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OBJECTIVES: One Key Question (OKQ) is a clinical screening tool to assess pregnancy desire in the next year. We aimed to 1) describe the effect of OKQ implementation on contraceptive counseling rates at preventive health visits and 2) evaluate primary care providers’ perception of OKQ implementation on their contraceptive counseling practices. STUDY DESIGN: We performed a quantitative retrospective chart review of preventive health visits at eight federally qualified health centers in Utah between 2014 and 2017. Implementation of OKQ included a brief training and inclusion of OKQ in the electronic medical record. Providers received OKQ training in August 2015 and re-training in March 2017. We assessed OKQ and contraceptive counseling documentation rates using interrupted-time-series analysis. We then conducted semi-structured interviews with providers and queried them about the impact of OKQ. We identified dominant themes using modified grounded theory to create an explanatory framework. RESULTS: Abstracting 6634 charts yielded 9840 visits with 56 unique providers (51% physician assistant, 34% physician, 14% nurse practitioner). Interrupted-time-series analysis showed a documentation increase of OKQ in late 2015 (2.6%) and again in spring 2017 (9%), however rates remained low. Contraceptive counseling rates (39.7%) did not change after OKQ implementation. Charts with evidence of a current contraceptive method were less likely to have a OKQ response documented. Interviewees reported OKQ’s algorithm did not alter their contraceptive counseling. CONCLUSIONS: OKQ did not change documented rates of contraceptive counseling and uptake was low in quantitative and qualitative analyses. Our study suggests limited usefulness of OKQ in the primary care setting. IMPLICATIONS: Implementation of the One Key Question tool through training and optional EHR field did not increase documented rates of contraceptive counseling in a large federally qualified health center or affect provider contraceptive counseling. Our study suggests limited usefulness of OKQ as a robust screening tool in this primary care setting.

We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre- and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements.Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5-minute educational video on mifepristone for EPL and completed pre- and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone.Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two-thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t-test; 95% confidence interval 2.82-3.72, p 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization.Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.

Background In the United States, more intrauterine device (IUD) users select levonorgestrel IUDs than copper IUDs for long-term contraception. Currently, clinicians offer only copper IUDs for emergency contraception because data are lacking on the efficacy of the levonorgestrel IUD for this purpose. Methods This randomized noninferiority trial, in which participants were unaware of the group assignments, was conducted at six clinics in Utah and included women who sought emergency contraception after at least one episode of unprotected intercourse within 5 days before presentation and agreed to placement of an IUD. We randomly assigned participants in a 1:1 ratio to receive a levonorgestrel 52-mg IUD or a copper T380A IUD. The primary outcome was a positive urine pregnancy test 1 month after IUD insertion. When a 1-month urine pregnancy test was unavailable, we used survey and health record data to determine pregnancy status. The prespecified noninferiority margin was 2.5 percentage points. Results Among the 355 participants randomly assigned to receive levonorgestrel IUDs and 356 assigned to receive copper IUDs, 317 and 321, respectively, received the interventions and provided 1-month outcome data. Of these, 290 in the levonorgestrel group and 300 in the copper IUD group had a 1-month urine pregnancy test. In the modified intention-to-treat and per-protocol analyses, pregnancy rates were 1 in 317 (0.3%; 95% confidence interval [CI], 0.01 to 1.7) in the levonorgestrel group and 0 in 321 (0%; 95% CI, 0 to 1.1) in the copper IUD group; the between-group absolute difference in both analyses was 0.3 percentage points (95% CI, -0.9 to 1.8), consistent with the noninferiority of the levonorgestrel IUD to the copper IUD. Adverse events resulting in participants seeking medical care in the first month after IUD placement occurred in 5.2% of participants in the levonorgestrel IUD group and 4.9% of those in the copper IUD group. Conclusions The levonorgestrel IUD was noninferior to the copper IUD for emergency contraception. (Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT02175030.).

