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OBJECTIVES: To evaluate how recent opioid, marijuana, and cannabidiol use affects pre-procedure pain-related anxiety for patients seeking abortion. METHODS: We conducted a prospective, cross-sectional anonymous survey of patients seeking abortion assessing recent substance use and anxiety about pain during and after abortion. We compared substance users' and non-users' anxiety scores. RESULTS: Among 217 participants, recent opioid users (5.3%) had higher median anxiety scores for pain during (7.0 vs 6.0; p=0.33) and after (8.0 vs 6.0; p=0.01) abortion than non-opioid users. Anxiety scores were similar for marijuana and cannabidiol users. CONCLUSIONS: Assessing recent opioid use may help guide counseling for anxiety about abortion.

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STUDY OBJECTIVE: To evaluate the relationship between body mass and levonorgestrel intrauterine device (LNG-IUD) expulsion in adolescents and young adults (AYA). DESIGN, SETTING, PARTICIPANTS & INTERVENTIONS: A retrospective chart review was conducted of nulliparous females aged 10-24 years who had a 52-milligram LNG-IUD placed between November 2017 and May 2021 by pediatric and adolescent gynecology providers at a tertiary children's hospital, including those who underwent metabolic and bariatric surgery (MBS). Primary analysis focused on 10-19 year olds as they had comparable anthropometrics (namely BMI percentile [BMIP] as defined by the Centers for Disease Control). Descriptive statistics included means, standard deviations (SD), and ranges for continuous variables counts and percentages for categorical variables. Chi-square or Fisher's exact tests were used to assess associations. Logistic regressions were fit to test the associations between BMIP, MBS, and the odds of expulsion. MAIN OUTCOME MEASURES & RESULTS: A total of 588 patients were included in the primary analysis (10-19 years). Mean age was 15.8 years (±2.0). Using BMIP, 15.5% (n = 91) of the sample was overweight and 22.3% (n = 131) were obese. Within 12 months, 33 patients (5.6%) experienced expulsion. Every one-unit increase in BMIP was associated with a 3% increase in the odds of expulsion (P = .008), and each increase in BMIP category (eg, overweight vs average/underweight) was significantly associated with increased odds of expulsion (OR = 2.77-4.28). Patients who had LNG-IUD placement during MBS (n = 43) had higher odds of expulsion (OR = 3.23; P = .024) than other patients. CONCLUSION: AYA with higher BMIP and/or who undergo MBS are at increased risk of LNG-IUD expulsion within one year of placement.

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Hydrosalpinx is defined as the obstruction and fluid distension of the fallopian tube. It is most often seen in the setting of pelvic inflammatory disease, but preserved fallopian tubes or tubal segments after hysterectomy can also develop hydrosalpinx. This case report highlights an instance of painful hydrosalpinx after vaginal hysterectomy and advocates for the complete removal of fallopian tubes as the standard of care at the time of hysterectomy of any route. In this case, a 40-year-old female, G4P3104, with a history of vaginal hysterectomy and prophylactic bilateral salpingectomy for abnormal uterine bleeding and symptomatic uterine leiomyoma two years prior, presented with one month of left lower quadrant pain. She was found to have an anechoic, tubular structure adjacent to the left ovary on transvaginal ultrasound. At the time of diagnostic laparoscopy, a 10x4 centimeter (cm) dilated hydrosalpinx was found and removed. Pathology confirmed the hydrosalpinx, and the patient's pain resolved after the surgery. Given our findings of painful hydrosalpinx following incomplete bilateral salpingectomy at the time of vaginal hysterectomy, attempts at the removal of the entire fallopian tube including the fimbriae are strongly recommended to prevent the morbidity of repeated surgery.

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Obstructive shock due to cardiac tamponade is a rare, life-threatening occurrence in the peripartum period. Etiologies include preeclampsia, infection, autoimmune conditions, and malignancy. Early recognition of the underlying disease process allows for multidisciplinary treatment and a favorable outcome. A 33-year-old presented for cardiac tamponade identified in the peripartum period. She was diagnosed with preeclampsia with severe features immediately prior to her repeat cesarean delivery and received magnesium prophylaxis. Postoperatively, she developed hypotension, tachycardia, and shortness of breath and was found to have a pericardial effusion with tamponade physiology. She underwent pericardial drain placement which was initially successful. However, she had recurrent symptomatic tamponade and thus a pericardial window was performed resulting in improvement of her symptoms. Workup revealed pericardial inflammation possibly secondary to a viral source, and she was successfully treated with anti-inflammatory therapy. We hypothesize that this patient's cardiac tamponade was caused by inflammatory pericarditis exacerbated by severe preeclampsia. Preeclampsia is a disease characterized by cardiovascular remodeling and fluid shifts in other compartments and thus is theorized to have contributed to this patient's effusion. Cardiac tamponade should be considered in the differential for any parturient presenting with hypotension and shortness of breath.

