Linda Marie Wetzel

A study to evaluate incidence of urinary tract infection (UTI) post-robotic-assisted hysterectomy and routine cystoscopy demonstrated a higher rate of UTI in younger patients with increased estimated blood loss (EBL) who underwent longer, more complex surgeries. Further, these patients were also noted to have a higher incidence of a malignant post-operative diagnosis. 

2019 American Association of Gynecologic Laparoscopists (AAGL) Congress

 in Vancouver by Katherine Kleinberg, a medical student from 

, Las Cruces, NM. Ms. Kleinberg was invited by the 

 to present her study findings at the Congress.

“The objectives of this study were to evaluate incidence of UTI status post-robotic-assisted hysterectomy and routine cystoscopy, to compare instances from malignant and benign surgical cases, and justify routine cystoscopy in robotic assisted hysterectomy,” Ms. Kleinberg stated.


	The 151 cases that made up this study were obtained from the database of a single gynecologic oncologist. In these cases, minimally invasive robotic total hysterectomy was performed for treatment of both benign and malignant disease, and patients who did not meet the standard of minimally invasive surgery were excluded. In all cases, routine cystoscopy was performed to detect any intraoperative injury to the ureters and bladder. No detectable urinary tract injury was reported in any of these patients.


	In those cases where routine cystoscopy was performed, dysuria was the most common urinary tract complaint in postoperative clinic visits. Postoperative UTIs were found in 21 (13.9%) of patients within 30 days of the procedure, with 2% to 9% of benign cases and 4% to 31% of malignant cases presenting with UTI. Patients with postoperative UTIs were noted to have had longer operating room times, more complex surgeries, higher estimated blood loss, and were younger. The only statistically significant variable reported between the malignant and benign cohorts was presence of postoperative complications, with incision cellulitis being the most common complication seen in patients with malignant disease.


	The results demonstrate that, although UTIs are common in women undergoing gynecologic surgery, rates of infection appeared to be higher in this cohort composed of patients in whom routine cystoscopy was performed. Ms. Kleinberg noted that a similar study consisting of a larger sample size should be considered.

Articles

Results presented at the 2019 AAGL Congress demonstrated a higher rate of UTI among younger patients with increased estimated blood loss (EBL) following the procedure.

Routine cystoscopy after minimally invasive hysterectomy associated with increased UTIs

State policies targeting drug and alcohol use during pregnancy have increased in number since 1974 and have become more punitive over time, according to a recent study of all statutes and regulations in the United States that pertain to the use of drugs or alcohol by pregnant women.

This study, conducted by the Pacific Institute for Research and Evaluation (PIRE) and the University of California, San Francisco, examined data from 1970 through 2016. Trends in individual types of policies were defined, as well as overall trends in policies state-to-state. The results of these studies were then compared to one another to build a more complete picture of the policy environment in the United States pertaining to pregnant women and substance use.

There were several policy types defined as part of the study. Punitive policies seek to control the behavior of the pregnant woman. Proponents of these policies maintain that restricting a woman’s access to drugs or alcohol is the best way to ensure the health of the pregnancy and the fetus, that the state has a duty to prevent the lifelong problems that affected children may experience including, if necessary, separating children from their parents.

Supportive policies seek to provide support services to pregnant women and families and do not attempt to threaten or coerce. Services might include education, early intervention, support or treatment. Mixed policies contain aspects of both punitive and supportive interventions. 

To define policy types, researchers identified a group of variables by which policies were rated. The variables were used to analyze individual policies and the overall policy environment for each state. The variables included:

Requirements for mandatory warning signs, mostly aimed at retail cannabis establishments.

Priority treatment policies, either for pregnant women only or for both pregnant women and women with children.

Prohibitions on using the results of medical testing as a part of criminal prosecution related to health of a fetus or child.

Mandatory involuntary commitment of a woman to a treatment facility or to the care of the state because of her substance abuse. 

Reporting requirements, either to Childrens Protective Services (CPS)to assess risks of child abuse or neglect, or for data and treatment purposes only.

