“Why would you do a fellowship for something that you already know how to do?”

My chiefs and attendings read my mind when I was wrestling with the idea of applying for a fellowship in minimally invasive gynecology (MIGS) as a second-year resident. 

I’ve loved surgery since medical school, so I was excited about my first surgical cases as an intern. I anticipated a steep learning curve, but by the end of the year, I felt like I’d barely taken a step. Much of the surgical teaching during my residency, as in most high-volume programs, is provided by private attendings. Skill levels vary, which I think is largely a product of the ob/gyn educational system. In most residencies, a great deal of time is spent on obstetrics, outpatient clinic, or night float coverage. We spend barely a year dedicated to gynecologic surgery. Contrast that with general surgery residents, who spend 5 years training in the operating room! 

More Residents Corner: Night call siren song

Now in my fourth year, I feel comfortable leading straightforward cases, but there’s no way I’m ready to tackle complex endometriosis or gigantic fibroid uteruses. Neither are most other ob/gyns straight out of training, and it’s the reason in-residency tracking and generalist fellowships are gaining traction.

On the other hand, watching surgical subspecialists operate is amazing. The way they navigate distorted anatomy, identify tissue planes, and troubleshoot unexpected challenges is beautiful. I want to grow up to be capable of that. But gynecologic oncology and urogynecology were not for me, and an unaccredited fellowship in MIGS seemed risky. I could graduate from residency and go directly into practice making $200,000+ a year. Or I could continue with my training making a PGY-5 salary, delaying financial stability for another 2 years. 

AAGL established the first MIGS fellowship in 2001, with just seven spots and now there are 48 programs. In 2018, MIGS was the most competitive fellowship, with 1.7 applicants per position (compared to 1.4 applicants per position in gynecologic oncology, historically the most competitive fellowship).

 In April, The American Board of Medical Specialties approved the American Board of Obstetrics and Gynecology's application for a Focused Practice Designation in Minimally Invasive Gynecologic Surgery. This step towards recognizing those that have significant experience in gynecologic surgery reflects what may be a response to an anticipated shift in the field from maintaining full ob/gyn practices to specializing in either obstetrics or gynecology. It is conceivable that eventually, physicians without fellowship training will not perform any gynecologic surgery. That would be a major change, but I think we all can agree that patients deserve the best chance at a good outcome, and on that point, the data favor high-volume surgeons.

With the advent of more medical treatment options for fibroids, heavy menstrual bleeding, and pelvic pain, the volume of gynecologic surgery across the country has fallen.

 Therefore, by default, more surgeons are becoming low-volume surgeons.

 So, even if I planned to hone my surgical skills in practice with the aid of a senior partner, the opportunity to progress might not really exist. If you operate once a month, how will you maintain your skills? Maybe it’s not absolutely necessary to do a fellowship, but there is no denying that doing three to five surgical cases a day, 5 days a week for 2 years, will accelerate your skills.

In the end, I decided to apply for the MIGS fellowship because I want to be the best surgeon I can be. I want my patients to get the best surgery for them. I don’t want to take shortcuts for my convenience or because of my skill level. I don’t want to fulgurate endometriosis and call it a day. I don’t want to do a supracervical hysterectomy because I’m afraid of the ureter. I don’t want to leave the fallopian tubes behind on a vaginal hysterectomy. I want my cases to be elegant, beautiful, purposeful. 

Are you a current intern or resident and interested in writing about your experiences? 

Email COGEditorial@mmhgroup.com to learn more about becoming a resident blogger.

: Dr. Misal originally stated that "In April, the American Board of Medical Specialties approved AAGL’s application for a focused practice designation in minimally invasive gynecology, which would require those seeking such a designation to complete a minimum of 100 MIGS procedures in patients with benign and complex gynecologic conditions." This was not AAGL's application. This is the American Board of OBstetrics and Gynecology's program. 

Vargas MV, Milad MP. Matching Trends for the Fellowship in Minimally Invasive Gynecologic Surgery Since Participation in the National Residency Match Program. 

Mowat A, Maher C, Ballard E. Surgical outcomes for low-volume vs high-volume surgeons in gynecology surgery: a systematic review and meta-analysis. 

Morgan DM, Kamdar NS, Swenson CW, Kobernik EK, Sammarco AG, Nallamothu B. Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women. 

Walter A. Every woman deserves a high-volume gynecologic surgeon. 

Articles

The choice to pursue a fellowship isn’t always straightforward, but one resident explains why she is choosing to follow her passion.

Why I chose a MIGS fellowship

With the growing trend of couples choosing to start their families at a later age, ob/gyns must be prepared to counsel patients regarding the effects of advanced paternal age (APA) on reproductive outcomes and on their future offspring. Compared to data from 1993, the proportion of live births to fathers aged 35 to 54 increased by 15% over 10 years, with the trend continuing to climb.

 In the United States, among fathers aged 35 to 39, 40 to 44, and 45 to 49 years, birth rates increased 61%, 63%, and 52%, respectively.

 Socioeconomic factors, increased life expectancy, and growing accessibility of assisted reproductive techniques (ART) all have contributed to the rise in paternal age.

