Download Class of 2010 - University of Illinois College of Medicine at Chicago

Class of 2010
1. Resident:
Research Advisor:
Title:
Brenton Jenkins, MD
Isabelle Wilkins, MD
Effects of the IDPA Obstetric Hemorrhage
Education Project Course on Visual Blood Loss
Estimates on Labor & Delivery at UIMC at Chicago
2. Resident:
Research Advisor:
Title:
Amy Katz, MD
Allison Cowett, MD, MPH
Provision of Postpartum Contraception in Women with
Chronic Medical Conditions
3. Resident:
Research Advisor:
Title:
Humera Mohammed, MD
Gary Loy, MD, MPH
Does Learning Style Impact Job Satisfaction among
Obstetrics and Gynecology Residents?
4. Resident:
Research Advisor:
Title:
Ramata Niang, MD
Jennifer Ahn, MD
Effect of Labetol on Antenatal Testing
5. Resident:
Title:
Dipti Patel, MD
Knowledge of Cervical Cancer Screening, Human
Papillomavirus and HPV Vaccine Among Midwestern
Gynecology Patients
6. Resident:
Research Advisor:
Title:
Roa Qato, MD
Valerie Swiatkowski, MD
Endometrial Preparation and Essure Placement
Success
7. Resident:
Research Advisor:
Title:
Ilana Ressler, MD
Bert Scoccia, MD
Risk Factors for Multiple Gestations in an IVF
Program
Effects of the IDPA Obstetric Hemorrhage Education Project Course on Visual Blood
Loss Estimates on Labor and Delivery at UIMC at Chicago
Brenton Jenkins, MD
Objectives: In late 2008 and early 2009, OB practitioners at UIC underwent the statewide
Obstetric Hemorrhage Education Project (OHEP). This statewide IDPH educational course
involved both a presentation and stations where participants visually estimated the simulated
blood lost. Our goal was to assess whether there was a statistically significant change in
visually estimated blood lost (vEBL) on the L and D ward when comparing the period before
and after the course.
Hypothesis: We hypothesized that there would be a statistically significant changes in vEBL
when the period before and after the course were compared.
Study Design: The mean vEBL was compared for a period roughly six months before and a
period roughly six months after the course. vEBL's entered into MARS by either a midwife or
an OB resident were used in the calculations. Four separate means were compared
pre/post course: mean vEBL for resident vaginal deliveries, mean vEBL for resident primary
cesareans, mean vEBL for resident repeat cesareans and mean vEBL for CNM vaginal
deliveries. Pre/post course means were compared using unpaired student t test. Power
calculations were done to calculate the sample size that would be required to yield a 0.80
power for both a 10% and 20% change in vEBL between the two groups.
Results: Only the mean vEBL for resident repeat cesareans showed a statistically significant
change when the pre/post means were compared. For resident vaginal deliveries the p
value approached but did not reach significance at 0.0514. For all three of the groups where
the vEBL change was not significant, our sample size was sufficient for a power of 0.80 for a
20% change in mean vEBL. For resident primary cesareans and CNM vaginal deliveries, the
sample size was sufficient for a 10% change in mean vEBL. For resident vaginal deliveries
the sample size was slightly too small for a power of 0.80 for a 10% change in vEBL.
Conclusion: Only one of the four mean vEBL's showed a significant change after the
course, and even this change was of questionable clinical significant with a change in mean
of 82 mL's. The other means failed to show a significant change after the course. Therefore,
we can say that in all cases but repeat cesareans the course failed to significantly change
how participants visually estimated blood loss in the clinical setting.
Provision of postpartum contraception in women with chronic medical conditions
Amy Katz MD
Background: Many chronic medical conditions have the potential to worsen in pregnancy
and adversely affect both maternal and fetal health, highlighting the importance of
unintended pregnancy prevention in this population. When women with chronic medical
conditions are pregnant, prenatal care is the ideal setting for providers to discuss postpartum
contraceptive options with patients. Despite this unique opportunity, contraceptive care may
be overshadowed by management of the chronic medical condition in pregnancy and the
added complexity of what contraceptives are appropriate in these women. We hypothesized
that chronic medical conditions present a barrier to the provision of safe and effective
contraceptive methods to women in the postpartum period and that these women would be
less likely than healthy women to receive postpartum contraception.
Research Objectives: To evaluate the post partum contraceptive prescribing practices of
the practitioners at University of Illinois Medical Center at Chicago (UIMCC) who care for
women with chronic medical conditions. To compare the postpartum contraception provided
to patients with chronic medical conditions versus healthy women.
Methods: We performed a retrospective cohort study using the existing database of patients
who delivered at UIMCC from July 2004 through September 2007. Patient demographics,
medical history, and method of planned birth control upon hospital discharge were collected.
Women with chronic medical conditions including diabetes, hypertension, heart disease and
history of venous thromboembolic disease comprised the cohort and were compared to
healthy women who served as controls. Statistical analysis was performed using chi square
test and t test where appropriate.
Results: The sample included 8314 women, 752 with chronic medical conditions and 7562
controls. The groups were similar in age, race, and marital status. Eighty-one percent of
women with chronic medical conditions versus 86 percent of controls were prescribed
contraception postpartum. (p<0.001). When grouped by condition, patients with diabetes (83
percent, p=0.04), chronic hypertension (80 percent, p<0.001) and heart disease (75 percent,
p<0.01) were less likely than their healthy counterparts to receive postpartum contraception.
The most commonly prescribed contraceptive methods were progesterone only methods in
the cohort and the control groups (28 percent versus 30 percent respectively, p=0.15). Nine
percent of the cohort versus four percent of controls underwent postpartum tubal sterilization
(p<0.001).
Conclusion: At a university hospital caring for an urban population, women with chronic
medical conditions, specifically diabetes, hypertension and heart disease, were less likely
than their healthy peers to receive postpartum contraception upon hospital discharge.
