The American College of Obstetricians and Gynecologists’ (ACOG) 2020 Virtual Conference starts this Friday, Oct. 30, with presentations by preeminent experts in ob/gyn. Presentations will be given through Saturday, Oct. 31. Check out the full schedule 

 and register to attend. It will stream live and on-demand.

 embrace telehealth when prescribing contraceptives, incorporate reproductive justice into their practice, and include the United States Medical Eligibility Criteria for Contraceptive Use (US MEC) as a contraceptive resource, according to Eve Espey, MD, MPH, Chair of ob/gyn at the University of New Mexico in Albuquerque.

In her presentation at the American College of Obstetricians and Gynecologists (ACOG) 2020 Virtual Conference, Dr. Espey notes that especially in the era of the COVID epidemic, telehealth sessions are a viable alternative to in-person clinical visits for contraception in patients seeking short-acting methods like oral contraceptive pills, the contraceptive patch, and the contraceptive ring.

“Telehealth visits serve to ensure patient-centered, shared decision-making counseling, as well as allowing the provider to confirm that the patients are good candidates with no contraindications for their method of choice,” Dr. Espey told 

In the case of estrogen-containing contraceptives, a history ruling out contraindications and a prior normal blood pressure (BP) reading in the chart or a self-reported normal BP is sufficient for prescribing the method.

“Similarly, a 12-month prescription of a contraception to be filled at a single pharmacy visit in states that permit this, and considering refills beyond a year, can improve care for patients during COVID,” Dr. Espey said.

SisterSong, a Women of Color Reproductive Justice Collective, defines reproductive justice as the human right to maintain personal bodily autonomy, have children or not have children, and parent children in safe and sustainable communities. “For clinicians, that means actively opposing reproductive oppression and adopting an entirely patient-centered framework, where we work to leave our biases at the door, respect the values and preferences of our patients, value the reproductive desires of all our diverse patients equally, and ensure affordable access to all contraceptives,” Dr. Espey said.

Reproductive justice also entails not pushing one’s own beliefs about who needs contraception and/or what kinds of contraceptives are most appropriate for any given patient. “Allow patients to drive conversations and decision-making about contraception, including honoring their decisions about whether and when to start and stop contraceptive methods,” Dr. Espey said.

The US Medical Eligibility Criteria (US MEC) provides user-friendly, data-driven guidance on appropriate candidates for contraception.

“The resource uses data from ongoing systematic literature reviews and integrates the best up-to-date evidence on safety of contraceptives for patients, with a number of different characteristics and conditions,” Dr. Espey said.

One of the new developments in contraception is the extended use of long-acting reversible contraception (LARC), particularly during the pandemic, “to ensure excellent contraception and minimize unnecessary patient-provider contact,” Dr. Espey said.

Passage of proactive policy measures to improve contraception adherence is also needed in many states; examples include passing legislation to require insurance coverage for 12 months of contraceptives dispensed at a time or passing contraceptive equity laws to ensure that contraceptives are covered to the same degree as other pharmaceuticals.

Two new contraceptives on the market are a 1-year combined estrogen-progestin vaginal ring and a new lower-dose contraceptive patch.

“Continuing contraceptive technology development ensures a wide array of methods to fulfill patients’ needs over their reproductive lifespans,” Dr. Espey said.

In addition, oral emergency contraception, including levonorgestrel (Plan B, Next Step) and ulipristal acetate (Ella) are not abortifacients, according to Dr. Espey. “The public and some providers remain confused about oral emergency contraception, which acts by delaying ovulation in contrast to mifepristone, which is one of two medications used for early medication abortion and for early pregnancy loss management,” she said.

Likewise, intrauterine devices (IUDs) do not cause pelvic inflammatory disease or tubal infertility. “These two conditions are caused by sexually transmitted infections and not independently by IUDs,” Dr. Espey said.

The ACOG 2020 Virtual Conference will be held on October 30 and 31 from noon to 4 pm ET. 

Dr. Espey reports no relevant financial disclosures.

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“Telehealth visits serve to ensure patient-centered, shared decision-making counseling, as well as allowing the provider to confirm that the patients are good candidates with no contraindications for their method of choice,” Dr. Espey said.

