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Publisher: Elsevier   (Total: 3051 journals)

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Showing 1 - 200 of 3048 Journals sorted alphabetically
A Practical Logic of Cognitive Systems     Full-text available via subscription   (Followers: 7)
AASRI Procedia     Open Access   (Followers: 15)
Academic Pediatrics     Hybrid Journal   (Followers: 24, SJR: 1.402, h-index: 51)
Academic Radiology     Hybrid Journal   (Followers: 22, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 86, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 25, SJR: 0.612, h-index: 27)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 30, 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: 358, 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   (Followers: 1)
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: 225, 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: 10, 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: 1)
Acta Poética     Open Access   (Followers: 4)
Acta Psychologica     Hybrid Journal   (Followers: 24, SJR: 1.365, h-index: 73)
Acta Sociológica     Open Access  
Acta Tropica     Hybrid Journal   (Followers: 6, 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: 4, 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)
Acute Pain     Full-text available via subscription   (Followers: 13)
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: 6)
Additive Manufacturing     Hybrid Journal   (Followers: 7, SJR: 1.039, h-index: 5)
Additives for Polymers     Full-text available via subscription   (Followers: 21)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 134, 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: 17, SJR: 0.739, h-index: 33)
Advances in Accounting     Hybrid Journal   (Followers: 9, 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: 26, 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: 11, SJR: 0.801, h-index: 26)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 22, 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: 25, 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 Cell Aging and Gerontology     Full-text available via subscription   (Followers: 4)
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: 27, 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: 9, SJR: 1.268, h-index: 45)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 29, 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 Dermatology     Full-text available via subscription   (Followers: 12)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 11)
Advances in Digestive Medicine     Open Access   (Followers: 6)
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: 43, 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: 42, 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: 50, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 16)
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: 22, SJR: 0.906, h-index: 24)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 0.497, h-index: 31)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 26)
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: 36, 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: 6)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 4)
Advances in Life Course Research     Hybrid Journal   (Followers: 8, SJR: 0.764, h-index: 15)
Advances in Lipobiology     Full-text available via subscription   (Followers: 2)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 9)
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: 6, 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: 22)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 10)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 8, SJR: 0.324, h-index: 8)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 4)
Advances in Oncobiology     Full-text available via subscription   (Followers: 3)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
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: 24, SJR: 0.4, h-index: 28)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 13)
Advances in Pharmacology     Full-text available via subscription   (Followers: 15, SJR: 1.718, h-index: 58)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 8, 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: 17)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 1.5, h-index: 62)
Advances in Psychology     Full-text available via subscription   (Followers: 62)
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: 2, SJR: 0.1, h-index: 2)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 5)
Advances in Space Research     Full-text available via subscription   (Followers: 362, SJR: 0.606, h-index: 65)
Advances in Structural Biology     Full-text available via subscription   (Followers: 8)
Advances in Surgery     Full-text available via subscription   (Followers: 7, SJR: 0.823, h-index: 27)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 30, SJR: 1.321, h-index: 56)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 16)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 13)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 1.878, h-index: 68)
Advances in Water Resources     Hybrid Journal   (Followers: 43, 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: 327, 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: 5, SJR: 0.344, h-index: 6)
Ageing Research Reviews     Hybrid Journal   (Followers: 8, SJR: 3.289, h-index: 78)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 413, SJR: 1.385, h-index: 72)
Agri Gene     Hybrid Journal  
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 16, SJR: 2.18, h-index: 116)
Agricultural Systems     Hybrid Journal   (Followers: 30, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 40, 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: 54, 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: 5, 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: 11, SJR: 0.922, h-index: 66)
Alcoholism and Drug Addiction     Open Access   (Followers: 8)
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   (Followers: 1)
Algal Research     Partially Free   (Followers: 8, 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: 4, SJR: 0.776, h-index: 35)
Alpha Omegan     Full-text available via subscription   (SJR: 0.121, h-index: 9)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 9, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 46, SJR: 4.289, h-index: 64)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 4)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 49, 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: 40, SJR: 0.574, h-index: 65)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 9, 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: 26, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 32, SJR: 2.313, h-index: 172)
American J. of Medicine     Hybrid Journal   (Followers: 46, 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: 200, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 59, SJR: 2.803, h-index: 148)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 6)
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: 25, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 26, SJR: 2.653, h-index: 228)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 24, SJR: 2.764, h-index: 154)
American J. of Surgery     Hybrid Journal   (Followers: 35, SJR: 1.286, h-index: 125)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, 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: 58, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 12)
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: 4, SJR: 2.577, h-index: 7)
Analytica Chimica Acta     Hybrid Journal   (Followers: 37, SJR: 1.548, h-index: 152)
Analytical Biochemistry     Hybrid Journal   (Followers: 166, SJR: 0.725, h-index: 154)
Analytical Chemistry Research     Open Access   (Followers: 8, SJR: 0.18, h-index: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 12)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 1)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 23, 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: 170, SJR: 1.907, h-index: 126)

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Journal Cover American Journal of Obstetrics and Gynecology
  [SJR: 2.255]   [H-I: 171]   [200 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9378
   Published by Elsevier Homepage  [3051 journals]
  • Aspirin for Evidence-Based Preeclampsia Prevention trial: effect of
           aspirin in prevention of preterm preeclampsia in subgroups of women
           according to their characteristics and medical and obstetrical history
    • Authors: David Wright; Liona C. Poon; Daniel L. Rolnik; Argyro Syngelaki; Juan Luis Delgado; Denisa Vojtassakova; Mercedes de Alvarado; Evgenia Kapeti; Anoop Rehal; Andrea Pazos; Ilma Floriana Carbone; Vivien Dutemeyer; Walter Plasencia; Nikos Papantoniou; Kypros H. Nicolaides
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Liona C. Poon, David Wright, Daniel L. Rolnik, Argyro Syngelaki, Juan Luis Delgado, Theodora Tsokaki, Gergo Leipold, Ranjit Akolekar, Siobhan Shearing, Luciana De Stefani, Jacques C. Jani, Walter Plasencia, Nikolaos Evangelinakis, Otilia Gonzalez-Vanegas, Nicola Persico, Kypros H. Nicolaides
      Background The Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia Prevention trial demonstrated that in women who were at high risk for preterm preeclampsia with delivery at <37 weeks’ gestation identified by screening by means of an algorithm that combines maternal factors and biomarkers at 11-13 weeks’ gestation, aspirin administration from 11 to 14 until 36 weeks’ gestation was associated with a significant reduction in the incidence of preterm preeclampsia (odds ratio 0.38; 95% confidence interval, 0.20 to 0.74; P=0.004). Objective We sought to examine whether there are differences in the effect of aspirin on the incidence of preterm preeclampsia in the Aspirin for Evidence-Based Preeclampsia Prevention trial in subgroups defined according to maternal characteristics and medical and obstetrical history. Study Design This was a secondary analysis of data from the Aspirin for Evidence-Based Preeclampsia Prevention trial. Subgroup analysis was performed to assess evidence of differences in the effect of aspirin on incidence of preterm preeclampsia in subgroups defined by maternal age (<30 and ≥30 years), body mass index (<25 and ≥25 kg/m2), racial origin (Afro-Caribbean, Caucasian and other), method of conception (natural and assisted), cigarette smoking (smoker and non-smoker), family history of preterm preeclampsia (present and absent), obstetrical history (nulliparous, multiparous with previous preterm preeclampsia and multiparous without previous preterm preeclampsia), history of chronic hypertension (present and absent). Interaction tests were performed on the full data set of patients in the intention to treat population and on the data set of patients who took ≥ 90% of the prescribed medication. Results are presented as forest plot with P values for the interaction effects, group sizes, event counts and estimated odds ratios. We examined whether the test of interaction was significant at the 5% level with a Bonferroni adjustment for multiple comparisons. Results There was no evidence of heterogeneity in the aspirin effect in subgroups defined according to maternal characteristics and obstetrical history. In participants with chronic hypertension preterm preeclampsia occurred in 10.2% (5/49) in the aspirin group and 8.2% (5/61) in the placebo group (adjusted odds ratio, 1.29; 95% confidence interval, 0.33–5.12). The respective values in those without chronic hypertension were 1.1% (8/749) in the aspirin group and 3.9% (30/761) in the placebo group (adjusted odds ratio, 0.27; 95% confidence interval, 0.12–0.60). In all participants with adherence of ≥90% the adjusted odds ratio in the aspirin group was 0.24 (95% confidence interval, 0.09–0.65); in the subgroup with chronic hypertension it was 2.06 (95% confidence interval, 0.40–10.71); and in those without chronic hypertension it was 0.05 (95% confidence interval, 0.01–0.41). For the complete data set the test of interaction was not significant at the 5% level (P = .055), but in those with adherence ≥90%, after adjustment for multiple comparisons, the interaction was significant at the 5% level (P = .0019). Conclusion The beneficial effect of aspirin in the prevention of preterm preeclampsia may not apply in pregnancies with chronic hypertension. There was no evidence of heterogeneity in the aspirin effect in subgroups defined according to maternal characteristics and obstetrical history.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.08.110
       