Does Learning Style impact Job Satisfaction among Obstetrics and Gynecology
Residents?
Humera Mohammed, MD
Purpose: Evaluating factors that may impact residency job satisfaction is critical in
understanding the reasons that residents leave the specialty. The purpose of this study is to
determine if there is a predominant learning style among obstetrics and gynecology residents
in a university based residency program, and if having a particular learning style impacts job
satisfaction.
Materials and Methods: The Kolb Learning Style Inventory, a standardized learning
assessment tool, was administered to obstetrics and gynecology residents at a university
based residency program. A residency job satisfaction questionnaire, a modified version of a
previously validated residency program evaluation tool, was administered to these same
residents. Each resident was classified into a particular learning style based on the Kolb
Learning Style Inventory. Comparisons in overall satisfaction scores were made between
residents with each learning style.
Results: All 28 residents in the residency program participated. Ten residents were of the
converger type, 10 were of the accommodator type, 4 were of the diverger type, and 4 of the
assimilator type. Residents that strongly favored the converger learning style had the highest
mean satisfaction scores (p=0.026). Residents who strongly favored the diverger learning
style have the lowest mean satisfaction scores (p=0.039).
Conclusion: The majority of obstetrics and gynecology residents are either of the converger
or accommodator learning style. Learning style affected job satisfaction. Residents of the
converger type had the highest mean satisfaction scores, while divergers had the lowest.
Knowledge of individual learning styles has the potential to guide early intervention for the
discontent.
Effect of Labetalol on Antenatal Testing
Ramata Niang, MD
Objective: To determine if treating chronic hypertension with labetalol adversely affects non
stress test results.
Methods: We performed a retrospective study from January 2003 to September 2007.
Patients were identified using the University of Illinois computerized Obstetrics database. All
patients with a diagnosis of chronic hypertension were queried in the database. Medical
therapy was then differentiated. Inclusion criteria were patients treated with labetalol or
methyldopa (comparison group). Exclusion criteria included multiple gestations, incomplete
antenatal testing charts or other antihypertensive medication use. Primary outcomes were
presence of reactive or nonreactive results on non stress test. For each patient, the average
of NST results was calculated and was then accounted as either reactive or non reactive test
result. Secondary outcomes evaluated included gestational age at delivery, birthweight,
presence of superimposed preeclampsia, and mode of delivery.
Results: Overall, 1006 patients were treated at UIC during that time period for chronic
hypertension. We reviewed 188 charts, after excluding multiple gestations pregnancies, other
antihypertensive treatment and incomplete antenatal testing charts. 76 patients were
included in the labetalol group and 36 in the methyldopa group. There were no statistical
difference in NST results between the methyldopa and the labetalol group. 80.65 % NST
were reactive in the methyldopa group and 83.7 % in the labetalol group. OR 1.25 with CI
0.44-3.50) and p 0.6743
Conclusions: Labetalol does not appear to cause blunted antenatal testing results. These
findings are consistent with previous studies showing no differences among these groups.
Knowledge of Cervical Cancer Screening, Human Papillomavirus, and HPV Vaccine
Among Midwestern Gynecology Patients
Dipti Patel MD
Background: Vaccines against HPV type 16&18 have potential to prevent 70% of current
cervical cancers. 1 in 4 women are infected with HPV. Acceptability of vaccine outside of
clinical trials is unclear. Many women are unaware of HPV and few understand the link
between HPV infection and cervical cancer. Continued screeing for cervical cancer will be
needed to treat cervical disease caused by other HPV types. Women must understand and
participate in conventional cancer prevention process after vaccination. Improving
acceptance will be facilitated by ensure women understand the treat of HPV and the
potential benefits of the vaccine.
Objective: We determined women’s knowledge of cervical cancer prevention process, the
human papillomavirus (HPV) and the HPV vaccine. To identify groups of women with limited
knowledge in order to allow clinicians to target women for intensive education outreach.
Methods: A survey of patients aged 18+ who presented to gynecology clinic of SIU between
March 5-May 11, 2007 were given anonymous, self administered questionnaires.
Results: Of 420 participating women, 378 (90%) correctly identified the puropose of the Pap
test, 345 (82%) knew who should receive the test, and 391 (92%) correcgtly identified the
risks for cervical cancer and the meaning of an abnormal Pap test. 275 (65%) had heard of
the HPV vaccine, and 45(11%) recognized its effectiveness in preventing cervical cancer.
165(39) were likely to recommend it, and only 33(8%) wanted to receive it. Advertising and
news stores were dominant sources of information about the HPV vaccine. Knowledge
about cervical cancer was better in women with higher income, private insurance, 5-10
partners, 2 or fewer children, some college education, Caucasians and married people.
Knowledge about HPV and HPV vaccination was better among Caucasians and women
under 45 years of age and current or previous smokerse.
Conclusions: Knowledge of cervical cancer screening, HPV, and the HPV vaccine is better
than historical reports, possibly reflecting the impact of advertising and news stories about
HPV vaccination. Knowledge was lower among women with demographic risks for cervical
cancer, suggesting that vaccination messages should be targeted to those women.
Endometrial Preparation and Essure Placement Success
Roa Qato, MD
Objective: To determine whether treatment with hormonal contraceptives prior to an Essure
(hysteroscopic sterilization) aids in successful placement of the device.
Design: Retrospective cohort study of all women who had a sterilization surgery that began
as an Essure.
Setting: All surgeries took place in an urban-based university hospital with an adjacent
outpatient clinic.
Patients: A database of all women who underwent a tubal sterilization procedure from 2002
(introduction of Essure to our institution) until 2008 was reviewed. 194 women had a tubal
sterilization procedure that began as an Essure. 7 women were excluded. Exclusion criteria
included women with insufficient data, uterine anomalies found on initial hysteroscopy on the
day of surgery and failure secondary to technical difficulties.
