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Publisher: Elsevier   (Total: 3042 journals)

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Showing 1 - 200 of 3042 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: 17, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 82, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 23, 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: 327, 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: 204, 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: 23, 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: 3)
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: 127, 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: 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: 25, 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: 20, 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 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: 10, 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: 41, 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: 40, 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: 47, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 15)
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: 12)
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: 21, 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: 25)
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: 35, 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: 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: 7, 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 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: 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: 19, SJR: 1.5, h-index: 62)
Advances in Psychology     Full-text available via subscription   (Followers: 59)
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 Research     Full-text available via subscription   (Followers: 339, 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: 6, 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: 15)
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: 308, 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: 402, 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: 30, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 38, 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: 50, 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: 9, SJR: 0.922, h-index: 66)
Alcoholism and Drug Addiction     Open Access   (Followers: 6)
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: 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)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 7, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 48, 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: 48, SJR: 3.157, h-index: 153)
American J. of Cardiology     Hybrid Journal   (Followers: 44, SJR: 2.063, h-index: 186)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 37, 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: 16, SJR: 1.653, h-index: 93)
American J. of Human Genetics     Hybrid Journal   (Followers: 31, SJR: 8.769, h-index: 256)
American J. of Infection Control     Hybrid Journal   (Followers: 24, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 34, 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: 179, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 55, 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: 23, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 25, 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: 34, 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: 55, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 10)
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: 158, 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: 11)
Anesthésie & Réanimation     Full-text available via subscription  
Anesthesiology Clinics     Full-text available via subscription   (Followers: 22, 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: 152, 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]   [179 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9378
   Published by Elsevier Homepage  [3042 journals]
  • Cesarean in the second stage: a possible risk factor for subsequent
           spontaneous preterm birth
    • Authors: Vincenzo Berghella; Alexis C. Gimovsky; Lisa D. Levine; Joy Vink
      Pages: 1 - 3
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Vincenzo Berghella, Alexis C. Gimovsky, Lisa D. Levine, Joy Vink


      PubDate: 2017-06-23T22:50:13Z
      DOI: 10.1016/j.ajog.2017.04.019
       
  • Reproductive considerations in the setting of chronic viral illness
    • Authors: Brent M. Hanson; Jessie A. Dorais
      Pages: 4 - 10
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Brent M. Hanson, Jessie A. Dorais
      Special considerations must be taken when patients with human immunodeficiency virus (HIV), hepatitis B, or hepatitis C desire to become pregnant. Patients with chronic viral illnesses desire to have children at rates similar to the general population, and options are available to decrease both vertical transmission and viral transmission between partners. Preconception counseling or consultation with fertility specialists is imperative in patients with HIV, hepatitis B, and hepatitis C so that reproductive goals can be addressed and optimized. In couples in which one partner has HIV, the use of highly active antiretroviral therapy or preexposure prophylaxis can significantly reduce the risk of transmission between serodiscordant partners. The use of density gradient sperm-washing techniques and intrauterine insemination or in vitro fertilization results in an apparent lack of transmission of HIV between partners when the male partner is HIV-positive. Vertical transmission of HIV from mother to child can be reduced by use of highly active antiretroviral therapy regimens throughout pregnancy or by cesarean delivery in the setting of high maternal viral load. Transmission of hepatitis B between partners can be eliminated by vaccinating the uninfected partner. Vertical transmission from a hepatitis B−infected mother to a child can be reduced by vaccinating neonates with the standard hepatitis B vaccine series as well as hepatitis B immune globulin. Recent data have shown the antiviral medication tenofovir to be an effective way to reduce vertical transmission in the setting of high maternal viral load or the presence of hepatitis B e antigen. There are multiple antiviral medications available to treat chronic hepatitis C, although access to these medications often is limited by cost. Similar to HIV-positive patients, in settings in which the male partner is infected with hepatitis C, density gradient sperm washing can be used before intrauterine insemination or in vitro fertilization to reduce transmission of hepatitis C between partners. No safe and effective method exists to reduce vertical transmission of hepatitis C once a woman becomes pregnant, highlighting the importance of treatment of hepatitis C before pregnancy.

      PubDate: 2017-06-23T22:50:13Z
      DOI: 10.1016/j.ajog.2017.02.012
       
  • Obesity and pelvic organ prolapse: a systematic review and meta-analysis
           of observational studies
    • Authors: Ayush Giri; Katherine E. Hartmann; Jacklyn N. Hellwege; Digna R. Velez Edwards; Todd L. Edwards
      Pages: 11 - 26.e3
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Ayush Giri, Katherine E. Hartmann, Jacklyn N. Hellwege, Digna R. Velez Edwards, Todd L. Edwards
      Background Studies evaluating the association between obesity and pelvic organ prolapse report estimates that range from negative to positive associations. Heterogeneous definitions for pelvic organ prolapse and variable choices for categorizing obesity measures have made it challenging to conduct meta-analysis. Objective We systematically evaluated evidence to provide quantitative summaries of association between degrees of obesity and pelvic organ prolapse, and identify sources of heterogeneity. Study Design We searched for all indexed publications relevant to pelvic organ prolapse up until June 18, 2015, in PubMed/MEDLINE to identify analytical observational studies published in English that reported risk ratios (relative risk, odds ratio, or hazard ratio) for body mass index categories in relation to pelvic organ prolapse. Random effects meta-analyses were conducted to report associations with pelvic organ prolapse for overweight and obese body mass index categories compared with women in the normal-weight category (referent: body mass index <25 kg/m2). Results Of the 70 studies that reported evidence on obesity and pelvic organ prolapse, 22 eligible studies provided effect estimates for meta-analysis of the overweight and obese body mass index categories. Compared with the referent category, women in the overweight and obese categories had meta-analysis risk ratios of at least 1.36 (95% confidence interval, 1.20–1.53) and at least 1.47 (95% confidence interval, 1.35–1.59), respectively. Subgroup analyses showed effect estimates for objectively measured clinically significant pelvic organ prolapse were higher than for self-reported pelvic organ prolapse. Other potential sources of heterogeneity included proportion of postmenopausal women in study and reported study design. Conclusion Overweight and obese women are more likely to have pelvic organ prolapse compared with women with body mass index in the normal range. The finding that the associations for obesity measures were strongest for objectively measured, clinically significant pelvic organ prolapse further strengthens this evidence. However, prospective investigations evaluating obesity and pelvic organ prolapse are few.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.01.039
       
  • Prenatal ultrasound diagnosis and outcome of placenta previa accreta
           after cesarean delivery: a systematic review and meta-analysis
    • Authors: Eric Jauniaux; Amar Bhide
      Pages: 27 - 36
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Eric Jauniaux, Amar Bhide
      Background Women with a history of previous cesarean delivery, presenting with a placenta previa, have become the largest group with the highest risk for placenta previa accreta. Objective The objective of the study was to evaluate the accuracy of ultrasound imaging in the prenatal diagnosis of placenta accreta and the impact of the depth of villous invasion on management in women presenting with placenta previa or low-lying placenta and with 1 or more prior cesarean deliveries. Study Design and Data Sources We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE for studies published between 1982 and November 2016. Study Eligibility Criteria Criteria for the study were cohort studies that provided data on previous mode of delivery, placenta previa, or low-lying placenta on prenatal ultrasound imaging and pregnancy outcome. The initial search identified 171 records, of which 5 retrospective and 9 prospective cohort studies were eligible for inclusion in the quantitative analysis. Study Appraisal and Synthesis Methods The studies were scored on methodological quality using the Quality Assessment of Diagnostic Accuracy Studies tool. Results The 14 cohort studies included 3889 pregnancies presenting with placenta previa or low-lying placenta and 1 or more prior cesarean deliveries screened for placenta accreta. There were 328 cases of placenta previa accreta (8.4%), of which 298 (90.9%) were diagnosed prenatally by ultrasound. The incidence of placenta previa accreta was 4.1% in women with 1 prior cesarean and 13.3% in women with ≥2 previous cesarean deliveries. The pooled performance of ultrasound for the antenatal detection of placenta previa accreta was higher in prospective than retrospective studies, with a diagnostic odds ratios of 228.5 (95% confidence interval, 67.2–776.9) and 80.8 (95% confidence interval, 13.0–501.4), respectively. Only 2 studies provided detailed data on the relationship between the depth of villous invasion and the number of previous cesarean deliveries, independently of the depth of the villous invasion. A cesarean hysterectomy was performed in 208 of 232 cases (89.7%) for which detailed data on management were available. Positive correlations were found in the largest prospective studies between the cumulative rates of the more invasive forms of accreta placentation and the sensitivity and specificity of ultrasound imaging but not with diagnostic odds ratio values. We found no data on the ultrasound screening of placenta accreta at the routine midtrimester ultrasound examination from the nonexpert ultrasound units. Conclusion Planning individual management for delivery is possible only with accurate evaluation of prenatal risk of accreta placentation in women presenting with a low-lying placenta/previa and a history of prior cesarean delivery. Ultrasound is highly sensitive and specific in the prenatal diagnosis of accreta placentation when performed by skilled operators. Developing a prenatal screening protocol is now essential to further improve the outcome of this increasingly more common major obstetric complication.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.02.050
       
