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Publisher: Elsevier   (Total: 3030 journals)

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Showing 1 - 200 of 3030 Journals sorted alphabetically
AASRI Procedia     Open Access   (Followers: 15)
Academic Pediatrics     Hybrid Journal   (Followers: 20, SJR: 1.402, h-index: 51)
Academic Radiology     Hybrid Journal   (Followers: 16, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 79, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 22, SJR: 0.612, h-index: 27)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 27, SJR: 2.515, h-index: 90)
Achievements in the Life Sciences     Open Access   (Followers: 4)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 5, SJR: 0.338, h-index: 19)
Acta Astronautica     Hybrid Journal   (Followers: 303, SJR: 0.726, h-index: 43)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 3)
Acta Biomaterialia     Hybrid Journal   (Followers: 25, SJR: 2.02, h-index: 104)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription  
Acta de Investigación Psicológica     Open Access   (Followers: 2)
Acta Ecologica Sinica     Open Access   (Followers: 8, SJR: 0.172, h-index: 29)
Acta Haematologica Polonica     Free   (SJR: 0.123, h-index: 8)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.604, h-index: 38)
Acta Materialia     Hybrid Journal   (Followers: 196, SJR: 3.683, h-index: 202)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.615, h-index: 21)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.442, h-index: 21)
Acta Oecologica     Hybrid Journal   (Followers: 9, SJR: 0.915, h-index: 53)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription   (Followers: 1)
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 3, SJR: 0.311, h-index: 16)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 2)
Acta Poética     Open Access   (Followers: 4)
Acta Psychologica     Hybrid Journal   (Followers: 21, SJR: 1.365, h-index: 73)
Acta Sociológica     Open Access  
Acta Tropica     Hybrid Journal   (Followers: 5, SJR: 1.059, h-index: 77)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 4)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 3)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.383, h-index: 19)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 2)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 5, SJR: 0.141, h-index: 3)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 4, SJR: 0.112, h-index: 2)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 4)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.967, h-index: 57)
Addictive Behaviors     Hybrid Journal   (Followers: 15, SJR: 1.514, h-index: 92)
Addictive Behaviors Reports     Open Access   (Followers: 5)
Additive Manufacturing     Hybrid Journal   (Followers: 7, SJR: 1.039, h-index: 5)
Additives for Polymers     Full-text available via subscription   (Followers: 20)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 120, SJR: 5.2, h-index: 222)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 11, SJR: 1.265, h-index: 53)
Advanced Powder Technology     Hybrid Journal   (Followers: 16, SJR: 0.739, h-index: 33)
Advances in Accounting     Hybrid Journal   (Followers: 8, SJR: 0.299, h-index: 15)
Advances in Agronomy     Full-text available via subscription   (Followers: 15, SJR: 2.071, h-index: 82)
Advances in Anesthesia     Full-text available via subscription   (Followers: 24, SJR: 0.169, h-index: 4)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 3)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 6, SJR: 1.054, h-index: 35)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 10, SJR: 0.801, h-index: 26)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 21, SJR: 1.286, h-index: 49)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 16, SJR: 3.31, h-index: 42)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.277, h-index: 43)
Advances in Botanical Research     Full-text available via subscription   (Followers: 3, SJR: 0.619, h-index: 48)
Advances in Cancer Research     Full-text available via subscription   (Followers: 26, SJR: 2.215, h-index: 78)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 0.9, h-index: 30)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 2.139, h-index: 42)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 12)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 24, SJR: 0.183, h-index: 23)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.665, h-index: 29)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 8, SJR: 1.268, h-index: 45)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 28, SJR: 0.938, h-index: 33)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 18, SJR: 2.314, h-index: 130)
Advances in Computers     Full-text available via subscription   (Followers: 16, SJR: 0.223, h-index: 22)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 11)
Advances in Digestive Medicine     Open Access   (Followers: 4)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 5)
Advances in Drug Research     Full-text available via subscription   (Followers: 22)
Advances in Ecological Research     Full-text available via subscription   (Followers: 39, SJR: 3.25, h-index: 43)
Advances in Engineering Software     Hybrid Journal   (Followers: 25, SJR: 0.486, h-index: 10)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 7)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 38, SJR: 5.465, h-index: 64)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 3)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 8)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 41, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 14)
Advances in Genetics     Full-text available via subscription   (Followers: 15, SJR: 2.558, h-index: 54)
Advances in Genome Biology     Full-text available via subscription   (Followers: 11)
Advances in Geophysics     Full-text available via subscription   (Followers: 6, SJR: 2.325, h-index: 20)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 18, SJR: 0.906, h-index: 24)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 0.497, h-index: 31)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 22)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 2, SJR: 0.396, h-index: 27)
Advances in Immunology     Full-text available via subscription   (Followers: 33, SJR: 4.152, h-index: 85)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 1.132, h-index: 42)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 3, SJR: 1.274, h-index: 27)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 4)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 4)
Advances in Life Course Research     Hybrid Journal   (Followers: 7, SJR: 0.764, h-index: 15)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 16, SJR: 1.645, h-index: 45)
Advances in Mathematics     Full-text available via subscription   (Followers: 10, SJR: 3.261, h-index: 65)
Advances in Medical Sciences     Hybrid Journal   (Followers: 5, SJR: 0.489, h-index: 25)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 5)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 4, SJR: 1.44, h-index: 51)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 21)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 10)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 6, SJR: 0.324, h-index: 8)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 3)
Advances in Oncobiology     Full-text available via subscription   (Followers: 3)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 15, SJR: 2.885, h-index: 45)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.148, h-index: 11)
Advances in Parasitology     Full-text available via subscription   (Followers: 7, SJR: 2.37, h-index: 73)
Advances in Pediatrics     Full-text available via subscription   (Followers: 20, SJR: 0.4, h-index: 28)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 14)
Advances in Pharmacology     Full-text available via subscription   (Followers: 13, SJR: 1.718, h-index: 58)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 7, SJR: 0.384, h-index: 26)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.248, h-index: 11)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 8)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 5)
Advances in Porous Media     Full-text available via subscription   (Followers: 4)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 18)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 17, SJR: 1.5, h-index: 62)
Advances in Psychology     Full-text available via subscription   (Followers: 56)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 5, SJR: 0.478, h-index: 32)
Advances in Radiation Oncology     Open Access  
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 1, SJR: 0.1, h-index: 2)
Advances in Space Research     Full-text available via subscription   (Followers: 332, SJR: 0.606, h-index: 65)
Advances in Structural Biology     Full-text available via subscription   (Followers: 7)
Advances in Surgery     Full-text available via subscription   (Followers: 6, SJR: 0.823, h-index: 27)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 28, SJR: 1.321, h-index: 56)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 14)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 12)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 1.878, h-index: 68)
Advances in Water Resources     Hybrid Journal   (Followers: 42, SJR: 2.408, h-index: 94)
Aeolian Research     Hybrid Journal   (Followers: 5, SJR: 0.973, h-index: 22)
Aerospace Science and Technology     Hybrid Journal   (Followers: 304, SJR: 0.816, h-index: 49)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.318, h-index: 36)
African J. of Emergency Medicine     Open Access   (Followers: 4, SJR: 0.344, h-index: 6)
Ageing Research Reviews     Hybrid Journal   (Followers: 7, SJR: 3.289, h-index: 78)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 390, SJR: 1.385, h-index: 72)
Agri Gene     Hybrid Journal  
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 15, SJR: 2.18, h-index: 116)
Agricultural Systems     Hybrid Journal   (Followers: 29, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 36, SJR: 1.546, h-index: 79)
Agriculture and Agricultural Science Procedia     Open Access  
Agriculture and Natural Resources     Open Access   (Followers: 1)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 48, SJR: 1.879, h-index: 120)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.434, h-index: 14)
Air Medical J.     Hybrid Journal   (Followers: 3, SJR: 0.234, h-index: 18)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.285, h-index: 3)
Alcohol     Hybrid Journal   (Followers: 9, SJR: 0.922, h-index: 66)
Alcoholism and Drug Addiction     Open Access   (Followers: 5)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 1, SJR: 0.436, h-index: 12)
Alexandria J. of Medicine     Open Access  
Algal Research     Partially Free   (Followers: 7, SJR: 2.05, h-index: 20)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 3)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.46, h-index: 29)
Allergology Intl.     Open Access   (Followers: 5, SJR: 0.776, h-index: 35)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 6, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 45, SJR: 4.289, h-index: 64)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 5)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 3)
American Heart J.     Hybrid Journal   (Followers: 45, SJR: 3.157, h-index: 153)
American J. of Cardiology     Hybrid Journal   (Followers: 47, SJR: 2.063, h-index: 186)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 34, SJR: 0.574, h-index: 65)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 6, SJR: 1.091, h-index: 45)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.653, h-index: 93)
American J. of Human Genetics     Hybrid Journal   (Followers: 32, SJR: 8.769, h-index: 256)
American J. of Infection Control     Hybrid Journal   (Followers: 25, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 31, SJR: 2.313, h-index: 172)
American J. of Medicine     Hybrid Journal   (Followers: 48, SJR: 2.023, h-index: 189)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 174, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 51, SJR: 2.803, h-index: 148)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 2)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.249, h-index: 88)
American J. of Otolaryngology     Hybrid Journal   (Followers: 22, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 23, SJR: 2.653, h-index: 228)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 21, SJR: 2.764, h-index: 154)
American J. of Surgery     Hybrid Journal   (Followers: 32, SJR: 1.286, h-index: 125)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 13, SJR: 0.653, h-index: 70)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 5)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.066, h-index: 51)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 52, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 3)
Anales de Cirugia Vascular     Full-text available via subscription  
Anales de Pediatría     Full-text available via subscription   (Followers: 2, SJR: 0.209, h-index: 27)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription   (SJR: 0.104, h-index: 3)
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 2, SJR: 2.577, h-index: 7)
Analytica Chimica Acta     Hybrid Journal   (Followers: 38, SJR: 1.548, h-index: 152)
Analytical Biochemistry     Hybrid Journal   (Followers: 154, SJR: 0.725, h-index: 154)
Analytical Chemistry Research     Open Access   (Followers: 7, SJR: 0.18, h-index: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 10)
Anesthésie & Réanimation     Full-text available via subscription  
Anesthesiology Clinics     Full-text available via subscription   (Followers: 21, SJR: 0.421, h-index: 40)
Angiología     Full-text available via subscription   (SJR: 0.124, h-index: 9)
Angiologia e Cirurgia Vascular     Open Access  
Animal Behaviour     Hybrid Journal   (Followers: 143, SJR: 1.907, h-index: 126)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 5, SJR: 1.151, h-index: 83)
Animal Reproduction Science     Hybrid Journal   (Followers: 5, SJR: 0.711, h-index: 78)
Annales d'Endocrinologie     Full-text available via subscription   (SJR: 0.394, h-index: 30)
Annales d'Urologie     Full-text available via subscription  
Annales de Cardiologie et d'Angéiologie     Full-text available via subscription   (SJR: 0.177, h-index: 13)
Annales de Chirurgie de la Main et du Membre Supérieur     Full-text available via subscription  
Annales de Chirurgie Plastique Esthétique     Full-text available via subscription   (Followers: 2, SJR: 0.354, h-index: 22)
Annales de Chirurgie Vasculaire     Full-text available via subscription   (Followers: 1)

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Journal Cover American Journal of Obstetrics and Gynecology
  [SJR: 2.255]   [H-I: 171]   [174 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9378
   Published by Elsevier Homepage  [3030 journals]
  • Exercise in pregnancy!
    • Authors: Vincenzo Berghella; Gabriele Saccone
      Pages: 335 - 337
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Vincenzo Berghella, Gabriele Saccone