Presence of statues or regulations that define the rules related to child abuse or neglect.


In 1980 only one state had a drug and pregnancy policy; by 10 years later that number had risen to 16 states. By 2000, 31 states had at least one policy, and by 2016 the number had climbed to 43.
 


After all data were analyzed, several key findings were identified:

By 2016 almost 85% of states had policies regarding drug use during pregnancy.

Policies regarding drug use during pregnancy have become less supportive over time.

Policies regarding drug use during pregnancy are often punitive, while most policies regarding alcohol use during pregnancy are supportive.

Also noted was that punitive policies place a disproportionate burden on low-income women and women of color, as such policies appear to deter women from seeking needed care. Even supportive care policies that provide direct services or support are not always readily available to disadvantaged women, further compromising their health and the health of their children. 

Missing from this study and a possible area of focus for future studies is the lack of ethnographic data as well as interactions between the policies and the overall social environments of the women in the different states. Further research may also focus on the reasons why some policies were enacted rather than others, and how states have enforced these policies. 

State policies targeting drug and alcohol use during pregnancy have increased in number and have become more punitive, but findings show that these policies may not encourage women to seek the needed care.

Comparing policies on drug and alcohol use by pregnant women

"  target="_blank">In 2018, maternal mortality is a major topic of discussion in obstetrical, public health and political circles. 

has dedicated a great deal of editorial space this year to articles and commentary on causes and consequences of these deaths. There clearly are many issues to explore about death of US mothers during pregnancy and the puerperium, including who is dying and why, and what can be done about it. 

Disparities in care received by certain patients and populations have been the focus of strong pushes for solutions from multiple sources. With health disparities, the focus typically is on race/ethnicity and socioeconomic factors as they relate to access to and quality of care. But an often forgotten disparity is geographic location. Earlier this year, an article in 

discussed the challenges of improving rural health care,

addressed general aspects of care, especially for rural hospitals and the current reimbursement system. 

The American College of Obstetricians and Gynecologists (ACOG) describes rural America as representing 75% of the national landmass and being home to 22.8% of US women aged 18 and older, with substantial variance in ethnic and racial composition.

ACOG Committee Opinion #586 outlines health disparities for rural women. Significantly, it notes that data describing both health and outcomes for these patients are limited overall, although risks related to level of rurality are evident. Clearly the challenges for a state such as Pennsylvania (reported to have the third largest rural population in the United States) will be different than those for states such as Montana or Alaska, which have smaller absolute numbers of rural residents spread over a much larger geographic area. But some statistics stand out. 

Overall, rural women are less likely to receive any preventative health care and screenings. Fewer than half of rural women live within a 30-minute drive to a hospital with perinatal services, and over 10% have a drive of 100 miles or more. Some states, such as Wyoming, have no tertiary care centers for pregnant women at all.

And because overall health outcomes generally are worse in rural communities due to increased incidences of obesity, cancer, cardiovascular disease, opioid use, and violent deaths, it would seem reasonable to assume that these outcomes would be echoed in the maternal death rates seen in rural communities.

Nationally, rural health care availability is under attack with closure of hospitals and lack of medical personnel in communities, as described by Dr. Lockwood in this month’s 

. ACOG reports that in 2010, 49% of the nation’s counties lacked an obstetrician-gynecologist, leaving over 10 million women-or 8% of those in our country-without that service. The challenge is even greater when one looks at hospital-based obstetrical services (or lack of) and birth outcomes in rural communities.

Clearly, the impact of closing a maternity ward in a rural hospital where the next nearest obstetrical unit is 100 miles away would be very different than in an urban community with another center of care less than 10 miles away. 

It is possible that pregnancy-associated deaths, rather than pregnancy-related deaths, may provide a unique window into the socioeconomic and cultural challenges faced by rural communities. Teasing out the possible differences, however, is not possible with our current system of state-collected data. State and national statistics, therefore, are inevitably dominated by the cause of maternal deaths in population centers simply due to sample size. To begin to address this problem, policy makers need to look at aggregate rural-based data to see if the causes of mortality and morbidity there are similar to those in urban settings and determine if interventions for urban patients can be applied to those in rural settings. 

