Though theoretical, the threat of aerosolized viral particles places health care providers at risk. Certain safety measures can be taken. View the full, peer-reviewed article, and more, in this month's edition of Contemporary OB/GYN.

July 2020 | Vol 65 No 07

Judith M. Orvos, ELS, is a a BELS-certified medical writer and editor and an editorial consultant for Contemporary OB/GYN.

While urging caution in interpretation of their results, the authors say the findings could be particularly important for management of nulliparas.

Findings from the study—which was stopped early because of a signifi cantly higher rate of peri-natal mortality in the expectant management group—were pub-lished in BMJ. 

SWEPIS (SWEdish Post-term Induction Study) was a multicenter, open-label, random-ized superiority trial conducted at 14 hospitals in Sweden from 2016 to 2018.

Of the 2760 women enrolled, all of whom had low-risk, uncomplicated pregnancies, 1381 were randomized to induction at 41 weeks and 1379 to ex-pectant management with induction at 42 weeks. In many centers in the UK and Scandinavia, induction is com-mon no later than 42 weeks. 

Recent studies have shown a significantly increased risk of perinatal mortality and morbidity at 41 weeks, and of stillbirth beginning at 39 weeks.

The primary outcome of SWEPIS was a composite of perinatal out-come including one or more of still-birth, neonatal mortality, Apgar < 7 at 5 minutes, pH < 7.00 or metabolic aci-dosis in the umbilical artery, hypoxic ischemic encephalopathy, intracranial hemorrhage, convulsions, meconium aspiration syndrome, mechanical ventilation within 72 hours, or obstetric brachial injury. 

The secondary outcome was perinatal mortality. The primary analysis was intent to treat.

In the induction group, there were fewer admissions to a [NICU], lower incidence of neonatal jaundice...and fewer infants with macrosomia.

No perinatal deaths occurred in the group induced at 41 weeks but six occurred in the expectant management group (5 stillbirths, 1 early neonatal death; P = 0.03). No differences were seen between the groups in the composite primary perinatal outcome (2.4% [33/1381] induction group; 2.2% [31/1379] expectant management; RR 1.06, 95% CI 0.6 to 1.73; P = 0.90). 

The proportion of cesarean deliveries, instrumental vaginal deliveries, or major maternal morbidities also did not differ between the groups.

The authors also found that in the induction group, there were fewer admissions to a neonatal intensive care unit, lower incidence of neonatal jaundice requiring therapy, and fewer infants with macrosomia. 

The rate of cesarean delivery did not differ significantly between the two groups. Of note, the researchers said, all perinatal deaths occurred in the nulliparous women. 

“If this finding can be replicated in fu-ture studies,” they indicated, “it could mean that nulliparous women may require particular attention, and interventions such as labor induction might be even more important in this group.” 

The number needed to treat with induction of labor at 41 weeks to prevent one perinatal death was 230, which the authors said was lower than previous estimates.

Moura APC, Ribeiro HSAA, Bernardo WM, et al. Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: Systematic review and meta-analysis. PLOS One. 2019;14(4):e0214842.

Articles

A nationwide study by Swedish researchers suggests that inducing labor at no later than 41 weeks could be one of the few interventions that reduce stillbirths. 

Inducing labor to reduce stillbirths

 found that more than 95% of the prescriptions were for short-acting opioids (SAOs) only, while 4.1% were for both SAOs and extended-release/long-acting opioids (LAOs).

Only 0.6% of women filled a prescription for LAOs alone.

“Endometriosis is a debilitating disease that can cause significant pelvic pain,” said principal investigator Sawsan As-Sanie, MD, MPH, co-chief of gynecology and director of minimally invasive gynecologic surgery at the University of Michigan in Ann Arbor. 

“However, currently available treatments are not consistently effective for all women, and some may resort to opioids to manage their pain, despite the fact that opioids are not recommended for the treatment of endometriosis pain or any other chronic non-malignant pain condition. Long-term opioid use can be associated with significant harm.”

The investigators, who sought to better understand the scope of opioid prescribing patterns in women with endometriosis, performed a retrospective cohort analysis of data from the Truven MarketScan Commercial database for the period January 2011 to December 2016.

Women who filled an opioid prescription within 12 months of their first endometriosis diagnosis were compared to women who did not fill an opioid prescription during the study period.

