A multigravida presented for a 13-week abortion. The surgeon noted a transverse vaginal septum with small central perforation at the time of bimanual exam. The surgeon performed dilation and suction curettage through the septum without resection in the outpatient setting.

OBJECTIVE To evaluate whether ulipristal acetate reduces the number of bleeding days in etonogestrel implant users in a 30-day period as compared with placebo. METHODS We performed a single-center, randomized, double-blind, placebo-controlled trial. Eligible participants were women aged 18-45 years with an etonogestrel implant in place for greater than 90 days and less than 3 years who reported greater than one bleeding episode in a 24-day period. Enrolled participants were randomized to receive 15 mg ulipristal acetate compared with an identical-appearing placebo daily for 7 days. Participants completed daily bleeding diaries using automated text messaging to evaluate whether ulipristal acetate reduces the number of bleeding days as compared with placebo. Secondary outcomes included participant satisfaction with bleeding and the effect of ulipristal acetate on ovulation status. A sample size of 52 per group (n=104) was planned, calculated with an effect size of a 30% reduction in bleeding days, SD of 10 days, and dropout of 15%. Our study was terminated early (N=65) as a result of a U.S. Food and Drug Administration hold, but power was sufficient for analysis. The effect of ulipristal acetate on ovulatory potential was evaluated in a subset with weekly serum progesterone. RESULTS From May 2017 to January 2018, 65 women were allocated to receive 15 mg ulipristal acetate (n=32) or placebo (n=33) daily for 7 days. Demographic characteristics were similar between groups. Women randomized to ulipristal acetate reported 5 fewer days of bleeding over a 30-day reference period after treatment (P=.002). At the conclusion of the 30-day follow-up period, women in the ulipristal acetate group were more satisfied with their bleeding profile than the placebo group (87.5% vs 60%, respectively; P<.001). Serum progesterone levels were nonovulatory in a subset of each group (placebo group range: less than 0.2-1.3 ng/mL; ulipristal acetate group range: less than 0.2-4.4 ng/mL). CONCLUSION Ulipristal acetate is well-tolerated and reduced the number of bleeding days in etonogestrel implant users in our study. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT03118297.

Background: The objective of the study was to estimate the personal usage of long-acting reversible contraception (LARC) among obstetrics and gynecology (Ob/Gyn) residents in the United States and compare usage between programs with and without a Ryan Residency Training Program (Ryan Program), an educational program implemented to enhance resident training in family planning.Materials and methods: We performed a web-based, cross-sectional survey to explore contraceptive use among Ob/Gyn residents between November and December 2014. Thirty-two Ob/Gyn programs were invited to participate, and 24 programs (75%) agreed to participate. We divided respondents into two groups based on whether or not their program had a Ryan Program. We excluded male residents without a current female partner as well as residents who were currently pregnant or trying to conceive. We evaluated predictors of LARC use using bivariate analysis and multivariable Poisson regression.Results: Of the 638 residents surveyed, 384 (60.2%) responded to our survey and 351 were eligible for analysis. Of those analyzed, 49.3% (95% confidence interval [CI]: 44.1%, 54.5%) reported current LARC use: 70.0% of residents in Ryan Programs compared to 26.8% in nonRyan Programs (RRadj 2.14, 95% CI 1.63-2.80). Residents reporting a religious affiliation were less likely to use LARC than those who described themselves as non-religious (RRadj 0.76, 95% CI 0.64-0.92). Of residents reporting LARC use, 91% were using the levonorgestrel intrauterine device.Conclusion: LARC use in this population of women's health specialists is substantially higher than in the general population (49% vs. 12%). Ob/Gyn residents in programs affiliated with the Ryan Program were more likely to use LARC.

Nearly 20% of women using contraception are using progestin-only contraception, including progestin-only pills, depot-medroxyprogesterone acetate, subdermal etonogestrel implants, and levonorgestrel intrauterine devices. This number will continue to grow with the increased provision of long-acting reversible contraception. Although overall satisfaction among women using progestin-only contraception is high, dissatisfaction and discontinuation may be associated with unscheduled bleeding and spotting. The exact etiology of irregular bleeding associated with progestin-containing contraceptives is not completely understood, yet several mechanisms have been suggested. Several therapies targeting these mechanisms have been evaluated with mixed results. This paper will review the physiology and management of unscheduled bleeding with progestin-containing contraceptives.

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Salmeen K, Brincat C. Time from consent to cesarean delivery during labor. Am J Obstet Gynecol 2013;209:212.e1-6.