Recent evidence demonstrates the effectiveness of the levonorgestrel 52mg intrauterine device (IUD) for emergency contraception compared to the copper (Cu T380A) IUD. One-year pregnancy and continuation rates after IUD placement for emergency contraception remain understudied.(s): We compared one-year pregnancy and IUD continuation rates and reasons for discontinuation among emergency contraception users randomized to the levonorgestrel 52mg IUD or a copper IUD.This participant-masked, randomized noninferiority trial recruited emergency contraception clients desiring an IUD from six Utah family planning clinics between August 2016 and December 2019. We randomized participants 1:1 to the levonorgestrel 52 mg IUD or copper T380A IUD. Treatment allocation was revealed to participants at the one-month follow up. Trained personnel followed participants by phone, text, or email at five timepoints over one year and reviewed electronic health records for pregnancy and IUD continuation outcomes for both confirmation and for non-responders. We assessed reasons for discontinuation and used Cox Proportional Hazard Models, Kaplan-Meier estimates, and log-rank tests to assess differences in continuation and pregnancy rates between groups.The levonorgestrel and copper IUD groups included 327 and 328 participants receiving the respective interventions. By intention-to-treat analysis at one year, pregnancy rates were similar between IUD types (9/327 (2.8%) levonorgestrel 52mg IUD vs 10/328 (3.0%) copper IUD (RR 0.9, 95% CI 0.4-2.2, p=0.82)). The majority of pregnancies occurred in participants after IUD removal, with only 1 device failure in each group. One-year continuation rates did not differ between groups with 204/327 (62.4%) of levonorgestrel 52mg IUD users and 183/328 (55.8%) of Cu T380A IUD users continuing IUD use at one year (RR 1.1, 95% CI 1.0-1.2, p=0.09). There were differences with regards for reasons for discontinuation between IUD types, with more bleeding and cramping cited among copper IUD users.(s): Pregnancy rates were low and similar between IUD types. Six in ten IUD emergency contraception users continued use at one year. One-year continuation rates were similar between IUD types.

Examine intrauterine device (IUD) switching or discontinuation up to 6 months after participant-masked randomization to different IUDs.Participants were randomized 1:1 to the copper T380A or levonorgestrel 52 mg IUD for emergency contraception and informed they could switch IUD type without cost at any time.Of the 327 subjects allocated to the levonorgestrel IUD, 7 (2.1%) switched their IUD type by 6 months versus 18 (5.5%) of the 328 copper IUD users (RR: 0.4 [95% CI: 0.2, 0.9], p = 0.03). Six-month IUD discontinuation occurred in 34 (10.4%) levonorgestrel and 35 (10.7%) copper IUD users.Individuals randomly assigned to IUD type at presentation for emergency contraception continue their assigned IUDs at high rates over 6 months.While many recruited individuals declined enrollment, those who accepted randomization had high continuation rates; the high continuation and low cross-over supports using IUD randomization as a tool for future investigation. Participants' similar rates of and reasons for switching and discontinuation by IUD type over the study period may impact clinical counseling.

Objective This study assessed the timing, frequency, use of backup method and 1-month pregnancy rates among individuals who had an intrauterine device (IUD) placed as emergency contraception and reported intercourse within 7 days post-placement. Study Design In this secondary analysis of a randomized control trial of IUDs for emergency contraception, 518 individuals reporting unprotected intercourse in the preceding 5 days had a 52 mg levonorgestrel intrauterine system (IUS) or 380 mm2 copper IUD placed outside the first week of their menstrual cycle. All participants were advised to use backup contraception for 7 days. We assessed pregnancy status 1 month after placement by urine testing or, when not available, by survey responses and electronic health record review. Participants reported whether their first sexual activity after device placement occurred within 7 days of their placement, the frequency of intercourse and whether they used backup contraception. Results Rapid return to sexual activity was common and use of backup contraception was rare, regardless of type of IUD placed. Of participants who resumed penile-vaginal intercourse in the first month, most (286/446, 64.1%) participants reported intercourse within 7 days of IUD placement; only 16.4% (74/446) used condoms or withdrawal. No pregnancies occurred among users of the levonorgestrel IUS who reported intercourse within 7 days of placement (0/138, 0.0%, 95% CI 0.0%, 2.6%) nor among users of the 380mm2 copper IUD (0/148, 0.0%, 95% CI 0.0%, 2.5%). Conclusion Pregnancy rates are low after placement of an IUD for emergency contraception, even among the many who resume intercourse within days following IUD placement without use of backup contraception. Implications Clinical guidelines should facilitate access to contraception, including elimination of unnecessary recommendations for backup contraception or abstinence in the 7 days following 52 mg levonorgestrel intrauterine system.

