Dr. Shaw specializes in general gynecology, family planning, contraception and early pregnancy management. She is involved with medical education and serves as the Residency Program Director and Associate Chair of Education for Obstetrics and Gynecology. Her clinical research is aimed at improving patient experiences and access to comprehensive reproductive health care. Dr. Shaw is an advocate for her patients and women's health both locally and abroad and partners with each patient to best provide the individualized care that suits their life and goals.
- Family Planning
- Obstetrics and Gynecology
- Global Health
Clinical Associate Professor, Obstetrics & Gynecology
Associate Chair of Education, Stanford University, Department of Obstetrics and Gynecology (2019 - Present)
Residency Program Director, Stanford University, Department of Obstetrics and Gynecology (2016 - Present)
Associate Director Division of Family Planning Services and Research, Stanford University Department of Obstetrics and Gynecology (2013 - Present)
Director for Ambulatory Care for Gynecology, Stanford Blake Wilbur Clinics (2015 - 2017)
Associate Residency Director, Stanford Department of Obstetrics and Gynecology (2013 - 2016)
Assistant Director for Ambulatory Care for Gynecology, Stanford Blake Wilbur Clinic (2013 - 2015)
Honors & Awards
Outstanding Stanford Faculty Professor in Ob|Gyn, Stanford University, Department of Ob/Gyn (2018)
Outstanding Faculty Professor in Gynecology, Stanford University Department of Ob/Gyn (2015)
Excellence in Teaching by a Clinical Fellow, Awarded by OB/GYN Residents (2013)
Intern Teaching Award, Second year resident elected by intern class for excellence in teaching (2009)
Boards, Advisory Committees, Professional Organizations
Member, Fellowship in Family Planning Advisory Board (2018 - Present)
Full Fellow, Society of Family Planning (2016 - Present)
Fellow, American College of Obstetrics and Gynecology (2015 - Present)
Member, Arthur Gold Humanism Honor Society (2007)
Member, Alpha Omega Alpha Honor Medical Society (2006)
Board Certification: Obstetrics and Gynecology, American Board of Obstetrics and Gynecology (2015)
Fellowship:Stanford School of Medicine (2013) CA
MS, Stanford School of Medicine, Epidemiology and Clinical Research (2013)
Residency:Oregon Health Science University (2011) OR
Medical Education:Albany Medical Center (2007) NY
Community and International Work
Contraception and Safe Abortion
Opportunities for Student Involvement
Current Research and Scholarly Interests
My research interests include expanding access to and and improving patient experience with contraception and abortion care both domestically and globally. I am also interested in medical education and resilience among physicians and trainees.
Labor and Delivery Implant Insertion: A Randomized Controlled Trial
A barrier to initiating progestin contraceptives in the early postpartum period is the concern of interference with breastfeeding, specifically lactogenesis. In this trial, the investigators aim to add to safety data on the effects of immediate insertion of the contraceptive implant on breastfeeding. The investigators seek to examine the time to lactogenesis with immediate post-delivery insertion in delivery room versus insertion of a contraceptive implant in the postpartum ward prior to medical discharge. For this study, 82 consenting women will be randomized to immediate implant insertion (0-2 hours following delivery) in the delivery room or insertion of the implant following delivery in postpartum room and prior to medical discharge (24-48 hours following delivery).
Self-Administered Vaginal Lidocaine Gel for Pain Management with Intrauterine Device Insertion: A Blinded, Randomized Controlled Trial.