  • Trauma in pregnancy: an underappreciated cause of maternal death
    • Authors: Sarah J. Kilpatrick
      Pages: 499 - 500
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Sarah J. Kilpatrick


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.09.012
       
  • The link between cell-free DNA, inflammation and the initiation of
           spontaneous labor at term
    • Authors: Mark Phillippe
      Pages: 501 - 502
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Mark Phillippe


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.09.003
       
  • Prophylactic bilateral salpingectomy at vaginal hysterectomy: time for a
           “policy”'
    • Authors: Rosanne M. Kho
      Pages: 503 - 504
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Rosanne M. Kho


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.08.020
       
  • Giants in Obstetrics and Gynecology: A profile of Donald R. Coustan, MD
    • Authors: Roberto Romero
      Pages: 505 - 511.e3
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Roberto Romero


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.06.037
       
  • Current and future role of genetic screening in gynecologic
           malignancies
    • Authors: Kari L. Ring; Christine Garcia; Martha H. Thomas; Susan C. Modesitt
      Pages: 512 - 521
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Kari L. Ring, Christine Garcia, Martha H. Thomas, Susan C. Modesitt
      The world of hereditary cancers has seen 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.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.04.011
       
  • Incorporating simulation into gynecologic surgical training
    • Authors: Kyle Wohlrab; J. Eric Jelovsek; Deborah Myers
      Pages: 522 - 526
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Kyle Wohlrab, J. Eric Jelovsek, Deborah Myers
      Today’s educational environment has made it more difficult to rely on the Halstedian model of “see one, do one, teach one” in gynecologic surgical training. There is decreased surgical volume, but an increased number of surgical modalities. Fortunately, surgical simulation has evolved to fill the educational void. Whether it is through skill generalization or skill transfer, surgical simulation has shifted learning from the operating room back to the classroom. This article explores the principles of surgical education and ways to introduce simulation as an adjunct to residency training. We review high- and low-fidelity surgical simulators, discuss the progression of surgical skills, and provide options for skills competency assessment. Time and money are major hurdles when designing a simulation curriculum, but low-fidelity models, intradepartmental cost sharing, and utilizing local experts for simulation proctoring can aid in developing a simulation program.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.05.017
       
  • The impact of uterine immaturity on obstetrical syndromes
           during adolescence
    • Authors: Ivo Brosens; Joanne Muter; Caroline E. Gargett; Patrick Puttemans; Giuseppe Benagiano; Jan J. Brosens
      Pages: 546 - 555
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Ivo Brosens, Joanne Muter, Caroline E. Gargett, Patrick Puttemans, Giuseppe Benagiano, Jan J. Brosens
      Pregnant nulliparous adolescents are at increased risk, inversely proportional to their age, of major obstetric syndromes, including preeclampsia, fetal growth restriction, and preterm birth. Emerging evidence indicates that biological immaturity of the uterus accounts for the increased incidence of obstetrical disorders in very young mothers, possibly compounded by sociodemographic factors associated with teenage pregnancy. The endometrium in most newborns is intrinsically resistant to progesterone signaling, and the rate of transition to a fully responsive tissue likely determines pregnancy outcome during adolescence. In addition to ontogenetic progesterone resistance, other factors appear important for the transition of the immature uterus to a functional organ, including estrogen-dependent growth and tissue-specific conditioning of uterine natural killer cells, which plays a critical role in vascular adaptation during pregnancy. The perivascular space around the spiral arteries is rich in endometrial mesenchymal stem-like cells, and dynamic changes in this niche are essential to accommodate endovascular trophoblast invasion and deep placentation. Here we evaluate the intrinsic (uterine-specific) mechanisms that predispose adolescent mothers to the great obstetrical syndromes and discuss the convergence of extrinsic risk factors that may be amenable to intervention.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.05.059
       
  • Mitochondrial replacement therapy: born in the USA: the untold story of a
           conceptual breakthrough
    • Authors: Eli Y. Adashi; I. Glenn Cohen
      Pages: 561 - 563
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Eli Y. Adashi, I. Glenn Cohen


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.032
       
  • Vulvar Crohn’s disease: a rare presentation
    • Authors: Sarah T. Cigna; Leia S. Mitchell; Andrew T. Goldstein
      First page: 616
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Sarah T. Cigna, Leia S. Mitchell, Andrew T. Goldstein


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.06.027
       
  • Measuring the impact of attending physician teaching in an obstetrics
           and gynecology residency program
    • Authors: Anthony M. Vintzileos
      Pages: 617 - 618
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Anthony M. Vintzileos


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.028
       
  • Showing your public face: does screening social media assess residency
           applicants’ professionalism'
    • Authors: Marie E. Sullivan; Gary N. Frishman; Roxanne A. Vrees
      Pages: 619 - 620
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Marie E. Sullivan, Gary N. Frishman, Roxanne A. Vrees


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.035
       
  • Do maternal obesity or smoking explain the lack of effectiveness of
           17-alpha hydroxyprogesterone caproate'
    • Authors: Kent D. Heyborne; Amanda A. Allshouse
      First page: 621
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Kent D. Heyborne, Amanda A. Allshouse


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.014
       
  • The value of the cerebroplacental ratio in appropriate-for-gestational-age
           fetuses
    • Authors: Isabelle Dehaene; Ann-Sophie Page; Geert Page
      Pages: 622 - 623
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Isabelle Dehaene, Ann-Sophie Page, Geert Page


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.027
       
  • Quality of life of menopausal women with genital urinary menopause
           syndrome
    • Authors: Angelo do Carmo Silva Matthes; Gustavo Zucca Matthes
      First page: 624
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Angelo do Carmo Silva Matthes, Gustavo Zucca Matthes


