Green, Isabel C.

INTRODUCTION: While rare, emergencies encountered during office procedures have the potential for significant morbidity if the team is caught unprepared. The aim of this study was to evaluate current availability of and needs for training in office emergencies in residency programs in the United States. METHODS: This was a cross-sectional survey of residents from accredited obstetrics and gynecology residency programs. Identified programs were those with representation in the American College of Obstetricians and Gynecologists Simulation Working Group (ACOG SWG). A multi-item instrument was developed, designed, and edited by representatives of the ACOG SWG for accuracy and content validity. Participants were asked to rate their level of agreement with statements on importance of training in the recognition and management of obstetrics and gynecology emergencies and their confidence in management of those emergencies. Specific emergencies encountered in the office, gynecologic surgery, and obstetrics were queried. RESULTS: Six programs participated for a total of 116 residents and a response rate of 62% (116/188). Most residents agreed office emergency (97.5%) and obstetric emergency training (94.8%) were important in residency training. While 65.5% were confident in managing a vasovagal episode in the office, 0.9% were confident in managing lidocaine toxicity. In contrast, the majority of residents felt confident in obstetric emergency management across all listed emergencies (hemorrhage, cord prolapse, shoulder dystocia, eclampsia). CONCLUSION: While rated as important to residency training, significant gaps exist within resident preparation for identification and management of office-based emergencies, providing an opportunity for curriculum development and education.

INTRODUCTION: Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Incidence of retained POC range from 1.5–3.7%. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease this. METHODS: A retrospective review of first trimester uterine evacuation procedures from 1/2015–2/2017 was performed, noting use of transabdominal ultrasonography (TAUS), retained products of conception (sonographic findings requiring surgical or medical intervention), and complications. A practice change was implemented in May 2018, in which intra-procedural TVUS was routinely performed. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, reoperation, and associated complications. Fisher's exact test was performed. RESULTS: Prior to implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman's and endometritis. Following implementation, 94 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (P=.01), no incidences of re-operation (P=.02), and one case of Asherman's. TVUS led to additional focused curettage in 20/94 (21.3%) of procedures. The endometrium was measured in 64 procedures, with a mean thickness of 5.5 mm (1–12 mm). CONCLUSION: Implementation of routine TVUS during uterine evacuation appears to reduce the incidence of retained POC and associated reoperation rates.

ABSTRACT Background Vaginal diazepam is frequently used to treat pelvic floor tension myalgia and pelvic pain despite limited knowledge of systemic absorption. Aim To determine the pharmacokinetic and adverse event profile of diazepam vaginal suppositories. Methods We used a prospective pharmacokinetic design with repeated assessments of diazepam levels. Eight healthy volunteers were administered a 10-mg compounded vaginal diazepam suppository in the outpatient gynecologic clinic. Serum samples were collected at 0, 45, 90, 120, and 180 minutes; 8, 24, and 72 hours; and 1 week following administration of a 10-mg vaginal suppository. The occurrence of adverse events was assessed using the alternate step and tandem walk tests, the Brief Confusion Assessment Method, and numerical ratings. Plasma concentrations of diazepam and active long-acting metabolites were measured. Pharmacokinetic parameters were calculated by standard noncompartmental methods. Results The mean peak diazepam concentration (Cmax) of 31.0 ng/mL was detected at a mean time (Tmax) of 3.1 hours after suppository placement. The bioavailability was found to be 70.5%, and the mean terminal elimination half-life was 82 hours. The plasma levels of temazepam and nordiazepam peaked at 0.8 ng/mL at 29 hours and 6.4 ng/mL at 132 hours, respectively. Fatigue was reported by 3 of 8 participants. Clinical Implications Serum plasma concentrations of vaginally administered diazepam are low; however the half-life is prolonged. Strengths & Limitations Strengths include use of inclusion and exclusion criteria aimed at mitigating clinical factors that could adversely impact diazepam absorption and metabolism, and the use of an ultrasensitive LC-MS/MS assay. Limitations included the lack of addressing the efficacy of vaginal diazepam in lieu of performing a pure pharmacokinetic study with healthy participants. Conclusion Vaginal administration of diazepam results in lower peak serum plasma concentration, longer time to peak concentration, and lower bioavailability than standard oral use. Providers should be aware that with diazepam’s long half-life, accumulating levels would occur with chronic daily doses, and steady-state levels would not be reached for up to 1 week. This profile would favor intermittent use to allow participation in physical therapy and intimacy.

INTRODUCTION: Bimanual pelvic examination is often performed for symptoms related to uterine fibroids (UF). We evaluated the clinical utility of this exam at the time of UF diagnosis in a community setting. METHODS: Retrospective sample of women diagnosed with UF between 2006 and 2010 in the Rochester Epidemiology Project, a population-based records-linkage system. Cohort includes a sample of women who had a pelvic examination within 12 months of UF diagnosis (n=141). Abnormal pelvic exam was defined as abnormal uterine size or shape, or any adnexal mass or fullness recorded by healthcare provider. We examined clinical and imaging characteristics using chi-squared for categorical and t tests for continuous data. Data reported as percentage or mean ± standard deviation. Volumes of the uterus and largest fibroid were calculated using the prolate ellipsoid formula. RESULTS: Women with UF and a normal pelvic exam (n=73) were younger than women with abnormal exam (n=68) (44.7±7.1 vs 46.9±5.4 years, P=.05), and had a higher BMI (29.4 ± 6.5 vs 26.6 ± 5.0 kg/m2, P=.007). Women with abnormal exam had significantly larger uterine volumes (226.0 ± 151.8 vs 150.9 ± 97.9 cm³, P=.005) and fibroid volumes (61.1±81.1 vs 19.9±52.8 cm³, P=.005). Abnormal examination was more frequently documented by gynecology providers (57.4%) than other providers (42.7%, P=.04). Fibroid symptoms were not associated with abnormal examination. CONCLUSION: Fifty-two percent of women with fibroids had a normal bimanual examination. Thus, a high suspicion of fibroids should prompt imaging. Lower BMI and larger uterine and fibroid dimensions increase fibroid diagnosis on pelvic examination.

BACKGROUND: In 2005, in response to a decline in residency applications in OBGYN, the American College of Obstetrics and Gynecology Presidential Task Force outlined strategies for attracting medical students to OBGYN. Our program implemented interventions across all years of medical school education, increased efforts to “teach the teachers,” and improve faculty and resident relations with students. Application rates increased, but little is still known about which interventions work. METHODS: This qualitative study received IRB approval. Students applying or recently matched into OB GYN residency programs from the Class of 2014–2016 were included. Eleven participants completed a phone interview exploring why they chose OB GYN, focusing on positive and negatives experiences. The survey instrument was designed to include open ended questions and a Likert-type survey. Grounded theory methodology was used for analysis. Participants received a $50 Starbucks card. RESULTS: Preliminary analysis identified the following themes: 1) potential for a “meaningful” job and a future role in women's health, advocacy for women or empowerment of women; 2) first impressions in the clinical clerkship and “welcoming” teams; 3) content and diversity of our field; 4) impact of supportive mentors in career decisions. DISCUSSION: Participants identify important events that even precede medical school, but commonly highlight finding meaning in their work, and identifying with others that share in their interest and goals as guiding them toward OB GYN.