 Although a woman’s natural fertility terminates with menopause, spermatogenesis continues throughout life.

Although APA is commonly defined as age 40 years or older, no universally accepted criteria for it exist. The American College of Medical Genetics (ACMG) has not established an age cutoff for APA and does not currently recommend additional screening or diagnostic intervention for offspring of older men.

 Specifying a clear paternal age for APA is complicated by the heterogeneity of the reproductive outcomes and offspring risks noted in the literature. As noted by Ramasamy et al., many studies do not define an age threshold for APA and those that establish a threshold span a wide range of ages.

While fathering children at an older age remains a viable option, couples should be counseled on the effects of APA that could impair conception, such as altered sperm parameters and reproductive hormones, and data supporting increased risk of adverse outcomes such as congenital birth defects, neurocognitive disorders, and fetal deaths. This review summarizes recent findings surrounding the reproductive risks of APA.

Have you read: New tools for counseling on prenatal genetic testing

Possible impairment of reproductive outcomes is an important implication of APA. With an age-related decrease in testosterone, older men experience decreases in libido, sexual function, and sexual frequency, reducing opportunities for conception.

 Further, a review of the literature from 1980 to 1999 found a decrease in semen volume (3%-22%), sperm motility (3%-37%), and percent normal sperm (4%-18%) in 50-year-old men compared with 30-year-old men.

 In addition, controlling for female age, actual rates of pregnancy fathered by men over age 50 years were 23% to 38% lower than those in men younger than age 30.

 Similarly, a meta-analysis of 90 studies quantifying the effect of male age on ejaculate traits (n=93,839) found statistically significant age-associated declines in semen volume, percent motility, progressive motility, morphology, and unfragmented cells, while sperm concentration had no associated changes with increasing male age.

 A retrospective study performed by Hossain et al. also identified significant decreasing trends in semen volume and sperm motility with increased paternal age.

 Similarly, a large prospective study identified decreases in sperm motility with increased paternal age.

 Further, lifestyle factors accrued over the life of the male-such as obesity, smoking, and marijuana use-also may contribute to impaired reproductive outcomes, though this remains an active area of research.

 These changes in semen parameters can be associated with fertility impairment in older men, but the association remains unproven.

The changes in semen parameters seen in older men may impact outcomes of ART. In couples who underwent ART, McPherson et al. found that women aged 35 with a partner older than age 40 had an approximately 10% decrease in live birth rate compared with women of similar age who had younger partners (n=4,057).

 In a retrospective study of 859 cycles of in vitro fertilization (IVF) and 1632 of intracytoplasmic sperm injection (ICSI), Chapuis et al. identified a significantly decreased rate of clinical pregnancies in men older than age 51 (28.2%) compared with men aged 20 to 29 (41.5%).

 However, this result may be confounded by the older maternal age in this study (36.5±4.9 years). 

After adjusting for female age, a retrospective study of 4,025 embryos from 1,169 IVF cycles found a significant decrease in euploidy rate in males older than age 40 compared to men aged 35 to 40 and younger than age 35.

 However, a recent multicenter study of 1,202 IVF/ICSI cycles (6,934 embryos) found no association between advancing paternal age and embryo aneuploidy.

 Furthermore, a large retrospective study of 2,204 intrauterine insemination cycles, 1,286 standard IVF/ICSI cycles, and 1,412 ovum donation IVF/ICSI cycles identified no association between male age and implantation, pregnancy, and miscarriage rates among maternal age groups.

 APA does not appear to conclusively impact ART outcomes, and certainly not to the extent contributed by advanced maternal age, but it remains an area of active research.

APA may also increase the risk to the fetus during pregnancy-particularly increased risk of spontaneous abortion and very preterm birth. Adjusting for maternal age, Kleinhaus et al. (2006) identified a 60% increase in odds of spontaneous abortion in fathers aged 40 or older when compared with fathers aged 25 to 29.

 Compared with that in men aged 20 to 24, a risk of very preterm birth (< 32 weeks) was increased by 70% in men aged 40 to 44 whose partners were aged 20 to 29.

 Similarly, another study demonstrated increased odds of very preterm births among fathers aged 45 to 49 compared with fathers aged 25 to 29, for both mothers aged 20 to 24 (91%) and mothers aged 25 to 29 (72%).

Altered reproductive outcomes in older men may be related to increased DNA fragmentation in sperm, with as much as 80% of DNA fragmentation attributed to oxidative stress.

 Singh et al identified a 15% increase in highly damaged DNA and 20% increase in DNA break number in sperm from men aged 36 to 57 compared with men aged 20 to 35 (n=66).

 A similar study found a significantly higher DNA fragmentation index (DFI) in men aged ≥ 45 compared with men aged < 45 years (

 < 0.01 for all comparisons , n=1,125); in particular, men aged ≥ 45 had a more than two-fold increase in DFI compared with men aged < 30 (32.0±17.1% vs. 15.2±8.4%).

 In addition, a recent meta-analysis of 26 studies identified a strong negative effect of male age on the percentage of sperm cells with unfragmented DNA (r = -0.209, 95% CI -0.287, -0.128).