The dataset comprised 58,472 women with endometriosis, of whom 61.7% filled an opioid prescription within the first year. While only 10% of women did not have any surgery in the first year after the first listed endometriosis diagnosis, the prevalence of patients who received an opioid prescription remained high, even after excluding opioids prescribed in the perioperative period (defined as anytime between 14 days before or 30 days after surgery). 

After excluding prescriptions in the perioperative period, 49% of women with endometriosis filled at least one opioid prescription.

Compared to endometriosis patients who did not fill an opioid prescription, endometriosis patients who filled an opioid prescription had significantly higher baseline comorbidities (especially gynecological and chronic pain comorbidities), endometriosis-related medication use, mental health disorders and substance abuse.

“I expected that this would be common after surgery, but was especially surprised that these patterns persisted, even after excluding opioid prescribing outside of the surgical period.” 

Patients who filled both LAO and SAO prescriptions had the highest total days' supply of opioids, proportion of days covered by prescriptions and morphine equivalent daily dose.

Baseline opioid abuse, opioid dependence, and opioid overdose were also significantly higher in the SAO and LAO-SAO groups compared to the non-opioid group: SAO: 0.3%, 2.2%, 0.2% respectively; LAO-SAO: 2.5%, 15.8%, 2.4% respectively; non-opioid: 0.2%, 1.2%, 0.1% respectively (

These patients also had the highest proportions of opioid switching and dose augmentation.

“While I do not recommend the use of opioids for the management of chronic pain in my practice, I was surprised by how commonly opioids are prescribed in women with endometriosis,” Dr. As-Sanie told 

Dr. As-Sanie said an important next step in understanding and optimizing endometriosis care is further research into when opioids are prescribed relative to the diagnosis and treatment timeline, and the reasons surrounding the use of opioids in relation to other recommended treatments, such as combined hormonal contraceptives, gonadotrophin-releasing hormone agonists (GnRHa), progestins, and surgical excision.

Dr. As-Sanie receives royalties from UpToDate, and is a consultant to AbbVie, Myovant Sciences, Bayer, and Merck.

As-Sanie S, Soliman AM, Evans K, et al. Short-acting and long-acting opioids utilization among women diagnosed with endometriosis in the United States: a population-based claims study. 

. Published online June 9, 2020. doi:10.1016/j.jmig.2020.05.029

Nearly two-thirds of women newly diagnosed with endometriosis filled an opioid prescription within the first year, according to a US population-based claims study. 

Opioid use in women with endometriosis

A significant positive association exists between hormone replacement therapy (HRT) and mammographic density (MD), according to a systematic literature review in the journal 

The review concluded that the highest increase in MD is among current users of HRT, particularly those taking continuous estrogen plus progestin (CEP).

“HRT has been used as an effective treatment for alleviating the climacteric symptoms of menopause, such as hot flushes, sleeping disturbance, depressive mood, and muscle and joint pain for many years,” said senior author Shadi Azam, PhD, a breast cancer epidemiologist at Karolinska Institute in Stockholm, Sweden.

 that various papers and reviews have evaluated the effect of different HRT regimes, state of exposure and risk of breast cancer. 

“However, ours is the first systematic review to assess the impact of HRT regimens on MD, which is an important risk factor for breast cancer,” she said.

Articles published between 2002 and 2019 from PubMed, Embase and Ovid were reviewed. Among the 22 studies that met the inclusion criteria, six studies showed that using estrogen plus progestin (E + P) HRT was associated with higher MD than estrogen alone.

Four studies reported that CEP was connected to higher MD than sequential estrogen plus progestin (SEP) or estrogen alone, but two studies showed that SEP caused slightly higher MD than CEP or estrogen alone.

“The review showed that MD significantly increases in women who have ever used HRT, compared to never users, with the highest increase in MD among current HRT users,” Dr. Azam said. “CPP users also have the highest increase in MD, followed by SEP users and estrogen alone users.”

Dr. Azam is not surprised by any of the findings. “Epidemiological evidence is rather consistent, suggesting that there is a positive association between HRT and MD,” she said.

However, it is unclear why HRT causes increasing MD, although one established hypothesis is based on the breast cell proliferation theory. 