Contraception lessons for 2020

Implementation of vaginal cleansing for cesarean delivery decreased the surgical site infection (SSI) rate by 33% over a 4-year period at one Pennsylvania hospital, according to a quality improvement study presented at the American College of Obstetricians and Gynecologists (ACOG) 2020 Virtual Conference.

However, the addition of intravenous azithromycin did not result in any additional change in SSI rate.

“Nonetheless, we continue to support the use of azithromycin at our hospital, given the strong evidence from the previous randomized controlled trials,” said principal investigator Johanna Quist-Nelson, MD, who at the time of the study was a maternal-fetal medicine fellow at Thomas Jefferson University Hospital in Philadelphia.

Dr. Quist-Nelson was inspired to complete the study during her training after observing how difficult it was for patients who experienced wound infections after cesarean. “Often these patients are in pain, have trouble breastfeeding and sometimes need to be re-admitted,” she said. “This can lead to poor bonding of the maternal-infant dyad and increase the risk for postpartum depression.”

After Dr. Quist-Nelson and her team noted a high rate of SSI, they reviewed evidence of low-risk interventions that could decrease that risk of wound infections, they sought to implement them.

“We aimed to reduce our SSI rate by 30% in a high-risk population by sequential implementation of vaginal cleansing and azithromycin for women who underwent a cesarean delivery after having labored or experienced prelabor rupture of membranes (PROM),” Dr. Quist-Nelson told 

The study consisted of 1,033 patients who delivered via cesarean during labor or after PROM at Thomas Jefferson Hospital from 2016 to 2019.

“The hospital serves an urban population, in which the majority of patients come from racial backgrounds that experience systemic racism,” Dr. Quist-Nelson said.

At the start of the study, the investigators initiated vaginal cleansing routinely for women in labor or with PROM prior to cesarean, and15 months before the addition of azithromycin to the same population.

All providers were trained in vaginal cleansing, which comprised 30 seconds of cleaning the perineum from the anterior to posterior direction using a sponge stick with 10% povidone-iodine or the sponge portion of a 4% chlorhexidine scrub brush.

Cleansing was performed at the time of urinary catheter placement in the operating room using povidone-iodine supplies that were also available prior to vaginal delivery.

Azithromycin 500 mg IV was ordered if cesarean delivery was planned within 1 hour. “Routine pre-operative antibiotics -- generally weight-based dosing of cefazolin -- were given preferentially prior to administration of azithromycin,” Dr. Quist-Nelson said. “The ideal timing of azithromycin was within 1 hour prior to incision, although the timing was dependent on the urgency of the cesarean delivery.”

Vaginal cleansing alone decreased the SSI rate by 33%, from 22.8% to 15.2%, over the study period.

“It was surprising to our team that azithromycin did not further lower our post-cesarean SSI rate,” Dr. Quist-Nelson said. “We had hoped to see a further decrease in our population.”

That implementation of vaginal cleansing and azithromycin are feasible and effective, according to Dr. Quist-Nelson, who is now an assistant professor of maternal-fetal medicine at the University of North Carolina in Chapel Hill.

To further decrease SSI with vaginal cleansing, she recommends that healthcare facilities take advantage of supplies already existing on their labor floor.

“Before we began the study, our hospital already had iodine-soaked sponges that came in packets,” Dr. Quist-Nelson said. “We simply ordered more of these packets and placed them prominently in the operating room.”

However, merely putting supplies in place is not enough. Providers still needed reminders after implementation in order to increase compliance. “Using a reminder system in the electronic medical record (EMR) was very helpful for our providers to remember to order azithromycin for the appropriate patients,” Dr. Quist-Nelson said.

Dr. Quist-Nelson reports no relevant financial disclosures.

Principal investigator Johanna Quist-Nelson, MD, was inspired to complete the study during her training after observing how difficult it was for patients who experienced wound infections after cesarean. 

Impact of vaginal cleansing and azithromycin on cesarean surgical site infections

The data below is a reflection of data collected weekly by the Centers for Disease Control and Prevention (CDC). The cases reported are only confirmed cases with laboratory evidence of SARS-CoV-2 infection.

Here’s the latest data, updated on October 29:

Pregnant women with COVID-19, United States:

Data is updated weekly based on data collected by the Centers for Disease Control and Prevention (CDC). The cases reported are only confirmed cases with laboratory evidence of SARS-CoV-2 infection. CDC’s case numbers are validated through a confirmation process with each jurisdiction.