 Interestingly, the effect size of male age on DNA fragmentation was the largest of the study. However, while sperm from older men have a loss of DNA integrity, likely secondary to oxidative stress, conclusions about the impact on reproductive outcomes remain unclear.

Because spermatogenesis is a continuous and ongoing process throughout the reproductive lifetime, spermatozoa are prone to acquiring DNA mutations, particularly due to the oxidative stress in aging men.

 This increased rate of mutation places the sperm of older men at risk of acquiring mutations that impact the health of their offspring. After the discovery of a link between APA and achondroplasia, an increasing number of disorders have been identified to be associated with increasing paternal age.

 Of note, incidence of chromosomal aneuploidies-an abnormal number of chromosomes-increases with the age of the father.

 When controlling for random variation, a study on genome-wide de novo single-nucleotide polymorphism (SNP) mutation rates in offspring similarly demonstrated two mutations per year of paternal age.

 In women aged 35 and greater, Fisch et al identified a two-fold increase in the rate of neonates with Trisomy 21 when the father was aged ≥ 40 compared with ≤ 24 years.

 Similarly, when controlling for maternal age, men aged ≥ 50 had a two-fold greater odds of a child with Down syndrome compared with men aged 25 to 29.

 In addition, one case-control study indicated that a 10-year increase in paternal age increased the odds of Down syndrome by 11%. Conversely, two studies identified no association between paternal age and Trisomy 13 or Trisomy 18.

 To investigate risk of sex chromosome anomalies compared to autosomal anomalies (adjusting for Down syndrome and paternal age), one study found that a 10-year increase in paternal age increased the odds of Klinefelter syndrome by 35%.

 Overall, APA appears to account for a small proportion of chromosomal aneuploidies.

Much of the literature similarly supports a correlation between paternal age and risk of neurocognitive disorders. 

Four hypotheses have been suggested to explain this increased risk with APA: 

Increased frequency of de novo mutations; 

Age-related epigenetic alterations in sperm; 

Selection into late fatherhood secondary to paternal psychiatric disorders or subclinical predisposition; and 

A recent review suggests that these etiologies-both inherited predisposition and de novo events-may all contribute to the complex neurocognitive disorders associated with APA.

 A large study of individuals born in Denmark over a 51-year span (n=2,894,688) identified a 34% increase in risk of any psychiatric diagnosis in offspring of fathers aged 45 or older compared with offspring of fathers aged 25 to 29.

 A similar study composed of individuals born in Sweden over a 28-year span (n=2,615,081) compared siblings and identified an increased risk of autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder, psychosis, bipolar disorder, suicide attempts, substance abuse, failing a grade, and low education attainment in offspring born to fathers aged 45 or older compared with fathers aged 20 to 24.

 Of note, risks for ADHD (hazard ratio [HR] 13.13, 95% CI 6.85-25.16) and bipolar disorder (HR 24.70, 95% CI 12.12-50.31) were particularly increased. A meta-analysis of 12 studies similarly found increased risk of schizophrenia associated with fatherhood at aged 30 or older compared to age 25 to 29, with the highest effect size in men aged 50 or older (RR 1.66, 95% CI 1.46-1.89).

Have you read - A New Normal: How Families And Fathers Are Affected By Maternal Mortality

The literature most strongly supports a link between APA and ASD. D’Onofrio et al. (2014) identified a nearly 3.5 times higher risk of ASD in offspring born to fathers aged 45 or older.

 A recent meta-analysis of 27 studies similarly found a 55% increased risk of ASD in the highest paternal age category; an increase of 10 years in paternal age was associated with a 21% increase in risk of ASD.

 This association has been supported by several other studies spanning a wide range of populations and databases.

 The neurocognitive implications of APA, particularly increased risk of ASD, must be considered when counseling patients regarding APA.

In addition to neurocognitive disorders and chromosomal aneuploidies, APA has been associated with an increased risk of congenital anomalies and cancer in the offspring.

 These findings are summarized in Table 1.

With a growing trend of delaying fatherhood, couples must be informed of the increased risks of producing abnormal offspring associated with APA. The ACMG currently recommends a prenatal counseling session regarding potential risks of APA such as Trisomy 21 and individualized genetic counseling for specific concerns. The process of conception in older men may be complicated by decreased libido or altered sperm characteristics. APA may or may not impair the outcomes of ART; some evidence suggests impaired ability to conceive and decreased rates of live birth in conceptions by older men, but any decreases in fertility attributed to APA are minor in comparison to those of advanced maternal age. The fetus may be at increased risk of spontaneous abortion and very preterm birth. Increased oxidative stress may be linked to higher rates of DNA fragmentation in older men, but data on the impact on reproductive outcomes remain inconclusive. 

Lastly, in the offspring of older men, certain medical comorbidities have also been identified, including ASD and acute lymphoblastic leukemia. Although the effect of APA on reproductive outcomes and medical comorbidities in the offspring remains an active area of research, we recommend that physicians discuss these risks-particularly Trisomy 21, psychiatric diagnoses, and ASD-with couples with male partners aged 40 or older. Studies differ in their definition of APA when assessing risk for chromosomal aneuploidies versus neurocognitive outcomes. Establishing a consensus definition of APA will help guide management and counseling of patients.