      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.01.023
       
  • A randomized clinical trial of exercise during pregnancy to prevent
           gestational diabetes mellitus and improve pregnancy outcome in overweight
           and obese pregnant women
    • Authors: Chen Wang; Yumei Wei; Xiaoming Zhang; Yue Zhang; Qianqian Xu; Yiying Sun; Shiping Su; Li Zhang; Chunhong Liu; Yaru Feng; Chong Shou; Kym J. Guelfi; John P. Newnham; Huixia Yang
      Pages: 340 - 351
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Chen Wang, Yumei Wei, Xiaoming Zhang, Yue Zhang, Qianqian Xu, Yiying Sun, Shiping Su, Li Zhang, Chunhong Liu, Yaru Feng, Chong Shou, Kym J. Guelfi, John P. Newnham, Huixia Yang
      Background Obesity and being overweight are becoming epidemic, and indeed, the proportion of such women of reproductive age has increased in recent times. Being overweight or obese prior to pregnancy is a risk factor for gestational diabetes mellitus, and increases the risk of adverse pregnancy outcome for both mothers and their offspring. Furthermore, the combination of gestational diabetes mellitus with obesity/overweight status may increase the risk of adverse pregnancy outcome attributable to either factor alone. Regular exercise has the potential to reduce the risk of developing gestational diabetes mellitus and can be used during pregnancy; however, its efficacy remain controversial. At present, most exercise training interventions are implemented on Caucasian women and in the second trimester, and there is a paucity of studies focusing on overweight/obese pregnant women. Objective We sought to test the efficacy of regular exercise in early pregnancy to prevent gestational diabetes mellitus in Chinese overweight/obese pregnant women. Study Design This was a prospective randomized clinical trial in which nonsmoking women age >18 years with a singleton pregnancy who met the criteria for overweight/obese status (body mass index 24≤28 kg/m2) and had an uncomplicated pregnancy at <12+6 weeks of gestation were randomly allocated to either exercise or a control group. Patients did not have contraindications to physical activity. Patients allocated to the exercise group were assigned to exercise 3 times per week (at least 30 min/session with a rating of perceived exertion between 12-14) via a cycling program begun within 3 days of randomization until 37 weeks of gestation. Those in the control group continued their usual daily activities. Both groups received standard prenatal care, albeit without special dietary recommendations. The primary outcome was incidence of gestational diabetes mellitus. Results From December 2014 through July 2016, 300 singleton women at 10 weeks’ gestational age and with a mean prepregnancy body mass index of 26.78 ± 2.75 kg/m2 were recruited. They were randomized into an exercise group (n = 150) or a control group (n = 150). In all, 39 (26.0%) and 38 (25.3%) participants were obese in each group, respectively. Women randomized to the exercise group had a significantly lower incidence of gestational diabetes mellitus (22.0% vs 40.6%; P < .001). These women also had significantly less gestational weight gain by 25 gestational weeks (4.08 ± 3.02 vs 5.92 ± 2.58 kg; P < .001) and at the end of pregnancy (8.38 ± 3.65 vs 10.47 ± 3.33 kg; P < .001), and reduced insulin resistance levels (2.92 ± 1.27 vs 3.38 ± 2.00; P = .033) at 25 gestational weeks. Other secondary outcomes, including gestational weight gain between 25-36 gestational weeks (4.55 ± 2.06 vs 4.59 ± 2.31 kg; P = .9), insulin resistance levels at 36 gestational weeks (3.56 ± 1.89 vs 4.07 ± 2.33; P = .1), hypertensive disorders of pregnancy (17.0% vs 19.3%; odds ratio, 0.854; 95% confidence interval, 0.434–2.683; P = .6), cesarean delivery (except for scar uterus) (29.5% vs 32.5%; odds ratio, 0.869; 95% confidence interval, 0.494–1.529; P = .6), mean gestational age at birth (39.02 ± 1.29 vs 38.89 ± 1.37 weeks’ gestation; P = .5); preterm birth (2.7% vs 4.4%, odds ratio, 0.600; 95% confidence interval, 0.140–2.573; P = .5), macrosomia (defined as birthweight >4000 g) (6.3% vs 9.6%; odds ratio, 0.624; 95% confidence interval, 0.233–1.673; P = .3), and large-for-gestational-age infants (14.3% vs 22.8%; odds ratio, 0.564; 95% confidence interval, 0.284–1.121; P = .1) were also lower in the exercise group compared to the control group, but without significant difference. However, infants born to women following the exercise intervention had a significantly lower birthweight compared with those born to women allocated to the control group (3345.27 ± 397.07 vs 3457.46 ± 446.00 g; P = .049).
      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.01.037
       
  • Syphilis during pregnancy: a preventable threat to maternal-fetal health
    • Authors: Martha W.F. Rac; Paula A. Revell; Catherine S. Eppes
      Pages: 352 - 363
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Martha W.F. Rac, Paula A. Revell, Catherine S. Eppes
      Syphilis remains the most common congenital infection worldwide and has tremendous consequences for the mother and her developing fetus if left untreated. Recently, there has been an increase in the number of congenital syphilis cases in the United States. Thus, recognition and appropriate treatment of reproductive-age women must be a priority. Testing should be performed at initiation of prenatal care and twice during the third trimester in high-risk patients. There are 2 diagnostic algorithms available and physicians should be aware of which algorithm is utilized by their testing laboratory. Women testing positive for syphilis should undergo a history and physical exam as well as testing for other sexually transmitted infections, including HIV. Serofast syphilis can occur in patients with previous adequate treatment but persistent low nontreponemal titers (<1:8). Syphilis can infect the fetus in all stages of the disease regardless of trimester and can sometimes be detected with ultrasound >20 weeks. The most common findings include hepatomegaly and placentomegaly, but also elevated peak systolic velocity in the middle cerebral artery (indicative of fetal anemia), ascites, and hydrops fetalis. Pregnancies with ultrasound abnormalities are at higher risk of compromise during syphilotherapy as well as fetal treatment failure. Thus, we recommend a pretreatment ultrasound in viable pregnancies when feasible. The only recommended treatment during pregnancy is benzathine penicillin G and it should be administered according to maternal stage of infection per Centers for Disease Control and Prevention guidelines. Women with a penicillin allergy should be desensitized and then treated with penicillin appropriate for their stage of syphilis. The Jarisch-Herxheimer reaction occurs in up to 44% of gravidas and can cause contractions, fetal heart rate abnormalities, and even stillbirth in the most severely affected pregnancies. We recommend all viable pregnancies receive the first dose of benzathine penicillin G in a labor and delivery department under continuous fetal monitoring for at least 24 hours. Thereafter, the remaining benzathine penicillin G doses can be given in an outpatient setting. The rate of maternal titer decline is not tied to pregnancy outcomes. Therefore, after adequate syphilotherapy, maternal titers should be checked monthly to ensure they are not increasing four-fold, as this may indicate reinfection or treatment failure.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2016.11.1052
       
  • Risk perception regarding drug use in pregnancy
    • Authors: Sofia F. Widnes; Jan Schjøtt
      Pages: 375 - 378
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Sofia F. Widnes, Jan Schjøtt
      Pregnant women, but also physicians, have unrealistically high perceptions of teratogenic drug effects. This may result in suboptimal treatment of disease and even influence decisions of whether to continue pregnancy. To attain more realistic teratogenic risk perceptions, several factors that influence this issue should be considered, and these are further discussed in this Clinical Opinion. Importantly, drug use may have several benefits, both for the pregnant woman’s health and to avoid negative fetal effects of untreated maternal disease. A greater focus on this aspect may act to balance risk perceptions. Furthermore, both pregnant women and physicians need access to drug information sources that provide realistic risk estimates to increase confidence in appropriate drug use and prescribing. We suggest that access to decision support and individually tailored information provided by drug information centers may contribute to this goal.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2016.12.007
       
  • Long-acting reversible contraception in adolescents: a systematic
           review and meta-analysis
    • Authors: Justin T. Diedrich; David A. Klein; Jeffrey F. Peipert
      Pages: 364.e1 - 364.e12
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Justin T. Diedrich, David A. Klein, Jeffrey F. Peipert
      Background Among adolescent pregnancies, 75% are unintended. Greater use of highly-effective contraception can reduce unintended pregnancy. Although multiple studies discuss adolescent contraceptive use, there is no consensus regarding the use of long-acting reversible contraception as a first-line contraception option. Objective We performed a systematic review of the medical literature to assess the continuation of long-acting reversible contraceptives among adolescents. Study Design Ovid-MEDLINE, Cochrane databases, and Embase databases were searched using key words relevant to the provision of long-acting contraception to adolescents. Articles published from January 2002 through August 2016 were selected for inclusion based on specific key word searches and detailed review of bibliographies. For inclusion, articles must have provided data on method continuation, effectiveness, or satisfaction of at least 1 long-acting reversible contraceptive method in participants <25 years of age. Duration of follow-up had to be ≥6 months. Long-acting reversible contraceptive methods included intrauterine devices and the etonogestrel implant. Only studies in the English language were included. Guidelines, systematic reviews, and clinical reviews were examined for additional citations and relevant points for discussion. Of 1677 articles initially identified, 90 were selected for full review. Of these, 12 articles met criteria for inclusion. All studies selected for full review were extracted by multiple reviewers; inclusion was determined by consensus among authors. For studies with similar outcomes, forest plots of combined effect estimates were created using the random effects model. The meta-analysis of observational studies in epidemiology guidelines were followed. Primary outcomes measured were continuation of method at 12 months, and expulsion rates for intrauterine devices. Results This review included 12 studies, including 6 retrospective cohort studies, 5 prospective observational studies, and 1 randomized controlled trial. The 12 studies included 4886 women age <25 years: 4131 intrauterine device users and 755 implant users. The 12-month continuation of any long-acting reversible contraceptive device was 84.0% (95% confidence interval, 79.0–89.0%). Intrauterine device continuation was 74.0% (95% confidence interval, 61.0–87.0%) and implant continuation was 84% (95% confidence interval, 77.0–91.0%). Among postpartum adolescents, the 12-month long-acting reversible contraceptive continuation rate was 84.0% (95% confidence interval, 71.0–97.0%). The pooled intrauterine device expulsion rate was 8.0% (95% confidence interval, 4.0–11.0%). Conclusion Adolescents and young women have high 12-month continuation of long-acting reversible contraceptive methods. Intrauterine devices and implants should be offered to all adolescents as first-line contraceptive options.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2016.12.024
       
  • The power of meta-analysis to address an
           important clinical question in obstetrics
    • Authors: Vincenzo Berghella
      Pages: 379.e1 - 379.e4
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Vincenzo Berghella
      After 17 years of collaborative research, a meta-analysis of randomized controlled trials on cerclage for singleton gestations with a prior spontaneous preterm birth and with a short transvaginal ultrasound cervical length <25mm before 24 weeks led to new clinical recommendations worldwide. This is an example of the power of meta-analyses, of why I like them, and why I think you should like them too. Many societies rank meta-analyses of randomized controlled trials as the best level of evidence, even above that of a single randomized controlled trial.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.01.028
       
  • Reducing health disparities by removing cost, access, and
           knowledge barriers
    • Authors: Melody Goodman; Ojiugo Onwumere; Laurel Milam; Jeffrey F. Peipert
      Pages: 382.e1 - 382.e5
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Melody Goodman, Ojiugo Onwumere, Laurel Milam, Jeffrey F. Peipert
      Background While the rate of unintended pregnancy has declined in the United States in recent years, unintended pregnancy among teens in the United States is the highest among industrialized nations, and disproportionately affects minority teens. Objective Our objective of this secondary analysis was to estimate the risk of unintended pregnancy for both Black and White teens age 15-19 years when barriers to access, cost, and knowledge are removed. Our hypothesis was that the Black-White disparities would be reduced when access, education, and cost barriers are removed. Study Design We performed an analysis of the Contraceptive CHOICE Project database. CHOICE is a longitudinal cohort study of 9256 sexually active girls and women ages 14-45 years in the St Louis, MO, region from 2007 through 2013. Two measures of disparities were used to analyze teenage pregnancy rates and pregnancy risk from 2008 through 2013 among teens ages 15-19 years. These rates were then compared to the rates of pregnancy among all sexually active teens in the United States during the years 2008, 2009, 2010, and 2011. We estimated an absolute measure (rate difference) and a relative measure (rate ratio) to examine Black-White disparities in the rates of unintended pregnancy. Results While national rates of unintended pregnancy are decreasing, racial disparities in these rates persist. The Black-White rate difference dropped from 158.5 per 1000 in 2008 to 120.1 per 1000 in 2011; however, the relative ratio disparity decreased only from 2.6-2.5, suggesting that Black sexually active teens in the United States have 2.5 times the rate of unintended pregnancy as White teenagers. In the CHOICE Project, there was a decreasing trend in racial disparities in unintended pregnancy rates among sexually active teens (age 15-19 years): 2008 through 2009 (rate difference, 18.2; rate ratio, 3.7), 2010 through 2011 (rate difference, 4.3; rate ratio, 1.2), and 2012 through 2013 (rate difference, –1.5; rate ratio, 1.0). Conclusion When barriers to cost, access, and knowledge were removed, such as in the Contraceptive CHOICE Project, Black-White disparities in unintended pregnancy rates among sexually active teens were reduced on both absolute and relative scales. The rate of unintended pregnancy was almost equal between Black and White teens compared to large Black-White disparities on the national level.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2016.12.015
       
