All Publications

  • Management of blood loss in second-trimester abortion. Current opinion in obstetrics & gynecology Kaur, S., Markwei, M. T., Shaw, K. A. 2024

    Abstract

    PURPOSE OF REVIEW: While major complications in second-trimester abortion are rare, blood loss and hemorrhage are among the most common and have the potential for high morbidity. Here, we review the current literature on risk factors, prevention, and treatment of blood loss in second-trimester abortion.RECENT FINDINGS: A comprehensive approach to hemorrhage during second-trimester abortions is essential. Understanding hemorrhage risk factors, prevention strategies, and treatment options makes second-trimester abortion safer. Some pharmacologic methods may both prevent and treat excessive blood loss. Mechanical methods are primarily used for treatment. Key risk factors include prior uterine scars, gestational duration, insufficient cervical preparation, high BMI, procedural inexperience, fetal demise, and halogenated anesthetics. Developing evidence-based protocols for and further research into hemorrhage related complications are crucial for improving safety in second-trimester abortion care.SUMMARY: Prevention of hemorrhage improves outcomes. However data are limited. For treatment, this includes using pharmacological interventions and mechanical methods. Identifying high-risk patients and implementing preprocedural optimization are proactive measures that aid in decreasing the occurrence and severity of blood loss and hemorrhage.

    View details for DOI 10.1097/GCO.0000000000000991

    View details for PubMedID 39361337

  • Perioperative Supplemental Oxygen and Postoperative Nausea and Vomiting: Subanalysis of a Trial, Systematic Review, and Meta-analysis ANESTHESIOLOGY Markwei, M. T., Babatunde, I. O., Kutlu-Yalcin, E., Essber, H. A., Mascha, E. J., Liu, L., Kurz, A. M., Sessler, D. I. 2023; 138 (1): 56-70

    Abstract

    Intraoperative supplemental oxygen may reduce postoperative nausea and vomiting by mitigating hypoxic stress on the gastrointestinal tract. The authors therefore tested the hypothesis that supplemental oxygen reduces nausea and vomiting in adults recovering from colorectal surgery at the Cleveland Clinic between January 28, 2013, and March 11, 2016.Initially, the authors conducted an unplanned subanalysis of a previous trial that evaluated the effect of 80% versus 30% intraoperative inspired oxygen on surgical site infection. Specifically, they assessed the effect of 80% versus 30% oxygen concentration on the incidence of postoperative nausea and/or vomiting. Thereafter, the authors conducted a systematic review and meta-analysis of the effect of supplemental oxygen on postoperative nausea and vomiting.The authors' underlying analysis included 5,057 colorectal surgeries on 4,001 patients. For 2,554 surgeries, assignment was to 80% oxygen, and in 2,503 surgeries, to 30%. Postoperative nausea and vomiting was 852 of 2,554 (33%) in 80% oxygen and 814 of 2,503 (33%) in 30% oxygen. The estimated relative risk (95% CI) of 80% versus 30% oxygen on postoperative nausea and vomiting was 1.04 (0.96 to 1.12) in a generalized estimating equation model adjusting for within-patient correlation for patients with multiple surgeries, P = 0.355. Furthermore, supplemental oxygen did not reduce antiemetic use (P = 0.911) or the severity of nausea and vomiting (P = 0.924). The authors' meta-analysis included 10 qualifying trials (6,749 patients) and did not find a difference in postoperative nausea and vomiting: relative risk, 0.97 [95% CI, 0.86 to 1.08], P = 0.55, I2 = 52%.The incidence of postoperative nausea and vomiting did not differ in patients assigned to 80% or 30% inspired oxygen. A meta-analysis of available trials similarly indicated that supplemental intraoperative oxygen does not reduce postoperative nausea and vomiting. Therefore, supplemental oxygen should not be given in the expectation that it will reduce nausea and vomiting.

