Research Department Publications 2017

Easter, S., Taouk, L., Schulkin, J., Robinson, J. (2017). Twin Vaginal Delivery: Innovate or Abdicate. American Journal of Obstetrics & Gynecology 216(5): 484-488.

Neonatal safety data along with national guidelines have prompted renewed interest in vaginal delivery of twins, particularly in the case of the noncephalic second twin. Yet, the rising rate of twin cesarean deliveries, coupled with the national decline in operative obstetrics, raises concerns about the availability of providers who are skilled in twin vaginal birth. Providers are key stakeholders for increasing rates of twin vaginal delivery. We surveyed a group of practicing obstetricians to explore potential barriers to the vaginal birth of twins with a focus on delivery of the noncephalic second twin. Among 107 responding providers, only 57% would deliver a noncephalic second twin by breech extraction. Providers who preferred breech extraction had a higher rate of maternal-fetal medicine subspecialty training (26.2% vs 4.3%; P<.01) and were more likely to be in an academic practice environment (36.1% vs 10.9%; P<.01) and to practice in high-volume centers that deliver >30 sets of twins annually (57.4% vs 34.8%; P=.02). Most providers (54.2%) were familiar with the findings from the recent randomized trial that demonstrated the safety of twin vaginal birth. However, knowledge of the trial was not associated statistically with a preference for breech extraction (62.3% vs 43.5%; P=.05). Providers who preferred breech extraction were more likely to agree with recent society guidelines that encourage the vaginal birth of twins (86.9% vs 63.0%; P<.01). In an adjusted analysis, the 46% of providers with a perceived need for more training were far less likely to prefer breech extraction for delivery of a noncephalic second twin (adjusted odds ratio, 0.38; 95% confidence interval, 0.16–0.95). Furthermore, 57% of providers who would not offer their patient breech extraction would be willing to consult a colleague for support with a noncephalic twin delivery. These results suggest that scientific evidence and society opinion are likely insufficient to reverse the national trends that favor cesarean delivery for twins. Instead, implementation of provider training and support programs is critical for increasing the rates of twin vaginal birth. Changing our national landscape of vaginal twin delivery may require innovation. Without novel provider-focused strategies, we may relinquish passively the requisite skills for not only our patients but also for future generations of obstetricians.

Hall, R., Anderson, B., Schulkin, J., Cantey, P., Montgomery, S., Jones, J. (2017). Survey of Obstetrician-Gynecologists in the United States about Taeniasis and Cysticercosis. American Journal of Tropical Medicine and Hygiene 96(1):233-242.

An estimated 50 million persons worldwide are infected with cysticerci, the larval forms of the Taenia solium tapeworm. Neurocysticercosis can cause seizures, epilepsy, and hydrocephalus, and fatal cases have been reported in the United States in immigrants and in travelers returning from endemic countries. Pregnant women with symptomatic neurocysticercosis present treatment challenges, whereas those with the adult tapeworm infection (i.e., taeniasis) can put their infants and other family members, as well as obstetrician-gynecologists and their staff, at risk for cysticercosis. A questionnaire developed by the American College of Obstetricians and Gynecologists was sent to a representative sample of 1,000 physicians to assess their awareness of T. solium infection and the potential for it to be encountered in an obstetrics and gynecology setting. In total, 31.4% of respondents correctly answered that taeniasis is caused by eating undercooked pork containing T. solium cysts (95% confidence interval [CI] = 26.6–36.5). While only 14.5% (95% CI = 11.0–18.6) of respondents correctly answered that cysticercosis is acquired by ingesting tapeworm eggs shed in human stools, twice that number (30.3%; 95% CI = 25.5–35.3) correctly answered that a mother with taeniasis can cause cysticercosis in her infant. Practicing in a state in which cysticercosis was reportable at the time of the survey was not significantly associated with answering any of the 12 knowledge questions correctly. Overall, knowledge of T. solium infection among U.S. obstetricians-gynecologists is limited. This may result in missed opportunities to diagnose and treat pregnant women with taeniasis, which may put family members and obstetrics clinical staff at risk for cysticercosis. 

Jones, N., Schulkin, J., Urban, R., Wright, J., Burke, W., Hou, J., McElwain, C., Tergas, A. (2017). Physicians' Perspectives and Practice Patterns Toward Opportunistic Salpingectomy in High- and Low-Risk Women.  Cancer Investigation 35(1):51-61.