  • The fourth trimester: a critical transition period with unmet maternal
           health needs
    • Authors: Kristin P. Tully; Alison M. Stuebe; Sarah B. Verbiest
      Pages: 37 - 41
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      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 because of 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 fourth trimester intersect and can compound one another. Enhanced collaboration among health care providers may improve the focus of clinical interactions to address the interrelated health issues most important to women.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.03.032
       
  • Overview of high-risk medical device recalls in obstetrics and
           gynecology from 2002 through 2016: implications for device safety
    • Authors: Timothy M. Janetos; Comeron W. Ghobadi; Shuai Xu; Jessica R. Walter
      Pages: 42 - 46.e1
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Timothy M. Janetos, Comeron W. Ghobadi, Shuai Xu, Jessica R. Walter
      The field of women’s health has endured numerous recent controversies involving medical devices such as pelvic meshes, laparoscopic morcellators, and a hysteroscopic sterilization device. With the recent passage of the 21st Century Cures Act, new legislation will change how the Food and Drug Administration regulates medical devices. Given these controversies and new changes, we investigated high-risk, class I recalls in women’s health from 2002 through 2016. Class I recalls for medical devices are defined by the Food and Drug Administration as the most serious recall events and are designated for situations when there is a reasonable probability of serious adverse health consequences or death. We defined a recall event as a group of unique Food and Drug Administration recalls that share a similar reason for recall and occurred within a 1-month time frame. In total, 7 class I recall events were identified encompassing 83 unique recalls affecting >88,000 medical devices in distribution. Recalls involved a broad range of devices used in women’s health including diagnostic assays for chlamydia and gonorrhea, a laparoscopic tissue morcellator, and obstetrical/gynecological surgical kits. Four of 7 (57%) recall events were due to postmarketing problems such as improper packaging and labeling while the remaining 3 (43%) recalls were due to premarketing problems (eg, software issues). Additionally, 3 of 7 (43%) recall events were cleared via the 510(k) pathway, while the remaining were essentially exempt from any form of premarket approval. Two recall events involved sterility concerns of 71 surgical kits used in obstetrics and gynecological surgeries representing the majority of affected devices (78,423) in distribution. Class I medical device recalls are rare but serious events. Most recalled devices in women’s health had minimal preapproval regulation and were recalled due to both premarketing and postmarketing reasons. Future regulatory efforts to improve postmarketing surveillance may mitigate the potential impact and frequency of class I recalls, but do not replace the need for a higher burden of proof for both safety and efficacy prior to medical device approval.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.03.021
       
  • Racial and ethnic disparities in postpartum care and contraception in
           California’s Medicaid program
    • Authors: Heike Thiel de Bocanegra; Monica Braughton; Mary Bradsberry; Mike Howell; Julia Logan; Eleanor Bimla Schwarz
      Pages: 47.e1 - 47.e7
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Heike Thiel de Bocanegra, Monica Braughton, Mary Bradsberry, Mike Howell, Julia Logan, Eleanor Bimla Schwarz
      Background Considerable racial and ethnic disparities have been identified in maternal and infant health in the United States, and access to postpartum care likely contributes to these disparities. Contraception is an important component of postpartum care that helps women and their families achieve optimal interpregnancy intervals and avoid rapid repeat pregnancies and preterm births. National quality measurements to assess postpartum contraception are being developed and piloted. Objective To assess racial/ethnic variation in receipt of postpartum care and contraception among low-income women in California. Study Design We conducted a prospective cohort study of 199,860 Californian women aged 15−44 with a Medicaid-funded delivery in 2012. We examined racial/ethnic variation of postpartum care and contraception using multivariable logistic regression to control for maternal age, language, cesarean delivery, Medicaid program, and residence in a primary care shortage area (PCSA). Results Only one-half of mothers attended a postpartum visit (49.4%) or received contraception (47.5%). Compared with white women, black women attended postpartum visits less often (adjusted odds ratio [aOR], 0.73; 95% confidence interval [CI], 0.71−0.76), were less likely to receive any contraception (aOR, 0.83; 95% CI, 0.78−0.89) and were less likely to receive highly effective contraception (aOR, 0.64; 95% CI, 0.58−0.71). Women with Spanish as their primary language were more likely to get any contraception (aOR, 1.15; 95% CI, 1.11−1.19) but had significantly lower odds of receiving a highly effective method (aOR, 0.94; 95% CI, 0.90−0.99) compared with women with English as their primary language. Similarly, women in PCSAs had a greater odds of getting any contraception (aOR, 1.06; 95% CI, 1.03−1.09), but 24% lower odds of getting highly effective contraception than women not living in PCSAs (aOR, 0.76; 95% CI, 0.73−0.79). Conclusion Significant racial/ethnic disparities exist among low-income Californian mothers’ likelihood of attending postpartum visits and receiving postpartum contraception as well as receiving highly effective contraception.

      PubDate: 2017-06-23T22:50:13Z
      DOI: 10.1016/j.ajog.2017.02.040
       
  • Disparities in the management of ectopic pregnancy
    • Authors: Jennifer Y. Hsu; Ling Chen; Arielle R. Gumer; Ana I. Tergas; June Y. Hou; William M. Burke; Cande V. Ananth; Dawn L. Hershman; Jason D. Wright
      Pages: 49.e1 - 49.e10
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Jennifer Y. Hsu, Ling Chen, Arielle R. Gumer, Ana I. Tergas, June Y. Hou, William M. Burke, Cande V. Ananth, Dawn L. Hershman, Jason D. Wright
      Background Ectopic pregnancy is common among young women. Treatment can consist of either surgery with salpingectomy or salpingostomy or medical management with methotrexate. In addition to acute complications, treatment of ectopic pregnancy can result in long-term sequelae that include decreased fertility. Little is known about the patterns of care and predictors of treatment in women with ectopic pregnancy. Similarly, data on outcomes for various treatments are limited. Objective We examined the patterns of care and outcomes for women with ectopic pregnancy. Specifically, we examined predictors of medical (vs surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs salpingectomy) among women who underwent surgery. Study Design The Perspective database was used to identify women with a diagnosis of tubal ectopic pregnancy treated from 2006–2015. Perspective is an all-payer database that collects data on patients at hospitals from throughout the United States. Women were classified as having undergone medical treatment, if they received methotrexate, and surgical treatment, if treatment consisted of salpingostomy or salpingectomy. Multivariable models were developed to examine predictors of medical treatment and of tubal conserving salpingostomy among women who were treated surgically. Results Among the 62,588 women, 49,090 women (78.4%) were treated surgically, and 13,498 women (21.6%) received methotrexate. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015 (P<.001). Among women who underwent surgery, salpingostomy decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<.001). Treatment in more recent years, at a teaching hospital and at higher volume centers, were associated with the increased use of methotrexate (P<.05 for all). In contrast, Medicaid recipients (adjusted risk ratio, 0.92; 95% confidence interval, 0.87-0.98) and uninsured women (adjusted risk ratio, 0.87; 95% confidence interval, 0.82-0.93) were less likely to receive methotrexate than commercially insured patients. Among those who underwent surgery, black (adjusted risk ratio, 0.76; 95% confidence interval, 0.69-0.85) and Hispanic (adjusted risk ratio, 0.80; 95% confidence interval, 0.66-0.96) patients were less likely to undergo tubal conserving surgery than white women and Medicaid recipients (adjusted risk ratio, 0.69; 95% confidence interval, 0.64-0.75); uninsured women (adjusted risk ratio, 0.60; 95% confidence interval, 0.55-0.66) less frequently underwent salpingostomy than commercially insured patients. Conclusion There is substantial variation in the management of ectopic pregnancy. There are significant race- and insurance-related disparities associated with treatment.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.03.001
       