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Cesarean scar pregnancy (CSP), or pregnancies with implantation in a prior cesarean section scar, are rare but may be becoming more common with an increase in cesarean section deliveries. History of prior CSP may also increase the risk for recurrent CSP. Several treatment options and combinations of treatment options for CSP have been described in the literature. Although the optimal treatment is unclear, the Society of Maternal-Fetal Medicine published recommendation guidelines, which include recommendations for the treatment/termination of CSP pregnancies. Treatment of CSP is recommended with operative resection, ultrasound-guided suction dilation and curettage (D&C), or intragestational methotrexate with or without treatment modalities. This is a case report of a patient with recurrent CSP. Her first CSP was incorrectly diagnosed as an incomplete abortion after unsuccessful treatment with misoprostol alone and ultimately was successfully treated with systemic methotrexate. Her second CSP is the basis of this case report and was successfully treated with oral mifepristone and systemic methotrexate (50 milligrams/meter2) before an ultrasound-guided suction D&C at 10 weeks 1 day gestational age. The combination of mifepristone, systemic methotrexate, and suction D&C under ultrasound guidance as a treatment for recurrent CSP has not previously been described in published literature.

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Spontaneous bilateral ectopic pregnancies are rare. In the majority of case reports, treatments prescribed were methotrexate, bilateral salpingectomy, or salpingectomy/salpingostomy. A 31-year-old gravida 3 para 0 at our institution underwent diagnostic laparoscopy due to ruptured ectopic pregnancy, and based on visual inspection, had a bilateral ectopic pregnancy. She underwent right salpingectomy for a ruptured ectopic pregnancy and had spontaneous expulsion of the left ectopic pregnancy with mobilization of the fallopian tube. She received methotrexate as per the two-dose protocol and was followed with a negative beta-human chorionic gonadotropin (b-hCG). Pathology confirmed bilateral tubal ectopic pregnancies. Spontaneous bilateral tubal ectopic pregnancy requires a high level of clinical suspicion. If a tubal pregnancy has expulsion of tissue intraoperatively, a two-dose protocol for methotrexate administration may be used for treatment, especially in the case of a bilateral ectopic pregnancy with fertility desires.

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OBJECTIVE: Permanent contraception through tubal sterilization is the preferred contraceptive method for 25% of women in the United States. Laparoscopic permanent contraception has an anecdotally high cancellation rate. Cancellations affect operating room utilization and may reflect barriers to care. We aimed to identify the short-notice cancellation (≤7 days from scheduled surgery) rate for laparoscopic permanent contraception, reasons for cancellation, and postcancellation outcomes. STUDY DESIGN: We performed a retrospective chart review of patients aged 18 to 50 who canceled or no-showed a scheduled laparoscopic permanent contraception surgery between May 2016 and May 2019 at an academic tertiary care hospital and academic county hospital in Denver, Colorado. We reviewed electronic health records to determine the time between cancellation and surgery date and documented reasons for cancellation. We evaluated contraceptive methods used and pregnancies within a year after the canceled surgery. RESULTS: The overall surgery cancellation rate for scheduled laparoscopic permanent contraception was 22% (123 of 558). Short-notice cancellation occurred for 71.5% of patients and 32.5% (40 of 123) canceled same day. The most common reason for cancellation was patient choice (74%) followed by financial/insurance issues (11.4%). In the year after their canceled surgery, 22% (27 of 123) of patients obtained permanent contraception and 5.7% (7 of 123) had a subsequent pregnancy. CONCLUSIONS: Among patients who canceled their laparoscopic permanent contraception, the vast majority canceled their surgery a week or less from their scheduled date. These short-notice cancellations may adversely affect both patients and the health care system. More research is needed on institutional policies to reduce laparoscopic permanent contraception cancellations while helping patients who want effective contraception find an option that works best for them. IMPLICATIONS: Our retrospective cohort study found that laparoscopic permanent contraception surgeries have an overall high cancellation rate at both an academic tertiary and an academic county hospital, with most cancellations occurring less than 7 days prior to surgery. Future research will be used to reduce barriers to permanent contraception while developing clinical tools to reduce surgery cancellation rates.

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Teenage pregnancy can have adverse social and health outcomes, and rates are high in Flint, Michigan as compared to the rest of the state and the USA. It is important to understand contributing factors to adolescent pregnancy to be able to better address this issue. This study examined qualitative data from interviews with 100 community members who participated in the Flint Women's Study, a study designed to better understand the hopes, dreams and needs of women in Flint, and their suggestions for how to address identified needs. Using a Community Based Participatory Approach, data were collected and analysed by a team of community members and academic researchers. The paper focuses on the theme of family planning among young women which included attitudes about contraception, sexuality education and bio-medical and structural barriers to accessing reproductive health. Community members emphasised the need for increased access to comprehensive contraception options, improved sexuality education in schools and from health care providers, and ultimately valuing young women.

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