BACKGROUND:  Opportunistic bilateral salpingectomy (OBS) has been proposed as an ovarian cancer risk-reducing strategy.

METHODS:  A survey was emailed to 300 members of the American College of Obstetricians and Gynecologists.

RESULTS:  125 (42%) surveys were returned: 60% female, 88% generalists, 67% private practice. Only 36% correctly identified the lifetime risk of ovarian cancer, only 23% understood the risk-reducing benefit of bilateral salpingo-oophorectomy. 75% perform salpingectomy during hysterectomy, 26-53% use for sterilization depending on approach. Concerns were increased operative time and complications. For BRCA mutations, 64% recommend BSO, 12% recommend a two-step risk-reducing strategy, and 14% refer to gynecologic oncology.

CONCLUSIONS:  We identified broad support and factors limiting willingness to perform OBS.

Lam, C., Matteson, K., Schulkin, J. (2017, Epub ahead of print). Assessing Abnormal Uterine Bleeding: Are Physicians Taking a Meaningful Clinical History? Journal of Women’s Health.

INTRODUCTION: Women with abnormal uterine bleeding (AUB) report significant reductions in quality of life (QOL), which can be attributed in many cases to the fear of embarrassing episodes of bleeding. We performed this study to determine whether or not during clinical encounters physicians addressed the impact of AUB on patient-reported QOL.

MATERIALS AND METHODS: Between October 2008 and May 2009, we conducted a cross-sectional study of members of the American College of Obstetricians and Gynecologists. Surveys were distributed using a mixed method (web- and mail-based) and included questions about physician characteristics and types of questions used when obtaining a clinical history from a patient with AUB. We calculated the proportion of physicians who endorsed asking each type of clinical question with 95% confidence intervals (CIs).

RESULTS: Four hundred seventeen questionnaires were returned (52%). Ninety-nine percent (95% CI 98.4%-99.9%) reported always asking a bleeding heaviness question, 87.2% (95% CI 83.2%-90.5%) reported always asking a QOL question, and 17.5% (95% CI 13.6%-21.9%) reported always asking a mood associated with bleeding question. Seventy-eight percent specifically asked patients about bleeding through their clothes, and 55% asked about changing social plans because of bleeding. Only 18% endorsed that asking about QOL was most essential for the evaluation of women with AUB. No physician characteristics such as years since completing residency, geography, or gender were associated with how commonly providers reported asking questions regarding impact of bleeding on QOL.

CONCLUSIONS: Physicians may not be optimizing patient-provider interactions during menstrual history taking with patients with AUB by failing to assess impact of AUB on QOL in a way that is meaningful to patients.

Marcewicz, L., Anderson, B., Schulkin, J., Grant, A., Byams, V. (2017, Epub ahead of print). Screening and treatment for iron deficiency anemia in women: results of a survey of obstetrician-gynecologists. Maternal and Child Health Journal.

OBJECTIVE: To better understand the knowledge, attitudes and practices of obstetrician-gynecologists with respect to screening and treatment for iron deficiency anemia (IDA).

METHODS: A total of 1,200 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists were invited to participate in a survey on blood disorders. Respondents completed a questionnaire regarding their patient population, screening and treatment practices for IDA, and general knowledge about IDA and its risk factors.

RESULTS: Overall response rate was 42.4%. Thirty-eight percent of respondents screen non-pregnant patients regularly, based on risk factors; 30.5% screen only when symptoms of anemia are present. For pregnant patients, 50.0% of respondents screen patients at their initial visit, while 46.2% screen every trimester. Sixty-one percent of respondents supplement pregnant patients when there is laboratory evidence of anemia; 31.6% supplement all pregnant patients. Forty-two percent of respondents screen post-partum patients based on their risk factors for IDA. However, when asked to identify risk factors for post-partum anemia, slightly more than half of respondents correctly identified young age and income level as risk factors for post-partum anemia; only 18.9% correctly identified pre-pregnancy obesity as a risk factor.

CONCLUSION: There are opportunities for increased education on IDA for obstetrician-gynecologists, specifically with respect to risk factors. There also appears to be substantial practice variance regarding screening and supplementation for IDA, which may correspond to variability in professional guidelines. Increased education on IDA, especially the importance of sociodemographic factors, and further research and effort to standardize guidelines is needed.

Power, M., Quaglieri, C., Schulkin, J. (2017, Epub ahead of Print). Reproductive Microbiomes: A New Thread in the Microbial Network. Reproductive Sciences.

