for Journals by Title or ISSN
for Articles by Keywords
help

Publisher: Elsevier   (Total: 3184 journals)

 A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  

        1 2 3 4 5 6 7 8 | Last   [Sort by number of followers]   [Restore default list]

Showing 1 - 200 of 3184 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 37, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 26, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 100, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 40, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 6)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 7)
Acta Astronautica     Hybrid Journal   (Followers: 436, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 28, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 3)
Acta Ecologica Sinica     Open Access   (Followers: 11, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 307, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 1, SJR: 1.793, CiteScore: 6)
Acta Poética     Open Access   (Followers: 4, SJR: 0.101, CiteScore: 0)
Acta Psychologica     Hybrid Journal   (Followers: 25, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 7, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 8)
Acute Pain     Full-text available via subscription   (Followers: 15, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 18, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 9, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 11, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 23)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 183, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 12, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 17, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 29, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 11, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 11, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 15, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 2, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 33, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 5)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 14)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 29, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 10, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 26, SJR: 1.562, CiteScore: 3)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 20, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.205, CiteScore: 1)
Advances in Dermatology     Full-text available via subscription   (Followers: 15)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 13)
Advances in Digestive Medicine     Open Access   (Followers: 12)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 7)
Advances in Drug Research     Full-text available via subscription   (Followers: 26)
Advances in Ecological Research     Full-text available via subscription   (Followers: 43, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 29, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 8)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 51, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 65, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 17)
Advances in Genetics     Full-text available via subscription   (Followers: 21, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 10, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 7, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 26, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 11, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 24)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 3, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 36, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 9, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 21, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 12, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 8, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 24)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 5)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 18, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 5, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 27, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 18)
Advances in Pharmacology     Full-text available via subscription   (Followers: 17, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 10)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 6)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 19)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 66)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 1, SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 6)
Advances in Space Research     Full-text available via subscription   (Followers: 421, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 5)
Advances in Surgery     Full-text available via subscription   (Followers: 13, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 37, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 53, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 383, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 12, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 475, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 18, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 31, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 45, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 4)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 58, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 7, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 12, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 11)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 2, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 10, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 54, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 6, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 6, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 58, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 63, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 46, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 12)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 37, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 29, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 36, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 50)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 248, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 66, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 32, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 28, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 39, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 66, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 24, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription   (Followers: 1)
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 5, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 44, SJR: 1.512, CiteScore: 5)
Analytica Chimica Acta : X     Open Access  
Analytical Biochemistry     Hybrid Journal   (Followers: 209, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 13, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 14)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25, SJR: 0.683, CiteScore: 2)
Angiología     Full-text available via subscription   (SJR: 0.121, CiteScore: 0)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1, SJR: 0.111, CiteScore: 0)
Animal Behaviour     Hybrid Journal   (Followers: 218, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 6, SJR: 0.937, CiteScore: 2)
Animal Reproduction Science     Hybrid Journal   (Followers: 7, SJR: 0.704, CiteScore: 2)

        1 2 3 4 5 6 7 8 | Last   [Sort by number of followers]   [Restore default list]

Similar Journals
Journal Cover
American Journal of Obstetrics and Gynecology
Journal Prestige (SJR): 2.7
Citation Impact (citeScore): 4
Number of Followers: 248  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0002-9378
Published by Elsevier Homepage  [3184 journals]
  • Undetectable Equals Untransmittable (U=U): Implications for Preconception
           Counseling for Human Immunodeficiency Virus Serodiscordant Couples
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Shweta J. Bhatt, Nataki Douglas Although limited by society guidelines from the American Society for Reproductive Medicine and the Centers for Disease Control in the past, many human immunodeficiency virus serodiscordant American couples who desired future childbearing were referred to Reproductive Endocrinology and Infertility specialists for in vitro fertilization. The access to and cost of assisted reproductive technology created a significant barrier to reproductive care in this patient population. New evidence-based guidelines by the Centers for Disease Control, however, endorse condomless intercourse timed to ovulation for human immunodeficiency virus serodiscordant couples with undetectable viral loads on antiretroviral therapy. In parallel, the Prevention Access Campaign’s “undetectable equals untransmittable” initiative advocates increasing awareness of the favorable prognosis of persons living with human immunodeficiency virus to remove the associated stigma of the disease and promote the safety of condomless intercourse in the setting of undetectable viral loads. With these new guidelines, human immunodeficiency virus serodiscordant couples may not require an automatic referral to the reproductive endocrinology and infertility specialist. Rather, providers of preconception care could recommend timed intercourse for these couples after confirmation of an undetectable viral load and discussion with the interdisciplinary team of health care professionals caring for persons living with human immunodeficiency virus.
       
  • Dairy consumption during adolescence and endometriosis risk
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): James L. Nodler, Holly R. Harris, Jorge E. Chavarro, A. Lindsay Frazier, Stacey A. Missmer BackgroundModifiable risk factors such as diet may be important in both the etiology and progression of endometriosis as well as the prevalence of pain symptoms and infertility associated with this condition. In adults, higher intake of dairy has been associated with lower risk of endometriosis diagnosis. There is currently no literature on whether dairy intake during adolescence - a potentially critical window of exposure - influences endometriosis risk.ObjectiveTo evaluate the association between consumption of dairy foods in adolescence and risk of laparoscopically-confirmed endometriosis.Study DesignA prospective cohort study, the Nurses’ Health Study II (NHSII), which has prospectively collected data since 1989. In 1998, when participants were ages 34 to 51, they completed a 124-item food frequency questionnaire about their high school diet (HS-FFQ).Cases were defined as those who self-reported laparoscopically-confirmed endometriosis. Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals for the association between dairy foods and laparoscopically-confirmed endometriosis.ResultsAmong women who completed the HS-FFQ in 1998, 581 cases of laparoscopically-confirmed endometriosis were diagnosed among 32 868 premenopausal women from 1998 to 2013. Women who consumed more than four servings/day of dairy foods during adolescence had a 32% lower risk of laparoscopically-confirmed endometriosis during adulthood (95% CI=0.47-0.96; ptrend=0.04) compared to women consuming one or fewer servings/day. The association was similar for low-fat and high-fat dairy foods. Yogurt and ice cream consumption, specifically, were associated with a lower risk of endometriosis. Those who consumed two or more servings of yogurt per week as an adolescent had a 29% lower risk of endometriosis diagnosis (95% CI=0.52-0.97; Ptrend=0.02) compared to those consuming less than one serving per week. In addition, women who consumed one or more servings/day of ice cream per day during adolescence had a 38% lower risk of endometriosis diagnosis (95% CI=0.40-0.94; Ptrend=0.20) compared to those consuming less than one serving per week.ConclusionOur findings suggest that dairy consumption, specifically yogurt and ice cream intake, in adolescence may reduce the risk of subsequent endometriosis diagnosis. Future studies in adolescent populations are needed to confirm these results.
       
  • Infertility and Mortality
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Natalie C. Stentz, Nathanael Koelper, Kurt T. Barnhart, Mary D. Sammel, Suneeta SenapatiABSTRACTBackgroundInfertility affects 1 in 10 American reproductive-age women. The impact of this disease beyond the reproductive years is largely unknown.ObjectiveTo determine the association of infertility history with all-cause and cause-specific mortality.Study DesignThis secondary analysis of a multicenter randomized clinical trial included 75,784 women (age 55-74) prospectively enrolled in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer screening trial from 1992-2001 and followed a minimum of 10 years for health-related outcomes and death (856,935 person-years). We examined the association of infertility history (inability to conceive for one year or greater) all-cause and cause-specific mortality using disease risk score adjusted Cox-proportional hazard regression models.ResultsInfertile women had a 10% increased risk of death (from any cause) during the study period compared to the unexposed (AHR 1.10, 95%CI 1.02-1.18, p=0.010). This effect was predominantly noted in women at an otherwise low risk of mortality, who had a 26% increased risk of death (AHR 1.26, 95%CI 1.12-1.42, p
       
  • Fragmentation of postoperative care after surgical management of ovarian
           cancer at 30-days and 90-days
    • Abstract: Publication date: Available online 11 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Stephanie Cham, Timothy Wen, Alexander Friedman, Jason D. Wright BackgroundFragmentation of care, wherein a patient is discharged from an index hospital and undergoes an unexpected readmission to a non-index hospital, is associated with increased risk of adverse outcomes. Fragmentation is not well characterized in ovarian cancer.ObjectiveThe objective of this study was to assess risk factors and outcomes associated with fragmentation of care among women who undergo surgical treatment of ovarian cancer.Study DesignThe Nationwide Readmission Database was used to identify all-cause 30-day and 90-day postoperative readmissions following surgical management of ovarian cancer between 2010-2014. Postoperative fragmentation was defined as readmission to a hospital other than the index hospital of the initial surgery. Multivariable regression analyses were used to identify predictors of fragmentation in both 30-day and 90-day readmissions. Similarly, multivariable models were developed to determine the association between fragmentation and mortality among women who were readmitted.ResultsA total of 10,445 patients (13.3%) were readmitted at 30-days and 14,124 patients (18.0%) were readmitted at 90-days. Of these, there was a 20.8% and 25.7% rate of postoperative care fragmentation for 30-day and 90-day readmissions, respectively. Patient risk factors associated with fragmented postoperative care included Medicare insurance, lower income quartiles, and non-routine discharge to facility. Hospital factors associated with decreased risk of fragmentation included operation at a metropolitan teaching hospital, and performance of extended procedures. Cost and length of stay for the readmission were similar among those who had fragmented and non-fragmented readmissions at both 30 and 90-days. While there was no association between mortality and fragmentation for patients readmitted within 30-days (OR=1.19; 95% CI, 0.93-1.51), patients who had a fragmented readmission at 90-days were 22% more likely to die than those readmitted at 90-days to their index hospital (OR=1.22; 95% CI, 1.00-1.49)ConclusionFragmentation of care is common in women with ovarian cancer who require postoperative readmission. Fragmented postoperative care is associated with an increased risk of mortality among women readmitted within 90-days of surgery.
       