  • Effects of high-intensity training on cardiovascular risk factors in
           premenopausal and postmenopausal women
    • Authors: Camilla M. Mandrup; Jon Egelund; Michael Nyberg; Martina H. Lundberg Slingsby; Caroline B. Andersen; Sofie Løgstrup; Jens Bangsbo; Charlotte Suetta; Bente Stallknecht; Ylva Hellsten
      Pages: 384.e1 - 384.e11
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Camilla M. Mandrup, Jon Egelund, Michael Nyberg, Martina H. Lundberg Slingsby, Caroline B. Andersen, Sofie Løgstrup, Jens Bangsbo, Charlotte Suetta, Bente Stallknecht, Ylva Hellsten
      Background Menopause is associated with increased risk of cardiovascular disease and the causal factors have been proposed to be the loss of estrogen and the subsequent alterations of the hormonal milieu. However, which factors contribute to the deterioration of cardiometabolic health in postmenopausal women is debated as the menopausal transition is also associated with increased age and fat mass. Furthermore, indications of reduced cardiometabolic adaptations to exercise in postmenopausal women add to the adverse health profile. Objective We sought to evaluate risk factors for type 2 diabetes and cardiovascular disease in late premenopausal and early postmenopausal women, matched by age and body composition, and investigate the effect of high-intensity training. Study Design A 3-month high-intensity aerobic training intervention, involving healthy, nonobese, late premenopausal (n = 40) and early postmenopausal (n = 39) women was conducted and anthropometrics, body composition, blood pressure, lipid profile, glucose tolerance, and maximal oxygen consumption were determined at baseline and after the intervention. Results At baseline, the groups matched in anthropometrics and body composition, and only differed by 4.2 years in age (mean [95% confidence limits] 49.2 [48.5-49.9] vs 53.4 [52.4-54.4] years). Time since last menstrual period for the postmenopausal women was (mean [95% confidence limits] 3.1 [2.6-3.7] years). Hormonal levels (estrogen, follicle stimulation hormone, luteinizing hormone) confirmed menopausal status. At baseline the postmenopausal women had higher total cholesterol (P < .001), low-density lipoprotein-cholesterol (P < .05), and high-density lipoprotein-cholesterol (P < .001) than the premenopausal women. The training intervention reduced body weight (P < .01), waist circumference (P < .01), and improved body composition by increasing lean body mass (P < .001) and decreasing fat mass (P < .001) similarly in both groups. Moreover, training resulted in lower diastolic blood pressure (P < .05), resting heart rate (P < .001), total cholesterol (P < .01), low-density lipoprotein-cholesterol (P < .01), total cholesterol/high-density lipoprotein-cholesterol index (P < .01), and improved plasma insulin concentration during the oral glucose tolerance test (P < .05) in both groups. Conclusion Cardiovascular risk factors are similar in late premenopausal and early postmenopausal women, matched by age and body composition, with the exception that postmenopausal women have higher high- and low-density lipoprotein-cholesterol levels. A 3-month intervention of high-intensity aerobic training reduces risk factors for type 2 diabetes and cardiovascular disease to a similar extent in late premenopausal and early postmenopausal women.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2016.12.017
       
  • Prospective Association of Fetal Liver Blood Flow at 30 Weeks Gestation
           with Newborn Adiposity
    • Authors: Satoru Ikenoue; Feizal Waffarn; Masanao Ohashi; Kaeko Sumiyoshi; Chigusa Ikenoue; Claudia Buss; Daniel L. Gillen; Hyagriv N. Simhan; Sonja Entringer; Pathik D. Wadhwa
      Abstract: Publication date: Available online 20 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Satoru Ikenoue, Feizal Waffarn, Masanao Ohashi, Kaeko Sumiyoshi, Chigusa Ikenoue, Claudia Buss, Daniel L. Gillen, Hyagriv N. Simhan, Sonja Entringer, Pathik D. Wadhwa
      Background The production of variation in adipose tissue accretion represents a key fetal adaptation to energy substrate availability during gestation. Because umbilical venous blood transports nutrient substrate from the maternal to the fetal compartment, and the fetal liver is the primary organ where nutrient inter-conversion occurs, it has been proposed that variations in the relative distribution of umbilical venous blood flow shunting either through ductus venosus or perfusing the fetal liver represents a mechanism underlying this adaptation. Objective The objective of the present study was to determine whether fetal liver blood flow assessed before the period of maximal fetal fat deposition (i.e., the third trimester of gestation) is prospectively associated with newborn adiposity. Study design A prospective study was conducted in a cohort of 62 uncomplicated singleton pregnancies. Fetal ultrasonography was performed at 30 weeks gestation for conventional fetal biometry and characterization of fetal liver blood flow (fLBF; quantified by subtracting ductus venosus flow from umbilical vein flow). Newborn body fat percentage was quantified by Dual Energy X-Ray Absorptiometry (DXA) imaging at 25.8 ± 3.3 (mean ± SEM) postnatal days. Multiple regression analysis was used to determine the proportion of variation in newborn body fat percentage explained by fLBF. Potential confounding factors included maternal age, parity, pre-pregnancy body mass index (ppBMI), gestational weight gain, gestational age at birth, infant sex, postnatal age at DXA scan, and mode of infant feeding. Results Newborn body fat percentage was 13.5 ± 2.4% (mean ± SEM). fLBF at 30 weeks gestation was significantly and positively associated with newborn total fat mass (r = 0.397, p < 0.001) and body fat percentage (r = 0.369, p = 0.004), but not with lean mass (r = 0.100, p = 0.441). After accounting for the effects of covariates, fLBF explained 13.5% of the variance in newborn fat mass. The magnitude of this association was particularly pronounced in non-overweight/non-obese mothers (ppBMI <25, n = 36), in whom fLBF explained 24.4% of the variation in newborn body fat percentage. Conclusions fLBF at the beginning of the third trimester of gestation is positively associated with newborn adiposity, particularly among non-overweight/non-obese mothers. This finding supports the role of fLBF as a putative fetal adaptation underlying variation in adipose tissue accretion.

      PubDate: 2017-04-21T12:21:41Z
      DOI: 10.1016/j.ajog.2016.11.264
       
  • Optimizing Postpartum Care for the Patient with Gestational Diabetes
           Mellitus
    • Abstract: Publication date: Available online 26 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Noelle G. Martinez, Charlotte M. Niznik, Lynn M. Yee
      Gestational diabetes mellitus (GDM) poses well-established risks to both the mother and infant. As over 50% of women with GDM will develop type 2 diabetes mellitus (T2DM) in their lifetime, performing postpartum oral glucose tolerance testing (OGTT) is paramount to initiation of appropriate lifestyle interventions and pharmacologic therapy. Nonetheless, test completion among women with GDM is estimated to be <50%, with particularly low rates in Latina patients, as well as patients with public insurance, low education levels, and low health literacy. Data suggest our current health services infrastructure loses patients in the postpartum gap between pregnancy-focused care and primary care. As previous studies have demonstrated strategies to promote OGTT completion for T2DM prevention, hereto is a proposal of best practices including 1) enhanced patient support for identifying long-term health care providers 2) patient-centered medical home utilization when possible 3) patient and provider test reminders, and 4) formalized obstetrician-primary care provider hand-offs using the “SBAR” (Situation Background Assessment Recommendation) mnemonic. These strategies deserve future investigation to solidify a multi-level approach for identifying and preventing the continuum of diabetes.

      PubDate: 2017-04-28T07:25:32Z
       
  • Sexual Function in Infertile Women with Polycystic Ovary Syndrome and
           Unexplained Infertility
    • Abstract: Publication date: Available online 26 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Michael P. Diamond, Richard S. Legro, Christos Coutifaris, Ruben Alvero, Randal D. Robinson, Peter A. Casson, Gregory M. Christman, Hao Huang, Karl R. Hansen, Valerie Baker, Rebecca Usadi, Aimee Seungdamrong, G. Wright Bates, R. Mitchell Rosen, William Schlaff, Daniel Haisenleder, Stephen A. Krawetz, Kurt Barnhart, J.C. Trussell, Nanette Santoro, Esther Eisenberg, Heping Zhang
      Background While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed. Objective To determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility. Study Design Secondary data analysis was performed on two of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials, “Pregnancy in Polycystic Ovary Syndrome Study II” and “Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation.” Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale. Results Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each p<0.001), greater phenotypic (Ferriman-Gallwey Hirsutism score, sebum score, and acne score; each p<0.001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each p<0.001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility. Conclusion Reproductive age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function.

      PubDate: 2017-04-28T07:25:32Z
       
  • Assessing the Potential Impact of Extending Antenatal Steroids to the Late
           Preterm Period
    • Abstract: Publication date: Available online 26 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Vivienne Souter, Ellen Kauffman, Ms Alice J. Marshall, Jodie G. Katon
      Background In 2016 guidance statements were issued by the Society for Maternal Fetal Medicine and by the American College of Obstetricians and Gynecologists about extending antenatal steroid use to selected late preterm singleton pregnancies. Objective To review antenatal steroid use prior to the 2016 guidance statements and assess the potential impact of these. Study Design This cohort study used chart-abstracted data from singleton deliveries from January 1, 2012 to March 31, 2016 at 12 centers participating in the Obstetrics Clinical Outcomes Assessment Program, a quality initiative in Washington State. Pregnancies with missing gestation at delivery, fetal anomalies, or antepartum demise were excluded. Antenatal steroid use prior to the 2016 guidance was evaluated based on the percentage of early preterm deliveries (23+0-33+6 weeks) and the percentage of all pregnancies that received antenatal steroids. Newborn complication rates were calculated for late preterm deliveries (34+0+0-36+6 weeks), grouped by whether they would be potentially eligible or ineligible for antenatal steroids based on the 2016 guidance statements. Results The opportunity for antenatal steroids was missed in 21.8% (226/1034) of early preterm deliveries and of all those who received antenatal steroids, 32.2% (614/1908) delivered at term. Seventy-four percent of preterm deliveries (n=2942) were in the late preterm period. Eighty percent (n=2363) of late preterm deliveries were potentially eligible for antenatal steroids and 60% of these (n=1411) delivered at 36 weeks. The rate of respiratory complications in newborns delivering at 34 and 35 weeks was higher in the group potentially eligible for late preterm antenatal steroids compared to those in the ineligible group. Of those delivering at 36 weeks, no differences were detected in prevalence of respiratory complications by potential eligibility for antenatal steroids; however, compared with the ineligible group, those potentially eligible had a lower risk of neonatal intensive care unit admission (p<0.001). More than 2/3 (69%; 171/248) of newborn respiratory complications among late preterm deliveries potentially eligible for antenatal steroids occurred in those delivering at 34-35 weeks. The highest rate of respiratory complications was in those ineligible for antenatal steroids due to pre-pregnancy diabetes or chorioamnionitis, regardless of gestational age at delivery. Conclusions Careful consideration of which pregnancies should receive late preterm antenatal steroids and how to identify these pregnancies is important to optimize benefits and mitigate potential risks of this intervention.