  • Immediate postpartum intrauterine device and implant program outcomes: a
           prospective analysis
    • Authors: Jennifer L. Eggebroten; Jessica N. Sanders; David K. Turok
      Pages: 51.e1 - 51.e7
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Jennifer L. Eggebroten, Jessica N. Sanders, David K. Turok
      Background In-hospital placement of intrauterine devices and contraceptive implants following vaginal and cesarean delivery is increasingly popular and responds to maternal motivation for highly effective postpartum contraception. Immediate postpartum intrauterine device insertion is associated with higher expulsion than interval placement, but emerging evidence suggests that the levonorgestrel intrauterine device may have a higher expulsion rate than the copper intrauterine device. Objective This study evaluated in-hospital provision, expulsion, and 6-month continuation of immediate postpartum copper T380 intrauterine devices, levonorgestrel intrauterine devices, and contraceptive implants. Study Design We offered enrollment in this prospective observational trial to women presenting to the University of Utah labor and delivery unit from October 2013 through February 2016 who requested an intrauterine device or implant for postpartum contraception during prenatal care or hospitalization at the time of delivery. Following informed consent, participants completed questionnaires prior to hospital discharge and at 3 and 6 months postpartum. Data on expulsions at 6 months were validated by chart abstraction. Results During the study period, 639 patients requested a postpartum intrauterine device or implant and 350 patients enrolled in prospective follow-up prior to discharge from the hospital. Among enrollees, 325 (93%) received their preferred contraceptive device prior to hospital discharge: 88 (27%) copper intrauterine device users, 123 (38%) levonorgestrel intrauterine device users, and 114 (35%) implant users. Participants predominantly were Hispanic (90%), were multiparous (87%), reported a household income <$24,000 per year (87%), and underwent a vaginal delivery (77%). At 6 months postpartum, 289 of 325 device recipients (89%) completed follow-up. Among levonorgestrel intrauterine device users 17% reported expulsions relative to 4% of copper intrauterine device users. The adjusted hazard ratio for expulsion was 5.8 (confidence interval, 1.3–26.4). There was no statistically significant difference in expulsions by delivery type or continuation by device type. Among the 21 women who experienced intrauterine device expulsions, 14 (67%) requested a replacement long-acting reversible contraception device for contraception. The 6-month device continuation was ≥80% for all device types. Conclusion An immediate postpartum long-acting reversible contraception program effectively provides women who desire highly effective reversible contraceptive devices with their method of choice prior to hospital discharge. Immediate postplacental levonorgestrel intrauterine device users have higher expulsion rates than copper intrauterine device users, but >8 of 10 women initiating an intrauterine device or implant continue use at 6 months postpartum.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.03.015
       
  • Assessment of serum HE4 levels throughout the normal menstrual cycle
    • Authors: Richard G. Moore; Beth Plante; Erin Hartnett; Jessica Mitchel; Christine A. Raker; Wendy Vitek; Elizabeth Eklund; Geralyn Lambert-Messerlian
      Pages: 53.e1 - 53.e9
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Richard G. Moore, Beth Plante, Erin Hartnett, Jessica Mitchel, Christine A. Raker, Wendy Vitek, Elizabeth Eklund, Geralyn Lambert-Messerlian
      Background Human epididymis protein 4 is a serum biomarker to aid in differentiating benign and malignant disease in women with a pelvic mass. Interpretation of human epididymis protein 4 results relies on robust normative data. Objective The purpose of this study was to evaluate whether human epididymis protein 4 levels are variable in women during the normal menstrual cycle. Study Design Healthy women, 18-45 years old, with regular menstrual cycles were recruited from community gynecologic practices in Rhode Island. Women consented to enroll and to participate by the donation of blood and urine samples at 5 specific times over the course of each cycle. Levels of reproductive hormones and human epididymis protein 4 were determined. Data were analyzed with the use of linear regression after log transformation. Results Among 74 enrolled cycles, 53 women had confirmed ovulation during the menstrual cycle and completed all 5 sample collections. Levels of estradiol, progesterone, and luteinizing hormone displayed the expected menstrual cycle patterns. Levels of human epididymis protein 4 in serum were relatively stable across the menstrual cycle, except for a small ovulatory (median, 37.0 pM) increase. Levels of human epididymis protein 4 in urine, after correction for creatinine, displayed the same pattern of secretion observed in serum. Conclusion Serum human epididymis protein 4 levels are relatively stable across the menstrual cycle of reproductive-aged women and can be determined on any day to evaluate risk of ovarian malignancy. A slight increase is expected at ovulation; but even with this higher human epididymis protein 4 level, results are well within the healthy reference range for women (<120 pM). Levels of human epididymis protein 4 in urine warrant further investigation for use in clinical practice as a simple and convenient sample.

      PubDate: 2017-06-23T22:50:13Z
      DOI: 10.1016/j.ajog.2017.02.029
       
  • Postpartum contraception: initiation and effectiveness in a large
           universal healthcare system
    • Authors: Michael R. Brunson; David A. Klein; Cara H. Olsen; Larissa F. Weir; Timothy A. Roberts
      Pages: 55.e1 - 55.e9
      Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1
      Author(s): Michael R. Brunson, David A. Klein, Cara H. Olsen, Larissa F. Weir, Timothy A. Roberts
      Background Repeat pregnancies after a short interpregnancy interval are common and are associated with negative maternal and infant health outcomes. Few studies have examined the relative effectiveness of postpartum contraceptive choices. Objective We aimed to determine the initiation trends and relative effectiveness of postpartum contraceptive methods, with typical use, on prevention of short delivery intervals (≤27 months) among women with access to universal healthcare, including coverage that entails no co-payments and allows unlimited contraceptive method switching. Study Design This retrospective cohort study included women who were enrolled in the United States military healthcare system who were admitted for childbirth between October 2010 and March 2015, with ≥6 months postpartum enrollment. With the use of insurance records, we determined the most effective contraceptive method initiated during the first 6 months after delivery, even if subsequently discontinued. Rates of interdelivery intervals of ≤27 months, as proxies for interpregnancy intervals ≤18 months, were determined with the use of the Kaplan-Meier estimator. Women who were disenrolled, who reached 27 months after delivery without another delivery, or who reached the end of the study period were censored. The influence of sociodemographic variables and contraceptive choices on time to subsequent delivery was evaluated by Cox regression analysis, which accounted for a possible correlation among multiple deliveries by an individual woman. Results During the study timeframe, 373,840 women experienced a total of 450,875 postpartum intervals. Women averaged 27 (standard deviation, 5.3) years of age at the time of delivery; 33.9% of them were <25 years old; 15.5% of them were active duty service members, and 31.6% of them had insurance sponsors of junior enlisted rank (which suggests lower income). Postpartum contraceptive methods that were initiated included self or partner sterilization (7%), intrauterine device (13.5%), etonogestrel implant (3.4%), depot medroxyprogesterone acetate (2.5%), and pill, patch, or ring (36.8%). Furthermore, 36.7% of them did not initiate a prescription method. Etonogestrel implant initiation increased from 1.7% of postpartum women in the first year of our study to 5.3% in the final year. The estimated short interdelivery interval rate was 17.4%, but rates varied with contraceptive method: 1% with sterilization, 6% with long-acting reversible contraception, 12% with depot medroxyprogesterone, 21% with pill, patch, or ring, and 23% with no prescription method. In a multivariable analysis, the adjusted hazard of a short interdelivery interval was highest among women who were younger, on active duty, or with officer insurance sponsors. Compared with nonuse of any prescription contraceptive, the use of an intrauterine device reduced the hazard of a subsequent delivery (adjusted hazard ratio, 0.19; 95% confidence interval, 0.18–0.20), as did etonogestrel implant (adjusted hazard ratio, 0.21; 95% confidence interval, 0.19–0.23); the pill, patch, or ring had less effect (adjusted hazard ratio, 0.80; 95% confidence interval, 0.78–0.81). Conclusion Postpartum initiation of long-acting reversible contraception is highly effective at the prevention of short interdelivery intervals, whereas pill, patch, or ring methods are associated with rates of short interdelivery intervals similar to users of no prescription contraception. This study supports long-acting reversible contraception as first-line recommendations for postpartum women who wish to retain fertility but avoid early repeat pregnancy.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.02.036
       
