Health Care Team Training and Simulation-Based Education in Obstetrics During the COVID-19 Pandemic

Health care team training and simulation-based education are important for preparing obstetrical services to meet the challenges of the COVID-19 pandemic. Priorities for training are identified in two key areas. First, the impact of infection prevention and control protocols on processes of care (e.g., appropriate and correct use of personal protective equipment, patient transport, preparation for emergency cesarean delivery with the potential for emergency intubation, management of simultaneous obstetric emergencies, delivery in alternate locations in the hospital, potential for increased decision-to-delivery intervals, and communication with patients). And second, the effects of COVID-19 pathophysiology on obstetrical patients (e.g., testing and diagnosis, best use of modified obstetric early warning systems, approach to maternal respiratory compromise, collaboration with critical care teams, and potential need for cardiopulmonary resuscitation). However, such training is more challenging during the COVID-19 pandemic because of the requirements for social distancing. This article outlines strategies (spatial, temporal, video-recording, video-conferencing, and virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic.     

Insertion and removal of Implanon®: practical considerations

ABSTRACT

Implanon®, a novel contraceptive implant containing the progestogen, etonogestrel (68 mg), provides highly effective, well-tolerated contraception for up to 3 years. Its single-rod design, semi-rigid polymer base and convenient pre-loaded presentation mean that Implanon® has potential insertion and removal advantages over the six-capsule Norplant® implant. Insertion of Implanon® is simple: the applicator needle is positioned subdermally and the cannula is withdrawn, leaving the implant rod in place. Implanon® is removed using the ‘pop out’ technique, involving a 2-mm incision. A meta-analysis of data from seven open-label, randomized studies in 1378 women compared the ease of insertion and removal of the Implanon® and Norplant® implants and the frequency of associated complications. It was approximately four times quicker to insert and remove Implanon® than Norplant® (mean insertion times 1.1 vs. 4.3 min, respectively; mean removal times 2.6 vs. 10.2 min, respectively). Insertion complications were very rare with both Implanon® (0.3%) and Norplant® (0.0%). However, Implanon® was associated with a significantly lower frequency of removal complications (0.2 vs. 4.8% with Norplant®; p < 0.001). Implant site abnormalities were uncommon. The simplicity of the insertion and removal procedures with Implanon® may have significant implications for contraceptive implant training programs and user counselling.     

Managing Expectations of Surgical Training: A National Perspective on Gynaecologic Endoscopy Practice

ObjectiveTo determine if the opinion of obstetrics and gynaecology postgraduate trainees differs from practising gynaecologists with respect to the expected endoscopic surgical skill set of a general gynaecologist upon graduation from residencyMethodsAn electronic survey was designed, validated, and pretested. It was sent to 775 Canadian obstetrics and gynaecology residents, fellows, and practising physicians through the Society of Obstetricians and Gynaecologists of Canada's electronic mailing list. Survey respondents were asked their opinion on the level of training (no extra post-residency training vs. fellowship) required to perform various endoscopic procedures.ResultsWe received 301 responses (39% response rate). Obstetrics and gynaecology trainees and practising physicians agreed on the training and skill level necessary to perform many endoscopic procedures. However, there were significant differences of opinion among trainees and practising physicians regarding advanced endoscopic procedures such as laparoscopic hysterectomy, cystotomy and enterotomy repair, and appendectomy. More trainees felt that a general gynaecologist without additional post-residency surgical training should be competent to perform such procedures, while practising physicians felt fellowship training was necessaryConclusionOur survey highlights the different expectations of learners versus those in practice with regard to skills required to perform certain endoscopic procedures, particularly laparoscopic hysterectomy Trainees who responded believed that after graduation from residency any obstetrician-gynaecologist should be able to perform more advanced endoscopic procedures, but practising physicians did not agree This discordance between learners and practising colleagues highlights an important educational challenge in obstetrics and gynaecology surgical training. Greater clarification of what is expected of our training programs would be beneficial for both residents and training programs     