      PubDate: 2017-04-28T07:25:32Z
       
  • Novel Oxytocin Receptor Variants in Laboring Women Requiring High Doses of
           Oxytocin
    • Abstract: Publication date: Available online 26 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Erin L. Reinl, Zane A. Goodwin, Nandini Raghuraman, Grace Y. Lee, Erin Y. Jo, Beakal M. Gezahegn, Meghan K. Pillai, Alison G. Cahill, Cristina de Guzman Strong, Sarah K. England
      Background Although oxytocin is commonly used to augment or induce labor, it is difficult to predict its effectiveness because oxytocin dose requirements vary significantly amongst women. One possibility is that women requiring high or low doses of oxytocin have variations in the oxytocin receptor gene. Objectives This work aims to identify oxytocin receptor gene variants in laboring women with low and high oxytocin dosage requirements. Study Design Term, nulliparous women requiring oxytocin doses of ≤4 milliunits/minute (low-dose requiring, n=83) or ≥20 milliunits/minute (high-dose requiring, n=104) for labor augmentation or induction were consented to a post-partum blood draw as a source of genomic DNA. Targeted-amplicon sequencing (coverage > 30X) with Illumina MiSeq was performed to discover variants in the coding exons of the oxytocin receptor gene. Baseline relevant clinical history, outcomes, demographics, and oxytocin receptor gene sequence variants and their allele frequencies were compared between low-dose-requiring and high-dose-requiring women. The Scale-Invariant Feature Transform algorithm was used to predict the effect of variants on oxytocin receptor function. Fisher’s exact or chi-squared tests were used for categorical variables, and Student t-tests or Wilcoxon rank sum tests were used for continuous variables. A P-value < 0.05 was considered statistically significant. Results The high-dose-requiring women had higher rates of obesity and diabetes and were more likely to have undergone labor induction and required prostaglandins. High-dose-requiring women were more likely to undergo cesarean for first stage arrest and less likely to undergo cesarean for non-reassuring fetal status. Targeted sequencing of the oxytocin receptor gene in the total cohort (n=187) revealed 30 distinct coding variants: 17 non-synonymous, 11 synonymous, and two small structural variations. One novel variant (A243T) was found in both the low- and high-dose-requiring groups. Three novel variants (Y106H, A240_A249del, and P197delfs*206) resulting in an amino acid substitution, loss of 9 amino acids, and a frameshift stop mutation, respectively, were identified only in low-dose-requiring women. Nine non-synonymous variants were unique to the high-dose-requiring group. These included three known variants (R151C, G221S, and W228C) and six novel variants not found in Ensembl or ExAC (M133V, R150L, H173R, A248V, G253R, and I266V). Of these, R150L, R151C, and H173R were predicted to damage oxytocin receptor function. There was no statistically significant association between the numbers of synonymous and non-synonymous substitutions in the patient groups. Conclusions Obesity, diabetes, and labor induction were associated with the requirement for high doses of oxytocin. We did not identify significant differences in the prevalence of oxytocin receptor variants between low-dose-requiring and high-dose-requiring women, but novel oxytocin receptor variants were enriched in the high-dose-requiring women. Additionally, we found three oxytocin receptor variants (two novel, one known) that were predicted to damage oxytocin receptor function and would likely increase an individual’s risk for requiring a high oxytocin dose. Further investigation of oxytocin receptor variants and their effects on protein function will inform precision medicine in pregnant women.

      PubDate: 2017-04-28T07:25:32Z
       
  • Randomized Controlled Trial of Intravenous Acetaminophen for Post-Cesarean
           Delivery Pain Control
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Brie Altenau, Catrina C. Crisp, C. Ganga Devaiah, Donna S. Lambers
      Background Cesarean delivery is a common surgery in the United States with 1.3 million performed during 2009.1 Obstetricians must balance the growing concern with opioid abuse, dependence and side effects with optimal post-operative pain control. IV acetaminophen may represent an additional method to decrease the reliance on opioid medications and improve post-operative pain following cesarean section. Objective To determine if administration of IV acetaminophen following routine scheduled cesarean delivery would decrease the need for narcotic medications to control post-operative pain. Study Design This was an IRB approved, double-blind, placebo-controlled randomized trial, registered on clinicaltrials.gov (NCT#: 02046382). Women scheduled to undergo cesarean delivery with regional anesthesia at term were recruited. All peri-operative and post-partum care was standardized via study order sets. Study patients were given all medications in a standardized manner receiving either acetaminophen 1000mg intravenous (IV) or 100 ml saline (placebo) every 8 hours for 48 hours for a total of 6 doses. The pharmacy prepared IV acetaminophen and saline in identical administration bags labeled “study drug” to ensure blinding. The initial dose of “study drug” was given within 60 minutes of skin incision. Quantity of breakthrough and scheduled analgesic medications and self-reported pain levels on the Faces Pain Scale (0-10) before and after study drug administration were collected. Patient demographics were extracted from the chart. Power calculation determined that 45 patients per arm were required to detect a 30% reduction in post-cesarean narcotic requirement with 80% power and a significance level of 0.05. Results 133 patients were consented for the study. 29 were excluded and 104 patients completed the study: 57 received IV acetaminophen and 47 received placebo. There were no differences in baseline demographic characteristics including patient age, body mass index, gravidity, parity, race, comorbidities, or number of prior cesarean deliveries. There were no differences between groups in estimated blood loss or length of stay. The total amount of oral narcotic medications consumed by patients receiving IV acetaminophen was significantly reduced when compared to the placebo group (47mg versus 65mg of oxycodone, p-value= 0.034). The total amount of ibuprofen used between groups was not different. There was no difference in pain scores between groups before and after study dose administration. There was no significant difference in narcotic side effects (nausea/emesis, respiratory depression, constipation) in either study arm. Conclusion IV acetaminophen in the post-operative period following cesarean delivery resulted in a significant decrease in oral narcotic consumption for pain control.

      PubDate: 2017-04-28T07:25:32Z
       
  • Ureteral Stone Diagnosed with 3-dimensional Transvaginal Ultrasonography
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Sa Ra Lee, Ha Na Yoon


      PubDate: 2017-04-28T07:25:32Z
       
  • Ovarian reserve Following Cesarean-delivery with Salpingectomy Versus
           Tubal Ligation – a Randomized Trial
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Hadas Ganer Herman, Ohad Gluck, Ran Keidar, Ram Kerner, Michal Kovo, David Levran, Jacob Bar, Ron Sagiv
      Background Epithelial ovarian cancer is assumed to derive from the fallopian tube. Salpingectomy has been previously demonstrated to reduce the risk of ovarian cancer, and may be used as a means of sterilization. Objective We aimed to compare short term ovarian reserve and operative complications in cases of salpingectomy and tubal ligation during cesarean delivery (CD). Study design Study patients who underwent elective CD at our institution and requested sterilization were randomized to bilateral salpingectomy or tubal ligation. Prior to surgery, blood samples were obtained for antimüllerian hormone (AMH). Surgical course was noted, including overall time, complications and post-operative hemoglobin. Repeat AMH samples were obtained from patients 6-8 weeks following surgery. Results 46 patients were recruited for participation, of whom 33 completed a follow up visit, and for which repeat AMH levels were available. Patients in the salpingectomy group were slightly older (37.0 ± 3.9 vs. 34.3± 4.1 years, p=0.02). No differences were noted in patient parity, body mass index and gestational age between the groups. Pregnancy and post-delivery AMH levels were not significantly different between the groups, with an average increase of 0.58 ± 0.98 vs. 0.39 ± 0.41 ng/mL in the salpingectomy and tubal ligation groups, respectively (p=0.45). Surgeries including salpingectomy were longer by an average 13 minutes (66.0 ± 20.5 vs. 52.3 ± 15.8 minutes, p=0.01). No difference was demonstrated between the groups regarding surgical complications and post- operative hemoglobin decrease. Conclusion Sterilization by salpingectomy appears to be as safe as tubal ligation regarding operative complications and subsequent ovarian reserve. As salpingectomy offers the advantage of cancer risk reduction, it may be offered in the settings of elective pre-planned surgeries.

      PubDate: 2017-04-28T07:25:32Z
       
  • Recipient Umbilical Artery Elongation (Redundancy) in Twin-Twin
           Transfusion Syndrome
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Roopali Donepudi, Lovepreet K. Mann, Christoph Wohlmuth, Anthony Johnson, Michael W. Bebbington, Kenneth J. Moise, David S. Boudreaux, Helena Gardiner, Ramesha Papanna
      Background Chronic hypertension in adults causes arterial lengthening in major arteries, but the effects of early fetal hypertension on the twin-twin transfusion syndrome (TTTS) recipient’s vascular architecture remains unknown. Objectives We hypothesize that arterial cord redundancy is related to recipient hypertension and subsequent heart failure. Our objectives were: 1) to establish a 3D color Doppler ultrasound method of measuring umbilical arterial (UA) length relative to its corresponding venous segment in the Umbilical cord using AV-angle, 2) to compare recipient AV-angle to gestational age-matched controls, and 3) to test the association of AV-angle with recipient heart failure. Study Design We compared three groups prospectively: TTTS pregnancies undergoing fetoscopic laser surgery (pre-operatively) and two groups of gestational age-matched controls - uncomplicated monochorionic diamniotic twin pregnancies (MCDA) and healthy singletons. Using a 3D color-Doppler volume image of 5 cms of cord near the placental insertion, we traced the UA and vein (UV) producing UA:UV length, (AV-index) and measured the AV-angle between UA and UV. Correlation of AV-angle to TTTS stage, maximum vertical pocket, UA indices, Ductus Venosus Doppler, and brain natriuretic peptide (BNP) were performed. We used pulsed-wave and tissue Doppler to measure tissue Doppler velocities and indexed cardiac output and correlated these with AV-angle. Comparative statistics, including multivariable linear regression examined the relationship between UA Doppler indices and AV-angle. Results AV-angle and AV-index correlated significantly (R2= 0.86; p<0.0001), hence, AV-angle was used for analysis. Mean AV-angle was 33.1º ± 31.5º in recipients (n=44), 9.5º ± 6º in MCDA (n=11; 22 fetuses) and 8.9º ± 8.3º in singleton controls (n=16) (p=<0.001). An AV-angle ≥ 26º (> 95th percentile for controls) was measured in 52% recipients. AV-angle was higher in TTTS stage 3R vs 1, (p=0.001). AV-angle increased with increasing UA pulsatility index (p<0.001), and decreased with increasing resistance index (p=0.02) after adjusting for gestational age. Inter-rater agreements to categorize abnormal AV-angle values was 95% (p<0.001). Abnormal Ductus Venosus Doppler and elevated recipient amniotic fluid NT-Pro BNP/protein levels correlated significantly with AV-angle. Abnormal AV-angles were associated with decreased indexed cardiac output, lower tissue Doppler velocities, higher right sided Tei indices, and severe tricuspid regurgitation. Conclusions Umbilical arterial lengthening occurs in 52% of recipients and is associated with abnormal Doppler flows, low systolic tissue Doppler velocities, reduced cardiac output and elevated markers of cardiac failure. This may reflect chronicity and severity of hypertension in the recipient fetus. Further research is needed to explore the mechanisms of elongation and long-term implications.

      PubDate: 2017-04-28T07:25:32Z
       
  • Adverse pregnancy, birth, and infant outcomes in twins: Effects of
           maternal fertility status and infant gender combinations The Massachusetts
           Outcomes Study of Assisted Reproductive Technology
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Barbara Luke, Daksha Gopal, Howard Cabral, Judy E. Stern, Hafsatou Diop
      Background It is unknown whether the risk of adverse outcomes in twin pregnancies among subfertile women, conceived with and without in vitro fertilization (IVF), differ from those conceived spontaneously. Objective To evaluate the effects of fertility status on adverse perinatal outcomes in twin pregnancies on a population basis. Study Design All twin live births of ≥22 weeks’ gestation and ≥350 grams birthweight to Massachusetts resident women in 2004-10 were linked to hospital discharge records, vital records, and IVF cycles. Women were categorized by their fertility status as in vitro fertilization (IVF), subfertile, or fertile, and by twin pair genders (all, like, unlike). Women whose births linked to IVF cycles were classified as IVF; those with indicators of subfertility but without IVF treatment were classified as subfertile; all others were classified as fertile. Risks of six adverse pregnancy outcomes (gestational diabetes, pregnancy hypertension, uterine bleeding, placental complications (placenta abruptio, placenta previa, and vasa previa), prenatal hospitalizations, primary cesarean), and nine adverse infant outcomes (very low birthweight, low birthweight, small-for-gestation birthweight, large-for-gestation birthweight, very preterm (<32 weeks), preterm, birth defects, neonatal death, and infant death) were modeled by fertility status with the fertile group as reference, using multivariate log binomial regression and reported as adjusted relative risk ratios (ARRs) and 95% confidence intervals (CI). Results The study population included 10,352 women with twin pregnancies (6,090 fertile, 724 subfertile, and 3,538 IVF). Among all twins, the risks for all six adverse pregnancy outcomes were significantly increased for the subfertile and IVF groups, with highest risks for uterine bleeding (ARR 1.92, 2.58, respectively), and placental complications (ARR 2.07and 1.83, respectively). Among all twins, the risks for those born to subfertile women were significantly increased for very preterm birth, and neonatal and infant death (ARR 1.36, 1.89, and 1.87, respectively); risks were significantly increased among IVF twins for very preterm birth, preterm birth, and birth defects (ARR 1.28, 1.07, and 1.26, respectively). Conclusions Risks of all maternal and most infant adverse outcomes are increased for subfertile and IVF twins. Among all twins, the highest risks were for uterine bleeding and placental complications for the subfertile and IVF groups, and neonatal and infant death in the subfertile group. These findings provide further evidence supporting single embryo transfer and more cautious use of ovulation induction.