    View details for DOI 10.1097/ALN.0000000000004428

    View details for Web of Science ID 000937297500009

    View details for PubMedID 36480644

  • Tidal Volume and Positive End-expiratory Pressure and Postoperative Hypoxemia during General Anesthesia: A Single-center Multiple Crossover Factorial Cluster Trial ANESTHESIOLOGY Turan, A., Esa, W., Rivas, E., Wang, J., Bakal, O., Stamper, S., Farag, E., Maheswari, K., Mao, G., Ruetzler, K., Sessler, D., Ventilation-PEEP Trial Grp 2022; 137 (4): 406-417

    Abstract

    Intraoperative mechanical ventilation is a major component of general anesthesia. The extent to which various intraoperative tidal volumes and positive end-expiratory pressures (PEEP) effect on postoperative hypoxia and lung injury remains unclear. We hypothesized that adults having orthopedic surgery, ventilation using different tidal volumes and PEEP levels affect the oxygenation within first hour in the postoperative care unit.We conducted a two-by-two factorial crossover cluster trial at the Cleveland Clinic Main Campus. We enrolled patients having orthopedic surgery with general anesthesia who were assigned to factorial clusters with tidal volumes of 6 or 10 ml/kg of predicted body weight and to PEEP of 5 or 8 cm H2O in 1-week clusters. The primary outcome was the effect of tidal volume or PEEP on time-weighted average peripheral oxygen saturation measured by pulse oximetry divided by the fraction of inspired oxygen (Spo2/Fio2 ratio) during the initial postoperative hour.We enrolled 2,860 patients who had general anesthesia for orthopedic surgery from September 2018 through October 2020. The interaction between tidal volume and PEEP was not significant (P = 0.565). The mean ± SD time-weighted average of Spo2/Fio2 ratio was 353 ± 47 and not different in patients assigned to high and low tidal volume (estimated effect, 3.5%; 97.5% CI, -0.4% to 7.3%; P = 0.042), for those assigned to high and low PEEP (estimated effect, -0.2%; 97.5% CI, -4.0% to 3.6%; P = 0.906). We did not find significant difference in ward Spo2/Fio2 ratio, pulmonary complications, and duration of hospitalization among patients assigned to various tidal volumes and PEEP levels.Among adults having major orthopedic surgery, postoperative oxygenation is similar, with tidal volumes between 6 and 10 ml/kg and PEEP between 5 and 8 cm H2O. Our results suggest that any combination of tidal volumes between 6 and 10 ml/kg and PEEP between 5 versus 8 ml cm H2O can be used safely for orthopedic surgery.

    View details for DOI 10.1097/ALN.0000000000004342

    View details for Web of Science ID 000860826300013

    View details for PubMedID 35939350

  • Effect of intraoperative subhypnotic infusion of propofol on postoperative nausea and vomiting: A retrospective analysis JOURNAL OF CLINICAL ANESTHESIA Yalcin, E., Kim, D., Mao, G., Rivas, E., Markwei, M., Chahar, P., Keebler, A., Cywinski, J. B., Kurz, A., Turan, A. 2022; 78: 110672

    Abstract

    To measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV.Retrospective Cohort Analysis Using Propensity Score Matching.Postanesthesia care unit and inpatient unit.Patients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio.None.The primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay.A total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion.Our study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.

    View details for DOI 10.1016/j.jclinane.2022.110672

    View details for Web of Science ID 000766779200032

    View details for PubMedID 35151144

  • Preincision adjunctive prophylaxis for cesarean deliveries a systematic review and meta-analysis AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Markwei, M. T., Babatunde, I., Rathi, N., Fan, C., Prah, M., Joo, J., Hackett, L., Soper, D. E., Goje, O. 2021; 225 (4): 382-+

