By Rebecca H. Allen, MD, MPH
Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports she receives grant/research support from Bayer and is a consultant for Merck.
In this retrospective cohort study of 279 women undergoing postpartum partial salpingectomy after vaginal delivery, the mean operative time for women with a BMI ≥ 30 kg/m2 was only 5.5 minutes longer than the time for women with a BMI < 30 kg/m2.
Deshpande NA, et al. Relationship between body mass index and operative time in women receiving immediate postpartum tubal ligation. Contraception 2019;100:106-110.
This was a retrospective cohort study conducted at the University of Pennsylvania between April 2013 and March 2017 of all women who underwent postpartum tubal ligation following a vaginal delivery. All procedures utilized the Pomeroy or Parkland method; no bilateral salpingectomies were performed. Women were excluded if their body mass index (BMI) was not documented at hospital admission for the delivery or if there was no operative or anesthesia record in the chart. The authors used the electronic medical record to abstract data on demographics, clinical characteristics, and the surgical procedure. The primary outcome was operative time, defined as incision time to closure time. The relationship between BMI and operative time was evaluated with multivariable linear regression adjusting for parity, prior abdominal surgery, age, time from vaginal delivery to postpartum tubal ligation (hours), quarter of the academic year, and patient race. The authors performed a secondary analysis evaluating a non-inferiority margin of 10 minutes operative time between women with a BMI ≥ 30 kg/m2 and a BMI < 30 kg/m2 and women with a BMI ≥ 40 kg/m2 and a BMI < 40 kg/m2.
A total of 279 women were included in the study with the following distribution: BMI < 25 kg/m2 (n = 29, 10%), BMI 25-29.9 kg/m2 (n = 79, 28%), BMI 30-34.9 kg/m2 (n = 103, 37%), BMI 35-39.9 kg/m2 (n = 44, 16%), and BMI ≥ 40 kg/m2 (n = 24, 9%). The majority of procedures were performed on postpartum day 0 (71.3%), and all attempted procedures were completed. The mean total operative time was 46.1 minutes (95% confidence interval [CI], 43.7-48.6) for women with a BMI ≥ 30 kg/m2 and 40.6 minutes (95% CI, 37.9-43.4) for women with a BMI < 30 kg/m2. This difference was within the pre-specified 10-minute noninferiority margin (P < 0.01). There was a 35-second increase in procedure time per unit of BMI. Women with a BMI ≥ 40 kg/m2 had a mean operative time of 48.2 minutes (95% CI, 42.3-54.0). Complication rates did not differ across BMI categories. The first and second academic quarters were associated with increased operative time and when controlled for, the difference in operative time between women with BMI ≥ 30 kg/m2 and BMI < 30 kg/m2 was reduced to 4.1 minutes (P > 0.01).
COMMENTARY
In the United States, postpartum partial salpingectomy is performed after 8-9% of all deliveries, representing half of all permanent contraceptive procedures.1 A recent U.S. study from 2008 to 2013 estimated postpartum permanent contraception rates to be 683-711 per 10,000 deliveries.2 The procedure was more common in women 35 years of age and older and during cesarean compared to vaginal delivery. Overall, postpartum tubal sterilization is convenient for the mother since she is already in the hospital for the delivery. The advantages of doing the procedure immediately postpartum are that existing epidural anesthesia potentially can be used and the woman does not have to restrict food and drink in preparation for the procedure another day.3
Despite the fact that the American College of Obstetricians and Gynecologists (ACOG) considers postpartum permanent contraception to be an “urgent” not “elective” procedure given the risks of unintended pregnancy in the future,4 many hospitals do not prioritize postpartum requests.5 It is estimated that approximately half of women who desire postpartum permanent contraception do not obtain the procedure for logistical issues, obstetric complications, medical reasons, or lack of a correctly signed federal sterilization consent form dated between 30 days and 180 days prior to the procedure if they have Medicaid insurance.5-8
One reason women may not undergo their desired procedure is obesity.7 This may be due to the surgeon’s reluctance to take on what he or she perceives to be a more difficult case for fear of not being able to complete the procedure or an increased risk of complications. Therefore, the authors of this study wanted to assess the relationship between BMI and operative time, using operative time as a proxy for the difficulty of the procedure. They found a difference in mean operative time of 5.5 minutes between the two groups (BMI < 30 kg/m2 and BMI ≥ 30 kg/m2), which was not clinically significant in their opinion. The authors reported that the procedures were performed by a diverse group of residents, fellows, and attendings at the hospital, which increases generalizability.
The limitations of the study included the fact that, as a retrospective study, there was no way to know how patients were selected for postpartum tubal ligation. It could be that only the most favorable patients were taken to surgery based on fundal height and abdominal examination. It is also unknown how many obese patients were denied procedures. Additionally, there is no information from the surgeon regarding their perception of the difficulty of the procedure. The use of operative time as a proxy measure of surgical complexity has certain flaws. Nevertheless, the findings are reassuring, and, anecdotally, we could do more to expand access to these procedures for obese women. We also should make sure that women who desire postpartum sterilization have a backup plan in case the sterilization does not happen. Offering immediate postpartum IUD or contraceptive implant insertion can provide an equally effective alternative if the desired sterilization is not completed. In addition, ACOG suggests working with hospital delivery units and obstetric anesthesia personnel to make the procedure a priority.4
REFERENCES
- Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril 2010;94:1-6.
- Moniz MH, et al. Inpatient postpartum long-acting reversible contraception and sterilization in the United States, 2008-2013. Obstet Gynecol 2017;129:1078-1085.
- Goodman EJ, Dumas SD. The rate of successful reactivation of labor epidural catheters for postpartum tubal ligation surgery. Reg Anesth Pain Med 1998;23:258-261.
- American College of Obstetricians and Gynecologists. Committee opinion no. 530: Access to postpartum sterilization. Obstet Gynecol 2012;120:212-215.
- Zite N, et al. Barriers to obtaining a desired postpartum tubal sterilization. Contraception 2006;73:404-407.
- Thurman AR, et al. Unfulfilled postpartum sterilization requests. J Reprod Med 2009;54:467-472.
- Boardman LA, et al. Barriers to completion of desired postpartum sterilization. R I Med J 2013;96:32-34.
- Wolfe KK, et al. An updated assessment of postpartum sterilization fulfillment after vaginal delivery. Contraception 2017;96:41-46.