Measurements & Main Results: Variables included demographics, BMI, and type of
endometrial preparation prior to scheduling of surgery. Reason for conversion was recorded
for women whose final surgical procedure was not an Essure. 194 women had Essure as an
initial procedure. 163 women were on hormonal therapy and 24 were not on any therapy
prior to the surgery, and were scheduled based on their menses. There was a statistically
significant difference in success rate between women who received hormonal therapy prior
to the surgery and those who did not (OR=7.65, 95% CI 2.64 – 22.15).
Conclusion: Hormonal treatment prior to undergoing the Essure procedure leads to
increased success in placement.
Risk Factors for Multiple Gestations in an IVF Program
Ilana Ressler, MD
Objective: To investigate what risk factors exist for multiple gestation in the UIC IVF
population. To compare IVF outcomes among women of different ethnic backgrounds.
Design: Retrospective cohort study in an academic IVF center.
Materials and Methods: Treatment cycles completed January 2004 to December 2007
were reviewed after IRB approval. Patients received OCPs before ovarian stimulation to
induce menses and prevent residual ovarian cyst formation. GnRH agonist or antagonist
protocols were used to prevent spontaneous ovulation. All patients received daily rFSH 150450 units, with or without hLH/FSH 75-150 units, starting on day 3 of the cycle. hCG 6,50010,000 units was given when 3 follicles >18mm. Oocyte retrieval was performed at 35 hours
and embryo transfer 72 hours later (Cleavage Day 3). Luteal support with progesterone in oil
50-100mg daily was used until 10 weeks gestation. Treatment cycle was the unit of analysis.
Variables were compared using chi-square and logistic regression analyses.
Results: 297 cycles were reviewed, resulting in 122 clinical pregnancies with 31.1% (38
cycles) twin gestations and 3.3% (four cycles) triplet gestation. The mean age was 34.3
years (range 22-44). White women had 48.8% of the cycles, Black 21.5%, Hispanic 19.5%,
Asian 7.1% and Other 3.0%. Factors that significantly increased the risk of multiple
gestations were: younger age (p<0.05), increased number of top quality embryos (p<0.05),
increased number of excess embryos for cryopreservation (p<0.05) and ethnicity (p<0.05).
The rate of multiple gestation of those who were pregnant according to ethnicity were: Black
47.4%, White 40.0%, Hispanic 20.0%, Asian 20% and Other 0% (p<0.05). The number of
embryos transferred was not significantly different across ethnic groups (p=NS).
Conclusions: This pilot study found that risks for having a multiple gestation in women
undergoing ART include younger age, increased number of top quality embryos, number of
excess embryos available for cryopreservation and ethnicity. When counseling patients prior
to IVF about their risks for multiple gestations, individual risk factors, including ethnicity,
should be taken into account.
Class of 2009
1. Resident:
Research Advisor:
Title:
Sophia Chin, MD
Yvonne Collins, MD
Characterization of Grade 4 Neutropenia in Gynecologic
Oncology Patients Receiving Chemotherapy
2. Resident:
Research Advisor:
Title:
Meredith Cruz, MD
Judith Hibbard, MD
Ambulatory Monitoring in Pregnant Patients with Palpitations
3. Resident:
Research Advisor:
Title:
Pooja Jain, MD
Bryna Harwood, MD, MS
Interval Tubal Sterilization: Procedure Selection, Outcomes
and Body Weight
4. Resident:
Research Advisor:
Title:
Alicia Mandujano, MD
Gary Loy, MD, MPH
Evaluation of Weight Gain in Obese Primigravidas: Is There an
Ideal Recommendation?
5. Resident:
Research Advisor:
Title:
Khyaati Modii, MD
Denise Elser, MD
Biologic vs Synthetic Graft Augmentation in Pelvic
Reconstructive Surgery
6. Resident:
Research Advisors:
Title:
My-Le To, DO
Denise Elser, MD
Analysis of Risk Factors for Ulcer Formation in
Postmenopausal Pessary Users
7. Resident:
Research Advisor:
Title:
Stephanie Wong, MD
Isabelle Wilkins, MD
Uterine Ruptures Associated with Previous Cesareans
Characterization of Grade 4 Neutropenia in Gynecology Oncology Patients Receiving
Chemotherapy
Sophia Chin MD
Background: Neutropenia is associated with the risk of life-threatening infections as well as
chemotherapy dose reductions and delays that likely compromise treatment outcomes
resulting in significant mortality. Previous studies have attempted to develop risk models
involving various factors such as age, cancer stage, and recurrent disease in order to assess
neutropenic risk with conflicting results.
Objective: We assessed whether patient age, cancer type, cancer stage, recurrent disease,
chemotherapy line, number of cycles completed or concurrent radiation had significant
impact on grade 4 neutropenia or mortality within 1 year. In addition we discovered the
incidence of febrile neutropenia.
Methods: A retrospective chart review of patients being treated with chemotherapy for any
gynecologic malignancy during the year to 2007 was performed and the above listed
variables were recorded for analysis in relation to grade 4 neutropenia and mortality within 1
year.
Results: 59 patients were compliant with chemotherapy for their gynecologic malignancy
and had records available for entry into this study. 14 patients experienced grade 4
neutropenia during the year of 2007, 2 cases of neutropenic fever were identified and 16
patients died within 1 year. Variables associated with mortality were stage (0.002), recurrent
disease (p 0.002), chemotherapy line (p 0.012), number of cycles completed (p 0.039), and
concurrent radiation therapy (0.004). In particularly, recurrent disease (OR 3.5 CI 1.55,
7.72), carboplatin/paclitaxel chemotherapy line (OR 3.5 CI 0.47, 25.9), and first cycle of
chemotherapy (OR 3.6 CI 1.85, 6.99) were found to be most significant regarding mortality.
