(s)
- Raksha Jain
- Department of Medicine, University of Texas Southwestern, 5323 Harry Hines Blvd., Dallas, TX 75390-8558, United States.
| | - Traci M Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, 120 Lytton Ave. Suite M060 University Center, Pittsburgh, PA 15213, United States
| | - Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 MCN, Nashville, TN 37232, United States
| | - Natalie E West
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St. 5th Floor, Baltimore, MD 21205, United States
| | - Kristina Montemayor
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St. 5th Floor, Baltimore, MD 21205, United States
| | - Moira L Aitken
- Department of Medicine, University of Washington, 1959 NE Pacific Street - Rm BB 1361, Seattle WA 98195-6522, United States
| | - Edith Cheng
- Maternal Fetal Medicine, Maternal Fetal Medicine, Medical Genetics, University of Washington, United States
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 1000 Courtyard, Philadelphia, PA 19106, United States
| | - Alexandra Wilson
- Department of Medicine, Cystic Fibrosis Clinical Research, National Jewish Health, 1400 Jackson Street, K333b, Denver, CO 80206, United States
| | - Caitlin Mann
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, B-1100 MCN, Nashville, TN 37232, United States
| | - Sigrid Ladores
- School of Nursing, The University of Alabama at Birmingham, NB 470L, 1720 2nd Avenue South, Birmingham, AL 35294-1210, United States
| | - Jacqui Sjoberg
- Adult with Cystic Fibrosis, 130 Johnston Dr, Highland Park, IL 60035, United States
| | - Madeline Poranski
- Adult with Cystic Fibrosis, 2700 University Ave. W. Apt. 416, St. Paul, MN 55114, United States
| | - Jennifer L Taylor-Cousar
- Departments of Medicine and Pediatrics, National Jewish Health, 1400 Jackson Street; J318, Denver, CO 80206, United States
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18
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Roe AH, Lang B, McAllister A, Gaitors MC, Smith-Whitley K, Schreiber CA, Sayani F. Contraceptive use and preferences among females with sickle cell disease. Contraception 2021; 105:42-45. [PMID: 34418379 DOI: 10.1016/j.contraception.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Females with sickle cell disease now have a life expectancy that extends well into and beyond their reproductive years. Pregnancy and childbirth are accompanied by high morbidity and mortality in this population, rendering contraception a critical part of their health care. METHODS We approached adult female patients of the Hospital of the University of Pennsylvania hematology clinic who were of reproductive age (ages 18-45) and carried a diagnosis of sickle cell disease. We evaluated contraceptive method uptake and method characteristic preferences, as well as other reproductive history, and compared contraceptive uptake rates to that from female respondent data from the National Survey of Family Growth (2017-2019). RESULTS Of 95 eligible patients, we completed surveys with 48 participants (response rate of 51%). Over half (n = 27, 56%) of participants were not currently using any form of contraception-double the rate of the general United States population (25%). The most common contraceptives currently used were the depot medroxyprogesterone (DMPA) injection (n = 6, 13%) and the progestin intrauterine device (IUD) (n = 6, 13%). DMPA uptake was significantly higher, and permanent contraceptive and oral contraceptive pill uptake significantly lower, among these participants with sickle cell disease compared to the general United States population. Participants' preferred contraceptive characteristics included effectiveness (n = 39, 81%), control over when to use the contraceptive (n = 39, 81%), and lack of side effects (n = 38, 79%). CONCLUSIONS Contraceptive uptake was significantly lower and method mix different among females with sickle cell disease compared to the general United States population. Further research is needed on contraceptive safety, non-contraceptive benefits, and contraceptive decision-making for females with sickle cell disease. IMPLICATIONS This study sheds light on the contraceptive choices and preferences of females with sickle cell disease, who are at disproportionate risk for pregnancy complications. In order to maximize the reproductive health of females with sickle cell disease, we must consider how their disease interacts with contraception and better understand how they approach contraceptive decision-making.
