Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 7.12 BV Screening, WHI, First Trimester Anatomy Ultrasound, and Postpartum Sterilization
In this episode, we discuss routine bacterial vaginosis screening in patients with preterm labor symptoms. Then, we discuss some dietary and other less-discussed findings from the Women's Health Initiative. We also discuss a new review article about first trimester anatomic ultrasounds. Finally, we answer a listener question about implementing postpartum sterilization routinely into unsupportive hospitals.
00:00:02 Testing for BV in Preterm Labor
00:12:28 Clinical Diagnosis of Bacterial Vaginosis
00:21:14 First Trimester Ultrasound in Women's Health
00:34:12 First Trimester Ultrasound Anomalies and Costs
00:38:29 The Cost-Effectiveness of Early Ultrasounds
00:46:32 Improving Postpartum Sterilization Access
00:55:32 Strategies for Postpartum Sterilization Procedures
Follow us on Instagram @thinkingaboutobgyn.
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Harrell.
Howard:Antonia.
Antonia:Howard.
Howard:What are we thinking about on today's episode?
Antonia:Well, we'll talk about a recent summary of the Women's Health Initiative. We've talked about that one before, but this is the new summary and an article about first trimester ultrasound. That's pretty good, and then we'll get to some listener questions too. But first, what's the thing we do without evidence?
Howard:Well, how about doing a routine test for bacterial vaginosis when we triage patients who present with symptoms of preterm labor? Or, for that matter, other tests like a urinalysis or fetal fibronectin? Even?
Antonia:Okay. Well, there are all sorts of things that could be done when a patient presents with contractions, to both evaluate for preterm labor and perhaps also for the cause of the contractions, and at residency programs there does tend to be a habit of doing every possible test or at least more than the bare minimum of tests on every patient, regardless of what their specific symptoms are, because I think the logic is, you never know when my chief resident or my attending might want a test that I didn't do, so I should just do all the tests and then I'll have all the information, whether they want it or not. These are often tests that need to be collected upfront before you get too far into doing things like a cervix exam, for example, because that can then invalidate some of these tests. And some of these tests, including BV or urine tests, are appropriate for certain patients with certain symptoms. But sometimes this process really is more automatic, like a shotgun approach, and then if we didn't need it, we didn't need it, but we got it regardless.
Antonia:It's like how I think the ER at one of the hospitals I have worked at in the past would run a urine pregnancy test on every single female that walked in, for anything, even if let's say it was someone that was obviously third trimester pregnant. You don't need to, you could just ask her or look at the baby kicking. But they would still run pregnancy tests, even if she was presenting for pain or something like that. So totally unnecessary, but I think that was part of their whole shotgun approach. Like that, so totally unnecessary, but I think that was part of their whole shotgun approach. And of course, any tests, even if it is fully appropriate, let alone an unnecessary test, can give you a false result and lead to misdiagnosis, possibly over-diagnosis or under-diagnosis, and of course, it can lead to extra cost. But why don't you tell us about bacterial vaginosis screening and these other tests in this setting?
Howard:Yeah, I've seen those pregnancy tests ordered on women with hysterectomies just because it's routine and sometimes I get told about the fact that it's HCGs four or five and need a 3 am consult.
Howard:But I think that residents yeah, they sometimes don't see the difference in what they do for purposes of like you were describing, to make sure all the bases are covered or even sometimes for their own educational benefit, they need to do lots of exams and things like that. They don't sometimes see the difference between that and then what the patient actually needs based upon scientific evidence. And, worse, sometimes they make up reasons that justify what they're doing, not understanding that they were just doing it, like you said, because the chief might ask for it or something. So I think one thing is that when a person comes to the hospital with contractions, we also have a tendency to pathologize that and look for a reason. In other words, maybe the contractions are due to something like a urinary tract infection or dehydration or bacterial vaginosis, as if these are causes of labor-like contractions or preterm labor.
Antonia:Well, I'll argue there might be some logic to that. We do know that asymptomatic bacteria is responsible or at least associated with a percentage of preterm deliveries. And we also know that preterm labor is more common among patients who are colonized with group B strep. But it's not to the point where if they have asymptomatic bacteria urea we admit them for observation because of the preterm labor risk. It's not that strong of an association of the preterm labor risk. It's not that strong of an association, but it is there.
Antonia:We have also talked before about how dehydration can cause contractions through the homology of oxytocin and the antidiuretic hormone. But treating in quotes, treating contractions with IV hydration, doesn't actually improve outcomes. And treating with antibiotics outside of the setting of chorioamnionitis, it does not reduce preterm labor, even in chorio it doesn't reduce preterm labor, it just prevents sepsis. But both of these are essentially examples, I think, of kind of placebo treatments, especially when you're treating empirically. I feel like they're done just as often as ever to appease patients and maybe to appease the chief or the attending and get them out of triage, especially once you've determined they're not actually in preterm labor. But you just don't want to send them out empty handed.
Howard:Yeah, but these are examples, I think, where the theory is trumped by empiric data. So hydrating patients with preterm contractions not only doesn't reduce the rate of preterm delivery, it doesn't even change the initial symptoms in controlled studies. And of course, getting IV fluids is thought of as a pretty benign intervention, but at best it's still wasting resources from people who actually need it and at worst there could be some rare complications of the IV infusion. So that means you shouldn't routinely give every patient with contractions an IV or check their urine specific gravity because you're worried that their contractions are due to dehydration. And I'll preempt anyone who's about to send us links to the studies associating asymptomatic bacteria or maybe BV with preterm labor.
Howard:Yes, there is an association, but not a direct cause and effect mechanism where you see theV with preterm labor. Yes, there is an association, but not a direct cause and effect mechanism where you see the symptoms of preterm labor and then boom, treat the underlying UTI or the bacterial vaginosis or something and the preterm labor arrests because you treated it. These cause and effect things, if anything, start weeks before you see clinical symptoms. So perhaps you need to do a urine culture to screen and treat asymptomatic patients, which we still need to talk about on here sometime about the frequency and how often we should be doing that at their, for example, their initial prenatal visit and maybe another time during the labor. We'll talk about that sometime. But when they're there in triage contracting every three or four minutes, it's not because they have a UTI.
