Journal Cover American Journal of Obstetrics and Gynecology
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   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9378
   Published by Elsevier Homepage  [3120 journals]
  • Fetal size standards to diagnose a small- or
           a large-for-gestational-age fetus
    • Authors: Roberto Romero; Adi L. Tarca
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Roberto Romero, Adi L. Tarca


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.217
       
  • 01: Minimally invasive sacrocolpopexy versus vaginal uterosacral ligament
           suspension: Comparing anatomic outcomes at 1 year
    • Authors: N. Noor; D. Bastawros; C.U. Eto; S. Iyer; M.E. Florian-Rodriguez; E. Lavelle; S. Lozo; M. Haviland; E.C. Von Bargen; D. Antosh
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): N. Noor, D. Bastawros, C.U. Eto, S. Iyer, M.E. Florian-Rodriguez, E. Lavelle, S. Lozo, M. Haviland, E.C. Von Bargen, D. Antosh


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.185
       
  • Fetal Growth: Evaluation and Management
    • Authors: Roberto Romero; John Kingdom; Russell Deter; Wesley Lee; Anthony Vintzileos
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Roberto Romero, John Kingdom, Russell Deter, Wesley Lee, Anthony Vintzileos


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.010
       
  • 02: Enhanced recovery after surgery (ERAS) implementation in an
           urogynecology population
    • Authors: C.M. Carter-Brooks; A.L. Du; A. Romanova; H. Zyczynski
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): C.M. Carter-Brooks, A.L. Du, A. Romanova, H. Zyczynski


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.186
       
  • Customized growth charts: rationale, validation and clinical benefits
    • Authors: Jason Gardosi; Andre Francis; Sue Turner; Mandy Williams
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Jason Gardosi, Andre Francis, Sue Turner, Mandy Williams
      Appropriate standards for the assessment of fetal growth and birthweight are central to good clinical care, and have become even more important with increasing evidence that growth-related adverse outcomes are potentially avoidable. Standards need to be evidence based and validated against pregnancy outcome and able to demonstrate utility and effectiveness. A review of proposals by the Intergrowth consortium to adopt their single international standard finds little support for the claim that the cases that it identifies as small are due to malnutrition or stunting, and substantial evidence that there is normal physiologic variation between different countries and ethnic groups. It is possible that the one-size-fits-all standard ends up fitting no one and could be harmful if implemented. An alternative is the concept of country-specific charts that can improve the association between abnormal growth and adverse outcome. However, such standards ignore individual physiologic variation that affects fetal growth, which exists in any heterogeneous population and exceeds intercountry differences. It is therefore more logical to adjust for the characteristics of each mother, taking her ethnic origin and her height, weight, and parity into account, and to set a growth and birthweight standard for each pregnancy against which actual growth can be assessed. A customized standard better reflects adverse pregnancy outcome at both ends of the fetal size spectrum and has increased clinicians’ confidence in growth assessment, while providing reassurance when abnormal size merely represents physiologic variation. Rollout in the United Kingdom has proceeded as part of the comprehensive Growth Assessment Protocol (GAP), and has resulted in a steady increase in antenatal detection of babies who are at risk because of fetal growth restriction. This in turn has been accompanied by a year-on-year drop in stillbirth rates to their lowest ever levels in England. A global version of customized growth charts with over 100 ethnic origin categories is being launched in 2018, and will provide an individualized, yet universally applicable, standard for fetal growth.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.011
       
  • 03: Surgical site infection prevention bundle for hysterectomy: Effect on
           costs of surgical admission and 30-day readmissions
    • Authors: S.E. Andiman; X. Xu; W. Teng; L. Fan
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): S.E. Andiman, X. Xu, W. Teng, L. Fan


