Long, Margaret E.

INTRODUCTION: Adverse patient events inevitably occur in OB/GYN practice. Health care provider who are “second victims” experience psychological trauma and progress through defined stages of recovery as they process the event. This experience is believed to be an under-recognized, yet prevalent phenomenon. Study aims were to determine the prevalence of second victims and the risk factors for feeling like a second victim among staff caring for OB/GYN patients to guide the implementation of new resources for second victims. METHODS: We administered the validated Second Victim Experience and Support Tool (SVEST) supplemented with non-validated questions to multidisciplinary team members caring for OB/GYN patients at Mayo Clinic in Rochester, MN. Respondents to the self-administered, anonymous survey included physicians, nurse practitioners, physician assistants, certified nurse midwife, registered nurses, allied health professionals, and desk staff. RESULTS: The survey was completed by 205 staff (117 OB only, 73 GYN only, 15 both). During their career, 44.8% felt like a second victim while 18.8% had this experience in the last 12 months. Residents and fellows had the highest percentage of second victims (41.7%). Respondents who reported greater psychological distress were more likely to report that they felt like a second victim after an adverse patient safety event within the preceding 12 months (p-value<0.001). The same finding was observed for measures of physical distress. CONCLUSION: OB/GYN team members report significant differences in physiological and physical symptoms after adverse events. Understanding and screening for psychological and physical symptoms may be useful in identifying second victims and guiding support following adverse events.

Executive Summary The risk of cervical cancer (CC) among women immunosuppressed for a variety of reasons is well documented in the literature. Although there is improved organ function, quality of life and life expectancy gained through use of immunosuppressant therapy, there may be increased long-term risk of cervical neoplasia and cancer and the need for more intense screening, surveillance, and management. Although guidance for CC screening among HIV-infected women (see Table 1) has been supported by evidence from retrospective and prospective studies, recommendations for CC screening among non-HIV immunosuppressed women remains limited because quality evidence is lacking. Moreover, CC screening guidelines for HIV-infected women have changed because better treatments evolved and resulted in longer life expectancy. The objective of this report was to summarize current knowledge of CC, squamous intraepithelial lesions, and human papillomavirus (HPV) infection in non-HIV immunocompromised women to determine best practices for CC surveillance in this population and provide recommendations for screening. We evaluated those with solid organ transplant, hematopoietic stem cell transplant, and a number of autoimmune diseases. A panel of health care professionals involved in CC research and care was assembled to review and discuss existing literature on the subject and come to conclusions about screening based on available evidence and expert opinion. Literature searches were performed using key words such as CC, cervical dysplasia/squamous intraepithelial lesion, HPV, and type of immunosuppression resulting in an initial group of 346 articles. Additional publications were identified from review of citations in these articles. All generated abstracts were reviewed to identify relevant articles. Articles published within 10 years were considered priority for review. Reviews of the literature were summarized with relevant statistical comparisons. Recommendations for screening generated from each group were largely based on expert opinion. Adherence to screening, health benefits and risks, and available clinical expertise were all considered in formulating the recommendations to the degree that information was available. Results Solid Organ Transplant: Evidence specific for renal, heart/lung, liver, and pancreas transplants show a consistent increase in risk of cervical neoplasia and invasive CC, demonstrating the importance of long-term surveillance and treatment. Reports demonstrate continued risk long after transplantation, emphasizing the need for screening throughout a woman's lifetime. Hematopoietic Stem Cell Transplant: Although there is some evidence for an increase in CC in large cohort studies of these patients, conflicting results may reflect that many patients did not survive long enough to evaluate the incidence of slow-growing or delayed-onset cancers. Furthermore, history of cervical screening or previous hysterectomy was not included in registry study analysis, possibly leading to underestimation of CC incidence rates. Genital or chronic graft versus host disease is associated with an increase in high-grade cervical neoplasia and posttransplant HPV positivity. Inflammatory Bowel Disease: There is no strong evidence to support that inflammatory bowel disease alone increases cervical neoplasia or cancer risk. In contrast, immunosuppressant therapy does seem to increase the risk, although results of observational studies are conflicting regarding which type of immunosuppressant medication increases risk. Moreover, misclassification of cases may underestimate CC risk in this population. Recently published preventive care guidelines for women with inflammatory bowel disease taking immunosuppressive therapy recommend a need for continued long-term CC screening. Systemic Lupus Erythematosus and Rheumatoid Arthritis: The risk of cervical high-grade neoplasia and cancer was higher among women with systemic lupus erythematosus than those with rheumatoid arthritis (RA), although studies were limited by size, inclusion of women with low-grade neoplasia in main outcomes, and variability of disease severity or exposure to immunosuppressants. In studies designed to look specifically at immunosuppressant use, however, there did seem to be an increase in risk, identified mostly in women with RA. Although the strength of the evidence is limited, the increase in risk is consistent across studies. Type 1 DM: There is a paucity of evidence-based reports associating type 1 DM with an increased risk of cervical neoplasia and cancer. Recommendations The panel proposed that CC screening guidelines for non-HIV immunocompromised women follow either the (1) guidelines for the general population or (2) current center for disease control guidelines for HIV-infected women. The following are the summaries for each group reviewed, and more details are noted in accompanying table: Solid Organ Transplant: The transplant population reflects a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance. Hematopoietic Stem Cell Transplant: These women have a greater risk of CC than the general population and guidelines for HIV-infected women are a reasonable approach for screening. A new diagnosis of genital or chronic graft versus host disease in a woman post–stem cell transplant results in a greater risk of CC than in the general population and should result in more intensive screening and surveillance. Inflammatory Bowel Disease: Women with inflammatory bowel disease being treated with immunosuppressive drugs are at greater risk of cervical neoplasia and cancer than the general population and guidelines for HIV-infected women are a reasonable approach for screening and surveillance. Those women with inflammatory bowel disease not on immunosuppressive therapy are not at an increased risk and should follow screening guidelines for the general population. Systemic Lupus Erythematosus and Rheumatoid Arthritis: All women with systemic lupus erythematosus, whether on immunosuppressant therapy or not and those women with RA on immunosuppressant therapy have a greater risk of cervical neoplasia and cancer than the general population and should follow CC screening guidelines for HIV-infected women. Women with RA not on immunosuppressant therapy should follow CC screening guidelines for the general population. Type 1 Diabetes Mellitus: Because of a lack of evidence of increased risk of cervical neoplasia and cancer among women with type 1 DM, these women should follow the screening guidelines for the general population.