      PubDate: 2017-04-28T07:25:32Z
       
  • Impact of USPSTF Recommendations for Aspirin for Prevention of Recurrent
           Preeclampsia
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Mary Catherine Tolcher, Derrick M. Chu, Lisa M. Hollier, Joan M. Mastrobattista, Diana A. Racusin, Susan M. Ramin, Haleh Sangi-Haghpeykar, Kjersti M. Aagaard
      Background The U.S. Preventive Services Task Force (USPSTF) recommends low-dose aspirin for the prevention of preeclampsia among women at high risk for primary occurrence or recurrence of disease. Recommendations for the use of aspirin for preeclampsia prevention were issued by the USPSTF in September 2014. Objectives To evaluate the incidence of recurrent preeclampsia in our cohort before and after the USPSTF recommendation for aspirin for preeclampsia prevention. Study Design This is a retrospective cohort study designed to evaluate rates of recurrent preeclampsia among women with a history of preeclampsia. We utilized a two hospital, single academic institution database from August 2011 through June 2016. We excluded multiple gestations and included only the first delivery for women with multiple deliveries during the study period. The cohort of women with a history of preeclampsia were divided into two groups, “before” and “after” the release of the USPSTF 2014 recommendations. Potential confounders were accounted for in multivariate analyses, and relative risk and adjusted relative risk were calculated. Results 17,256 deliveries occurred during the study period. A total of 417 women had a documented history of prior preeclampsia; 284 women “before” and 133 women “after” the USPSTF recommendation. Comparing the before and after groups, the proportion of Hispanic women in the after group was lower and the method of payment differed between the groups (P <.0001). The prevalence of type 1 diabetes was increased in the after period, but overall rates of pregestational diabetes were similar (6.3% before versus 5.3% after; P >.05). Risk factors for recurrent preeclampsia included maternal age >35 years (RR, 1.83; 95% CI, 1.34-2.48), Medicaid insurance (RR, 2.08; 95% CI, 1.15-3.78), type 2 diabetes (RR, 2.13; 95% CI, 1.37-3.33), and chronic hypertension (RR, 1.96; 95% CI, 1.44-2.66). The risk of recurrent preeclampsia was decreased by 30% in the after group (adjusted relative risk (aRR), 0.70; 95% CI, 0.52- 0.95). Conclusion Rates of recurrent preeclampsia among women with a history of preeclampsia decreased by 30% after release of the USPSTF recommendation for aspirin for preeclampsia prevention. Future prospective studies should include direct measures of aspirin compliance, gestational age at initiation, and explore the influence of race and ethnicity on the efficacy of this primary prevention.

      PubDate: 2017-04-28T07:25:32Z
       
  • The Maternal Childbirth Experience More than a Decade after Delivery
    • Abstract: Publication date: Available online 25 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Carla M. Bossano, Kelly M. Townsend, Alexandra C. Walton, Joan L. Blomquist, Victoria L. Handa
      Background Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period. Objective This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery. Study Design This was a planned, supplementary analysis of data collected for the Mothers’ Outcomes after Delivery (MOAD) study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to MOAD study participants >10 years from their first delivery. This validated questionnaire yields three scores: fulfillment, distress and difficulty. These three scores were compared by mode of delivery (cesarean with prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined. Results Among 576 women, 10.1 to 17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differed between women delivering by cesarean and those delivering vaginally: women delivering vaginally reported greater fulfillment (0.40 [-0.37, 0.92] versus 0.15 [-0.88, 0.66], p<0.001) and less distress (-0.34 [-0.88, 0.38] versus 0.20 [-0.70, 0.93], p<0.001) than those who delivered by cesarean. Women who delivered by cesarean prior to labor reported the greatest median fulfillment,scores and the lowest median difficulty scores. Median distress scores were lowest among those who delivered by spontaneous vaginal birth. Among women who underwent cesarean delivery, labor induction and prolonged second stage were associated with higher difficulty scores. These factors did not affect satisfaction scores among women who delivered vaginally. Among women who delivered vaginally, operative vaginal delivery was associated with less favorable scores across all three scores. Conclusion Maternal satisfaction with childbirth is influenced by mode of delivery. The birth experience leaves an impression on women more than a decade after delivery.
      Teaser Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period. This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery. This was a planned, supplementary analysis of data collected for the Mothers’ Outcomes after Delivery (MOAD) study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to MOAD study participants >10 years from their first delivery. This validated questionnaire yields three scores: fulfillment, distress and difficulty. These three scores were compared by mode of delivery (cesarean prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined. Among 576 women, 10.1 to 17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differ...
      PubDate: 2017-04-28T07:25:32Z
       
  • The Clinical Significance of an Estimated Fetal Weight Below the 10th
           Centile: A Comparison of Outcomes Between <5th versus 5th-9th Centile
    • Authors: Malgorzata Mlynarczyk; Suneet P. Chauhan; Hind A. Baydoun; Catherine M. Wilkes; Kimberly R. Earhart; Yili Zhao; Christopher Goodier; Eugene Chang; Nicole M. Lee Plenty; E Kaitlyn Mize; Michelle Owens; Shilpa Babbar; Dev Maulik; Emily DeFranco; David McKinney; Alfred Z. Abuhamad
      Abstract: Publication date: Available online 20 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Malgorzata Mlynarczyk, Suneet P. Chauhan, Hind A. Baydoun, Catherine M. Wilkes, Kimberly R. Earhart, Yili Zhao, Christopher Goodier, Eugene Chang, Nicole M. Lee Plenty, E Kaitlyn Mize, Michelle Owens, Shilpa Babbar, Dev Maulik, Emily DeFranco, David McKinney, Alfred Z. Abuhamad
      Background The association between small for gestational age (SGA; birth weight < 10th centile for gestational age) and neonatal morbidity is well established. Yet there is a paucity of data on the relationship between suspected SGA (sonographic estimated fetal weight <10th centile), at two thresholds and subsequent neonatal morbidity. Objective The objective of this study was to determine the relationship between sonographic estimated fetal weight (SEFW) < 5th centile versus 5-9th centile and neonatal morbidity. Study Design This retrospective study involved five centers and included non-anomalous, singletons, with SEFW <10th centile for gestational age (GA) who delivered from 2009 to 2012. Composite neonatal morbidity included respiratory distress syndrome, proven sepsis, IVH grade III or IV, NEC, thrombocytopenia, seizures or death. Odd ratios were adjusted (aOR) for center, maternal age, race, body mass index at first visit, smoking status, use of alcohol, use of drugs and neonatal gender. Results Of 834 women with suspected SGA fetuses, 513 (62%) had SEFW <5th percentile and 321 (38%) had SEFW of 5-9th percentile for GA. At delivery, 81% of women with suspected SGA had confirmed SGA. With SEFW <5th percentile group 59% of neonates had birthweight (BW) <5th centile; with SEFW 5-9th percentile, 41% had BW <5th percentile and 36% had weight at 5-9th centile. NICU admission differed significantly for those below 5th centile (29%) compared to those at 5-9th centile (15%; P < 0.001). The composite neonatal morbidity among the SEFW <5th centile group was higher than the SEFW of 5-9th centile group (31% vs. 13%; aOR 2.41, 95% CI 1.53-3.80). Similar findings were noted when the analysis was limited to SEFW within 28 days of delivery (aOR of 2.22, 95% CI 1.34-3.67). Conclusions Eight of ten suspected SGA had BW <10th percentile for GA with the prediction of actual birth weight being more accurate in <5th centile group. Neonates with SEFW of <5th percentile were more likely to be admitted to NICU, and have complications than those with SEFW of 5-9th percentile.

      PubDate: 2017-04-21T12:21:41Z
      DOI: 10.1016/j.ajog.2017.04.020
       
  • Outpatient endometrial aspiration: an alternative to methotrexate for
           pregnancy of unknown location
    • Authors: Iris G. Insogna; Leslie V. Farland; Stacey A. Missmer; Elizabeth S. Ginsburg; Paula C. Brady
      Abstract: Publication date: Available online 19 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Iris G. Insogna, Leslie V. Farland, Stacey A. Missmer, Elizabeth S. Ginsburg, Paula C. Brady
      Objective To evaluate the utility of an endometrial sampling protocol for the diagnosis of pregnancies of unknown location following in vitro fertilization. Study Design A retrospective cohort study of 14,505 autologous fresh and frozen in vitro fertilization cycles from 10/2007 to 9/2015 was performed; 110 patients were diagnosed with pregnancy of unknown location, defined as a positive human chorionic gonadotropin (hCG) without ultrasound evidence of intrauterine or ectopic pregnancy, and an abnormal hCG trend (<53% rise or <15% fall in two days). These patients underwent outpatient endometrial sampling with Karman cannula aspiration. Patients with hCG decline ≥15% within 24 hours of sampling and/or villi detected on pathologic analysis were diagnosed with failing intrauterine pregnancy and had weekly hCG measurements thereafter. Those with hCG declines <15% and no villi identified were diagnosed with ectopic pregnancy and treated with intramuscular methotrexate (50 mg/m2) or laparoscopy. Results Across 8 years of follow-up, among women with pregnancy of unknown location, failed intrauterine pregnancy was diagnosed in 46 patients (42%) and ectopic pregnancy in 64 patients (58%). Clinical variables including fresh or frozen embryo transfer, day of embryo transfer, serum hCG at the time of sampling, endometrial thickness, and presence of an adnexal mass were not significantly different between patients with failed intrauterine pregnancy or ectopic pregnancy. In patients with failed intrauterine pregnancy, 100% demonstrated adequate post-sampling hCG declines, while villi were identified in just 46% (n=21). Patients with failed intrauterine pregnancy had significantly shorter time to resolution (negative serum hCG) after sampling compared to patients with ectopic pregnancy (12.6 vs 26.3 days, p-value<0.001). Conclusion Using this safe and effective protocol of endometrial aspiration with Karman cannula, a large proportion of women with pregnancy of unknown location are spared methotrexate, with a shorter time to pregnancy resolution than those receiving methotrexate.

      PubDate: 2017-04-21T12:21:41Z
      DOI: 10.1016/j.ajog.2017.04.023
       
  • Factors influencing repeated teenage pregnancy: a review and meta-analysis
    • Authors: Joemer C. Maravilla; Kim S. Betts; Camila Couto e Cruz; Rosa Alati
      Abstract: Publication date: Available online 19 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Joemer C. Maravilla, Kim S. Betts, Camila Couto e Cruz, Rosa Alati
      Objective Existing evidence of predictors of repeated teenage pregnancy (RTP) has not been rigorously assessed. This systematic review provides a comprehensive evaluation of protective and risk factors associated with RTP through a meta-analytical consensus. Data sources Pubmed, EMBASE, CINAHL, ProQuest, PsychINFO, ScienceDirect, Scopus and Web of Science databases, from 1997 to 2015; and reference list of other relevant research papers and related reviews. Study eligibility criteria Eligibility criteria included 1) epidemiological studies which analysed factors associated with repeated pregnancy or birth among adolescents under 20 years of age who were nulliparous or experienced at least one pregnancy; 2) experimental studies with an observational component adjusted for the intervention. Study appraisal and synthesis methods We performed narrative synthesis of study characteristics, participant characteristics, study results and quality assessment. We also conducted random-effects and quality-effects meta-analyses with meta-regression to obtain pooled odds ratios (PORs) of identified factors, and determine sources of between-study heterogeneity. Results Twenty six eligible epidemiologic studies mostly from USA (n=24) showed over 47 factors with no evidence of publication bias for each meta-analysis. Use of contraception [pooled odds ratio (POR)=0.60, 95% confidence interval (95%CI)=0.35-1.02] particularly long-acting reversible contraceptives (POR=0.19, 95%CI=0.08-0.45) considerably reduced RTP risk. Among studies concerning contraception, the number of follow-up visits (adjusted coefficient=0.72, p=0.102) and country of study (unadjusted coefficient= 2.57, permuted p=0.071) explained between-study heterogeneity. Education-related factors, including higher level of education (POR=0.74, 95%CI=0.60-0.91) and school continuation (POR=0.53, 95%CI=0.33-0.84), were found to be protective. Conversely, depression (POR=1.46, 95%CI=1.14-1.87), history of abortion (POR=1.66, 95%CI=1.08-2.54) and relationship factors, such as partner support, increased the RTP risk. Conclusions Contraceptive use, educational factors, depression and history of abortion are the highly influential predictors of RTP. However, there is a lack of epidemiological studies in low- and middle-income countries to measure the extent and characteristics of RTP across more varied settings.