In menstruating women, it has been observed that breast epithelial cell proliferation is increased due to high levels of estrogen and progestin.

Study findings can be helpful in primary prevention of breast cancer and secondary prevention of false-negative diagnosis of small tumors, according to Dr. Azam.

“From the primary prevention perspective, our results indicate that HRT should be minimized at the lowest doses needed for as short of time as possible,” she said, “And from the secondary prevention perspective, women who currently use HRT and for whom an increase in MD is detected by mammography screening may require additional screening procedures, shorter screening intervals and the use of advanced imaging techniques such as magnetic resonance imaging/ultrasound for detecting small tumors.”

Dr. Azam emphasized that MD is one of the strongest risk factors for breast cancer. 

“At a given age and body mass index (BMI), women with very dense breasts (more than 75% dense) have a four- to six-times greater risk of breast cancer compared with women with less dense tissue (occupying less than 5% of the breast),” she said.

To prevent breast cancer, “HRT should be given with caution and consideration.” Dr. Azam said.

Dr. Azam reports no relevant financial disclosures.

Azam S, Jacobsen KK, Aro AR, et al. Hormone replacement therapy and mammographic density: a systematic literature review. 

. 2020;183(2):555-759. doi:10.1007/s10549-020-05744-w

Link between hormone replacement therapy and mammographic density

According to the American College of Obstetricians and Gynecologists (ACOG), there are several benefits of using the stem cells in cord blood to treat disease

Stem cells from cord blood can be given to more people than those from bone marrow. The stems cells in cord blood are less likely to be rejected than those in bone marrow.

It is easier to collect cord blood than bone marrow, as bone marrow collection poses risks and can be painful for the donor.

Unlike bone marrow stem cells, cord blood can be used to strengthen immune systems during cancer treatments.

ACOG also notes, however, that cord blood does not contain as many stem cells as bone marrow. “Units from several donors can be combined to increase the number of stem cells if a transplant is needed for an adult.”

As many ob/gyns know, cord blood must be stored carefully. According to the Food and Drug Administration, “cord blood stored for personal use, for first- or second-degree relatives, and that also meets other criteria in FDA’s regulations, does not require the agency’s approval before use. Private cord banks must still comply with other FDA requirements.”

“Not every cord blood unit will meet requirements for public banking, adds Safa Karandish, M.T., an FDA consumer safety officer. If that happens, some of this donated cord blood may be used for non-clinical research.”

Cord Blood Banking. American College of Obstetrics and Gynecology. Accessed July 6, 2020. 

https://www.acog.org/patient-resources/faqs/pregnancy/cord-blood-banking#advantages

Cord Blood: What You Need to Know. Food and Drug Administration. Accessed July 6, 2020. 

https://www.fda.gov/consumers/consumer-updates/cord-blood-what-you-need-know?deliveryName=USCDC_277-DM31597

For Cord Blood Awareness Month, here are some updated usages and FDA regulations for practitioners using cord blood.

Cord Blood Awareness: Quick facts

Obstetrics and Gynecology has undergone notable change in the last few decades: advancement in subspecialties, greater diversity in practitioners, liability, robotics, and much more. The healthcare industry overall is experiencing an historic transformation that is impacting many facets of medicine. 

Patients’ expectations, communication, access to health information, and desire for transparency and accessibility are just a few of the many aspects that are different today than they were a short time ago.

In the midst of the proliferation of the Internet and related technologies, the Millennial generation emerged in the workforce, and according to the U.S. Bureau of Labor Statistics, Millennials will comprise 75% of employees by 2030. 

Generational awareness and proactive adaptations are paramount to enhance relationships among providers and patients and to maximize the attributes of each respective workplace age group.

Generations are defined as cohorts of people born in a span of roughly 15 to 20 years that are influenced and often characterized by the social, economic, and political events that occur during their formative years. 

These experiences help to shape a common system of beliefs, attitudes, and values held prominently within each group. Generations are often named by pop culture and the media, however, the United States Census Bureau defined one generation, the Baby Boomers.


The current healthcare workforce is composed of members of the Silent Generation (born 1928-1945), Baby Boomers (1946-1964), Generation X (1965-1980), and Millennials (1981-1996). 

Members of Generation Z (1997-2012) are just beginning to enter medical school and careers in healthcare (Figure 1). 