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Affiliation(s)
- Andrea H Roe
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.
| | - Britt Lang
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Arden McAllister
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Morine Cebert Gaitors
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Kim Smith-Whitley
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Courtney A Schreiber
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Farzana Sayani
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Division of Hematology and Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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19
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Roe AH, McAllister A, Flynn AN, Martin B, Jiang E, Koelper N, Schreiber CA. The effect of mifepristone pretreatment on bleeding and pain during medical management of early pregnancy loss. Contraception 2021; 104:432-436. [PMID: 33930380 DOI: 10.1016/j.contraception.2021.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare participant-reported bleeding and pain with two medication regimens for early pregnancy loss (EPL). STUDY DESIGN We performed a secondary analysis of a randomized trial in which participants took either mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally 24 hours later or misoprostol alone for medical management of EPL. Participants reported bleeding and pain (Numeric Pain Rating Scale, NPRS, 0-10) with daily paper diaries and at study visits on trial days 3, 8, and 30. We used, Fisher's exact, Pearson chi-square, Wilcoxon rank sum, and Student's t-tests to compare onset, duration, and severity of bleeding and pain symptoms between trial arms after misoprostol administration. RESULTS Among 291 participants who submitted diary data, 143 received mifepristone pretreatment. A larger proportion of this group reported moderate or heavy bleeding on trial day 2, the day of misoprostol administration, compared with those who did not receive pretreatment (73% vs 47%, p < 0.01). Between days 4 and 8, more mifepristone-pretreatment participants reported mild or no bleeding, compared with the misoprostol-only arm (78% vs 61%, p < 0.01). Average pain score for trial days 2-4 was higher for the pretreatment group compared with the misoprostol-only group (6.9 vs 6.0, p = 0.01), and there was a trend toward shorter total duration of pain (15 vs 19 hours, p = 0.08). These differences remained after controlling for treatment success across arms. CONCLUSIONS Mifepristone pretreatment increased the severity of pain but not bleeding and resulted in a shorter trajectory of symptoms during medical management of EPL. IMPLICATIONS Mifepristone pretreatment decreases the duration of heavy bleeding and there was a trend toward decreased duration of pain during medical management of miscarriage, indicating that this medication improves the efficiency, in addition to the efficacy, of this treatment.
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Affiliation(s)
- Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104.
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104
| | - Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104
| | - Brandon Martin
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104
| | - Eva Jiang
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States 19104
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20
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Flynn AN, Roe AH, Koelper N, McAllister A, Sammel MD, Schreiber CA. Timing and efficacy of mifepristone pretreatment for medical management of early pregnancy loss. Contraception 2021; 103:404-407. [PMID: 33476659 DOI: 10.1016/j.contraception.2021.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine the time interval between mifepristone and misoprostol administration associated with the most efficacious early pregnancy loss (EPL) management. STUDY DESIGN We performed a secondary analysis of a randomized trial. Participants with EPL were instructed to take 200 mg oral mifepristone followed by 800 mcg vaginal misoprostol 24 hours later. The primary outcome was gestational sac expulsion at the first follow-up visit (1-4 days after misoprostol use) after a single dose of misoprostol and no additional intervention within 30 days after treatment. Despite specification of drug timing, participants used the medication over a range of time. We graphed sliding average estimates of success and assessed the proportion of treatment successes over time to define timing interval cohorts for analysis. We used multivariable generalized linear regression to assess the association between time interval and success. RESULTS Of 139 eligible participants, 70 (50.4%) self-administered misoprostol before 24 hours, and 69 (49.6%) at or after 24 hours. We defined the following time intervals: 0 to 6 hours (n = 22); 7 to 20 hours (n = 29); and 21 to 48 hours (n = 88). Success occurred in 96.6% of the 7- to 20-hour cohort compared to 54.6% and 87.5% of the cohorts self-administering misoprostol earlier or later, respectively. When adjusting for race, gestational age, diagnosis, bleeding at presentation, insurance status, and enrollment site, participants administering misoprostol between 0 and 6 hours (adjusted risk ratio 0.58, 95% CI 0.40-0.85) and 21 to 48 hours (adjusted risk ratio 0.91, 95% CI 0.72-0.99) had a lower risk of success when compared to participants administering 7 to 20 hours after mifepristone. CONCLUSIONS These data suggest that medical management of EPL has the highest likelihood of success when misoprostol is self-administered 7 to 20 hours after mifepristone. IMPLICATIONS These preliminary data suggest that patients have the highest likelihood of success when misoprostol is taken between 7 and 20 hours after mifepristone. In contrast with medical abortion, simultaneous medication administration may not be as effective as delayed. Future research is needed to confirm the optimal medication time interval.