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.029
       
  • A vicious cycle of causes and consequences of dyspareunia: rethinking the
           approach to management of genitourinary syndrome of menopause
    • Authors: Jason Gandhi; Sardar Ali Khan
      First page: 625
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Jason Gandhi, Sardar Ali Khan


      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.030
       
  • Influence of paternal age on perinatal outcomes
    • Authors: Emily G. Hurley; Emily A. DeFranco
      Pages: 566.e1 - 566.e6
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Emily G. Hurley, Emily A. DeFranco
      Background There is an increasing trend to delay childbearing to advanced parental age. Increased risks of advanced maternal age and assisted reproductive technologies are widely accepted. There are limited data regarding advanced paternal age. To adequately counsel patients on risk, more research regarding advanced paternal age is necessary. Objective We sought to determine the influence of paternal age on perinatal outcomes, and to assess whether this influence differs between pregnancies achieved spontaneously and those achieved with assisted reproductive technology. Study Design A population-based retrospective cohort study of all live births in Ohio from 2006 through 2012 was completed. Data were evaluated to determine if advanced paternal age is associated with an increased risk of adverse outcomes in pregnancies. The analysis was stratified by status of utilization of assisted reproductive technology. Generalized linear regression models assessed the association of paternal age on pregnancy complications in assisted reproductive technology and spontaneously conceived pregnancies, after adjusting for maternal age, race, multifetal gestation, and Medicaid status, using Stata software (Stata, Release 12; StataCorp, College Station, TX). Results Paternal age was documented in 82.2% of 1,034,552 live births in Ohio during the 7-year study period. Paternal age ranged from 12-87 years, with a median of 30 (interquartile range, 26-35) years. Maternal age ranged from 11-62 years, with a median of 27 (interquartile range, 22-31) years. The use of assisted reproductive technology in live births increased as paternal age increased: 0.1% <30 years vs 2.5% >60 years, P < .001. After accounting for maternal age and other confounding risk factors, increased paternal age was not associated with a significant increase in the rate of preeclampsia, preterm birth, fetal growth restriction, congenital anomaly, genetic disorder, or neonatal intensive care unit admission. The influence of paternal age on pregnancy outcomes was similar in pregnancies achieved with and without assisted reproductive technology. Conclusion Older paternal age does not appear to pose an independent risk of adverse perinatal outcomes, in pregnancies achieved either with or without assisted reproductive technology. However, small effect sizes such as very small risk increases or decreases may not be detectable despite the large sample size in this study of >830,000 births.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.034
       
  • The feasibility, safety, and effectiveness of hysteroscopic sterilization
           compared with laparoscopic sterilization
    • Authors: Lina Antoun; Paul Smith; Janesh K. Gupta; T. Justin Clark
      Pages: 570.e1 - 570.e6
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Lina Antoun, Paul Smith, Janesh K. Gupta, T. Justin Clark
      Background In contrast to conventional laparoscopic sterilization, newer hysteroscopic approaches avoid the need for hospital admission, general anesthesia, and prolonged recovery. However, there are concerns that the feasibility, safety, and efficacy of hysteroscopic sterilization may be lower than established laparoscopic sterilization. Objective We sought to evaluate the outcomes of hysteroscopic sterilization compared with laparoscopic sterilization in routine clinical practice in a comparative observational cohort study. Study Design This study was carried out at University of Birmingham, United Kingdom, National Health Service teaching hospital, office hysteroscopy clinics, and day-case hospital unit. In all, 1085 women underwent hysteroscopic sterilization and 2412 had laparoscopic sterilization. Hysteroscopic sterilization was carried out using the tubal implant permanent birth control system in the office setting and laparoscopic sterilization using the tubal ligation system as a day-case under general anesthesia. Outcome data were collected regarding feasibility (technical completion of the sterilization procedure, satisfactory radiological confirmation at 3 months–hysterosalpingogram or transvaginal pelvic ultrasound scan), safety events within 30 days of procedures, reoperations, and unintended pregnancies within 1 year of procedures. Results Hysteroscopic sterilization was successful in 992/1085 (91.4%; 95% confidence interval, 89.6–93.0%) at the first attempt. In comparison, bilateral tubal ligation was successfully performed in 2400/2412 (99.5%; 95% confidence interval, 99.2–99.8%) of patients who underwent laparoscopic sterilizations (odds ratio, 18.8; 95% confidence interval, 10.2–34.4). In all, 902/1085 (83.1%; 95% confidence interval, 80.8–85.2%) of successfully performed hysteroscopic procedures attended for radiological confirmation testing were considered satisfactory. The rate of adverse events within 30 days were similar: 2/1085 (0.2%) vs 3 (0.12%; 95% confidence interval, 0.04–0.36%). There were 3/1085 (0.3%; 95% confidence interval, 0.1–0.8%) unintended pregnancies after hysteroscopic sterilization compared with 5/2412 (0.2%; 95% confidence interval, 0.1–0.5%) laparoscopic sterilization (odds ratio, 1.3; 95% confidence interval, 0.3–5.6). Median length of follow-up for pregnancy outcome was 5 years. Hysteroscopic sterilization was associated with a higher risk of reoperation at 1 year compared to laparoscopic sterilization (odds ratio, 6.2; 95% confidence interval, 2.8–14.0) and the commonest reintervention was unilateral salpingectomy (12/22, 54.5%). Conclusion Hysteroscopic sterilization has been introduced as a more convenient, office-based method of permanent fertility control. However, while the small risk of unintended pregnancy is comparable to conventional laparoscopic sterilization, women should also be counselled regarding its lower success rate in successfully completing the procedure and its higher rate of failed reoperation.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.011
       
  • Cost-effectiveness of treatments for heavy menstrual bleeding
    • Authors: Jennifer C. Spencer; Michelle Louie; Janelle K. Moulder; Victoria Ellis; Lauren D. Schiff; Tarek Toubia; Matthew T. Siedhoff; Stephanie B. Wheeler
      Pages: 574.e1 - 574.e9
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Jennifer C. Spencer, Michelle Louie, Janelle K. Moulder, Victoria Ellis, Lauren D. Schiff, Tarek Toubia, Matthew T. Siedhoff, Stephanie B. Wheeler
      Background Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown. Objective The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine system. Study Design We formulated a decision tree evaluating private payer costs and quality-adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality-adjusted life years, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied. Results The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing intrauterine system was cost-effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness-to-pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios. Conclusion Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.024
       