Stage 1 and 2 disease (OR 1.69 CI 1.30, 2.20) and concurrent radiation (OR 1.59 CI 1.26,
2.00) were found to be protective against death. Age and cancer type were not found to have
a significant correlation to mortality. There were no correlations for the above variables for
grade 4 neutropenia except for stage of disease (p 0.040), which noted Stage 4 disease to
carry the greatest risk (OR3.0 CI 1.23, 7.43). The incidence of febrile neutropenia was 3.4%
for our population during the year of 2007.
Conclusions: In contrary to previous studies age did not show a significant impact on grade
4 neutropenia or mortality. In our population, patients with later stage disease, recurrent
disease, and had completed first cycle of chemotherapy resulted in higher mortality and
therefore should be monitored closely and considered high risk. Patients which are past
their first cycle of chemotherapy, have stage 1 or 2 disease, primary disease, and are
receiving concurrent radiation had less mortality and therefore these factors may used for
reassurance for our population. In addition, our incidence of febrile neutropenia is lower than
reported in previous studies.
Ambulatory Monitoring In Pregnant Patients with Palpitations.
Meredith Cruz, MD
Purpose: Palpitations, dizziness and syncope are frequent complaints in pregnancy and
may be benign, but often prompt referral to Cardiology. The purpose of our work is to assess
the nature of rhythm disturbances (RD) in pregnant women with these symptoms as
determined by event recorder tracing (ERT) evaluation, a more accurate method than Holter
monitoring. We hypothesize that benign arrhythmias will be a frequent finding on ERT and
associated with benign outcomes in women referred for symptoms, but women with
preexisting heart disease (HD) or arrhythmias will be more likely to have serious RD and
poorer outcomes.
Methods: We screened 126 gravidas referred to Cardiology for palpitations, syncope, or
dizziness that underwent ERT 10/02-3/08. ERT were reviewed and arrhythmias classified by
severity of RD; benign: sinus/sinus arrhythmia/sinus tachycardia or serious: supraventricular
tachycardia /atrial fibrillation/flutter/ventricular tachycardia/heart block. Variables collected
were age, race, parity, BMI, gestational age at referral/delivery, history of RD/HD, cardiac
function, hypertension, preeclampsia, birthweight, APGARS, neonatal complications.
Results: Baseline demographics of the cohort include mean age of 26.8+/-7.8yrs, 31.1%
primips, 41.5% AA, 34.0% Hispanics, 13.2% Caucasian, 1.9% Asian, and 9.4% other. Mean
BMI 28.9+/-7.9. Mean GA at referral 22.6 wks +/- 8.3 days and GA at delivery 37.7 wks +/3.5 days. 67 of the 126 women screened had ERT’s performed. 79% had benign
arrhythmias and 21% serious. Only 4 patients had LV dysfunction at time of evaluation and 8
women had a history of CHD. In our ERT cohort women with a history of arrhythmias had a
4.7-fold increase in serious RD during gestation (OR 4.7, 95% CI 1.1- 20.3, p=0.01). We
noted that obese women (BMI>30) had a 4-fold increase risk in the occurrence of serious RD
during gestation (OR 3.95, 95% CI 1.0-17.7, p=0.03). A diagnosis of serious RD did not
result in greater chance of CS, a greater risk for induction of labor, nor having a newborn with
cardiac arrhythmias.
Conclusion: A full cardiac workup may only be warranted in pregnant women who present
with palpitations, dizziness or syncope with a hx of structural heart dz, arrhythmias, or
obesity, a group that surprisingly had a 4-fold increased risk of having a severe RD. There is
no evidence that a CS is required, nor induction of labor for gravidas with a serious RD.
Interval tubal sterilization: procedure selection, outcomes, and body weight.
Pooja Jain MD
Background: The rate of obesity is increasing in the United States. Previous studies of
laparoscopic tubal ligation show an increased risk of surgical complications in obese women.
Laparoscopic tubal ligation (LS) and hysteroscopic tubal occlusion (HS) have not been
directly compared in the obese population.
Purpose: To determine if selection of interval sterilization procedure (LS vs HS), procedure
success, or complication rates differ in a cohort of obese and non-obese women.
Methods: We performed a retrospective cohort study of women scheduled for interval
sterilization from 1 January 2003 to 20 August 2007. Patient demographics, medical and
surgical histories, sterilization procedure, outcomes and complications were collected.
Statistical analysis was performed using chi square test, t test, and Fisher exact test as
appropriate.
Results: 375 patient records were reviewed. Obese women accounted for 54% of the
patient population. The obese and non-obese populations were similar in age, parity, race,
and surgical history. In comparing obese and non-obese women, no significant differences
were seen in procedure selection (LS vs HS, p=0.17), procedure completion (p=0.20), or
surgical complications (p=0.18). When separated by sterilization method, no significant
differences were seen in procedure completion (LS p=0.49, HS p=0.26) or complications (LS
p=0.16, HS p=1.00) among obese versus non-obese women.
Conclusion: In a cohort of patients opting for tubal sterilization, obesity did not affect
surgical route selection, procedure completion rate, or surgical complication rate.
Laparoscopic and hysteroscopic sterilization were similar in completion and complication
rates when obese and non-obese women were compared.
Evaluation of weight gain in obese primigravidas; Is there an ideal recommendation?
Alicia Mandujano, MD
Background: The increased risks associated with obesity (BMI ≥30 kg/m2) in pregnancy are
well established, including a greater risk for gestational diabetes, preeclampsia, operative
vaginal delivery, cesarean delivery, and infection. Though the Institute of medicine have
established guidelines for weight gain in obese pregnant patient, these recommendations do
not include an upper limit of weight gain (i.e. maximum weight gain). There are no studies
assessing the ideal weight restriction in the morbidly obese gravida.
Objective: The purpose of this study is to determine an acceptable weight gain in obese
primigravidas (BMI≥30 kg/m2), and to identify what if any increased morbidity is associated
with excessive weight gain in the obese and morbidly obese gravida.