Antonia:So obviously, if they are presenting with, let's say, uti symptoms dysuria, hematuria, maybe urgency frequency, it burns and it hurts when they pee, maybe they have flank pain or chills or something like that, then you would run a urine as a diagnostic test to look for signs of infection.
Howard:Sure. And someone could maybe argue that a patient with contractions can't always tell what hurts. Maybe it really is dysuria rather than contraction pain, I don't know. Or what is urgency during pregnancy because the uterus is pressing on the bladder. Those things are difficult. But of course the performance of a urinalysis by itself isn't good enough to determine whether they have bacteria. So that's a different problem. But if that's your reasoning, that you think you're treating, you're testing the urine because they have symptoms, that's fine.
Howard:But I'm talking about universally checking for infection in every woman with preterm contractions, without any risk assessment, without the history. Essentially it's like rainbow panels in the emergency department, like you described. That's not evidence-based. Essentially it's like rainbow panels in the emergency department, like you described. That's not evidence-based. And I'll also remind listeners here that the US Services Preventive Task Force specifically recommends against screening and treating for asymptomatic BV in pregnancy. I think the biggest issue here is just that we are pathologizing what's probably just regular contractions. Women have contractions when they're pregnant. They actually start fairly early on and it's not pathological that they may present with runs of regular uterine contractions, at least for time. That's the whole point of understanding about Braxton-Hicks type contractions, the goal of triage in labor delivery for these patients isn't to find a cause for the contractions. But the goal of triage is to differentiate those Braxton-Hicks type contractions from actual preterm labor contractions and then, if the patient actually is in preterm labor, to provide chemoprophylaxis against group B strep and corticosteroids for fetal lung maturation.
Antonia:It can be a slippery slope for residents who are learning about all of these things to think that they have more control than they actually do over patients with their contractions and possible preterm labor process. I remember in my own case it took a while for my mind to shift during my training because at least as an intern I was used to. People are coming to the doctor because there's something wrong, especially in a similar kind of unscheduled setting. They're going to the ER or urgent care, especially if they're hurting. But in labor and delivery triage obviously there are things that can be going wrong that walk into L&D triage. But a lot of times we have to learn to say congratulations, these symptoms that are very painful and very concerning to you are fine and normal and there's nothing wrong. There's nothing we're going to do. These are supposed to be happening Bye. And that's a mind shift that it doesn't necessarily feel right at first, but this is especially low routine pregnancies. It's going to happen.
Howard:And they're nervous and they're anxious and what they really want is to know that they're not having their baby early. They often are relieved to know that everything's okay, but, as you said, they're also frustrated perhaps, and they're in pain and they want something done. And then, if you have a strong dose of the therapeutic imperative, all of a sudden you're prescribing tocolytics to take home with and telling them to be on bed rest and everything else.
Antonia:Yeah, yeah, no-transcript is actually present and even if it was, it likely wouldn't be affecting the course of preterm labor. So let's say they get the UA. It's normal they do a full assessment for any kind of vaginitis negative and then when the patient doesn't deliver, doesn't even have any cervical change, they ultimately go home. Usually by then the contractions have magically slowed down. The lesson is she wasn't in preterm labor, she was just having Braxton-Hooks contractions. But she had this whole full workup to get to that answer.
Howard:Right. But also she may go home and not be in labor. But at the same time there was moderate leukocyte esterase. So she got a shot of Rocephin and there was a clue cell and she got treated for BV and now she comes back to your office in three days with a yeast infection because of other complications from antibiotics et cetera. So that's where the harm from all that comes from no benefit to the patient and potential harm. And that's where that brings us back to bacterial vaginosis in particular. So if a patient doesn't have symptoms of bacterial vaginosis then the resident should not be looking for it.
Howard:There is this idea about bacterial vaginosis having a common etiology with preterm labor, and women who have had especially recurrent BV have a higher incidence of preterm labor, probably for some underlying immune reasons. But the BV itself isn't the cause of that. But what I see commonly is the patient will present, as you said, and then she's given a speculum exam and a fetal fibronectin is collected and then she's evaluated, maybe with a swab to test for rupture of membranes, maybe a wet mount is collected and oftentimes gonorrhea and chlamydia probe is done, a group B strep swab is collected and then her cervix is checked and then she may not even be dilated and a couple of hours later her contractions have, as you said, they've gone away and she's still not dilated and she's sent home. But she may be, incidentally, treated for BV. She didn't have, because on the wet mount that was collected someone's seen some clue cells.
Antonia:I want to put a little disclaimer here.
Antonia:I don't think this is the majority of how triages work in the US, at least when we're working up preterm contractions, because the proportion of academic programs to community programs is very low, so in most cases community programs don't work this way.
Antonia:But all of this, all of these hypotheticals, do take me back to my own early days, obviously in an academic program and just trying to stay above the water and memorize everything that I'm told, everything that I I'm supposed to do. In the moment it's impossible to do a full literature search on every little detail every day to confirm how strong the evidence is for it or not. So I don't know if this is still the norm at academic programs or not, because I'm not in that setting anymore right now. But in this scenario the resident does this full workup for Braxton Hicks. After doing this enough times on their OB, whatever night's rotation or day rotation, they might start to just even subconsciously believe that BV is some sort of pathology. Maybe it's an irritant that is causing preterm contractions somehow, and they've done every patient that they screened in triage with contractions. They've done them a favor by finding and treating it. They're not letting the patient go empty handed, and they might even believe that they're reducing the risk of preterm birth.
Howard:Yeah, it's like antibiotics for URIs at walk-in clinics that again that you feel like the patient wants something. You want to make them happy. I will say that it's not just in academic programs. This is spreading a bit with laborist programs, where a lot of the funding for laborist programs comes from treating every triage like an emergency room visit, and so some of these workups are being done at community hospitals that have laborists more and more, because it upcodes the level of the visit as well. That's a different financial incentive we don't have to talk about, but the point is, though, is that bacterial vaginosis isn't a clinical entity defined by the presence of clue cells on microscopy, and even if you believe that this was a high-risk patient and so you were looking for asymptomatic BV because of their risk factors, you still need to fulfill the AMSO criteria for diagnosis.