American journal of obstetrics and gynecology
BACKGROUND: A major barrier to intrauterine device use is fear of pain during insertion. Trials exploring analgesic interventions for intrauterine device insertion have yielded mixed results, and no standardized pain management guidelines currently exist for this procedure. In an abortion-related study, self-administered lidocaine gel over a prolonged time interval showed promise as a method of pain control.OBJECTIVE(S): To assess pain control with intrauterine device insertion after patient-administered lidocaine gel compared to placebo.STUDY DESIGN: We conducted a randomized, blinded trial of women undergoing levonorgestrel or copper intrauterine device insertion in an outpatient gynecology clinic between July 2016 and April 2017. Participants self-administered either 20 mL of 2% lidocaine gel or placebo gel vaginally at least 15-minutes prior to intrauterine device insertion. No other analgesics were administered. The primary outcome was pain during intrauterine device insertion, measured on a 100-mm visual analog scale (VAS, 0 being "no pain" and 100 being "worst pain imaginable"). Secondary outcomes included anticipated and baseline pain and pain with speculum insertion and tenaculum placement. In a post-procedure questionnaire, participants reported acceptability of vaginal gel and willingness to wait for pain control. Median values were assessed due to the non-normal distribution of visual analog scale scores using the Mann-Whitney U test. Predictors of IUD insertion pain were assessed using a multiple linear regression.RESULTS: In total, 220 women were randomized and 215 were included in analysis (108 in lidocaine gel, 107 in placebo gel groups). Median (range) time from gel administration to speculum insertion was 21 (14-74) and 20 (12-43) minutes in the lidocaine and placebo groups, respectively (p=.13). The median pain scores during intrauterine device insertion were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (p=.09). Among secondary outcome time points, only median pain scores at speculum insertion were significantly different between the lidocaine and placebo groups (7 (0-81) mm versus 11 (0-80) mm, respectively; p=.046). Anticipated pain and menstrual pain were both predictors of pain with IUD insertion. The majority of women in both groups found the amount of vaginal leakage following gel insertion to be acceptable (>80%). Ninety-two percent (n= 194) of participants stated they would be willing to wait before intrauterine device placement for a potential analgesic effect.CONCLUSION(S): Self-administered lidocaine gel at least 15-minutes before intrauterine device insertion does not appear to reduce pain compared with placebo, but may help with speculum insertion. We found that women are willing to extend visit time to gain pain control. Self-administration of local anesthetic is acceptable to patients and should be considered in future research.
View details for DOI 10.1016/j.ajog.2018.11.1085
View details for PubMedID 30444982
Advances in the management of early pregnancy loss.
Current opinion in obstetrics & gynecology
PURPOSE OF REVIEW: To describe recent advances in management of early pregnancy loss.RECENT FINDINGS: Addition of mifepristone to current protocols for medical management of miscarriage increases effectiveness of a single dose of misoprostol and significantly reduces subsequent aspiration procedures. Women with an incomplete evacuation after medical management may be treated expectantly with similar rates of complete expulsion compared with surgical management at 6 weeks. As cytogenetic analysis improves, analysis of products of conception can be performed whether collected after surgical or medical management and is an efficient strategy in starting a recurrent pregnancy loss work-up. For those seeking pregnancy after miscarriage, conception immediately following an early pregnancy loss is not associated with increased risk of subsequent miscarriage. However, recent studies suggest that the original intendedness of the pregnancy resulting in miscarriage does not predict future reproductive goals of the woman, so family planning should be discussed at the time of miscarriage.SUMMARY: Miscarriage is a common experience among reproductive-aged women and advances in medical management and modern-day aspiration techniques make the use of the sharp curette obsolete.
View details for DOI 10.1097/GCO.0000000000000501
View details for PubMedID 30299321
Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen.
Obstetrics and gynecology
2017; 129 (5): 800-809
To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake.This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression.Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, β=0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, β=0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001).Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.
View details for DOI 10.1097/AOG.0000000000001971
View details for PubMedID 28383371
Update on second-trimester surgical abortion.
Current opinion in obstetrics & gynecology
2016; 28 (6): 510-516
To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques.Confirming previous studies, a recent retrospective observational cohort study, including 54 911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol.Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.
View details for PubMedID 27684047
Self-Administered Lidocaine Gel for Pain Control With First-Trimester Surgical Abortion: A Randomized Controlled Trial.