Study Design: A retrospective review was performed assessing all obese primigravidas
delivering at ≥37 weeks gestation, between August 2002 & August 2007, at the University of
Illinois Hospital. Subjects must have had documented obesity (BMI ≥30 kg/m2) prior to
pregnancy as noted in their initial visit. Subjects’ weight at delivery must also have been
documented. Subjects with specific pre-existing medical conditions, including hypertension,
diabetes, GI disorders, or GI surgery were excluded from the study. All cases were assessed
for occurrence/ incidence of gestational diabetes, pregnancy induced hypertension,
preeclampsia, operative vaginal delivery, shoulder dystocia, cesarean section, wound
infection, birth weight, and neonatal APGAR scores. The rates of these pregnancy
complications were compared between obese women who gained more than 15 lbs during
their pregnancy and those who gained less than 15 lbs during their pregnancy. Univariate,
bivariate and multivariate analyses of data were performed. P value ≤0.05 was considered
statistically significant.
Results: A total of 867 obese patients were assessed. Of these, 641 (73.9%) gained >15
lbs, compared to 163 (18.8%) who gained 0-14 lbs. Sixty three (7.3%) lost weight during their
pregnancy. Demographic data showed no differences. Patients who had gained >15 lbs did
have a higher incidence of PIH, preeclampsia, and GBBS positive lab which was statistically
significant when compared to patients that had gained between 0-14lbs or had lost weight.
There were no statistically significant differences between the two groups in their incidence
of operative delivery, cesarean section, shoulder dystocia, endometritis, IUGR, or gestational
diabetes.
Conclusion: Obese primigravidas who gain more than 15 lbs during their pregnancy have a
higher incidence of PIH, preeclampsia, & GBBS positive lab than patients who gain less than
15 lbs or lose weight.
Biologic vs. Synthetic Graft Augmentation in Pelvic Reconstructive Surgery
Khyaati Modii, MD
Objective: To assess the success of and complications associated with the use of biologic
versus synthetic grafts for corrective surgery in patients with pelvic organ prolapse.
Methods: All patients undergoing pelvic reconstructive surgery including vault suspension,
cystocele or rectocele repair with xenograft or mesh augmentation from January 2005 to May
2008 by one Urogynecology practice were assessed. Data was collected and compared on
indication for surgery, type of surgery performed, type of graft used, surgery outcome and
complications. Success was identified in those patients who reported a subjective
improvement in their presenting symptoms and who did not require reoperation for
recurrence or mesh related complications. Complications assessed included intra-operative
injury related to mesh placement as well as post-operative complaints/ symptomatology or
evidence of graft failure. Data was analyzed using the Pearson Chi-square analysis and the
student t-test where applicable. This study was IRB approved.
Results: Over this 3-year period 174 women underwent corrective surgery for pelvic organ
prolapse. There was no difference in demographics between those receiving biologic versus
synthetic grafts, with a mean age of 56.7 years in those receiving biologic grafts and
62.3years in those receiving a synthetic graft. Indication for corrective surgery was also not
different between the 2 groups, and included prolapse, urinary symptoms, pain, and
dyspareunia. In total, 66 (37.9%) biologic grafts were placed, while 106 (60.9%) synthetic
meshes were used. Vaginal reconstructive surgery using biologic graft had a success rate of
95.5%, compared to repair utilizing synthetic mesh, which had a success rate of 87.7%
(p=0.09). Bladder injury was the only intra-operative complications documented (2.4%) and
was not significantly different between the two groups, (p= 0.575). Postoperative
complication types were similar between the two groups and included persistent pain 19.8%,
recurrent prolapse 8.7%, wound infection 5.2%, dyspareunia 2.3%, and fistula formation
0.6%. A vaginal erosion rate of 11% was also noted among graft recipients as a whole. The
rate of vaginal erosion was significantly different between the two groups. Those receiving a
biological graft had a significantly lower incidence of erosion when compared to those
receiving the synthetic mesh (1.5% versus 17%; p = 0.002 ). Similarly, 11% of patients
required graft excision, with 95% of these being in those with synthetic grafts.
Conclusion: Biological and synthetic grafts have similar success rates in patients requiring
corrective surgery for pelvic organ prolapse, however use of synthetic mesh was associated
with a significantly higher rate of erosion and need for excision. A prospective analysis
randomizing patients to native tissue repair, augmentation with xenograft, or augmentation
with synthetic mesh to compare long-term success rates, complications, and re-operation
rates is warranted.
Analysis of Risk Factors for Ulcer Formation in Postmenopausal Pessary Users.
My-Le To, DO
Objective: To determine if bacterial vaginosis (BV) predisposes to development of vaginal
ulcers in postmenopausal women who use a pessary to treat pelvic organ prolapse; and,
whether treatment with low-dose vaginal estrogen cream (Estrace) or treatment with a
vaginal antibiotic gel (Metrogel) is more effective in helping the ulcer heal.
Methods: This is a prospective randomized trial of 115 women who were seen every 3
months and a swab of vaginal secretions was analyzed for BV. If an ulcer developed, then
the patient was randomized to either Estrace or Metrogel.
Results: We determined that 100 patients were required to provide 80% power to detect
differences at 0.05 level assuming clinical significance at 10% difference in ulceration rate.
Thirty five patients (29.6 %) were diagnosed with at least one or more ulcers. Atrophy was
observed in 40 of the 52 (76.9 %) times when an ulcer was present. Ten patients with ulcers,
while 8 patients without ulcers, opted for surgery. All of the tests for BV were negative.
Using chi-square, there was significant association between incidence of ulceration and type
of pessary used (p= 0.032), and between ulcer size and type of pessary worn ANOVA (p=
0.031). There was no significant difference between time to ulcer resolution in women
treated with Estrace vs. Metrogel (p> 0.05). When comparing gellhorn and gehrung
pessaries with ulcer formation there was significance in the size of ulcer area (p=0.032).
Conclusion: BV is not associated with the development of vaginal ulcers; instead, the ulcers
may be due to the effect of pressure caused by a foreign object in the vagina.
