; Professor and Chair of Obstetrics and Gynecology; and Gillette Professorship of Obstetrics and Gynecology at 

Catherine Y. Spong, MD

Last year was a big one for obstetrics and gynecology, with major legal decisions impacting our practice, stacked on reopening from the pandemic. Additionally, several medical advances have been published, providing evidence for our practice. I reviewed some of these advances along with some impactful articles that were important to us as women’s health care providers.

, an article on addressing physician burnout published in January 2021 highlighting the effect of the pandemic on our profession tops the journal’s list of most popular articles.

 Although the popularity may be related in part to the article’s selection as an American College of Obstetricians and Gynecologists maintenance of certification article, its content resonates with many. Bradford and Glaser address workplace culture as a major source of burnout, with a push to implement a positive workplace culture, address schedules to minimize meetings timed to interfere with personal time, and consider the impact of positive leadership that can help address the burden of heavy workloads and stress that often plague the health care provider.

A landmark study by Tita and colleagues was published in the 

 on the treatment for mild chronic hypertension (blood pressure [BP] < 160/100 mm Hg) in pregnancy with a target of < 140/90 mmHg.

 Of 2408 women with chronic hypertension at < 23 weeks of gestation, active treatment to achieve BP < 140/90 mmHg reduced adverse outcomes (severe preeclampsia, indicated preterm birth, abruption, fetal and neonatal death; 30% vs 37%) with no impact on small for gestational age infants (11% vs 10%). The implications from the trial have prompted the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to change their recommendations to target BP control to < 140/90 mmHg.

Similarly, in gynecologic oncology, Makker and colleagues evaluated over 800 women with advanced endometrial cancer with recurrence after platinum-based chemotherapy to determine if the addition of lenvatinib and pembrolizumab improved outcome.

 They found improved progression-free and overall survival with the addition of these therapies at 1 year. The Society of Gynecologic Oncology highlights these results and the best practices for management of recurrent metastatic endometrial cancer incorporating these findings.

 published a cohort study of 2,548,372 pregnancies evaluating buprenorphine (n = 10,704) and methadone (4387). The investigators reported an increase in neonatal abstinence (69% vs 52%), preterm birth (25% vs 14%), and low birth weight (15% vs 8%) with methadone; severe maternal complications were similar, at 3.3% to 3.5%. Understanding how best to manage opioid use disorder during and after pregnancy is essential to optimize care for this growing group of women.

A number of 2022 publications highlight the impact of COVID-19 on pregnancy outcomes, fertility, and menstruation, as well as outcomes of COVID-19 vaccination during pregnancy.

 Other noteworthy studies, interestingly, did not demonstrate effectiveness for interventions that one might think would be beneficial. Tucker and Chappell and colleagues reported on 2 studies (BUMP 1 and BUMP 2), both randomized clinical trials of pregnant women, that found that blood pressure self-monitoring with telemonitoring did not improve timing of diagnosis of hypertension or blood pressure control.

As we embark on 2023, we can be assured that more data will be forthcoming to guide our practices as well as to address practice issues with a goal to improve the workforce and workplace.

Bradford L, Glaser G. Addressing physician burnout and ensuring high-quality care of the physician workforce. 

. 2021;137(1):3-11. doi:10.1097/AOG.0000000000004197

Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy. 

. 2022;386(19):1781-1792. doi:10.1056/NEJMoa2201295

ACOG. Clinical guidance for the integration of the findings of the Chronic Hypertension and Pregnancy (CHAP) study. April 2022. Accessed December 8, 2022. 

https://www.acog.org/en/clinical/clinical-guidance/practice-advisory/articles/2022/04/clinical-guidance-for-the-integration-of-the-findings-of-the-chronic-hypertension-and-pregnancy-chap-study

Makker V, Colombo N, Casado Herráez A, et al. Lenvatinib plus pembrolizumab for advanced endometrial cancer. 

. 2022;386(5):437-448. doi:10.1056/NEJMoa2108330

Recurrent endometrial cancer: a Society of Gynecologic Oncology podcast. February 24, 2022. Accessed December 8, 2022. 

https://connected.sgo.org/content/recurrent-endometrial-cancer-society-gynecologic-oncology-podcast

Zaçe D, La Gatta E, Petrella L, Di Pietro ML. The impact of COVID-19 vaccines on fertility-a systematic review and meta-analysis. 

. 2022;40(42):6023-6034. doi:10.1016/j.vaccine.2022.09.019

Magnus MC, Örtqvist AK, Dahlqwist E, et al. Association of SARS-CoV-2 vaccination during pregnancy with pregnancy outcomes. 

