2016 Publications

Fay, E., Hoppe, K., Eckert, L., Schulkin, J. (2016). Survey of Obstetrics and Gynecology Residents Regarding Pneumococcal Vaccination in Pregnancy: Education, Knowledge, and Barriers to Vaccination. Infectious Diseases in Obstetrics and Gynecology.

OBJECTIVE: The 23-valent pneumococcal vaccine is recommended for adults over 65 years of age and younger adults with certain medical conditions. The Centers for Disease Control and Prevention (CDC) state insufficient evidence to recommend routine pneumococcal vaccination during pregnancy, but the vaccine is indicated for pregnant women with certain medical conditions. We designed this project to gauge obstetrics and gynecology (OB/GYN) resident knowledge of maternal pneumococcal vaccination.

METHODS: We administered a 22-question survey to OB/GYN residents about maternal pneumococcal vaccination. We performed descriptive analysis for each question.

RESULTS: 238 OB/GYN residents responded. Overall, 69.3% of residents reported receiving vaccination education and 86.0% reported having ready access to vaccine guidelines and safety data. Most residents knew that asplenia (78.2%), pulmonary disease (77.3%), and HIV/AIDS (69.4%) are indications for vaccination but less knew that cardiovascular disease (45.0%), diabetes (35.8%), asthma (42.8%), nephrotic syndrome (19.7%), and renal failure (33.6%) are also indications for vaccination.

CONCLUSION: OB/GYN residents are taught about vaccines and have ready access to vaccine guidelines and safety data. However, knowledge of indications for pneumococcal vaccination in pregnancy is lacking. Likely, the opportunity to vaccinate at-risk pregnant patients is being missed.

Jones, K., Carroll, S., Hawks, D., McElwain, C., Schulkin, J. (2016). Efforts to improve immunization coverage during pregnancy among ob-gyns. Infectious Diseases in Obstetrics and Gynecology.

BACKGROUND: Influenza and Tdap vaccines are vital factors for improving maternal and neonatal health outcomes.

METHODS: A prospective, longitudinal study was conducted to determine whether the American College of Obstetricians and Gynecologists’ (ACOG) efforts to increase ob-gyn use of their immunization toolkits and vaccination administration were successful. A pre- and post-intervention questionnaire was mailed to a random sample of 1,500 ACOG members between August 2012 and July 2015.
RESULTS: Significantly more post-intervention survey ob-gyns reported that they received the immunization toolkits than pre-intervention survey ob-gyns (84.5% versus 67.0%, p < .001). The large majority of ob-gyns from both surveys (76.9% vs. 78.9%) reported that they offered or planned to offer influenza vaccinations to their patients for the 2012-2013 and 2014-2015 flu seasons. Post-intervention survey respondents were significantly more likely than pre-intervention survey participants to report that they routinely offer Tdap vaccinations to all patients during pregnancy (76.8% versus 59.3%, p < .001).

CONCLUSION: ACOG’s efforts to improve ob-gyn use of immunization toolkits and vaccine administration appear to have been successful in several ways. ACOG’s toolkits are an example of an effective intervention to overcome barriers to offering vaccines and help improve influenza and Tdap immunization coverage for pregnant women.

Lum, D., Sokol, E., Berek, J., Schulkin, J., Chen, L., McElwain, C., Wright, J. (2016). Impact of the 2014 FDA Warnings Against Power Morcellation. Journal of Minimally Invasive Gynecology.

OBJECTIVE: To determine whether members of the AAGL Advancing Minimally Invasive Gynecologic Surgery Worldwide (AAGL) and members of the American College of Obstetricians and Gynecologists Collaborative Ambulatory Research Network (ACOG CARN) have changed their clinical practice based on the 2014 FDA warnings against power morcellation.

DESIGN: Survey study.

SETTING: Participants were invited to complete this online survey


INTERVENTIONS: An online anonymous survey with 24 questions regarding demographics and changes to clinical practice during minimally invasive myomectomies and hysterectomies based on the 2014 FDA warnings against power morcellation.  

MEASUREMENTS AND RESULTS: A total of 615 AAGL members and 54 ACOG CARN members responded (response rates of 8.2% and 60%, respectively). Before the FDA warnings, 85.8% and 86.9%, respectively, were using power morcellation during myomectomies and hysterectomies. After the FDA warnings, 71.1% and 75.8% of respondents reported stopping use of power morcellation during myomectomies and hysterectomies. The most common reasons cited for discontinuing the use of power morcellation or using it less often were hospital mandate (45.6%), the concern for legal consequences (16.1%), and the April 2014 FDA warning (13.9%). Nearly half of respondents (45.6%) reported an increase in their rate of laparotomy. Most (80.3%) believed that the 2014 FDA warnings have not led to an improvement in patient outcomes and have led to harming patients (55.1%). 
CONCLUSION: AAGL and ACOG CARN respondents reported decreased use of power morcellation during minimally invasive gynecologic surgery after the 2014 FDA warnings, the most common reason cited being hospital mandate. Rates of laparotomy have increased. Most members surveyed believe that the FDA warnings have not improved patient outcomes.