Although each generation has stereotyped descriptors, it is important to acknowledge that individual members may not always demonstrate these characteristics or self-identify with their own generation, depending on unique cultural conditions and life experiences.

Figure 2 summarizes the characteristics, experiences, innovations, and workplace attitudes for each generation. Members of the Silent Generation were children of crisis; their formative years occurred during the Great Depression and World War II, and thus birth rates were the lowest of any generation. 

The Silent Generation came of age in an era of great scarcity and austerity and are known to be hard-working rule-followers who value stability and avoid rocking the boat. 

Early in their careers, members were thought to be happy to have a secure job, even if it was not the most desirable, and loyally kept their noses to the grindstone. For many, this loyalty holds fast today.

Baby Boomers were born during social and political upheaval but were also raised during a period of economic prosperity. They are characterized as competitive and ambitious, and are high-achieving, goal-oriented employees. 

Striving towards and realizing the American Dream was a priority for many. Baby Boomers live to work, and many continue to work beyond the typical retirement age due to the joy they find in their occupations.

Resourceful and self-sufficient, Generation X’ers were dubbed “latchkey kids”; both parents often worked outside the home, so members of this generation looked after themselves and their younger siblings. 

Many saw their mother and father divorce and were raised in single-parent households. Having witnessed the workaholic approaches of their Silent Generation or Baby Boomer predecessors, Generation X’ers have a mantra of “work to live” and value a more flexible work environment.

Millennials are the first generation to have been immersed in digital technology early in life; many had computers in their classrooms and were natural adopters of electronic modes of communication. 

Their parents tended to be protective and very involved; “helicopter” and “snowplow” parents are widely used descriptors. Millennials are the most educated of any generation; nearly 40% of millennials have a bachelor’s degree or higher, compared with 15% of the Silent Generation.

Members of this cohort are marrying later, starting families later, and are the most racially and ethnically diverse generation in the history of the workforce. 

More than any other generation, Millennials are in search of a work-life integration that grants both personal and professional fulfillment.

From house calls to smartphones, communication among members of the healthcare team and with patients has varied widely over the last several decades. While members of the earlier generations may recall a time when house calls were not unheard of, the evolution of clinical productivity standards now demands that physicians from all generations embrace email and increasingly text messaging. 

Even the telephone is quickly becoming obsolete as practitioners seek to both deliver and consume communication asynchronously, sending and receiving when time allows. 

Millennials who came of age during the smart machine revolution, which began around the turn of the 21st century and is ongoing, strongly prefer and are hastening the adoption of more modern communication regimes. 

Millennials often expect this type of communication to be the norm, and it is not uncommon for them, when joining a practice, to start a group text thread among partners that they use freely at all hours of the day and night.

Just as the lines of communication are being redrawn, perhaps more uncomfortable for some, the traditional clinical chains of command are being blurred by eager and confident members of later generations. 

Years ago, it would have been improper for a medical student to address an attending by their first name, but some new attendings actually prefer and invite trainees to dismiss formalities. This type of disregard for hierarchy sends ripple effects throughout academic departments and practices that are tolerated differently based on organizational philosophy and cultural acceptance of change. 

A side effect of the gradual dissolution of hierarchy may be an exaggeration of ambiguity in how trainees and colleagues of different generations perceive workplace mistreatment by both peers and superiors.

Team-based approaches to learning and problem solving have been hardwired into newer generations. While most can easily conjure images from childhood of a favorite teacher at the chalkboard espousing wisdom to the masses, Millennials experienced the beginning phases of an ongoing reformation of classroom teaching that more heavily emphasizes problem-based learning in peer groups. 

Recognizing that collaboration in the healthcare workplace is natural and necessary, many medical schools have trended in this direction, as well. 

This evolution of teaching and learning has broad implications for how generations of physicians relate and work together. Millennials, for example, may have learned to frequently seek out the opinions of various care-team members while earlier generations might have been trained to make decisions based more on their own understanding and experience.

What is work and what is life? There are thousands of articles on work-life “balance,” “fit,” “blend,” and “integration.” 

The ratios of time and energy spent on personal and professional endeavors may vary not only by generation but also depending on stage of life. The values of any one member of a generation may change as the milestone events of life unfold. 