  • Mothers with long QT syndrome are at increased risk for fetal death:
           Findings from a multicenter international study
    • Abstract: Publication date: Available online 11 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Bettina F. Cuneo, Alexander M. Kaizer, Sally Ann Clur, Heikki Swan, Ulrike Herberg, Annika Winbo, Annika Rydberg, Kristina Haugaa, Susan Etheridge, Michael J. Ackerman, Federica Dagradi, Stacy A.S. Killen, Annette Waker-Gussmann, D.Woodrow Benson, A.A.M. Wilde, Zhaoxing Pan, Aimee Lam, Carla Spazzolini, Hitoshi Horigome, Peter J. Schwartz BackgroundMost fetal deaths are unexplained. Long QT syndrome (LQTS) is a genetic disorder of cardiac ion channels. Affected individuals, including fetuses, are predisposed to sudden death. We sought to determine the risk of fetal death in familial LQTS, in which the mother or father carries LQTS genotype. In addition, we assessed whether risk differed if the LQTS genotype was inherited from the mother or father.Objective(s): This was a retrospective review of pregnancies in families with the 3 most common heterozygous pathogenic LQTS genotypes in KCNQ1 (LQT1), KCNH2 (LQT2) or SCN5A (LQT3), which occur in ∼1/2000 individuals. The purpose of our study was to compare pregnancy and birth outcomes in familial LQTS with the normal population and between maternal and paternal carriers of the LQTS genotype. We hypothesized that fetal death before (miscarriage) and after (stillbirths) 20 weeks gestation would be increased in familial LQTS compared to the normal population, and the parent of origin would not affect birth outcomes.Study DesignOur study was a multicenter observational case series of 148 pregnancies from 103 families (80 mothers, 23 fathers) with familial LQTS (60 LQT1, 29 LQT2, 14 LQT3) recruited from 11 international centers with expertise in hereditary heart rhythm diseases, pediatric and/or adult electrophysiology, and high-risk pregnancies. Clinical databases from these sites were reviewed for LQTS occurring in men or women of childbearing age (18-40 years). Pregnancy outcomes (livebirth, stillbirth and miscarriage), birthweights and gestational age at delivery were compared between LQTS genotypes and between maternal vs. paternal LQTS-affected status using logistic regression analysis.ResultsMost offspring (80%, 118/148) were term live born, and 66% (73/110) had LQTS. Newborns of LQTS mothers were delivered earlier and, when controlling for gestational age, weighed less than newborns of LQTS fathers. Fetal arrhythmias were rarely observed, but stillbirths (fetal death> 20 weeks) were 8 times more frequent in LQTS (4% vs.∼ 0.5%) while miscarriages (fetal death ≤ 20 weeks) were 2 times that of the general population (16% vs. 8%). The likelihood of fetal death was significantly greater with maternal vs. paternal LQTS (24.4% vs. 3.4%, P=0.036). Only 10% of all fetal deaths underwent postmortem LQTS testing; 2 of 3 were positive for the family LQTS genotype.Conclusion(s): This is the first report demonstrating that mothers with LQTS are at increased risk of fetal death and uncovers a previously unreported etiology of stillbirth. Our results suggest that maternal effects of LQTS channelopathy may cause placental or myometrial dysfunction conferring increased susceptibility to fetal death and growth restriction in newborn survivors, regardless of LQTS status.
       
  • Placental growth factor predicts time to delivery in women with signs or
           symptoms of early preterm preeclampsia: a prospective multicenter study.
    • Abstract: Publication date: Available online 10 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): John R. Barton, Doug A. Woelkers, Roger B. Newman, C. Andrew Combs, Helen Y. How, Kim A. Boggess, James N. Martin, Kenneth Kupfer, Baha M. Sibai, PETRA (Preeclampsia Triage by Rapid Assay) Trial BackgroundThere is a robust association between altered angiogenic factor concentrations, including placental growth factor and clinically recognized preeclampsia. Alterations in concentrations of angiogenic factors precede the clinical onset of preeclampsia by several weeks. The temporal relationship between the measured angiogenic factors and the time to delivery in women presenting with suspected preeclampsia at
       
  • Non-Candidal Vaginitis: A Comprehensive Approach to Diagnosis & Management
    • Abstract: Publication date: Available online 9 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Chemen M. Neal, Lauren H. Kus, Linda O. Eckert, Jeffrey F. Peipert Vaginitis is one of the most common causes of patient visits to gynecologists, primary care providers, and urgent care centers. However, many women leave without a clear diagnosis or experience recurrent symptoms despite treatment. The three most common etiologies of vaginitis are trichomonas, bacterial vaginosis, and vulvovaginal candidiasis, which account for an estimated 70% of cases. The remaining 30% may be related to other causes of vaginitis, including atrophic vaginitis, desquamative inflammatory vaginitis, and vaginal erosive disease.The purpose of this review is to describe the non-candidal causes of acute and recurrent vaginitis, with the goal of improving the likelihood of accurate diagnosis as well as efficient and effective therapy. We excluded candidal vaginitis from our review, as there was a recently published review on this topic in the American Journal of Obstetrics and Gynecology.The clinical presentation and evaluation of patients with symptoms of vaginitis can be triaged into one of two diagnostic pathways: non-inflammatory and inflammatory vaginitis. The most common non-inflammatory cause is bacterial vaginosis. Features such as irritation, purulent discharge, and the presence of polymorphonuclear neutrophils are more suggestive of an inflammatory process. Trichomoniasis is the most common cause of inflammatory vaginitis. Other well-described forms of inflammatory vaginitis include atrophic vaginitis, desquamative inflammatory vaginitis, and erosive disease. We present a review of the pathogenesis, symptoms, exam findings, diagnostic testing, and treatment for each of these causes of non-candidal vaginitis.
       
  • Bacterial Vaginosis and Surgical Site Infections
    • Abstract: Publication date: Available online 6 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): David E. Soper Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge or malodor, affecting up to one-third of US women. Most women with BV are unaware of the infection, making it difficult to diagnose in the absence of a microscopic examination of vaginal discharge or using point-of-care testing. Untreated BV elevates the risk of postoperative surgical infections in women undergoing obstetric and gynecologic procedures. Treatment with antimicrobial agents that target BV has been shown to reduce the rate of postoperative infections following hysterectomy and surgical abortions. Furthermore, in a cost-comparison model, screening for and treatment of BV prior to hysterectomy was shown to be superior to no screening in terms of infection rates and cost. The BV diagnostic criteria are simple and screening tests are inexpensive; BV screening is a relatively fast process in patients who present for preoperative appointments. Treatment options approved by the FDA include metronidazole, clindamycin, tinidazole, and secnidazole. Given the prevalence of BV and the risks associated with operating on a woman with untreated BV, women undergoing hysterectomy, surgical abortion, and potentially cesarean delivery should be screened for BV, and those who screen positive should be treated with an appropriate antimicrobial agent.
       
  • Changing the conversation: Applying a health equity framework to maternal
           mortality reviews
    • Abstract: Publication date: Available online 6 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Michael R. Kramer, Andrea E. Strahan, Jessica Preslar, Julie Zaharatos, Amy ST. Pierre, Jacqueline Grant, Nicole L. Davis, David Goodman, William Callaghan The risk of maternal death in the U.S. is higher than peer nations and rising, and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual’s risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees (MMRC) make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death, and when appropriate to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the ‘community vital signs’ – the social and community context in which women live, work, and seek healthcare – MMRCs may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.
       
  • October 2015 (vol. 213, no. 4, pages 508.e7 and 508.e9)
    • Abstract: Publication date: Available online 5 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s):
       
  • The Duration of Fetal Antenatal Steroid Exposure Determines the Durability
           of Preterm Ovine Lung Maturation
    • Abstract: Publication date: Available online 5 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Matthew W. Kemp, Masatoshi Saito, Augusto F. Schmidt, Haruo Usuda, Shimpei Watanabe, Shinichi Sato, Takushi Hanita, Yusaku Kumagai, Tsukasa Takahashi, Gabrielle C. Musk, Lucy Furfaro, Lisa Stinson, Erin L. Fee, Peter J. Eddershaw, Matthew S. Payne, Kiara Smallwood, James Bridges, John P. Newnham, Alan H. JobeABSTRACTObjectiveAntenatal corticosteroids (ACS) are the standard of care for maturing the fetal lung and improving outcomes for preterm infants. ACS dosing remains un-optimized, and there is little understanding of how different treatment to delivery intervals may affect treatment efficacy. The durability of a lung maturational response is important because the majority of women treated with ACS do not deliver within the widely accepted 1-7 day window of treatment efficacy. We used a sheep model to test duration of fetal exposures for efficacy at delivery intervals from 1 to 10 days.MethodsFor infusion studies, ewes with single fetuses were randomised to receive an intravenous bolus and maintenance infusion of betamethasone phosphate to target 1-4ng/mL fetal plasma betamethasone for 36 hours, with delivery at either 2, 4 or 7 days-post treatment or sterile saline as control. Animals receiving the clinical treatment were randomised to receive either:i) a single injection of 0.25mg/kg with a 1:1 mixture of betamethasone phosphate + betamethasone acetate with delivery at either 1 or 7 days post treatment; or ii) two treatments of 0.25 mg/kg betamethasone phosphate + betamethasone acetate spaced at 24 hours (giving approximately 48 hours of fetal steroid exposure) with delivery at 2, 5, 7 or 10 days post-treatment. Negative control animals were treated with saline. All lambs were delivered at 121±3 days gestational age and ventilated for 30 minutes to assess lung function.ResultsPreterm lambs delivered at 1 or 2 days post-ACS treatment had significant improvements in lung maturation for both intravenous and single dose intramuscular treatments. After 2 days the efficacy of 36 hour betamethasone phosphate infusions was lost. The single dose of 1:1 betamethasone phosphate + betamethasone acetate also was ineffective at 7 days. In contrast, animals treated with two doses had significant improvements in lung maturation at 2, 5 and 7 days, with treatment efficacy reduced by 10 days.ConclusionIn preterm lambs, the durability of ACS treatment depends on the duration of fetal exposure and is independent of the IV or IM maternal route of administration. For acute 24-48 hour post-treatment deliveries, a 24 hour fetal ACS exposure was sufficient for lung maturation. A fetal exposure duration of at least 48 hours was necessary to maintain long-term treatment durability. A single dose ACS treatment should be sufficient for women delivering within
       
  • August 2019 (vol. 221, no. 2, pages 146.e5 and 146.e10)
    • Abstract: Publication date: Available online 5 September 2019Source: American Journal of Obstetrics and GynecologyAuthor(s):
       
  • Cystoscopy at the time of benign hysterectomy: a decision analysis
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Douglas H. Gilchrist-Scott, Margaret G. Mueller, Kimberly S. Kenton
       
