Search

This study aimed to explore the rates of positive and negative Chlamydia trachomatis and Neisseria gonorrhoeae test results in patients screened for these infections and later experienced preterm delivery or preterm premature rupture of membranes. The team conducted a retrospective chart review of patients admitted for preterm premature rupture of membranes or who experienced preterm delivery between April 1, 2009, and April 30, 2015. Patients lacking chlamydia and gonorrhea screening before admission were excluded from the study. Four hundred and six patients met the inclusion criteria. The prevalence of chlamydia infection at initial prenatal screening before admission was 13.3%. Among those for whom the prenatal chlamydia test was negative, 1.7% of patients had a positive subsequent chlamydia test on admission screening. Among those for whom the prenatal chlamydia test was positive, 18.5% had a positive subsequent chlamydia test on admission screening. Positive prenatal test (P=.002) and age 25 years or less (P

Long acting reversible contraceptives (LARC), including intrauterine devices (IUDs) and contraceptive implants, can support an individual in meeting their reproductive goals by allowing them to prevent pregnancy effectively. These devices can also limit an individual’s control over reproduction because they generally require an in-person visit to a health care provider for removal. Returning for another visit may be logistically challenging for many individuals who may need to arrange for transportation, childcare, or take time off from work. Effectively negotiating with a provider to request removal may be additionally challenging for medically underserved and disenfranchised people who may not feel empowered to do so. The objective of this study was to assess providers’ willingness to honor patients’ requests for IUD and contraceptive implant removal on the day of the request. A survey was conducted in which clinicians were presented with scenarios of women requesting IUD or implant removal. Clinicians were asked what they were most likely to do. A total of 105 clinicians were surveyed. The responses of 60 clinicians who inserted IUDs and 57 who provided the contraceptive implant were included in the analysis. When asked about same-day removal of an IUD or implant from a dissatisfied patient who requested removal, 40% stated they would remove the implant, and 57% stated they would remove the IUD on the day of the request. Findings from this study suggest many clinicians would be unwilling or unable to accommodate a patient’s request for device removal at the time of their visit. This delay or refusal represents a significant barrier for patients and has implications for reproductive autonomy that should be further explored.

Primary care physicians (PCPs) play a major role in patient access to appropriate health care. This study examines PCPs' perceptions and management of female pelvic floor disorders. Surveys were mailed to family medicine and internal medicine physicians associated with the Hawai'i Medical Service Association. A total of 150 respondents were included. Only 34%, 38%, and 9% of respondents correctly identified the prevalence of urinary incontinence (UI), overactive bladder (OAB), and pelvic organ prolapse (POP), respectively. For disease-specific screening, the highest response was that PCPs "sometimes" screen for UI (36%) and OAB (45%) but "hardly ever" screen for POP (43%). With regards to management of UI and OAB, respondents would either treat (30% UI, 39% OAB) or start treatment then refer (53% UI, 49% OAB). For POP, nearly all of respondents (81%) would immediately refer. When consultation is necessary, there was a similar rate of referral to urology and urogynecology for UI (38% urology, 42% urogynecology), and a similar rate of referral to gynecology and urogynecology for POP (47% gynecology, 48% urogynecology). For OAB, PCPs would refer to urology (54.0%), then urogynecology (31%), and lastly gynecology (13%). A majority of respondents were "somewhat familiar" (56%) with urogynecology as a subspecialty, while 27% were "very familiar", 13% were "slightly unfamiliar", and 3% were "very unfamiliar". This study shows that most PCPs are not comfortable managing common urogynecologic problems and would likely benefit from education on how to diagnose, treat, and refer for these conditions in order to optimize patient care.

As part of the strategic plan to improve preconception care, health care providers are advised to counsel women about developing a reproductive life plan. Women are asked think about whether they want to become pregnant and have children and if so, when they would like to do so. The utility of a reproductive life plan is based on the premise that an individual has control over their own health and reproduction. Less is known regarding the beliefs of health care providers which may be important for strategizing educational and training programs. We conducted this project to examine whether health care providers in the Pacific Basin region who are providing reproductive health care, believe they have control over their own health. The Multidimensional Health Locus of Control Scale was used to survey attendees of the Annual Title X Reproductive Health Conference in Saipan, Commonwealth of the Northern Marianas. The cohort of reproductive health care providers surveyed (n=21) showed high internal control scores with a mean of 29.9 (SD = 3.5) and a range of 21 to 36 (maximum score = 36) consistent with individuals who have a strong belief that their health is most influenced by their own behavior. Chance and "powerful others" scores were consistent with means noted in other studies of healthy individuals. Understanding providers' health beliefs can aid in designing and executing more effective interventions to improve reproductive health outcomes.