Antonia:Well, let's go over those criteria again quickly, mainly for our med student and resident listeners. So just as a refresh, you need at least three of the four criteria to have a clinical diagnosis of bacterial vaginosis. So first one is a homogeneous kind of milk, milky, milk-like thin discharge that coats the vaginal walls. So this could be seen on a speculum exam and it does need to be distinguished in your kind of clinical judgment from normal mucus-like discharge, especially in pregnancy. There's just more of that and that could be something a little bit on the subjective side that people might struggle with. They might want to err more on the side of abnormal if they're in doubt. So the next criteria is clue cells. On microscopy, and so this is vaginal epithelial cells that have so much adherent bacteria that it obscures both the outline and especially the nucleus of the cell. So you have to be able to see that that is an epithelial but that all of the outlines are obscured by little bacterial dots. And a lot of times you might find residents calling something a clue cell because they see some bacteria on there, but really the nucleus is still visible. So it's not technically a clue cell yet. The third criteria is pH of the discharge that is greater than 4.5. So you have to have a speculum, you have to have a slide for microscopy and pH paper. So far and a couple of things. On this pH thing, a lot of places I've worked at didn't even have a consistent supply of pH paper. So sometimes we'd run and steal the urinalysis dipstick that one of them is pH, or sometimes we would just leave the criterion out. Maybe if we thought the other three criteria were obviously yes or obviously no, then we wouldn't even worry about this part. But let's say that we did have the pH paper and we tested it and it was very like dark blue is the basic. Now we would have to distinguish is this BV or is this ruptured membranes? Because that would also turn the pH indicator high and if there's a copious amount of discharge that might be tough to tell apart. So then you'd be also working in a separate evaluation for membrane rupture.
Antonia:So the fourth AM cell criteria is the odor. So a lot of times the patients will complain of fishy odor and I feel like some of these are fairly subjective. This is the most subjective in my opinion, because I've had patients who are so distressed by their odor that the way they describe it. Before we do the exam I'm expecting a very strong odor and then I barely notice anything. And then on the flip side I've had patients specifically deny any concerns, any abnormalities relating to odor, when I'm asking a review of systems. And then on exam there's this really overpowering fishy odor.
Antonia:So how do you tell which one of those patients is more likely to have BV? So technically you're supposed to test for this by taking a sample and adding 10% KOH, the potassium hydroxide, which is how you do the wet prep, and then seeing if that releases a distinctive amine odor. So I think really any strong odor that you notice from that would be a positive test. But in practice that really could be somewhat subjective, especially if there already was some kind of noticeable odor before you ever even took the sample. And now you're trying to just isolate on the KOH whiff test from something that was already filling up your nostrils.
Howard:Yeah, it's all more complicated than it seems at first blush, but that's a great review and I think that the AMSO criteria is what we'd be using at a point of care exam like this in a labor and delivery triage when you're screening these particular patients. So that's the criteria that folks need to think about. There are, of course, other ways of testing for BV, and there's even an argument to be made for empiric treatment. In many cases we have molecular tests that screen for the presence of a bacterium or bacteria, usually just Gardnerella, but some of them are expanded and they'll test for other atypical organisms as well.
Howard:To my knowledge, none of those give you instant answers like the AmELS criteria do. So that wouldn't be a point of care test. But the gold standard is probably the Nugent score. But these tests aren't being done for patients during obstetric triage. Essentially, all that's happening is the patient might have a little bit of discharge, probably because she's pregnant, and they're interpreting the contractions as a symptom of BV, which it isn't, and then, if they do a wet mount, they're seeing some clue cells or what they think are clue cells on microscopy and telling the patient that she has BV and then treating her for it.
Antonia:Yeah well, we don't have time to get into each one of these criteria and the positive predictive value and all of that stuff. But the general principle is remember that a patient needs a sufficient pre-test probability before you even perform a test. And if you distort that pre-test probability by assuming that the contractions alone are a symptom of BV, then you're going to over-diagnose patients with it and over-prescribe metronidazole, for example, and potentially cause harm with unnecessary metronidazole treatments. Maybe they'll have a bad reaction or a really intolerable side effect, maybe they'll develop some kind of resistance, maybe they'll get a yeast infection or maybe they'll just they'll be down the copay or on the large scale. Insurance is just going to waste more money on this useless test.
Antonia:And, in the same way, if you do collect those upfront tests that can't be collected after you do a vaginal exam so that might include a fetal fibronectin or something like an amnesia or amnesiob, you don't need to send them. You can collect and discard. If you collect them first, do your assessment and then decide. This is a low pretest probability. We could talk on maybe another episode in the future about the pros and cons of fetal fibronectin, especially in comparison with ultrasound for cervical length, but I'll briefly state that, right now at least, acog does not recommend fetal fibronectin as a routine way to screen for preterm labor. But we can talk more about that another day. So let's get on to our main topic. We wanted to talk about a couple articles, and then we do also have a couple good listener questions today.
Howard:All right. Well, in the May 28th edition of JAMA there is a review article of the Women's Health Initiative randomized trials plural, because there are, of course, many of them that were published over the years and, as you said, we've talked a lot about the WHI on this podcast over our many seasons. And one thing, people, and this new review is worthwhile despite all of that, because it really summarizes the collected data from many of these trials in one source, which is difficult to do. If you want to try to do this on your own, you might not even know what all the WHI publications are. All of these studies need to be taken in totality and they were published over many different years and I think a lot of times we cherry pick from one publication or another and not look at the data in its totality. Instead, a lot of folks just focus on what was initially said at the press conference back in 2002, when the data hadn't even been tabulated, and I think that's why there's so much misinformation about the WHI trials and the publications that came from that.
Howard:But this is a nice summary of the totality of what we've learned from WHI, again with its limitations. Now people forget that this trial was about more than just hormones. The study also looked at other things like diet and vitamin supplementation and how those things might affect women's cardiovascular health. Cardiovascular health was again the original intent of the study. They were trying to see if Premarin and PremPro would be positive for cardiovascular protection for patients which they thought it might be and were telling people it was before this trial was published. So they include a lot of information about supplements and dietary choices as a way of controlling for what seemed like obvious confounders for cardiovascular disease.