Obstetrics and gynecology
2016; 128 (2): 297-303
To compare pain control at various time points during first-trimester surgical abortion using a patient-administered lidocaine gel compared with a traditional lidocaine paracervical block.We conducted a randomized controlled trial of women undergoing surgical abortion at less than 12 weeks of gestation in an outpatient setting. The primary outcome was pain at cervical dilation as measured on a 100-mm visual analog scale. A sample size of 142 participants was planned to detect a 15-mm or greater difference on the 100-mm visual analog scale with 90% power and a significance level of .025, adding 10% for participant dropout and protocol violations. Participants received either 12 mL of a 1% lidocaine paracervical block or 20 mL of a self-administered, 2% lidocaine gel 20-30 minutes before procedure initiation. Secondary outcomes included anticipated pain, baseline pain, pain with speculum and tenaculum placement, pain after suction aspiration, and pain 30-45 minutes postoperatively.From April to October 2015, a total of 142 women were enrolled (68 in the paracervical block group, 69 in the gel group, and five not analyzed as a result of participant withdrawal). Sociodemographic characteristics were similar between groups. The mean pain score with cervical dilation was 60 mm (95% confidence interval [CI] 54-66) in the paracervical block group and 64 mm (95% CI 59-69) in the gel group (P=.3). There was no significant difference between mean pain scores at any time points measured.Self-administration of lidocaine gel before first-trimester surgical abortion is noninferior to a traditional paracervical lidocaine block and should be considered as an alternative, noninvasive approach to pain control for first-trimester surgical abortion.ClinicalTrials.gov, https://clinicaltrials.gov, NCT02447029.
View details for DOI 10.1097/AOG.0000000000001532
View details for PubMedID 27400015
Assessment of a simplified insertion technique for intrauterine devices
INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS
2016; 134 (1): 29-32
To explore a simplified technique for intrauterine device (IUD) insertion.The present prospective longitudinal study enrolled patients aged at least 18years presenting at the gynecology clinic of Stanford University for IUD insertion between June 1, 2013 and June 30, 2014. No pelvic examination or uterine sounding was performed prior to IUD insertion. Transvaginal ultrasonography was performed immediately after insertion and at 4-6weeks to confirm device placement. The primary outcome was successful IUD placement.The study enrolled 50 patients. IUD insertion was completed successfully without any cervical manipulation in 40 (80%) participants. Sounding was not needed for any procedures. A cervical dilator was required to locate the internal os for 10 (20%) patients. The mean distance between IUDs and the endometrial verge immediately following insertion was 2.9mm. IUD insertion was rated "difficult" by the physician performing the procedure in 3 (6%) patients. No perforations were recorded. IUD expulsion occurred in 3 (6%) patients; menorrhagia was the indication for IUD insertion in two of these patients.IUD insertion without prior pelvic examination and sounding was feasible; this technique could reduce the need for instrument use during insertion and, consequently, the pain associated with insertion.
View details for DOI 10.1016/j.ijgo.2015.12.004
View details for Web of Science ID 000379558200007
View details for PubMedID 27113419
Immediate postpartum provision of long-acting reversible contraception.
Current opinion in obstetrics & gynecology
2015; 27 (6): 460-464
The objective of this review is to describe current literature regarding the role and characteristics of long-acting reversible contraception (LARC) used immediately postpartum.Copper and levonorgestrel intrauterine devices (IUDs) inserted immediately postpartum at the time of both vaginal and cesarean deliveries are associated with higher rates of continuation at 6-12 months when compared with IUDs placed at the postpartum visit (4-8 weeks after delivery), despite higher rates of expulsion. IUDs and contraceptive implants are cost-effective when used immediately postpartum, and they are associated with longer interpregnancy intervals. There is limited evidence regarding the effects of immediate postpartum LARC on breastfeeding.Use of LARC methods in the immediate postpartum period is both effective and safe, and could reduce unmet need for contraception during this time. More research is needed to explore various immediate postpartum IUD insertion methods and the effects of immediate postpartum progestin-containing LARC on breastfeeding.
View details for DOI 10.1097/GCO.0000000000000224
View details for PubMedID 26536209
Update on long-acting reversible methods.
Current opinion in obstetrics & gynecology
2015; 27 (6): 471-475
The last several years have seen a number of important clinical and academic advances in long-acting reversible contraceptive (LARC) methods, such that many professional medical organizations now recommend these methods as first-line contraception for all women.Recent data support the use of LARC in a variety of special circumstances including adolescents, nulliparous women and immediately postpartum and postabortion. Evidence also shows that traditional methods of pain control with intrauterine device (IUD) insertion and cervical preparation prior to insertion may not be warranted. Further, the extended use of IUDs is safer and more effective than previously realized.The rising uptake of LARC methods in the United States has the potential to dramatically decrease undesired pregnancies and abortion rates, and should be considered an effective option in the majority of women.