The authors report no potential conflicts of interest with regard to this article.

Bray I, Gunnell D, Davey Smith G. Advanced paternal age: how old is too old? 

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Eisenberg ML, Meldrum D. Effects of age on fertility and sexual function. 

Sharma R, Agarwal A, Rohra VK, Assidi M, Abu-Elmagd M, Turki RF. Effects of increased paternal age on sperm quality, reproductive outcome and associated epigenetic risks to offspring. 

Sigman M. Introduction: What to do with older prospective fathers: the risks of advanced paternal age. 

Toriello HV, Meck JM. Statement on guidance for genetic counseling in advanced paternal age. 

Ramasamy R, Chiba K, Butler P, Lamb DJ. Male biological clock: a critical analysis of advanced paternal age. 

Weinstein M, Stark M. Behavioral and biological determinants of fecundability. 

Mirone V, Ricci E, Gentile V, Basile Fasolo C, Parazzini F. Determinants of erectile dysfunction risk in a large series of Italian men attending andrology clinics. 

Handelsman DJ. Male reproductive ageing: human fertility, androgens and hormone dependent disease. 

Kaufman JM, T’Sjoen G. The effects of testosterone deficiency on male sexual function. 

Kidd SA, Eskenazi B, Wyrobek AJ. Effects of male age on semen quality and fertility: a review of the literature. 

Johnson SL, Dunleavy J, Gemmell NJ, Nakagawa S. Consistent age-dependent declines in human semen quality: A systematic review and meta-analysis. 

Hossain MM, Fatima P, Rahman D, Hossain HB. Semen parameters at different age groups of male partners of infertile couples. 

Mukhopadhyay D, Varghese AC, Pal M, et al. Semen quality and age-specific changes: a study between two decades on 3,729 male partners of couples with normal sperm count and attending an andrology laboratory for infertility-related problems in an Indian city. 

Payne KS, Mazur DJ, Hotaling JM, Pastuszak AW. Cannabis and male fertility: A systematic review. 

Haque O, Vitale JA, Agarwal A, du Plessis SS. The effect of smoking on male infertility. In: du Plessis SS, Agarwal A, Sabanegh J Edmund S, eds. 

A Complete Guide to Lifestyle and Environmental Factors

. New York, NY: Springer New York; 2014:19-30. 

Khullar K, Agarwal A, du Plessis SS. BMI and obesity. In: du Plessis SS, Agarwal A, Sabanegh J Edmund S, eds. 

Male Infertility: A Complete Guide to Lifestyle and Environmental Factors

. New York, NY: Springer New York; 2014:31-45.

McPherson NO, Zander-Fox D, Vincent AD, Lane M. Combined advanced parental age has an additive negative effect on live birth rates-data from 4057 first IVF/ICSI cycles. 

Chapuis A, Gala A, FerriÃ¨res-Hoa A, et al. Sperm quality and paternal age: effect on blastocyst formation and pregnancy rates. 

Bronet F. Male age also matters: impact on embryo aneuploidy rate. 

Carrasquillo RJ, Rubio C, Kohn TP, Simon C, Ramasamy R, Al-Asmar N. Advanced paternal age does not affect embryo aneuploidy in egg donor cycles. 

Bellver J, Garrido N, RemohÃ­ J, Pellicer A, Meseguer M. Influence of paternal age on assisted reproduction outcome. 

Kleinhaus K, Perrin M, Friedlander Y, Paltiel O, Malaspina D, Harlap S. Paternal age and spontaneous abortion. 

Zhu JL, Madsen KM, Vestergaard M, Basso O, Olsen J. Paternal age and preterm birth. 

Astolfi P, De Pasquale A, Zonta LA. Paternal age and preterm birth in Italy, 1990 to 1998. 

Singh NP, Muller CH, Berger RE. Effects of age on DNA double-strand breaks and apoptosis in human sperm. 

Moskovtsev SI, Willis J, Mullen JBM. Age-related decline in sperm deoxyribonucleic acid integrity in patients evaluated for male infertility. 

Crow JF. The origins, patterns and implications of human spontaneous mutation.

Penrose LS. Parental age in achondroplasia and mongolism. 

Griffin DK, Abruzzo MA, Millie EA, Feingold E, Hassold TJ. Sex ratio in normal and disomic sperm: evidence that the extra chromosome 21 preferentially segregates with the Y chromosome. 

Kong A, Frigge ML, Masson G, et al. Rate of de novo mutations, father’s age, and disease risk. 

Older age in men may impair conception and it can also have implications for fetal wellbeing, birth outcomes, and long-term health of offspring.