Insertion problems, removal problems, and contraception failures with Implanon

OBJECTIVE: Analysis of the results of a national pharmacovigilance study on Implanon, a contraceptive implant containing 68 mg of etonogestrel. PATIENTS AND METHODS: This survey concerns cases of pregnancies (contraception failures), of migrations and of insertion or removal problems with Implanon reported to French Regional Drug Pharmacovigilance Centres and to Organon SA between May 2001 and September 2002. RESULTS: In France, 39 unintended pregnancies were reported over 17 months. The pregnancies were in 77% of cases (N = 30) due to an insertion technique error (implant not found when pregnancy has been diagnosed). For 3 patients (7,6%), pregnancy was due to a failure of etonogestrel contraceptive effect, explained twice by its association with an enzymatic inductor drug. For 4 patients (10%), pregnancy was due to an untimely insertion (insertion after day 5 of menstrual cycle or woman already pregnant). For two patients, no information was available. The incidence of reported pregnancies in France is estimated at 0.359 / 10(3) implants [0.246-0.482], in accordance with a typical Pearl Index of 0.06 [0.04-0.08]. Twenty-eight suspected migrations (N = 11), problems or failures in removal of the implant (N = 11) and insertion difficulties (N = 6) were notified, corresponding to an incidence of 0.257/10(3) implants [0.162-0.363]. DISCUSSION AND CONCLUSION: Occurrence of pregnancy is possible with Implanon, due to errors in the insertion technique (device not really inserted) or to a non-respect of the SPC recommendations (drug-drug interaction or untimely insertion). Insertion problems can lead to localisation problems (implant not visible by X-ray) then needing further tests and even harmful practice (removal under general anaesthesia). That is why a real and strict training is highly recommended to physicians.     

To Have or Not to Have Sex? COVID-19 and Sexual Activity Among Chinese-Speaking Gay and Bisexual Men in Hong Kong

BackgroundThe coronavirus disease 2019 (COVID-19) outbreak has fundamentally changed daily routine, including sexual activity. However, most research on sexual activity during the COVID-19 pandemic focused on heterosexual individuals. The only study so far on men who have sex with men was conducted in the United States.AimOur study expands the understanding of sexual activity during the COVID-19 pandemic by studying gay and bisexual men in Hong Kong. Although sexual desire and sexual activity continue to be important aspects of one's life during the COVID-19 pandemic, there are COVID-19–related barriers to having sex. This study therefore examined the association between sexual desire, COVID-19–related barriers, and whether to engage in sexual activity or not during the COVID-19 pandemic.Methods857 cisgender sexual minority people in Hong Kong participated in an online survey study, and for this article, only male participants were included in the analysis, yielding an analytical sample of 376 gay and bisexual men.OutcomesParticipants were asked to assess their sexual desire (ie, sexual drive and sexual motivation), COVID-19–related barriers (ie, perceived difficulties to have sex with another person during the pandemic and perceived risk of COVID-19 infection), and sexual activity during the COVID-19 pandemic.ResultsIt was found that while sexual desire remained prevalent among the gay and bisexual men, COVID-19–related barriers were also commonly observed. Sexual drive and sexual motivation were positively associated with sexual activity. Perceived difficulties to have sex with another person during the pandemic and perceived risk of COVID-19 infection were negatively predictive of engaging in sexual activity, after controlling for general sexual desire.Clinical ImplicationsUnderstanding the ambivalence and driving and inhibiting factors for having sex during the COVID-19 pandemic can provide a new framework for understanding people's sexual activity during an unprecedented scale of the pandemic. It is likely that abstinence would not work as the respondents expressed strong sexual desire and that the pandemic is going to last for a long time. Governments, policy makers, and sexual scientists need to work together to come up with practicable, feasible, and easy-to-follow guidelines for having sex during the pandemic.Strength & LimitationsThis is one of the first studies to examine the impact of COVID-19 on sexual activity among gay and bisexual men. The results should be interpreted with caution because of the use of cross-sectional design and nonprobability sampling.ConclusionSexual desire and COVID-19–related barriers serve as driving and inhibiting factors in explaining whether or not people have sex during the COVID-19 pandemic.Suen YT, Chan RCH, Wong EMY. To Have or Not to Have Sex? COVID-19 and Sexual Activity Among Chinese-Speaking Gay and Bisexual Men in Hong Kong. J Sex Med 2021;18:29–34.     