  • Reply
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): William A. Grobman, Aaron B. Caughey
       
  • Should we offer elective induction of labor to nulliparous women at 39
           weeks'
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Joanna Sichitiu, David Desseauve
       
  • More research is needed prior to the implementation of genome-wide
           cell-free DNA testing in specific populations (Response to letter
           L19-020A: Confined placental trisomy detection through cell-free DNA in
           the maternal circulation: Benefit for pregnancy management)
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Gian Carlo Di Renzo, José Luis Bartha, Catia M. Bilardo
       
  • Confined placental trisomy detection through cell-free DNA in the maternal
           circulation: Benefit for pregnancy management
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Dong-Zhi Li, Yi He
       
  • Text message remote monitoring reduced racial disparities in postpartum
           blood pressure ascertainment
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Adi Hirshberg, Mary D. Sammel, Sindhu K. Srinivas
       
  • Impact of team training on visit cycle time in ambulatory reproductive
           health care centers
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Siripanth Nippita, Laura E. Dodge, Michele R. Hacker, Toni H. Golen, Maureen E. Paul, Siripanth Nippita, Laura E. Dodge, Michele R. Hacker, Toni H. Golen, Maureen E. Paul, Laura E. Dodge, Michele R. Hacker, Elizabeth Poitras, Evelyn M. Intondi, Maureen E. Paul
       
  • Pathways to pregnancy for sexual minority women in same-sex marriages
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Janelle M. Downing
       
  • Placental anastomoses in a spontaneous monochorionic-triamniotic triplet
           pregnancy
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Christoph Wohlmuth
       
  • An infiltrated vulvar plaque: Metastatic cutaneous Crohn’s disease
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Anuradha Bishnoi, Nirmalya Banerjee, Uma Nahar Saikia, Davinder Parsad
       
  • Blood pressure trajectory and category and risk of hypertensive disorders
           of pregnancy in nulliparous women
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Alisse Hauspurg, Samuel Parry, Brian M. Mercer, William Grobman, Tamera Hatfield, Robert M. Silver, Corette B. Parker, David M. Haas, Jay D. Iams, George R. Saade, Ronald J. Wapner, Uma M. Reddy, Hyagriv SimhanBackgroundRecently updated American College of Cardiology/ American Heart Association (ACC/AHA) guidelines redefine blood pressure categories as stage 1 hypertension (systolic, 130–139 mm Hg or diastolic, 80–89 mm Hg), elevated (systolic, 120–129 mm Hg and diastolic,
       
  • Tranexamic acid in the routine treatment of postpartum hemorrhage in the
           United States: a cost-effectiveness analysis
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Leanna S. Sudhof, Scott A. Shainker, Brett D. EinersonBackgroundThe World Maternal Antifibrinolytic trial demonstrated that tranexamic acid administered during postpartum hemorrhage reduces hemorrhage-related mortality and laparotomies. The World Health Organization has thus recommended early use of tranexamic acid in the treatment of postpartum hemorrhage. This recommendation has not been universally adopted in the United States, in part because of concerns about cost-effectiveness.ObjectiveWe aim to demonstrate the cost-effectiveness of routine tranexamic acid administration in the treatment of postpartum hemorrhage in the United States, where the rate of hemorrhage-related mortality is lower than that described in the World Maternal Antifibrinolytic trial.Study DesignWe constructed a decision tree comparing 3 strategies in women with a clinical diagnosis of postpartum hemorrhage: no tranexamic acid, tranexamic acid given at any time, and ideal use of tranexamic acid given within 3 hours of delivery. The study was performed from a health care institution perspective with a time horizon of delivery until 6 weeks postpartum. We included interventions that differed by arm in the World Maternal Antifibrinolytic trial (hemorrhage-related mortality, laparotomies, and brace or compression sutures) and incorporated probabilities and costs based on available data for a population of women with postpartum hemorrhage in the United States. In our base case, the rate of postpartum hemorrhage–related mortality was 0.0388%, and the cost of tranexamic acid was $37.80. We assumed that the relative risk reduction in death and laparotomy with tranexamic acid would be similar to the World Maternal Antifibrinolytic trial (19% and 36%, respectively). The primary outcome was incremental cost per hemorrhage-related death averted, and a main secondary outcome was incremental cost per laparotomy avoided under each strategy. Another planned secondary outcome was cost per quality-adjusted life-year. We anticipated that the risk reduction (benefit) because of tranexamic acid in the United States may be less than in the World Maternal Antifibrinolytic trial; thus, we performed 1-way and 2-way sensitivity analyses to explore the parameter uncertainty across a wide range of data-supported estimates. Probabilistic sensitivity analyses with Monte Carlo simulation were performed.ResultsTranexamic acid strategies were dominant (more effective and cost saving) compared with no tranexamic acid for patients with postpartum hemorrhage in the United States. One-way analyses showed that tranexamic acid is cost saving as long as the relative risk reduction of death with tranexamic acid is greater than 4.7%; the model was not sensitive to any other variables. Threshold analyses outside the bounds defined in the model showed that tranexamic acid is cost saving as long as the relative risk reduction of laparotomy with tranexamic acid is greater than 7% or the cost of tranexamic acid is less than $194. A 2-way sensitivity analysis of the risk reduction of death because of tranexamic acid and the baseline risk of postpartum hemorrhage–related death confirmed that tranexamic acid is cost saving across a wide range of plausible estimates. Furthermore, probabilistic sensitivity analysis demonstrated that the tranexamic acid strategies are cost saving in>99.9% of 10,000 Monte Carlo simulations. Despite the initial cost of administration, the annual net cost savings expected from routine use of tranexamic acid for the treatment of postpartum hemorrhage in the United States is $11.3 million, and we estimate that 9 maternal deaths would be averted in 1 year with this strategy. Giving tranexamic acid within 3 hours would almost triple the cost savings and improve maternal outcomes much further.ConclusionA policy of routine tranexamic acid early in the treatment of postpartum hemorrhage is likely to be cost saving in the United States. This conclusion holds true even when the relative risk reduction with tranexamic acid is significantly less than reported in the World Maternal Antifibrinolytic trial and when tranexamic acid is significantly more expensive than currently reported.
       
  • An abnormal cerebroplacental ratio (CPR) is predictive of early childhood
           delayed neurodevelopment in the setting of fetal growth restriction
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Cathy Monteith, Karen Flood, Ragamallika Pinnamaneni, Terri A. Levine, Fiona A. Alderdice, Julia Unterscheider, Fionnuala M. McAuliffe, Patrick Dicker, Elizabeth C. Tully, Fergal D. Malone, Adrienne ForanBackgroundFetal growth restriction accounts for a significant proportion of perinatal morbidity and death. The cerebroplacental ratio is gaining much interest as a useful tool in differentiating the “at-risk” fetus in both fetal growth restriction and appropriate-for-gestational-age pregnancies. The Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction group has demonstrated previously that the presence of this “brain-sparing” effect is associated significantly with adverse perinatal outcomes in the fetal growth restriction cohort. However, data about neurodevelopment in children from pregnancies that are complicated by fetal growth restriction are sparse and conflicting.ObjectiveThe aim of the Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction NeuroDevelopmental Assessment Study was to determine whether children born after fetal growth-restricted pregnancies are at additional risk of adverse early childhood developmental outcomes compared with children born small for gestational age. The objective of this secondary analysis was to describe the role of cerebroplacental ratio in the prediction of adverse early childhood neurodevelopmental outcome.Study DesignParticipants were recruited prospectively from the Perinatal Ireland multicenter observational Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction study cohort. Fetal growth restriction was defined as birthweight
       
  • Assessment of blood-brain barrier integrity and neuroinflammation in
           preeclampsia
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Richard M. Burwick, Brandon M. Togioka, Rosa J. Speranza, Jessica E. Gaffney, Victoria H.J. Roberts, Antonio E. Frias, Mónica RincónBackgroundAlthough blood-brain barrier integrity is intact under normal pregnancy conditions, animal studies suggest that blood-brain barrier impairment occurs in preeclampsia. Yet, human data are limited, and the integrity of the blood-brain barrier has not been assessed in women with preeclampsia.ObjectiveWe sought to test the hypothesis that the integrity of the blood-brain barrier is impaired and that neuroinflammation is increased in women with preeclampsia.Study DesignWe performed an observational case-control study in pregnant women>24 weeks gestation who underwent spinal anesthesia for elective cesarean delivery or combined spinal epidural analgesia for labor. Cases were women with preeclampsia, and control subjects were women with either healthy pregnancy, chronic hypertension, or gestational hypertension. Paired samples of blood, urine, and cerebrospinal fluid were collected from each subject before delivery. We measured albumin, C5a, C5b-9, tumor necrosis factor-α, and interleukin-6 concentrations in plasma and cerebrospinal fluid, and albumin, C5a, and C5b-9 concentrations in urine, using colorimetric or enzyme-linked immunosorbent assays. The ratio of albumin in cerebrospinal fluid to plasma (Qalb) was used as a surrogate for maternal blood-brain barrier integrity. Cerebrospinal fluid concentrations of C5a, C5b-9, tumor necrosis factor-α, and interleukin-6 were used as surrogate markers of neuroinflammation. Differences in Qalb and cerebrospinal fluid protein concentrations between groups were assessed by nonparametric test of medians.ResultsForty-eight subjects were enrolled, which included 16 cases with preeclampsia, 16 control subjects with healthy pregnancy, and 16 control subjects with either chronic or gestational hypertension. Qalb values were not increased in preeclampsia cases compared with healthy or hypertensive control subjects (Qalb median, 3.5 [interquartile range, 2.9–5.1] vs 3.9 [interquartile range, 3.0–4.8] vs 3.9 [interquartile range, 3.0–4.8]; P=.78]. Moreover, Qalb values were not increased in the subset of women with preeclampsia with severe features (n=8) compared with those without severe features (n=8; Qalb median, 3.5 [interquartile range, 3.3–4.9] vs 3.7 [interquartile range, 2.3–5.5]; P=.62]. Cerebrospinal fluid concentrations of C5a, C5b-9, tumor necrosis factor-α and interleukin-6 were not increased in cases of preeclampsia, compared with control subjects with either healthy pregnancy, chronic hypertension, or gestational hypertension (P>.05, all comparisons). In contrast to the negative findings in cerebrospinal fluid, plasma concentrations of both C5b-9 and interleukin-6 and urine concentrations of C5a and C5b-9 were increased in cases of preeclampsia.ConclusionThrough measurements of albumin, complement proteins, and cytokines in paired samples of blood and cerebrospinal fluid at the time of delivery, we found no evidence of blood-brain barrier impairment or neuroinflammation in preeclampsia. Larger studies that will investigate a wider range of proteins are suggested to validate our findings.
       