Antonia:They do say the trial does not support the use of hormone therapy to prevent cardiovascular disease or any other chronic disease, but that it is of course appropriate for bothersome vasomotor symptoms in patients that don't have contraindications to hormone therapy. But I think you're getting at something that really hasn't gotten as much coverage from the WHI as all of the hormone stuff. They say here in this review that it does not support routine supplementation with calcium or vitamin D to prevent fractures, nor does it support a low-fat diet or increased fruits and vegetables and grains, at least for the prevention of breast or colorectal cancer.
Howard:Yeah, that information has been sitting there for two decades now and we always talk about the WHI being the most important and largest trial about hormones at least about Premarin and Primpro and also maybe the most controversial trial about hormones, but we forget that it's also one of our largest sources of evidence that menopausal patients shouldn't be taking calcium and vitamin D routinely for the prevention of osteopenia and osteoporosis, and it turns out to be some of the most compelling evidence about the role of fiber and low-fat diets, at least related to the prevention of two important cancers, as you said breast and colorectal cancer. I think the internet is full of advice that high-fiber and low-fat diets prevent cancer, but in fact, our best longitudinally and prospectively controlled data in WHI actually says it doesn't.
Antonia:Yeah, this review article has a ton of other data about all the outcomes, but I would encourage people to go back to our third episode ever in season one and listen to that for a fuller discussion of all the side effects and stuff about hormones. But this new article is a great summary of all of that.
Howard:It's a good starting point before you delve further into each individual article and a good summary, as I said, of all these different publications over the years. It's also interesting to me that many folks who would routinely condemn hormone replacement therapy because it causes cancer or something like that, they cite the WHI as their evidence for that and often are misappropriately doing so or taking some data points out of context, but in the same breath, folks ignore the WHI when it contradicts some of the standard dietary advice given to patients. There's a lot of stuff on TikTok and Instagram and things like that that talk about that exact type of diet being a way of preventing cancer, of those particular cancers, while at the same time, hormones cause cancer, and so it's just contradictory and cherry picking and Instagram and TikTok is not a great place to learn about science.
Antonia:Yeah, Just don't listen to TikTok. Well, let's do the next article. So in the June 2024 green journal there is a nice expert review article about first trimester ultrasound screening in routine obstetric practice, and I know this is something you've been thinking about a lot and have written about in the past. So what did you think about that article?
Howard:Well, I did think it was a really great article and it shows all the potential value of first trimester anatomic ultrasounds and what you can see and what you can diagnose and things like that Now full disclosure. I've written I've been paid to write an article similar to this that goes through some of the usages of first trimester ultrasound for a large company that sells ultrasound machines, and so I have been reading a lot about this over the last couple of years and am fascinated by many of these things, and I do think it's very exciting, and the article really goes through step-by-step all the things that can now be detected with varying degrees of certitude during a first trimester, right around 12-week ultrasound, late first trimester. Now my problem, though, with the article is that the authors essentially it seems like they're wholeheartedly recommending that essentially everybody gets one of these, and that's where I think the real problem with the article is.
Antonia:Yeah, it definitely seems like even from early on you can tell they're advocating for it to be integrated into routine practice, even for the very lowest risk patients, and there aren't currently societal recommendations for this to be part of routine obstetric care currently societal recommendations for this to be part of routine obstetric care. So I think they just need to be more careful, considering practical and economic implications of this. So they say that the best time for this first trimester ultrasound to be done as a way to screen for anomalies would be right around 13 weeks. I think they said like 12 and a half to 13 and a half would be the most optimal. So that can be a little bit awkward timing compared to how things are typically done and, I think, a lot of clinics right now.
Antonia:So I ran through a few questions in my mind like what if we were to adopt this? Do you bring the patient in for confirmation of viability at 10 weeks before drawing the NIPT? Do you do just Doppler and then the labs and then back again at 13 weeks for this ultrasound? Or do you just send them straight to the lab at 10 weeks without an appointment? Hope you're not running the labs on a non-viable pregnancy since you couldn't confirm the viability yet, and then bring them in at 13 weeks for this ultrasound? Or do you make them wait to get both the ultrasound and the nipt labs at the same time at 13 weeks to consolidate things? Or do you just do this whole first trimester ultrasound thing at 10 weeks and possibly miss more anomalies since you're doing it earlier? So I I think the 13-week timing. I understand why it can catch more things, but how to shift practices to it, like they seem to be advocating for, is going to be something to figure out.
Howard:Well, I'm always the one with the more cynical view of a lot of these things, and I think that what they're envisioning is that you might see them at 10 to 11 weeks and run your NIPT and do all that and then refer them to their office two or three weeks later for the ultrasound, because that's the pattern they talks about the change in the rates of reporting nucleotranslucency measurements before and after the onset of cell-free DNA testing, these non-invasive prenatal tests or I guess really we should call them non-invasive prenatal screens.
Howard:And so, specifically, there's an article that says that the annual number of NT scans being performed in the United States has dropped from about 450,000 a year in 2012, and that was just before you started to see cell-free DNA technology become widespread to just over 100,000 or so a year in 2022. And that's a major change for maternal fetal medicine practices because, for the most part, all of those old NT scans, well, they were being done at a maternal fetal medicine practice, and that was because the scans required special certification and training to perform them, even though, for being honest, they aren't that difficult. But it was a nice referral base for MFMs that existed for many years and hundreds of thousands of patients nearly half a million patients a year were going almost always to an MFM getting this scan done as part of our old screening strategy for fetal aneuploidy. And then along came the cell-free DNA technology, which, at this point at least, is cheaper and significantly more accurate, and the only thing surprising to me about that article is that there's still 100,000 of these being done every year.
Antonia:Yeah, it's surprising to me too, now that you can do this full first trim, why not just do that?