Objectives The ideal frequency of cervical cancer screening in women with solid organ transplants (SOTs) remains to be determined. We aimed to assess the longitudinal rates of cytologic and histologic cervical abnormalities in women after SOT. Methods We retrospectively reviewed health records of women aged 18 to 60 years who received their first kidney, liver, pancreas, or combination transplant at Mayo Clinic (Rochester, Minnesota) from 1995 through 2011. Patient demographics, cervical cytology and histology, and high-risk human papillomavirus (hrHPV) testing data were abstracted. All women included in the study had documentation of at least 1 cervical cytologic assessment after SOT. Cumulative incidence of abnormal cytology or histology was estimated using the Kaplan-Meier method. Results In total, 459 women (mean age at SOT, 43.9 years) were included in the study. Pre-SOT cytology was benign in 226 (97.4%) of 232 patients with available results. During follow-up, 9 women had cervical intraepithelial neoplasia grade 3 or higher (CIN3+) histology. The cumulative incidence of CIN3+ was 0.2% (95% confidence interval [CI], 0%–0.6%) at 1 year after SOT, 0.7% (95% CI, 0%–1.5%) at 2 years, 1.9% (95% CI, 0.5%–3.3%) at 5 years, and 3.1% (95% CI, 0.4%–5.7%) at 10 years. At the time of the first post-SOT cervical cytology, a greater proportion of women who were hrHPV positive had abnormal findings compared with hrHPV-negative women (10/15 [66.7%] vs 1/71 [1.4%]; p < .001). Conclusions The cumulative incidence of CIN3+ in the first 5 years after SOT approximates the level of risk for which annual cytologic assessment has been recommended.

INTRODUCTION: Obesity is associated with postnatal depression; however, the prevalence of postnatal depression in women after bariatric surgery has not been further evaluated. METHODS: For this observational investigation, women, ages 18-45 years, with pregnancy from 1989-2015 and bariatric surgery were identified using the Olmsted County Rochester Epidemiology Project and ICD-9 codes. Those with surgery after pregnancy and/or without permission to use their records were excluded. Charts were reviewed for maternal and infant characteristics and outcomes. Postnatal depression was identified from a positive screen, referral for mood disorder, antidepressant medication increase, suicidality, or provider diagnosis from delivery to 12 months postpartum. RESULTS: Ninety-one women with pregnancy >23 weeks after surgery and available data were reviewed. The average body mass index at time of surgery was 47±8.6 kg/m2 (N=88) and at time of pregnancy 32±6.6 kg/m2 (N=89). The average age at surgery was 29±4.1 years and at delivery 33±4.4 years. Roux-en-Y gastric bypass was the most common surgery (N=70, 77%). Pregnancy outcomes included: 14% preterm deliveries (<37 weeks, N=13), 67% vaginal deliveries (N=61), no stillbirths, and 97% singleton deliveries (N=88). Mean singleton birthweight was 3225 grams (±471, N=86). Postnatal depression was noted in 38% of women (N=35), which is significantly higher than that for obese women in general (13-18%) when a 1-sample proportion test is conducted for comparison (38%vs18%, p <0.0001). CONCLUSION: Postnatal depression may be increased in women with a history of bariatric surgery. Further investigation is needed, but particular care should be taken to screen and diagnose these high-risk women.