For example, maternal deaths from motor vehicle accidents may be more common in remote rural settings due to the long distances at high speeds that rural women travel on a regular basis to obtain care. In that setting, seat belt education may be more important than it would be in a metropolitan area. Postpartum hemorrhage (PPH) deaths may be more preventable if tranexamic acid and cryoprecipitate were available as well as six to eight units of total blood products in the hospital blood bank, together with streamlined procedures for obtaining those products in emergency situations. Or interventions in a rural setting may focus on early recognition of risk of PPH or active blood loss, basic stabilization techniques and prompt transport rather than a detailed mass transfusion protocol. 

In addressing any health care disparity, accurate data are critical to identifying specific problems and tailoring interventions to address actual issues rather than issues “perceived” by “outsiders.” Because the absolute numbers of maternal deaths are small in rural states given their overall lower populations and birth rates, it is impossible for a single state to have numbers sufficient to accurately interpret data without aggregation of five or more years of information. With current published state reports, it is also impossible to aggregate data across states because they use different definitions and presentations for their aggregate state data. Until recently, that has stood in the way of accurate data collection and management across the nation.   

Working toward solutions: ACOG maternal mortality task force

In 2017, to help address these challenges and better identify sources of health care disparities in rural settings, ACOG District VIII launched a Maternal Mortality Task Force. District VIII is uniquely situated to collect data on rural maternity care and deaths. District VIII is made up of 12 states as well as Guam, American Samoa, Alberta, British Columbia, and Central America. Those states alone make up over 50% of the land mass of the United States but only about 15% of the US population resides in those areas. Much of the population in the 12 states is concentrated in one or two urban settings (e.g., Alaska with Anchorage and Juno). Using data standards developed by the Centers for Disease Control (CDC) and the Association of Maternal and Child Health Programs (AMCHP) and employed by the national Maternal Mortality Review Information Application (or MMRIA) database, it is possible to capture information about the distance from the woman’s home to where she delivered as well as the level of maternity care available where the delivery occurred. The data collected also include details of a patient’s circumstances, building an extensive narrative that covers all aspects of her experience of pregnancy and then presenting those facts in standardized format for examination and analysis.  

The ACOG District VIII Task Force hopes to be able to aggregate the data over the 12 states using the structure of the MMRIA database. Without specifying state or county, data will be combined across the region, using references of distance from hospitals and levels of care as the standard. That, in turn, will produce samples sizes large enough to allow examination of rural vs urban causes of death on an annual or biannual basis. This larger data pool would also allow for quicker identification of unique evolving issues (Hantavirus, suicides or motor vehicle accidents) and evaluation of intervention strategies. Because the 12 states have some of the largest populations of indigenous people, a detailed data collection of this type may also be of great assistance in documenting data for increased maternal morbidity and mortality associated with this particular group and guiding interventions. 

To accomplish this ambitious goal, the sections in District VIII are working with their respective departments of health to enact legislation as needed to support MMRCs and to encourage and empower individual departments of health to provide their data through MMRIA to the CDC. As more states enter data into the CDC database, the task force will look at the reports, identify issues to address, identify already established interventions a state may have that can be exported to other states in the region and continue to educate our district providers as to steps they can take to decrease our unacceptable national maternal mortality statistics and disparities. 

Iglehart JK.  The Challenging Quest to Improve Rural Health Care – Health Policy report. N Engl J Med. 2018;378:473-479.

Murphy KM, Hughes LS, Conway P. A path to sustain rural hospitals. JAMA. 2018;319(12):1193-1194.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 586:  Health disparities in rural women.  2014 Feb;(2 Pt 1):384-388.

Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S.  Association between loss of hospital-based obstetric services and birth outcomes in rural counties in the US. JAMA. 2018;319(12):1239-1247.