Objective Research has called for more exploration into how reproductive autonomy (which includes agency over pregnancy decisions) is related to structural, relational, and individual elements. Thus, we use surveys to investigate how one potential indicator of reproductive autonomy—feelings of control over pregnancy—may relate to structural, relational, and individual factors in emerging adults’ (age 18–24) lives. Methods Using survey data from 2594 emerging adult women participating in a contraceptive initiative in Utah (USA), we analyzed level of agreement with the statement: “I feel that I have control over whether or not I get pregnant,” exploring relationships between sociodemographic characteristics and agreement with the statement. We used chi-square tests and multinomial logistic regression to investigate relationships between individual, relational, and structural factors and feelings of control. Results Most participants (86%) agreed with the statement (n = 2231), while the remainder were neutral or disagreed. Participants reporting poverty-level incomes (RRR: 1.80; 95 %CI 1.25–2.59) and previous unwanted pregnancies (RRR: 2.74; 95 %CI: 1.56–4.81) were more likely to describe “neutral” feelings of control. Conclusion Findings indicate a relationship between feelings of control over pregnancy and several factors, and these results may help identify reproductive autonomy access gaps among emerging adults. More work should investigate these relationships as well as the meaning of “neutral” responses when it comes to assessments of control over pregnancy. Trial Registration: Clinicaltrials.gov identifier NCT02734199, Registered 12 April 2016.

Key Points Question What are the quality and certainty of evidence for an association between hormonal contraceptive use and the risk of adverse health outcomes in meta-analyses of randomized clinical trials and cohort studies? Findings In this umbrella review of 58 meta-analyses of randomized clinical trials and cohort studies describing 156 associations between hormonal contraceptive use and adverse health outcomes among women, no associations with adverse outcomes, including cardiovascular and cancer risk, were supported by high-quality evidence. However, the association between the use of a levonorgestrel-releasing intrauterine system and reductions in endometrial polyps associated with tamoxifen use was graded as having high-quality evidence. Meaning The results of this umbrella review supported preexisting understandings of the risks and benefits associated with hormonal contraceptive use, suggesting that the associations between hormonal contraceptive use and adverse health outcomes are not supported by high-quality evidence., Importance Meta-analyses have reported conflicting data on the safety of hormonal contraception, but the quality of evidence for the associations between hormonal contraceptive use and adverse health outcomes has not been quantified in aggregate. Objective To grade the evidence from meta-analyses of randomized clinical trials (RCTs) and cohort studies that assessed the associations between hormonal contraceptive use and adverse health outcomes among women. Data Sources MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched from database inception to August 2020. Search terms included hormonal contraception, contraceptive agents, progesterone, desogestrel, norethindrone, megestrol, algestone, norprogesterones, and levonorgestrel combined with terms such as systematic review or meta-analysis. Evidence Review The methodological quality of each meta-analysis was graded using the Assessment of Multiple Systematic Reviews, version 2, which rated quality as critically low, low, moderate, or high. The Grading of Recommendation, Assessment, Development and Evaluations approach was used to assess the certainty of evidence in meta-analyses of RCTs, with evidence graded as very low, low, moderate, or high. Evidence of associations from meta-analyses of cohort studies was ranked according to established criteria as nonsignificant, weak, suggestive, highly suggestive, or convincing. Results A total of 2996 records were screened; of those, 310 full-text articles were assessed for eligibility, and 58 articles (13 meta-analyses of RCTs and 45 meta-analyses of cohort studies) were selected for evidence synthesis. Sixty associations were described in meta-analyses of RCTs, and 96 associations were described in meta-analyses of cohort studies. Among meta-analyses of RCTs, 14 of the 60 associations were nominally statistically significant (P ≤ .05); no associations between hormonal contraceptive use and adverse outcomes were supported by high-quality evidence. The association between the use of a levonorgestrel-releasing intrauterine system and reductions in endometrial polyps associated with tamoxifen use (odds ratio [OR], 0.22; 95% CI, 0.13-0.38) was graded as having high-quality evidence, and this evidence ranking was retained in the subgroup analysis. Among meta-analyses of cohort studies, 40 of the 96 associations were nominally statistically significant; however, no associations between hormonal contraceptive use and adverse outcomes were supported by convincing evidence in the primary and subgroup analyses. The risk of venous thromboembolism among those using vs not using oral contraception (OR, 2.42; 95% CI, 1.76-3.32) was initially supported by highly suggestive evidence, but this evidence was downgraded to weak in the sensitivity analysis. Conclusions And Relevance The results of this umbrella review supported preexisting understandings of the risks and benefits associated with hormonal contraceptive use. Overall, the associations between hormonal contraceptive use and cardiovascular risk, cancer risk, and other major adverse health outcomes were not supported by high-quality evidence., This umbrella review assesses evidence from meta-analyses of randomized clinical trials and cohort studies examining the association between hormonal contraceptive use and adverse health outcomes among women.