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Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Nathanael Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Leech MM, Stransky OM, Talabi MB, Borrero S, Roe AH, Kazmerski TM. Exploring the reproductive decision support needs and preferences of women with cystic fibrosis . Contraception 2020; 103:32-37. [PMID: 33068614 DOI: 10.1016/j.contraception.2020.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES As women with cystic fibrosis (CF) live longer, healthier lives, they increasingly face decisions related to their reproductive health. This qualitative study explores their unique decision support needs and preferences to aid in the development of a CF-specific reproductive goals decision aid. STUDY DESIGN Womenwith CF age 18-44 years participated in individual, semi-structured, telephone-based interviews, and women with CF age 18 years and older participated in semi-structured focus group discussions (FGDs). Both explored experiences and attitudes surrounding parenthood, pregnancy, contraception, and preferences for reproductive health care provision.FGDs also explored the use, content, and format of a reproductive goals decision aid for women with CF. We transcribed interviews and FGDs and conducted content and thematic analyses using an inductive approach. RESULTS Twenty women (age range 20-42 years) participated in interviews and 18 women (age range 26-63 years) participated in three FGDs. Major themes identified included: 1) CF complicates pregnancy and parenting decisions; 2) Women make contraceptive decisions within the context of their CF; 3) Women with CF prefer to receive reproductive health counseling from their CF team; 4) Women with CF desire defragmented, coordinated reproductive health care; and 5) A disease-specific reproductive goals decision aid would encourage relevant parenting, pregnancy, and contraceptive discussions. CONCLUSION Women with CF have unique reproductive health care needs and often face uncertainty and disjointed care when making reproductive health and contraceptive decisions. IMPLICATIONS This study underscores the central role of the CF team and illustrates opportunities to better support women with CF in their decisions surrounding sexual and reproductive health, including through a patient-centered, disease-specific, reproductive goals decision aid.
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Affiliation(s)
- Mary M Leech
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Olivia M Stransky
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA
| | - Mehret Birru Talabi
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA; UPMC, Pittsburgh, PA, USA
| | - Sonya Borrero
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA; UPMC, Pittsburgh, PA, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Traci M Kazmerski
- Center for Women's Health Research and Innovation, Pittsburgh, PA, USA; Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Ti AJ, Roe AH, Whitehouse KC, Smith RA, Gaffield ME, Curtis KM. Effectiveness and safety of extending intrauterine device duration: a systematic review. Am J Obstet Gynecol 2020; 223:24-35.e3. [PMID: 31954154 DOI: 10.1016/j.ajog.2020.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/05/2019] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To systematically review the literature to determine if extended use of intrauterine devices, including the copper or levonorgestrel intrauterine device, beyond approved durations is effective and safe for preventing pregnancy. STUDY DESIGN We searched PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Global Index Medicus from inception through June 2019. We considered primary studies of women using the T380A copper or currently available levonorgestrel intrauterine devices past their approved duration (extended use). The primary outcome was pregnancy. Safety outcomes included adverse events and side effects that led to discontinuation. We abstracted study data into evidence tables and assessed study quality as related to the risk of bias, precision, and external validity. For each intrauterine device type, we calculated a pooled pregnancy rate during the first 2 years of extended use using the Poisson inverse variance method. RESULTS Of 4068 studies identified by our search, 4 good-to-poor-quality studies of the 52 mg levonorgestrel intrauterine device (approved for 5 years), with a total of 2098 women starting extended use, and 2 good-to-fair-quality studies of the T380A copper intrauterine device (approved for 10 years), with 245 women starting extended use, met inclusion criteria. For the levonorgestrel intrauterine device, the pooled pregnancy rate was 0.02 per 100 person-years (95% confidence interval, 0.00-0.45) in year 6, 0.03 per 100 person-years (95% confidence interval, 0.00-0.71) in year 7, and 0.02 per 100 person-years (95% confidence interval, 0.00-0.29) in years 6 and 7 combined. During this same time, annual rates of adverse events or discontinuation owing to side effects ranged from 0 to 3.7 per 100 participants. For the copper intrauterine device, the pooled pregnancy rate for years 11 and 12 was 0.0 per 100 person-years (95% confidence interval, 0.0-0.8), and annual rates of adverse events and discontinuation owing to side effects during extended use ranged from 0 to 4.6 per 100 participants. CONCLUSION The available evidence suggests that rates of pregnancy, adverse events, and discontinuation owing to side effects during the first 2 years of extended use of the 52 mg levonorgestrel intrauterine device and the T380A copper intrauterine device are low and comparable to rates during approved duration of use. Data were limited in quantity and quality, and may not be generalizable to all intrauterine device users.