  • A vicious cycle of causes and consequences of dyspareunia: rethinking the
           approach to management
    • Authors: Jason Gandhi; Sardar Ali Khan
      Abstract: Publication date: Available online 23 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Jason Gandhi, Sardar Ali Khan


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.030
       
  • Recap: Minimally invasive treatment for cesarean scar pregnancy using a
           double balloon catheter: Additional suggestions to the technique
    • Authors: Ilan E. Timor-Tritsch; Ana Monteagudo; Andrea Kaelin Agten
      Abstract: Publication date: Available online 23 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Ilan E. Timor-Tritsch, Ana Monteagudo, Andrea Kaelin Agten


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.031
       
  • Quality of life of menopausal women with genital urinary menopause
           syndrome
    • Authors: Ângelo do Carmo Silva Matthes; Gustavo Zucca Matthes
      Abstract: Publication date: Available online 22 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Ângelo do Carmo Silva Matthes, Gustavo Zucca Matthes


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.029
       
  • Measuring the impact of attending physician teaching in an obstetrics and
           gynecology residency program
    • Authors: Anthony M. Vintzileos
      Abstract: Publication date: Available online 22 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Anthony M. Vintzileos


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.028
       
  • The Value of the Cerebroplacental Ratio in Appropriate for Gestational Age
           Fetuses
    • Authors: Isabelle Dehaene; Ann-Sophie Page; Geert Page
      Abstract: Publication date: Available online 22 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Isabelle Dehaene, Ann-Sophie Page, Geert Page


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.027
       
  • May 2017 (vol. 216, no. 5, page 522)
    • Abstract: Publication date: Available online 22 July 2017
      Source:American Journal of Obstetrics and Gynecology


      PubDate: 2017-07-24T12:02:24Z
       
  • The use of intrapartum ultrasound to diagnose malpositions and cephalic
           malpresentations
    • Authors: Federica Bellussi; Tullio Ghi; Aly Youssef; Ginevra Salsi; Francesca Giorgetta; Dila Parma; Giuliana Simonazzi; Gianluigi Pilu
      Abstract: Publication date: Available online 22 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Federica Bellussi, Tullio Ghi, Aly Youssef, Ginevra Salsi, Francesca Giorgetta, Dila Parma, Giuliana Simonazzi, Gianluigi Pilu
      Fetal malpositions and cephalic malpresentations are a well recognized cause of failure to progress in labor. They frequently require operative delivery, and are associated with an increased probability of fetal and maternal complications. Traditional obstetrics emphasizes the role of digital examinations, but recent studies have demonstrated that this approach is inaccurate and that intrapartum ultrasound is far more precise. The objective of this review is to summarize the current body of literature and provide recommendations to identify malpositions and cephalic malpresentations with ultrasound. We propose a systematic approach consisting of a combination of transabdominal and transperineal scans and describe the findings that allow an accurate diagnosis of normal and abnormal position, flexion and synclitism of the fetal head. The management of malpositions and cephalic malpresentation is currently a matter of debate, and is individualized depending upon the general clinical picture and the expertise of the provider. Intrapartum sonography allows a precise diagnosis and therefore offers the best opportunity to design prospective studies with the aim of establishing evidence-based treatment. The article is accompanied by a video that demonstrates the sonographic technique and findings.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.025
       
  • Reply
    • Authors: Asma Khalil
      Abstract: Publication date: Available online 22 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Asma Khalil


      PubDate: 2017-07-24T12:02:24Z
       
  • Effect of remote cesarean delivery on complications during hysterectomy: a
           cohort study
    • Authors: Susanne Hesselman; Ulf Högberg; Maria Jonsson
      Abstract: Publication date: Available online 21 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Susanne Hesselman, Ulf Högberg, Maria Jonsson
      Background Cesarean section is frequently performed worldwide, and follow-up studies reporting complications at subsequent surgery are warranted. Objectives The aim of the study was to investigate the association between a previous abdominal delivery and complications during a subsequent hysterectomy, and to estimate the fraction of complications driven by the presence of adhesions. Study design This was a longitudinal population based register study of 25354 women undergoing a benign hysterectomy at 46 hospital units in Sweden 2000–2014. Results Adhesions were found in 45 % of the women with a history of cesarean delivery. Organ injury affected 2.2 %. The risk of organ injury (aOR 1.74, 95 % CI 1.41–2.15) and post-operative infection (aOR 1.26, 95 % CI 1.15-1.39) was increased with prior cesarean section, irrespective of whether adhesions were present or not. The direct effect on organ injury by a personal history of cesarean delivery was estimated to 73 %, and only 27 % was mediated by the presence of adhesions. Previous cesarean was a predictor of bladder injury (aOR 1.86, 95 % CI 1.40–2.47) and bowel injury (aOR 1.83, 95 % CI 1.10-3.03) but not ureter injury. A personal history of other abdominal surgeries was associated with bowel injury (aOR 2.27, 95 % CI 1.37–3.78), and the presence of endometriosis increased the risk of ureter injury (aOR 2.15, 95 % CI 1.34–3.44). Conclusions Prior cesarean delivery is associated with an increased risk of complications during a subsequent hysterectomy, but the risk is only partly attributable to the presence of adhesions. Previous cesarean delivery and presence of endometriosis were major predisposing factors of organ injury at the time of the hysterectomy whereas background and perioperative characteristics were of minor importance.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.021
       
  • 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
      Abstract: Publication date: Available online 20 July 2017
      Source:American Journal of Obstetrics and Gynecology
      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. Objectives 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 post-operative follow-up. Descriptive analyses were performed to characterize the sample and compare those with successful and unsuccessful completion of planned salpingectomy using student’s t-test, and Chi-square 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%) of women. Mean operating time for bilateral salpingectomy was 11 minutes (± 5.6), with additional estimated blood loss of 6 mL (± 16.3). 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 grams 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 non-completion 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 (OR 2.9, 95% CI 1.5-5.5, p=0.006) and uterine fibroids (OR 5.8, 95% CI 1.5-22.5, p=0.02) were the only significant factors associated with unsuccessful bilateral salpingectomy. Mean menopause scores improved after successful salpingectomy (12.7 vs 8.6, p <0.001). Conclusions 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: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.017
       
  • Bacterial endotoxin exposure invokes transcriptional changes in embryonic
           murine neural stem cells
    • Authors: Sarah M. Estrada; Andrew S. Thagard; Amber D. Lane; Mary J. Dehart; Irina Burd; Peter G. Napolitano; Nicholas Ieronimakis
      Abstract: Publication date: Available online 20 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Sarah M. Estrada, Andrew S. Thagard, Amber D. Lane, Mary J. Dehart, Irina Burd, Peter G. Napolitano, Nicholas Ieronimakis


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.016
       
  • Ovarian mass-differentiating benign from malignant. The value of the
           International Ovarian Tumor Analysis (IOTA) ultrasound rules
    • Authors: Jacques S. Abramowicz; Dirk Timmerman
      Abstract: Publication date: Available online 20 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Jacques S. Abramowicz, Dirk Timmerman
      Ovarian cancer, the fifth most common cause of cancer death among women, has the highest mortality rate of all gynecologic cancers. General survival rate is under 50% but can reach 90% if disease is detected early. Ultrasound is presently the best modality to differentiate between benign and malignant status. The patient with a malignant mass should be referred to an oncology surgeon since results have been shown to be superior to treatment by a specialist. Several ultrasound-based scoring systems exist for assessing the risk of an ovarian tumor to be malignant. The International Ovarian Tumor Analysis (IOTA) group, published two such systems: the Simple Ultrasound Rules and the Assessment of Different NEoplasias in the adneXa (ADNEX) model. The Simple Rules classifies a tumor as benign, malignant or indeterminate and the ADNEX model determines the risk for a tumor to be benign or malignant and, if malignant, the risk of various stages. Sensitivity of the Simple rules and ADNEX model (using a cut-off of 10% to predict malignancy), are 92% and 96.5%, respectively and the specificity 96% and 71.3%, respectively. These models are the best predictive tests for the preoperative classification of adnexal tumors. Their intent is to help the specialist make management decisions when faced with a patient with a persistent ovarian mass. The models are simple, easy to use and have been validated in multiple reports but not in the USA. We suggest they should be validated and widely introduced into medical practice in the USA.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.019
       