Recurrent pregnancy loss (RPL), commonly defined as 3 consecutive losses

Reproductive-age women are a fast-growing component of active-duty military personnel who experience deployment and combat more frequently than previous service-era women Veterans. With the expansion of the number of women and their roles, the United States Departments of Defense and Veterans Affairs have prioritized development and integration of reproductive services into their health systems. Thus, understanding associations between deployments or combat exposures and short- or long-term adverse reproductive health outcomes is imperative for policy and programmatic development. Servicewomen and women Veterans may access reproductive services across civilian and military or Veteran systems and providers, increasing the need for awareness and communication regarding deployment experiences with a broad array of providers. An example is the high prevalence of military sexual trauma reported by women Veterans and the associated mental health diagnoses that may lead to a lifetime of high risk-coping behaviors that increase reproductive health risks, such as sexually transmitted infections, unintended pregnancies, and others. Care coordination models that integrate reproductive healthcare needs, especially during vulnerable times such as at the time of military separation and in the immediate postdeployment phase, may identify risk factors for early intervention with the potential to mitigate lifelong risks.

OBJECTIVE To identify clinical variables associated with increased risk of composite adverse outcome in a cohort of women with puerperal group A streptococci infection. METHODS Our prospective case registry enrolled patients between 1991 and 2017. Chart abstraction was conducted for admission demographic and clinical data in patients with culture-proven puerperal group A streptococci infection. We created a composite variable of signs of capillary leakage including pulmonary edema, pleural effusion, ascites, and abdominal distention. The composite adverse outcome included death, hysterectomy, intensive care unit admission, mechanical ventilation, and blood transfusion. Clinical characteristics were compared between those with a composite adverse outcome and those without. We fit unadjusted log-linear models with robust error variance to measure the relative risk of a composite adverse outcome associated with clinical and demographic variables among patients with group A streptococci. RESULTS Thirty-five of 71 (49%) patients had an adverse outcome. Women who had adverse outcomes had higher admission heart rates (126±19 vs 112±22 beats per minute, P=.008) and respiratory rates (26±10 vs 20±5 breaths per minute, P=.01), lower systolic blood pressure (98±24 vs 114±19 mm Hg, P=.004), and were more likely to have signs of capillary leakage (77% vs 20%, P

BACKGROUND: Misoprostol, a synthetic prostaglandin E1 analog, is commonly used for treatment and prevention of postpartum hemorrhage. Known side effects include transient hyperthermia, chills, nausea, vomiting, and diarrhea. CASE: After a precipitous vaginal delivery complicated by postpartum hemorrhage (600-mL blood loss), a healthy 21-year-old multiparous patient received 800 micrograms rectal misoprostol. Within 30 minutes, she developed rigors, severe hyperthermia (41.5°C [106.7°F]), tachycardia (170s), and transient encephalopathy. Antibiotics and a cooling protocol were initiated in the intensive care unit. Her abnormal vital signs resolved 7–8 hours later. Extensive workup was negative. CONCLUSION: It is important to consider misoprostol toxicity in postpartum hyperthermia, rigors, and tachycardia. Misoprostol should be used judiciously given a lack of evidence for its effectiveness and its potential for serious side effects.

Appreciation of pelvic anatomy spatial relationships is critical for long-term comprehension of anatomy. This self-guided study module for pelvic anatomy highlights important structures and guides students at their own pace through the complex process of realizing spatial relationships viewed in radiology atlases of serial and still imaging. It is intended to be used in conjunction with a human gross anatomy course to create synergistic learning of anatomy by multiple representations of structures. The guide makes complex radiological atlases, which often contain overwhelming numbers of labels and descriptions, more accessible to students. The descriptions in the guide are intentionally compatible with any serial imaging radiological atlas of normal pelvic human anatomy, digital or print. In addition, extensive single frame images and labeled serial imaging are included in this resource which may be of use to instructors and students as a stand-alone resource in and of themselves. This study guide has been time-tested for 4 years with improvements each year. These materials were successfully implemented in 2008 and 2009, revised based on student feedback and study outcomes, and re-implemented in 2010 and 2011. Included here are the 2011 materials. Strongly positive student feedback was received, and formal evaluation of the 2008 version demonstrated statistically and practically significant higher radiology and gross anatomy exam scores (approximately a letter grade) when students utilized the study guide.