Currently, there are 56 U.S.-affiliated jurisdictions reporting cases of COVID-19, including 50 states, District of Columbia, Guam, New York City, the Northern Marina Islands, Puerto Rico, and the U.S. Virgin Islands.

 and additional information from the CDC’s 

Data on COVID-19 during pregnancy, as reported by the CDC, in collaboration with state, local, and territorial health departments and external partners.

COVID-19 Pregnancy Data in the United States: October 29 Update

The study was led by researchers at the National Institutes of Health’s (NIH) 

National Institute of Child Health and Human Development (NICHD) and aimed to identify homogenous depressive symptom trajectories over the postpartum period and examine the demographic and perinatal factors associated with different trajectories.

Approximately 1 in 4 women experienced high levels of depressive symptoms at some point in the 3 years after giving birth, according to the results in 

Researchers used Upstate KIDS, a population-based birth cohort study, to recruit 4,866 mothers and provided 5-question assessments of depressive symptoms at 4, 12, 24, and 36 months postpartum. Maternal demographic and perinatal conditions were obtained from vital records and/or maternal reports.

The study showed four depression trajectories: low-stable (74.7%), which was characterized by low symptoms at all waves; low-increasing (8.2%), characterized by initially low but increasing symptoms; medium-decreasing (12.6%) characterized by initially moderate but remitting symptoms; and high-persistent (4.5%), characterized by high symptoms at all waves.

Infertility treatment, multiple birth, pre-pregnancy BMI, gestational hypertension, and infant sex were not differentially associated with depressive symptom trajectories.

“Our study indicates that six months may not be long enough to gauge depressive symptoms,” said Diane Putnick, Ph.D., the primary author and a staff scientist in the NICHD Epidemiology Branch in a press release. “These long-term data are key to improving our understanding of mom’s mental health, which we know is critical to her child’s well-being and development.”

The study participants, noted the researchers, were primarily white, non-Hispanic women. They called for future studies to include a more diverse, broad population to provide more inclusive data on postpartum depression.

Putnick, D, Sundaram R, Bell E, Ghassabian A, et al. Trajectories of Postpartum Depressive Symptoms. Pediatrics. October 2020. DOI: doi.org/10.1542/peds.2020-0857

Postpartum depression may persist three years after giving birth. News release. National Institutes of Health. October 27, 2020. Accessed October 27, 2020. 

www.nih.gov/news-events/news-releases/postpartum-depression-may-persist-three-years-after-giving-birth

New research suggests that postpartum depression may persist for 3 years following birth. 

Postpartum depression may persist for 3 years after birth

Breastfeeding has been linked to many positive influences for the infant. The impact of breastfeeding and infections that occur after the first year of life have been studied, but the results have been mixed. An 

 takes a look at if a link existed between the duration of breastfeeding and the number of infant hospitalizations that are a result of infection as well as symptoms of infection in the home.

The researchers used the Odense Child Cohort. They utilized text message questionnaires to ask questions about breastfeeding and symptoms of infection. Parents received questions about breastfeeding every week until their child was weaned and the questions about infection symptoms were received biweekly when their child was aged 12 to 36 months. The Danish National Patient Registry was used to find the hospitalization data.

A new study investigated whether breastfeeding could reduce infection and infection symptoms within the first 3 years of life. 

Study suggests breastfeeding could reduce early childhood infections

Participants include Joyce A. O'Shaughnessy, MD, Baylor-Sammons Cancer Center; Adam M. Brufsky, MD, University of Pittsburg Cancer Institute; Sarah A. Hurvitz, MD, UCLA Jonsson Comprehensive Cancer Center; Kevin M. Kalinsky, MD, Columbia University Medical Center; and Sara M. Tolaney, MD, MPH, Dana-Farber Cancer Institute.

The experts discuss new data from the European Society for Medical Oncology’s (ESMO) Virtual Congress 2020 and standards of care for early-stage triple-negative breast cancer.

“I think that increasingly for our patients with early-stage triple-negative breast cancer, we treat with neoadjuvant chemotherapy. I think that this is for a number of reasons so that we could see how patients are responding to the treatments that we’re giving,” said Dr. Kalinsky.

From OncLive, five experts share their perspectives and opinions on the latest research related to triple-negative breast cancer. 