Reproductive risks of advanced paternal age

COMMITTEE ON PRACTICE BULLETINS-OBSTETRICS 

Practice Bulletin #203: Chronic Hypertension in Pregnancy. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e26-50. Full text of Practice Bulletin #203 is available to ACOG members at 

http://www.acog.org/Resources-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Chronic-Hypertension-Pregnancy

Chronic hypertension is present in 0.9-1.5% of pregnant women (1) and may result in significant maternal, fetal, and neonatal morbidity and mortality. The rate of maternal chronic hypertension increased by 67% from 2000 to 2009, with the largest increase (87%) among African American women. This increase is largely secondary to the obesity epidemic and increasing maternal age (1,2). The trend is expected to continue.

The purpose of this document is to clarify the criteria used to define and diagnose chronic hypertension before or during pregnancy, to review the effects of chronic hypertension on pregnancy and vice versa, and to appraise the available evidence for management options. The purpose of these revised best practice recommendations is to provide a rational approach to chronic hypertension in pregnancy based on new research and relevant pathophysiologic and pharmacologic considerations.

Taking a rational approach to hypertension in the pregnant patient

The new American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on chronic hypertension in pregnancy

 replaces the prior ACOG task force hypertension in pregnancy report from 2013, which covered the full range of hypertensive diseases in pregnancy in an extremely thorough way.  However, several factors prompted a needed update with a dedicated focus on chronic hypertension in pregnancy, particularly the new recommendations issued by the American College of Cardiology (ACC) and the American Heart Association (AHA) on the diagnosis and management of hypertensive disease in adults.

More ACOG committee opinion commentary - What Is The Ob/Gyn’s Role In Treating Sexual Assault Survivors?

Chronic hypertension in pregnancy is defined as any one of the following:

Hypertension diagnosed or present before pregnancy, whether or not a woman is on antihypertensive medication

Elevated blood pressure prior to 20 weeks of gestation on two occasions at least 4 hours apart. For the purposes of this diagnosis, a threshold of 140 mm Hg systolic or 90 mm Hg diastolic or both is used.

The basic core of these recommendations is unchanged from the ACOG task force report. However, it is unclear how to align the recent ACC/AHA guidelines

 with these pregnancy-related recommendations.  The ACC/AHA criteria for diagnosing hypertension in adults now classify blood pressure into four categories based on blood pressure results, with stage I hypertension (and recommendation for treatment) starting at a lower blood pressure threshold than we typically use for pregnancy, systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg.

While there is no consensus on how to apply the ACC/AHA recommendations to pregnancy, there does not appear to be benefit to initiating antihypertensive medication during pregnancy or low-dose aspirin for preeclampsia prevention for women who meet criteria for stage I hypertension during pregnancy based on a recent secondary analysis of a multicenter randomized controlled trial.

  However, data are limited on outcomes and preventative measures in women with stage I chronic hypertension.  Therefore, according to ACOG, it is reasonable to continue managing patients who met the criteria for a diagnosis of hypertension based on ACC/AHA recommendations (including stage I hypertension) prior to pregnancy as chronically hypertensive during pregnancy.

The bulletin also addresses another hot diagnosis: white coat hypertension.  Women with white coat hypertension are hypertensive during office visits but otherwise normotensive. They should be observed carefully during pregnancy as they are at increased risk of developing preeclampsia and gestational hypertension.

 Ambulatory blood pressure monitoring may be helpful when making decisions about starting antihypertensive medications in these patients.

Chronic hypertension carries risks to both mother and fetus during pregnancy, with severe and uncontrolled hypertension associated with the highest risks for both. For the mother, there is an increased risk of mortality, cerebrovascular accidents, pulmonary edema, and renal failure; however, the absolute risk of these complications remains low. Fetal risks include increased risk of stillbirth or perinatal death, fetal growth restriction, preterm birth (mostly ascribed to an increase in indicated preterm deliveries), and congenital anomalies, with the highest risk of these abnormalities correlating with presence of maternal end-organ damage.

The prepregnancy period remains the ideal time to initiate care-to look for end-organ damage, assess medications, look for signs of secondary hypertension (such as underlying renal, endocrine or vascular disease) and refer the patient for evaluation if needed, discuss the role of low-dose aspirin for preeclampsia prevention, improve blood pressure control prior to conception, and modify other risk factors that often are seen in conjunction with chronic hypertension, such as diabetes mellitus and obesity.

In case you missed it: Hypertensive Disorders Of Pregnancy

Antepartum management is targeted toward blood pressure control, reducing risk of complications such as preeclampsia, identifying maternal and fetal complications early, and determining optimal timing of delivery.  At the first prenatal visit, baseline labs should be sent, including serum aspartate aminotransferase and alanine aminotransferase, serum creatinine, serum electrolytes, blood urea nitrogen, complete blood count, and spot urine protein/creatinine ratio or 24-hour urine for total protein and creatinine.  Electrocardiogram or echocardiogram should be ordered as appropriate.  Patients with either chronic hypertension or white coat hypertension should be advised to initiate low-dose aspirin (81 mg daily) between 12 and 28 weeks (optimally before 16 weeks) and continue it until delivery for prevention of preeclampsia.