  • Cost-effectiveness of population based BRCA testing with varying Ashkenazi
           Jewish ancestry
    • Authors: Ranjit Manchanda; Shreeya Patel; Antonis C. Antoniou; Ephrat Levy-Lahad; Clare Turnbull; D. Gareth Evans; John L. Hopper; Robert J. Macinnis; Usha Menon; Ian Jacobs; Rosa Legood
      Pages: 578.e1 - 578.e12
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Ranjit Manchanda, Shreeya Patel, Antonis C. Antoniou, Ephrat Levy-Lahad, Clare Turnbull, D. Gareth Evans, John L. Hopper, Robert J. Macinnis, Usha Menon, Ian Jacobs, Rosa Legood
      Background Population-based BRCA1/BRCA2 testing has been found to be cost-effective compared with family history–based testing in Ashkenazi-Jewish women were >30 years old with 4 Ashkenazi-Jewish grandparents. However, individuals may have 1, 2, or 3 Ashkenazi-Jewish grandparents, and cost-effectiveness data are lacking at these lower BRCA prevalence estimates. We present an updated cost-effectiveness analysis of population BRCA1/BRCA2 testing for women with 1, 2, and 3 Ashkenazi-Jewish grandparents. Study Design Decision analysis model. Methods Lifetime costs and effects of population and family history–based testing were compared with the use of a decision analysis model. 56% BRCA carriers are missed by family history criteria alone. Analyses were conducted for United Kingdom and United States populations. Model parameters were obtained from the Genetic Cancer Prediction through Population Screening trial and published literature. Model parameters and BRCA population prevalence for individuals with 3, 2, or 1 Ashkenazi-Jewish grandparent were adjusted for the relative frequency of BRCA mutations in the Ashkenazi-Jewish and general populations. Incremental cost-effectiveness ratios were calculated for all Ashkenazi-Jewish grandparent scenarios. Costs, along with outcomes, were discounted at 3.5%. The time horizon of the analysis is “life-time,” and perspective is “payer.” Probabilistic sensitivity analysis evaluated model uncertainty. Results Population testing for BRCA mutations is cost-saving in Ashkenazi-Jewish women with 2, 3, or 4 grandparents (22-33 days life-gained) in the United Kingdom and 1, 2, 3, or 4 grandparents (12-26 days life-gained) in the United States populations, respectively. It is also extremely cost-effective in women in the United Kingdom with just 1 Ashkenazi-Jewish grandparent with an incremental cost-effectiveness ratio of £863 per quality-adjusted life-years and 15 days life gained. Results show that population-testing remains cost-effective at the £20,000–30000 per quality-adjusted life-years and $100,000 per quality-adjusted life-years willingness-to-pay thresholds for all 4 Ashkenazi-Jewish grandparent scenarios, with ≥95% simulations found to be cost-effective on probabilistic sensitivity analysis. Population-testing remains cost-effective in the absence of reduction in breast cancer risk from oophorectomy and at lower risk-reducing mastectomy (13%) or risk-reducing salpingo-oophorectomy (20%) rates. Conclusion Population testing for BRCA mutations with varying levels of Ashkenazi-Jewish ancestry is cost-effective in the United Kingdom and the United States. These results support population testing in Ashkenazi-Jewish women with 1-4 Ashkenazi-Jewish grandparent ancestry.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.06.038
       
  • Cell-free DNA, inflammation, and the initiation of spontaneous term
           labor
    • Authors: Christina A. Herrera; Jay Stoerker; John Carlquist; Gregory J. Stoddard; Marc Jackson; Sean Esplin; Nancy C. Rose
      Pages: 583.e1 - 583.e8
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Christina A. Herrera, Jay Stoerker, John Carlquist, Gregory J. Stoddard, Marc Jackson, Sean Esplin, Nancy C. Rose
      Background Hypomethylated cell-free DNA from senescent placental trophoblasts may be involved in the activation of the inflammatory cascade to initiate labor. Objective To determine the changes in cell-free DNA concentrations, the methylation ratio, and inflammatory markers between women in labor at term vs women without labor. Study Design In this prospective cohort study, eligible participants carried a nonanomalous singleton fetus. Women with major medical comorbidity, preterm labor, progesterone use, aneuploidy, infectious disease, vaginal bleeding, abdominal trauma, or invasive procedures during the pregnancy were excluded. Maternal blood samples were collected at 28 weeks, 36 weeks, and at admission for delivery. Total cell-free DNA concentration, methylation ratio, and interleukin-6 were analyzed. The primary outcome was the difference in methylation ratio in women with labor vs without labor. Secondary outcomes included the longitudinal changes in these biomarkers corresponding to labor status. Results A total of 55 women were included; 20 presented in labor on admission and 35 presented without labor. Women in labor had significantly greater methylation ratio (P = .001) and interleukin-6 (P < .001) on admission for delivery than women without labor. After we controlled for body mass index and maternal age, methylation ratio (adjusted relative risk, 1.38; 95% confidence interval, 1.13 to 1.68) and interleukin-6 (adjusted relative risk, 1.12, 95% confidence interval, 1.07 to 1.17) remained greater in women presenting in labor. Total cell-free DNA was not significantly different in women with labor compared with women without. Longitudinally, total cell-free DNA (P < .001 in labor, P = .002 without labor) and interleukin-6 (P < .001 in labor, P = .01 without labor) increased significantly across gestation in both groups. The methylation ratio increased significantly in women with labor from 36 weeks to delivery (P = .02). Conclusion Spontaneous labor at term is associated with a greater cell-free DNA methylation ratio and interleukin-6 compared with nonlabored controls. As gestation advances, total cell-free DNA concentrations and interleukin-6 levels increase. A greater methylation ratio reflects a greater maternal contribution (vs placental) in women with labor, likely resulting from greater levels of neutrophils, lymphocytes, and uterine activation proteins at the time of labor. Although not significant, women in labor had a greater total cell-free DNA concentration and thus could theoretically have more hypomethylated DNA available for interaction with the inflammatory cascade. Larger studies are needed to investigate this theory.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.05.027
       
  • Amniotic fluid transcriptomics reflects novel disease mechanisms in
           fetuses with myelomeningocele
    • Authors: Tomo Tarui; Aimee Kim; Alan Flake; Lauren McClain; John D. Stratigis; Inbar Fried; Rebecca Newman; Donna K. Slonim; Diana W. Bianchi
      Pages: 587.e1 - 587.e10
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Tomo Tarui, Aimee Kim, Alan Flake, Lauren McClain, John D. Stratigis, Inbar Fried, Rebecca Newman, Donna K. Slonim, Diana W. Bianchi
      Background Cell-free RNA in amniotic fluid supernatant reflects developmental changes in gene expression in the living fetus, which includes genes that are specific to the central nervous system. Although it has been previously shown that central nervous system–specific transcripts are present in amniotic fluid supernatant, it is not known whether changes in the amniotic fluid supernatant transcriptome reflect the specific pathophysiologic condition of fetal central nervous system disorders. In myelomeningocele, there is open communication between the central nervous system and amniotic fluid. Objectives The purpose of this study was to identify molecular pathophysiologic changes and novel disease mechanisms that are specific to myelomeningocele by the analysis of amniotic fluid supernatant cell-free RNA in fetuses with open myelomeningocele. Study Design Amniotic fluid supernatant was collected from 10 pregnant women at the time of the open myelomeningocele repair in the second trimester (24.5±1.0 weeks); 10 archived amniotic fluid supernatant from sex and gestational age–matched euploid fetuses without myelomeningocele were used as controls (20.9±0.9 weeks). Differentially regulated gene expression patterns were analyzed with the use of human genome expression arrays. Results Fetuses with myelomeningocele had 284 differentially regulated genes (176 up- and 108 down-regulated) in amniotic fluid supernatant. Known genes that were associated with myelomeningocele (PRICKLE2, GLI3, RAB23, HES1, FOLR1) and novel dysregulated genes were identified in association with neurodevelopment and neuronal regeneration (up-regulated, GAP43 and ZEB1) or axonal growth and guidance (down-regulated, ACAP1). Pathway analysis demonstrated a significant contribution of inflammation to disease and a broad influence of Wnt signaling pathways (Wnt1, Wnt5A, ITPR1). Conclusion Transcriptomic analyses of living fetuses with myelomeningocele with the use of amniotic fluid supernatant cell-free RNA demonstrated differential regulation of specific genes and molecular pathways relevant to this central nervous system disorder, which resulted in a new understanding of pathophysiologic changes. The data also suggested the importance of pathways that involve secondary disease, such as inflammation, in myelomeningocele. These newly identified pathways may lead to hypotheses that can test novel therapeutic targets as adjuncts to fetal surgical repair.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.022
       