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Roe AH, McAllister A, Sammel MD, Schreiber CA. Pregnancy intentions and contraceptive uptake after miscarriage. Contraception 2020; 101:427-431. [PMID: 32199790 PMCID: PMC7430048 DOI: 10.1016/j.contraception.2020.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify factors associated with contraceptive uptake among participants in a miscarriage management clinical trial. STUDY DESIGN We performed a secondary analysis of a multi-center, randomized controlled trial of medical management regimens for miscarriage between 5 and 12 completed weeks. Pregnancy intention was measured by patient report after miscarriage diagnosis. Participants were offered contraception in accordance with standard clinical care once their miscarriage was completed. We analyzed participants as a cohort and fit a multivariable model to describe demographic characteristics and pregnancy intentions independently associated with contraceptive uptake. RESULTS Of 244 participants with available contraceptive outcomes, 121 (50%) stated that this pregnancy was planned, and 218 (90%) stated that they had planned to continue the pregnancy to term. Ninety-seven participants (40%) initiated contraception: 33 (14%) selected a long-acting reversible method, 44 (18%) a short-acting reversible method, and 20 (8%) condoms or emergency contraception, while 147 (60%) declined contraception after miscarriage completion. In the multivariable model, unplanned pregnancy (aRR 2.13, 95% CI: 1.45-3.13) and lack of intention to continue the pregnancy (aRR 1.61, 95% CI: 1.18-2.20) were independently associated with contraceptive uptake. Of participants who declined contraception, 85 (57%) did so in order to conceive again. Nearly one-quarter of participants who declined contraception described the index pregnancy as unplanned, but after miscarriage planned to conceive a new pregnancy. CONCLUSION Patients with unplanned pregnancy who miscarried were twice as likely to initiate contraception as those with planned pregnancy, however pregnancy intentions sometimes changed after miscarriage. IMPLICATIONS Miscarriage management represents an important opportunity to clarify pregnancy goals and provide contraceptive counseling. Although unplanned pregnancy correlates with contraceptive uptake, we do not recommend using this clinically to predict contraceptive need. Future research should examine how best to measure pregnancy intention and its relationship to the experience of miscarriage.
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Affiliation(s)
- Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, United States.