  • Validation of a new method to assess estimated blood loss in the obstetric
           population undergoing cesarean delivery
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Fawzi Saoud, Amanda Stone, Anna Nutter, Gary D. Hankins, George R. Saade, Antonio F. SaadBackgroundPostpartum hemorrhage is the leading cause of maternal mortality in developing countries and the primary cause of one-quarter of all maternal deaths globally. Inaccuracy in estimating blood loss obscures the diagnosis of postpartum hemorrhage and its management.ObjectiveOur objective was to compare assessment of blood loss using the quantitative Triton system (Gauss Surgical, Inc, Los Altos, CA) with other measures of blood loss in women undergoing cesarean delivery.Study DesignWomen scheduled for cesarean deliveries at our facility were included. Intraoperative blood loss was measured using the Triton, which was masked to the clinical team, as well as estimated by the surgeon (subjective estimated blood loss). The relation between the 2 methods (Triton and subjective estimated blood loss) and postoperative hemoglobin as well as delta hemoglobin (postoperative minus preoperative hemoglobin) was determined using the Spearman correlation. Triton measurement and subjective estimated blood loss were compared between women with delta hemoglobin in the upper quartile (cases) vs all other quartiles (control). Prediction of delta hemoglobin in the upper quartile also was evaluated for each method, and the area under the receiver operating characteristic curves was compared.ResultsThe trial enrolled 242 patients. The mean blood loss estimated by the Triton device was significantly lower than that estimated by clinical judgment (415.3±260.6 vs 799.6±215.6 mL, P
       
  • Point-of-care HIV viral load in pregnant women without prenatal care: a
           cost-effectiveness analysis
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Carmen M. Avram, Karen S. Greiner, Ellen Tilden, Aaron B. CaugheyBackgroundRoutine cesarean delivery has been shown to decrease mother-to-child-transmission of HIV in women with high viral load greater than 1000 copies/mL; however, women presenting late in pregnancy may not have viral load results before delivery.ObjectiveOur study investigated the costs and outcomes of using a point-of-care HIV RNA viral load test to guide delivery compared with routine cesarean delivery for all in the setting of unknown viral load.Study DesignA decision-analytic model was constructed using TreeAge software to compare HIV RNA viral load testing vs routine cesarean delivery for all in a theoretical cohort of 1275 HIV-positive women without prenatal care who presented at term for delivery, the estimated population of HIV-positive women without prenatal care in the United States annually. TreeAge Pro software is used to build decision trees modeling clinical problems and perform cost-effectiveness, sensitivity, and simulation analysis to identify the optimal outcome. The average cost per test was $15.22. To examine the downstream impact of a cesarean delivery and because most childbearing women in the United States will deliver 2 children, we incorporated a second pregnancy and delivery in the model. Primary outcomes were mother-to-child transmission, delivery mode, cesarean delivery–related complications, cost, and quality-adjusted life years. Model inputs were derived from the literature and varied in sensitivity analyses. The cost-effectiveness threshold was $100,000/quality-adjusted life year.ResultsMeasuring viral load resulted in more HIV-infected neonates than routine cesarean delivery for all due to viral exposure during more frequent vaginal births in this strategy. There were no observed maternal deaths or differences in cesarean delivery–related complications. Quantifying viral load increased cost by $3,883,371 and decreased quality-adjusted life years by 63 compared with routine cesarean delivery for all. With the threshold set at $100,000/quality-adjusted life year, the viral load test is cost-effective only when the vertical transmission rate in women with high viral load was below 0.68% (baseline: 16.8%) and when the odds ratio of vertical transmission with routine cesarean delivery for all compared with vaginal delivery was above 0.885 (baseline: 0.3).ConclusionsFor HIV-infected pregnant women without prenatal care, quantifying viral load to guide mode of delivery using a point-of-care test resulted in increased costs and decreased effectiveness when compared with routine cesarean delivery for all, even after including downstream complications of cesarean delivery.
       
  • Pharmacokinetics of vaginal progesterone in pregnancy
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Rupsa C. Boelig, Athena F. Zuppa, Walter K. Kraft, Steve CaritisBackgroundCharacterization of pharmacokinetics is lacking for vaginal progesterone in pregnancy. Dosing of vaginal progesterone for preterm birth prevention has been empirical. Owing to pregnancy-related changes in vaginal and uterine blood flow, hepatic metabolism, renal clearance, and endogenously elevated serum progesterone, studies outside of pregnancy may not be applicable. The lack of the pharmacokinetics profile of vaginally administered progesterone in pregnancy limits the ability to define the exposure–response relationship needed to optimize dosing, which has implications for its use in research and clinical care regarding management of short cervix, prevention of recurrent preterm birth, and prevention of recurrent miscarriage.ObjectiveThis was a study to establish the feasibility of using serum progesterone to establish basic pharmacokinetic parameters of vaginal progesterone in pregnancy for preterm birth prevention.Study DesignThis is a prospective study of 6 low-risk singletons at 18 0/7 to 23 6/7 weeks’ gestation with body mass index 20–40. Exclusion criteria were current vaginitis, abnormal Pap smear, prescription medication use, cervical length ≤25 mm, prior preterm birth, and contraindication to progesterone. Participants received a single dose of 200 mg micronized vaginal progesterone and serum progesterone levels were evaluated every 2 hours from 0 to 12 hours and then 24 hours post dose. Primary outcome was concentration/time profile of serum progesterone.ResultsMedian (range) maternal age was 27 (21.5–33.3) years, median body mass index was 26.5 (23.3–29.0) kg/m2, and median gestational age was 22.9 (21.0–23.4) weeks. Median baseline serum progesterone was 47 (40–52) ng/mL, median peak concentration was 54 (48–68) ng/mL, and median time to peak was 12 (4–15) hours. There was a trend in rising serum progesterone over baseline with a median change in peak concentration of 11 ng/mL and interquartile range of 2–22. Median percent change from baseline was an increase by 24% (interquartile range, 4%–53%). However, there was no clear elimination phase and the median area under the curve was 112 ng*h/mL with an interquartile range of -43 to 239.ConclusionUnlike in nonpregnant individuals, administration of vaginal progesterone in pregnant individuals only minimally impacts systemic exposure. There is a limited trend of rising serum progesterone over baseline levels, with significant inter-individual variability. Serum progesterone is unlikely to be a good candidate for establishing pharmacokinetics or dosing of vaginal progesterone in pregnancy for preterm birth prevention.
       
  • A comparison of vaginal versus buccal misoprostol for cervical ripening in
           women for labor induction at term (the IMPROVE trial): a triple-masked
           randomized controlled trial
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): David M. Haas, Joanne Daggy, Kathleen M. Flannery, Meredith L. Dorr, Carrie Bonsack, Surya S. Bhamidipalli, Rebecca C. Pierson, Anthony Lathrop, Rachel Towns, Nicole Ngo, Annette Head, Sarah Morgan, Sara K. QuinneyBackgroundCervical ripening is commonly needed for labor induction. Finding an optimal route of misoprostol dosing for efficacy, safety, and patient satisfaction is important and not well studied for the buccal route.ObjectiveTo compare the efficacy and safety of vaginal and buccal misoprostol for women undergoing labor induction at term.Study DesignThe IMPROVE trial was an institutional review board–approved, triple-masked, placebo-controlled randomized noninferiority trial for women undergoing labor induction at term with a Bishop score ≤6. Enrolled women received 25 mcg (first dose), then 50 mcg (subsequent doses) of misoprostol by assigned route (vaginal or buccal) and a matching placebo tablet by the opposite route. The primary outcomes were time to delivery and the rate of cesarean delivery performed urgently for fetal nonreassurance. A sample size of 300 was planned to test the noninferiority hypothesis.ResultsThe trial enrolled 319 women, with 300 available for analysis, 152 in the vaginal misoprostol group and 148 in the buccal. Groups had similar baseline characteristics. We were unable to demonstrate noninferiority. The time to vaginal delivery was lower for the vaginal misoprostol group (median [95% confidence interval] in hours: vaginal: 20.1 [18.2, 22.8] vs buccal: 28.1 [24.1, 31.4], log-rank test P = .006, Pnoninferiority = .663). The rate of cesarean deliveries for nonreassuring fetal status was 3.3% for the vaginal misoprostol group and 9.5% for the buccal misoprostol group (P = .033). The rate of vaginal delivery in
       
  • A pharmacokinetic assessment of optimal dosing, preparation, and
           chronotherapy of aspirin in pregnancy
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Renuka Shanmugalingam, XiaoSuo Wang, Gerald Münch, Ian Fulcher, Gaksoo Lee, Katrina Chau, Bei Xu, Roshika Kumar, Annemarie Hennessy, Angela MakrisBackgroundThe benefit of aspirin in preventing preeclampsia is well established; however, studies over the years have demonstrated variability in outcomes with its use. Potential contributing factors to this variation in efficacy include dosing, time of dosing, and preparation of aspirin.ObjectiveWe aimed to compare the difference in pharmacokinetics of aspirin, through its major active metabolite, salicylic acid, in pregnant women and nonpregnant women, and to examine the effect of dose (100 mg vs 150 mg), preparation (enteric coated vs non−enteric-coated), and chronotherapy of aspirin (morning vs evening) between the 2 groups.Materials and MethodsTwelve high-risk pregnant women and 3 nonpregnant women were enrolled in this study. Pregnant women were in 1 of 4 groups (100 mg enteric coated, 100 mg non−enteric-coated, 150 mg non−enteric-coated morning dosing, and 150 mg non−enteric-coated evening dosing), whereas nonpregnant women undertook each of the 4 dosing schedules with at least a 30-day washout period. Blood samples were collected at baseline (before ingestion) and at 1, 2, 4, 6, 12, and 24 hours after ingestion of aspirin. Plasma obtained was analyzed for salicylic acid levels by means of liquid chromatography−mass spectrometry. Pharmacokinetic values of area under the curve from time point 0 to 24 hours point of maximum concentration, time of maximum concentration, volume of distribution, clearance, and elimination half-life were analyzed for statistical significance with SPSS v25 software.ResultsPregnant women had a 40% ± 4% reduction in area under the curve from time point 0 to 24 hours (P < .01) and 29% ± 3% reduction in point of maximum concentration (P < .01) with a 44% ± 8% increase in clearance (P < .01) in comparison to that in nonpregnant women when 100 mg aspirin was administered. The reduction in the area under the curve from time point 0 to 24 hours, however, was minimized with the use of 150 mg aspirin in pregnant women, with which the area under the curve from time point 0 to 24 hours was closer to that achieved with the use of 100 mg aspirin in nonpregnant women. There was a 4-hour delay (P < .01) in the time of maximum concentration, a 47% ± 3% reduction in point of maximum concentration (P < .01) and a 48% ± 1% increase in volume of distribution (P < .01) with the use of 100 mg enteric-coated aspirin compared to non−enteric-coated aspirin, with no difference in the overall area under the curve. There was no difference in the pharmacokinetics of aspirin between morning and evening dosing.ConclusionThere is a reduction in the total drug metabolite concentration of aspirin in pregnancy, and therefore a dose adjustment is potentially required in pregnant women. This is likely due to the altered pharmacokinetics of aspirin in pregnancy, with an increase in clearance. There was no difference in the total drug metabolite concentration of aspirin between enteric-coated and non−enteric-coated aspirin and between morning and evening dosing of aspirin. Further pharmacodynamic and clinical studies are required to examine the clinical relevance of these pharmacokinetic findings.
       