Ovarian stimulation for fertility preservation in an oncology patient with etonogestrel implant in place

PurposeTo describe a case of a young woman who presented for fertility preservation and underwent ovarian stimulation with an etonogestrel implant in place.MethodsA 24-year old, gravida 0, with an etonogestrel implant and newly diagnosed lower extremity sarcoma and DVT desiring oocyte cryopreservation prior to adjuvant chemotherapy and radiation. To avoid delay in her oncologic care and allow for continued use of contraception post-retrieval, the patient underwent controlled ovarian hyperstimulation (COH) without removal of the etonogestrel implant.ResultsBaseline labs included follicle-stimulating hormone 9 mIU/mL, luteinizing hormone 4.9 mIU/mL, estradiol 42 pg/mL, anti-Müllerian hormone 5.1 ng/mL, and antral follicle count greater than 40. The patient was placed on an antagonist protocol and stimulated with 125 IU Gonal-F and 75 IU Menopur. She received a total of 12 days of gonadotropin stimulation. On the day of trigger, her estradiol was 1472 pg/mL, lead follicle 21.5 mm with a total of 25 follicles measured > 12 mm. She was triggered with 5000 U hCG. She had a total of 23 oocytes retrieved, 17 of which were metaphase II and vitrified.ConclusionsCOH and successful oocyte cryopreservation can be achieved in patients with an etonogestrel implant in situ without apparent detrimental effects to oocyte yield or maturity. Due to the etonogestrel implant’s inhibitory effects on LH, it is recommended to use an hCG trigger for final oocyte maturation.     

Postgraduate Training in Pediatric and Adolescent Gynecology: Trainees' Perspectives

ObjectiveThe purpose of this study was to evaluate resident trainees’ perspectives on the pediatric and adolescent gynecology (PAG) training in obstetrics and gynecology training programs in Europe.Study DesignThis study was a cross-sectional survey using an online questionnaire, on the basis of the PAG training in obstetrics and gynecology section of the European Board & College of Obstetrics and Gynaecology Project of Achieving Consensus in Training curriculum. We aimed to survey the national programs in 35 European Network of Trainees in Obstetrics and Gynaecology (ENTOG) member countries. Taking part in the survey was voluntary. The questionnaire was shared on the ENTOG online platforms.ResultsNinety obstetrics and gynecology trainees in 33 of 35 countries responded to our questionnaire. Of the 35 ENTOG member countries, 33 participated in the survey, and a total of 90 responses were collected, giving a response rate of 9% of all European trainees and representing 94% of the member countries. Only 27% of trainees reported having a PAG rotation during their training program, and a PAG elective was only available to 34% of the trainees. Forty-one percent reported that PAG training was not included in their curriculum (no official rotations or lectures planned). Despite the lack of formal training, 72% of trainees felt able to diagnose and manage prepubertal vaginal bleeding and adnexal masses in children and adolescents by the end of their training. Most (58%) also confirmed that they could determine indications for treatment of vulval, vaginal, perineal, and rectal conditions.However, despite scoring positively for the management and counseling of subjects that often overlap with adult patients, such as “contraception in adolescents with health problems,” “acute abdominal pain,” “menstrual abnormalities,” and “vaginal discharge,” the study revealed poorer scores when the trainees were asked about more specific PAG topics such as “premature puberty” and “developmental disorders of the genital tract.”ConclusionMost core training programs across Europe do not include formal PAG training, and trainees reported a need to improve the provision of core PAG training in Europe.     

Impact of the COVID-19 Pandemic on Access to Fertility Care: A Retrospective Study at a University-Affiliated Fertility Practice