Shah NT. Eroding access and quality of childbirth care in rural US counties. JAMA. 2018;319(12):1203-1204.

Wetzel LM. Maternal mortality statistics; data collection methods improving but still a challenge. Contemp OB/GYN. 2018:63(1):24-27.

Women who give birth in rural areas face unique challenges because of geography but state-based data collection hampers efforts to understand and address the factors that place them at particular risk for morbidity and mortality.

Maternal death  in rural America

 to discuss the results of the ARRIVE trial and what these findings mean for ob/gyns and their patients.

Dr. Charles J. Lockwood sits down with Linda Marie Wetzel, Executive Editor for Contemporary OB/GYN, to discuss the results of the ARRIVE study and what these findings mean for ob/gyns and their patients.

Podcast: Discussing the ARRIVE trial results

Results from a multicenter US trial do not support a recommendation for use of extended-release gabapentin alone as a treatment for vulvodynia. Published in 

, the findings were originally presented at the International Society of Vulvovaginal Disease World Congress, held in 2017 in Mendoza, Argentina.

Although gabapentin is recommended and commonly prescribed for vulvodynia, its value in such cases is usually associated with complaints that have neuropathic components, such as dynamic allodynia. Otherwise, tests on the effectiveness of gabapentin have been limited to reports with methodologic flaws and subjective measures that called into question the accuracy of the results.

In a double-blind, placebo-controlled randomized crossover trial conducted from August 2012 to January 2016, gabapentin 1,200-3,000 mg/d was compared with placebo in treatment of vulvodynia. In a search to ensure a racially and geographically diverse sample, over 200 patients were screened at 3 academic institutions. Eighty-nine were selected – mean age of these patients was 37, and over half of them were black. All were diagnosed with localized provoked vulvodynia, defined as superficial vulvar vestibular pain provoked by touch, and reported having experienced pain for over 5 years. Of these patients, 45 received gabapentin first and then placebo, and 44 received placebo first and then gabapentin. Results of a standard tampon insertion and removal test were utilized as the surrogate marker for dyspareunia as well as for sexual intercourse and daily pain.

The study consisted of screening and randomization, followed by 8 weeks of treatment including dose titration, maintenance, and then taper. Following cross-over the series was repeated. Each patient was scheduled for visits at 6, 8, 14, and 16 weeks. Patients who were taking oral contraceptives, hormone therapy or selective serotonergic reuptake inhibitors (SSRIs) and were on a stable regimen were allowed to continue with those medications. During the study period, “rescue medication” for pain, such as acetaminophen, aspirin, or nonsteroidal anti-inflammatories, was permitted if use was documented. Opioids and topicals were not allowed and were considered a violation of the testing protocol. At the end of the testing period, 66 patients had successfully completed the trial.

Results of the tampon test indicated that the pain experienced by the patients using gabapentin was no different than the pain experienced by women taking placebo (adjusted mean 4.0, 95% CO 3.0–4.9 vs 4.3, 95% CO 3.4–5.2, difference -0.3, 95% CI -0.7 to 0.0; 

 = .07). There was also no improvement reported in related pain - pain with sexual intercourse (adjusted mean 3.9, 95% CI 2.4–5.3 vs 4.0, 94% CI 2.5–5.4, difference -0.1, 95% -0.9 to 0.6; 

 = .76) and daily pain (adjusted mean 2.7%, 95% CI 1.8–3.6 vs 2.9, 95% CI 2.0–3.8, difference -0.2, 95% -0.5 to -0.2; 

 = .36). Testers noted that this study did not include a “no-treatment” arm to study and define any placebo or placebo-independent effects at work. 

The authors of this study concluded that the study did not generate sufficient evidence to support gabapentin as a first-line treatment of vulvodynia but suggested that further testing with inclusion of physical therapy, behavioral counseling and sexual counseling may be of value. They also recommended studies to determine whether presentation of symptoms or patient demographics are associated with treatment outcomes.