What remains constant, however, are the positive professional and personal benefits of sustained maintenance of self-care. 

Many are familiar with pre-flight instructions that advise passengers to don their own oxygen masks before assisting others; if providers aren’t mentally and physically healthy themselves, how can anyone expect them to care for their patients effectively?

Just as generation and stage of life are important determinants of values, gender cannot be overlooked. Today, more than half of ob/gyns are women, and over 80% of medical students who match into the specialty are female.

Compare these numbers to 1970 when 93% of ob/gyns were men. And in 1970, many male physicians were not also responsible for caregiving and domestic duties. Women in medicine are almost twice as likely as men to have partners who are employed full-time (86% of females versus 45% of males). 

Females in medicine with partners and children reported spending an average of 8.5 hours more on parenting and domestic tasks than their male counterparts each week.

Physicians feel they are being asked to do more with less. There never seem to be enough hours in the day to complete work responsibilities, let alone adequate time for family and pleasure. 

And while it may be easy for some to dismiss these sentiments as an insufficient work ethic in younger generations, one must carefully consider the disruptive transformation of modern healthcare delivery that is significantly influencing the dynamics of work-life integration. 

Volumes could be devoted to an exploration of how this topic impacts other vital industries just as acutely as medicine, but take for example the mass exodus of teachers from the K-12 education arena. Only in recent history have regulations led to a demand for student recordkeeping so burdensome that the careers of many educators are extinguished prematurely. 

The original meaning many teachers sought from a profession once regarded as a cornerstone of our society is being increasingly eroded, and this is a refrain that sounds all too familiar to many physicians today.

Whether symptoms of burnout have actually increased dramatically, or there is now more attention called to exhaustion, or both, job flexibility that allows for some work-life integration is highly valued, especially by younger generations. This begs the question: Is it possible to achieve work-life balance as a physician? 

Understandably, there will be less of a balance and more of a blend as an ob/gyn, but creative solutions are imperative to ensure the feasibility of fulfilling both home and work responsibilities, within reason. 

Further, these adaptations play a critical role in preventing exacerbation of the upcoming physician shortage by doctors who don’t maximize their career potential and instead retire early, decrease to part-time or less, or even change careers.

One would assume that shifting careers from a physician to a different profession was previously unlikely, but Millennials and likely future generations perceive their careers to be less defining of their identities. As mentioned, professional 

 personal fulfillment are highly regarded by Millennials. 

As such, opportunities to develop hobbies, devote time to family and friends, and volunteer in the local community and beyond will need to be recognized and supported by employers to ensure satisfaction and stability in the workforce.

A generational divide may seem inevitable; however, gaps can be narrowed with effort.

Employers and organizations that provide support in the way of formalized mentoring programs will facilitate the dissemination of wisdom to newer generations and encourage goal setting. Clinical skills, productivity pearls, and expertise amassed through decades of practice are invaluable resources for junior partners. 

Beyond these attributes, mentors may guide mentees by facilitating network connections and providing advice on promotion and career pathway optimization. Mentors serve as sounding boards during professionally challenging times or when difficult situations arise.

Reverse mentoring can occur in the same partnership; in this scenario the junior physician mentors the senior physician in unique skillsets they possess, especially adaptation to technology, which is second nature to Generation X and certainly to Millennials. 

Reverse mentorship can offer mentees advice on electronic health record efficiency, template sharing, app utilization, website and social media presence, and more.

Formal mentorships are excellent resources for physicians in every career stage. These relationships can be created in departments and practices, or through utilization of the American College of Obstetricians and Gynecologists Mentor Program, especially when local connections are more limited. 

As mentors and mentees begin to exchange viewpoints and develop relationships, generational understanding is naturally achieved, reinforced, and enriched.

Opportunities forflexibility in scheduling can be employee-friendly and also patient-friendly. Consider offering evening or weekend office hours a few times per month, which are highly desirable to Millennial patients. 

Members of younger generations may gladly exchange morning hours for evening hours on occasion, as this may afford the opportunity to be involved in school activities for their children or errand-running that is otherwise not possible with a traditional physician schedule.

Similarly, setting up a practice to offer and receive reimbursement for e-visits or video visits is another convenient way to efficiently deliver healthcare. This can allow for occasional windows of time to work outside of the traditional office setting or even from home. 