  • Uterine and fetal placental Doppler indices are associated with maternal
           cardiovascular function: Reply
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Jasmine Tay, Christoph Lees
       
  • The effect of parity on longitudinal maternal hemodynamics
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Hua Zen Ling, Gavin P. Guy, Alessandra Bisquera, Liona C. Poon, Kypros H. Nicolaides, Nikos A. KametasBackgroundParous women have a lower risk for pregnancy complications, such as preeclampsia or delivery of small-for-gestational-age neonates. However, parous women are a heterogeneous group of patients because they contain a low-risk cohort with previously uncomplicated pregnancies and a high-risk cohort with previous pregnancies complicated by preeclampsia and/or small for gestational age. Previous studies examining the effect of parity on maternal hemodynamics, including cardiac output and peripheral vascular resistance, did not distinguish between parous women with and without a history of preeclampsia or small for gestational age and reported contradictory results.ObjectiveThe objective of the study was to compare maternal hemodynamics in nulliparous women and in parous women with and without previous preeclampsia and/or small for gestational age.Study DesignThis was a prospective, longitudinal study of maternal hemodynamics, assessed by a bioreactance method, measured at 11+0 to 13+6, 19+0 to 24+0, 30+0 to 34+0, and 35+0 to 37+0 weeks’ gestation in 3 groups of women. Group 1 was composed of parous women without a history of preeclampsia and/or small for gestational age (n = 632), group 2 was composed of nulliparous women (n = 829), and group 3 was composed of parous women with a history of preeclampsia and/or small for gestational age (n = 113). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal characteristics, medical history, and development of preeclampsia or small for gestational age in the current pregnancy.ResultsIn groups 1 and 2, cardiac output increased with gestational age to a peak at 32 weeks and peripheral vascular resistance showed a reversed pattern with its nadir at 32 weeks; in group 1, compared with group 2, there was better cardiac adaptation, reflected in higher cardiac output and lower peripheral vascular resistance. In group 3 there was a hyperdynamic profile of higher cardiac output and lower peripheral vascular resistance at the first trimester followed by an earlier sharp decline of cardiac output and increase of peripheral vascular resistance from midgestation. The incidence of preeclampsia and small for gestational age was highest in group 3 and lowest in group 1.ConclusionThere are parity-specific differences in maternal cardiac adaptation in pregnancy.
       
  • Clinical and molecular characterization of ovarian carcinoma displaying
           isolated lymph node relapse
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Robert L. Hollis, Juliet Carmichael, Alison M. Meynert, Michael Churchman, Amelia Hallas-Potts, Tzyvia Rye, Melanie MacKean, Fiona Nussey, Colin A. Semple, C. Simon Herrington, Charlie GourleyBackgroundDisease relapse is the primary cause of death from ovarian carcinoma. Isolated lymph node relapse is a rare pattern of ovarian carcinoma recurrence, with a reported median postrelapse survival of 2.5 to 4 years. To date, investigations have not compared isolated lymph node relapse ovarian carcinoma directly to a matched extranodal relapse cohort or performed molecular characterization of cases that subsequently experience isolated lymph node relapse.ObjectiveHere we seek to compare the clinical outcome, tumor-infiltrating lymphocyte burden, and frequency of known prognostic genomic events in isolated lymph node relapse ovarian carcinoma vs extranodal relapse ovarian carcinoma.Study DesignForty-nine isolated lymph node relapse ovarian carcinoma patients were identified and matched to 49 extranodal relapse cases using the Edinburgh Ovarian Cancer Database, from which the clinical data for identified patients were retrieved. Matching criteria were disease stage, histologic subtype and grade, extent of residual disease following surgical debulking, and age at diagnosis. Clinicopathologic factors and survival data were compared between the isolated lymph node relapse and extranodal relapse cohorts. Genomic characterization of tumor material from diagnosis was performed using panel-based high-throughput sequencing and tumor-infiltrating T cell burden was assessed using immunohistochemistry for CD3+ and CD8+ cells.ResultsIsolated lymph node relapse cases demonstrated significantly prolonged postrelapse survival and overall survival vs extranodal relapse upon multivariable analysis (HRmulti = 0.52 [0.33–0.84] and 0.51 [0.31–0.84]). Diagnostic specimens from high-grade serous ovarian carcinomas that subsequently displayed isolated lymph node relapse harbored significantly greater CD3+ and CD8+ cell infiltration compared to extranodal relapse cases (P = .001 and P = .009, Bonferroni-adjusted P = .003 and P = .019). Isolated lymph node relapse high-grade serous ovarian carcinoma cases did not show marked enrichment or depletion of cases with BRCA1/2 mutation or CCNE1 copy number gain when compared to their extranodal relapse counterparts (24.4% vs 19.4% and 18.2% vs 22.6%, P = .865 and P = .900).ConclusionIsolated lymph node relapse ovarian carcinoma represents a distinct clinical entity with favorable outcome compared to extranodal relapse. There was no clear enrichment or depletion of BRCA1/2 mutation or CCNE1 gain in the isolated lymph node relapse ovarian carcinoma cohort compared with extranodal relapse cases, suggesting that these known prognostic genomically defined subtypes of disease do not display markedly altered propensity for isolated lymph node relapse. Diagnostic tumor material from isolated lymph node relapse patients demonstrated greater CD3+ and CD8+ cell infiltration, indicating stronger tumor engagement by T cell populations, which may contribute to the more indolent disease course of isolated lymph node relapse.
       
  • Histologic correlation between smartphone and coloposcopic findings in
           patients with abnormal cervical cytology: experiences in a tertiary
           referral hospital
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Yusuke Tanaka, Yutaka Ueda, Reisa Kakubari, Mamoru Kakuda, Satoshi Kubota, Satoko Matsuzaki, Akiko Okazawa, Tomomi Egawa-Takata, Shinya Matsuzaki, Eiji Kobayashi, Tadashi KimuraBackgroundSmartphones recently have been applied in the medical setting. However, the literature evaluating the utility of smartphones in gynecologic oncology is limited.ObjectiveTo evaluate the utility of a smartphone in the detection of uterine cervical lesions in patients with abnormal cervical cytology.Study DesignSeventy-five women with abnormal cervical cytology were enrolled. Two doctors independently inspected the uterine cervix by using smartphone or colposcopy. Images were captured using acetic acid, and biopsies were taken as standard-of-care procedures. The diagnostic performance of the smartphone for cervical intraepithelial neoplasm 1 or worse and cervical intraepithelial neoplasm 2 or worse were evaluated, and the kappa value was calculated to determine the chance corrected agreement of the histologic diagnoses based on the smartphone and colposcopic findings.ResultsThere was a substantial agreement between histologic diagnoses based on the smartphone and colposcopic findings, with a kappa value of 0.67 (95% confidence interval, 0.43–0.90). The sensitivity, specificity, positive predictive value, and negative predictive value of the smartphone in the diagnosis of cervical intraepithelial neoplasm 1 or worse were 0.89 (95% confidence interval, 0.79–0.96), 0.33 (95% confidence interval, 0.08–0.70), 0.91 (95% confidence interval, 0.81-0.97), and 0.30 (95% confidence interval, 0.07–0.65), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of cervical intraepithelial neoplasm 2 or worse were 0.92 (95% confidence interval, 0.81–0.98), 0.24 (95% confidence interval, 0.09–0.45), 0.71 (95% confidence interval, 0.58–0.81), and 0.60 (95% confidence interval, 0.26–0.88), respectively.ConclusionWe found that there was a substantial agreement between the histologic diagnoses based on the smartphone and colposcopic findings. The smartphone seems to be useful and may be an alternative to colposcopy.
       