Smid, M., Smiley, S., Schulkin, J., Stamilio, D., Stuebe, A. (2016). The problem of the pannus: physician preferences for cesarean skin incision in morbidly obese women. American Journal of Perinatology.3: 463-472.

OBJECTIVE: This study aims to determine preferences of a nationally representative sample of obstetrician/gynecologists (OB/GYNs) regarding cesarean delivery (CD) incision practices for women with morbid obesity (body mass index _ 40 kg/m2). 

STUDY DESIGN: We conducted an online survey using the American College of Obstetricians and Gynecologists database. We compared physician demographics, practice characteristics, and CD incision type preference. 

RESULTS: After exclusion of ineligible participants, 247 OB/GYNs completed the survey (42% response rate). In nonemergency CD of morbidly obese women, 84% of physicians preferred a Pfannenstiel skin incision (67% preferring taping the pannus; 17% without taping the pannus). In emergency CD, 66% preferred a Pfannenstiel incision (46% without taping the pannus; 20% with taping the pannus) and 20% a vertical incision. For both emergency and nonemergency CD, there was no difference in incision type preferences by provider years in practice, practice scope, or number of CD performed each year. 

CONCLUSION: Given the preference of a Pfannenstiel incision with taping the pannus during CD of morbidly obese women, further investigation is needed to assess the risks and benefits of this incision and the practice of elevating the pannus.

Stark, L., Power, M., Turrentine, M., Samelson, R., Siddiqui, M., Paglia, M., Strassberg, E., Kelly, E.,   Murtough, K., Schulkin, J. (2016) Influenza Vaccination among Pregnant Women: Patient Beliefs and Medical Provider Practices. Infectious Diseases in Obstetrics and Gynecology.

OBJECTIVE:  The purpose of this study was to understand the attitudes and practices of patients and medical providers regarding the influenza vaccination, as well as identifying potential barriers that exist in vaccine acceptance among pregnant women.

STUDY DESIGN:  We recruited four medical centers to participate in a study on the attitudes and practices of medical providers and pregnant patients regarding influenza vaccination. Medical providers and patients were given voluntary surveys and medical record data was collected over two flu seasons, from 2013 to 2015.

RESULTS:  Discrepancies between self-reports of medical providers and patients and medical records were observed. Nearly 80% of patients self-reported accepting the influenza vaccine, but medical record data only reported 36% of patients accepting the vaccine. Similarly, all medical providers reported giving recommendations for the vaccine, but only 85% of patients reported receiving a recommendation. Age, education, a medical provider’s recommendation, and educational materials were found to positively influence patient beliefs about the influenza vaccine. Accepting the vaccine was influenced by a patient’s previous actions, beliefs, and a medical provider’s recommendation. Patients who reported previously not accepting the vaccine and had negative feelings towards the vaccine but accepted it while pregnant reported concern for the health and safety of their baby.

CONCLUSION:  Future research should focus on groups that may be less likely to accept the vaccine and ways to dispel negative myths. Medical provider should continue to strongly recommend the vaccine and provide educational materials.

Dhesi, A., Murtough, K., Lim, j., Schulkin, J., McGovern, P., Power, M., Morelli, S. (2016, Epub ahead of  print). Metabolic screening in patients with polycystic ovary syndrome is largely underutilized among obstetrician-gynecologists. AJOG.

BACKGROUND:  Women with polycystic ovary syndrome have substantially higher rates of insulin resistance, impaired glucose tolerance, type 2 diabetes, dyslipidemia, and metabolic syndrome when compared with women without the disease. Given the high prevalence of these comorbidities, guidelines issued by the American College of Obstetricians and Gynecologists and the Endocrine Society recommend that all women with polycystic ovary syndrome undergo screening for impaired glucose tolerance and dyslipidemia with a 2 hour 75 g oral glucose tolerance test and fasting lipid profile upon diagnosis and also undergo repeat screening every 2-5 years and every 2 years, respectively. Although a hemoglobin A1C and/or fasting glucose are widely used screening tests for diabetes, both the American College of Obstetricians and Gynecologists and the Endocrine Society preferentially recommend the 2 hour oral glucose tolerance test in women with polycystic ovary syndrome as a superior indicator of impaired glucose tolerance/diabetes mellitus.