Though Obstetrics and Gynecology may be more limited than specialties such as Psychiatry in the visit types that can be offered electronically, opportunities do exist and will become more commonplace as generational demand increases.

Laborist and gynecologic hospitalist models have increased patient safetyand can provide unique appeals of acute, inpatient medicine and defined shifts.

Though these models lack the benefit of patient continuity, both junior and senior physicians, as well as many practices, find this to be an attractive alternative to relinquishing obstetric services earlier in a career than desired and can also increase productivity in the office.

Encourage input from all generations when crafting new policies and procedures and in solving problems. Harnessing the creativity of the group is likely to yield different perspectives and invoke innovation. When meeting together, all generations will appreciate a clear agenda with defined and respected start and end times. 

Consider whether an email or text thread would be just as effective and more efficient than face-to-face contact. Leaders should strive to acknowledge the attributes and perspectives of each generation to achieve harmony and optimize productivity.

As we strive to enhance our relationships with our colleagues and patients, it would benefit us all to consider the values, characteristics, and experiences of every generation. 

With some effort, generational gaps can be narrowed and ob/gyns of all ages will thrive at home and at work and continue to deliver high-quality care to our patients.

Bialik K, Fry R. Millennial life: How young adulthood today compares with prior generations. https://www.pewsocialtrends.org/essay/millennial-life-how-young-adulthood-today-compares-with-prior-generations/. Pew Research Center. February 14, 2019.

Rayburn W. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implication. Washington, DC: ACOG; 2017.

Jolly S, Griffith K, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. 

Association of American Medical Colleges.New findings confirm predictions on physician shortage. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage. August 23, 2019.

ACOG Committee Opinion 459. The Obstetric and Gynecologic Hospitalist. Committee Opinion No. 459. American College of Obstetricians and Gynecologists. 

Bridging the generational gap in the physician workforce.

Introducing Dr. Millennial

The scientific approach to categorizing mesh complications, as well as optimal methods to address them, have been complicated by the rapid proliferation and evolution of materials and techniques that have been used over the past 20 years in surgical treatment of pelvic floor disorders. 

In addition, terminology used to diagnose and categorize mesh complications, as well as the descriptions of surgical procedures to manage them, have been adopted inconsistently, further hampering development of a collective experience with a standardized lexicon. 

Finally, much of the high-quality data on management of mesh complications is based on materials that are rarely used or not commercially available today.

Women experiencing mesh complications need to be heard, and should have access to resources and providers who are most able to help. Many women require multiple procedures to address their mesh complications, and for some of these patients, relief is incomplete. 

We should strive to optimize the treatment at the initial diagnosis of a mesh-related complication.

: Using the best and most relevant evidence available, provide guidance for the FPMRS subspecialist caring for patients who may be experiencing mesh complications.

: Provide an algorithm outlining treatment choices for patients with mesh-related complications that can be used as a platform for shared decision-making in the treatment of these complications.

: Identify and prioritize gaps in evidence concerning specific mesh complications and their treatments.

: Identify provider and health facility characteristics that may optimize the outcomes of treatments for these complications

The treatment algorithm requires consistent and accurate terminology for treatment procedures, as follows:

: either no mesh is removed (e.g., dissecting and primarily closing vaginal epithelium), or a small edge of mesh is removed such that the structural integrity of the implant is left intact.

: a segment/component of the mesh is removed or transected, such that the structural integrity of the implant is altered.

 removal of segments or components of mesh beyond, or not in contact with, the vagina

the surgical goal is the removal of 100% of the implant; extirpation.

The treatment algorithm is presented, along with the level of evidence supporting each decision node. Recognizing that some patients will require more than one procedure, the recommendation is made that treatments are not repeated; if a given treatment is unsuccessful, consideration should be given to advancing to the next item on the algorithm.

Full text of “Management of Mesh-Related Complications for the FPMRS Specialist” can be found 

This was created in partnership with the American Urogynecologic Society (AUGS). AUGS was established in 1979 and represents more than 1,900 members, including practicing physicians, nurse practitioners, physical therapists, nurses and health care professionals, and researchers from many disciplines.

The American Urogynecologic Society (AUGS) released new information on managing mesh problems, which includes guidance, treatment algorithms and ways to optimize treatment outcomes for these complications.