. 2022;327(15):1469-1477. doi:10.1001/jama.2022.3271

McClymont E, Albert AY, Alton GD, et al. Association of SARS-CoV-2 infection during pregnancy with maternal and perinatal outcomes. 

. 2022;327(20):1983-1991. doi:10.1001/jama.2022.5906

Gray KJ, Bordt EA, Atyeo C, et al. Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. 

. 2021;225(3):303.e1-303.e17. doi:10.1016/j.ajog.2021.03.023

Tucker KL, Mort S, Yu LM, et al. Effect of self-monitoring of blood pressure on diagnosis of hypertension during higher-risk pregnancy: The BUMP 1 Randomized Clinical Trial 

. 2022;327(17):1656-1665. doi:10.1001/jama.2022.4712

Chappell LC, Tucker KL, Galal U, et al. Effect of self-monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension: The BUMP 2 Randomized Clinical Trial. 

. 2022;327(17):1666-1678. doi:10.1001/jama.2022.4726

Articles

Last year was a big one for obstetrics and gynecology.

2022: A year in review

Emerging from a period during which routines were upturned, rules discarded, and reality significantly altered, we as leaders try to piece together the new normal. Many leaders and employees alike yearn for a return to the old way of doing things, but it is clear that people appreciate and want to continue with remote work, telework, telemeetings, and flexible schedules. Given the competitive workforce, changing personal priorities, and decreased loyalty to employers, leaders must adapt to the current environment if they want to retain staff.

Leading now is different than leading during the crisis of the COVID pandemic. Looking back at those who succeeded leading during the pandemic, we can see that they took bold, decisive—and often surprising and unexpected—action. For instance, the season suspension by the NBA commissioner on March 11, 2020—the same day the World Health 

Organization formally designated coronavirus as a pandemic but before public gatherings were restricted—reduced the spread of the virus and resulted in others taking similar actions. Bold leaders acted decisively and did not downplay risk or delay action. They sought novel solutions in keeping with the requirements of the moment and the changing workplace.

Leading in the post-pandemic climate requires the assimilation of a workplace that has altered dramatically. A survey by McKinsey & Company asked people why they were leaving their jobs without another one to replace it 

 Respondents said they did so due to uncaring leaders, unsustainable work performance, and a lack of career progression and meaningful work. 

Leaders who push to return to the pre-pandemic workplace face resistance from individuals who want to continue working remotely or in a hybrid model. This need must be balanced by the desire for inclusivity, to feel part of a team, and connected to the practice or institution. Walking the line between providing flexibility and inclusivity is a major challenge for us today.

As obstetrician-gynecologist leaders in our offices, hospitals, clinics, and academic institutions, we are now also challenged by the current political and social climate

Identifying opportunities to ensure access to care and training, and navigating the new laws and regulations means an added layer of requirements, which keep leaders for our specialty in crisis mode. Thus, we must remember the lessons learned during the pandemic and those the current climate presents to us.

Be decisive, identify a course, continually monitor progress, and adjust the course as needed

Leverage the crisis to create opportunities

Be transparent, honest, and
admit mistakes

However, in the meantime we must embrace crisis leadership that fits for the current climate. This includes creating an environment that engages employees, recognizes that flexibility is critical, and offers opportunities for inclusivity and a sense of belonging. As leaders we must make the workplace welcoming, issue clear messaging that assures employees they are important to the organization, and develop opportunities for their growth. An environment that encourages two-way communication is likewise essential, as employees who have a voice are more likely to feel—and be—engaged and less likely to leave. 

Furthermore, their ideas are often valuable and instrumental to progress. Two qualities that are essential for leaders in obstetrics and gynecology are empathy and getting your hands dirty. Empathy goes a long way toward helping employees understand we are human and can see their point of view. Helping when needed enhances our approachability and gives us insight into the challenges and opportunities faced daily by staff.

In short, although it feels good to leave the pandemic behind, as obstetric and gynecology leaders we continue to have crisis issues to handle as well as new expectations to meet from a changed workforce. The new laws and regulations keep us in crisis mode. However, we can and must incorporate the lessons the pandemic taught us to create post-pandemic opportunities. 

