American journal of obstetrics and gynecology
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Am. J. Obstet. Gynecol. · Nov 2017
Social determinants of access to minimally invasive hysterectomy: reevaluating the relationship between race and route of hysterectomy for benign disease.
Racial and socioeconomic disparities exist in access to medical and surgical care. Studies of national databases have demonstrated disparities in route of hysterectomy for benign indications, but have not been able to adjust for patient-level factors that affect surgical decision-making. ⋯ When accounting for the effect of numerous pertinent demographic and clinical factors, the odds of undergoing minimally invasive hysterectomy were diminished in women of Hispanic ethnicity and in those enrolled in Medicaid but were not discrepant along racial lines. However, both racial and socioeconomic disparities were observed with respect to access to robot-assisted hysterectomy despite the availability of robotic assistance in all hospitals treating the study population. Strategies to ensure equal access to all minimally invasive routes for all women should be explored to align delivery of care with the evidence supporting the broad implementation of these procedures as safe, cost-effective, and highly acceptable to patients.
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Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. ⋯ Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation.
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Am. J. Obstet. Gynecol. · Nov 2017
First sacral nerve and anterior longitudinal ligament anatomy: clinical applications during sacrocolpopexy.
The recommended location of graft attachment during sacrocolpopexy is at or below the sacral promontory on the anterior surface of the first sacral vertebra. Graft fixation below the sacral promontory may potentially involve the first sacral nerve. ⋯ Awareness of the first sacral nerve position, approximately 2.5 cm below the midpoint of the sacral promontory and 2 cm to the right of midline, should help anticipate and avoid somatic nerve injury during sacrocolpopexy. Knowledge of the approximate 2-mm thickness of the anterior longitudinal ligament should help reduce risk of discitis and osteomyelitis, especially when graft is affixed above the level of the sacral promontory.
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Am. J. Obstet. Gynecol. · Nov 2017
Evidence that children born at early term (37-38 6/7 weeks) are at increased risk for diabetes and obesity-related disorders.
Prematurity is known to be associated with high rates of endocrine and metabolic complications in the offspring. Offspring born early term (37-38 6/7 weeks' gestation) were also shown to exhibit long-term morbidity resembling that of late preterm, in several health categories. ⋯ Deliveries occurring at early term are associated with higher rates of long-term pediatric endocrine and metabolic morbidity of the offspring as compared with deliveries occurring at a later gestational age. This association may be due to absence of full maturity of the hormonal axis in early term neonates or, alternatively, suggest an underlying fetal endocrine dysfunction as the initial mechanism responsible for spontaneous early term delivery.
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Am. J. Obstet. Gynecol. · Oct 2017
Randomized Controlled TrialImpact of evidence-based interventions on wound complications after cesarean delivery.
A number of evidence-based interventions have been proposed to reduce post-cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. ⋯ Implementation of evidence-based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence-based measures.