  • Amniotic fluid transcriptomics reflects novel disease mechanisms in
           fetuses with myelomeningocele
    • Authors: Tomo Tarui; Aimee Kim; Alan Flake; Lauren Mcclain; John Stratigis; Inbar Fried; Rebecca Newman; Donna K. Slonim; Diana W. Bianchi
      Abstract: Publication date: Available online 20 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Tomo Tarui, Aimee Kim, Alan Flake, Lauren Mcclain, John Stratigis, Inbar Fried, Rebecca Newman, Donna K. Slonim, Diana W. Bianchi
      Background Cell-free (cf) RNA in amniotic fluid supernatant (AFS) reflects developmental changes in gene expression in the living fetus, including genes specific to the central nervous system (CNS). Although it has been previously shown that CNS-specific transcripts are present in AFS, it is not known whether changes in the AFS transcriptome reflect the specific pathophysiology of fetal CNS disorders. In myelomeningocele, there is open communication between the CNS and amniotic fluid. Objectives To identify molecular pathophysiologic changes and novel disease mechanisms specific to myelomeningocele by analyzing AFS cfRNA in fetuses with open myelomeningocele. Study Design AFS was collected from 10 pregnant women at the time of the open myelomeningocele repair in the second trimester (24.5+/-1.0 wks) and 10 archived AFS from sex and gestational age-matched euploid fetuses without myelomeningocele were used as controls (20.9+/-0.9 wks). Differentially regulated gene expression patterns were analyzed using Human Genome U133 Plus 2.0 arrays. Results Fetuses with myelomeningocele had 284 differentially-regulated genes (176 up- & 108 down-regulated) in AFS. Known genes 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 pathology and a broad influence of Wnt signaling pathways (Wnt1, Wnt5A, ITPR1). Conclusion(s) Transcriptomic analyses of living fetuses with myelomeningocele using AFS cfRNA demonstrated differential regulation of specific genes and molecular pathways relevant to this CNS disorder, resulting in a new understanding of pathophysiological changes. The data also suggested the importance of pathways involving secondary pathology, 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: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.022
       
  • Impact of Preimplantation Genetic Screening on Donor oocyte-recipient
           cycles in the United States
    • Authors: David H. Barad; Sarah. K. Darmon; Vitaly. A. Kushnir; David. F. Albertini; Norbert Gleicher
      Abstract: Publication date: Available online 20 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): David H. Barad, Sarah. K. Darmon, Vitaly. A. Kushnir, David. F. Albertini, Norbert Gleicher
      Objective Our objective was to estimate the contribution of Preimplantation genetic screening to in-vitro fertilization pregnancy outcomes in donor oocyte-recipient cycles. Methods This is a retrospective cross-sectional study of United States national data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2005-2013. Society for Assisted Reproductive Technology Clinic Outcome Reporting relies on voluntarily annual reports by over 90% of United States in-vitro fertilization centers. We evaluated pregnancy and live birth rates in donor oocyte-recipient cycles after first embryo transfer with day 5/6 embryos. Statistical models, adjusted for patient and donor ages, number of embryos transferred, race, infertility diagnosis and cycle year were created to compare live birth rates in 392 Preimplantation genetic screening and 20,616 Control cycles. Results Overall, pregnancy and live birth rates were significantly lower in Preimplantation genetic screening cycles than in control cycles. Adjusted odds of live birth for Preimplantation genetic screening cycles were reduced by 35% (OR 0.65, 95% CI 0.53 to 0.80; P < 0.001). Conclusion Preimplantation Genetic Screening, as practiced in donor oocyte-recipient cycles over the past nine years, has not been associated with improved odds of live birth or reduction in miscarriage rates.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.023
       
  • Quality Measures in High-Risk Pregnancies: Executive Summary of a
           Cooperative Workshop of the Society for Maternal-Fetal Medicine, National
           Institute of Child Health and Human Development, and the American College
           of Obstetricians and Gynecologists
    • Authors: Brian K. Iriye; Kimberly D. Gregory; George R. Saade; William A. Grobman; Haywood L. Brown
      Abstract: Publication date: Available online 20 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Brian K. Iriye, Kimberly D. Gregory, George R. Saade, William A. Grobman, Haywood L. Brown


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.018
       
  • Do Maternal Obesity or Smoking Explain the Lack of Effectiveness of 17
           Alpha-Hydroxyprogesterone Caproate'
    • Authors: Kent D. Heyborne; Amanda A. Allshouse
      Abstract: Publication date: Available online 18 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Kent D. Heyborne, Amanda A. Allshouse


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.014
       
  • Response to Letter-to-the-Editor: Do Maternal Obesity or Smoking Explain
           the Lack of Effectiveness of 17-Alpha Hydroxyprogesterone Caproate'
    • Authors: David B. Nelson; Donald D. McIntire; Kenneth J. Leveno
      Abstract: Publication date: Available online 18 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): David B. Nelson, Donald D. McIntire, Kenneth J. Leveno


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.013
       
  • Evaluating Ureteral patency in the Post-Indigo Carmine Era: A Randomized
           Controlled Trial
    • Authors: Cara Grimes; Sonali Patankar; Timothy Ryntz; Nisha Philip; Khara Simpson; Mireille Truong; Connie Young; Arnold Advincula; Obianuju S. Madueke-Laveaux; Ryan Walters; Cande V. Ananth; Jin Hee Kim
      Abstract: Publication date: Available online 18 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Cara Grimes, Sonali Patankar, Timothy Ryntz, Nisha Philip, Khara Simpson, Mireille Truong, Connie 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 intra-operative evaluation of ureteral patency. Objective We performed a randomized controlled trial to compare surgeon satisfaction with four 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 un-blinded 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 with the statement and 100 indicating strong disagreement with the statement. The 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 two-tailed. Results One hundred and thirty 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 mm (0, 83), 20 mm (0, 82), 0 mm (0,44) and 23 mm (3, 96) for phenazopyridine, sodium fluorescein, mannitol, and normal saline, respectively; (P <0.001). Surgery length, cystoscopy length, and time to surgeon confidence in visualization of ureteral jets were not different across the four randomized groups. During the 189-day follow-up, no differences in adverse events were seen among the groups, including urinary tract infections. Conclusions 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: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.012
       