Antonia:But we have talked about that before in a prior episode that even though that NT might provide some information about even other conditions besides aneuploidy, like severe heart defects, it's not currently recommended to be done as a routine screening in addition to NIPT, because it doesn't fulfill the criteria of a good screening test in and of itself. I know it's really the only option in triplet pregnancies because you can't do a reliable NIPT for that, but in really all other cases it's not adding anything. For one, it's already very rare to even have a severely thickened nuchal translucency, but most pregnancies that do have a severely abnormal measurement are going to miscarry, whether it's because aneuploidy or some other abnormality, well before even their 20 week scan and there's no intervention to prevent that. So it's. It doesn't make sense to have this highly specialized ultrasound measurement to be a routine part of prenatal care for something that there's no intervention for, and it's already a very rare thing that you're looking for to begin with.
Howard:Right, but if you're a maternal fetal medicine doctor, a big part of what you've been doing for the last several years was in how you finance your workflow and your practice setting is was taking these referrals, and that's been taken away, because generalist OBGYNs aren't referring patients for this screening for the most part anymore to the subspecialists because they can just order the non-invasive prenatal screen in their own office. But over the last decade, as ultrasound technology has improved at the time of those nucleotranslucency tests, we've found all sorts of other little neat tricks, little things that we've learned and can do fairly detailed examinations with a 12 to 13 week fetus. Now we of course know that a thickened NT can represent many other abnormalities besides Down syndrome and including severe cardiac defects, but you can also diagnose pretty easily things like gastroschisis or omphalocele, or certainly things like acrania, cystic hygromas, ectopia, cordis, amniotic band sequence, megacystitis, body stock anomalies, a lot of different things. And yes, I know, I said gastroschisis, that's actually how it's pronounced, so I don't want to sound stupid, but if you're not seeing gastroschisis, look it up.
Howard:We're also learning, though, that you can detect abnormally implanted pregnancies in cesarean scar niches and understand more today the correspondence of cesarean scar pregnancies with placenta accretus spectrum disorders.
Howard:So it's pretty cool to see all the things that you can potentially diagnose and there's a lot more than what I just listed. But the question is does it make sense that every patient in the US have this detailed ultrasound at 12 weeks and then another one at 18 to 20 weeks, along with non-invasive prenatal screening? Will you find enough things that change the course of the management of the pregnancy and is it cost effective to do that? And those questions can only be answered with clinical trials that assess those outcomes. So what bothers me is that the folks who might financially benefit from doing all these extra ultrasounds which are pretty cool and again I'm personally interested in them, especially in select patients who might have higher risk or be at risk for them but they're the ones recommending, without any scientific evidence, specifically the kind of trials that look at cost effectiveness and things like that that we adopt this as a universal part of prenatal care.
Antonia:Well, obviously in this article they didn't say this should be something that every general OBGYN sends every one of their routine OB patients to the MFM for they didn't say that. I'm sure you could try to read between the lines and read that out of it. My impression from this article was that they gave a short checklist of all of the structures and components of what would constitute this first trimester ultrasound. That also screens for anomalies, and my impression was this could be done by any sonographer that's been appropriately trained or any obstetric provider if they're doing the ultrasounds, and I think it could be essentially analogous to what we now might call the dating ultrasound or the viability confirmation ultrasound. At least where I'm at, I think we already keep our MFM consultants plenty busy. They don't seem to be asking for more business and I don't think they could handle us sending all of our patients to them for this scan.
Antonia:So I don't.
Howard:You're less cynical than I am.
Antonia:Well.
Howard:But I will say I will say. The reason why I say that, though, is these it is there is a learning curve, for sure, and it is something that will require most people to have additional training, and the thing about it is to me is I know how to do these things because I've been interested in it, but it's harder than an NT, and if people were sending their NTs to MFMs, I just think that's the way this is going to go, but I agree with you, it should be something that a general OBGYN should know how to do.
Antonia:Yeah, it's just the NT has to be so precise.
Antonia:I think people can do it, but they're probably afraid that if they just move the cursor just a half millimeter they'll miss something.
Antonia:Anyway, but that's how we got continuous electronic fetal monitoring as a universal part of obstetric care, without the scientific evidence to back it. So we can think through all sorts of anomalies that you just mentioned, for example, and that's not exhaustive list. And we can think through all sorts of anomalies that you just mentioned, for example, and there's that's not exhaustive list and we can think about what the management would be and how knowing about that at 12 weeks or 13 weeks or whenever it's done, would be so much better than knowing about it at 18 to 20 weeks. Unfortunately, many of these anomalies would have no potential prenatal intervention besides planning, mentally preparing or even just terminating the pregnancy, especially if it's a fatal anomaly, and I would never minimize the value of being able to do that so many weeks earlier. I think we just have to be economically smart about how to incorporate this testing so that we're still not overburdening the healthcare system by millions of extra dollars with a bunch of additional ultrasound visits and charges if we don't have to do it that way.
Howard:Yeah, the additional economic cost of this I would guess would be in the $500 to $800 range per pregnancy when you consider all the extra stuff generated from it, especially if this is going to maternal fetal medicine. And right now for a lot of Medicaid patients we're only getting $1,200 for the whole pregnancy, for 13 visits and a delivery in two postpartum visits. So this is not the place to spend extra money when we're desperately trying to take care of the patients we have with minimum resources. But that's it. And also I'll say that I've had this conversation with some MFMs who are involved in maybe changing some of the recommendations, and it's being talked about as a reproductive rights issue because, as you said, the main intervention that would come from this would be the earlier ability to terminate, and so anytime you bring up costs, the conversation shifts to abortion rights essentially. So that's also not a fair way of going about this. That's a shift in the conversation. That's unfair. But you're right, it is preferable. If you need to terminate an anomalous pregnancy, it's preferable to do that at 13 or 14 weeks than at 19 or 20 or 21 weeks, depending on when that mid-trimester ultrasound is. There's no doubt about that. The question again is just cost effectiveness. It's also true, as you mentioned about thickened NTs, that a lot of the anomalies that exist at 12 weeks won't exist at 15 weeks because the pregnancy won't survive to 15 weeks due to the severity of the anomaly. So the question for a lot of these other defects that we listed, and many more that we didn't, is how many of them would lead to an earlier termination that would have otherwise still been viable at 20 weeks and would have led to a termination then.