View details for DOI 10.1097/GCO.0000000000000227
View details for PubMedID 26536210
Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial
2015; 91 (4): 313-319
The objective was to investigate mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19weeks of gestation, with the aim of improving procedure access, convenience and comfort.This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7weeks of gestation randomized to receive either one set of osmotic dilators plus mifepristone the day prior to procedure (mifepristone group) or two sets of osmotic dilators (placed 18-24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects.Mean gestational age was similar between groups (20weeks); more nulliparous subjects were randomized to the mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means -56s, with confidence interval (95% CI -4:09 to +2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was >3cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a "better than expected" experience.Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety.Use of mifepristone for cervical preparation before surgical abortion after 19weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.
View details for DOI 10.1016/j.contraception.2014.11.014
View details for PubMedID 25499589
- In reply. Obstetrics and gynecology 2015; 125 (4): 989-?
Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth
OBSTETRICS AND GYNECOLOGY
2014; 124 (6): 1111-1119
To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.
View details for DOI 10.1097/AOG.0000000000000542
View details for Web of Science ID 000345341100008
- Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations World Health Organization. 2014
Effect of a combined estrogen and progesterone oral contraceptive on circulating adipocytokines adiponectin, resistin and DLK-1 in normal and obese female rhesus monkeys.
2013; 88 (1): 177-182
BACKGROUND: Hormonal contraception is the most common medication used by reproductive aged women but there is little understanding of the impact of hormonal contraception on obesity and metabolism. Adipokine levels (adiponectin, resistin) and markers of adipocyte development (DLK-1) are altered in obese animals and humans and are associated with increased cardiovascular risk. We sought to determine the effect of combined hormonal oral contraceptive pills (COCs) on circulating adiponectin, resistin and DLK-1 levels in obese and normal-weight rhesus macaque monkeys. METHODS: Serum adiponectin, resistin and DLK-1 levels in reproductive-age female rhesus macaques of normal (n = 5, mean = 5.76 kg) and inherently obese (n = 5, mean = 8.11 kg) weight were determined before, during and 2 months after cessation of 8 months of continuous treatment with COCs. RESULTS: The obese group alone showed a significant decrease (p<.01) in weight with COC use, which returned to baseline after COC cessation. Baseline adiponectin levels prior to COC treatment were lower in the obese group (p<.05). Adiponectin levels increased from baseline in both groups, but more so in the obese group (p<.05). Resistin levels were similar at baseline, with an increase in both groups following treatment. Circulating resistin remained elevated above baseline levels after COC cessation, particularly in the obese group (p<.05). While DLK-1 levels did not change significantly in either group, a trend for higher levels in obese animals was observed. CONCLUSIONS: COC use may alter metabolic processes via direct (resistin) or indirect (adiponectin) means, while unchanging DLK1 levels suggest they do not affect adipocyte development. COCs may directly increase resistin levels, as observed in both groups. As adiponectin is inversely related to adipocyte mass, increased levels in the obese group are likely attributed to weight loss.
View details for DOI 10.1016/j.contraception.2012.10.029
View details for PubMedID 23218850
Mifepristone-Misoprostol Dosing Interval and Effect on Induction Abortion Times A Systematic Review
OBSTETRICS AND GYNECOLOGY
2013; 121 (6): 1335-1347
To examine the effect of the interval between mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13-24 weeks).We searched MEDLINE (1966-2012), ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, and mifepristone and reviewed reference lists of published reports.Our search revealed 138 articles of which 29 met inclusion criteria: 20 randomized controlled trials and nine observational studies. Studies were included if, in any study arm, mifepristone and misoprostol were used for medical abortion in the second trimester.Two authors independently reviewed the articles and abstracted the data using standardized data abstraction templates to summarize data. Discrepancies were resolved by consensus. Three studies directly compared a 1-day to 2-day mifepristone-misoprostol interval; they showed small differences in median induction times (weighted average 7.3 hours, range 7-8.5 for a 1-day interval; weighted average 6.8 hours, range 6.3-7.2 for a 2-day interval) and no significant difference in percent expelled by 12 hours or 24 hours. When all randomized studies using mifepristone and misoprostol were pooled by comparable mifepristone-misoprostol interval and misoprostol dose, induction times (first misoprostol dose to expulsion) were only 1-2 hours longer for a 12- to 24-hour interval compared with a 36-48-hour interval, whereas total abortion times (mifepristone to expulsion) were at least 18 hours longer in the 36- to 48-hour group. Induction times varied by misoprostol dosing, with 400-microgram misoprostol protocols resulting in shorter induction times than 200-microgram protocols.Shortening the mifepristone-misoprostol interval, thereby reducing total abortion time, does not compromise the safety or efficacy of second-trimester medication abortion and may be used to accommodate patient or health care provider preference.