  • Pain and activity after vaginal reconstructive surgery for pelvic organ
           prolapse and stress urinary incontinence
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Matthew D. Barber, Linda Brubaker, Ingrid Nygaard, Clifford Y. Wai, Keisha Y. Dyer, David Ellington, Amaanti Sridhar, Marie G. Gantz, Kay Dickersin, Luohua Jiang, Missy Lavender, Kate O’Dell, Kate Ryan, Paul Tulikangas, Lan Kong, Donna McClish, Leslie Rickey, David Shade, Ashok Tuteja, Susan YountBackgroundLittle is known about short- and long-term pain and functional activity after surgery for pelvic organ prolapse.ObjectiveThe objectives of the study were to describe postoperative pain and functional activity after transvaginal native tissue reconstructive surgery with apical suspension and retropubic synthetic midurethral sling and to compare these outcomes between patients receiving 2 common transvaginal prolapse repairs, uterosacral ligament, and sacrospinous ligament vaginal vault suspension.Study DesignThis planned secondary analysis of a 2 × 2 factorial randomized trial included 374 women randomized to receive uterosacral (n = 188) or sacrospinous (n = 186) vaginal vault suspension to treat both stages 2–4 apical vaginal prolapse and stress urinary incontinence between 2008 and 2013 at 9 medical centers. Participants were also randomized to receive perioperative pelvic muscle therapy or usual care. All patients received transvaginal native tissue repairs and a midurethral sling. Participants completed the Surgical Pain Scales (0–10 numeric rating scales; higher scores = greater pain) and Activity Assessment Scale (0–100; higher score = higher activity) prior to surgery and at 2 weeks, 4–6 weeks, and 3 months postoperatively. The MOS 36-item Short-Form Health Survey was completed at baseline and 6, 12, and 24 months after surgery; the bodily pain, physical functioning, and role–physical subscales were used for this analysis (higher scores = less disability). Self-reported pain medication use was also collected.RESULTSBefore surgery, average pain at rest and during normal activity were (adjusted mean ± SE) 2.24 ± 0.23 and 2.76 ± 0.25; both increased slightly from baseline at 2 weeks (+0.65, P = .004, and +0.74, P = .007, respectively) and then decreased below baseline at 3 months (–0.87 and –1.14, respectively, P < .001), with no differences between surgical groups. Pain during exercise/strenuous activity and worst pain decreased below baseline levels at 4–6 weeks (–1.26, P = .014, and –0.95, P = .002) and 3 months (–1.97 and –1.50, P < .001) without differences between surgical groups. Functional activity as measured by the Activity Assessment Scale improved from baseline at 4–6 weeks (+9.24, P < .001) and 3 months (+13.79, P < .001). The MOS 36-item Short-Form Health Survey Bodily Pain, Physical Functioning, and Role–Physical Scales demonstrated significant improvements from baseline at 6, 12, and 24 months (24 months: +5.62, +5.79, and +4.72, respectively, P < .001 for each) with no differences between groups. Use of narcotic pain medications was reported by 14.3% of participants prior to surgery and 53.7% at 2 and 26.1% at 4–6 weeks postoperatively; thereafter use was similar to baseline rates until 24 months when it decreased to 6.8%. Use of nonnarcotic pain medication was reported by 48.1% of participants prior to surgery, 68.7% at 2 weeks, and similar to baseline at 3 months; thereafter use dropped steadily to 26.6% at 2 years. Uterosacral ligament suspension resulted in less new or worsening buttock pain than sacrospinous suspension at 4–6 weeks postoperatively (4.6% vs 10.5%, P = .043) but no difference in groin or thigh pain.ConclusionPain and functional activity improve for up to 2 years after native tissue reconstructive surgery with uterosacral or sacrospinous vaginal vault suspension and midurethral sling for stages 2–4 pelvic organ prolapse. On average, immediate postoperative pain is low and improves to below baseline levels by 4–6 weeks.
       
  • The two Achilles heels of surgical randomized controlled trials:
           differences in surgical skills and reporting of average performance
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Farr R. Nezhat, Cande V. Ananth, Anthony M. VintzileosRandomized controlled trials of surgery are fundamentally different from randomized controlled trials of medications because it is difficult to blind or mask a surgical procedure or perform “sham” operations. An additional challenge is the variation in skills and surgical proficiency of participating centers and surgeons. Addressing heterogeneity in surgical proficiency remains of paramount importance, especially when randomized controlled trials involve a new or complex procedure such as minimally invasive radical surgery. In the presence of such heterogeneity, it is very cumbersome to evaluate objectively and monitor surgical skills so that most trials simply report associations that are averaged across surgeons and hospitals/centers. Such reporting is not transparent because the rates of complications and adverse outcomes are reported only as averages, and these averages may not apply to the individual participating surgeons or centers. These factors, coupled with the inherent nongeneralizability of findings from such randomized controlled trials, because of the strict inclusion and exclusion criteria for enrollment, may lead to conclusions that no longer apply to real life for individual surgeons or centers. Case in point is a recently published noninferiority randomized controlled trial that reported that minimally invasive radical hysterectomy was associated with lower rates of disease-free survival (86% vs 96.5% at 4.5 years) and overall survival (93.8% vs 99% at 3 years) than open abdominal radical hysterectomy in patients with cervical cancer. However, randomized controlled trials that involve 2 competing complex or new procedures may be affected by tremendous confounding because of variations in surgical proficiency and also nonstandardization for other confounding factors such as patient selection categories (ie, stage of cancer) and adjuvant postoperative therapies that may affect long-term survival. The purpose of this Viewpoint is not to provide an exhaustive review of the trial's shortcomings but to use it as an illustration to focus on 2 challenging areas that most randomized controlled trials of a new complex surgical procedure suffer from: (1) unadjusting or not correcting for surgical skill variability and (2) nontransparent reporting of averaged results. We provide suggestions to overcome these deficiencies through robust methods and statistical approaches.
       
  • The continuing burden of Rh disease 50 years after the introduction of
           anti-Rh(D) immunoglobin prophylaxis: call to action
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Gerard H.A. Visser, Gian Carlo Di Renzo, Steven L. Spitalnik, Gerard H.A. Visser, Gian Carlo Di Renzo, Diogo Ayres-de-Campos, Maria Fernanda Escobar, Eytan Barnea, P.K. Shah, Anwar Nasser, Luc de Bernis, Luming Sun, Wanda Kay Nicholson, Isabel Lloyd, Salimah Walani, Gerhard Theron, William StonesSevere morbidity and death because of Rh disease have only been reduced by approximately 50% globally during the last 50 years, despite the advent of anti-Rh(D) immunoglobin prophylaxis, which has resulted in>160,000 perinatal deaths and 100,000 disabilities annually. This apparent failure to take appropriate preventive measures is of great concern. Thus, there is a great need to do much better. We wish to draw attention to the unnecessary continuing burden of Rh disease, to discuss some of the reasons for this failure, and to provide suggestions for a better way forward.
       
  • Preeclampsia: the role of persistent endothelial cells in uteroplacental
           arteries
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Ivo Brosens, Jan J. Brosens, Joanne Muter, Patrick Puttemans, Giuseppe BenagianoWe explore the potential role of the endothelial lining of uteroplacental arteries in the pathogenesis of preeclampsia, a severe pregnancy disorder characterized by incomplete invasion of the uterine vasculature by extravillous trophoblast and angiogenic imbalance. In normal pregnancy, the endothelium disappears progressively from the uteroplacental arteries and is replaced by trophoblast and deposition of fibrofibrinoid structure, underpinning the so-called physiological transformation of uterine spiral arteries. We hypothesize that partial persistence of the endothelium, albeit injured, initiates a chain of events leading to the emergence of preeclampsia in 3 sequential stages. The first stage results in retention of the endothelium in uteroplacental arteries secondary to incomplete physiological transformation of the vessels. Consequently, the uteroplacental vessels are reactive to pathological cues, which drives local arteriopathy. The second stage starts with progressive reduction in uteroplacental blood flow, generating oxidative stress in the whole placenta, and heightened maternal inflammation in response to circulating trophoblastic debris. In the third stage, generalized endotheliosis causes systemic angiogenic imbalance, hypertension, and other clinical manifestation of preeclampsia.
       
  • Learning from experience: cellular and molecular bases for improved
           outcome in subsequent pregnancies
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Debra Goldman-Wohl, Moriya Gamliel, Ofer Mandelboim, Simcha YagelThe frequencies of preeclampsia, fetal growth restriction, fetal demise, and low birthweight are lower in subsequent pregnancies. Enhanced maternal cardiovascular adaptation, shorter first and second stages of labor, and more robust lactation also have been observed in subsequent as compared with first pregnancies. We sought to investigate the cellular and molecular bases for better outcomes in subsequent pregnancies. Based on the knowledge that specialized immune cells at the maternal–fetal interface, decidual natural killer cells, promote development of the placental bed and conversion of the spiral arteries by secreting a myriad of angiogenic and growth factors, we asked whether decidual natural killer cells differ in subsequent as compared with first pregnancies. This idea stemmed from recent studies suggesting that natural killer cells, although part of the innate immune system, possess some features of adaptive immunity, including a certain type of immune cell memory, termed trained immunity. We found that decidual natural killer cells from parous women “remember pregnancy” and differ from decidual natural killer cells of primigravidae. Compared with the decidual natural killer cells of first pregnancy, these cells, that we termed pregnancy-trained decidual natural killer cells, express greater levels of the natural killer receptors NKG2C and leukocyte immunoglobulin-like receptor B1, which interact with ligands expressed on invasive trophoblasts. Furthermore, they secrete greater levels of several growth factors, including vascular endothelial growth factor α as well as interferon-γ, augmenting remodeling of the placental bed. We propose that this pregnancy-trained memory dwells in the epigenome, where memory of stimuli is known to persist even when the stimulus is no longer present. This epigenetic memory apparently resides in endometrial natural killer cells between pregnancies. We suggest that this trained memory, which we coined pregnancy-trained decidual natural killer cells, may be the missing link in the immune basis for enhanced subsequent pregnancy. Epigenetic memory (chromatin modification) also may afford a global explanation for additional findings of enhanced maternal cardiovascular adaptation, shorter first and second stages of labor, and more robust lactation. Understanding the molecular and cellular bases of improved outcomes of subsequent pregnancy may lead to the development of treatment modalities designed for women at high risk for pregnancy disorders originating at the maternal–fetal interface.
       
  • Importance of research in reducing maternal morbidity and mortality rates
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Nahida Chakhtoura, Juanita J. Chinn, Katherine L. Grantz, Esther Eisenberg, Shavon Artis Dickerson, Charisee Lamar, Diana W. Bianchi
       
  • Prolapse, pain, and pelvic floor muscle dysfunction
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Catherine S. Bradley
       
  • AJOG opens editorial office in China: Professor Huixia Yang
           appointed Editor
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Roberto Romero
       
  • Information for Readers
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s):
       
  • AJOG MFM TOC Page
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s):
       
  • Revitalizing research in genitourinary syndrome of menopause
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Martha F. Goetsch
       
  • Reply
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Olivia H. Chang, Marie Fidela R. Paraiso
       
  • Uterine and fetal placental Doppler indices are associated with maternal
           cardiovascular function
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Simcha Yagel
       
  • Reply
    • Abstract: Publication date: September 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 3Author(s): Lauren A. Cadish, Beri M. Ridgeway, Jonathan P. Shepherd
       
  • Primary Ovarian Insufficiency and Human Papilloma Virus Vaccines: A Review
           of the Current Evidence
    • Abstract: Publication date: Available online 31 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Mindy S. Christianson, Patricia Wodi, Kawsar Talaat, Neal Halsey Human papilloma virus is the primary causative agent for cervical cancer, and vaccination is the primary means of preventing anogenital cancers caused by human papilloma virus infection. Despite the availability of human papilloma virus vaccines for over a decade, coverage rates lag behind the other vaccines. Public concerns regarding safety of human papilloma virus vaccines have been identified as an important barrier to vaccination, including concerns that the human papilloma virus vaccine causes primary ovarian insufficiency, driven in part by isolated reports of ovarian failure following the human papilloma virus vaccine. We summarize published peer-reviewed literature on human papilloma virus vaccines and primary ovarian insufficiency reviewing information contained in the case reports and series. Health care providers should address any patient concerns about primary ovarian insufficiency and the human papilloma virus vaccine by acknowledging the case reports but noting the lack of association found in a recently published epidemiologic study of approximately 60,000 females. Current evidence is insufficient to suggest or support a causal relationship between human papilloma virus vaccination and primary ovarian insufficiency.
       