ObjectiveTo elucidate the impact of the COVID-19 pandemic on access to fertility services.MethodsA retrospective quality improvement study was conducted at a university-affiliated fertility practice in southwestern Ontario. Annual procedural volumes for intrauterine and donor inseminations (IUI/DI), in vitro fertilization and intracytoplasmic sperm injections (IVF/ICSI), and frozen embryo transfers (FET) during the COVID-19–affected year were compared with mean annual volumes from the 2 preceding years. In addition, volumes for the same procedures were compared between the first quarter of 2021 and mean first quarter volumes from 2018 to 2019. Piecewise linear regressions were conducted to evaluate whether any changes in monthly procedural volume were attributable to the COVID-19 pandemic.ResultsIn 2020, our fertility practice attained the mean annual volumes of 89.7% for IUI/DI, 69.0% for IVF/ICSI, and 60.6% for FET. In contrast, in 2021, we performed mean first quarter volumes of 130.1% for IUI/DI, 164.3% for IVF/ICSI, and 126.8% for FET. The slopes of the pre- and post–COVID-19 segments of the piecewise linear regressions were significantly different for IUI/DI (P < 0.001) and IVF/ICSI (P = 0.001), but not for FET (P = 0.133).ConclusionThe COVID-19 pandemic resulted in decreased annual volumes of medically assisted reproductive procedures at a university-affiliated fertility practice in southwestern Ontario. Impact on monthly procedural volume was confirmed for IUI/DI and IVF/ICSI by linear regression. Local adaptations helped compensate and exceed expected volumes in 2021. As a result, the COVID-19 pandemic resulted in a short-lived limitation in access to fertility care.     

The Etonogestrel Implant in Adolescents: Factors Associated With Removal for Bothersome Bleeding in the First Year After Insertion

Study ObjectiveTemporizing measures such as hormonal pills can temporarily improve the side effect of breakthrough bleeding in individuals using the etonogestrel implant. The aims of this study were to determine demographic factors that are associated with bothersome bleeding and to evaluate the impact of prescribing temporizing measures on implant continuation.DesignRetrospective chart review.SettingThe research was conducted in an adolescent medicine primary and specialty care clinic, an adolescent family planning clinic, and a clinic that cares for parenting adolescents.ParticipantsA chart review was conducted on 1200 patients aged 12-24 years who received the implant in 2016.Interventions and Main Outcome MeasuresThe primary outcome measure was removal of the implant within the first year of use. We followed each patient for 1 year to determine rates of removal, reasons for removal, and temporizing measures prescribed for bleeding.ResultsYounger age and lower body mass index were associated with reporting bothersome vaginal bleeding. Patients who were nulliparous or had bothersome bleeding were more likely to have the implant removed in the first year. Patients who received a temporizing measure for bleeding were more likely to retain the implant for 1 year than were those who did not receive one (67.1% vs 40%, P < .001).ConclusionsSome patients are more likely to report concerns with bleeding or to have the implant removed in the first year after insertion. Prescribing temporizing measures to control bothersome vaginal bleeding may decrease rates of removal in the first year.     

The pharmacokinetics and pharmacodynamics of Implanon®, a single-rod etonogestrel contraceptive implant

ABSTRACT

This paper reviews pharmacokinetic and pharmacodynamic studies with Implanon®, which provides serum etonogestrel levels sufficient to inhibit ovulation within 8 h of insertion. After a peak of 813 pg/ml at 4 days, levels reach steady state (200 pg/ml) after 4–6 months and remain sufficient to prevent ovulation for 3 years. Variability is lower than with Norplant®. Etonogestrel levels are similar in most ethnic groups, but 40% higher in women weighing < 50 kg. After implant removal, etonogestrel is not detectable within 1 week. Implanon® inhibits ovulation by preventing the mid-cycle luteinizing hormone peak. Although it initially suppresses follicular development and estradiol production, ovarian activity slowly increases after 6 months, and follicle stimulating hormone and estradiol levels are almost normal. Endogenous progesterone levels remain in the subovulatory range for > 3 yean in most subjects. In ovarian ultrasound studies, ovulation occurred in < 5% of users after 30 months of use. Ovulation was observed in most women within 3–4 weeks of implant removal. The pharmacokinetics and pharmacodynamics of Implanon® indicate that it has high contraceptive efficacy, as reflected in a zero pregnancy rate over 5629 woman-years of use. Its excellent reliability, ease of use, and reversibility make Implanon® a valuable addition to current contraceptives.     