Uterine Ruptures Associated with Previous Cesarean Section
Stephanie Wong, MD
OBJECTIVES: 1. To characterize VTOL risk factors in patients with uterine ruptures
associated with previous cesarean section at UICMC. 2. To characterize the risk factors of
the general VTOL population at UICMC. 3. To investigate whether, as a QA committee
recommendation, VTOLs should be discouraged in patients with risk factors and to propose
guidelines to use to counsel patient regarding their risks
METHODS: We conducted a retrospective cohort study from March, 2002 and September,
2007 at University of Illinois at Chicago Medical Center. This study included all uterine
ruptures associated with a previous cesarean section. Patients were identified using the
MARS database and then referred the Quality Improvement Committee. A control group of
patients attempting VTOL was then made by matching 2 VTOLs per 1 uterine rupture based
on date of delivery. Chart review was then performed assessing established risk factors for
both VTOL failure and uterine rupture. These factors were then compared between the two
groups.
RESULTS: Essentially all patients that VTOL at UICMC have at least 1 risk factor. There
were no statistically significant differences in risk factors, individually or as a sum, between
the two groups. A trend was noted indicating association between uterine rupture and >1
uterine scar, >BMI, and reoccurring indication for C/S, individually. There was no obvious cut
off for the total number of risk factors that seemed to be more associated with uterine
rupture.
CONCLUSIONS: UICMC has a high risk population; almost all patient attempting VTOL
have at least 1 risk factor. Uterine ruptures could be eliminated if we refused VTOL to
patients with multiple risk factors, but it would significantly decrease our VTOL and VBAC
rate. The most significant risk factor for uterine rupture at UICMC is >1 CS.
Class of 2008
1. Resident:
Research Advisor:
Title:
Marie Cabiya, MD
Allison Cowett, MD, MPH
IUD Knowledge, Attitudes, and Experience Among
Senior Obstetrics and Gynecology Residents
2. Resident:
Research Advisor:
Title:
Julie Chor, MD
Allison Cowett, MD, MPH
Administration of Ibuprofen for Pain Relief at the time
of IUD Insertion: A randomized Controlled Trial
3. Resident:
Research Advisor:
Title:
Priya Koduri, MD
Isabelle Wilkins, MD
Association Between Prenatal Care and Eclampsia
Outcomes in an Urban Indian Setting
4. Resident:
Research Advisor:
Title:
Kathleen Slugocki, DO
Judith Hibbard, MD
Depression During Pregnancy and Compliance with
the Six week Postpartum Visit
5. Resident:
Research Advisor:
Title:
Karishma Rai, MD
Isabelle Wilkins, MD
Post Caesarian Endometritis Surgical Site Wound
Infection
6. Resident:
Research Advisor:
Title:
Joshua Yune, MD
Denise Elser, MD
Essure Hysteroscopic Sterilization: Outcomes in One
Community Hospital
7. Resident:
Research Advisor:
Title:
Nausheen Zaidi, MD
Tarun Jain, MD
Moderate Conscious Sedation for In Vitro Fertilization
(IVF) Oocyte Retrieval Procedures
IUD Knowledge, Attitudes, and Experience Among Senior Obstetrics and Gynecology
Residents.
Marie Cabiya, MD
Background: Despite evidence that the intrauterine device (IUD) is a safe and effective
method of contraception, the IUD remains largely underutilized in the Unites States in
comparison to other nations. Prior studies have shown that physicians’ knowledge and
attitudes regarding the IUD affect the willingness to prescribe it to patients.
Objective: To describe senior Obstetrics and Gynecology residents’ knowledge, experience
and attitudes regarding IUD provision. To assess if knowledge, experience and attitudes
correlate with plans for IUD provision following residency.
Study Design: Nationwide electronic self-administered survey.
Methods: Participation in the survey was requested through an email sent to all Obstetrics
and Gynecology residency program directors to be forwarded to all third and fourth year
residents. The anonymous electronic survey contained a total of 23 questions regarding
demographics, knowledge of factual information pertaining to IUD provision, experience with
IUD insertion, attitudes towards IUD use and plans for provision in future practice. 72
respondents were required to detect a 20% difference in planned IUD provision in future
practice between residents with high versus low IUD knowledge scores (alpha 0.05 and
power 80%). T test and chi square test will be used to compare continuous variables and
categorical variables, respectively. Individual variables found to be significant in unilateral
analysis will be evaluated using logistic regression.
Results: A total of 195 residents responded. Third and fourth year residents responded in
equal numbers (49.7% and 50.3% respectively) and the majority of respondents were female
(83.1%). The majority of respondents train at university (76.8%) versus community affiliated
(20.6%) programs. Twenty percent of respondents reported training in a program with a
Family Planning Fellowship. Sixty percent of respondents answered at least seven of eight
knowledge questions correctly. Residents’ reported varied experience with IUD insertion
during residency: no insertions, 2.6%; 1-20 insertions, 44.6%; 21-50 insertions, 40.5%; 51100 insertions, 10.3%. 87.2% of residents described feeling very confident to insert an IUD
without supervision. Greater than 95% exhibited a positive attitude towards IUD provision
while 10% expressed concern that prescribing the IUD may lead to legal action against them.
96.4% of respondents reported planning to prescribe and insert IUDs following residency.
Conclusions: While insertion experience among the survey respondents was varied,
residents demonstrated an overall proficiency in factual knowledge of the IUD as a highly
effective and safe form of contraception. Respondents demonstrated a positive attitude
towards the IUD, and the intention to prescribe and insert in future practice was strong.
Further analysis will evaluate the relationship between demographic factors and IUD
experience, attitudes, knowledge base.
Administration of Ibuprofen for Pain Relief at the Time of IUD Insertion: A Randomized
Controlled Trial.