      PubDate: 2017-04-21T12:21:41Z
      DOI: 10.1016/j.ajog.2017.04.021
       
  • Evaluation of Patient Preparedness for Surgery: A Randomized Controlled
           Trial
    • Authors: Kristie A. Greene; Allison M. Wyman; Lauren A. Scott; Stuart Hart; Lennox Hoyte; Renee Bassaly
      Abstract: Publication date: Available online 18 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Kristie A. Greene, Allison M. Wyman, Lauren A. Scott, Stuart Hart, Lennox Hoyte, Renee Bassaly
      Background Patient preparedness for pelvic reconstructive surgery has important implications for patient satisfaction and perception of improvement after surgery. The ideal method in which to optimally prepare patients for surgery has not been determined. Objective To evaluate the impact of a preoperative patient education video on patient preparedness prior to sacrocolpopexy as measured by a preoperative preparedness questionnaire (PPQ). Study Design We performed a single-blind, randomized stratified clinical trial at a single academic center evaluating the use of a preoperative patient education video as an adjunct to preoperative counseling on patient preparedness. Eligible patients presenting for their preoperative appointment prior to undergoing pelvic reconstructive surgery were randomized to watch a preoperative video vs. usual care. Preoperative questionnaires assessing patient preparedness, understanding, perception of time, and actual time spent with healthcare team were administered at the end of this visit. The primary outcome was patient preparedness for pelvic reconstructive surgery as measured by a preoperative preparedness questionnaire (PPQ). Secondary outcomes included actual time spent during physician-patient encounter, perception of time spent with healthcare team, and identification of patient factors associated with patient preparedness. Results Of the total 100 recruited patients, 52 were randomized to the video group and 48 to the usual care group. The use of the video did not increase overall patient preparedness (71.1% with video vs. 68.8% usual care, p=0.79) prior to surgery. The use of the video did not decrease the amount of time spent during the physician-patient encounter (16.9± 5.6 min vs. 17.1±5.4 min, p=0.87). There was a significant association between patient preparedness and perception that the health care team spent sufficient time with the patient (89.5% vs. 10.5%; p < 0.001), but no association was observed between preparedness and actual time spent (17.4±5.4 min vs.16.5± 5.5 min, p=0.47). Those with history of previous surgery (82.1% vs. 33.3%, p = 0.002) and those with more significant apical prolapse (0.6 ± 4.6 vs. -1.6 ± 3.9, p=0.05) were more likely to report feeling prepared for surgery. Conclusion The majority of patients undergoing pelvic surgery at our institution felt prepared prior to undergoing surgery. The use of preoperative education video did not increase overall patient preparedness for surgery. Greater preparedness was associated with patient perception of how much time the health care team spent with the patient but not actual time spent. (Clinicaltrials.gov number NCT02076360).

      PubDate: 2017-04-21T12:21:41Z
      DOI: 10.1016/j.ajog.2017.04.017
       
  • Confounding, Causality and Confusion: The Role of Intermediate Variables
           in Interpreting Observational Studies in Obstetrics
    • Authors: Cande V. Ananth; Enrique F. Schisterman
      Abstract: Publication date: Available online 17 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Cande V. Ananth, Enrique F. Schisterman
      Both prospective and retrospective cohort, and case-control studies are some of the most important study designs in epidemiology because, under certain assumptions, they can mimic a randomized trial when done well. These assumptions include but not limited to properly accounting for two important sources of bias: confounding and selection bias. While not adjusting the causal association for an intermediate variable will yield an unbiased estimate of the exposure-outcome’s total causal effect, it is often that obstetricians will want to adjust for an intermediate variable to assess if the intermediate is the underlying driver of the association. Such a practice must be weighed in light of the underlying research question, and whether such an adjustment is necessary should be carefully considered. Gestational age is, by far, the most commonly encountered variable in obstetrics that is often mislabeled as a confounder when, in fact, it may be an intermediate. If, indeed, gestational age is an intermediate but if mistakenly labeled as a confounding variable and consequently adjusted in an analysis, the conclusions can be unexpected. The implications of this over adjustment of an intermediate as though it were a confounder can render an otherwise persuasive study downright meaningless. This commentary provides an exposition of confounding bias, collider stratification and selection biases, with applications in obstetrics and perinatal epidemiology.

      PubDate: 2017-04-21T12:21:41Z
      DOI: 10.1016/j.ajog.2017.04.016
       
  • Pregestational type 2 diabetes mellitus induces cardiac hypertrophy in the
           murine embryo through cardiac remodeling and fibrosis
    • Authors: Xue Lin; Penghua Yang Albert Reece Peixin Yang
      Abstract: Publication date: Available online 13 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Xue Lin, Penghua Yang, E. Albert Reece, Peixin Yang
      Background Cardiac hypertrophy is highly prevalent in patients with type 2 diabetes mellitus (T2DM). Experimental evidence has implied that pregnant women with T2DM and their children are at an increased risk of cardiovascular diseases. Our previous mouse model study has revealed that maternal T2DM induces structural heart defects in their offspring. Objective The present study aims to determine whether maternal T2DM induces embryonic heart hypertrophy in a murine model of diabetic embryopathy. Study design The T2DM embryopathy model was established by feeding 4-week-old female C57BL/6J mice with a high-fat diet (HFD) for 15 weeks. Cardiac hypertrophy in embryos at embryonic day 17.5 was characterized by measuring heart size and thickness of the right and left ventricle walls and the interventricular septum, as well as the expression of β-myosin heavy chain (β-MHC), atrial natriuretic peptide (ANP), insulin-like growth factor 1 (IGF1), desmin (DES), and adrenomedullin (ADM). Cardiac remodeling was determined by collagen synthesis and fibronectin synthesis. Fibrosis was evaluated by Masson staining and determining the expression of connective tissue growth factor (CTGF), osteopontin (OPN), and Galectin 3 (GAL3) genes. Cell apoptosis also was measured in the developing heart. Results The thicknesses of the left ventricle walls and the interventricular septum of embryonic hearts exposed to maternal diabetes were significantly thicker than those in the nondiabetic (ND) group. Maternal diabetes significantly increased β-MHC, ANP, IGF1 and DES expression, but decreased expression of ADM. Moreover, collagen synthesis was significantly elevated, whereas fibronectin synthesis was suppressed, in embryonic hearts from diabetic dams, suggesting that cardiac remodeling is a contributing factor to cardiac hypertrophy. The cardiac fibrosis marker, GAL3, was induced by maternal diabetes. Furthermore, maternal T2DM activated the pro-apoptotic c-Jun-N-terminal kinase (JNK1/2) stress signaling and triggered cell apoptosis by increasing the number of TUNEL positive cells (10.4 ± 2.2% of the T2DM group vs. 3.8 ± 0.7% of the ND group, P < 0.05). Conclusions Maternal T2DM induces cardiac hypertrophy in embryonic hearts. Adverse cardiac remodeling, including elevated collagen synthesis, suppressed fibronectin synthesis, profibrosis and apoptosis, is implicated as the etiology of cardiac hypertrophy.

      PubDate: 2017-04-14T11:59:44Z
       
  • Tocolysis after preterm premature rupture of membranes and neonatal
           outcome: a propensity-score analysis
    • Authors: Elsa Lorthe; Goffinet Marret Christophe Vayssiere Cyril Flamant Mathilde Quere
      Abstract: Publication date: Available online 13 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Elsa Lorthe, François Goffinet, Stéphane Marret, Christophe Vayssiere, Cyril Flamant, Mathilde Quere, Valérie Benhammou, Pierre-Yves Ancel, Gilles Kayem
      Background There are conflicting results regarding tocolysis in cases of preterm premature rupture of membranes. Delaying delivery may reduce neonatal morbidity due to prematurity, allow for prenatal corticosteroids and, if necessary, in utero transfer. However, that may increase risks of maternofetal infection and its adverse consequences. Objective To investigate whether tocolytic therapy in cases of preterm premature rupture of membranes is associated with improved neonatal or obstetric outcomes. Study design EPIPAGE 2 is a French national prospective population-based cohort study of preterm births that occurred in 546 maternity units in 2011. Inclusion criteria in this analysis were women with preterm premature rupture of membranes at 24 to 32 weeks’ gestation and singleton gestations. Outcomes were survival to discharge without severe morbidity, latency prolonged by ≥ 48 hours and histological chorioamnionitis. Uterine contractions at admission, individual and obstetric characteristics, and neonatal outcomes were compared by tocolytic treatment or not. Propensity scores and inverse probability of treatment weighting for each woman were used to minimize indication bias in estimating the association of tocolytic therapy with outcomes. Results The study population consisted of 803 women; 596 (73.4%) received tocolysis. Women with and without tocolysis did not differ in neonatal survival without severe morbidity (86.7% vs 83.9%, p=.39), latency prolonged by ≥ 48 hr (75.1% vs 77.4%, p=.59) or histological chorioamnionitis (50.0% vs 47.6%, p=.73). After applying propensity scores and assigning inverse probability of treatment weighting, tocolysis was not associated with improved survival without severe morbidity as compared with no tocolysis (odds ratio 1.01 [95% Confidence Interval 0.94-1.09], latency prolonged by ≥ 48 hr (1.03 [0.95-1.11]), or histological chorioamnionitis (1.03 [0.92-1.17]). There was no association between the initial tocolytic drug used (oxytocin receptor antagonists or calcium-channel blockers vs no tocolysis) and the three outcomes. Sensitivity analyses of women (1) with preterm premature rupture of membranes at 26 to 31 weeks’ gestation, (2) who delivered at least 12 hr after rupture of membranes, with direct admission after the rupture of membranes and (3) presence or (4) absence of contractions, gave similar results. Conclusion Tocolysis in cases of preterm premature rupture of membranes is not associated with improved obstetric or neonatal outcomes; its clinical benefit remains un-proven.

      PubDate: 2017-04-14T11:59:44Z
       
  • In vivo evidence of significant levator-ani muscle stretch on MR images of
           a live childbirth
    • Authors: Nikhil Sindhwani; Christian Bamberg Nele Famaey Geertje Callewaert Joachim Dudenhausen
      Abstract: Publication date: Available online 13 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Nikhil Sindhwani, Christian Bamberg, Nele Famaey, Geertje Callewaert, Joachim W. Dudenhausen, Ulf Teichgräber, Jan Deprest
      Objective Vaginal childbirth is believed to be a significant risk factor for the development of pelvic floor dysfunction later in life. Previous studies have explored the use of medical imaging and simulations of childbirth to determine the stretch in the levator ani muscle. Bamberg et al, 2012, have recorded MR images of a live childbirth of a 24 year old woman giving birth vaginally for the second time, using a 1.0 Tesla open high-field scanner. Our objective was to determine the stretch ratios in the levator muscle using these MR images of live childbirth. Materials and Methods 3D MR image sequences were also obtained to visualize coronal and axial planes before and after the childbirth. These images were obtained before the expulsion phase without pushing. These scans were used to reconstruct the levator muscle and the fetal head in three dimensions. The fetal head was approximated to be an ellipsoid and it is assumed that its middle section is visible in dynamic MR images. Assuming incompressibility, the full deformation field of the fetal head is then calculated. Real-time cine MR images were acquired for the during the expulsion phase, occurring over 2 contractions in the mide-sagittal plane. The levator muscle stretch is estimated using a custom program. The program calculates points of contact between the fetal head ellipsoid and the LAM model as the head descends down the birth canal and moves them orthogonal to its surface. Circumferential stretch was calculated to represent the extension needed in order to allow the passage of the fetal head. Results Starting from a position where the pre-expulsion phase, the levator muscle experiences a maximum circumferential stretch of 248% on the posterior LAM region of the muscle. The location of the maximum stretch was at the posterior-medial portion of the LAM, as shown in previously published finite element (FE) simulations. However, the maximal stretch was notably less than that predicted by FE models. This is because our baseline 3D model of the levator muscle is created from images taken shortly before expulsioni and thus is already in a stretched state. Further, the FE models are created from images of a healthy nulliparous woman, while this study uses images from a para 2 woman. Conclusions This study is the first attempt to estimate the stretch in LAM during using MR images of a live childbirth. The stretch was significant and the locations corroborate with previous findings of finite element models.

      PubDate: 2017-04-14T11:59:44Z
       
  • SMFM Special Report: Coding update of the SMFM definition of low risk for
           cesarean delivery from ICD-9-CM to ICD-10-CM
    • Authors: J.C. Armstrong; McDermott G.R. Saade S.K. Srinivas
      Abstract: Publication date: Available online 13 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): J.C. Armstrong, P. McDermott, G.R. Saade, S.K. Srinivas
      In 2015, the Society for Maternal Fetal Medicine (SMFM) developed a low risk for cesarean delivery definition based on administrative claims-based diagnosis codes described by the International Classification of Disease, Clinical Modification, 9th revision. The SMFM definition is a clinical enrichment of two available measures from the Joint Commission (JC) and the Agency for Healthcare Research and Quality (AHRQ) measures. The SMFM measure excludes diagnosis codes that represent clinically relevant risk factors that are absolute or relative contraindications to vaginal birth while retaining diagnosis codes such as labor disorders that are discretionary risk factors for cesarean delivery. The introduction of the International Classification of Disease, Clinical Modification, 10th revision in October 2015 expanded the number of available diagnosis codes and enabled a greater depth and breadth of clinical description. These coding improvements further enhance the clinical validity of the SMFM definition and its potential utility in tracking progress towards the goal of safely lowering the U.S. cesarean delivery rate. This report updates the SMFM definition of low risk for cesarean delivery using International Classification of Disease, Clinical Modification, 10th revision coding.