Howard:And how certain are we about the ultrasound findings at that earlier ultrasound? In other words, are we certain enough that with no follow-up we're going to go ahead and proceed with the termination of the pregnancy? Is there a chance of false positive findings that ultimately just cause some concern for no reason to patients? And of course there are easily definitively diagnosed severe anomalies that require no follow-up. For sure. Things like acrania comes to mind and in those cases if the patient chose termination they're likely very grateful to be able to proceed with that as early and as safely as possible. But there are other more vague and questionable findings in ultrasound that may put the patient in limbo of getting follow-up testing and still have what actually amounts to a longer drawn-out process when you get to the 18 or 20-week ultrasound and find out well, we were worried about nothing and that's when you get the answer. So, again, it's not about the theory of what we can see, it's about the pragmatic implementation.
Antonia:Yeah. So, for example, there could be a lot of cardiac abnormalities that are going to require follow-up well past 20 weeks to get a definitive diagnosis and prognosis. So in those cases the added value of that first trimester ultrasound is a little bit more questionable. But again, anything abnormal that the first trimester ultrasound could pick up is going to be pretty rare, pretty low incidence. An OBGYN might go four or five years in routine practice, or longer, before having a patient discover the severe type of abnormality that would show up on an early or even a second trimester ultrasound. That would be something lethal that they would consider termination for. So if this ultrasound is not something that you're already doing in your workflow for other purposes like dating or viability confirmation that you could easily adopt this new checklist for is it cost effective to add it in to what you're already doing as a whole new screening test for your entire population?
Howard:Right, and that's a good point If you're already doing an ultrasound at 12 weeks yeah.
Howard:Maybe the standard of care should be that you're not missing a cranias and other severe anomalies, Absolutely. The question is should you add it though, is the issue or another strategy might be doing? If this is one of the concerns is doing the ultrasound that traditionally is done at 18 to 20 weeks, more at 15 to 16 weeks and for patients of the right BMI, there's no reason why you can't merge 12 and 18 together and see everything you need to do and still just perform one ultrasound while getting some answers three or four or five weeks earlier. But even knowing that you could eventually spare someone from a 20 plus week termination. A lot of folks are having these at 20 weeks and then it takes an MFM consult and then now you're 22 weeks before you've got a definitive diagnosis and a decision to terminate. But even knowing that we could spare somebody from that later 20-plus week termination and it could be 22 weeks if you think about the real workflow where somebody got their anatomy scan at 20 weeks and then referred to MFM and then gets a definitive diagnosis Of course we want to spare a person from that later termination, which is just more difficult and more emotionally harmful and more physically harmful, but the question still is it worth applying this test to the whole general population?
Howard:Because it isn't free and there's a lot of other things we could spend that money on that might mean much more to our patients and more of our patients and improve their outcomes, than doing these extra additional first trimester ultrasounds.
Howard:And that's why we have to have cost effectiveness studies before adopting something like this into practice, and, whatever that cost is, we have to weigh it against other potential areas where we could have spent the same amount of money and made a more impactful difference, and that's the whole principle of medical justice. We have limited financial resources and we have labor and delivery units closing around the country due to a lack of funding, and spending three or four hundred thousand extra dollars perhaps in screening costs per extra earlier termination of pregnancy by three or four or five weeks may also be balanced by creating a lot of unnecessary anxiety about women with normal pregnancies, and so you have to have studies to really look at the cost benefit analysis of all that, and we need to spend that money where it most desperately needs to be spent, and I just don't think this is where it is as cool as I think it is.
Antonia:It is a cool article.
Howard:It absolutely is, and I, as I said, I've been learning and using a lot of these techniques for a while, but I'm not charging patients for it. Usually If I stick an ultrasound on and see somebody's 12-week pregnancy which I usually do then I look for as many of these things as I can pragmatically see, and I've been doing like 12-week gender ultrasounds for a long time and in all that time I've done thousands of those. I have picked up a couple of early gastroschises and a crania or two in all that time and done it at 12 or 13 weeks rather than later.
Antonia:Now, just as a caveat, it is hard to tell the gender at 12 weeks. Don't make that the standard that everyone comes expecting that.
Howard:Yeah, but my point is, I've done lots of these.
Antonia:I've done thousands of 12 or 13 week ultrasounds. Right yeah, so yeah, but it's not common or a hundred percent.
Howard:No, not.
Antonia:Yeah, Okay, but I am curious the few that you picked up doing that. Do you think that it changed the courses of those patients' pregnancies?
Howard:Well, of course, the patients with gastroschisis almost never terminate because there's a very fixable and survivable abnormality that you just mainly want to make sure there's appropriate delivery and planning for. And when termination for fetal anomalies was still legal in Tennessee, which it isn't now, of course, I'm not sure how much time and morbidity I might have saved the patients with lethal fetal anomalies who did terminate. But yeah, obviously a patient with a crania is likely to terminate. Yeah, well, in my shorter career I have seen one gastroschisis.
Antonia:Wow, I've never said it that way. Sounds weird. Sounds weird to say, right, yeah. It feels weird to say, well, I've seen a case of that where it was only detected at birth because the interpreting radiologist completely missed it at 20 weeks. That's in a place where radiologists were doing the anatomy scans. But who knows if a first trimester ultrasound would have caught it in that patient's case or not, maybe an extra set of eyes could have, or maybe it really was that subtle and that baby still did fine.
Antonia:It was just a shock. Obviously low-risk pregnancy. But I definitely have also seen cases of acrania where the patients learned of it at 20 weeks and they were not able to afford a termination that far along and so they carried on until they went into labor at full term and had to watch this baby die, which obviously was horrible. So I would never argue against the benefits of a first trimester ultrasound in that scenario where they could have afforded it and gone through with a safe first trimester termination of a lethal anomaly. But I believe the article quoted a pretty low detection rate with these.
Antonia:I think it was somewhere in the neighborhood of 50% of abnormalities that would be seen either at the 20-week ultrasound or maybe just present at birth that they could actually detect with this first trimester ultrasound. So it could also provide some false reassurance because that means there's a high rate of things being missed at that stage. And of course, in the case of the false positive findings we really should not underestimate the anxiety and stress of patients thinking there's something wrong for months and months potentially, when everything's actually fine. But I do think it's amazing how much anatomy you really can see in the first trimester. But again just back to our bottom line here is that we need to be responsible with our scarce economic resources.