Although gabapentin is recommended and commonly prescribed for vulvodynia, its value in such cases is usually associated with complaints that have neuropathic components, such as dynamic allodynia.

Does gabapentin work for vulvodynia?

	In the past 20 years while maternal mortality ratios (MMR) have fallen 48% in developed nations and 44% worldwide, the number of maternal deaths in the United States has actually doubled, from a low of 12/100,000 births in 1990 to 28/100,000 in 2013.

 At first glance, these numbers may look low, but these increases mean that the US mortality rate during that time has also increased, making it 1 of only 20 nations worldwide, 12 of which are in sub-Saharan Africa, where that has occurred. Currently, the United States has a higher MMR than nations such as Iran, Syria, Ukraine, and Jamaica.

	According to the Centers for Disease Control and Prevention (CDC), up to half of the maternal deaths in the United States should be preventable.

 If that is true, then we need to ask ourselves, why are these women dying? And who are they? Are there quantifiable differences in risk factors among women of different ages, races, ethnic or social groups or those who live in different locations? And because these answers are critical if our nation is to address the overall problem of maternal mortality effectively, intelligently and efficiently, what is the best way to obtain these data and be assured of their accuracy? 

	The Word Health Organization (WHO) defines maternal mortality/maternal death as, “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management (direct or indirect obstetric death), but not from accidental or incidental causes.”

 In these instances, direct deaths are those caused by obstetric complications or any events that may arise from treatment or attempted treatment of these complications. Indirect deaths, on the other hand, are deaths that result from previously existing diseases or diseases that developed during pregnancy which are not caused by the pregnancy, but which are aggravated by it. The maternal mortality ratio is the number of maternal deaths per 100,000 live births.

Within these broad definitions of maternal mortality, several other distinctions are of value when collecting information about maternal death. For instance, a pregnancy-related death describes the death of a woman from any cause while she is pregnant or within 42 days of the termination of pregnancy. A later maternal death describes the death of a woman of either direct or indirect obstetric causes, more than 42 days but less than 1 year after pregnancy termination. The lifetime risk is the probability that a 15-year-old will eventually die of a maternal cause based on the existing risk of death for her country and the year.

	Seeking to address the causes of maternal death is not a new effort. Currently, in the United States there are 2 national sources for maternal death information. The first is the National Center for Health Statistics (NCHS), which is part of the US Federal Statistical System and is the central resource for official vital statistics about health and health care in the United States. The NCHS determines the number of maternal deaths by using ICD-10 codes assigned according to information found on women’s death certificates.

	The second source is the Pregnancy Mortality Surveillance System (PMSS-MM), which relies on death certificates that have either been marked with a check-box as being pregnancy-related or linked to a birth record or fetal death record registered in the year immediately preceding the maternal death. All marked certificates are reviewed by medical epidemiologists to determine the relation between any linked records, confirm a cause of death and then compile all the information into the overall mortality ratio.

	Each of these methods, however, does present challenges. States use different death forms and not all of them ask the same questions or identify a pregnancy-related death in the same way. Plus, there is no provision for recording other information that might add clarity to a specific case. Consequently, the number of maternal deaths is significantly under-reported. As the assessment processes have begun to evolve, the MMR has risen, leading to the question of whether numbers of maternal deaths are actually increasing or simply being more accurately reported.

NEXT: Maternal Mortality Review Committees

	For almost 100 years, many states and jurisdictions supported the creation of local Maternal Mortality Review Committees (MMRCs) whose jobs have been to bring greater clarity to the numbers and causes of maternal death nationwide. These committees may have uncovered valuable information but the ability to do comprehensive analyses across multiple agencies and populations was seriously impaired by the independence of the committees, the uncoordinated nature of data collected, and the different collection formats used. Some areas did not have resource committees at all, making it impossible to draw complete conclusions nationwide.