For patients not already on an antihypertensive medication, antihypertensive therapy should be initiated when the systolic blood pressure is 160 mm Hg or more, diastolic 110 mm Hg, or both.  The target range is 120 to 160 mm Hg systolic and 80 to 110 mm Hg diastolic.  Lower targets may be desirable in women with signs of end-organ damage.

Which antihypertensives are best during pregnancy?  

Nifedipine and labetalol are recommended above other antihypertensive medications.  Methyldopa may be used but appears to be less effective than nifedipine or labetalol in achieving blood pressure control. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are generally not recommended due to the risks of fetal renal dysgenesis and calvarial hypoplasia. Other medications, such as conidine and prozosin, can be considered as second-line agents. Acute treatment of severely elevated blood pressure can be achieved using intravenous (IV) labetalol, IV hydralazine, and/or oral nifedipine.  The Practice Bulletin provides several different algorithms for achieving urgent blood pressure control.  Care should be taken to avoid overcorrection of blood pressure leading to hypotension, which can affect uterine perfusion.

Third-trimester ultrasound to assess fetal growth is advised in women with chronic hypertension. In terms of additional evaluation such as subsequent growth ultrasounds or fetal surveillance with nonstress testing or biophysical profiles, the Practice Bulletin does not make a solid recommendation due to limited data.

Timing of delivery depends on whether a patient is on antihypertensive medication and the degree of blood pressure control.  For all patients, delaying delivery later than 39 0/7 weeks should only be considered after a careful evaluation of the risks and benefits.

Chronic hypertension not on antihypertensive medication:  not earlier than 38 0/7 weeks

Chronic hypertension on antihypertensive medication with good control:  not earlier than 37 0/7 weeks

Chronic hypertension with superimposed preeclampsia without severe features:  at 37 0/7 weeks; if at a later gestational age than 37 0/7 weeks, then upon diagnosis.

Chronic hypertension with superimposed preeclampsia with severe features:  not later than

34 0/7 weeks; if at a later gestational age than 34 0/7 weeks, then upon diagnosis.

Immediate delivery after maternal stabilization is recommended if any of the following are present at any gestational age in women with superimposed preeclampsia:  uncontrollable severe hypertension, eclampsia, pulmonary edema, disseminated intravascular coagulation, new or worsening renal insufficiency, placental abruption, or abnormal fetal testing.

Fetal monitoring: Continuous fetal monitoring during labor is advised in women with chronic hypertension at higher risk of adverse outcomes (e.g., those who requre any blood pressure control or with other short-term or long-term sequelae).

Axial anesthesia: Axial anesthesia is safe even in the setting of severe hypertension. Unless contraindicated by thrombocytopenia, it should be used for cesarean delivery as general anesthesia may pose higher risks for women with severe hypertension.

A patient’s blood pressure should be evaluated in the first 1 to 2 weeks after delivery, either with an early outpatient office visit or with home blood pressure monitoring. Target blood pressure is systolic blood pressure of 150 mm Hg or less and diastolic blood pressure of 100 mm Hg or less. The patient can be maintained on the medication used in pregnancy or she can be transitioned back to her pre-pregnancy medication.  Medications such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are compatible with breastfeeding.  NSAID use appears to be safe in postpartum patients with chronic hypertension. Methyldopa should be avoided because it often can be associated with depression.

Diagnosing superimposed preeclampsia:  Up to 20% to 50% of women with chronic hypertension develop superimposed preeclampsia.  Diagnosing superimposed preeclampsia in patients with chronic hypertension can be a challenge.  It can be difficult to determine whether a surge in blood pressure represents worsening chronic hypertension or superimposed preeclampsia.  ACOG indicates that laboratory testing can be helpful in distinguishing between the two by evaluating platelet count, liver function tests, and uric acid levels.

Ashley S. Roman, MD, MPH, reviews some of the new updates discussed in ACOG Practice Bulletin #203: Chronic Hypertension in Pregnancy.

Prenatal visits are an opportunity to discuss future fertility plans and contraceptive planning following delivery. As ob/gyns, we have a responsibility to ensure that women feel empowered to make contraceptive decisions that best fit their needs and desires. Thus, it is important to review patients’ medical comorbidities as well as their preferences and beliefs during prenatal care to develop a postpartum contraceptive plan. 

A provider’s contraceptive counseling approach has implications for the patient-physician relationship, patient satisfaction, and contraceptive continuation. Studies have shown that patient satisfaction with counseling is correlated with higher rates of contraceptive use and greater satisfaction with contraceptive choice.

 High-quality, fair counseling should incorporate the concept of shared decision-making-in which the provider and the patient work collaboratively, with the provider offering medical information and expertise and the patient stipulating her experiences and preferences-in order to select a method that is safe, effective, and meets the needs, desires, and expectations of the patient.

 It is also important to recognize that disparities exist in contraceptive care because of racial, ethnic, and economic differences.

 In addition, there is the potential for bias in contraceptive counseling or recommendations.