Howard:Yeah, okay. Well, we do have a great listener. Question or two, let's see if we can get them both done.
Antonia:Let's do it.
Howard:All right, here's the first one. Hello, best OBGYN podcast. We were identified correctly First time caller, long time listener. First I'd like to send my appreciation for your all's content. I've heard you both speak at the annual clinical meeting in Nashville in 2019 as a resident and have tuned in ever since. I'm continuing to strive for that 97% vaginal hysterectomy rate and getting closer. I wonder if you can talk regarding implementation of postpartum sterilization procedures within an L&D unit. It's been a challenge to gain traction instilling such a practice into my facility, with resistance from providers citing variable L&D schedules, limited anesthesia support, unpredictable L&D OR utilization, etc. How can we provide this timely service for interested patients instead of the alternative of lengthy delays once they discharge? Thanks from one trying to tie up loose ends in Tennessee.
Antonia:That is a great tagline and our listener came up with it all themselves, so you're off the hook.
Howard:Yeah, I'm not good at it. So we encourage them to provide their own.
Antonia:Well, this issue they bring up is tricky and I think it seems to be a cultural thing as much as anything else. It was the same at my old hospital where I remember a lot of times charge nurses would just flat out refuse to let us do a postpartum tubal, like if we mentioned oh, this patient wants a tubal immediately, just nope, nope, not today. They'd say things like census is too high, we're just too busy, et cetera. But now at my current hospital I'm in a community hospital the patients really most of the time get their tubals done with no drama and it's just such a stark contrast. I was pleasantly surprised by it and I'm just not the slightest bit convinced that there actually are these resources reasons that you just can't do it at all.
Antonia:We definitely still have our busy days at my current hospital. There's days where every single room is full, triage is overflowing. We still get it done because we have to get it done. That's the mindset and I think maybe there's this is just my theory. Maybe there's more urgency in my current setting because everyone understands that if the patient doesn't get her requested sterilization now that they have to sign that Medicare paper 30 days in advance or more, they've signed for it. It's been the plan all the way along. We may never be able to do it. It's either now or never is how we look at it, and so I love this question because it's, I think, the perfect timing to address it, since there was just a research letter on this in the June 2024 Green Journal.
Howard:Yeah, so this research letter is entitled National Postpartum Permanent Contraceptive Practices and Perceived Barriers, and this was a survey of 109 academic medical centers. They had 68 respondents and 95% of them said that they offered postpartum sterilization, but 87% said that there was a problem with fulfillment at their institution and, as you said, the worst performing of these institutions said that there were cultural barriers that stood in the way of getting them done.
Antonia:Yeah, I think one of the limitations of this study and this research letter is that it's just from academic medical centers who had family planning specialists, so this does not represent the vast majority of labor and delivery units out there in this country, and that's a problem, I think, with a lot of published literature where the research comes from academic places which are the minority of what practices actually are. Community hospitals like where you and I work at, for example, or just smaller centers without all the subspecialists, could stand to learn a thing or two from the big academic centers that have a full research department, every single subspecialist. But I'd say, just as often the opposite can be true, and I suspect that academic medical centers are probably doing a whole lot worse with postpartum tubals than the small community centers are. But maybe that's just my current bias right now.
Howard:No, I think you're probably right. I have no problem doing postpartum tubals in my facility either, and my guess is that the barriers to fulfillment would be different in community hospitals or smaller centers than these large academic centers.
Howard:In the large academic centers the units are very busy and there are dedicated operating rooms and anesthesia services just for the maternity ward. They may still perceive that these resources are spread so thin that postpartum sterilization is an elective and delayable procedure. But compare that to smaller centers like mine or yours, where we don't even have I don't have dedicated maternity operating rooms.
Antonia:We have one, but yeah.
Howard:And it may be full right. So we just add the surgeries into the main operating room and obviously it helps if the delivery volume is lower and there isn't constantly a C-section or something else occupying your OR. But smaller hospitals can certainly get overrun on a busy night and usually the doctor is on double or triple duty. If they're on call or they may be in the clinic at the same time or in the OR at the same time, they're not just sitting around in the labor ward all day, and this happens to me all the time. I wouldn't do the tubal before an emergency cesarean, but I certainly prioritize the tubal to go as soon as possible after delivery so we can do it.
Antonia:Yeah, yeah. In that study, 86% of respondents said that OR availability was an issue and 78% said that they would have to use the labor and delivery anesthesia team. 75% said that the LND attending and residents were the ones who would be doing this surgery and 82% said they would use the same ORs as they normally would use for cesarean deliveries. So you can immediately see that if that unit is busy and there are patients you're thinking about doing a cesarean on that you're watching their labor closely. You may be constantly bumping the tubal because that seems less urgent, and then it could just get to the point where you've bumped it so long that now you're just going to decide to cancel it altogether and say let's just try it at six weeks instead.
Howard:Yeah, and something else, and maybe this is more true in the community hospital. The reasons are different. So, first, just the reimbursement for postpartum sterilization is poor, particularly if it's done on the same day of service as the delivery itself. And second, these procedures can be difficult to do, particularly if the patient's obese, and particularly if you're doing a complete salpingectomy rather than just a partial salpingectomy.
Antonia:Yeah. So in this research letter only 11% said that they thought the surgical skills were the barrier to getting it done. But I'm guessing that's a huge underestimate. I think that people are that this is actually a big underlying factor. But then people are don't want to say I just don't feel like I'm good at this surgery. So they talk about overall availability instead as a kind of a cop-out. But yeah, I agree that sometimes this takes longer than a C-section in certain situations.