  • Incomplete Excision of Cervical Intraepithelial Neoplasia as a Predictor
           of the Risk of Recurrent Disease – a 16 Year Follow-Up Study
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Susanna Alder, David Megyessi, Karin Sundström, Ellinor Östensson, Miriam Mints, Karen Belkić, Marc Arbyn, Sonia Andersson BackgroundWomen treated for high-grade cervical intraepithelial neoplasia (CIN, grade 2 or 3) are at elevated risk of developing cervical cancer. Suggested factors identifying women at highest risk for recurrence post-therapeutically include incomplete lesion excision, lesion location, size and severity, older age, treatment modality and presence of high-risk human papilloma virus (hrHPV) after treatment. This question has been intensively investigated over decades, but there is still substantial debate as to which of these factors or combination of factors most accurately predict treatment failure.ObjectivesIn this study, we examine the long-term risk of residual/recurrent CIN2+ among women previously treated for CIN2 or 3 and how this varies according to margin status (considering also location), as well as comorbidity (conditions assumed to interact with hrHPV acquisition and/or CIN progression), post-treatment presence of hrHPV and other factors.Study DesignThis prospective study included 991 women with histopathologically-confirmed CIN2/3 who underwent conization in 2000-2007. Information on the primary histopathologic finding, treatment modality, comorbidity, age and hrHPV status during follow-up and residual/recurrent CIN2+ was obtained from the Swedish National Cervical Screening Registry and medical records. Cumulative incidence of residual/recurrent CIN2+ was plotted on Kaplan–Meier curves, with determinants assessed by Cox regression.ResultsDuring a median of 10 years and maximum of 16 years follow-up, 111 patients were diagnosed with residual/recurrent CIN2+. Women with positive/uncertain margins had a higher risk of residual/recurrent CIN2+ than women with negative margins, adjusting for potential confounders (hazard ratio (HR)=2.67; 95% confidence interval (CI): 1.81–3.93). The risk of residual/recurrent CIN2+ varied by anatomical localization of the margins (endocervical: HR=2.72; 95%CI: 1.67–4.41) and both endo- and ectocervical (HR=4.98; 95%CI: 2.85-8.71). The risk did not increase significantly when only ectocervical margins were positive/uncertain. The presence of comorbidity (autoimmune disease, human immunodeficiency viral infection, hepatitis B and/or C, malignancy, diabetes, genetic disorder and/or organ transplant) was also a significant independent predictor of residual/recurrent CIN2+. In women with positive hrHPV findings during follow-up, the HR of positive/uncertain margins for recurrent/residual CIN2+ increased significantly compared to women with hrHPV positive findings but negative margins.ConclusionsPatients with incompletely excised CIN2/3 are at increased risk of residual/recurrent CIN2+. Margin status combined with hrHPV results and consideration of comorbidity may increase the accuracy for predicting treatment failure.
       
  • Cerebroplacental ratio and estimated fetal weight, the two different
           yardsticks
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): José Morales-Roselló, Gabriela Loscalzo, Silvia Buongiorno, Alfredo Perales-Marín
       
  • Management of Genitourinary Syndrome of Menopause in Female Cancer
           Patients: A Focus on Vaginal Hormonal Therapy
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Katie K. Crean-Tate, Stephanie S. Faubion, Holly J. Pederson, Jennifer A. Vencill, Pelin Batur Genitourinary syndrome of menopause is a condition describing the hypoestrogenic effects on the female genitals and lower urinary tract leading to symptoms such as vaginal dryness, vulvar and vaginal burning, dyspareunia and dysuria. Genitourinary syndrome of menopause is experienced by over half of postmenopausal women, and is even more pervasive in women with cancer. Due to treatments such as surgery, chemotherapy, radiation, and hormonal therapy, women may experience early menopause resulting in earlier and more severe symptoms. Understanding the scope of this issue in female breast and gynecologic cancer survivors and identifying treatment options for this complex patient population are paramount. Tailored patient treatments include nonhormonal therapies (vaginal moisturizers, lubricants, pelvic floor physical therapy, dilator therapy, counseling), systemic and local hormonal therapies. Consensus recommendations by medical societies and associated evidence are reviewed, with emphasis on safety and efficacy of local vaginal hormonal therapies, and management variations noted depending on cancer type and characteristics. With knowledge and understanding of the unmet need associated with under-recognition and under-treatment of genitourinary syndrome of menopause, providers caring for women with cancer are in a position to improve the quality of life of their patients by providing safe and effective treatments.
       
  • Reply: Letter to the Editors Hysterectomy and the Risk of Osteoporosis
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Hyo Geun Choi, Suk Woo Lee
       
  • Hysterectomy and the risk of osteoporosis
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Abraham N. Morse
       
  • REPLY TO: THE LETTER TO THE EDITOR BY ROBLEDO ET AL (Generalizability from
           well-designed RCT’s underpin their scientific strength)
    • Abstract: Publication date: Available online 28 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Farr R. Nezhat, Cande V. Ananth, Anthony M. Vintzileos
       
  • Generalizability from well-designed RCT's underpin their scientific
           strength
    • Abstract: Publication date: Available online 28 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Kristy P. Robledo, Pedro Ramirez, Val Gebski
       
  • Reply to the clinical utility of noninvasive prenatal screening for
           pathogenic copy number variants
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Matthew Hoi Kin Chau, Daljit Singh Sahota, Kwong Wai Choy
       
  • Recurrent erythema before menses: autoimmune progesterone dermatitis
           caused by hypersensitivity to progesterone
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Yuan Chang, Mingyue Wang
       
  • Re: Unexpected term NICU admissions: a marker of obstetrical care
           quality'
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Jonathan M. Snowden, Suzan L. Carmichael, Mark A. Klebanoff
       
  • Oophoropexy for recurrent adnexal torsion complicated by utero-ovarian
           ligament rupture
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Boughizane Sassi, Bannour Badra, Bannour Imen
       
  • Clinical utility of noninvasive prenatal screening for pathogenic copy
           number variants
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Li-Li Xu, Dong-Zhi Li
       
  • Specific birth defects in pregnancies of women with diabetes – National
           Birth Defects Prevention Study, 1997-2011
    • Abstract: Publication date: Available online 24 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Sarah C. Tinker, Suzanne M. Gilboa, Cynthia A. Moore, D. Kim Waller, Regina M. Simeone, Shin Y. Kim, Denise J. Jamieson, Lorenzo D. Botto, Jennita Reefhuis, National Birth Defects Prevention Study BackgroundDiabetes is associated with an increased risk for many birth defects and is likely to have an increasing impact on birth defect prevalence due to the rise in diabetes in the United States in recent decades. One of the first analyses in which specific birth defects were assessed for their relationship with both pregestational and gestational diabetes used data from the initial six years of the National Birth Defects Prevention Study. That analysis reported strong associations for pregestational diabetes with several birth defects, but few exposures among some of the less common birth defects led to unstable estimates with wide confidence intervals. Since that analysis, the study continued to collect data for another eight years, including information on approximately 19,000 additional cases and 6,900 additional controls.ObjectivesOur objective was to use data from the National Birth Defects Prevention Study, the largest population-based birth defects case-control study in the United States, to provide updated and more precise estimates of the association between diabetes and birth defects, including some defects not previously assessed.Study DesignWe analyzed data on deliveries from October 1997 through December 2011. Mothers of case and control infants were interviewed about their health conditions and exposures during pregnancy, including diagnosis of pregestational (type 1 or type 2) diabetes before the index pregnancy or gestational diabetes during the index pregnancy. Using logistic regression, we separately assessed the association between pregestational and gestational diabetes with specific categories of structural birth defects for which there were at least three exposed case infants. For birth defect categories for which there were at least five exposed case infants, we calculated odds ratios adjusted for maternal body mass index, age, education, race/ethnicity, and study site; for defect categories with three or four exposed cases we calculated crude odds ratios.ResultsPregestational diabetes was reported by 0.6 percent of mothers of control infants (71 / 11,447) and 2.5 percent of mothers of case infants (775 / 31,007). Gestational diabetes during the index pregnancy was reported by 4.7 percent of mothers of control infants (536 / 11,447) and 5.3 percent of mothers of case infants (1,653 / 31,007). Pregestational diabetes was associated with strong, statistically significant odds ratios (range: 2.5 to 80.2) for 46 of 50 birth defects considered. The largest odds ratio was observed for sacral agenesis (adjusted OR [aOR]: 80.2; 95% CI: 46.1, 139.3). A greater than 10-fold increased risk was also observed for holoprosencephaly (aOR: 13.1; 95% CI: 7.0, 24.5), longitudinal limb deficiency (aOR: 10.1; 95% CI: 6.2, 16.5), heterotaxy (aOR: 12.3; 95% CI: 7.3, 20.5), truncus arteriosus (aOR: 14.9; 95% CI: 7.6, 29.3), atrioventricular septal defect (aOR: 10.5; 95% CI: 6.2, 17.9), and single ventricle complex (aOR: 14.7; 95% CI: 8.9, 24.3).For gestational diabetes, statistically significant odds ratios were fewer (12 of 56) and of smaller magnitude (range: 1.3 to 2.1; 0.5 for gastroschisis).ConclusionsPregestational diabetes is associated with markedly increased risk for many specific births defects. Because glycemic control before pregnancy is associated with a reduced risk for birth defects, ongoing quality care for persons with diabetes is an important opportunity for prevention.
       