Yoga instructors’ reported benefits and disadvantages associated with functioning online: A convenience sampling survey

BackgroundAmong numerous changes in response to the COVID-19 pandemic, most yoga classes have repositioned online. However benefits, difficulties and satisfaction of teaching yoga online remain to be studied. With this background the present survey aimed to determine: (i) benefits, disadvantages and satisfaction of teaching yoga online and (ii) their association with characteristics related to (a) socio-demographic, (b) online yoga teaching experience and (c) yoga practice.MethodsThree hundred and five yoga instructors were invited to take part in the online survey. Of these, 181 (m:f = 98:83) responded to the survey satisfactorily and were included.ResultsThe three most common benefits of teaching yoga online were: (i) a sense of safety from risk of COVID-19 (93.92%), (ii) cost saving (82.87%) and (iii) wider access to trainees within India (77.90%). The three most common disadvantages were: (i) technical difficulties (74.03%), (ii) missing in-person contact (63.90%) and (iii) concern that online instructions can lead to injury (59.16%). Around 66.30% respondents were satisfied with the monitoring of trainees during online yoga classes while 70.16% respondents were satisfied with the level of attention they could pay to the topic they were teaching during online yoga class. The benefits and disadvantages of teaching yoga online varied with the characteristics of yoga instructors (p < 0.05, χ2 test).ConclusionsThe benefits and disadvantages of teaching yoga online are of relevance during and beyond the pandemic. Characteristics related to (i) socio-demographics, (ii) online yoga teaching and (iii) yoga practice influence reported benefits and disadvantages of teaching yoga online.     

Preeclampsia and Severe Maternal Morbidity During the COVID-19 Pandemic: A Population-Based Cohort Study in Ontario,Canada

ObjectiveSignificant changes to the delivery of obstetrical care that occurred with the onset of the COVID-19 pandemic may be associated with higher risks of adverse maternal outcomes. We evaluated preeclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome and composite severe maternal morbidity (SMM) among pregnant people who gave birth during the COVID-19 pandemic and compared these data with those of people who gave birth before the pandemic in Ontario, Canada.MethodsThis was a population-based, retrospective cohort study using linked administrative data sets from ICES. Data on pregnant people at ≥20 weeks gestation who gave birth between March 15, 2020, and September 30, 2021, were compared with those of pregnant people who gave birth within the same date range for the years 2015–2019. We used multivariable logistic regression to assess the effect of the pandemic period on the odds of preeclampsia/HELLP syndrome and composite SMM, adjusting for maternal baseline characteristics and comorbidities.ResultsThere were no differences between the study periods in the adjusted odds ratios (aORs) for preeclampsia/HELLP syndrome among primiparous (aOR 1.00; 95% CI 0.91–1.11) and multiparous (aOR 0.94; 95% CI 0.81–1.09) patients and no differences for composite SMM (primiparous, aOR 1.00; 95% CI 0.95–1.05; multiparous, aOR 1.01; 95% CI 0.95–1.08).ConclusionAdverse maternal outcomes were not higher among pregnant people who gave birth during the first 18 months of the COVID-19 pandemic in Ontario, Canada, when compared with those who gave birth before the pandemic.     

Effect of cost on early removal of contraceptive implants: a prospective cohort study

Objectives: To evaluate the effect of the cost of subdermal etonogestrel implant (SEI) on the continuation rate one year after insertion, and to assess the reasons given by users to remove the implant before the expiration date.

Methods: Prospective cohort study conducted among 265 women who chose the SEI as a contraceptive method in a sexual and reproductive health center in the eastern region of Spain, between October/2012 and October/2017. The sample was divided into two cohorts depending on the cost of the implant for the user (free-of-charge or requiring partial payment). Kaplan–Meier survival curves were used to compare the cumulative removal rates of free implants with partially paid implants within the first year of insertion. Cox proportional hazards models were used to control for confounders.

Results: After adjusting for confounders, no significant associations were found between the cost of the implant and its removal within a year of insertion. No significant associations were found in the reasons given for implant removal and for the duration of implant use.

Conclusions: Cost was not associated with SEI continuation rates within the first year of use. No other significant variables were found to explain implant removal within one year of use.     