Nina, a 34-year-old G4P3 at 28 weeks’ gestation, presents for her prenatal appointment. Her medical history is complicated by chronic hypertension, controlled with labetalol and nifedipine, and Crohn’s disease without medications. She has an obstetric history significant for three preterm deliveries at 36, 35, and 34 weeks due to induction of labor for preeclampsia with severe features. Nina also has a complicated surgical history, with multiple bowel surgeries and a small bowel resection due to Crohn’s disease. She feels that this pregnancy will complete her childbearing and is interested in discussing birth control options. In addition, she is concerned because she will lose her health insurance 60 days after delivery and she wants to have an effective contraceptive method in place beforehand.

Considering Nina's medical history, what contraceptive method meets her desire to avoid pregnacny, minimize risks, and addresses her insurance coverage concerns follwoing delivery?

Correct answer: D. Immediate postpartum intrauterine device

Nina has indicated a desire to avoid additional pregnancies and a concern for lack of health insurance coverage in the future.  Therefore, you and she may decide together to focus your counseling on long-acting reversible contraception (LARC), such as the intrauterine device (IUD) and the subdermal implant, and permanent contraception. 

It is important to explore this patient’s and her partner’s interest in male sterilization or vasectomy, the safest and most effective form of permanent contraception, because permanent sterilization would help Nina to achieve her fertility goals. Female sterilization, however, may not be the safest contraceptive method, because Nina’s surgical history may complicate a surgeon’s ability to complete a tubal ligation or may put her at increased risk of surgical complications. LARC is both safe and extremely effective. Both the IUD and implant can be placed immediately postpartum, which may relieve this patient’s concerns about postpartum follow-up and insurance coverage. Alternatively, you can place the LARC at her postpartum visit. 

Have you read: Counseling For Combined Hormonal Contraception

In regard to other contraceptive methods, combined hormonal contraception is contraindicated with this patient’s history of chronic hypertension. Progestin-only pills are safe; however, they may not be ideal, as they require daily dosing within a short window of time. DMPA is an option but, it may not be accessible to Nina if she loses health insurance. Her prenatal visit today is a good opportunity to explore her interest in LARC methods and timing of placement, her and her partner’s interest in vasectomy, and potential risks of female sterilization.
	 

One consideration in contraceptive counseling is the patient’s reproductive life plans, including wanting to avoid pregnancy or planning for a future pregnancy and its timing. A conversation about reproductive expectations provides an opportunity for the provider and patient to review medical comorbidities and for preconception counseling to be undertaken for women who want to become pregnant. The American College of Obstetricians and Gynecologists (ACOG) recommends that ideally, pregnancies be spaced by 18 months to allow for adequate physiologic preparation for a subsequent pregnancy and bonding between mother and child.

 Shorter interpregnancy intervals are associated with higher risk of preterm birth and low birth weight.

 Many women resume sexual activity prior to 6 weeks postpartum, and those who wait to initiate contraception may be at risk for short-interval pregnancy.

Placement of LARC after birth before the mother is discharged allows a woman to leave the hospital with a highly effective contraceptive method. The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) lists immediate postpartum LARC as category 1 or 2 for healthy breastfeeding or non-breastfeeding women, meaning that it is safe to use.

Until recently, reimbursement was uncommon for LARC devices and placement procedures in the inpatient setting. However, growing awareness of the importance of these procedures has pushed many states to revise their Medicaid policies to include reimbursement for immediate postpartum LARC in addition to the global fee for delivery.

 Additional efforts are being made to advocate for immediate postpartum LARC reimbursement from commercial payers.

 Ob/gyns should inquire about insurance coverage and discuss financial concerns with their patients so that information can be incorporated into the contraceptive plan prior to delivery and IUD insertion.  
	 

The contraceptive implant is an effective form of LARC that poses no increased risks when inserted during the postpartum stay. It is safe for women who want to breastfeed.

 Studies have shown that infant weight at 1 year, infant intake of breast milk, and volume and content of breast milk produced are not impacted by immediate postpartum insertion of the implant.

In addition, there are few logistical barriers to immediate postpartum insertion. The implant can be inserted in the delivery room or at any time before discharge using the same technique as for interval insertion.

 There are no contraindications associated with postpartum insertion of the contraceptive implant.

Immediate postplacental insertion (IPPI) of an IUD is not only convenient for the patient, but also safe and effective for postpartum contraception (Table 1). It is important to review the advantages and disadvantages of such insertion (Table 2).

 IPPI is not associated with increased risks of infection, uterine perforation, or postpartum bleeding.

 It is an easy skill for ob/gyns to learn and requires little additional equipment. Furthermore, postplacental IUD insertion is safe for mother and infant during breastfeeding. Recent studies have shown that receiving an immediate postplacental hormonal IUD has no effect on time to lactogenesis, and there are no differences in reports of breastfeeding at 8 weeks postpartum between women whose IUDs were inserted immediately after delivery of the placenta and those in whom insertion was delayed.

 One disadvantage of IPPI compared to delayed insertion is a higher expulsion rate

(approximately 2%-27% in the first postpartum year).
	 

There are few contraindications to IUD placement in general, including anatomic anomalies such as arcuate uterus, bicornuate uterus, or didelphys uterus; active pelvic infection; cervical cancer; and gestational trophoblastic disease. Postplacental IUD placement is contraindicated under the following conditions: intrauterine infection, postpartum hemorrhage, and puerperal sepsis.