  • Preterm labor in the absence of acute histologic chorioamnionitis is
           characterized by cellular senescence of the chorioamniotic membranes
    • Authors: Nardhy Gomez-Lopez; Roberto Romero; Olesya Plazyo; George Schwenkel; Valeria Garcia-Flores; Ronald Unkel; Yi Xu; Yaozhu Leng; Sonia S. Hassan; Bogdan Panaitescu; Jeeyeon Cha; Sudhansu K. Dey
      Pages: 592.e1 - 592.e17
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Nardhy Gomez-Lopez, Roberto Romero, Olesya Plazyo, George Schwenkel, Valeria Garcia-Flores, Ronald Unkel, Yi Xu, Yaozhu Leng, Sonia S. Hassan, Bogdan Panaitescu, Jeeyeon Cha, Sudhansu K. Dey
      Background Decidual senescence has been considered a mechanism of disease for spontaneous preterm labor in the absence of severe acute inflammation. Yet, signs of cellular senescence have also been observed in the chorioamniotic membranes from women who underwent the physiological process of labor at term. Objective We aimed to investigate whether, in the absence of acute histologic chorioamnionitis, the chorioamniotic membranes from women who underwent spontaneous preterm labor or labor at term exhibit signs of cellular senescence. Study Design Chorioamniotic membrane samples were collected from women who underwent spontaneous preterm labor or labor at term. Gestational age-matched nonlabor controls were also included. Senescence-associated genes/proteins were determined using reverse transcription quantitative polymerase chain reaction analysis (n = 7-9 each for array; n = 26-28 each for validation), enzyme-linked immunosorbent assays (n = 7-9 each), immunoblotting (n = 6-7 each), and immunohistochemistry (n = 7-8 each). Senescence-associated β-galactosidase activity (n = 7-11 each) and telomere length (n = 15-22 each) were also evaluated. Results In the chorioamniotic membranes without acute histologic chorioamnionitis: (1) the expression profile of senescence-associated genes was different between the labor groups (term in labor and preterm in labor) and the nonlabor groups (term no labor and preterm no labor), yet there were differences between the term in labor and preterm in labor groups; (2) most of the differentially expressed genes among the groups were closely related to the tumor suppressor protein (TP53) pathway; (3) the expression of TP53 was down-regulated in the term in labor and preterm in labor groups compared to their nonlabor counterparts; (4) the expression of CDKN1A (gene coding for p21) was up-regulated in the term in labor and preterm in labor groups compared to their nonlabor counterparts; (5) the expression of the cyclin kinase CDK2 and cyclins CCNA2, CCNB1, and CCNE1 was down-regulated in the preterm in labor group compared to the preterm no labor group; (6) the concentration of TP53 was lower in the preterm in labor group than in the preterm no labor and term in labor groups; (7) the senescence-associated β-galactosidase activity was greater in the preterm in labor group than in the preterm no labor and term in labor groups; (8) the concentration of phospho-S6 ribosomal protein was reduced in the term in labor group compared to its nonlabor counterpart, but no differences were observed between the preterm in labor and preterm no labor groups; and (9) no significant differences were observed in relative telomere length among the study groups (term no labor, term in labor, preterm no labor, and preterm in labor). Conclusion In the absence of acute histologic chorioamnionitis, signs of cellular senescence are present in the chorioamniotic membranes from women who underwent spontaneous preterm labor compared to those who delivered preterm in the absence of labor. However, the chorioamniotic membranes from women who underwent spontaneous labor at term did not show consistent signs of cellular senescence in the absence of histologic chorioamnionitis. These results suggest that different pathways are implicated in the pathological and physiological processes of labor.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.08.008
       
  • Role of early second-trimester uterine artery Doppler screening to predict
           small-for-gestational-age babies in nulliparous women
    • Authors: Samuel Parry; Anthony Sciscione; David M. Haas; William A. Grobman; Jay D. Iams; Brian M. Mercer; Robert M. Silver; Hyagriv N. Simhan; Ronald J. Wapner; Deborah A. Wing; Michal A. Elovitz; Frank P. Schubert; Alan Peaceman; M. Sean Esplin; Steve Caritis; Michael P. Nageotte; Benjamin A. Carper; George R. Saade; Uma M. Reddy; Corette B. Parker
      Pages: 594.e1 - 594.e10
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Samuel Parry, Anthony Sciscione, David M. Haas, William A. Grobman, Jay D. Iams, Brian M. Mercer, Robert M. Silver, Hyagriv N. Simhan, Ronald J. Wapner, Deborah A. Wing, Michal A. Elovitz, Frank P. Schubert, Alan Peaceman, M. Sean Esplin, Steve Caritis, Michael P. Nageotte, Benjamin A. Carper, George R. Saade, Uma M. Reddy, Corette B. Parker
      Background Trophoblastic invasion of the uterine spiral arteries substantially increases compliance to accommodate increased blood flow to the placenta. Failure of this process impedes uterine artery blood flow, and this may be detected by uterine artery Doppler flow studies. However, the clinical utility of uterine artery Doppler flow studies in the prediction of adverse pregnancy outcomes in a general population remains largely unknown. Objective We sought to determine the utility of early second-trimester uterine artery Doppler studies as a predictor of small-for-gestational-age neonates. Study Design Nulliparous women with a viable singleton pregnancy were recruited during their first trimester into an observational prospective cohort study at 8 institutions across the United States. Participants were seen at 3 study visits during pregnancy and again at delivery. Three indices of uterine artery Doppler flow (resistance index, pulsatility index, and diastolic notching) were measured in the right and left uterine arteries between 16 weeks 0 days’ and 22 weeks 6 days’ gestation. Test characteristics for varying thresholds in the prediction of small for gestational age (defined as birthweight <5th percentile for gestational age [Alexander growth curve]) were evaluated. Results Uterine artery Doppler indices, birthweight, and gestational age at birth were available for 8024 women. Birthweight <5th percentile for gestational age occurred in 358 (4.5%) births. Typical thresholds for the uterine artery Doppler indices were all associated with birthweight <5th percentile for gestational age (P < .0001 for each), but the positive predictive values for these cutoffs were all <15% and areas under receiver operating characteristic curves ranged from 0.50-0.60. Across the continuous scales for these measures, the areas under receiver operating characteristic curves ranged from 0.56-0.62. Incorporating maternal age, early pregnancy body mass index, race/ethnicity, smoking status prior to pregnancy, chronic hypertension, and pregestational diabetes in the prediction model resulted in only modest improvements in the areas under receiver operating characteristic curves ranging from 0.63-0.66. Conclusion In this large prospective cohort, early second-trimester uterine artery Doppler studies were not a clinically useful test for predicting small-for-gestational-age babies.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.06.013
       