Antonia:If this was universally just a quick, easy, fun surgery that everyone loves to do, I think providers would push a lot harder against someone telling them, no, we don't have the availability, and they would get these done more. So as simple as the procedure might sound, it can certainly be very difficult and people can really struggle with them and get frustrated because you are trying to do something through a smaller incision and that requires some more manipulation and troubleshooting and it is quicker and easier to do laparoscopically under general anesthesia. So then that's another scenario, I think, where the provider will just say let's just do it, then It'll be easier, for me at least. But for equipment and anesthesia safety reasons, we generally don't just pull in the whole laparoscopic tower and do these general laparoscopy in the immediate postpartum setting and, like I said, I think people will look for the slightest reasons in some cases, especially trainees who are still trying to learn this.
Antonia:I remember every time this would come up in the residency program I was just at, at least with certain residents their whole face would just fall like they'd have been up all night and they were on to do the tubal and like their soul would just leave their body the whole idea of struggling through a tiny umbilical incision and an awake patient.
Howard:Well, the question originally was how do we make this better and improve access for patients who want a sterilization procedure before they leave the hospital? Or perhaps what can large academic medical centers learn from smaller community hospitals that are doing a great job of this already? So I think issues like OR availability and nursing availability and all those things which were cited in the survey can be mitigated by use of the main operating room. It doesn't have to be the first choice, but if your labor and delivery ORs are occupied, then automatically just add it onto the main OR and make that an expectation.
Antonia:Yeah, and part of making that an expectation is emphasizing that access to immediate sterilization is not an elective procedure in the same way that breast augmentation is. It's actually urgent, and that is the term that ACOG uses for this. You have to think about it as it's now or never, because it oftentimes is so. It's just as important, if not more so, than so many of the other surgeries that are scheduled every day in operating rooms around the country. So I think it still comes back to a cultural issue.
Howard:Right. Well, if you move the case to the main operating room whenever there's resistance to scheduling, then that also. If anything helps your labor delivery nursing ratios at least for a little while they're gone. Another thing would be to involve your GYN team in doing these cases rather than your labor and delivery team. Labor and delivery is almost always more hectic than the gynecology service, especially if you're moving it to the main, just let the GYN team do it.
Antonia:Yeah, and I'm already forgetting. There's a difference, because you and me, we are the OB and the GYN team, and postpartum and triage and clinic when it's our turn to be on. So and circumcisions too. For me at least, all of those used to be different people on different teams where I was trained, but if you are in a setting where there are separate teams and you're having trouble with getting a postpartum tubal accommodated on labor and delivery, then maybe pass it on to the main OR and GIND team instead, because, like I said, most likely it's a lot more urgent than any of the other things they're doing. Maybe they're operating on a ruptured ectopic or something, but then follow that before you do the elective hysteroscopy or something. So let's address, though, how to make these easier to do and even enjoyable.
Howard:Well, I have a couple of pieces of advice for that, and we can post a video that I made a while ago that has four tips for easier postpartum sterilization although that's a salpingectomy, not a total partial salpingectomy, not a total salpingectomy. But one thing is to do this as close as possible to the time of delivery. I like to do them an hour or so after the patient's delivered. So if you're going to work on changing a culture or making this a more urgent procedure, then go for the gold and try to institutionalize getting them to the OR about an hour after they deliver. The uterus is still big at that time it's bigger than it will be the next morning. And after they deliver, the uterus is still big.
Antonia:At that time it's bigger than it will be the next morning and their epidural is more likely to work. So it's better than waiting, all right. What about in obese patients? This article did mention.
Howard:BMI as one contributing factor to these procedures going unfulfilled Right. And that gets to the skill issue. Partly, and people don't want again to say it, but when the patient's obese and all of these other soft barriers all of a sudden become mountains and obstacles to not do the case, they might not be honest about their motivation, but people really don't want to do postpartum sterilizations on obese patients. So I think optimizing technique can help with obese patients. But I'll also point out something that'll be obvious when I say it, but it's completely foreign to most folks Postpartum sterilization doesn't have to be through a mini laparotomy in the umbilicus.
Howard:If she's tiny and her uterus is shrunken down to five centimeters below the umbilicus already you can do it much lower, even down where you would normally cut a cesarean, if that's helpful, if you're doing it the next day, and in the opposite case it could be done laparoscopically for some obese patients, if that's the best option, and this shouldn't by any means become routine. But if you're not going to do a postpartum sterilization procedure because you don't think you can, because the patient is morbidly obese, and you're going to instead do an interval procedure six weeks later, well you might as well take her to the OR now and do a laparoscopic sterilization procedure the next morning after she delivered.
Antonia:Yeah and do a laparoscopic sterilization procedure the next morning after she delivered. Yeah, the only downside is that would take away the benefits of having the epidural already in place if they had one for labor. But a lot of times, even if the patients do have an epidural catheter in place, they still have to get general anesthesia anyway because the epidural just they can't dose it back up for whatever reason. And so if you're doing it under general and you're you just decide to do it laparoscopically say the next morning she's been NPO overnight you still probably don't make her length of stay any longer. So overall it's a huge benefit to the patient and the healthcare system. Financially.
Antonia:I haven't done this personally, but with obese patients I remember where I trained a lot of my attendings. Would they just had this cutoff BMI 40,? No, we are not doing this. But where I'm at now the average BMI is pretty high and if I said no to every BMI 40, I wouldn't be doing these at all. But I just tell patients I might have to make a slightly bigger incision. It doesn't end up being that big and it's just slightly bigger than two to three centimeters and it still looks fairly small when you get it done.
Howard:Yeah, so right, you can still do that, and so these are just options, and my point, though, is that we shouldn't be denying sterilizations just because the patient's obese. That's something that it's our job to know how to overcome, and, all that being said, again, this doesn't need to become routine. I've only done this once in my career, where I did laparoscopy because the patient's BMI was probably 65. And I just felt that was the best way. So you can do most of them, as you said, still through the umbilicus, albeit with a slightly larger incision.
Antonia:Yeah, I don't think I've had someone with that big of a BMI, so I'll remember the laparoscopy next time. So plenty to think about here. Hopefully this helps our listener along. So I think we were going to do another question, but we're a little bit out of time so we're going to save it for the next one. We promise it was a really good one, but for now we'll close up the Thinking About OBGYN website. We'll have links to the things we talked about studies and videos and we'll be back in a couple of weeks and we'll get to this next listener question next time.
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