The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed:Salmeen K, Brincat C. Time from consent to cesarean delivery during labor. Am J Obstet Gynecol 2013;209:212.e1-6. The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Salmeen K, Brincat C. Time from consent to cesarean delivery during labor. Am J Obstet Gynecol 2013;209:212.e1-6. See related article, page 212Discussion Questions■How important is this study question?■What was the study design?■What is Winsorizing?■What were the study results?■What are the strengths and limitations of this study?■What further research would you recommend? See related article, page 212 ■How important is this study question?■What was the study design?■What is Winsorizing?■What were the study results?■What are the strengths and limitations of this study?■What further research would you recommend? Informed consent is "both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states," notes the American Medical Association. Along with the diagnosis, physicians are to detail the therapeutic route under consideration and alternatives—what these are, why they are used, the risks and benefits of each option. The risks and benefits of forgoing treatment should also be discussed. Patients then need a chance to ask questions. But how long do patients have to contemplate what they've been told, especially in emergent situations? Journal Club members discussed a new study that explored this question. Researchers Salmeen and Brincat examined the informed consent process among laboring women who had an unscheduled cesarean section. Discussants agreed that this was a timely and important issue in medicine; especially in obstetrics, where obtaining consent is an everyday issue. The main aim of the study was to determine the amount of time that passed between consent to surgery and incision. In addition, the investigators looked at whether certain factors put women at higher risk for particularly short consent times. In explaining their work, they state that "although the practice of obtaining informed consent for cesarean delivery during labor is common, the process has not previously been described in the literature." In this retrospective observational cohort investigation, 63% of the women in the study population were white, and the average age was 29 years. Notably, 52% had a body mass index that characterized them as obese; 31% were overweight. Most were nulliparous and on average, the women were carrying a full-term pregnancy. The study site was an academic center with a moderate volume of 4000 deliveries per year. Subjects were drawn from the medical records of all cesarean deliveries performed in 2004. After excluding all scheduled cesarean deliveries, the authors then chose the first 100 cesarean deliveries performed for urgent indications. Nine were then excluded for missing or incomplete medical records. Another patient was excluded because she consented to cesarean delivery during a prenatal admission that took place prior to the start of labor. To obtain the time data most critical to the study question, the authors preferred to use the time documented on the consent forms. When the time was not provided on the consent form, the authors took the time associated with documentation of consent from nursing or physician labor notes, flow sheets, and operating room records. The main finding was that, in the authors' opinion, time for informed consent was suboptimal. Overall, the median time from consent to surgery was 48 minutes. Consent time was significantly shorter for women undergoing cesarean section for fetal indications, which is in line with what we see clinically. Both a fetal heart rate indication for delivery and use of fetal scalp electrodes were significantly associated with increased odds for <30 min of consent time. Journal club participants felt that the study findings argued for obtaining consent for cesarean delivery during outpatient prenatal visits if possible. They recognized that this may be difficult to achieve 100% of the time. Members lauded the authors for tackling an understudied question. One limitation raised was that this study measured time but not necessarily quality of the consent process. Participants also agreed that further work is needed in this area, including studies focused on assessing the quality of the consent process and women's post-delivery perceptions of this essential exchange. Discussion: 'Time from consent to cesarean delivery,' by Salmeen et alAmerican Journal of Obstetrics & GynecologyVol. 209Issue 3PreviewIn the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Salmeen K, Brincat C. Time from consent to cesarean delivery during labor. Am J Obstet Gynecol 2013;209:212.e1-6. Full-Text PDF

Background Neurogenesis, the production of neural cell-types from neural stem cells (NSCs), occurs during development as well as within select regions of the adult brain. NSCs in the adult subependymal zone (SEZ) exist in a well-categorized niche microenvironment established by surrounding cells and their molecular products. The components of this niche maintain the NSCs and their definitive properties, including the ability to self-renew and multipotency (neuronal and glial differentiation). Results We describe a model in vitro NSC niche, derived from embryonic stem cells, that produces many of the cells and products of the developing subventricular zone (SVZ) and adult SEZ NSC niche. We demonstrate a possible role for apoptosis and for components of the extracellular matrix in the maintenance of the NSC population within our niche cultures. We characterize expression of genes relevant to NSC self-renewal and the process of neurogenesis and compare these findings to gene expression produced by an established neural-induction protocol employing retinoic acid. Conclusions The in vitro NSC niche shows an identity that is distinct from the neurally induced embryonic cells that were used to derive it. Molecular and cellular components found in our in vitro NSC niche include NSCs, neural progeny, and ECM components and their receptors. Establishment of the in vitro NSC niche occurs in conjunction with apoptosis. Applications of this culture system range from studies of signaling events fundamental to niche formation and maintenance as well as development of unique NSC transplant platforms to treat disease or injury.