  • Predictors of laparoscopic simulation performance among practicing
           obstetrician gynecologists
    • Authors: Shyama Mathews; Michael Brodman; Debra D'Angelo; Scott Chudnoff; Peter McGovern; Tamara Kolev; Giti Bensinger; Santosh Mudiraj; Andreea Nemes; David Feldman; Patricia Kischak; Charles Ascher-Walsh
      Pages: 596.e1 - 596.e7
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Shyama Mathews, Michael Brodman, Debra D'Angelo, Scott Chudnoff, Peter McGovern, Tamara Kolev, Giti Bensinger, Santosh Mudiraj, Andreea Nemes, David Feldman, Patricia Kischak, Charles Ascher-Walsh
      Background While simulation training has been established as an effective method for improving laparoscopic surgical performance in surgical residents, few studies have focused on its use for attending surgeons, particularly in obstetrics and gynecology. Surgical simulation may have a role in improving and maintaining proficiency in the operating room for practicing obstetrician gynecologists. Objective We sought to determine if parameters of performance for validated laparoscopic virtual simulation tasks correlate with surgical volume and characteristics of practicing obstetricians and gynecologists. Study Design All gynecologists with laparoscopic privileges (n = 347) from 5 academic medical centers in New York City were required to complete a laparoscopic surgery simulation assessment. The physicians took a presimulation survey gathering physician self-reported characteristics and then performed 3 basic skills tasks (enforced peg transfer, lifting/grasping, and cutting) on the LapSim virtual reality laparoscopic simulator (Surgical Science Ltd, Gothenburg, Sweden). The association between simulation outcome scores (time, efficiency, and errors) and self-rated clinical skills measures (self-rated laparoscopic skill score or surgical volume category) were examined with regression models. Results The average number of laparoscopic procedures per month was a significant predictor of total time on all 3 tasks (P = .001 for peg transfer; P = .041 for lifting and grasping; P < .001 for cutting). Average monthly laparoscopic surgical volume was a significant predictor of 2 efficiency scores in peg transfer, and all 4 efficiency scores in cutting (P = .001 to P = .015). Surgical volume was a significant predictor of errors in lifting/grasping and cutting (P < .001 for both). Self-rated laparoscopic skill level was a significant predictor of total time in all 3 tasks (P < .0001 for peg transfer; P = .009 for lifting and grasping; P < .001 for cutting) and a significant predictor of nearly all efficiency scores and errors scores in all 3 tasks. Conclusion In addition to total time, there was at least 1 other objective performance measure that significantly correlated with surgical volume for each of the 3 tasks. Higher-volume physicians and those with fellowship training were more confident in their laparoscopic skills. By determining simulation performance as it correlates to active physician practice, further studies may help assess skill and individualize training to maintain skill levels as case volumes fluctuate.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.002
       
  • Liposomal bupivacaine decreases pain following retropubic sling placement:
           a randomized placebo-controlled trial
    • Authors: Donna Mazloomdoost; Rachel N. Pauls; Erin N. Hennen; Jennifer Y. Yeung; Benjamin C. Smith; Steven D. Kleeman; Catrina C. Crisp
      Pages: 598.e1 - 598.e11
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Donna Mazloomdoost, Rachel N. Pauls, Erin N. Hennen, Jennifer Y. Yeung, Benjamin C. Smith, Steven D. Kleeman, Catrina C. Crisp
      Background Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively. Objective The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement. Study Design This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed “current level of pain”; the evening items queried “current level of pain,” “most intense pain today,” “average pain today with activity,” and “average pain today with rest.” Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed. Results One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m2. Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m2; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted. Conclusion Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.001
       
  • Evaluating ureteral patency in the post-indigo carmine era: a randomized
           controlled trial
    • Authors: Cara L. Grimes; Sonali Patankar; Timothy Ryntz; Nisha Philip; Khara Simpson; Mireille Truong; Constance Young; Arnold Advincula; Obianuju S. Madueke-Laveaux; Ryan Walters; Cande V. Ananth; Jin Hee Kim
      Pages: 601.e1 - 601.e10
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Cara L. Grimes, Sonali Patankar, Timothy Ryntz, Nisha Philip, Khara Simpson, Mireille Truong, Constance Young, Arnold Advincula, Obianuju S. Madueke-Laveaux, Ryan Walters, Cande V. Ananth, Jin Hee Kim
      Background Many gynecologic, urologic, and pelvic reconstructive surgeries require accurate intraoperative evaluation of ureteral patency. Objective We performed a randomized controlled trial to compare surgeon satisfaction with 4 methods of evaluating ureteral patency during cystoscopy at the time of benign gynecologic or pelvic reconstructive surgery: oral phenazopyridine, intravenous sodium fluorescein, mannitol bladder distention, and normal saline bladder distention. Study Design We conducted an unblinded randomized controlled trial of the method used to evaluate ureteral patency during cystoscopy at time of benign gynecologic or pelvic reconstructive surgery. Subjects were randomized to receive 200 mg oral phenazopyridine, 25 mg intravenous sodium fluorescein, mannitol bladder distention, or normal saline bladder distention during cystoscopy. The primary outcome was surgeon satisfaction with the method, assessed via a 100-mm visual analog scale with 0 indicating strong agreement and 100 indicating strong disagreement with the statement. Secondary outcomes included comparing visual analog scale responses about ease of each method and visualization of ureteral jets, bladder mucosa and urethra, and operative information, including time to surgeon confidence in the ureteral jets. Adverse events were evaluated for at least 6 weeks after the surgical procedure, and through the end of the study. All statistical analyses were based on the intent-to-treat principle, and comparisons were 2-tailed. Results In all, 130 subjects were randomized to phenazopyridine (n = 33), sodium fluorescein (n = 32), mannitol (n = 32), or normal saline (n = 33). At randomization, patient characteristics were similar across groups. With regard to the primary outcome, mannitol was the method that physicians found most satisfactory on a visual analog scale. The median (range) scores for physicians assessing ureteral patency were 48 (0-83), 20 (0-82), 0 (0-44), and 23 (3-96) mm for phenazopyridine, sodium fluorescein, mannitol, and normal saline, respectively (P < .001). Surgery length, cystoscopy length, and time to surgeon confidence in visualization of ureteral jets were not different across the 4 randomized groups. During the 189-day follow-up, no differences in adverse events were seen among the groups, including urinary tract infections. Conclusion The use of mannitol during cystoscopy to assess ureteral patency provided surgeons with the most overall satisfaction, ease of use, and superior visualization without affecting surgery or cystoscopy times. There were no differences in adverse events, including incidence of urinary tract infections.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.012
       