Will it Hurt? The Intrauterine Device Insertion Experience and Long-Term Acceptability Among Adolescents and Young Women

Study ObjectiveTo examine how the intrauterine device (IUD) insertion experience affects long-term IUD acceptability among adolescents.DesignText to Web survey study.SettingBoston Children's Hospital and Cambridge Health Alliance in Massachusetts.Participants, Interventions, and Main Outcome MeasuresNulliparous adolescents aged 13-21 years who received an IUD or etonogestrel implant between January 2012 and May 2018.ResultsWe received survey responses from 95 adolescents (n = 46 IUD; n = 49 implant; response rate = 95/1098 (9%)). Mean current age (20.8 years) and time since device insertion (2.4 years) were similar between groups. Although a large proportion of both groups (64%) experienced moderate to severe preprocedural anxiety, IUD users expected more insertional pain compared with implant users (55.6 vs 39.6; P = .01). Compared with implant users, more IUD users experienced moderate to severe insertional pain (80% vs 18%; P < .0001), recalled that the procedure hurt more than expected (52% vs 4%; P < .0001), and endorsed lower rates of pain management satisfaction (72.4 vs 85.6; P = .04). Most respondents would recommend their method to a friend (75%) or consider getting the same device in the future (63%). When explicitly asked, more IUD users reported that dislike of the insertion procedure might or would probably prevent them from getting the same device in the future (41% vs 14%; P = .005).ConclusionCompared with implant users, IUD users reported more negative insertion experiences, although preprocedural anxiety was prevalent in both groups. Dislike of the insertion experience might negatively affect adolescents’ willingness to continue using an IUD in the future. Findings should encourage multimodal interventions to holistically improve the IUD insertion experience.     

Telehealth Care in a Pediatric and Adolescent Gynecology Clinic During the COVID-19 Pandemic

BackgroundSince the onset of the COVID-19 pandemic, health care systems have increased their telehealth services to meet the changing public health needs. Before the pandemic, telehealth was used primarily in surgical specialties for postoperative visits and rural medicine. However, out of necessity, nearly all medical and surgical subspecialties incorporated this virtual technology to improve patient health care access in a short time. Few studies have addressed telehealth in pediatric and adolescent gynecology (PAG) to date.Study ObjectiveTo describe the large-scale utilization of telehealth visits, assess patient experience, and improve access to care in a large academic ambulatory gynecology PAG clinicMethodsThis retrospective, cross-sectional quality improvement study was performed by administering patient surveys and compiling aggregate data from the EPIC electronic health record in the Division of Pediatric and Adolescent Gynecology clinics at a single children's hospital between March 2020 and March 2021. Patient demographic characteristics, payer characteristics, visit type and purpose, and patient experience were reviewed.InterventionsWider expansion of telehealth in PAG clinics at a single institutionResultsA total of 6159 telehealth appointments were performed, involving 6 clinic sites and 9 providers. Telehealth visits constituted 50% of the total ambulatory volume (12,527). Most patients were located within the institution's state (99.5%), and the remaining called into their telehealth visits from a neighboring state. Most patients were 18 years of age or younger (73%). Video visits lasted 15-30 minutes and included routine follow-up (66.3%), new/consult visits (28.4%), postoperative visits (1.6%), and urgent follow-up (0.2%). The patient population was ethnically diverse by self-identification: 61.4% White, 38.4% Hispanic, 16% Black, 4.4% Asian, and 0.4% Native Hawaiian/American Indian/Alaska Native. Payer mix included self-pay (45.5%), private payer (32.2%), and Medicaid/CHIP (22.3%). Conditions seen ranged from menstrual management (71%) and routine preventive or acute gynecologic concerns (21%) to surgical evaluation for congenital anomalies, endometriosis, fertility preservation, and genital concerns or pelvic masses (8%). Telehealth visits met patient expectations for 87.3% of respondents. Patient-reported opportunities for improvement included improving set-up instructions and more consistent audio/video connections. Challenges identified by providers included difficulty utilizing interpreters, technology limitations, and privacy constraints during HEADSS examination.ConclusionsThis study demonstrates how a large, diverse volume of patients with PAG needs received appropriate care through a telehealth format during the COVID-19 pandemic. Patients were satisfied with the services, but opportunities for improvement were elicited to allow for continued refining of this health care delivery tool in the future.