    Abstract

    This study aimed to systematically review the relative effectiveness of preincision cefazolin with or without adjunctive prophylaxis (macrolides or metronidazole) vs cefazolin alone in decreasing the incidence of postcesarean delivery surgical site infections.We performed a systematic search on PubMed, Ovid EMBASE, Google Scholar, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from October 25, 2020, to November 25, 2020, to identify studies comparing cefazolin with adjunctive macrolides or metronidazole with cefazolin alone. The reference lists were reviewed, and a manual search of articles published after the last database search was performed.Overall, 3 randomized controlled trials and 1 prospective observational study of reproductive-age women undergoing cesarean deliveries were included in the study. We excluded studies of women who were immunocompromised (eg, patients who were HIV positive) or women with a diagnosis of chorioamnionitis before cesarean delivery. All patients received first-line cefazolin (either cefazolin 1 g or 2 g). We compared preincision cefazolin alone with preincision cefazolin plus adjunctive therapy (500 mg, oral or intravenous formulations of azithromycin, metronidazole, or clarithromycin).A total of 6 review authors independently assessed the risk of bias for each study, using the Cochrane Risk of Bias criteria. Synthesis and further appraisal were done using the Grading of Recommendations, Assessment, Development, and Evaluation levels and the American College of Obstetricians and Gynecologists appraisal guidelines. Disagreements were resolved by discussion. Treatment effects were evaluated using meta-analysis, and pooled relative risks and 95% confidence intervals were generated using random-effects models using the Review Manager 5 software (version 5.4.1).Overall, 3 randomized controlled trials and 1 prospective observational study representing 2613 women met the criteria for inclusion. Significant reductions in surgical site infections (relative risk, 0.46; 95% confidence interval, 0.34-0.63; 3 randomized controlled trials) and the duration of hospital stay (weighted mean difference, -1.46; 95% confidence interval, -2.21 to -0.71; 2 randomized controlled trials) were observed with preincision cefazolin and adjunctive prophylaxis compared with cefazolin alone. No significant difference was observed in maternal febrile morbidity (relative risk, 0.38; 95% confidence interval, 0.11-1.25; 2 randomized controlled trials).Our findings have provided evidence for the use of preincision adjunctive extended-spectrum prophylaxis with cefazolin over cefazolin alone. However, future investigations are required to establish the relative efficacies of different adjunctive antibiotic options.

    View details for DOI 10.1016/j.ajog.2021.04.259

    View details for Web of Science ID 000720311600004

    View details for PubMedID 33964219

  • PREIMPLANTATION AND PRENATAL GENETIC TESTING UPTAKE INMOTHERS FOLLOWING ASSISTED REPRODUCTIVE TECHNOLOGY. Markwei, M., Farrell, R., Yao, M., Desai, N. ELSEVIER SCIENCE INC. 2021: E22

    View details for Web of Science ID 000699951500051

  • Risks for Recurrent Vulvovaginal Candidiasis Caused by Non-Albicans <i>Candida</i> Versus <i>Candida Albicans</i> JOURNAL OF WOMENS HEALTH Boyd Tressler, A., Markwei, M., Fortin, C., Yao, M., Procop, G. W., Soper, D. E., Goje, O. 2021; 30 (11): 1588-1596

    Abstract

    Background: Vulvovaginal candidiasis (VVC) is the second most common vulvovaginitis (VV). About 20% of women will experience recurrent infections in their lifetime with non-albicans Candida (NAC) species being one of the causative agents. Although studies have looked at risk factors for recurrent VVC they are limited in scope. In this study, we explore whether risks of recurrent VVC are increased with NAC infections compared to Candida albicans infections. Methods: Through an institutional review board-approved retrospective chart review, we identified 174 women with positive yeast cultures and followed their charts to assess recurrent visits and treatments. We also assessed several baseline variables such as race, age, body mass index (BMI), obstetric history, probiotic use, contraceptive use, mycological therapy, steroid use, hormone replacement therapy, menopausal status, and medical comorbidities. Results: Women with NAC VV were more likely to have multiple visits for recurring infections compared to women who had C. albicans VV (66% vs. 34%). The women with multiple recurrences were younger, had a lower BMI, had lower parity, and endorsed higher use of probiotics. Conclusion: Women with positive NAC cultures were more likely to have multiple visits to their physicians for VV complaints. Identifying the causative species using vaginal fungal cultures can more accurately guide therapy and lead to better outcomes for these patients.