	In 2015, a project called “Building U.S. Capacity to Review and Prevent Maternal Deaths” worked with the CDC and the Association of Maternal and Child Health Programs (AMCHP) to unite the efforts of the different MMRCs and collect data on maternal deaths in formats that are both consistent and comparable. This platform is called the Maternal Mortality Review Information Application (MMRIA, or “Maria”). The study started with the MMRCs in Colorado, Delaware, Georgia and Ohio. Data were entered by these states into the central Maternal Mortality Review Data System (MMRDS) which is held by the CDC. The focus of the centralized data collection was to “demonstrate the use of standardized review committee data for understanding the preventability, critical factors that contribute to death, and best opportunities for reducing pregnancy-related deaths, rather than trends in mortality over time.”

	When a case of possible maternal death is identified, the MMRCS utilizes the services of a variety of health professionals (from areas such as public health, obstetrics, gynecology, nursing, midwifery, forensic pathology, mental and behavioral health, social workers, patient advocates) and a wide range of records - medical and non-medical, ante- and post-partum; informant interviews, social service records, etc. -  to build a narrative for each case that covers all aspects of the patient’s personal experience throughout her pregnancy, up to her death. When complete, each case is analyzed by committee to determine:

The patient’s cause of death and any relation to pregnancy is assigned to 1 of 4 categories:  Pregnancy-Related, Pregnancy-Associated but NOT Related, Not Pregnancy-Related or Associated, Unable to Determine if Pregnancy-Related or Associated (Table 1).

This information is obtained from the PMSS-MM and acts as an informational link between the PMSS-MM records and the MMRIA, promoting consistency between the systems.

 If the committee determines that reasonable changes in any 1 of 5 areas - to the patient, provider, community, facility or systems of care - might have prevented the death, then the death is considered to be preventable. The committee also has the option of documenting the degree of preventability assigned, from “none” through 4 levels, to “strong.”

What were the critical contributing factors to the death?

 Contributing factors are assigned to 1 of 5 areas – again, to the patient, provider, community, facility or systems of care. Each factor is assigned to an explanatory class category, such as delays, adherence, lack of knowledge, etc., with a concise description of the specific factor.

What are the recommendations and actions that address the contributing factors?

 Any actions or recommendations that might have prevented or contributed to the prevention of this specific death are identified, with information about who should initiate action, when the action should be initiated, and a description of the action itself.

What is the anticipated impact of those actions if implemented?

 The MMRCs assign a specific level of prevention to each recommendation to determine whether an action would prevent the contributing factor before it occurred (primary prevention), reduce the impact of a contributing factor that has occurred (secondary prevention), or reduce the impact or progression of an ongoing contributing factor (tertiary prevention). The recommendations are then prioritized, with those supporting primary prevention, usually, as the higher priority.

	In 2016 over 30 states were contacted to define ways to integrate them into the MMRDS and identify their individual data needs. Because of those interactions, project staff have begun to add other information to the system, such as details about suicide, mental health criteria, drug abuse, and partner abuse. Partnerships with Violent Death Reporting systems in different states have also been initiated. The addition of information about these challenging issues placed in the context of pregnancy will provide an even more complete image of what is killing our nation’s mothers and, hopefully, guide us in our search for tools and techniques to reduce the number of these unfortunate deaths. 

	1. MacDorman, Marian F. PhD; Declercq, Eugene PhD; Thoma, Marie E. PhD. Trends in Maternal Mortality by Sociodemographic Characteristics and Cause of Death in 27 States and the District of Columbia. Obstetrics & Gynecology: May 2017 - Volume 129 - Issue 5 - p 811–818 doi: 10.1097/AOG.0000000000001968

	2. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015.

	3. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. 13;384(9947):980-1004. doi: 10.1016/S0140-6736(14)60696-6. Epub 2014 May 2. Erratum in: Lancet. 2014 Sep 13;384(9947):956. PMID:24797575

	4. Maternal Mortality CDC 2017. Report from Maternal Mortality Review Committees: A View into Their Critical Role. 

Data collection methods are improving but still a challenge.