View details for DOI 10.1097/AOG.0b013e3182932f37
View details for Web of Science ID 000319436100028
Obesity and oral contraceptives: A clinician's guide
BEST PRACTICE & RESEARCH CLINICAL ENDOCRINOLOGY & METABOLISM
2013; 27 (1): 55-65
Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.
View details for DOI 10.1016/j.beem.2012.09.001
View details for Web of Science ID 000315003700007
View details for PubMedID 23384746
- The Unmet Need for Family Planning Around the Globe for Women's Health: A Practical Guide for the Health Care Provider Springer. 2013; 2013th
Obesity Epidemic: How to Make a Difference in a Busy OB/GYN Practice
OBSTETRICAL & GYNECOLOGICAL SURVEY
2012; 67 (6): 365-373
At just one-third of the American population, those with a normal body mass index are now in the minority in the United States, whereas 68% are overweight or obese. The key to reducing the prevalence of obesity and improving the health of our population is, of course, screening and prevention. Screening (as simple as a weight and height) is effective, inexpensive, and already part of the routine vital signs taken at every visit. However, providers often avoid tackling the issue of weight due to a misperception that treatment is not effective, or from fear of causing offense or compromising rapport. However, clearly more harm is done by not discussing this important health issue. Cardiovascular disease remains the number 1 killer of women, and obesity is the leading modifiable risk factor. Beyond heart disease, obesity has implications for every visit type seen in the OB/GYN office, from contraception to pregnancy to abnormal bleeding to cancer. In addition, maternal obesity adversely affects future generations, making the impact of obesity a never-ending cycle. OB/GYNs are often the only physicians that reproductive-aged women see, and, thus, OB/GYNs have the opportunity to provide a potentially life-altering intervention. Effective treatment is available and includes lifestyle changes, behavioral counseling, medication, and bariatric surgery. Time is always a limitation in a busy practice but becoming more comfortable with how to approach patients, the language to use and tailoring counseling can save time increase impact.
View details for DOI 10.1097/OGX.0b013e318259ee6a
View details for Web of Science ID 000306740700017
View details for PubMedID 22713163
Self-administered lidocaine gel for local anesthesia prior to osmotic dilator placement: a randomized trial.
OBJECTIVE(S): To compare pain scores during cervical dilator placement prior to dilation and evacuation (D&E) with patient-administered vaginal lidocaine gel versus lidocaine paracervical block (PCB).STUDY DESIGN: We conducted an unblinded randomized trial of women≥18years of age undergoing surgical abortion at≥16weeks gestation in two outpatient clinics. We randomized participants to receive self-administered lidocaine gel 2% 20mL intravaginally 15-30min before procedure initiation, or lidocaine 1% 12mL PCB immediately prior to dilator placement. Participants rated their pain at various time points using a visual analog scale (VAS), including anticipated and baseline pain, speculum insertion, tenaculum placement, cervical dilator placement (primary outcome), and speculum removal.RESULTS: We enrolled 72 women and analyzed data for 69 participants. Socio-demographic characteristics and VAS scores at all time points, except for anticipated pain, were similar between groups. The median pain score with dilator placement was 48mm in the gel group and 61mm in the PCB group (p=.23). Procedure times the gel group and PCB group were 3.7min and 5.2min, respectively (p<.01). Lidocaine gel was non-inferior to PCB for reported pain scores (VAS) with dilator placement with a difference in means of-8mm (95% CI -21,5), favoring the gel.CONCLUSIONS: Self-administration of lidocaine gel prior to placement of cervical dilators for D&E is non-inferior to paracervical lidocaine block for local anesthesia and is a potential alternative to PCB for pain management with osmotic dilator placement.IMPLICATIONS: Lidocaine gel and similar products represent non-invasive, non-painful methods of local anesthesia for a variety of outpatient gynecologic procedures. Given our non-inferiority findings, if gel anesthetics are available they should be considered as an alternative to paracervical block.
View details for DOI 10.1016/j.contraception.2018.11.013
View details for PubMedID 30500336
Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data.