    View details for DOI 10.1089/jwh.2020.8811

    View details for Web of Science ID 000675567100001

    View details for PubMedID 34292794

  • Critical care in obstetrics: a strategy for addressing maternal mortality AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Padilla, C., Markwei, M., Easter, S., Fox, K. A., Shamshirsaz, A. A., Foley, M. R. 2021; 224 (6): 567-573

    View details for DOI 10.1016/j.ajog.2020.12.1208

    View details for Web of Science ID 000744167100002

  • Impact of the COVID-19 Pandemic and Obstetrician and Gynecologist Workforce Distribution on Vaccine Deployment and Predicting Women's Healthcare Shortages CUREUS JOURNAL OF MEDICAL SCIENCE Shastri, T., Rasendran, C., Markwei, M., Hur, C., Goje, O. 2021; 13 (4): e14545

    Abstract

    Background Obstetricians and gynecologists, who serve a vital role in providing women's healthcare in the United States, are at risk of COVID-19 exposure via asymptomatic patients and deliveries. This study analyzes state-level geographical distribution of COVID-19 cases and age distribution of Obstetricians and gynecologists (OB/GYNs) to project which US regions will experience a more significant COVID-19 patient burden and provides a guide for vaccine distribution in the OB/GYN workforce. Methods The Association of American Medical Colleges' state-level workforce data is combined with COVID-19 case data reported by Johns Hopkins University. All data and code are available at https://github.com/cxr244/covid-obgyn. Results Our findings illustrate that OB/GYNs in the Midwestern region of the US experience the highest number of COVID-19 patients per OB/GYN over 60 years of age: North Dakota, South Dakota, Iowa, Wisconsin, and Idaho have the highest burden of COVID-19 patients per OB/GYN, warranting vaccine distribution priority. Additionally, states with the highest proportion of OB/GYNs over the age of 60 like Florida (38%), New Mexico (37%), Alabama (36%), California (36%), and New Jersey (34%), should be strongly considered for priority vaccine allocation, to mitigate predicted OB/GYN workforce shortages.  Conclusion When planning and executing vaccine allocation, especially in the early stages of distribution, it is critical to evaluate which communities can benefit the greatest from the limited number of vaccines. A strategy of distribution of COVID-19 vaccines to older physicians with a more significant COVID-19 burden can minimize shortages of providers within these states and ensure adequate access to women's healthcare within the communities they serve.

    View details for DOI 10.7759/cureus.14545

    View details for Web of Science ID 000640973200007

    View details for PubMedID 34017660

    View details for PubMedCentralID PMC8130649

  • Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY Goje, O., Markwei, M., Kollikonda, S., Chavan, M., Soper, D. E. 2021; 28 (3): 556-564

    Abstract

    To compare the success rate, complications, and hospital length-of-stay of 3 modalities of minimally invasive management of tubo-ovarian abscesses (TOAs): laparoscopy, ultrasound-guided drainage, and computed tomography-guided drainage.Electronic-based search in PubMed, EMBASE, Ovid MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, using the following Medical Subject Heading terms: "minimally invasive surgical procedures," "drainage," "abscess," "tubo-ovarian," "ovarian diseases," and "fallopian tube diseases."Of the 831 articles in the initial results, 10 studies were eligible for inclusion in our systematic review.A total of 975 patients were included in our study; 107 (11%) had laparoscopic drainage procedures, and 406 (42%) had image-guided (ultrasound or computed tomography) drainage of TOAs. Image-guided TOA drainage had higher success rates (90%-100%) than laparoscopic drainage (89%-96%) and the use of antibiotic treatment alone (65%-83%). Patients treated with image-guided drainage had no complications (for up to 6 months of follow-up) and shorter lengths of hospital stay (0-3 days on average) compared with laparoscopic drainage (5-12 days) or conservative management with antibiotics alone (7-9 days).Although conservative management of TOAs with antibiotics alone remains first-line, our review indicates that better outcomes in the management of TOA were achieved by minimally invasive approach compared with conservative treatment with antibiotics only. Of the minimally invasive techniques, image-guided drainage of TOAs provided the highest success rates, the fewest complications, and the shortest hospital stays compared with laparoscopy. The low magnitude of evidence in the included studies calls for further randomized trials. This systematic review was registered in the International Prospective Register of Systematic Review (register, http://www.crd.york.ac.uk/PROSPERO;CRD 42020170345).