Experts discuss triple-negative breast cancer

“Why not?” said Aaron Caughey, a professor and chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland, who is presenting on timing of induction of labor Oct. 30 at the American College of Obstetricians and Gynecologists (ACOG) 

“We know that the optimal gestational age to deliver is full-term: between 39 and 40 weeks,” Dr. Caughey told 

. “However, some pregnancies extend beyond this point.”

Dr. Caughey said that although all women could be induced in the 39- to 40-week range, “there has been a concern that intervening will lead to more cesareans and be too costly.”

In 2006, Dr. Caughey and his associates started showing that despite most clinicians’ beliefs, perhaps early induction does not cause more cesareans. Other investigators have found similar findings, and the recent large, randomized trial, ARRIVE, demonstrated that induction of labor at 39 weeks in nulliparous women as compared to expectant management leads to a lower rate of cesareans.

“The evidence suggests outcomes are as good or better for delivery at 39 to 40 weeks gestation as opposed to waiting until 41 weeks,” Dr. Caughey said.

Dr. Caughey believes the revelation that induction of labor might actually reduce the risk of cesarean delivery will be a surprise to many clinicians. And while he has conducted some of this research, he believes that “healthy suspicion of the findings is well-founded as studies should be replicated and studied in a range of clinical environments.

For many clinicians, “when one spends time on the labor floor, women being induced have a higher risk of cesarean. Thus, when one compares women with induction to women with spontaneous labor, induction of labor does have a higher risk of cesarean,” Dr. Caughey said. 

“But when one compares induction of labor to expectant management of the pregnancy in the full term (39 to 40 weeks gestation) and post-term (41 weeks gestation) periods, it appears that there are enough developments with expectant management that induction of labor does not increase the risk of cesarean.”

A 2018 cost-effectiveness analysis of induction of labor at 39 weeks of gestation versus expectant management among a theoretical cohort of 1.6 million low-risk nulliparous women found that induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy, again consistent with the ARRIVE trial. The analysis also concluded that induction of labor resulted in 795 fewer cases of stillbirth.

“Despite induction of labor being associated with increased costs, there was an increase in quality-adjusted life-years (QALYs), with an incremental cost-effectiveness ratio of $87,691.91 per QALY,” said Dr. Caughey, who spearheaded the analysis.

However, if the cost of induction of labor was increased by $180, elective induction would no longer be cost-effective.

Hence, while induction of labor in the full-term period is not a violation of the standard of care, the evidence is still evolving and local practice patterns can impact these outcomes.

“Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks is dependent on local capacity and careful evaluation and allocation of healthcare resources, along with patient preferences,” Dr. Caughey said. “Going forward, we will have to see how early induction of labor plays out in a variety of settings.”

Dr. Caughey reports no relevant financial disclosures.

Is 39 the new 41 when it comes to weeks of gestation for induction of labor?

Timing of induction of labor

In the second installment of a 2-part Infertility series, 

 outlines a shared decision-making method when treating the infertile couple. “Effective treatment will depend on the diagnosis, but can range from simple to very complex,” the authors said.

“The diagnosis of the infertile couple​”

Let us know: Send us a message on Facebook, Twitter, or send an email to our editorial staff.

What did you think of this month’s cover story? October 2020

Presentations will be given through Saturday, Oct. 31. Check out the full schedule 

The guidelines, developed by a consensus of 19 national organizations convened by ASCCP, are an update to 2012 consensus guidelines. New guidelines emphasize reducing invasive procedures while maintaining high standards of cancer prevention.

New guidance for managing further testing in patients with minimal abnormalities detected during cervical cancer screenings will be shared at the American College of Obstetricians and Gynecologists (ACOG) 2020 Virtual Conference.

“Although the older guidelines represented a conceptual breakthrough in risk-based management, those recommendations retained a continued reliance on complicated algorithms and insufficiently incorporated past screening history,” said Rebecca Perkins, MD, first co-author of the new guidelines. “Since their issuance, we have developed a more nuanced understanding of how prior results affect risk, and more variables to consider, such as the natural progression of human papillomavirus (HPV) and cervical carcinogenesis.”

Screening outcomes among 1.5 million people revealed that 90% of test results were normal and only 0.75% were severely abnormal.