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, United States
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, 13001 E. 17th Place, B119, Bldg 500, 3rd Floor West Wing, Aurora, CO 80045, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, United States
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24
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Barbieri JS, Roe AH, Mostaghimi A. Simplifying contraception requirements for iPLEDGE: A decision analysis. J Am Acad Dermatol 2020; 83:104-108. [PMID: 32068040 DOI: 10.1016/j.jaad.2020.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND For persons of childbearing potential prescribed isotretinoin, the iPLEDGE program requires use of 2 simultaneous methods of contraception or commitment to abstinence. OBJECTIVE To model the relative effectiveness of a variety of contraception strategies for patients taking isotretinoin, including those that are acceptable according to iPLEDGE. METHODS We performed a decision analysis modeling the estimated rate of pregnancy with various contraception strategies during a typical 6-month course of isotretinoin. RESULTS Tier 1 contraception options (eg, subdermal hormonal implant, intrauterine devices) each had effectiveness of >99.5% alone. When combined with a secondary form of contraception, tier 2 contraception options (eg, depot medroxyprogesterone injections, combined oral contraceptives) each had effectiveness >99%. LIMITATIONS Sensitivity analyses were conducted to evaluate the impact of uncertain parameters on the results. CONCLUSION There may be opportunities to simplify iPLEDGE by recognizing the high effectiveness of tier 1 contraception options and increasing use of secondary forms of contraception among those using tier 2 contraception options as their primary form of contraception. Future studies are needed to understand the most effective strategies in clinical practice to prevent unintended pregnancy for patients taking isotretinoin to improve outcomes and provide patient-centered care.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Andrea H Roe
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
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25
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Miller CA, Roe AH, McAllister A, Meisel ZF, Koelper N, Schreiber CA. Patient Experiences With Miscarriage Management in the Emergency and Ambulatory Settings. Obstet Gynecol 2019; 134:1285-1292. [PMID: 31764740 PMCID: PMC6882532 DOI: 10.1097/aog.0000000000003571] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/25/2019] [Accepted: 09/12/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantitatively and qualitatively describe the patient experience for clinically stable patients presenting with miscarriage to the emergency department (ED) or ambulatory clinics. METHODS We present a subanalysis of a mixed-methods study from 2016 on factors that influence miscarriage treatment decision-making among clinically stable patients. Fifty-four patients were evaluated based on location of miscarriage care (ED or ambulatory-only), and novel parameters were assessed including timeline (days) from presentation to miscarriage resolution, number of health system interactions, and number of specialty-based provider care teams seen. We explored themes around patient satisfaction through in-depth narrative interviews. RESULTS Median time to miscarriage resolution was 11 days (range 5-57) (ED) and 8 days (range 0-47) (ambulatory-only). We recorded a mean of 4.4±1.4 (ED) and 3.0±1.2 (ambulatory-only) separate care teams and a median of 13 (range 8-20) (ED) and 19 (range 8-22) (ambulatory-only) health system interactions. Patients seeking care in the ED were younger (28.3 vs 34.0, odds ratio [OR] 5.8, 95% CI 1.8-18.7), more likely to be of black race (28.3 vs 34.0, OR 3.3, 95% CI 1.1-10.0), uninsured or insured through Medicaid (16 vs 6, OR 6.8, 95% CI 2.1-22.5), and more likely to meet criteria for posttraumatic stress disorder when compared with ambulatory-only patients (10 vs 3, OR 6.0, 95% CI 1.5-23.4). Patients valued diagnostic clarity, timeliness, and individualized care. We found that ED patients reported a lack of clarity surrounding their diagnosis, inefficient care, and a mixed experience with health care provider sensitivity. In contrast, ambulatory-only patients described a streamlined and sensitive care experience. CONCLUSION Patients seeking miscarriage care in the ED were more likely to be socioeconomically and psychosocially vulnerable and were less satisfied with their care compared with those seen in the ambulatory setting alone. Expedited evaluation of early pregnancy problems, with attention to clear communication and emotional sensitivity, may optimize the patient experience.
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Affiliation(s)
- Carolyn A Miller
- Departments of Obstetrics and Gynecology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania
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26
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Roe AH, Fortin J, Gelfand D, Janiak E, Maurer R, Goldberg A. Advance notice of contraceptive availability at surgical abortion: a pilot randomised controlled trial. BMJ Sex Reprod Health 2018; 44:187-192. [PMID: 30012721 DOI: 10.1136/bmjsrh-2017-200023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 04/24/2018] [Accepted: 05/01/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND With advance notice about the availability and effectiveness of contraceptive methods, abortion patients have more time and information for decision-making. We assessed the impact of an informational telephone call prior to the surgical abortion visit on patient contraceptive knowledge. METHODS This was a pilot randomised controlled trial. Prior to their abortion visit, participants were randomised to the intervention message, a standardised notification about the availability, effectiveness and safety of long-acting (LARC) and short-acting reversible contraception (SARC) on the day of the abortion, or to the control message, a reiteration of appointment logistics without information about contraception. At the visit, participants completed a pre-procedure survey to assess contraceptive knowledge and usefulness of the intervention. The primary outcome was knowledge of LARC availability immediately after surgical abortion. A secondary outcome was contraceptive method uptake. RESULTS We enrolled 234 subjects. The pre-visit telephone notification improved knowledge that LARC is available immediately after surgical abortion (71.3% vs 50.9%, P<0.01). Participants in both study arms found the telephone notifications useful. Post-abortion contraceptive method choice did not differ between study arms. CONCLUSIONS Advance notice about contraception was acceptable to surgical abortion patients and improved their contraceptive knowledge. TRIAL REGISTRATION NUMBER NCT02836561.