Almost every part of our body has a coevolved microbial community. The expressed microbial genes comprise the various microbiomes that play important roles in normal physiology and development. The various microbiomes are separate, yet often connected, with the species composition of one affecting others. The female reproductive system microbiomes (eg, vaginal, placental, and mammary/milk) remain less well explored than the gut microbiome although they comprise a large proportion of the female microbial network. This review examines the evidence for interconnectivity between the female reproductive microbiomes, other maternal microbiomes, and developing infant microbiomes and the potential roles of each in health and disease. Disruptions in maternal microbiomes may be linked to pregnancy complications and maternal, fetal, and neonatal health. The diversity of the vaginal microbiome's makeup, which appears to vary across ethnicity, has led researchers to reconsider the idea of a "healthy" or "normal" vaginal microbial community. Less is known about the possible placental microbiome, although an association between the placenta's bacterial makeup and preterm labor and other pregnancy complications is being investigated. The mammary/milk microbiome appears to be influenced by maternal characteristics and may play a role in inoculating the infant but may also be affected by the infant's oral microbiome. Probiotic therapies such as "vaginal seeding" offer potential health benefits but require more rigorous testing. Exploring the reproductive microbiomes in detail and pairing this information with an individual's detailed medical history will provide a more complete picture of the status and importance of the microbial network to health.

Smid, M., Dotters-Katz, S., McElwain, C., Stuebe, A., Volckmann, E., Schulkin, J. (2017, Epub ahead of print). Pregnancy after bariatric surgery: National survey of obstetrician’s comfort, knowledge, and practice patterns. Obesity Surgery.

OBJECTIVE: To survey a nationally representative sample of obstetricians regarding comfort, knowledge and practice patterns of caring for pregnant women after bariatric surgery.

MATERIALS AND METHODS: We conducted an online survey of US obstetricians and describe obstetrician’s demographics, practice settings and practice patterns. We assessed respondent’s knowledge and recommended practices. We compared provider knowledge by years since completing residency, scope of practice (generalist or specialist), and practice setting (academic setting or other). Statistical significance was set at p < .05.

RESULTS: A total of 106 completed the survey (response rate of 54%). Respondents had a median age of 47 and median 17 years in practice. 62% were generalists. Nearly all of the respondents (94%) had some experience with caring for pregnant women after bariatric surgery and 83% reported feeling “very comfortable” (48%) or “somewhat comfortable” (35%) providing care for this population. Most (74%) were aware of increased risk of small for gestational age after surgery. Only 13% were able to correctly identify all recommended nutritional labs and 20% reported that they “did not know” which labs are recommended. There were no differences in comfort, experience, knowledge and practice patterns by physician characteristics and practice settings.

CONCLUSION: While most obstetricians are aware of perinatal risks after bariatric surgery, a substantial percentage of obstetricians are unaware of recommended practices regarding nutrition and nutritional monitoring. As bariatric surgery becomes increasingly prevalent among reproductive age women, educational interventions to increase obstetricians’ knowledge of optimal care of pregnant women after bariatric surgery are urgently needed.

Taouk, L., Farrow, V., Schulkin, J. (2017). Amount and Quality of Sleep: Exploring the Role of Stress and Work Experience in a Sample of Obstetrician-Gynecologists. Journal of Psychosomatic Obstetrics and Gynecology 2:1-6

INTRODUCTION: Sufficient sleep is necessary for optimal performance and the delivery of safe and effective health care. To establish an empirical understanding of physician fatigue, the present study investigated the factors that contributed to the amount and the quality of sleep among obstetricians and gynecologists (ob-gyns).

METHODS: A survey of personal and work experiences was sent to 495 eligible physicians belonging to the American College of Obstetricians and Gynecologists (ACOG). Data were obtained from 287 ob-gyns for a response rate of 58.0%. Associations between sleep-related items and measures of stress and work-related factors were explored.

RESULTS: Ob-gyns in our sample reported sleeping an average of 6.5 hours a night with 29.2% indicating that they received very or fairly bad quality of sleep. Average amount and quality of sleep were found to be independently related to the hours worked weekly, colleague support for a work-home balance, practice setting, perceived work-control, physician-specific stressors and perceived stress. In summary models, hours worked and perceived stress scores consistently emerged as predictors of amount of sleep.

CONCLUSIONS: Overall, findings explained a small portion of the variance in sleep. Considering the multitude of factors that contribute to sleep, subtle associations warrant further investigation.

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