  • Intrauterine growth discordance across gestation and birthweight
           discordance in dichorionic twins
    • Abstract: Publication date: Available online 24 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Melissa M. Amyx, Paul S. Albert, Alaina M. Bever, Stefanie N. Hinkle, John Owen, William A. Grobman, Roger B. Newman, Edward K. Chien, Robert E. Gore-Langton, Germaine M. Buck Louis, Katherine L. Grantz BackgroundThough inter-twin size difference is an important measure of fetal growth, the appropriate cut-point to define discordance is unclear. Few studies have assessed inter-twin differences in estimated fetal weight longitudinally or in relation to size differences at birth.ObjectivesTo estimate the magnitude of percent differences in estimated fetal weight across gestation in dichorionic twins in relation to a fixed discordance cut-point and compare classification of aberrant fetal growth by different measures (estimated fetal weight differences, birthweight discordance, small for gestational age).Study DesignWomen age 18-45 years from 8 US centers with dichorionic twin pregnancies at 8 weeks 0 days (8w0d)-13w-6d gestation planning to deliver in participating hospitals were recruited into the NICHD Fetal Growth Studies--Dichorionic Twins study and followed through delivery (n=140; 2012-2013). Ultrasounds were conducted at 6 targeted study visits to obtain fetal biometrics and calculate estimated fetal weight. Percent estimated fetal weight and birthweight differences were calculated: ([Weightlarger-Weightsmaller]/Weightlarger)*100; discordance was defined as ≥18% for illustration. Birth sizes for gestational age (both, one, or neither small for gestational age) were determined; twins were categorized into combined birthweight+small for gestational age groups: birthweight discordance ≥18% (yes, no) with both, one, or neither small for gestational age. Linear mixed models estimated percentiles of estimated fetal weight percent differences across gestation and compared estimated fetal weight differences between combined birthweight discordance and small for gestational age groups. Fishers’ exact test compared birthweight discordance and small for gestational age classifications.ResultsMedian estimated fetal weight percent difference increased across gestation (5.9% at 15.0, 8.4% at 38.0 weeks), with greater disparities at higher percentiles (e.g., 90th percentile: 15.6% at 15.0, 26.3% at 38.0 weeks). As gestation advanced, an increasing percentage of pregnancies were classified as discordant using a fixed cut-point: 10% at 27.0, 15% at 34.0, and 20% at 38.0 weeks. Birthweight discordance and small for gestational age classifications differed (P=0.002); for birthweight discordance ≥18% versus < 18%: 44% versus 71% had neither small for gestational age; 56% versus 18% had one small for gestational age; no cases (0%) versus 11% had both small for gestational age, respectively. Estimated fetal weight percent difference varied across gestation by birthweight discordance+small for gestational age classification (P=0.040). Estimated fetal weight percent difference increased with birthweight discordance ≥18% (neither small for gestational age: 0.46%/week [95%CI 0.08, 0.84]; one small for gestational age: 0.57%/week [95%CI 0.25, 0.90]), but less so without birthweight discordance (neither small for gestational age: 0.17%/week [95%CI 0.06, 0.28]; one small for gestational age: 0.03%/week [95%CI -0.17, 0.24]); both small for gestational age: 0.10%/week [95%CI -0.15, 0.36]).ConclusionThe percentage of dichorionic pregnancies exceeding a fixed discordance cut-point increased over gestation. A fixed cut-point for defining twin discordance would identify an increasing percentage of twins as discordant as gestation advances. Small for gestational age and percent weight differences assess distinct aspects of dichorionic twin growth. A percentile cut-point may be more clinically useful for defining discordance, although further study is required to assess whether any specific percentile cut-point correlates to adverse outcomes.
       
  • Association between Adjuvant Posterior Repair and Success of Native Tissue
           Apical Suspension
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Gary Sutkin, Halina M. Zyczynski, Amaanti Sridhar, J. Eric Jelovsek, Charles R. Rardin, Donna Mazloomdoost, David D. Rahn, John N. Nguyen, Uduak U. Andy, Isuzu Meyer, Marie G. Gantz, NICHD Pelvic Floor Disorders Network BackgroundPosterior repairs and perineorrhaphies are often performed in prolapse surgery to reduce the size of the genital hiatus. The benefit of an adjuvant posterior repair at the time of sacrospinous ligament fixation or uterosacral ligament suspension is unknown.ObjectiveWe aimed to determine if an adjuvant posterior repair at transvaginal apical suspension is associated with improved surgical success.Study DesignThis secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss [OPTIMAL] trial compared 24-month outcomes in 190 participants who had a posterior repair (posterior repair group) and 184 who did not (No posterior repair) at the time of SSLF or USLS. Concomitant posterior repair was performed at surgeon’s discretion. Primary composite outcome of ‘surgical success’ was defined as no prolapse beyond the hymen, point C ≤ -2/3TVL, no bothersome bulge symptoms, and no retreatment at 24 months. The individual components were secondary outcomes. Propensity score methods were employed to build models that balanced posterior repair and No posterior repair groups for ethnographic factors and preoperative Pelvic Organ Prolapse Quantification (POPQ) values. Adjusted ORs were calculated to predict surgical success based on the performance of a posterior repair. Groups were also compared with unadjusted Chi Square analyses. An unadjusted probability curve was created for surgical success as predicted by preoperative genital hiatus (GH).ResultsWomen in the posterior repair group were less likely to be Hispanic or Latino, were more likely to have had a prior hysterectomy and be on estrogen therapy. The groups did not differ with respect to pre-operative POPQ stage; however, subjects in the posterior repair group had significantly greater preoperative posterior wall prolapse. There were no group differences in surgical success using PS methods (66.7% posterior repair vs 62.0% no posterior repair, aOR 1.07 (0.56, 2.07), p: 0.83) or unadjusted test (66.2% posterior repair vs. 61.7% No posterior repair, p: 0.47). Individual outcome measures of prolapse recurrence (bothersome bulge symptoms, prolapse beyond the hymen or retreatment for prolapse) also did not differ by group. Similarly, there were no differences between groups in anatomic outcomes of any individual compartment (anterior, apical, or posterior) at 24 months. There was high variation in performance of posterior repair by surgeon [IQR 15%-79%]. The unadjusted probability of overall success at 24 months, regardless of posterior repair, decreased with increasing GH such that a GH of 4.5 cm was associated with 65.8% success (95% CI: 60.1%, 71.1%).ConclusionConcomitant posterior repair at sacrospinous ligament fixation or uterosacral ligament suspension was not associated with surgical success after adjusting for baseline covariates using propensity scores or unadjusted comparison. Posterior repair may not compensate for the pathophysiology that lead to enlarged pre-operative GH which remains prognostic of prolapse recurrence.
       
  • May 2019 (vol. 220, no. 5, page 504)
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s):
       
  • The natural history of urinary incontinence subtypes in the Nurses’
           Health Studies
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Vatche A. Minassian, Kaitlin A. Hagan, Elisabeth Erekson, Andrea M. Austin, Donald Carmichael, Julie PW. Bynum, Francine Grodstein BackgroundUrinary incontinence (UI) subtypes often differ by symptom severity and treatment profiles; in particular, mixed UI is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence (UI) subtypes, which could help better identify and treat patients prior to development of more intractable disease.ObjectiveTo evaluate the onset of UI subtypes, and transitions between subtypes over 8 years, using two large cohorts of middle-age and older women with incident UI.Study DesignWe identified 10,349 women with incident UI (stress, urgency, and mixed subtypes), from the Nurses’ Health Study and Nurses’ Health Study II, age 41-83 years, using repeated mailed questionnaires. We defined stress UI as leakage with coughing, sneezing, or activity; urgency UI as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed UI when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of UI subtypes 4 years and 8 years after UI onset, we used multivariable-adjusted generalized estimated equations with a multinomial outcome.ResultsAt UI onset in 2004-5, 56% of women reported stress UI symptoms, 23% reported urgency UI symptoms, and 21% reported mixed UI symptoms. Women with stress UI or urgency UI at onset were likely to report the same UI type 4 and 8 years later (Stress UI at onset: 70% and 60% reported stress UI at years 4 and 8, respectively; Urgency UI at onset: 68% and 64% reported urgency UI at years 4 and 8, respectively). Nonetheless, for both stress and urgency UI, women with more severe symptoms at onset were more likely to progress to mixed UI. Women with mixed UI at onset had more variation over time, although the largest subset continued to report mixed UI (45% reported mixed UI at year 4, 43% reported mixed UI at year 8). Few women across all UI subtypes reported resolution of symptoms over 4 to 8 years of follow-up (4-12%).When considering the likelihood of remaining with or progressing to mixed UI over follow-up, according to age, body mass index and UI severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed UI (e.g., women
       
  • The Society for Maternal-Fetal Medicine (SMFM) Fetal Anomalies Consult
           Series
    • Abstract: Publication date: Available online 21 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Society for Maternal-Fetal Medicine
       
  • Hypertelorism
    • Abstract: Publication date: Available online 21 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Beryl R. Benacerraf, Bryann S. Bromley, Angie C. Jelin
       
  • Micrognathia
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Beryl R. Benacerraf, Bryann S. Bromley, Angie C. Jelin
       
  • Paramedian Oro-Facial Cleft
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): SMFM Publications Committee
       
  • Median Facial Cleft
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): SMFM Publications Committee
       
  • Anophthalmia and Microphthalmia
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Beryl R. Benacerraf, Bryann S. Bromley, Angie C. Jelin
       
  • SMFM Fetal Anomalies Consult Series #1: Facial Anomalies
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Society for Maternal-Fetal Medicine (SMFM), Beryl R. Benacerraf, Bryann S. Bromley, Angie C. Jelin
       
  • Absent Nasal Bone
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Beryl R. Benacerraf, Bryann S. Bromley, Angie C. Jelin
       
  • Hypotelorism
    • Abstract: Publication date: Available online 20 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): SMFM Publications Committee
       
  • October 2011 (vol. 205, no. 4, pages 362.e4-.e6)
    • Abstract: Publication date: Available online 19 August 2019Source: American Journal of Obstetrics and GynecologyAuthor(s):
       
 
 
JournalTOCs
School of Mathematical and Computer Sciences
Heriot-Watt University
Edinburgh, EH14 4AS, UK
Email: journaltocs@hw.ac.uk
Tel: +00 44 (0)131 4513762
Fax: +00 44 (0)131 4513327
 
Home (Search)
Subjects A-Z
Publishers A-Z
Customise
APIs
Your IP address: 18.206.48.142
 
About JournalTOCs
API
Help
News (blog, publications)
JournalTOCs on Twitter   JournalTOCs on Facebook

JournalTOCs © 2009-