Before beginning the insertion procedure, a brief history should be taken to assess for exclusion criteria, which include recent (within the last 3 months) or active intrauterine infection, known uterine cavity abnormality, and any absolute contraindications (e.g. Wilson’s disease). A postpartum history also should be taken to assess for exclusion criteria such as intrapartum fever greater than 38.0°C or clinical concern for chorioamnionitis, postpartum hemorrhage, and retained placenta requiring manual removal or dilation and curettage. Finally, timing should be confined to within 10 minutes of placental delivery. At that point, the IUD packaging can be opened for placement. 

Insertion technique following vaginal delivery 

A postplacental IUD can be inserted manually or with the aid of ring forceps (Table 1). First, grasp the IUD and advance it through the cervix. Next, place a hand abdominally to stabilize the uterine fundus. Advance the IUD to the fundus with confirmation from the abdominal hand. Release the IUD, taking care to avoid dislodging it from the fundus. At the provider’s discretion, ultrasound can be used to confirm the IUD location. Finally, inspect the vagina for proper string visualization. Because the Copper IUD strings are 12 cm, they are not expected to be visualized at or through the cervix after insertion; if the strings are visible, consider reinsertion of the IUD to ensure fundal placement. Most strings will pass spontaneously through the cervix and can be visualized and trimmed at a follow-up visit. The levonorgestrel (LNG)-IUS strings are longer, however, and should also be trimmed to the level of the cervix after insertion.
	
	

Insertion technique following cesarean delivery

If inserted following cesarean delivery, an IUD should be manually placed at the top of the uterine fundus. Before closing the uterine incision, place the strings in the lower uterine segment (LNG-IUS strings may need to be trimmed prior to placement). When the cervix is dilated, the strings will usually descend spontaneously through the cervix in the weeks following delivery. If the cervix is closed, strings may be left in the lower uterine segment or passed through the cervix with ring forceps. If a ring forceps is used, recheck to make sure the IUD remains at the fundus of the uterus before closing the uterine incision. The strings may be trimmed at a follow-up visit.
	 

All pregnant patients should be screened for 

 and if the results are positive at any point, they must be treated prior to IUD placement. If a patient has not been screened prior to admission for delivery, a urine screening can be done then. If the results are found to be positive post-insertion, the patient can be treated with the IUD in place. Any clinical evidence of infection warrants consideration of IUD removal followed by treatment.

If postpartum endometritis is diagnosed after IUD insertion, remove the IUD and treat with intravenous antibiotics. The patient can then be counseled about the option of having an interval IUD insertion at a postpartum visit. Women with postpartum sepsis can have an interval IUD insertion 3 months after successful treatment of intrauterine infection.

Ultrasound follow-up is not required after postplacental IUD insertion. There are no data on malpositioned IUDs following postplacental insertion. Data from interval postpartum insertion have found no increased risk of pregnancy with a low-lying LNG-IUS,

 and there are no data to support increased risk of pregnancy with a low-lying Copper IUD.

Before discharge, patients who have had postplacental IUD insertion must be instructed about its side effects, possible complications, and warning signs. They all should receive education on IUD expulsion and should be advised to call with expulsion concerns. Almost all expulsions occur in the first 3 months after insertion. In addition, patients should be aware that in the next few weeks, the IUD strings may descend to the introitus and that they can be shortened at a follow-up visit.  All patients who have a postplacental IUD placement should be offered a visit in 2 weeks for a string check because the strings may be at the level of the introitus as the uterus subinvolutes postpartum. Women with postplacental IUD insertion should still be scheduled for routine postpartum follow-up at 4 to 8 weeks. 

Postpartum contraceptive counseling is a multistep process that should be patient-centered (Table 3).

 For our patient Nina, discussing a contraceptive plan during her prenatal visits allows you to identify her fertility and contraceptive preferences and counsel her in a way that respects reproductive autonomy while minimizing coercive practices. LARC may be a good option for a woman like Nina who wants extremely effective contraception immediately following delivery. Immediate postpartum LARC is easy to place and one of many safe and effective options for postpartum contraception that can help to optimize birth spacing and decrease risk of unintended pregnancy. With relationship-building and thoughtful counseling, you can identify a safe postpartum contraceptive method that meets the needs and goals of patients like Nina. 

Koenig MA, Hossain MB, Whittaker M. The influence of quality of care upon contraceptive use in rural Bangladesh. 

This installment in our series looks at postpartum contraceptive options for a pregnant patient with comorbidities

Vol 64 No 05

Why I chose a MIGS fellowship

Reproductive risks of advanced paternal age

Taking a rational approach to hypertension in the pregnant patient

Counseling on complex contraception dilemmas: Case 2

Congenital syphilis makes a comeback

Redefining postpartum care

Was this rectocele repair necessary?

Drug for postmenopausal osteoporosis gets nod from FDA

Experimental vaccine for HPV-associated CIN2/3

Should ob/gyns use metformin to treat pregnant women with PCOS?

FDA proposes updates to mammography regulations