  • Evidence that Children Born at Early Term (37-38-6/7 weeks) Are at
           Increased Risk for Diabetes and Obesity-related Disorders
    • Authors: Dorit Paz Levy; Eyal Sheiner; Tamar Wainstock; Ruslan Sergienko; Daniella Landau; Asnat Walfisch
      Abstract: Publication date: Available online 18 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Dorit Paz Levy, Eyal Sheiner, Tamar Wainstock, Ruslan Sergienko, Daniella Landau, Asnat Walfisch
      Background Prematurity is known to be associated with high rates of endocrine and metabolic complications in the offspring. Early term (37 0/7-38 6/7 weeks’ gestation) born offspring were also shown to exhibit long term morbidity resembling that of late preterm, in several health categories. Objective We aimed to determine whether early term delivery impacts on the long-term endocrine and metabolic health of the offspring. Study design A population-based cohort analysis was performed, including all term singleton deliveries occurring during 1991-2013 at a single regional tertiary medical center. Congenital malformations and multiple pregnancies were excluded. Gestational age upon delivery was sub-divided into early term deliveries, and deliveries occurring at full term and later (≥39 0/7 weeks’ gestation, comparison group). Endocrine and metabolic morbidity (including diabetes, obesity, hypoglycemia, hyperlipidemia, hypothyroidism, etc.) of the offspring, up to the age of 18 years, was evaluated according to hospitalization files. Kaplan-Meier survival curves were used to compare cumulative morbidity incidence. A Weibull parametric survival model was used to control for time to event, siblings, and other confounders. Results During the study period 225 260 term deliveries met the inclusion criteria. Of them, 24% (n=54 073) occurred at early term. Endocrine and metabolic morbidity was significantly more common in the early term group (0.51% vs. 0.41%, p=0.003). Specifically, over-weight and obesity were more common among the early term group (p=0.002). Differences were more prominent among children older than 5 years, who exhibited higher rates of type I diabetes mellitus, as well as obesity, when born at early term (p<0.05). The survival curves demonstrated higher cumulative incidence of total endocrine and metabolic morbidity in the early term group. Using the Weibull parametric survival model, while controlling for siblings, maternal diabetes, hypertension, labor induction, and Apgar score, early term delivery exhibited an independent association with long-term childhood endocrine and metabolic morbidity of the offspring (adjusted HR 1.17, 95%CI 1.01-1.34,) and more so beyond the age of 5 years (adjusted HR 1.30, 95%CI 1.08-1.56). Conclusion Deliveries occurring at early term are associated with higher rates of long term pediatric endocrine and metabolic morbidity of the offspring as compared with deliveries occurring at a later gestational age. This association may be due to absence of full maturity of the hormonal axis in early term neonates or, alternatively, suggesting an underlying fetal endocrine dysfunction as the initial mechanism responsible for spontaneous early term delivery.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.015
       
  • Utilization of Apical Vaginal Support Procedures at Time of Inpatient
           Hysterectomy Performed for Benign Conditions: A National Estimate
    • Authors: Whitney Trotter Ross; Melanie R. Meister; Jonathan P. Shepherd; Margaret A. Olsen; Jerry L. Lowder
      Abstract: Publication date: Available online 14 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Whitney Trotter Ross, Melanie R. Meister, Jonathan P. Shepherd, Margaret A. Olsen, Jerry L. Lowder
      Background Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports re-establishment of apical support at time of hysterectomy, regardless of whether the hysterectomy is performed for prolapse. National rates of apical support procedure performance at time of inpatient hysterectomy have not been well described. Objective To estimate trends and factors associated with use of apical support procedures at time of inpatient hysterectomy for benign indications in a large national database. Study Design The National Inpatient Sample was used to identify hysterectomies performed from 2004-2013 for benign indications. ICD-9 codes were used to select both procedures and diagnoses. The primary outcome was performance of an apical support procedure at time of hysterectomy. Descriptive and multivariable analyses were performed. Results There were 3,509,230 inpatient hysterectomies performed for benign disease between 2004 and 2013. In both non-prolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (p <0.0001). There were 2,790,652 (79.5%) hysterectomies performed without a diagnosis of prolapse, and an apical support procedure was performed in only 85,879 (3.1%). There was a significant decrease in the proportion of hysterectomies with concurrent apical support procedure (high of 4.0% in 2004 to 2.5% in 2013, p <0.0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically-assisted vaginal) were associated with performance of an apical support procedure. During the study period, 718,578 (20.5%) inpatient hysterectomies were performed for prolapse diagnoses and 266,743 (37.1%) included an apical support procedure. There was a significant increase in the proportion of hysterectomies with concurrent apical support procedure (low of 31.3% in 2005 to 49.3% in 2013, p<0.0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (medium and large), and hysterectomy type (total laparoscopic and laparoscopic supracervical) were associated with performance of an apical support procedure. Conclusions This national database study demonstrates that apical support procedures are not routinely performed at time of inpatient hysterectomy regardless of presence of prolapse diagnosis. Educational efforts are needed to increase awareness of the importance of re-establishing apical vaginal support at time of hysterectomy regardless of indication.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.010
       
  • 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
      Abstract: Publication date: Available online 13 July 2017
      Source:American Journal of Obstetrics and Gynecology
      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 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 five academic medical centers in New York City were required to complete a laparoscopic surgery simulation assessment. The physicians took a pre-simulation survey gathering physician self-reported characteristics and then performed 3 basic skills tasks (enforced peg transfer (PT), lifting & grasping (LG), and cutting (CT)) on the Surgical Science LapSim®virtual reality laparoscopic simulator. 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 three tasks (p=0.001 for PT; p=0.041 for LG; p<0.001 for CT). Average monthly laparoscopic surgical volume was a significant predictor of two efficiency scores in PT, and all four efficiency scores in CT (p=0.001 to p=0.015). Surgical volume was a significant predictor of errors in LG and CT (p<0.001 for both). Self-rated laparoscopic skill level was a significant predictor of total time in all three tasks (p<0.0001 for PT, p=0.009 for LG, p<0.001 for CT) and a significant predictor of nearly all efficiency scores and errors scores in all three tasks. Discussion In addition to total time, there was at least one other objective performance measure that significantly correlated with surgical volume for each of the three 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: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.07.002
       
  • 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
      Abstract: Publication date: Available online 13 July 2017
      Source:American Journal of Obstetrics and Gynecology
      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 To determine the utility of early second trimester uterine artery Doppler studies as a predictor of small for gestational age (SGA) neonates. Study Design Nulliparous women with a viable singleton pregnancy were recruited during their first trimester into an observational prospective cohort study at eight institutions across the United States. Participants were seen at three 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 SGA (defined as birth weight <5th percentile for gestational age [Alexander growth curve]) were evaluated. Results Uterine artery Doppler indices, birth weight, and gestational age at birth were available for 8,024 women. Birth weight <5th percentile for gestational age occurred in 358 (4.5 percent) of the births. Typical thresholds for the uterine artery Doppler indices were all associated with birth weight <5th percentile for gestational age (P<0.0001 for each), but the positive predictive values for these cutoffs were all <15 percent and areas under receiver operating characteristic curves (AUCs) ranged from 0.50 to 0.60. Across the continuous scales for these measures, the AUCs ranged from 0.56 to 0.62. Incorporating maternal age, early pregnancy BMI, race/ethnicity, smoking status prior to pregnancy, chronic hypertension, and pre-gestational diabetes in the prediction model resulted in only modest improvements in the AUCs ranging from 0.63 to 0.66. Conclusion In this large prospective cohort, early second trimester uterine artery Doppler studies were not a clinically useful test for predicting SGA babies.

      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.06.013
       
  • Giants in Obstetrics and Gynecology Series: A profile of
           Leon Speroff, MD
    • Authors: Roberto Romero
      Abstract: Publication date: Available online 12 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Roberto Romero


      PubDate: 2017-07-24T12:02:24Z
      DOI: 10.1016/j.ajog.2017.06.028
       
  • Short-term costs of preeclampsia to the United States health care system
    • Authors: Warren Stevens; Tiffany Shih; Devin Incerti; Thanh G.N. Ton; Henry C. Lee; Desi Peneva; George A. Macones; Baha M. Sibai; Anupam B. Jena
      Abstract: Publication date: Available online 11 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Warren Stevens, Tiffany Shih, Devin Incerti, Thanh G.N. Ton, Henry C. Lee, Desi Peneva, George A. Macones, Baha M. Sibai, Anupam B. Jena
      Background Preeclampsia is a leading cause of maternal morbidity and mortality and adverse neonatal outcomes. Little is known about the extent of the health and cost burden of preeclampsia in the United States. Objective This study sought to quantify the annual epidemiological and health care cost burden of preeclampsia to both mothers and infants in the United States in 2012. Study Design We used epidemiological and econometric methods to assess the annual cost of preeclampsia in the United States using a combination of population-based and administrative data sets: the National Center for Health Statistics Vital Statistics on Births, the California Perinatal Quality Care Collaborative Databases, the US Health Care Cost and Utilization Project database, and a commercial claims data set. Results Preeclampsia increased the probability of an adverse event from 4.6% to 10.1% for mothers and from 7.8% to 15.4% for infants while lowering gestational age by 1.7 weeks (P < .001). Overall, the total cost burden of preeclampsia during the first 12 months after birth was $1.03 billion for mothers and $1.15 billion for infants. The cost burden per infant is dependent on gestational age, ranging from $150,000 at 26 weeks gestational age to $1311 at 36 weeks gestational age. Conclusion In 2012, the cost of preeclampsia within the first 12 months of delivery was $2.18 billion in the United States ($1.03 billion for mothers and $1.15 billion for infants), and was disproportionately borne by births of low gestational age.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.04.032
       