“Colposcopy is still recommended if the estimated risk of currently having a precancer or cancer is from 4% to 24% or if testing results are positive for the HPV types 16 or 18, which are most highly associated with cervical cancer,” said Dr. Perkins, an associate professor of ob/gyn at Boston University School of Medicine and Boston Medical Center.

If the risk of currently having a precancer is from 25% to 59%, the patient may choose either a colposcopy with biopsy or proceed directly to treatment. But if the risk is 60% or higher, it is preferred that patients undergo treatment without requiring a biopsy first, according to Dr. Perkins. 

“This was an option in the prior guidelines, but has been more clearly defined in the new guidelines,” she said.

In addition, patients with minor abnormalities, such as Pap test results that indicate low-grade or atypical squamous cells of undetermined significance (ACS-US) or HPV infections, “can defer colposcopy, if these results were preceded by negative screening with either HPV testing or co-testing within the past 5 years or if preceded by a colposcopy at which precancer was not found in the past year,” Dr. Perkins told 

. “Previously, colposcopy was always recommended for these outcomes, but new data indicate that follow-up in 1 year is safe for many patients.”

Adhering to the new guidelines will result in fewer patients being referred to colposcopy, “and those who are referred are at higher risk for precancer,” Dr. Perkins said. “The new guidelines are also designed to minimize unnecessary biopsies where precancer is not found, reduce patient harm and allow resources to be concentrated on high-risk patients.”

Hence, colposcopists should have a high level of suspicion and biopsy all abnormal-appearing areas, typically two to four biopsies per colposcopy. 

“They should also expect that a higher proportion of their colposcopy patients will have precancer requiring treatment,” Dr. Perkins said.

The guidelines’ framework is based on a patient's risk of precancer rather than a specific combination of test results. 

“This will allow more personalized recommendations for patients, and more streamlined incorporation of new screening and diagnostic technologies into clinical practice,” Dr. Perkins said. “Management of abnormal test results will shift from paper algorithms to electronic decision aids, which will further facilitate patient care predicated on the best available data.”

Dr. Perkins reports no relevant financial disclosures.

The American College of Obstetricians and Gynecologists’ (ACOG) 2020 Virtual Conference starts this Friday, Oct. 30, with presentations by preeminent experts in ob/gyn. 

New ASCCP consensus guidelines for managing abnormal cervical cancer screening test results

There are a multitude of reasons for parents to want to know the gender of their baby. Maybe they want to get started on the nursery or register for the baby shower.

A baby’s gender is often detected via ultrasound around 20 weeks of pregnancy.

To answer the question, Dr. Saam Ramzi Ismali developed a theory (Ramzi’s method) that fetal sex could be determined as early as 6 weeks into pregnancy. The theory claims that the location of the placenta, or trophoblast, can define fetal gender as early as six weeks via ultrasound. If the placenta is developing on the left side, the sex is female. If it is developing on the right, the sex is male.

Unfortunately, Ramzi’s method has not been confirmed in any additional studies. There are no outward signs of sex until about 9 weeks of pregnancy. Differentiated genitalia cannot be seen clearly until about 15 weeks.

 As a result, many ob/gyns dismiss the validity of Ramzi’s method entirely.

A gender prediction method that has been studied, however, is the use of cell-free DNA. Researchers used cell-free fetal DNA in plasma of pregnant women to determine early gender of the fetus with 96.7% accuracy.

Fetal Development: Stages of Growth. Cleveland Clinic. Accessed October 21, 2020. 

https://my.clevelandclinic.org/health/articles/7247-fetal-development-stages-of-growth

Santiago-Munoz P. Boy or girl? The difficulties of early gender prediction. diction. 

December 20, 2016. Accessed October 21, 2020. 

https://utswmed.org/medblog/gender-prediction/

Zargari M, Sadeghi MR, Shahhosseiny MH, et al. Fetal Sex Determination using Non-Invasive Method of Cell-free Fetal DNA in Maternal Plasma of Pregnant Women During 6(th)- 10(th) Weeks of Gestation. 

A baby’s gender is often detected via ultrasound around 20 weeks of pregnancy. What if there was a way to know sooner? 

Experts discuss triple-negative breast cancer

Timing of induction of labor

What did you think of this month’s cover story? October 2020

New ASCCP consensus guidelines for managing abnormal cervical cancer screening test results

Can placental location accurately predict fetal gender?