  • Feasibility of prophylactic salpingectomy during vaginal hysterectomy
    • Authors: Danielle D. Antosh; Rachel High; Heidi W. Brown; Sallie S. Oliphant; Husam Abed; Nisha Philip; Cara L. Grimes
      Pages: 605.e1 - 605.e5
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Danielle D. Antosh, Rachel High, Heidi W. Brown, Sallie S. Oliphant, Husam Abed, Nisha Philip, Cara L. Grimes
      Background The American Congress of Obstetricians and Gynecologists recommends that “the surgeon and patient discuss the potential benefits of the removal of the fallopian tubes during a hysterectomy in women at population risk of ovarian cancer who are not having an oophorectomy,” resulting in an increasing rate of salpingectomy at the time of hysterectomy. Rates of salpingectomy are highest for laparoscopic and lowest for vaginal hysterectomy. Objective The primary objective of this study was to determine the feasibility of bilateral salpingectomy at the time of vaginal hysterectomy. Secondary objectives included identification of factors associated with unsuccessful salpingectomy and assessment of its impact on operating time, blood loss, surgical complications, and menopausal symptoms. Study Design This was a multicenter, prospective study of patients undergoing planned vaginal hysterectomy with bilateral salpingectomy. Baseline medical data along with operative findings, operative time, and blood loss for salpingectomy were recorded. Uterine weight and pathology reports for all fallopian tubes were reviewed. Patients completed the Menopause Rating Scale at baseline and at postoperative follow-up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using Student t test, and χ2 test when appropriate. Questionnaire scores were compared using paired t tests. Results Among 77 patients offered enrollment, 74 consented (96%), and complete data were available regarding primary outcome for 69 (93%). Mean age was 51 years. Median body mass index was 29.1 kg/m2; median vaginal parity was 2, and 41% were postmenopausal. The indications for hysterectomy included prolapse (78%), heavy menstrual bleeding (20%), and fibroids (11%). When excluding conversions to alternate routes, vaginal salpingectomy was successfully performed in 52/64 (81%) women. Mean operating time for bilateral salpingectomy was 11 (±5.6) minutes, with additional estimated blood loss of 6 (±16.3) mL. There were 8 surgical complications: 3 hemorrhages >500 mL and 5 conversions to alternate routes of surgery, but none of these were due to the salpingectomy. Mean uterine weight was 102 g and there were no malignancies on fallopian tube pathology. Among the 17 patients in whom planned bilateral salpingectomy was not completed, unilateral salpingectomy was performed in 7 patients. Reasons for noncompletion included: tubes high in the pelvis (8), conversion to alternate route for pathology (4), bowel or sidewall adhesions (3), tubes absent (1), and ovarian adhesions (1). Prior adnexal surgery (odds ratio, 2.9; 95% confidence interval, 1.5–5.5; P = .006) and uterine fibroids (odds ratio, 5.8; 95% confidence interval, 1.5–22.5; P = .02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6; P < .001). Conclusion Vaginal salpingectomy is feasible in the majority of women undergoing vaginal hysterectomy and increases operating time by 11 minutes and blood loss by 6 mL. Women with prior adnexal surgery or uterine fibroids should be counseled about the possibility that removal may not be feasible.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.017
       
  • Interactions among pelvic organ protrusion, levator ani descent, and
           hiatal enlargement in women with and without prolapse
    • Authors: Anne G. Sammarco; Lahari Nandikanti; Emily K. Kobernik; Bing Xie; Alexandra Jankowski; Carolyn W. Swenson; John O.L. DeLancey
      Pages: 614.e1 - 614.e7
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Anne G. Sammarco, Lahari Nandikanti, Emily K. Kobernik, Bing Xie, Alexandra Jankowski, Carolyn W. Swenson, John O.L. DeLancey
      Background Pelvic organ prolapse has 2 components: (1) protrusion of the pelvic organs beyond the hymen; and (2) descent of the levator ani. The Pelvic Organ Prolapse Quantification system measures the first component, however, there remains no standard measurement protocol for the second mechanism. Objective We sought to test the hypotheses that: (1) difference in the protrusion area is greater than the area created by levator descent in prolapse patients compared with controls; and (2) prolapse is more strongly associated with levator hiatus compared to urogenital hiatus. Study Design Midsagittal magnetic resonance imaging scans from 30 controls, 30 anterior predominant, and 30 posterior predominant prolapse patients were assessed. Levator area was defined as the area above the levator ani and below the sacrococcygeal inferior pubic point line. Protrusion area was defined as the protruding vaginal walls below the levator area. The levator hiatus and urogenital hiatus were measured. Bivariate analysis and multiple comparisons were performed. Bivariate logistic regression was performed to assess prolapse as a function of levator hiatus, urogenital hiatus, levator area, and protrusion. Pearson correlation coefficients were calculated. Results The levator area for the anterior (34.0 ± 6.5 cm2) and posterior (35.7 ± 8.0 cm2) prolapse groups were larger during Valsalva compared to controls (20.9 ± 7.8 cm2, P < .0001 for both); similarly, protrusion areas for the anterior (14.3 ± 6.2 cm2) and posterior (14.4 ± 5.7 cm2) prolapse groups were both larger compared to controls (5.0 ± 1.8 cm2, P < .0001 for both). The levator hiatus length for the anterior (7.2 ± 1 cm) and posterior (6.9 ± 1 cm) prolapse groups were longer during Valsalva compared to controls (5.2 ± 1.5 cm, P < .0001 for both); similarly, urogenital hiatus lengths for the anterior (5.7 ± 1 cm) and posterior (6.3 ± 1.1 cm) prolapse groups were both longer than controls (3.8 ± 0.8 cm, P < .0001 for both). The difference in levator area in prolapse patients compared with controls was greater than the difference in protrusion area (14.0 ± 7.2 cm2 vs 9.4 ± 5.9 cm2, P < .0002). The urogenital hiatus was more strongly associated with prolapse than the levator hiatus (odds ratio, 12.9; 95% confidence interval, 4.1–39.2, and odds ratio, 4.3; 95% confidence interval, 2.3–7.5). Levator hiatus and urogenital hiatus are both correlated with levator and protrusion areas, and all were associated with maximum prolapse size (P ≤ .001, for all comparisons). Conclusion In prolapse, the levator area increases more than the protrusion area and both the urogenital hiatus and levator hiatus are larger. The odds of prolapse for an increase in the urogenital hiatus are 3 times larger than for the levator hiatus, which leads us to reject both the original hypotheses.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.07.007
       
  • First sacral nerve and anterior longitudinal ligament anatomy: clinical
           applications during sacrocolpopexy
    • Authors: M.E. Florian-Rodriguez; J. Hamner; M. Corton
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Maria E. Florian-Rodriguez, Jennifer J. Hamner, Marlene M. Corton
      Background The recommended location of graft attachment during sacrocolpopexy is at or below the sacral promontory on the anterior surface of the first sacral vertebra. Graft fixation below the sacral promontory may potentially involve the first sacral nerve. Objective The objectives of this study were to examine the anatomy of the right first sacral nerve relative to the midpoint of the sacral promontory and to evaluate the thickness and ultrastructural composition of the anterior longitudinal ligament at the sacral promontory level. Study Design Anatomic relationships were examined in 18 female cadavers (8 unembalmed and 10 embalmed). The midpoint of the sacral promontory was used as reference for all measurements. The most medial and superior point on the ventral surface of the first sacral foramen was used as a marker for the closest point at which the first sacral nerve could emerge. Distances from midpoint of sacral promontory and the midsacrum to the most medial and superior point of the first sacral foramen were recorded. The right first sacral nerve was dissected and its relationship to the presacral space was noted. The anterior longitudinal ligament thickness was examined at the sacral promontory level in the midsagittal plane. The ultrastructural composition of the ligament was evaluated using transmission electron microscopy. Height of fifth lumbar to first sacral disc was also recorded. Descriptive statistics were used for data analyses. Results Median age of specimens was 78 years and median body mass index was 20.1 kg/m2. Median vertical distance from midpoint of sacral promontory to the level of the most medial and superior point of the first sacral foramen was 26 (range 22-37) mm. Median horizontal distance from the midsacrum to the first sacral foramen was 19 (range 13-23) mm. In all specimens, the first sacral nerve was located just behind the layer of parietal fascia covering the piriformis muscle, and thus, outside the presacral space. Median anterior longitudinal ligament thickness at the sacral promontory level was 1.9 (range 1.2-2.5) mm. Median fifth lumbar to first sacral disc height was 16 (8.3-17) mm. Conclusion Awareness of the first sacral nerve position, approximately 2.5 cm below the midpoint of the sacral promontory and 2 cm to the right of midline, should help anticipate and avoid somatic nerve injury during sacrocolpopexy. Knowledge of the approximate 2-mm thickness of the anterior longitudinal ligament should help reduce risk of discitis and osteomyelitis, especially when graft is affixed above the level of the sacral promontory.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2016.12.159
       