  • First sacral nerve and anterior longitudinal ligament anatomy: clinical
           applications during sacrocolpopexy
    • Authors: Maria E. Florian-Rodriguez; Jennifer Hamner; Marlene M. Corton
      Abstract: Publication date: Available online 11 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Maria E. Florian-Rodriguez, Jennifer 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. Objectives 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 kilograms per meter squared. 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 mm (range 22-37 mm). Median horizontal distance from the midsacrum to the first sacral foramen was 19 mm (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 mm (1.2-2.5 mm). Median fifth lumbar to first sacral disc height was 16 mm (8.3-17 mm). Conclusions 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: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.008
       
  • Trends in End of Life Care and Healthcare Spending in Women with Uterine
           Cancer
    • Authors: Benjamin Margolis; Ling Chen; Melissa K. Accordino; Grace Clarke Hillyer; June Y. Hou; Ana I. Tergas; William M. Burke; Alfred I. Neugut; Cande V. Ananth; Dawn L. Hershman; Jason D. Wright
      Abstract: Publication date: Available online 11 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Benjamin Margolis, Ling Chen, Melissa K. Accordino, Grace Clarke Hillyer, June Y. Hou, Ana I. Tergas, William M. Burke, Alfred I. Neugut, Cande V. Ananth, Dawn L. Hershman, Jason D. Wright
      Background High intensity care including hospitalizations, chemotherapy and other interventions at the end of life is costly and often of little value for cancer patients. Little is known about patterns of end of life care and resource utilization for women with uterine cancer. Objective We examined the costs and predictors of aggressive end of life care for women with uterine cancer. Methods In this observational cohort study the Surveillance, Epidemiology and End Results-Medicare linked database was used to identify women >65 who died from uterine cancer from 2000-2011. Resource utilization in the last month of life including ≥2 hospital admissions, >1 emergency department visit, ≥1 intensive care unit admission or use of chemotherapy in the last 14 days of life was examined. High intensity care was defined as the occurrence of any of the above outcomes. Logistic regression models were developed to identify factors associated with high intensity care. Total Medicare expenditures in the last month of life are reported. Results Of the 5,873 patients identified, the majority had stage IV (30.2%) cancer, were white (79.9%) and had endometrioid tumors (47.6%). High intensity care was rendered to 42.5% of women. During the last month of life, 15.0% had >2 hospital admissions, 9.0% had a hospitalization >14 days, 15.3% had >1 emergency department visits, 18.3% had an intensive care unit admission and 6.6% received chemotherapy in the last 14 days of life. The percentage of women who received high intensity care was stable over the study period. Characteristics of younger age, black race, higher number of comorbidities, stage IV disease, residence in the eastern US and more recent diagnosis were associated with high intensity care. The median Medicare payment during the last month of life was $7,645. Total per beneficiary Medicare payments remained stable from $9,656 (IQR, $3,190-$15,890) in 2000 to $9,208 (IQR, $3,309-$18,554) by 2011. The median healthcare expenditure was four times as high for those who received high intensity care compared to those who did not (median $16,173 vs $4,099). Conclusion Among women with uterine cancer, high intensity care is common in the last month of life, associated with substantial monetary expenditures, and does not appear to be decreasing.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.006
       
  • Interactions between 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
      Abstract: Publication date: Available online 11 July 2017
      Source:American Journal of Obstetrics and Gynecology
      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 two 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. Objectives 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 Mid-sagittal MRI 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±6.5cm2) and posterior (35.7±8.0cm2) prolapse groups were larger during Valsalva compared to controls (20.9±7.8cm2, p<.0001 for both); similarly, protrusion areas for the anterior (14.3±6.2cm2) and posterior (14.4±5.7cm2) were both larger than controls (5.0±1.8cm2, p<.0001 for both). The levator hiatus length for the anterior (7.2±1cm) and posterior (6.9±1cm) were longer during Valsalva compared to controls (5.2±1.5cm, p<.0001 for both); similarly, urogenital hiatus lengths for the anterior (5.7±1cm) and posterior (6.3±1.1cm) were both longer than controls (3.8±0.8cm, 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 ± 7.2cm2 v. 9.4 ± 5.9cm2, p<.0002). The urogenital was more strongly associated with prolapse than the levator hiatus (OR: 12.9, 95% CI: (4.1-39.2), OR: 4.3, 95% CI: (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≤0.001, for all comparisons). Conclusions 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 three times larger than for the levator hiatus, which leads us to reject both the original hypotheses.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.007
       
  • The Incidence of Transfusion and Associated Risk Factors in Pelvic
           Reconstructive Surgery
    • Authors: Lopa K. Pandya; Courtney Lynch; Andrew F. Hundley; Silpa Nekkanti; Catherine O. Hudson
      Abstract: Publication date: Available online 11 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Lopa K. Pandya, Courtney Lynch, Andrew F. Hundley, Silpa Nekkanti, Catherine O. Hudson
      Background Almost 400,000 female pelvic reconstructive operations were performed in 2010 for urinary incontinence and pelvic organ prolapse in the United States, and it is likely that this will continue to increase each year. There is a lack of population-based data evaluating the risk of blood transfusion after urogynecologic procedures. Objectives To assess the incidence of blood transfusion related to pelvic reconstructive surgery in a large national surgical quality database and to identify transfusion-associated risk factors. Study Design This retrospective cohort study was performed using the National Surgery Quality Improvement Program (NSQIP) database from the years 2010-2014. All women undergoing surgery for pelvic floor disorders were identified by CPT code. Demographic and clinical variables were abstracted. The incidence of blood transfusion was determined. A multivariate logistic regression analysis was performed to identify clinical factors independently associated with blood transfusion. Results 54,387 women underwent pelvic reconstructive surgery between 2010 and 2014 in the NSQIP database. 686 (1.26%) of these subjects received a blood transfusion. The median age was 57 years (range 28-89). 0.81% of the population was underweight (BMI <18.5), 27.0% was normal weight (BMI 18.5-24.9), 35.6% was overweight (BMI 25-29.9), and 36.7% was obese (BMI ≥ 30). The majority of subjects in the study cohort were Caucasian (91.4%) followed by African Americans (4.6%), the remainder included Asian, American Indian/Alaska Native and Native Hawaiian/Pacific Islander. Hispanic ethnicity was reported in 9.3% of the population. American Society of Anesthesiologists (ASA) Class 1 and 2 represented a majority of the sample (76.5%). Concomitant hysterectomy was performed in 20,735 (38.1%) of the population. In the multivariate analysis, preoperative hematocrit less than 30 (OR 13.68; 95% CI 10.65-17.59), history of coagulopathy (OR 3.74; 95% CI 2.50-5.60), and concomitant hysterectomy (OR 1.77; 95% CI 1.49- 2.12) were factors independently associated with receiving blood transfusion (all p<0.05). When compared to ASA Class I, patients who were Class 3 (OR 2.82, P<.01; 95% CI 2.02-3.93), or Class 4 (OR 6.56, P<.01; 95% CI 3.65-11.78) were more likely to require a transfusion. When compared to Caucasian subjects, African Americans (OR 1.73, P <.01; 95% CI 1.27-2.36) and Hispanics (OR 1.92, P<.01; 95% CI 1.54-2.40) were more likely to require a transfusion. In this cohort, overweight (OR 0.75; CI 95% 0.62-0.93) and obese (OR 0.61; 95% CI 0.49-0.75) subjects were less likely to receive a transfusion. When compared to a vaginal approach, patients who had a minimally invasive approach (OR 0.63; 95% CI 0.49-0.83) were less likely to receive a transfusion, while those with an open approach were more likely to receive a transfusion (OR 5.43; 95% CI 4.49-6.56). Age was not a risk factor for transfusion. Conclusion Transfusion after pelvic reconstructive surgery is uncommon. The variables that are associated with transfusion are preoperative hematocrit less than 30, ASA class, bleeding disorders, non-white race, Hispanic ethnicity, and concomitant hysterectomy. Recognition of these factors can help guide preoperative counseling regarding transfusion risk after pelvic reconstructive surgery and individualize preoperative preparation.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.005
       