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Affiliation(s)
- Andrea H Roe
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Jennifer Fortin
- Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Danielle Gelfand
- Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Elizabeth Janiak
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Rie Maurer
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alisa Goldberg
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
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Abstract
The objective of this study was to determine the clinical pregnancy rate with 2 inseminations compared to a single intrauterine insemination (IUI) in a given cycle using frozen-thawed donor sperm. This was a retrospective study at a university practice; patients were women using donor sperm. We conducted a comparison of single IUI, intracervical insemination (ICI) followed by an IUI on the next day, and double IUI (2 consecutive days); clinical pregnancy rate was the main outcome measure. The cycle-specific and total pregnancy rates were not significantly different between the 3 protocol groups (306 cycles). The average pregnancy rate over 3 cycles was 10.2% for IUI, 15.3% for ICI/IUI, and 13.7% for IUI/IUI (P = .47). After controlling for repeated measures per subject and age, gravidity, and use of Clomid, there was no significant difference between protocols. The ICI/IUI (odds ratio [OR] = 1.70; 95% confidence interval [CI], 0.83-3.51) and IUI/IUI (OR = 1.5; 95% CI, 0.52-4.33) protocols appeared more likely to result in a clinical pregnancy than the single IUI protocol. Current information on the optimal number of inseminations per cycle using donor sperm is limited. Our large study using 3 protocols found an increase in pregnancy rate with the addition of either an ICI or IUI to a single IUI protocol in a natural or Clomid cycle but did not meet statistical significance. Additional prospective studies are needed to better counsel patients using donor sperm.
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Affiliation(s)
- Diana E Chavkin
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
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28
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Stone WS, Giuliano AJ, Tsuang MT, Braff DL, Cadenhead KS, Calkins ME, Dobie DJ, Faraone SV, Freedman R, Green MF, Greenwood TA, Gur RE, Gur RC, Light GA, Mintz J, Nuechterlein KH, Olincy A, Radant AD, Roe AH, Schork NJ, Siever LJ, Silverman JM, Swerdlow NR, Thomas AR, Tsuang DW, Turetsky BI, Seidman LJ. Group and site differences on the California Verbal Learning Test in persons with schizophrenia and their first-degree relatives: findings from the Consortium on the Genetics of Schizophrenia (COGS). Schizophr Res 2011; 128:102-10. [PMID: 21288694 PMCID: PMC6819951 DOI: 10.1016/j.schres.2011.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 01/05/2011] [Accepted: 01/07/2011] [Indexed: 10/18/2022]
Abstract
Genetic studies of schizophrenia focus increasingly on putative endophenotypes because their genetic etiology may be simpler than clinical diagnosis. The Consortium on the Genetics of Schizophrenia (COGS), a multisite family study, aims to identify the genetic basis of several endophenotypes including verbal declarative memory (VDM), a neurocognitive function that shows robust impairment in schizophrenia. We present data on one type of measure of VDM, the California Verbal Learning Test, Second Edition (CVLT-II), in schizophrenia probands (n=305), their full biological siblings (n=449) and parents (n=232), and in community comparison subjects (CCS; n=509) across seven sites. Probands performed more poorly on each of five CVLT-II measures compared to related sibling and parent groups and CCS. Siblings and parents performed significantly worse than CCS on one measure (Discriminability), but with smaller effect sizes and less impairment than observed previously. The results raise questions about the homogeneity of VDM as an endophenotype, about methodological issues related to sampling, and about psychometric issues that impact the utility of the CVLT for detecting VDM deficits in nonpsychotic relatives of persons with schizophrenia.