      PubDate: 2017-04-14T11:59:44Z
       
  • Letter to the Editor about Proposed diagnostic criteria for the case
           definition of amniotic fluid embolism in research studies AJOG October
           2016; 408-412
    • Authors: Offer Erez
      Abstract: Publication date: Available online 12 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Offer Erez


      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.009
       
  • Management of Sexuality, Intimacy, and Menopause Symptoms (SIMS) in
           Ovarian Cancer Patients: Expert Review
    • Authors: Margaret Whicker; Jonathan Black; Gary Altwerger; Gulden Menderes; Jacqueline Feinberg; Elena Ratner
      Abstract: Publication date: Available online 12 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Margaret Whicker, Jonathan Black, Gary Altwerger, Gulden Menderes, Jacqueline Feinberg, Elena Ratner
      Issues of sexuality, intimacy, and early menopause significantly impact the quality of life of patients following the diagnosis and treatment of ovarian cancer. These are undertreated problems. Successful treatment requires the provider’s awareness of the problem, ability to identify it, and willingness to treat it. Unfortunately many providers do not address these issues in the pre-treatment or perioperative period. Furthermore, patients do not often alert their providers to their symptoms. While systemic hormone therapy may improve many of the issues, they are not appropriate for all patients given their action on estrogen receptors. However, other non-hormonal treatments exist including selective serotonin reuptake inhibitors, antiepileptics, natural remedies, and pelvic floor physical therapy. In addition psychological care and the involvement of the partner can be helpful in managing the sexual health concerns of these patients. At the time of diagnosis or at initial consultation, women should be informed of the potential physiologic, hormonal, and psychosocial effects of ovarian cancer on sexuality and also that there is a multi-modal approach to dealing with symptoms.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.012
       
  • Current and Future Role of Genetic Screening in Gynecologic Malignancies
    • Authors: Kari L. Ring; Christine Garcia; Martha H. Thomas; Susan C. Modesitt
      Abstract: Publication date: Available online 12 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Kari L. Ring, Christine Garcia, Martha H. Thomas, Susan C. Modesitt
      The world of hereditary cancers has seen an exponential growth in recent years. While Hereditary Breast and Ovarian Cancer and Lynch syndrome account for the majority of mutations encountered by gynecologists, newly identified deleterious genetic mutations continue to be unearthed with their associated risks of malignancies. However, these advances in genetic cancer predispositions then force practitioners and their patients to confront the uncertainties of these less commonly identified mutations and the fact that there is limited evidence to guide them in expected cancer risk and appropriate risk reduction strategies. Given the speed of information, it is imperative to involve cancer genetics experts when counseling these patients. In addition, coordination of screening and care in conjunction with specialty high risk clinics, if available, allows for patients to have centralized management for multiple cancer risks under the guidance of physicians with experience counseling these patients. The objective of this review is to present the current literature regarding genetic mutations associated with gynecologic malignancies as well to propose screening and risk reduction options for these high risk patients.
      Teaser The objective is to review the current literature regarding genetic mutations associated with gynecologic malignancies as well as screening and risk reduction options for patients found to carry specific genetic mutations.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.011
       
  • “Can 3D Power Doppler Indices Improve The Prenatal Diagnosis of a
           Potentially Morbidly Adherent Placenta in Patients With Placenta
           Previa?”
    • Authors: Ziad A. Haidar; Ramesha Papanna; Baha M. Sibai; Nina Tatevian; Oscar A. Viteri; Patricia C. Vowels; Sean C. Blackwell; Kenneth J. Moise
      Abstract: Publication date: Available online 9 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Ziad A. Haidar, Ramesha Papanna, Baha M. Sibai, Nina Tatevian, Oscar A. Viteri, Patricia C. Vowels, Sean C. Blackwell, Kenneth J. Moise
      Background Traditionally, 2D ultrasound parameters have been used for the diagnosis of a suspected morbidly adherent placenta (MAP) previa. More objective techniques have not been well studied yet. Objective To determine the ability of prenatal 3D power Doppler analysis of flow and vascular indices to predict the morbidly adherent placenta (MAP) objectively. Methods Prospective cohort study was performed in women between 28-32 weeks with known placenta previa. Patients underwent a two-dimensional (2D) gray-scale ultrasound that determined management decisions. 3D power Doppler volumes were obtained during the same examination and vascular, flow, and vascular flow indices were calculated after manual tracing of the viewed placenta in the sweep; data was blinded to obstetricians. MAP was confirmed by histology. Severe MAP (sMAP) was defined as: increta/percreta on histology, blood loss > 2000 ml, and > 2 units of PRBC transfused. Sensitivities, specificities, predictive values and likelihood ratios (LR) were calculated. Student-t and Chi-square tests, logistic regression, receiver-operating characteristic (ROC) curves, and intra and inter-rater agreements using Kappa statistics were performed. Results 1) Fifty women were studied: 23 had MAP, of which 12 (52.2%) were sMAP. 2) 2D parameters diagnosed MAP with a sensitivity of 82.6% (95% CI 60.4-94.2), a specificity of 88.9% (95% CI 69.7-97.1), positive predictive value 86.3% (95% CI 64.0-96.4), negative predictive value 85.7% (95% CI 66.4-95.3), LR+ 7.4 (95% CI 2.5-21.9), and LR- 0.2 (95% CI 0.08-0.48). 3) Mean values of vascular index (32.8±7.4) and vascular flow index (14.2±3.8) were higher in MAP (p < 0.001). 4) Area under the ROC curve for vascular and vascular flow indices were 0.99 and 0.97, respectively. 5) Vascular index ≥ 21 predicted MAP with a sensitivity and a specificity of 95% (95% CI 88.2-96.9) and 91% respectively (95% CI 87.5-92.4), 92% positive predictive value (95% CI 85.5-94.3), 90% negative predictive value (95% CI 79.9-95.3), LR+ 10.55 (95% CI 7.06-12.75), and LR- 0.05 (95% CI 0.03-0.13). 6) For sMAP, 2D ultrasound had a sensitivity of 33.3% (95% CI 11.3-64.6), a specificity of 81.8% (95% CI 47.8-96.8), positive predictive value 66.7% (95% CI 24.1-94.1), negative predictive value 52.9% (95% CI 28.5-76.1), LR+ 1.83 (95% CI 0.41-8.11), and LR- 0.81 (95% CI 0.52-1.26). A vascular index ≥ 31 predicted the diagnosis of sMAP with a 100% sensitivity (95% CI 72-100), 90% specificity (95% CI 81.7-93.8), 88% positive predictive value (95% CI 55.0-91.3), 100% negative predictive value (95% CI 90.9-100), LR+ 10.0 (95% CI 3.93-16.13), and LR- 0 (95% CI 0-0.34). Intra-rater and inter-rater agreement were 94% (p < 0.001) and 93% (p < 0.001) respectively. Conclusion Vascular index accurately predicts the morbidly adherent placenta in patients with placenta previa. In addition, 3D Power Doppler vascular and vascular flow indices were more predictive of severe cases of MAP compared to 2D ultrasound. This objective technique may limit the variations in diagnosing MAP due to the subjectivity of 2D ultrasound interpretations.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.005
       
  • Excessive duration of intrauterine balloon placement
    • Authors: Alouini
      Abstract: Publication date: Available online 8 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): S. Alouini


      PubDate: 2017-04-14T11:59:44Z
       
  • Marijuana and pregnancy: objective education is good, biased education is
           not
    • Authors: Ciara A. Torres; Carl L. Hart
      Abstract: Publication date: Available online 8 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Ciara A. Torres, Carl L. Hart


      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.003
       
  • Pregnancy, Birth, and Infant Outcomes by Maternal Fertility Status: The
           Massachusetts Outcomes Study of Assisted Reproductive Technology
    • Authors: Barbara Luke; Daksha Gopal; Howard Cabral; Judy E. Stern; Hafsatou Diop
      Abstract: Publication date: Available online 8 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Barbara Luke, Daksha Gopal, Howard Cabral, Judy E. Stern, Hafsatou Diop
      Background Births to subfertile women, with and without infertility treatment, have been reported to have lower birthweights and shorter gestations, even when limited to singletons. It is unknown whether these decrements are due to parental characteristics or aspects of infertility treatment. Objective To evaluate the effect of maternal fertility status on the risk of pregnancy, birth, and infant complications Study Design All singleton live births of ≥22 weeks’ gestation and ≥350 grams birthweight to Massachusetts resident women in 2004-10 were linked to hospital discharge and vital records. Women were categorized by their fertility status as in vitro fertilization (IVF), subfertile, or fertile. Women whose births linked to IVF cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System were classified as IVF. Women with indicators of subfertility but not treated with IVF were classified as subfertile. Women without indicators of subfertility or IVF treatment were classified as fertile. Risks of fifteen adverse outcomes (gestational diabetes, pregnancy hypertension, antenatal bleeding, placental complications (placenta abruptio and placenta previa), prenatal hospitalizations, primary cesarean, very low birthweight (<1,500g), low birthweight (<2,500g), small-for-gestation birthweight (Z-score ≤-1.28), large-for-gestation birthweight (Z-score ≥1.28), very preterm (<32 weeks), preterm (<37 weeks), birth defects, neonatal death (0-27 days), and infant death (0-364 days of life) were modeled by fertility status with the fertile group as reference, and the subfertile group as reference, using multivariate log binomial regression and reported as adjusted risk ratios (ARRs) and 95% confidence intervals. Results The study population included 459,623 women (441,420 fertile, 8,054 subfertile, and 10,149 IVF). Women in the subfertile and IVF groups were older than their fertile counterparts. Risks for six out of six pregnancy outcomes and six out of nine infant outcomes were increased for the subfertile group, and five out of six pregnancy outcomes and seven out of nine infant outcomes were increased for the IVF group. For four of the six pregnancy outcomes (uterine bleeding, placental complications, prenatal hospitalizations, and primary cesarean) and two of the infant outcomes (low birthweight and preterm) the risk was greater in the IVF group, with non-overlapping confidence intervals to the subfertile group, indicating a substantially higher risk among IVF-treated women. The highest risks for the IVF women were uterine bleeding (ARR 3.80, 95% CI 3.31, 4.36) and placental complications (ARR 2.81, 95% CI 2.57, 3.08), and for IVF infants, very preterm birth (ARR 2.13, 95% CI 1.80, 2.52) and very low birthweight (ARR 2.15, 95% CI 1.80, 2.56). With subfertile women as reference, risks for the IVF group were significantly increased for uterine bleeding, placental complications, prenatal hospitalizations, primary cesarean, low and very low birthweight, and preterm and very preterm birth. Conclusions These analyses indicate that, compared to fertile women, subfertile and IVF-treated women tend to be older, have more pre-existing chronic conditions, and are at higher risk for adverse pregnancy outcomes, particularly uterine bleeding and placental complications. The greater risk in IVF-treated women may reflect more severe infertility, more extensive underlying pathology, or other unfavorable factors not measured in this study.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.006
       