The literature suggests that women of different races are more or less likely to use certain contraceptive methods and patient race can influence which contraceptive recommendations a provider makes. To explore whether health care providers treat individuals of different races differently, we conducted a preliminary investigation on whether medical students recommended different contraceptive methods for hypothetical patients presenting with the same clinical features who only varied by race. Third- and fourth-year medical students (n=103) at the University of Hawai‘i completed an online survey. Students read case studies about a 23-year-old and 36-year-old patient and then made contraceptive recommendations. All students reviewed the same scenarios, with the exception of the patient’s name which was randomly assigned to represent one of five racial/ethnic groups (White, Chinese, Filipina, Native Hawaiian, and Micronesian). Recommendations were analyzed using χ2 tests and bivariate logistic regressions. For the younger patient, students were most likely to recommend intrauterine devices (IUDs), followed by the contraceptive pill and Etonogestrel implant; recommendations did not differ by race/ethnicity (P = .91). For the older patient, students were most likely to recommend IUDs or sterilization, and Micronesian women were more likely to receive sterilization recommendations compared to White women (60% versus 27%, P = .04). In summary, contraceptive recommendations, specifically the frequency of recommending sterilization varied by race. Our findings add to the literature exploring the role of a patient’s race/ethnicity on recommendations for contraception and highlights the need for more studies exploring the etiology of health care disparities

The primary objective was to determine the theoretical number of colposcopies at a resident clinic if the 2012 American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines were applied. The secondary objective was to determine the actual number of colposcopies before and after the ASCCP guidelines. This was a two-part descriptive study. The first part applied the 2012 ASCCP guidelines to all pre-guideline colposcopy cases at a single resident clinic. These theoretical results were then compared to the actual number of colposcopies. The second part compared the actual number of colposcopies during the one-year time period before and after the guidelines. Chi-Square tests and Fisher's Exact tests were used to examine the association of categorical variables. Seventy-three colposcopies were performed during the pre-guideline period. After applying the 2012 ASCCP guidelines, 52.1% would not have been indicated, resulting in 35 colposcopies. The largest reductions would have occurred in patients with low grade cytologic abnormalities. Applying the new guidelines, patients 24 years and younger would have been less likely than patients ages 25 to 64 to require colposcopy (P

The birth plan was developed as a way for pregnant women to communicate their desires and expectations for labor and delivery. Standardized birth plans have been used by some birth facilities as a communication tool. In this quality improvement project, we sought to describe communication, trust, and satisfaction scores after delivery in a group of patients who used a standardized birth plan. All pregnant women at 24 or more weeks of gestation were asked to complete a short, standardized birth plan. Communication, trust, and satisfaction were assessed before and after delivery. Descriptive analyses showed that communication, trust, and satisfaction scores were high following delivery. Scores for all three factors increased significantly following delivery though increases were modest. Most patients (84%) indicated they would use a birth plan with a subsequent delivery.

Elective delivery from 37 to 39 weeks gestation (early-term deliveries) is a Joint Commission National Quality Measure, and hospitals report on early-term elective delivery rates through Outcome Research Yields Excellence (ORYX) vendors. The objective of this study was to compare early-term elective deliveries, identified through ORYX vendors with those identified through manual chart review, the traditional method of medical record review. We reviewed early-term labor inductions and cesarean deliveries at a single hospital from June 1, 2010 to May 31, 2012. Rates of early-term elective deliveries identified by the data vendor were compared to physician chart review. Overall, the rate of elective deliveries by ORYX was 3% compared to 2% by physician chart review (RR 1.51 [95% CI 1.12–2.03], P < .001). Of the 116 elective early-term deliveries identified by vendor and/or chart review, vendors classified significantly more inductions and cesareans as elective (P < .001) and missed nine elective deliveries. Of the 107 deliveries identified as elective by ORYX, 62 (57.9%) were verified by chart review, including 69.0% of cesareans and 36.1% of inductions. Findings from this study suggest substantial discrepancy between identification of early-term elective deliveries by data vendors and physician chart review, and indicate that vendor-derived data may overestimate the number of electively delivered patients.

The levonorgestrel intrauterine device (LNG-IUD) is a safe, effective, long-acting, reversible contraceptive that reduces unintended pregnancy and decreases heavy menstrual bleeding. Many procedures such as IUD insertion are more challenging in overweight and obese women. The objective of this study was to describe LNG-IUD insertion, continuation, and complications in overweight and obese women in an ethnically diverse population in Hawai'i. A retrospective cohort study of women who had a LNG-IUD inserted at the University of Hawai'i, Department of Obstetrics and Gynecology Resident and Faculty practice sites between January 2009 and December 2010 was performed. A total of 149 women were followed. The most commonly reported races were Asian (32%), Native Hawaiian (26%), and non-Hawaiian Pacific Islander (20%). The mean BMI of the study population was 28.4 (standard deviation 7.2) with 37% classified as normal weight, 30% as overweight, and 33% as obese. Overall, 76% of women continued the LNG-IUD 12 months after insertion. No statistically significant difference emerged in 12-month IUD continuation between the BMI groups. Difficult (5%) and failed (3%) IUD insertions were rare for all BMI groups. IUD complications occurred in 9% of women and included expulsion and self-removal. In this diverse population, the majority of women continued to use the LNG-IUD one year after insertion with low rates of difficult insertions and complications.

Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates.A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness.Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted.Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

Clinical training in most medical schools consists of separate rotations, based out of tertiary-care facilities, across the core medical disciplines. In addition to a traditional clinical curriculum, the University of Hawai‘i offers a longitudinal clinical curriculum as an option to medical students. The longitudinal curriculum provides students with an innovative, alternative educational track to achieve their educational goals in clinical medicine. The objective of this study was to describe the obstetrics and gynecology procedural experiences of third-year medical students who participated in a longitudinal curriculum versus a traditional block clerkship. The number of procedures reported by third-year medical students who participated in a non-traditional, longitudinal clerkship was compared with the number of procedures reported by students who participated in the traditional block third-year curriculum between July 2007 and June 2009. National Board of Medical Examiners (NBME) subject scores, clerkship grade and chosen residency specialty were also compared. The mean number of pelvic exams (longitudinally-trained 36 [SD 33] versus block-trained 8 [SD 6], [t=4.3, P

While surgical abortion is a safe procedure, the most common complication is excessive bleeding. Methods to conservatively manage hemorrhage are gaining popularity. The authors present a case of a Cesarean scar rupture that occurred after an intrauterine balloon tamponade was placed to treat postabortion bleeding.

To study postpartum follow-up rates, as well as counseling opportunities, among Queen Emma Clinic patients before and after the implementation of the Queen Emma Clinic Postpartum Follow-up Initiative.This was a retrospective chart review of 221 women who received prenatal care at the Queen Emma Clinic and gave birth between April 2006 and April 2008. In April 2007 the postpartum initiative was started. The primary outcome was the number of postpartum follow-up visits. Secondary outcomes included breastfeeding, contraceptive use, depression screening and referral, follow-up screening for patien ts with gestational diabetes and subsequent pregnancy.Postpartum follow-up rates were significantly higher after the Postpartum Follow-up Initiative (86.1% compared with 71.7%, P =.012). When comparing timing of follow-up, the first postpartum visit occurred approximately one week sooner in the post intervention group (2.96 weeks compared with 3.73 weeks, P=0.38) with no difference in timing of the second postpartum visit (6.62 weeks compared with 6.42 weeks, P=.72). In the post intervention group there were more patients breastfeeding at the first postpartum visit (28.7% compared with 16%, P=.015), as well as the second postpartum visit (28.7% compared with 12.3%, P=0.01). There were also more women using contraception in the post intervention group (84.3% compared with 71.7%, P=.009). There was no difference in depression screening or referral, follow-up screening for gestational diabetes, or timing of subsequent pregnancies.The Postpartum Follow-Up Initiative improved postpartum follow-up rates, as well as breastfeeding, and contraceptive use.

Bliss Kaneshiro, Tod AebyDepartment of Obstetrics and Gynecology, John A Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USAAbstract: The intrauterine device (IUD), primarily in the form of the copper IUD, is used by more than 150 million women around the world, making it the most widely used reversible method of contraception. With a remarkably low failure rate of less than 1 per 100 women in the first year of use, the Copper T-380A is in the top tier of contraceptives in terms of efficacy. Risks of utilization include perforation and an increased risk of infection in the first 20 days following insertion. Overall, the number of adverse events is low, making the Copper T-380A a very safe contraceptive method. The most common reasons for the discontinuation of this method are menstrual bleeding and dysmenorrhea. However, cumulative discontinuation rates of Copper T-380A are lower than that have been reported for other methods, indicating that the Copper T-380A is highly acceptable to women. After 5 years, approximately 50% of all women, who have a Copper T-380A inserted, will continue to use this highly effective contraceptive method.Keywords: contraception, perforation, expulsion, pelvic inflammatory disease, continuation

There is a high prevalence of type 2 diabetes among Micronesians leading to the assumption that they are at an increased risk for gestational diabetes. The objective of this study was to determine the prevalence of gestational diabetes among the Micronesian population in Honolulu, Hawai'i. Secondary objectives were to determine factors associated with gestational diabetes and compare maternal and fetal outcomes between the Micronesian gestational diabetic and non-diabetic populations.A retrospective chart review was performed of all delivery records from January 1997 to December 2006. Data were analyzed using measures of association and multiple logistic regression.Of the 2966 charts reviewed, 2303 met inclusion criteria. The prevalence of gestational diabetes was 6.2% and the prevalence of type 2 diabetes was 0.8%. In comparison to the non-diabetic group, the gestational diabetic population was significantly older (p=0.002) and heavier (p0.001). Micronesians with gestational diabetes had higher rates of cesarean section and hypertensive disorders. However, rates of shoulder dystocia were not statistically different. Infants of gestational diabetic mothers experienced higher rates of neonatal intensive care unit admission and hypoglycemia.The prevalence of gestational diabetes in the Micronesian population is lower than expected given the high prevalence of obesity and type 2 diabetes among Micronesians. Those with gestational diabetes are at an increased risk for maternal and neonatal morbidity. Future public health endeavors should address increasing rates of obesity in the United States, specifically in Pacific Islander populations.