Catherine Y. Spong, MD,editor in chief, is professor and vice chair in the Department of Obstetrics and Gynecology and chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas, Texas. She holds the Gillette Professorship of Obstetrics and Gynecology.
Email her at cspong@mjhlifesciences.com

1. De Smet A, Dowling B, Mugayar-Baldocchi M, Schaninger B. Gone for now, or gone for good? How to play the new talent game and win back workers. McKinsey & Company. March 9, 2022. Accessed November 1, 2022. https://www.mckinsey.com/capabilities/people-and-organizational-performance/our-insights/gone-for-now-or-gone-for-good-how-to-play-the-new-talent-game-and-win-back-workers

Although leadership in our post-pandemic climate is probably no more challenging than at any other time, it certainly feels that way.

Leadership in the new reality

 for many a comforting tradition of order, back-to-school supplies (unbelievably relaxing to many) and new beginnings. For senior medical students and residents, it is a time of opportunity, new potential, and fresh beginnings. As we look at the field of resident positions in obstetrics and gynecology, it is clear that not only have there been new positions growing for the field, but there has also been growing interest from the medical profession 

As I listen to the medical students interested in obstetrics and gynecology, preparing their chair letters, not only do they provide the typical reasons—a mixture of medicine and surgery, the ability to follow a patient over their life course, able to capture all of medicine in one field, present for life events vital for a critical event for a patient, and able to care for a patient in a vulnerable time—they have also highlighted the importance to support women and families, to provide needed care, and to participate in critical life events. The current generation of enthusiastic students entering our field have a lens to equity that we did not yet own at a similar time in our lives.

These observations give me hope for our specialty. I have seen interest in obstetrics and gynecology increase despite the COVID-19 pandemic and political situations. Many students voice an interest in not only in the intersection of surgery and medicine and continuums of care, but also the importance of supporting women and families. Their passion and excitement are infectious.

I think back to my decisions—I was torn between surgery and obstetrics and gynecology. This, on the background of my parents telling me to go into any field except obstetrics and gynecology due to the litigation and malpractice issues, but that was a long time ago. As I recognized, as do many students, the opportunities in obstetrics and gynecology are huge, as are the ability to practice both medicine and surgery. Furthermore, there is the opportunity for pure joy, which I reckon is limited in other fields. We tend to remember who delivered our baby—not so much who controlled blood glucose or a fixed a broken bone. We have the opportunity to be present at a time that is vital and critical in life.

As the leaves begin to change, and our students consider their choices, I encourage you to reflect on your reasons to pursue obstetrics and gynecology, and on the field’s importance— not just for you, but for your patients and for their families—and reconnect with your passions. 

Catherine Spong,editor in chief, is professor and vice chair in the Department of Obstetrics and Gynecology and Chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology.

1. Results and Data 2022 Main Residency Match. The National Residency Match Program. May 2022. Accessed September 7, 2022. https://www.nrmp.org/wp-content/uploads/2022/05/2022-Main-Match-Results-and-Data_Final.pdf

Why obstetrics and gynecology is seeing an increase in applicants

A rising interest: Why obstetrics and gynecology is seeing an increase in applicants

It has been one hot summer, especially here in the Dallas-Fort Worth, Texas, area. We saw a record-breaking streak of consecutive days over 100 °F and without rain. 

With the summer months sweltering on, the editors and contributors of Contemporary OB/GYN® have been hard at work carefully crafting a great issue that touches upon a variety of subjects within obstetrics and gynecology. 

There are several excellent must-read articles this month:

 is an article by Melissa M. Mauskar, MD; Hunter J. Pyle, BBA; and Audrey K. Rutherford, MD, on vulvovaginal dermatology essentials needed every day to accurately identify various vulvar conditions and determine the appropriate treatment. the authors also provide information on how to best approach patients with vulvovaginal concerns in the clinic. 

, written by Danielle M. Alm, PharmD, BCPs, BCPPs; Reina Puri; and Christine Payne, takes a deep dive into the various contraceptives on the market and describes some best practices for discussing birth control with adolescent patients.

by Brian K. Iriye, MD; and James D. Keller, MD, provides thoughtful and informative tips on how to make meetings both effective and efficient.

 explains the latest phase 3 data for fezolinetant (Astellas Pharma) to treat moderate to severe vasomotor symptoms associated with menopause. The data were presented at the American College of Obstetricians and Gynecologists' Annual Clinical and Scientific Meeting in May 2022 in san Diego, California. 

 features an article by Bertie Geng, MD; and Alla Vash-Margita, MD, about cervical cancer screening guidelines in adolescents. And although average-risk adolescents don’t need Papanicolaou tests, this article gives an update on special populations of adolescent patients who do.

So, as you sit back, relax, and read this August issue of Contemporary OB/GYN® (I hope by a pool or in the shade), please let me know whether there are any topics you would be interested in reading about. Email me at cspong@mjhlifesciences.com. 