    View details for DOI 10.1016/j.jmig.2020.09.014

    View details for Web of Science ID 000632642200024

    View details for PubMedID 32992023

  • Optimizing mother-baby wellness during the 2019 coronavirus disease pandemic: A case for telemedicine. Women's health (London, England) Markwei, M., Goje, O. 2021; 17: 17455065211013262

    Abstract

    BACKGROUND: The 2019 coronavirus disease pandemic poses unique challenges to healthcare delivery. To limit the exposure of providers and patients to severe acute respiratory syndrome coronavirus 2, the Centers for Disease Control and Prevention encourages providers to use telehealth platforms whenever possible. Given the maternal mortality crisis in the United States and the compounding 2019 coronavirus disease public health emergency, continued access to quality preconception, prenatal, intrapartum, and postpartum care are essential to the health and well-being of mother and baby.OBJECTIVE: This commentary explores unique opportunities to optimize virtual obstetric care for low-risk and high-risk mothers at each stage of pregnancy.METHODS: In this review paper, we present evidence-based literature and tools from first-hand experience implementing telemedicine in obstetric care clinics during the pandemic.RESULTS: Using the best evidence-based practices with telemedicine, health care providers can deliver care in the safest, most respectful, and appropriate way possible while providing the critical support necessary in pregnancy. In reviewing the literature, several studies endorse the implementation of specific tools outlined in this article, to facilitate the implementation of telemedicine. From a quality improvement standpoint, evidence-based telemedicine provides a solution for overburdened healthcare systems, greater confidentiality for obstetric services, and a personalized avenue for health care providers to meet maternal health needs in the pandemic.CONCLUSION: During the COVID-19 pandemic, continued access to quality prenatal, intrapartum, and postpartum care are essential to the health and well-being of mother and baby.

    View details for DOI 10.1177/17455065211013262

    View details for PubMedID 33926323

  • Capacity assessment of selected health care facilities for the pilot implementation of Package for Essential Non-communicable Diseases (PEN) intervention in Ghana PAN AFRICAN MEDICAL JOURNAL Nyarko, K., Ameme, D., Ocansey, D., Commeh, E., Markwei, M., Ohene, S. 2016; 25: 16

    Abstract

    Non-communicable diseases (NCDs) continue to pose threats to human health and development worldwide. Though preventable, NCDs kill more people annually than all other diseases combined. The four major NCDs namely cardiovascular diseases, chronic respiratory diseases, diabetes and cancers share common modifiable risk factors. In order to prevent and control NCDs, Ghana has adopted the World Health Organisation Package for Essential NCD (WHO-PEN) intervention, to be piloted in selected districts before a nationwide scale-up. We assessed the capacity of these facilities for the implementation of the WHO-PEN pilot.We conducted a cross-sectional health facility-based survey using a multistage sampling technique. We collected data on human resource, equipment, service utilization, medicines availability and health financing through interviews and observation. Descriptive data analysis was performed and expressed in frequencies and relative frequencies.In all, 23 health facilities comprising two regional hospitals, three district hospitals, nine health centres and nine Community-based Health Planning and Services (CHPS) compounds from three regions were surveyed. All the hospitals had medical officers whilst 4 (44.4%) of the health centres had physician assistants. Health financing is mainly by the National Health Insurance Scheme (NHIS). None of the health facilities had spacers and only one health centre had oxygen cylinder, glucometer and nebulizer.Gaps exist in the human resource capacity and service delivery at the primary care levels, the focus of WHO-PEN intervention. Adequately equipping the primary health care level with trained health workers, basic equipment, medications and diagnostics will optimize the performance of WHO-PEN intervention when implemented.

    View details for DOI 10.11604/pamj.supp.2016.25.1.6252

    View details for Web of Science ID 000619666500016

    View details for PubMedID 28149441

    View details for PubMedCentralID PMC5257011