  • Racial and Ethnic Differences in the Prevalence of Metabolic Syndrome and
           its Components of Metabolic Syndrome in Women with Polycystic Ovary
           Syndrome (PCOS): A Regional Cross-Sectional Study
    • Authors: Jessica L. Chan; Sujata Kar; Eszter Vanky; Laure Morin-Papunen; Terhi Piltonen; Johanna Puurunen; Juha S. Tapaniennen; Gustavo Arantes Rosa Maciel; Sylvia Asaka Yamashita Hayashida; Jose Maria Saores; Edmund Chada Baracat; Jan Roar Mellembakkam; Anuja Dokras
      Abstract: Publication date: Available online 8 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Jessica L. Chan, Sujata Kar, Eszter Vanky, Laure Morin-Papunen, Terhi Piltonen, Johanna Puurunen, Juha S. Tapaniennen, Gustavo Arantes Rosa Maciel, Sylvia Asaka Yamashita Hayashida, Jose Maria Saores, Edmund Chada Baracat, Jan Roar Mellembakkam, Anuja Dokras
      Background – PCOS is a heterogeneous disorder and its presentation varies with race and ethnicity. Reproductive age women with PCOS are at increased risk of metabolic syndrome however, it is not clear if prevalence of metabolic syndrome and clustering of its components differs based on race and ethnicity. Moreover, the majority of these women do not undergo routine screening for metabolic syndrome. Objectives To compare the prevalence of metabolic syndrome and clustering of its components in women with PCOS in the United States with women in India, Brazil, Finland, and Norway. Study Design This is a cross-sectional study performed in 1089 women with PCOS from 1999-2016 in five outpatient clinics in the United States, India, Brazil, Finland and Norway. PCOS was defined by the Rotterdam criteria. Main outcome measures were: metabolic syndrome prevalence, blood pressure (BP), body mass index (BMI), fasting high-density lipoprotein cholesterol (HDL-C), fasting triglycerides (TG), fasting glucose. Data from all sites were re-evaluated for appropriate application of diagnostic criteria for PCOS, identification of PCOS phenotype and complete metabolic work-up. The US white women with PCOS were used as the referent group. Logistic regression models were used to evaluate associations between race and metabolic syndrome prevalence and its components and to adjust for potential confounders, including age and body mass index. Results The median age of the entire cohort was 28 years. Women from India had the highest mean Ferriman-Gallwey score for clinical hyperandrogenism (15.6±6.5, p<0.001) . The age-adjusted OR for metabolic syndrome was highest in U.S. Black women [4.52 (95% CI 2.46-8.35)] compared with U.S. White women. When adjusted for age and body mass index, the prevalence was similar in the two groups. Significantly more Black women met body mass index and blood pressure criteria (p< 0.001), and fewer met fasting triglycerides criteria (p < 0.05). The age- and body mass index - adjusted prevalence of metabolic syndrome was highest in Indian women [OR 6.53 (95% CI 3.47-12.30]) with abnormalities in glucose and fasting high-density lipoprotein cholesterol criterion and in Norwegian women (OR 2.16 (95% CI 1.17-3.98)] with abnormalities in blood pressure, glucose and fasting high-density lipoprotein cholesterol criterion. The Brazilian and Finnish cohorts had similar prevalence of metabolic syndrome and its components compared to US white women. Conclusion Despite a unifying diagnosis of PCOS, there are significant differences in the prevalence of metabolic syndrome and clustering of its components based on race and ethnicity, which may reflect contributions from both racial and environmental factors. Our findings indicate the prevalence of metabolic syndrome components varies in women with PCOS, such that compared to Caucasian women from the US, Black US women had the highest prevalence, whereas women from India and Norway have a higher prevalence of metabolic syndrome independent of obesity. The differences in clustering of components of metabolic syndrome based on ethnicity highlight the need to routinely perform complete metabolic screening to identify specific targets for cardiovascular risk reduction strategies in these reproductive age women.

      PubDate: 2017-04-14T11:59:44Z
      DOI: 10.1016/j.ajog.2017.04.007
       
  • September 2016 (vol. 215, no. 3, page 395)
    • Abstract: Publication date: Available online 7 April 2017
      Source:American Journal of Obstetrics and Gynecology


      PubDate: 2017-04-14T11:59:44Z
       
  • Information for Readers
    • Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4


      PubDate: 2017-04-14T11:59:44Z
       
  • An ounce of prevention…
    • Authors: Donald Coustan
      Abstract: Publication date: April 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 216, Issue 4
      Author(s): Donald R. Coustan


      PubDate: 2017-04-14T11:59:44Z
       
  • Increased risk of peripartum perinatal mortality in unplanned births
           outside institution - a retrospective population-based study
    • Authors: Hilde M. Engjom; Nils-Halvdan Morken; Even Høydahl; Ole F. Norheim; Kari Klungsøyr
      Abstract: Publication date: Available online 6 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Hilde M. Engjom, Nils-Halvdan Morken, Even Høydahl, Ole F. Norheim, Kari Klungsøyr
      Background Births in midwife-led institutions may reduce the frequency of medical interventions and provide cost-effective care, while larger institutions offer medically and technically advanced obstetric care. Unplanned births outside institution and intrapartum stillbirths have frequently been excluded in previous studies on adverse outcomes by place of birth Objective To assess peripartum mortality by place of birth and travel time to obstetric institutions, with the hypothesis that centralization reduces institution availability but improves mortality. Material and methods National population-based retrospective cohort study of all births in Norway from 1999 to 2009 (n=648 555) using data from the Medical Birth Registry of Norway and Statistics Norway, and includingbirths from 22 gestational weeks or birth weight ≥ 500g. Main exposures were travel time to the nearest obstetric institution and place of birth. Main clinical outcome was peripartum mortality, defined as death during birth or within 24 hours. Intrauterine fetal deaths prior to start of labour were excluded from the primary outcome. Results 1 586 peripartum deaths were identified (2.5/1000 births). Unplanned birth outside institution had three times higher mortality (8.4/1000) than institutional births (2.4/1000), relative risk 3.5 (95% confidence interval 2.5 to 4.9) and contributed 2% (95% CI 1.2 to 3.0%) of the peripartum mortality at the population level. Risk of unplanned birth outside institution increased from 0.5% to 3.3% and 4.5% with travel time <1-hour, 1-2 hours and >2 hours respectively. In obstetric institutions the mortality rate at term ranged from 0.7/1000 to 0.9/1000. Comparable mortality rates in different obstetric institutions indicated well-functioning routines for referral. Conclusion Unplanned birth outside institution was associated with increased peripartum mortality and with long travel time to obstetric institutions. Structural determinants have important impact on perinatal health in high-income countries, also for low-risk births. The results show the importance of skilled birth attendance and warrant attention from clinicians and policy makers to negative consequences of reduced access to institutions.

      PubDate: 2017-04-06T23:32:09Z
      DOI: 10.1016/j.ajog.2017.03.033
       
  • Clarification of Estimating Fetal Weight between 10-14 Weeks Gestation,
           NICHD Fetal Growth Studies
    • Authors: Germaine M. Buck Louis; Jagteshwar Grewal
      Abstract: Publication date: Available online 5 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Germaine M. Buck Louis, Jagteshwar Grewal


      PubDate: 2017-04-06T23:32:09Z
      DOI: 10.1016/j.ajog.2017.03.030
       
  • The 4th Trimester: A Critical Transition Period with Unmet Maternal Health
           Needs
    • Authors: Kristin P. Tully; Alison M. Stuebe; Sarah B. Verbiest
      Abstract: Publication date: Available online 5 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Kristin P. Tully, Alison M. Stuebe, Sarah B. Verbiest
      After childbirth, most American women are not scheduled for follow up care for 6 weeks, and this visit is poorly attended. Many new mothers feel unprepared for the common health issues they encounter and are uncertain of whom to contact. To improve care, the 4th Trimester Project is bringing together mothers, health care providers, and other stakeholders to explore what families need most from birth to 12 weeks postpartum. Eighty-seven individuals convened in March 2016 in Chapel Hill, NC. Four major topic areas emerged: (1) the intense focus on women’s health prenatally is unbalanced by infrequent and late postpartum care; (2) medical practice guidelines often do not align with women’s experiences and constraints; (3) validation of women as experts of their infants and elevating their strengths as mothers is necessary to achieve health goals; and (4) mothers need comprehensive care, which is difficult to provide due to numerous system constraints. Considerations for improving postpartum services include enabling more convenient care for families that is holistic, culturally appropriate, conversation-based, and equitable. Maternal health issues in the 4th Trimester intersect and can compound one another. Enhanced collaboration among health care providers may improve the focus clinical interactions to address the interrelated health issues most important to women.

      PubDate: 2017-04-06T23:32:09Z
      DOI: 10.1016/j.ajog.2017.03.032
       
  • The “morbidly adherent placenta” team: Recognition and respect
           are needed
    • Authors: Shigeki Matsubara; Hironori Takahashi; Alan Kawarai Lefor
      Abstract: Publication date: Available online 4 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Shigeki Matsubara, Hironori Takahashi, Alan Kawarai Lefor


      PubDate: 2017-04-06T23:32:09Z
      DOI: 10.1016/j.ajog.2017.03.031
       
  • Cesarean Section in the Second Stage of Labor and the Risk of Subsequent
           Premature Birth
    • Authors: Stephen Wood; Selphee Tang; Susan Crawford
      Abstract: Publication date: Available online 4 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Stephen Wood, Selphee Tang, Susan Crawford
      Background Cesarean section is being increasingly used by obstetricians for indicated deliveries in the second stage of labor. Unplanned extension of the uterine incision involving the cervix often occurs with these surgeries. Therefore, we hypothesized that cesarean section in the second stage of labor may increase the rate of subsequent spontaneous premature birth. Objective To determine if Cesarean section in the late first stage of labor or in the second stage of labor increases the risk of a subsequent spontaneous preterm birth. Study Design Retrospective cohort study of matched first and second births from a large Canadian perinatal database. The primary outcomes were spontaneous premature birth before 37 and before 32 weeks of gestation in the second birth. The exposure was stage of labor and cervical dilation at the time of the first Cesarean section. The protocol and analysis plan was registered prior to obtaining data at Open Science (org osf.io/u5xgv). Results In total, 189021 paired first and second births were identified. The risk of spontaneous preterm delivery less than 37 and 32 weeks of gestation in the second birth was increased when the first birth was by Cesarean section in the 2nd stage of labor, Relative Risk 1.57 95% CI (1.43, 1.73) and Relative Risk 2.12 95% CI (1.67, 2.68) respectively. The risk of perinatal death in the second birth, excluding congenital anomalies, was also correspondingly increased, Relative Risk 1.44 95% CI (1.05, 1.96). Conclusions Cesarean section in 2nd stage of labor was associated with a two-fold increase in the risk of spontaneous preterm birth less than 32 weeks of gestation in a subsequent birth. This information may inform management of operative delivery in the second stage.

      PubDate: 2017-04-06T23:32:09Z
      DOI: 10.1016/j.ajog.2017.03.006
       
  • Multivitamin use and adverse birth outcomes in high-income countries: a
           systematic review and meta-analysis
    • Authors: Hanne T. Wolf; Hanne K. Hegaard; Lene D. Huusom; Anja B. Pinborg
      Abstract: Publication date: Available online 2 April 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Hanne T. Wolf, Hanne K. Hegaard, Lene D. Huusom, Anja B. Pinborg
      Background In high-income countries (HIC), a healthy diet is widely accessible. However, a change towards a poor quality diet with a low nutritional value in HIC has led to an inadequate vitamin intake during pregnancy. Objective We conducted a systematic review and meta-analysis to evaluate the association between multivitamin use among women in HIC and the risk of adverse birth outcomes (preterm birth (PTB) (primary outcome), low birth weight, small-for-gestational age (SGA), stillbirth, neonatal death, perinatal mortality and congenital anomalies without further specification). Study design We searched electronic databases (MEDLINE, Embase, Cochrane, Scopus and CINAHL) from inception to 17 June 2016 using synonyms of “pregnancy”, “study/trial type” and “multivitamins”. Eligible studies were all studies in HIC investigating the association between multivitamin use (three or more vitamins or minerals in tablets or capsules) and adverse birth outcomes. We evaluated randomized, controlled trials using the Cochrane Collaboration tool. Observational studies were evaluated using the Newcastle-Ottawa Scale. Meta-analyses were applied on raw data for outcomes with data for at least two studies and were conducted using RevMan (version 5.3). Outcomes were pooled using the random-effect model. The quality of evidence was assessed using the GRADE approach. Results We identified 35 eligible studies including 98,926 women. None of the studies compared the use of folic acid and iron versus use of multivitamins. Use of multivitamin did not change the risk of the primary outcome PTB RR 0.84 (95% CI 0.69-1.03). However, the risk of SGA RR 0.77 (95% CI 0.63-0.93), neural tube defects (NTD) RR 0.67 (95% CI 0.52-0.87), cardiovascular defects RR 0.83 (95% CI 0.70-0.98), urine tract defects RR 0.60 (95% CI 0.46-0.78), and limb deficiencies RR 0.68 (95% CI 0.52-0.89) was decreased. Of the 35 identified studies, only four were RCTs. The degree of clinical evidence according to the GRADE system was low or very low for all outcomes except for recurrence of NTD where a moderate degree of clinical evidence was found. Conclusion Routine multivitamin use in HIC can be recommended, but with caution due to the low quality of evidence. RCTs or well-performed, large prospective cohort studies are needed.

      PubDate: 2017-04-06T23:32:09Z
      DOI: 10.1016/j.ajog.2017.03.029
       
 
 
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