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.187
       
  • The World Health Organization fetal growth charts: concept, findings,
           interpretation, and application
    • Authors: Torvid Kiserud; Alexandra Benachi; Kurt Hecher; Rogelio González Perez; José Carvalho; Gilda Piaggio; Lawrence D. Platt
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Torvid Kiserud, Alexandra Benachi, Kurt Hecher, Rogelio González Perez, José Carvalho, Gilda Piaggio, Lawrence D. Platt
      Ultrasound biometry is an important clinical tool for the identification, monitoring, and management of fetal growth restriction and development of macrosomia. This is even truer in populations in which perinatal morbidity and mortality rates are high, which is a reason that much effort is put onto making the technique available everywhere, including low-income societies. Until recently, however, commonly used reference ranges were based on single populations largely from industrialized countries. Thus, the World Health Organization prioritized the establishment of fetal growth charts for international use. New fetal growth charts for common fetal measurements and estimated fetal weight were based on a longitudinal study of 1387 low-risk pregnant women from 10 countries (Argentina, Brazil, Democratic Republic of Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) that provided 8203 sets of ultrasound measurements. The participants were characterized by median age 28 years, 58% nulliparous, normal body mass index, with no socioeconomic or nutritional constraints (median caloric intake, 1840 calories/day), and had the ability to attend the ultrasound sessions, thus essentially representing urban populations. Median gestational age at birth was 39 weeks, and birthweight was 3300 g, both with significant differences among countries. Quantile regression was used to establish the fetal growth charts, which also made it possible to demonstrate a number of features of fetal growth that previously were not well appreciated or unknown: (1) There was an asymmetric distribution of estimated fetal weight in the population. During early second trimester, the distribution was wider among fetuses <50th percentile compared with those above. The pattern was reversed in the third trimester, with a notably wider variation >50th percentile. (2) Although fetal sex, maternal factors (height, weight, age, and parity), and country had significant influence on fetal weight (1–4.5% each), their effect was graded across the percentiles. For example, the positive effect of maternal height on fetal weight was strongest on the lowest percentiles and smallest on the highest percentiles for estimated fetal weight. (3) When adjustment was made for maternal covariates, there was still a significant effect of country as covariate that indicated that ethnic, cultural, and geographic variation play a role. (4) Variation between populations was not restricted to fetal size because there were also differences in growth trajectories. (5) The wide physiologic ranges, as illustrated by the 5th–95th percentile for estimated fetal weight being 2205–3538 g at 37 weeks gestation, signify that human fetal growth under optimized maternal conditions is not uniform. Rather, it has a remarkable variation that largely is unexplained by commonly known factors. We suggest this variation could be part of our common biologic strategy that makes human evolution extremely successful. The World Health Organization fetal growth charts are intended to be used internationally based on low-risk pregnancies from populations in Africa, Asia, Europe, and South America. We consider it prudent to test and monitor whether the growth charts’ performance meets the local needs, because refinements are possible by a change in cut-offs or customization for fetal sex, maternal factors, and populations. In the same line, the study finding of variations emphasizes the need for carefully adjusted growth charts that reflect optimal local growth when public health issues are addressed.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.010
       
  • 04: A retrospective study reviewing the risks related to recurrence of
           stress incontinence following revision of midurethral sling
    • Authors: M.S. Cramer; H. Goldstein; D. Thompson; B. Vakili; E. Saks; M. Fagan
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): M.S. Cramer, H. Goldstein, D. Thompson, B. Vakili, E. Saks, M. Fagan


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.188
       
  • The INTERGROWTH-21st fetal growth standards: toward the global integration
           of pregnancy and pediatric care
    • Authors: Aris T. Papageorghiou; Stephen H. Kennedy; Laurent J. Salomon; Douglas G. Altman; Eric O. Ohuma; William Stones; Michael G. Gravett; Fernando C. Barros; Cesar Victora; Manorama Purwar; Yasmin Jaffer; Julia A. Noble; Enrico Bertino; Ruyan Pang; Leila Cheikh Ismail; Ann Lambert; Zulfiqar A. Bhutta; José Villar
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Aris T. Papageorghiou, Stephen H. Kennedy, Laurent J. Salomon, Douglas G. Altman, Eric O. Ohuma, William Stones, Michael G. Gravett, Fernando C. Barros, Cesar Victora, Manorama Purwar, Yasmin Jaffer, Julia A. Noble, Enrico Bertino, Ruyan Pang, Leila Cheikh Ismail, Ann Lambert, Zulfiqar A. Bhutta, José Villar
      The purpose of the INTERGROWTH-21st project was to develop international, prescriptive standards for fetal growth assessed by ultrasound and fundal height, preterm postnatal growth, newborn size and body composition, maternal weight gain, and infant development at the age of 2 years. Hence, we have produced, based on World Health Organization recommendations, the first comprehensive set of international standards of optimal fetal and newborn growth that perfectly match the existing World Health Organization child growth standards. Uniquely, the same population was followed up longitudinally from 9 weeks of fetal life to 2 years of age, with growth, health, and nutritional status assessment at 2 years supporting the appropriateness of the population for construction of growth standards. The resulting package of clinical tools allows, for the first time, growth and development to be monitored from early pregnancy to infancy. The INTERGROWTH-21st fetal growth standards, which are based on observing >4500 healthy pregnancies, nested in a study of >59,000 pregnancies from populations with low rates of adverse perinatal outcomes, show how fetuses should grow–rather than the more limited objective of past references, which describe how they have grown at specific times and locations. Our work has confirmed the fundamental biological principle that variation in human growth across different populations is mostly dependent on environmental, nutritional, and socioeconomic factors. We found that when mothers' nutritional and health needs are met and there are few environmental constraints on growth, <3.5% of the total variability of skeletal growth was due to differences between populations. We propose that not recognizing the concept of optimal growth could deprive the most vulnerable mothers and their babies of optimal care, because local growth charts normalize those at highest risk for growth restriction and overweight, and can be valuable for policymakers to ensure rigorous evaluation and effective resource allocation. We strongly encourage colleagues to join efforts to provide integrated, evidence-based growth monitoring to pregnant women and their infants worldwide. Presently, there are 23.3 million infants born small for gestational age in low- to middle-income countries according to the INTERGROWTH-21st newborn size standards. We suggest that misclassification of these infants by using local charts could affect the delivery of optimal health care.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.011
       