INTRODUCTION: The Pregnancy Reasonably Excluded Guide (PREG) questionnaire is based on traditional methods of excluding pregnancy including sterilization, menopause, and the World Health Organization criteria. The PREG has been validated and shows a 99-100% negative predictive value for pregnancy (Selected practice recommendations for contraceptive use, 2013: adapted from the world health organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep 2013; 62:1‒60.). Pregnancy testing in our outpatient surgical settings varied by provider. This study compared utilization of pregnancy tests in the outpatient gynecologic surgery setting after implementation of universal PREG administration. METHODS: All women undergoing outpatient gynecologic surgery were prospectively evaluated between March and September 2016. Administration of the PREG to women 18-49, excluding those undergoing procedures related to pregnancy, was implemented in July and rates of pregnancy testing pre- and post-implementation were compared using Fisher’s exact test. RESULTS: 369 patients underwent an outpatient gynecologic procedure during the study period (excluding a two week washout period after implementation). In the pre-implementation group, 136 met inclusion criteria with 45 pregnancy tests performed (33.1%). After implementation, 80 patients met inclusion criteria and 17 pregnancy tests were performed as indicated by PREG response (21.3%), demonstrating over one third reduction in pregnancy test administration (p = 0.086). No pregnancy tests were positive and no false negative evaluations were identified. Physician and nursing staff requested continued use of the PREG after the trial. CONCLUSION: PREG administration on admission for outpatient gynecologic surgery consistently and effectively identifies patients in whom pregnancy testing improves the value of care.

Background: Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods. Methods: Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF–12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test. Results: A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 ( p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 ( p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF–12 scores improved for global physical function ( p < .001) and mental function ( p = .002). Conclusions: Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.

Background: Care of the gynecologic cancer survivor extends beyond cancer treatment to encompass promotion of sexual, cardiovascular, bone, and brain health; management of fertility, contraception, and vasomotor symptoms; and genetic counseling. Methods: This is a narrative review of the data and guidelines regarding care and surveillance of the gynecologic cancer survivor. We searched databases including PubMed, Cochrane, and Scopus using the search terms gynecologic cancer, cancer surveillance, and cancer survivor and reached a consensus for articles chosen for inclusion in the review based on availability in the English language and publication since 2001, as well as key older articles, consensus statements, and practice guidelines from professional societies. However, we did not undertake an extensive systematic search of the literature to identify all potentially relevant studies, nor did we utilize statistical methods to summarize data. We offer clinical recommendations for the management of gynecologic cancer survivors based on review of evidence and our collective clinical experience. Results: Key messages include the limitations of laboratory studies, including CA-125, and imaging in the setting of gynecologic cancer surveillance, hormonal and non-hormonal management of treatment-related vasomotor symptoms and genitourinary syndrome of menopause, as well as recommendations for general health screening, fertility preservation, and contraception. Conclusions: A holistic approach to care extending beyond cancer treatment alone benefits gynecologic cancer survivors. In addition to surveillance for cancer recurrence and late treatment side effects, survivors benefit from guidance on hormonal, contraceptive, and fertility management and promotion of cardiovascular, bone, brain, and sexual health.

The value of pelvic examination for healthy asymptomatic women has been called into question given the lack of benefit for ovarian and endometrial cancer screening, the ability to screen for sexually transmitted infections without a pelvic examination, and the uncoupling of the procurement of contraception with a pelvic examination. Still, there are indications for performing pelvic examinations in symptomatic women and in some high risk women. How do we as clinicians apply current evidence and expert opinion to our medical practice? Our recommendation to consider a pelvic examination at 3-5-year intervals with cervical cancer screening to elicit gynecologic and sexual health concerns offers a compromise between continuation of unnecessary annual pelvic examinations and complete elimination of these examinations.