Beating the heat

It’s a growing specialty within our field and often is underappreciated.

In this issue, you’ll find articles (some of which are detailed below) on gynecologic care for the adolescent, including care of the transgender adolescent patient, common pediatric vulvar conditions, the second part of our pediatric adolescent gynecologic emergencies series, and more.

We tapped experts in the field to address these topics and—appreciating the political nature of some—worked to ensure that the data and expertise were shared across the specialty to provide the best possible coverage.

Appointments specifically for adolescent gynecology are limited in
many areas of the US. As we provide coverage for these needs and topics,
it is essential that we communicate the importance of addressing
concerns, as well as critical support, for the adolescent going through a
medical situation.

Care for transgender patients may need to extend beyond the medical scenario if their care is affected by political agendas. It is vital for obstetrician-gynecologists (ob-gyns) to advocate for the care of our patients and ensure appropriate, evidence-based care.

Pediatric vulvar conditions are often hidden, unrecognized, or unacknowledged. Our advocacy to ensure they are evaluated and addressed is critical.

Adolescent gynecologic care may be provided through pediatric adolescent medicine clinics or ob-gyn adolescent gynecology clinics (after subspecialty training). It is vital to ensure appropriate expertise, interest, and support are provided.

Ultimately for the ob-gyn, these individuals are the future of our
field, and providing the best care now ensures a bright future for the patient population. 

Catherine Y. Spong, MD,editor in chief, is professor and chair in the Department of Obstetrics and Gynecology at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology. Email her at cspong@mjhlifesciences.com.

This month we focus on pediatric adolescent gynecologic topics, which are critical to our practices (and our families). 

The world of the pediatric adolescent patient

Thrust into the front lines of the pandemic, we were called upon to not only care for patients with COVID-19 but to do so against the backdrop of ongoing nonelective care. Put simply, obstetrics never stopped. As we reflect on the heroic work of our colleagues and friends, it is interesting to frame our experiences through ebbs and flows of case counts for the past 2 years. 

We saw community burden through a unique lens given constant patient volume, access to COVID-19 testing in outpatient and inpatient areas with integrated electronic health records, early universal testing at delivery for mothers and exposed infants, and screening for those admitted during antepartum care.

Indeed, being in the labor and delivery department the past 2 years often felt like one was the canary in the coal mine. As COVID-19 surges came and went, we felt that the day-to-day rise in number of positive cases we diagnosed foreshadowed the rise in hospitalizations. 

Taking this to our statisticians, we asked them to see whether they could prove our hypothesis. The statistics were more complex than we expected.

At Parkland Hospital in Dallas, Texas, where there are nearly 12,000 births per year, the service was testing as many as 50 women a day. A time series analysis was used to compare the number of new COVID-19 cases in obstetrics and the number of new COVID-19 cases hospitalized in the Dallas–Fort Worth trauma service area. 

The Kwiatkowski-Phillips-Schmidt-Shin test was used to test the assumption of stationarity in both data sets. This assumption indicates that each time series has no dependence on the time it is being observed (no trend, seasonality, etc). 

Figure: Obstetrics COVID-19 Case Volume vs Hospital COVID-19 Census

The data were determined to be stationary, and the Granger causality test was used to determine whether the obstetrics COVID-19 counts at differing lags in addition to the changing hospital census counts were useful for forecasting the hospital census count in the future. 

A lag of 1 would indicate using obstetrics counts 1 day prior, a lag of 2 would be using the obstetrics counts 2 days prior, and so on. We tested to see how far out the obstetric case counts became the “canary.” Lags of 1 to 7 days were tested to assess the usefulness of the prior week of obstetrics data in forecasting the Dallas–Fort Worth hospital census. 

 values were adjusted using the Bonferroni method to control the inflated type I error rate due to multiple testing. Statistical significance is indicated
by 

Interestingly, the data proved our point. The obstetric COVID-19 cases 1 day prior forecasted hospital census increases in our metroplex (

Table: Do Obstetric COVID-19 Case Counts Predict Future Rises in Hospital Census?

We believe the same could be done with continued ongoing local surveillance, but that is not yet a reality because most community testing is done for an indication rather than universally. That is, community testing availability waxes and wanes in response to a recognized surge. 

Although these data are limited in predicting a surge far in advance, the labor and delivery department statistics did serve as a safety signal for the community. Ob-gyns were the canaries in the coal mines of COVID-19 community burden. We hope to use this insight and similar data in the future to guide targeted responses to disease spread. 

Obstetrics and gynecologists (ob-gyns) are tough.