  • Prenatal chromosomal microarray analysis in fetuses with congenital heart
           disease: a prospective cohort study
    • Authors: Yan Wang; Li Cao; Dong Liang; Lulu Meng; Yun Wu; Fengchang Qiao; Xiuqing Ji; Chunyu Luo; Jingjing Zhang; Tianhui Xu; Bin Yu; Leilei Wang; Ting Wang; Qiong Pan; Dingyuan Ma; Ping Hu; Zhengfeng Xu
      Abstract: Publication date: Available online 8 November 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Yan Wang, Li Cao, Dong Liang, Lulu Meng, Yun Wu, Fengchang Qiao, Xiuqing Ji, Chunyu Luo, Jingjing Zhang, Tianhui Xu, Bin Yu, Leilei Wang, Ting Wang, Qiong Pan, Dingyuan Ma, Ping Hu, Zhengfeng Xu
      Backgroud Currently, chromosomal microarray analysis is considered as the first-tier test in pediatric care and prenatal diagnosis. However, the diagnostic yield of CMA for prenatal diagnosis of congenital heart disease has not been evaluated based on a large cohort. Objective Our aim was to evaluate the clinical utility of chromosomal microarray as the first-tier test for chromosomal abnormalities in fetuses with congenital heart disease. Study Design In this prospective study, 602 prenatal cases of congenital heart disease were investigated using SNP array over a 5-year period. Results Overall, pathogenic chromosomal abnormalities were identified in 125 (20.8%) cases, with 52.0% of them being numerical chromosomal abnormalities. The detection rates of likely pathogenic copy number variations and variants of uncertain significance were 1.3% and 6.0%, respectively. The detection rate in congenital heart disease plus additional structural anomalies (48.9% vs. 14.3%, P < 0.0001) or intrauterine growth retardation group (50.0% vs. 14.3%, P = 0.044) was significantly higher than that in isolated congenital heart disease group. Additionally, the detection rate in congenital heart disease with additional structural anomalies group was significantly higher than that in congenital heart disease with soft markers group (48.9% vs. 19.8%, P < 0.0001). No significant difference was observed in the detection rates between congenital heart disease with additional structural anomalies and congenital heart disease with intrauterine growth retardation groups (48.9% vs. 50.0%), congenital heart disease with soft markers and congenital heart disease with intrauterine growth retardation groups (19.8% vs. 50.0%), as well as congenital heart disease with soft markers and isolated congenital heart disease groups (19.8% vs. 14.3%). The detection rate in fetuses with congenital heart disease plus mild ventriculomegaly was significantly higher than those with other types of soft markers (50.0% vs. 15.6%, P < 0.05). Conclusion Our study suggests chromosomal microarray analysis is a reliable and high-resolution technology and should be used as the first-tier test for prenatal diagnosis of congenital heart disease in clinical practice.

      PubDate: 2017-11-10T18:43:58Z
      DOI: 10.1016/j.ajog.2017.10.225
       
  • Maternal Hemodynamics: A Method to Classify Hypertensive Disorders of
           Pregnancy
    • Authors: Enrico Ferrazzi; Tamara Stampalija; Lorenzo Monasta; Daniela Di Martino; Sharona Vonck; Wilfried Gyselaers
      Abstract: Publication date: Available online 2 November 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Enrico Ferrazzi, Tamara Stampalija, Lorenzo Monasta, Daniela Di Martino, Sharona Vonck, Wilfried Gyselaers
      Background The classification of hypertensive disorders of pregnancy (HDP) is based on the time at the onset of hypertension, proteinuria, and other associated complications. Maternal hemodynamic interrogation in HDP considers not only the peripheral blood pressure but also the entire cardiovascular system, and it might help to classify the different clinical phenotypes of this syndrome. Objectives This study aimed to examine cardiovascular parameters in a cohort of patients affected by HDP according to the clinical phenotypes that prioritize fetoplacental characteristics and not the time at onset of HDP. Study Design At the Fetal Maternal Medicine Unit of Ziekenhuis Oost-Limburg (Genk, Belgium), maternal cardiovascular parameters were obtained through impedance cardiography using a non-invasive continuous cardiac output monitor (NICCOMO©,) with the patients placed in a standing position. The patients were classified as follows: pregnant women with HDP who delivered appropriate for gestational age (AGA) fetuses and pregnant women with HDP who delivered small for gestational age (SGA) fetuses. Normotensive pregnant women with an AGA fetus at delivery were enrolled as the control group. The possible impact of obesity (Body Mass Index ≥30 kg/m2) on maternal hemodynamics was reassessed in the same groups. Results Maternal age, parity, BMI, and blood pressure were not significantly different between the HDP-AGA and HDP-SGA groups. The mean uterine artery PI was highly significantly higher in the HDP-SGA group. The cardiac output (CO) and cardiac index (CI) were significantly lower in the HDP-SGA group (CO=6.5 L/min, CI=3.6) than in the HDP-AGA group (CO=7.6 L/min, CI 3.9) but not between the HDP-AGA and control group (7.6 L/min, CI=4.0). Total vascular resistance (TVR) was significantly higher in the HDP-SGA group than in the HDP-AGA group and the control group. All HDP women showed signs of central arterial dysfunction. The cardiovascular parameters were not influenced by gestational age at the onset of HDP, and no difference was observed between the women with AGA fetuses affected by preeclampsia or by gestational hypertension with AGA fetuses. The obese-HDP-AGA and obese-HDP-SGA women showed a significant increase in cardiac output, as well as significant changes in other parameters, compared with the non-obese HDP-AGA and non-obese HDP-SGA women. Conclusions Significantly low cardiac output and high total vascular resistance characterized the women with HDP associated with SGA due to placental insufficiency, independent of the gestational age at the onset of hypertension. The cardiovascular parameters were not significantly different in the women with AGA or SGA fetuses who were affected by preeclampsia or gestational hypertension. These findings support the view that maternal hemodynamics may be a candidate diagnostic tool to identify hypertensive disorders in pregnancies associated with SGA fetuses. This additional tool matches other reported evidence provided by uterine Doppler velocimetry, low vascular growth factors in the first trimester, and placental pathology. Obesity is associated with a significantly higher cardiac output and outweighs other determinants of hemodynamics in pregnancy; therefore, in future studies on hypertensive disorders, obesity should be studied as an additional disease and not simply as a demographic characteristic.

      PubDate: 2017-11-04T18:13:03Z
      DOI: 10.1016/j.ajog.2017.10.226
       
  • Information for Readers
    • Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5


      PubDate: 2017-11-04T18:13:03Z
       
  • November 2016 (vol. 215, no. 5, page 601.e3)
    • Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5


      PubDate: 2017-11-04T18:13:03Z
       
  • Reply
    • Authors: David Nelson; Donald McIntire Kenneth Leveno
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): David B. Nelson, Donald D. McIntire, Kenneth J. Leveno


      PubDate: 2017-11-04T18:13:03Z
       
  • Reply
    • Authors: Asma Khalil
      Abstract: Publication date: November 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 5
      Author(s): Asma Khalil


      PubDate: 2017-11-04T18:13:03Z
       
 
 
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