Health services research
OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.
View details for DOI 10.1111/1475-6773.13041
View details for PubMedID 30198185
Deployment and Preterm Birth Among United States Army Soldiers
American Journal of Epidemiology
With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.
View details for DOI 10.1093/aje/kwy003
View details for PubMedCentralID PMC5889029
Contraceptive counseling in reproductive-aged women treated for breast cancer at a tertiary care institution: a retrospective analysis
2017; 96 (4): 248–53
The objective was to assess the frequency of documented contraceptive and fertility preservation counseling for women treated for breast cancer.We conducted a chart analysis of female breast cancer patients (n=211) ages 18-45 years receiving chemotherapy treatment at Stanford Comprehensive Cancer Center from 2010 to 2014. Primary outcomes of contraceptive counseling and fertility preservation counseling documentation were assessed for frequency. Secondary outcomes included pregnancy testing, contraception use and pregnancy during treatment.Among the total sample (n=211), sexual activity was documented in 24% of patients (n=51). Fifty-one percent (n=108) of patients received pregnancy testing prior to initiation of treatment. Past contraception use was documented in 74% of patients (n=156) and current contraception use in 25% (n=53). Twenty-six percent of patients received fertility preservation counseling alone (n=54), 10% received contraceptive counseling alone (n=22), and 12% received both types of counseling (n=25). Patients were three times more likely to receive contraceptive counseling if using contraception at diagnosis [odds ratio (OR) 3.1, confidence interval (CI) 1.1-9.1, p=.04], and older women were significantly less likely to receive counseling (OR 0.2, CI 0.1-1.0, p=.04). Two patients became pregnant and had an abortion during treatment (1%), and neither patient was using contraception nor received contraceptive or fertility preservation counseling.Documentation of fertility preservation counseling occurs more frequently than contraceptive counseling, but both occur suboptimally. Lack of documentation does not allow us to conclude that counseling did not occur, but it suggests the need to improve documentation and increase awareness of contraceptive needs and counseling.Women undergoing breast cancer treatment do not consistently receive counseling on contraception or fertility preservation as a part of their care. Efforts are needed to ensure that women treated for breast cancer routinely receive counseling about fertility preservation and contraceptive options.
View details for DOI 10.1016/j.contraception.2017.06.004
View details for Web of Science ID 000412793200006
View details for PubMedID 28645785
Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia
PAEDIATRIC AND PERINATAL EPIDEMIOLOGY
2017; 31 (3): 185-194
Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.
View details for DOI 10.1111/ppe.12349
View details for Web of Science ID 000400170000004
View details for PubMedID 28328031
Contraceptive Practices of Women With Complex Congenital Heart Disease.
American journal of cardiology
2017; 119 (6): 911-915
Understanding the contraceptive practices of women with complex congenital heart disease (CHD) and providing them individualized contraception counseling may prevent adverse events and unplanned high-risk pregnancies. Given this, we sought to examine the contraceptive practices in women with CHD, describe adverse events associated with contraceptive use, and describe the provision of contraception counseling. Women >18 years were recruited from 2011 to 2014 from 9 adult CHD (ACHD) centers throughout North America. Subjects completed a 48-item questionnaire regarding contraceptive use and perceptions of contraception counseling, and a medical record review was performed. Of 505 subjects, median age was 33 (interquartile range 26 to 44) and 81% had CHD of moderate or great complexity. The majority (86%, 435 of 505) of the cohort had used contraception. The types included barrier methods (87%), oral contraception (OC) 84%, intrauterine device (18%), Depo-Provera (15%), vaginal ring (7%), patch (6%), hormonal implant (2%), Plan B (19%), and sterilization (16%). Overall OC use was not significantly different by CHD complexity. Women with CHD of great complexity were more likely to report a thrombotic event while taking OC than those with less complex CHD (9% vs 1%, p = 0.003). Contraception counseling by the ACHD team was noted by 43% of subjects. Unplanned pregnancy was reported by 25% with no statistical difference by CHD complexity. In conclusion, contraceptive practices of women with complex CHD are highly variable, and the prevalence of blood clots while taking OC is not insignificant while provision of contraception counseling by ACHD providers appears lacking.
View details for DOI 10.1016/j.amjcard.2016.11.047
View details for PubMedID 28087052