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A Look at Pregnancy-Related Attrition in General Surgery

A Look at Pregnancy-Related Attrition in General Surgery

Studies show that attrition from general surgery programs is high, even with the introduction of work-hour limitations and new restrictions on hours for general surgery residents. Research has also shown that many factors play a role in residency attrition, most notably lifestyle considerations. Several studies have linked female sex to an increased risk of attrition, but not all research has corroborated this relationship. “Women still represent the minority among surgical residents throughout the United States,” says Erin G. Brown, MD. “There are many stereotypes regarding attrition among female residents, including pregnancy during residency being a risk factor for attrition.” Exploring the Issue A significant number of residents report being perceived negatively if they become pregnant during training, according to some investigations. “Since more women are entering medicine, it’s important to examine the potential links between sex, pregnancy, and attrition,” says Dr. Brown. To address this research gap, Dr. Brown and colleagues conducted a study to determine whether child rearing during training increased the risk of attrition from general surgery residency. The study, published in JAMA Surgery, was a retrospective review of general surgery residents at the University of California, Davis over a 10-year period. The study team analyzed voluntary and involuntary attrition rates as well as the incidence of child rearing among residents. “Our study found that neither sex nor child rearing was a risk factor for attrition in general surgery residencies,” Dr. Brown says. Overall, the attrition rate for women was not significantly different from the proportion of men who left the general surgery residency program. The attrition rate, which was 18.8%, was comparable with rates published in...
Pregnancy-Related Deaths Rising in the U.S.

Pregnancy-Related Deaths Rising in the U.S.

To a physician, any disease-related death is one too many. But death is a certainty of life; and despite best efforts, deaths from cancer, heart disease and/or Alzheimer’s are more readily understood, albeit painfully accepted. Not so with death near the time of birth. To hear that a woman has died during her pregnancy, or shortly after giving birth, is seemingly more stunning to the senses. But all physicians and the general public need to take note of a statistic that, for years, has gone unnoticed by many: There has been a persistent increase in maternal mortality from pregnancy-related causes. A “pregnancy-related death” is defined as “death of a woman while pregnant or within 1 year of pregnancy termination—regardless of the duration or site of the pregnancy—from any cause related to, or aggravated by, the pregnancy or its management, but not from accidental or incidental causes.” Since 1990, the rate of pregnancy-related deaths for all women in the United States has essentially doubled, according to the Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System. Between 1987-1990, the rate was 9.1 pregnancy-related deaths per 100,000 live births; the rate in 2011 was 17.8/100,000 (Figure 1). (2) CDC researcher Dr. Andreea Creanga and colleagues published this data in the American College of Obstetricians and Gynecologists’ January 2015 issue of Obstetrics & Gynecology. The data indicate that pregnancy-related mortality increased for all American women and within all age groups. The greatest threat is in women 40 years of age and older, regardless of race (Figure 2). (1) The increase of deaths in women of advanced maternal age is not surprising. American...
A Look at Opioid Use During Pregnancy

A Look at Opioid Use During Pregnancy

According to NIH data, prescriptions for opioids have increased dramatically in the general population, rising by more than 200 million between 1991 and 2009. In 2014, the American Society of Anesthesiologists distributed a list as part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign to help physicians and patients engage in conversations about treatments or medications that are commonly prescribed in pain medicine but are not always necessary. The list noted that opioid analgesics should not be prescribed as first-line therapy to treat chronic non-cancer pain. Little is known, however, about the use of opioids during pregnancy. Assessing Prevalence & Patterns of Opioid Use In a study by Brian T. Bateman, MD, MSc, and colleagues, researchers sought to define the prevalence and patterns of opioid use in a large cohort of pregnant women. Published in Anesthesiology, the study looked at data from more than 530,000 pregnant women enrolled in commercial insurance plans who delivered babies between 2005 and 2011. “We found that 14.4% of pregnant women were prescribed opioids at some point in their pregnancy,” says Dr. Bateman. “Most opioid exposures were for short courses, typically lasting less than a week.” The study also found that 5.7% of women were given an opioid in the first and second trimester, and 6.5% were given one in the third trimester. Overall, 2.2% were dispensed opioids three or more times during their pregnancy. Back pain was the most common condition for which opioids were prescribed. Other conditions included abdominal pain, migraine, joint pain, and fibromyalgia. Rates of opioid use also varied throughout the United States, with the highest occurring...
Detecting and Managing Preeclampsia

Detecting and Managing Preeclampsia

As one of the leading causes of maternal mortality worldwide, pre-eclampsia does not distinguish between social status, and its causes are poorly understood. Hypertension higher than 140 mmHg systolic and 90 mmHg diastolic that occurs after the 20-week gestational period and ends post-partum is pregnancy induced. In the U.S., pre-eclampsia and eclampsia are responsible for over 17% of maternal deaths. Patients with pre-eclampsia present with proteinuria, visual disturbances, headaches, and edema. From the point of diagnosis, careful monitoring and management are required to preserve the health of the mother and fetus. As a condition that may be caused by the trophoblastic invasion of the spiral arterioles at the site of the placenta, pre-eclampsia can hinder fetal development. The mother is at risk of grandmal seizures, general organ malfunction due to impaired circulation, and severe neurological manifestations. The severity of this condition means that those working with pregnant women at a primary and secondary care level need to play a role in monitoring its emergence and managing it if it does occur. The Latest ACOG Guidelines on Diagnosing Pre-eclampsia The Committee on Practice Bulletins–Obstetrics of the American College of Obstetricians and Gynecologists (ACOG) has developed a practice bulletin on the diagnosis and management of pre-eclampsia and eclampsia. While Pregnancy Induced Hypertension (PIH) is present when a woman’s blood pressure rises above 140/90 mmHg after the 20-week period, there are stricter criteria for diagnosing severe pre-eclampsia that require careful monitoring. Systolic blood pressure of 160 mmHg or higher on one occasion or diastolic blood pressure of 110 mmHg or higher on two or more occasions can lead to a pre-eclampsia diagnosis. Proteinuria of 5g or higher in...

A Look at Near-Miss Mortality and Morbidity in Pregnancy

Previous research suggests that timely delivery of appropriate healthcare services may prevent almost half of all pregnancy-related deaths in the United States. Although maternal deaths are increasingly attributed to preexisting condi­tions, the relative effect of these conditions and the extent to which maternal morbidity and mortality are concentrated in high-risk patients have not been well defined. Focusing on Near-Miss Pregnancy Events Jill M. Mhyre, MD, and colleagues had a study published in the November 2011 issue of Anesthesiology that sought to iden­tify which preexisting conditions predicted maternal morbidity, mortality, and “near- miss” events. A near miss occurs when preg­nant women or recently postpartum women survive a life-threatening event, either because of high-quality medical care or by chance alone. “In our study, we investigated women who died as well as those who sur­vived an event in the hopes of uncovering important lessons with regard to predicting outcomes and preventing progression from near misses to death,” says Dr. Mhyre. A near miss was defined as end-organ injury that impacted hospital discharge. The highest rates of near-miss morbidity or mortality events were found among women with pulmonary hypertension (PH), malig­nancy, and systemic lupus erythematosus (Table). Advancing maternal age and non-white race also increased risk for near-miss morbidity or mortality. “While the effect sizes we observed for age and race were relatively modest when compared with certain medical conditions, these effects remained statistically significant even after controlling for all other medical and obstet­ric conditions,” Dr. Mhyre says. “The abso­lute rate per thousand deliveries increased three-fold when age older than 40 was com­pared with ages 20 to 34, but the adjusted odds ratio was...
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