  • Fetal growth standards: the NICHD fetal growth study approach in context
           with INTERGROWTH-21st and the World Health Organization Multicentre Growth
           Reference Study
    • Authors: Katherine L. Grantz; Mary L. Hediger; Danping Liu; Germaine M. Buck Louis
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Katherine L. Grantz, Mary L. Hediger, Danping Liu, Germaine M. Buck Louis
      Three recently completed longitudinal cohort studies have developed intrauterine fetal growth charts, one in the United States and two international. This expert review compares and contrasts the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies, INTERGROWTH-21st and World Health Organization Multicentre Growth Reference Study conclusions in light of differences in aims, sampling frames, and analytical approaches. An area of controversy is whether a single growth reference is representative of growth, regardless of ethnic or country origin. The INTERGROWTH and World Health Organization Fetal studies used a similar approach as the World Health Organization Multicentre Growth Reference Study for infants and children, the aim of which was to create a single international reference for the best physiological growth for children aged 0–5 years. INTERGROWTH made the same assumption (ie, that there would be no differences internationally among countries or racial/ethnic groups in fetal growth when conditions were optimal). INTERGROWTH found differences in crown-rump length and head circumference among countries but interpreted the differences as not meaningful and presented a pooled standard. The World Health Organization Multicentre Growth Reference Study was designed to create a pooled reference, although they evaluated for and presented country differences, along with discussion of the implications. The Eunice Kennedy Shriver National Institute of Child Health and Human Development Study was designed to assess whether racial/ethnic-specific fetal growth standards were needed, in recognition of the fact that fetal size is commonly estimated from dimensions (head circumference, abdominal circumference, and femur length) in which there are known differences in children and adults of differing racial/ethnic groups. A pooled standard would be derived if no racial/ethnic differences were found. Highly statistically significant racial/ethnic differences in fetal growth were found resulting in the publication of racial/ethnic-specific derived standards. Despite all 3 studies including low-risk status women, the percentiles for fetal dimensions and estimated fetal weight varied among the studies. Specifically, at 39 weeks, the 50th percentile for estimated fetal weight was 3502 g for whites, 3330 g for Hispanics, 3263 g for Asians, and 3256 for blacks in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Study, compared with 3186 g for INTERGROWTH and 3403 g for World Health Organization Multicentre Growth Reference Study. When applying these standards to a clinical population, it is important to be aware that different percentages of small- and large-for-gestational-age fetuses will be identified. Also, it may be necessary to use more restrictive cut points, such as the 2.5th or 97.5th, for small-for-gestational-age or large-for-gestational-age fetuses, respectively. Ideally, a comparison of diagnostic accuracy, or misclassification rates, of small-for-gestational-age and large-for-gestational-age fetuses in relation to morbidity and mortality using different criteria is necessary to make recommendations and remains an important data gap. Identification of the appropriate percentile cutoffs in relation to neonatal morbidity and mortality is needed in local populations, depending on which fetal growth chart is used. On a final point, assessment of fetal growth with a one-time measurement remains standard clinical practice, despite recognition that a single measurement can indicate only size. Ultimately, it is knowledge about fetal growth in addition to other factors and clinical judgment that should trigger intervention.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.11.593
       
  • 06: Longitudinal change in pelvic floor muscle strength in parous women
    • Authors: E. Myer; J. Roem; J. Blomquist; V. Handa
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): E. Myer, J. Roem, J. Blomquist, V. Handa


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.190
       
  • Individualized growth assessment: conceptual framework and practical
           implementation for the evaluation of fetal growth and neonatal growth
           outcome
    • Authors: Russell L. Deter; Wesley Lee; Lami Yeo; Offer Erez; Uma Ramamurthy; Medha Naik; Roberto Romero
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Russell L. Deter, Wesley Lee, Lami Yeo, Offer Erez, Uma Ramamurthy, Medha Naik, Roberto Romero
      Fetal growth abnormalities can pose significant consequences on perinatal morbidity and mortality of nonanomalous fetuses. The most widely accepted definition of fetal growth restriction is an estimated fetal weight less than the 10th percentile for gestational age according to population-based criteria. However, these criteria do not account for the growth potential of an individual fetus, nor do they effectively separate constitutionally small fetuses from ones that are malnourished. Furthermore, conventional approaches typically evaluate estimated fetal weight at a single time point, rather than using serial scans, to evaluate growth. This article provides a conceptual framework for the individualized growth assessment of a fetus/neonate based on measuring second-trimester growth velocity of fetal size parameters to estimate growth potential. These estimates specify size models that generate individualized third-trimester size trajectories and predict birth characteristics. Comparisons of measured and predicted values are used to separate normally growing fetuses from those with growth abnormalities. This can be accomplished with individual anatomical parameters or sets of parameters. A practical and freely available software (Individualized Growth Assessment Program) has been developed to allow implementation of this approach for clinical and research purposes.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.210
       