  • Health and economic burden of preeclampsia: no time for complacency
    • Authors: Rui Li; Eleni Z. Tsigas; William M. Callaghan
      Abstract: Publication date: Available online 11 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Rui Li, Eleni Z. Tsigas, William M. Callaghan


      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.06.011
       
  • A profile of Donald R. Coustan, MD
    • Authors: Roberto Romero
      Abstract: Publication date: Available online 10 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Roberto Romero


      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.06.037
       
  • Drug interactions between non-rifamycin antibiotics and hormonal
           contraception: A systematic review
    • Authors: Katharine B. Simmons; Lisa B. Haddad; Kavita Nanda; Kathryn M. Curtis
      Abstract: Publication date: Available online 8 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Katharine B. Simmons, Lisa B. Haddad, Kavita Nanda, Kathryn M. Curtis
      Objective To determine whether interactions between non-rifamycin antibiotics and hormonal contraceptives result in decreased effectiveness or increased toxicity of either therapy. Data sources We searched MEDLINE, Embase, clinicaltrials.gov and Cochrane libraries from database inception through June, 2016. Study eligibility criteria We included trials, cohort, case-control, and pharmacokinetic (PK) studies in any language addressing pregnancy rates, pharmacodynamics or PK outcomes when any hormonal contraceptive and non-rifamycin antibiotic were administered together versus apart. Of 7291 original records identified, 29 met criteria for inclusion. Study appraisal and synthesis methods Two authors independently assessed study quality and risk of bias using the United States Preventive Services Task Force evidence grading system. Findings were tabulated by drug class. Results Study quality ranged from good to poor and addressed only oral contraceptive pills, emergency contraception pills and the combined vaginal ring. Two studies demonstrated no difference in pregnancy rates in women using oral contraceptives with and without non-rifamycin antibiotics. No differences in ovulation suppression or breakthrough bleeding were observed in any study combining hormonal contraceptives with any antibiotic. No significant decreases in any progestin PK parameter occurred during co-administration with any antibiotic. Ethinyl estradiol area under the curve decreased when administered with dirithromycin but no other drug. Conclusion Evidence from clinical and PK outcomes studies does not support the existence of drug interactions between hormonal contraception and non-rifamycin antibiotics. Data are limited by low quantity and quality for some drug classes. Most women can expect no reduction in hormonal contraceptive effect with concurrent use of non-rifamycin antibiotics.
      Teaser Current limited data from clinical and pharmacokinetic studies indicate that most women taking hormonal contraception with non-rifamycin antibiotics can expect no reduction in contraceptive effectiveness.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.003
       
  • The Development of a Retroperitoneal Dissection Model
    • Authors: Aisha A. Yousuf; Helena Frecker; Abheha Satkunaratnam; Eliane M. Shore
      Abstract: Publication date: Available online 8 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Aisha A. Yousuf, Helena Frecker, Abheha Satkunaratnam, Eliane M. Shore
      Knowledge of ureteric anatomy is essential for ureteric injury prevention in laparoscopic gynecologic surgery. Rates of injury increase with limited surgical experience and reduced surgical volume. Currently there are no low-fidelity or high-fidelity simulation models for teaching and practicing ureteric dissection. Our goal was to design a laparoscopic simulation model for retroperitoneal anatomy with high face validity that is low-cost and easily reproducible.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.004
       
  • 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
      Abstract: Publication date: Available online 8 July 2017
      Source:American Journal of Obstetrics and Gynecology
      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. Objectives The objectives were 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 slings 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 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,’ and 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 10mm on 100mm Visual Analog Scale. To account for 10% drop out, 114 participants were needed. Results One hundred fourteen women were enrolled. After 5 exclusions, 109 were analyzed: 54 received intervention, and 55 received placebo. Mean participant age was 52 years, and mean body mass index was 30.4. Surgical and demographic characteristics were similar except for a slightly higher body mass index in the placebo group (31.6 vs 29.2, p=.050), and less placebo arm subjects received midazolam during anesthesia induction (44 vs 52, p= 0.015). For the primary outcome, pain score (mm) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0, 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 was 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: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.07.001
       
  • Giants in Obstetrics and Gynecology Series: A profile of Alan H.
           DeCherney, MD
    • Authors: Roberto Romero
      Abstract: Publication date: Available online 8 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Roberto Romero


      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.06.028
       
  • Reply
    • Authors: Hilde Engjom; Nils-Halvdan Morken Kari
      Abstract: Publication date: Available online 6 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Hilde M. Engjom, Nils-Halvdan Morken, Kari Klungsøyr


      PubDate: 2017-07-12T11:37:22Z
       
  • Proceedings: Beyond Ultrasound First Forum on improving the quality of
           ultrasound imaging in obstetrics and gynecology
    • Authors: Beryl R. Benacerraf; Katherine K. Minton; Carol B. Benson; Bryann S. Bromley; Brian D. Coley; Peter M. Doubilet; Wesley Lee; Samuel H. Maslak; John S. Pellerito; James J. Perez; Eric Savitsky; Norman A. Scarborough; Joseph Wax; Alfred Z. Abuhamad
      Abstract: Publication date: Available online 6 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Beryl R. Benacerraf, Katherine K. Minton, Carol B. Benson, Bryann S. Bromley, Brian D. Coley, Peter M. Doubilet, Wesley Lee, Samuel H. Maslak, John S. Pellerito, James J. Perez, Eric Savitsky, Norman A. Scarborough, Joseph Wax, Alfred Z. Abuhamad
      The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.06.033
       
  • 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; Gareth Evans; John Hopper; Robert J. Macinnis; Usha Menon; Ian Jacobs; Rosa Legood
      Abstract: Publication date: Available online 6 July 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Ranjit Manchanda, Shreeya Patel, Antonis C. Antoniou, Ephrat Levy-Lahad, Clare Turnbull, Gareth Evans, John Hopper, Robert J. Macinnis, Usha Menon, Ian Jacobs, Rosa Legood
      Background Population based BRCA1/BRCA2 testing has been found to be cost-effective compared to family-history based testing in Ashkenazi-Jewish (AJ) women >30years with four AJ-grandparents. However, individuals may have one, two or three AJ 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 one, two and three AJ grandparents. Methods Life time costs and effects of population and family-history based testing were compared using a decision analysis model. 56% BRCA carriers are missed by family-history criteria alone. Analyses are conducted for UK and USA populations. Model parameters are obtained from the GCaPPS trial and published literature. Model parameters and BRCA population prevalence for individuals with three, two or one AJ grandparents are adjusted for the relative frequency of BRCA mutations in the AJ and general populations. Incremental cost-effectiveness ratios were calculated for all AJ-grandparent scenarios. Costs along with outcomes discounted at 3.5%. The time horizon of the analysis is ‘life-time’ and perspective is ‘payer’. Probabilistic sensitivity-analysis (PSA) evaluated model uncertainty. Results Population testing for BRCA mutations is cost saving in AJ women with two, three or four grandparents (22-33 days life-gained) in UK and one, two, three or four grandparents (12-26 days life-gained) in USA populations respectively. It is also extremely cost-effective in UK women with just one AJ-grandparent with an incremental-cost-effectiveness-ratio (ICER)= £863/QALY and 15days life-gained. Results show that population-testing remains cost-effective at the £20,000-30000/QALY and $100,000/QALY willingness-to-pay thresholds for all four AJ-grandparent scenarios with ≥95% simulations found to be cost-effective on PSA. Population-testing remains cost-effective in the absence of reduction in breast cancer risk from oophorectomy and at lower RRM (13%)/RRSO (20%) rates. Conclusions Population-testing for BRCA mutations is cost-effective in the UK and USA with varying levels of AJ ancestry. These results support population testing in AJ women with 1-4 AJ-grandparent ancestry.

      PubDate: 2017-07-12T11:37:22Z
      DOI: 10.1016/j.ajog.2017.06.038
       
  • Information for Readers
    • Abstract: Publication date: July 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 1


      PubDate: 2017-06-23T22:50:13Z
       
 
 
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