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Affiliation(s)
- William S. Stone
- Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Harvard Medical School Department of Psychiatry, Boston, Massachusetts,Harvard Institute of Psychiatric Epidemiology and Genetics, Boston, Massachusetts,Corresponding Author. . Current postal address: Harvard Medical School, Department of Psychiatry/BIDMC, 2nd Floor East, 401 Park Drive, Boston, MA 02215. Tel.: 617-998-5035; fax: 617-998-5007
| | - Anthony J. Giuliano
- Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Harvard Medical School Department of Psychiatry, Boston, Massachusetts
| | - Ming T. Tsuang
- Harvard Institute of Psychiatric Epidemiology and Genetics, Boston, Massachusetts,Department of Psychiatry, University of California San Diego, La Jolla, California
| | - David L. Braff
- Department of Psychiatry, University of California San Diego, La Jolla, California
| | - Kristin S. Cadenhead
- Department of Psychiatry, University of California San Diego, La Jolla, California
| | - Monica E. Calkins
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dorcas J. Dobie
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington,the Department of Veteran Affairs VISN-20 Mental Illness Research, Education, and Clinical Center; Seattle, Washington
| | - Stephen V. Faraone
- Medical Genetics Research Program and Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY 13210, U.S.A
| | - Robert Freedman
- Department of Psychiatry, University of Colorado Health Sciences Center, Denver, Colorado
| | - Michael F. Green
- Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Tiffany A. Greenwood
- Department of Psychiatry, University of California San Diego, La Jolla, California
| | - Raquel E. Gur
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ruben C. Gur
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory A. Light
- Department of Psychiatry, University of California San Diego, La Jolla, California
| | - Jim Mintz
- Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Keith H. Nuechterlein
- Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Ann Olincy
- Department of Psychiatry, University of Colorado Health Sciences Center, Denver, Colorado
| | - Allen D. Radant
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington,the Department of Veteran Affairs VISN-20 Mental Illness Research, Education, and Clinical Center; Seattle, Washington
| | - Andrea H. Roe
- Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Harvard Medical School Department of Psychiatry, Boston, Massachusetts
| | - Nicholas J. Schork
- Department of Psychiatry, University of California San Diego, La Jolla, California
| | - Larry J. Siever
- Department of Psychiatry, The Mount Sinai School of Medicine, New York, New York,James J. Peters VA & VISN3 Mental Illness Research, Education and Clinical Center, Bronx, New York
| | - Jeremy M. Silverman
- Department of Psychiatry, The Mount Sinai School of Medicine, New York, New York
| | - Neal R. Swerdlow
- Department of Psychiatry, University of California San Diego, La Jolla, California
| | - Alison R. Thomas
- Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Harvard Medical School Department of Psychiatry, Boston, Massachusetts
| | - Debby W. Tsuang
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington,the Department of Veteran Affairs VISN-20 Mental Illness Research, Education, and Clinical Center; Seattle, Washington
| | - Bruce I. Turetsky
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Larry J. Seidman
- Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Harvard Medical School Department of Psychiatry, Boston, Massachusetts,Harvard Institute of Psychiatric Epidemiology and Genetics, Boston, Massachusetts
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29
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Deer HM, Beck ED, Roe AH. Respiratory exposure of museum personnel to dichlorvos insecticide. Vet Hum Toxicol 1993; 35:226-228. [PMID: 8351794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Dichlorvos (DDVP) is an organophosphate insecticide used to protect museum specimens from insect pests. Respiratory exposure of museum personnel to DDVP has not been studied previously. Analysis of air samples from museum rooms where DDVP was being used when the ventilation system was "on" showed a lower and significantly different (p = 0.025) amount of DDVP when compared to air samples collected from the same rooms when the ventilation system was "off". The DDVP concentrations of all samples collected were below the threshold limit value established by the American Conference of Governmental Industrial Hygienists.
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Affiliation(s)
- H M Deer
- Utah State University, UMC 4620, Logan 84322
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