Julie Chor, MD
Objective: To determine if the administration of Ibuprofen 30-60 minutes prior to insertion of
the Mirena IUD reduces the pain at the time of IUD insertion.
Study Design: Randomized double-blinded controlled trial.
Methods: Women opting to the Mirena IUD for contraception were randomized to receive
either Ibuprofen 800mg versus placebo 30-60 minutes prior to Mirena IUD insertion. Subjects
were excluded if they had a history of GI bleed or gastric ulcer, bleeding disorder, NSAID
allergy, or renal failure. Participants completed investigator administered face to face preinsertion surveys regarding their reproductive history and anticipated pain with IUD insertion.
Participants were asked to score their level of pain immediately after IUD insertion using a 10
cm visual analog scale. They were contacted via phone within one week following the IUD
insertion to complete a post-insertion survey.
Results: 15 women have been enrolled to date with a mean age of 26.9 years. 12 of 15
subjects reported a history of dysmenorrhea. Subjects rated the pain at the time of IUD
insertion [mean (range) 1.3 (0-6.5)] as less than both anticipated pain before IUD insertion
[mean (range) 4.9 (0.6-9.9)] and recollected pain several days after IUD insertion [mean
(range) 3.4 (0 -10)]. Additionally, subjects rated the pain tenaculum placement [mean (range)
3.9 (0.1-9.2)] as greater than the pain from IUD insertion [mean (range) 1.3 (0-6.5)].
Conclusion: Women’s pain at the time of IUD insertion is less than the pain anticipated prior
to IUD insertion. Conveying the low degree of pain from IUD insertion may help make the
IUD a more appealing method of contraception for American women.
Association Between Prenatal Care and Eclampsia Outcomes in an Urban Indian
Setting
Priya Koduri, MD
INTRODUCTION: Recognition of symptoms of impending eclampsia may lead to patients
seeking earlier medical intervention which may improve pregnancy outcomes. The objective
of this study was to examine the association between prenatal care and eclampsia outcomes
in an urban Indian setting.
METHODS: This was a retrospective chart review of eclamptic patients at two Indian
hospitals. Charts were reviewed for demographical data, prenatal care, symptoms such as
headache,visual disturbances or epigastric pain, number of seizures, time from first seizure
to admission, and hospital course. Neonatal outcomes included birthweight, NICU
admission, and survival. Univariate and bivariate analysis were performed.
RESULTS: Sixty charts were reviewed. 22% of patients were second trimester; 79% reported
at least one symptom and 18% reported >3 symptoms. Patients had an average of 2.9
seizures and 64% were unconsciousness upon presentation. 38% of fetuses had a neonatal
or intrauterine death (IUFD) and 56 % were admitted to the NICU. Mean birthweight was
1724 gms.
52% had 3 prenatal visits; compared to those with <3 visits, they had fewer pre-admission
seizures (2.4 vs 3.5, p<0.03), were less likely to present unconscious (48% vs 80%, p<0.01)
and have an NICU admission ( 50% vs 62%, NS) but more likely to have an IUFD (42% vs
30%, p=NS). There were no differences in seizures to admit times, infant birthweight and
number of symptoms patients experienced.
CONCLUSIONS: Patients with <3 prenatal visits were more likely to present unconscious;
although they had poorer neonatal outcomes these differences were not statistically
significant. Prenatal care alone may not improve maternal and neonatal outcome; additional
avenues of intervention need to be explored.
Depression During Pregnancy and Compliance with the Six week Postpartum Visit
Kathleen Slugocki, DO
Objective: To determine if there is an association between antenatal depression and
failure to attend the 6 week postpartum visit at the outpatient clinics at UIC. Secondly, to
identify the medical, social and economic risk factors for depression and postpartum
compliance.
Study Design: Patients where enrolled prospectively at prenatal visits at UIC clinics
between gestational weeks 24 and 36. Patients were eligible if >18yr, were not being
treated for depression in the current pregnancy and had no major fetal anomalies.
Patients were given a PHQ9 and demographic risk factor survey, then were followed
postpartum and charts reviewed for risk factors for depression and poor compliance.
Poor Compliance was defined as failure to present for post partum visit 6-8 weeks after
delivery. Patient groups were defined by PHQ9 score of ≥ 5 as at risk for depression,
and ≤ 4 as not at risk. A power analysis was performed with alpha of 0.05, with 80%
power; 310 patients were needed to detect a 20% decrease in compliance. Chi square
analysis was used to calculate p-value.
Results: 271 patients where enrolled into the study. Group A with PHQ9 ≥ 5 had 104
patients with 62 compliant and 42 noncompliant. Group B with PHQ9 ≤ 4 had 167
patients with 97 compliant and 70 noncompliant. The analysis comparing postpartum
compliance of patients with elevated PHQ9 scores > 5 did not show a statistical
difference. There was no association between other known risk factors such as
substance abuse and co-morbid conditions with poor patient compliance with post
partum visits.
Conclusions: Although UIC Women’s health clinics have overall poor compliance with
postpartum visits, approximately 50%, patients at increased risk for depression did not
show a statistically different rate of compliance. This may reflect the fact that all at risk
patients were referred for intervention, and excellent care is provided to patients with
high risk conditions. Many patients declined referrals to psychiatry secondary to
associating their symptoms with pregnancy. The second consideration is that a PHQ9 >
5 may not be diagnostic for depression in pregnancy. In the future having a larger
sample size might allow for stratifying for PHQ-9 score by severity.
Post Caesarian Endometritis Surgical Site Wound Infection
Karishma Rai, MD
Objective: To identify specific risk factors at the University of Illinois at Chicago labor and
delivery unit for post caesarian section endometritis and surgical site wound infection.
Study Design: A retrospective observational review was performed accessing all women
delivering by caesarian section between April 2004 to July 2006 at UIC. Medical records
were reviewed to identify those reported to have a postoperative complication of endometritis
or surgical site infection. Specific factors associated with these infections were assessed.