AUGS Consensus Statement: Managing mesh problems

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 July 2:

Pregnant women with COVID-19, United States

Stay tuned for the next data update on July 7, 2020. 

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.

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: July 2 Update

Recent studies have found that neonatal intensive care unit (NICU) admissions, initial hospitalized days, short stays, and additional NICU utilization trends vary significantly in the United States health care system.

 However, NICU utilization trends have yet to be thoroughly investigated.

set out to explore NICU utilization trends using the Kaiser Permanente Southern California health care system. Participants included every woman who gave birth in a Kaiser Permanente Southern California hospital, and her newborn, from January 2010 to December 2018.

Trends studied included NICU admission, NICU patient-days, readmission rates and mortality rates. 

In those 8 years, 320,340 births occurred, and researchers found that NICU utilization had decreased. However, researchers noted that it did not lead to an increase in readmissions or mortality.

For more information about this study and its additional findings, visit 

NICU utilization trends have yet to be thoroughly investigated. 

New study analyzes NICU utilization trends

Forty-three percent of American women aged 18 to 85 report experiencing some form of sexual complaint; however, the actual incidence of self-reported significant distress from these issues is closer to 12%.

Defined as distress due to lack of desire, impaired arousal, inability to achieve orgasm, pain with sex, or a combination of the above, sexual dysfunction is a commonly ignored topic given the societal stigma surrounding open discussion of female sexuality.

Unfortunately, this bias toward under reportingextends to health care providers, who also report being less comfortable bringing up female sexuality.

While in part, this is due to the perception that there is inadequate time in clinic to address sexuality issues, some providers do not feel proficient in sexual dysfunction knowledge or management.

Although over the last 10 years there has been a cultural shift toward acknowledging the spectrum of sexual relationships and conditions, several recent studies on training received in sexual medicine have not found increased attention on education in this area.

Discomfort among practitioners who are managing sexual dysfunction remains high.

 In addition, while the Internet has made it easier for patients to find information about their symptoms, they remain less likely to bring up intimate issues with their healthcare providers unless directly asked.

Despite this hesitancy from patients and practitioners to delve into sexual health, many studies support the idea that regular sexual expression is associated with improved psychological well-being and reduction in physical problems.

Intimacy has been found to be vital to overall well-being.

The aim of this article is to briefly review how to incorporate sexual dysfunction evaluation and simple treatments into current practice.

As health care practitioners, we effectively diagnose and treat disorders within our specialty. The challenge of sexual dysfunction is that the etiology may be complex, which can make starting the conversation about sexual function daunting. 

However, the American College of Obstetricians and Gynecologists (ACOG) recommends that all obstetrician and gynecologists should be initiating “clinical discussion of sexual function during routine care visits to identify issues that may require further exploration and to helpdestigmatize discussion.”

Although medical education regarding sexual medicine remains lacking, an advanced understanding is not needed to help patients feel comfortable. 

Start by normalizing the topic, ensuring patients that sexual problems are common and that the first step in improvement is being willing to talk about it. It can be effective to start the conversation with a simple open-ended question, for example: “Many women have concerns about sex. I wanted to check in and see how you’re doing.”

Allowing the patient to speak freely, followed by empathetic listening and asking pointed, detailed clarifying questions gives the patient space to express herself.

If short appointment times are the primary barrier to discussing sexual health, there are validated sexual function checklists, such as the Patient-Reported Outcomes Measurement System or Female Sexual Function Index (FSFI), that can be incorporated into the intake process; however, the onus is then on the provider to acknowledge aberrant answers and schedule follow-up appointments.

If a patient raises specific issues, begin by validating her concerns. If you are under time constraints, it’s acceptable toschedule a future focused sexual health follow-up appointment.

During that visit, take a detailed sexual history that includes: the patient’s sexual/gender identities, nature/duration/chronology and onset of symptoms, severity of distress caused by symptoms, patients’ personal attempts to alleviate symptoms, relationship quality, past/current abuse history (sexual, verbal, emotional or physical), and Internet/social media usage.

Assess hygiene, sleep quality, and body changes/image concerns.

Patients and practitioners may be hesitant to delve into sexual health, but talking about it is one way to normalize it.