METHODS:  An online survey study targeting American College of Obstetricians and Gynecologists fellows and junior fellows.

RESULTS:  However, we found that gynecologists underutilize current recommendations for metabolic screening in women with polycystic ovarian syndrome. Of the respondents, 22.3% would not order any screening test at the initial visit for at least 50% of their patients with polycystic ovary syndrome. The most common tests used to screen for impaired glucose tolerance in women with polycystic ovary syndrome were hemoglobin A1C (51.0%) and fasting glucose (42.7%). Whereas 54.1% would order a fasting lipid profile in at least 50% of their polycystic ovary syndrome patients, only 7% of respondents order a 2 hour oral glucose tolerance test.

CONCLUSION:  We call for increased efforts to encourage obstetrician-gynecologists to address metabolic abnormalities in their patients with polycystic ovary syndrome. Such efforts should include education of physicians early in their careers, at the medical student and resident level. Efforts should also include implementation of continuing medical education activities, both locally and at the national level, to improve understanding of the metabolic implications of polycystic ovary syndrome. Electronic medical record systems should be utilized to generate prompts for appropriate screening tests in patients with a diagnosis of polycystic ovary syndrome. Because obstetrician-gynecologists may be the only physicians seen by many polycystic ovary syndrome patients, particularly those in their young reproductive years, such interventions could effectively promote optimal preventative health care and early diagnosis of metabolic comorbidities in these at-risk women.

Taouk, L., Schulkin, J. (2016, Epub ahead of print). Transgenerational transmission of pregestational and prenatal experience: maternal adversity, enrichment, and underlying epigenetic and environmental mechanisms. Journal of Developmental Origins of Health and Disease 4:1-14.

Transgenerational transmission refers to positive and negative adaptations in brain function and behavior that affect following generations. In this paper, empirical findings regarding the transgenerational transmission of maternal adversity during three critical periods – childhood, pregestational adulthood and pregnancy – will be reviewed in terms of pregnancy outcomes, maternal care, offspring behavior and development, and physiological functioning. Research on the transgenerational transmission of enrichment and the implications for interventions to ameliorate the consequences of adversity will also be presented. In the final section, underlying epigenetic and environmental mechanisms that have been proposed to explain how experience is transferred across generations through transgenerational transmission will be reviewed. Directions for future research are suggested throughout.

In Press

Urban, R., Taouk, L., Mendiratta, V., Peters, E., Schulkin, J. (2016, In Press.) Obstetrician/gynecologist practice patterns in the care of obese patients with endometrial hyperplasia and carcinoma. AJOG.

OBJECTIVE: This study was conducted to investigate obstetricians and gynecologists’ (ob-gyns’) counselling practices and perspectives pertaining to obesity in the context of a diagnosis of endometrial hyperplasia or carcinoma.

METHODS: A cross-sectional national survey study of ob-gyns was conducted and the results were analyzed with chi-square and t-tests.

RESULTS: One-hundred and forty physicians responded to the survey for a response rate of 55.34%. Most respondents (45.2%) indicted that about half of their patients were overweight or obese. However, only 11.1% had received prior training in obesity management or counseling. Two thirds of respondents selected the diagnosing physician (36.5%) or a general ob-gyn (35.8%) as best suited to address weight reduction as a therapeutic strategy for patients with endometrial hyperplasia. Nearly all respondents (95.6%) agreed that other physicians, such as gynecologic oncologists or primary care physicians should also address it. Approximately half of respondents (47.1%) believed that at least one patient had left their practice because of an attempt to help them with their issue of being overweight or obese.

CONCLUSION: General ob-gyns discuss obesity and the associated health risks with patients having a new diagnosis of endometrial hyperplasia and cancer. In addition, they believe that discussing the risks of obesity should be a multidisciplinary effort. Further efforts to provide provider education on the risks and management of obesity are needed.

Hall, R., Anderson, B., Schulkin, J., Cantey, P., Montgomery, S., Jones, J. (2016, In Press). Survey of Obstetrician-Gynecologists in the United States about Taeniasis and Cysticercosis. Tropical Medicine and Hygiene.

Mohamed, S., Power, M., Schulkin, J., Al-Hendy, A. (2016, In Press). Opinions and practice of US-based obstetrician-gynecologists regarding vitamin D screening and supplementation of pregnant women. Journal of Pregnancy.

Urban, R., Schulkin, J. (2016, In Press). Implementing the flipped classroom on a gynecologic oncology service. Journal of Reproductive Medicine.


American Congress of Obstetricians and Gynecologists
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