Results: Of the 164 patients with infection, the mean age was 27, mean gestational age
was 37 weeks and 40% underwent a caesarian section for a non-reassuring fetal
assessment. Of the population studied, 70% had a BMI greater than 25. 63% of the patients
demonstrated a fever (T>100.4) 43% had internal uterine monitoring. One third of the
population had significant co-morbid conditions (CHTN, DM, ect). 13% had notable
prolonged rupture of membranes and 11% underwent emergent caesarian sections. 10%
were diagnosed with chorioamnionitis. 9% of the patients had multiples sterile vaginal
exams (>8) during labor. The 164 patients were further divided into 3 divisions:
endometritis (n=92), surgical site wound infection (n=72) and chorioamnionitis (n=16) with
BMI’s of 63%, 58%, and 88%. In the endometritis group, 12% had prolonged labor, 17%
prolonged rupture of membranes, 48% with intrauterine monitoring, and 8.6% had more than
8 sterile vaginal exams in labor. The surgical site wound infection group had similar
findings: 14% had prolonged labor, 20% prolonged rupture of membranes, 38% with
intrauterine monitoring, and 9.7% had more than 8 sterile vaginal exams in labor. In the
chorioamnionitis group, 25% had prolonged labor, 38% had prolonged rupture of
membranes, 69% had intrauterine monitoring and 6% had more than 8 sterile vaginal exams.
Conclusion: This retrospective observational review illustrates that patients with BMI>25%,
prolonged rupture of membranes, and concurrent co morbid conditions appear to be at
higher risk for post caesarian endometritis and surgical site wound infection. Multiple
approaches need to be taken to minimize risk factors associated with endometritis and
surgical site infections as well as early, aggressive intervention in order to decrease the
incidence and subsequent morbidity to patients.
Evaluation of Essure Hysteroscopic Sterilization Outcomes in One Community
Hospital
Joshua Yune, MD
Study Objectives: To investigate the efficacy of Essure hysteroscopic tubal occlusion in
clinical practice at one community hospital with regard to successful placement on the 1st
attempt, the compliance rate for hysterosalpingogram (HSG) and the rate of successful tubal
occlusion at 3-months post-procedure confirmed by HSG.
Design: Retrospective chart review and surgeon survey of ESSURE cases from Feb 2004 to
Jan 2006.
Setting: One community hospital and its affiliated ambulatory surgicenter in Midwest.
Patients: Two hundred seven patients from the top 9 (high volume) surgeons. Interventions:
Essure (Conceptus Inc., Mountain View, CA) hysteroscopic sterilization.
Measurements and Main Results: From the total of 207 cases, 191 (92.2%) were
successfully placed bilaterally on the attempt. Of these 191 patients, 171 had a follow-up
HSG (89.5%) and the remainder were lost to follow-up. At 3 months post-procedure, 160 of
these 171 patients (93.5%) demonstrated successful occlusion of both fallopian tubes by
HSG. Reasons for failed placement included poor visualization(11/16) and/or occlusion of
tubal ostia. The remaining causes were uterine perforation (n=4) and uterine anomaly (n=1).
Of the 11 cases in which there was successful device placement but with at least one patent
tube seen at the 3 month HSG, 3 demonstrated dislocation of the Essure device.
Conclusions: The rate of successful placement of the Essure device on the first attempt at
this community hospital was 92% which is slightly better than demonstrated in a prior study.
Almost 95% with successful placement had documented tubal occlusion at 3 months.
However, a sizable number of patients did not return for the follow-up HSG, as required in the
US. Including the patients who did not comply with HSG, 77.2% of the total Essure
placements in this cohort demonstrated successful placement by HSG at 3 months postprocedure.
Moderate Conscious Sedation for In Vitro Fertilization (IVF) Oocyte Retrieval
Procedures
Nausheen Zaidi, MD
OBJECTIVE: To determine whether intravenous conscious sedation (using a
benzodiazepine and opioid) provides adequate pain control during transvaginal ultrasoundguided oocyte retrieval, and if there is a difference in patient satisfaction using the opioids
Fentanyl (Sublimase) or Meperidine (Demerol).
DESIGN: Self-administered survey of patients undergoing IVF oocyte retrieval.
MATERIALS & METHODS: A post-oocyte retrieval questionnaire was administered to 461
consecutive patients undergoing IVF from 2001-03 at the University of Illinois Medical
Center. The one-page questionnaire was administered by a medical assistant, void of any
patient identifiers, and completed by patients prior to going home after the oocyte retrieval.
The questionnaire addressed procedural pain management, post-procedure recovery
satisfaction, and overall assessment. A 4-point rating scale was used (excellent, good, fair,
and poor). From 2001-02, Midazolam (Versed) 1-3 mg and either Fentanyl 75-250 mcg or
Meperidine 75-175 mg were administered (intravenously) to 203 patients. In 2003, one
physician administered Midazolam and Fentanyl to 71 patients (Group-A) and another
physician administered Midazolam and Meperidine to 38 patients (Group-B). The same
technique/protocol, support staff, and patient survey were used. Chi-square test was used to
compare results between Groups A and B.
RESULTS: Of the 312 patients evaluated, 91.5% rated ‘excellent’ (65%) or ‘good’ (27%)
pain prevention from the medication provided, and 91.4% rated ‘excellent’ (74 %) or ‘good’
(18%) expectation of pain relief. Furthermore, 97.5% rated ‘excellent’ (80%) or ‘good’ (17%)
recovery from the sedation, and 98.5% rated the overall experience of conscious sedation as
‘excellent’ (81%) or ‘good’ (17%). Less than 3% of patients gave a ‘poor’ rating for any
category. There was no statistically significant difference between Groups A and B for all of
the questionnaire responses.
CONCLUSIONS: Moderate conscious sedation provides adequate pain control during IVF
oocyte retrieval procedures. When considering different opioids, no significant differences in
pain relief were found between Fentanyl and Meperidine.