  • 07: Uterosacral ligament suspension: A radiographic study of suture
           location in live subjects
    • Authors: B. Smith; C.V. Herfel; J. Yeung; A. Shatkin-Margolis; C.C. Crisp; S.D. Kleeman; R.N. Pauls
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): B. Smith, C.V. Herfel, J. Yeung, A. Shatkin-Margolis, C.C. Crisp, S.D. Kleeman, R.N. Pauls


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.191
       
  • A new customized fetal growth standard for African American women: the
           PRB/NICHD Detroit study
    • Authors: Adi L. Tarca; Roberto Romero; Dereje W. Gudicha; Offer Erez; Edgar Hernandez-Andrade; Lami Yeo; Gaurav Bhatti; Percy Pacora; Eli Maymon; Sonia S. Hassan
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement
      Author(s): Adi L. Tarca, Roberto Romero, Dereje W. Gudicha, Offer Erez, Edgar Hernandez-Andrade, Lami Yeo, Gaurav Bhatti, Percy Pacora, Eli Maymon, Sonia S. Hassan
      Background The assessment of fetal growth disorders requires a standard. Current nomograms for the assessment of fetal growth in African American women have been derived either from neonatal (rather than fetal) biometry data or have not been customized for maternal ethnicity, weight, height, and parity and fetal sex. Objective We sought to (1) develop a new customized fetal growth standard for African American mothers; and (2) compare such a standard to 3 existing standards for the classification of fetuses as small (SGA) or large (LGA) for gestational age. Study Design A retrospective cohort study included 4183 women (4001 African American and 182 Caucasian) from the Detroit metropolitan area who underwent ultrasound examinations between 14-40 weeks of gestation (the median number of scans per pregnancy was 5, interquartile range 3-7) and for whom relevant covariate data were available. Longitudinal quantile regression was used to build models defining the “normal” estimated fetal weight (EFW) centiles for gestational age in African American women, adjusted for maternal height, weight, and parity and fetal sex, and excluding pathologic factors with a significant effect on fetal weight. The resulting Perinatology Research Branch/Eunice Kennedy Shriver National Institute of Child Health and Human Development (hereinafter, PRB/NICHD) growth standard was compared to 3 other existing standards--the customized gestation-related optimal weight (GROW) standard; the Eunice Kennedy Shriver National Institute of Child Health and Human Development (hereinafter, NICHD) African American standard; and the multinational World Health Organization (WHO) standard--utilized to screen fetuses for SGA (<10th centile) or LGA (>90th centile) based on the last available ultrasound examination for each pregnancy. Results First, the mean birthweight at 40 weeks was 133 g higher for neonates born to Caucasian than to African American mothers and 150 g higher for male than female neonates; maternal weight, height, and parity had a positive effect on birthweight. Second, analysis of longitudinal EFW revealed the following features of fetal growth: (1) all weight centiles were about 2% higher for male than for female fetuses; (2) maternal height had a positive effect on EFW, with larger fetuses being affected more (2% increase in the 95th centile of weight for each 10-cm increase in height); and (3) maternal weight and parity had a positive effect on EFW that increased with gestation and varied among the weight centiles. Third, the screen-positive rate for SGA was 7.2% for the NICHD African American standard, 12.3% for the GROW standard, 13% for the WHO standard customized by fetal sex, and 14.4% for the PRB/NICHD customized standard. For all standards, the screen-positive rate for SGA was at least 2-fold higher among fetuses delivered preterm than at term. Fourth, the screen-positive rate for LGA was 8.7% for the GROW standard, 9.2% for the PRB/NICHD customized standard, 10.8% for the WHO standard customized by fetal sex, and 12.3% for the NICHD African American standard. Finally, the highest overall agreement among standards was between the GROW and PRB/NICHD customized standards (Cohen's interrater agreement, kappa = 0.85). Conclusion We developed a novel customized PRB/NICHD fetal growth standard from fetal data in an African American population without assuming proportionality of the effects of covariates, and without assuming that these effects are equal on all centiles of weight; we also provide an easy-to-use centile calculator. This standard classified more fetuses as being at risk for SGA compared to existing standards, especially among fetuses delivered preterm, but classified about the same number of LGA. The comparison among the 4 growth standards also revealed that the most important factor determining agreement among standards is whether they account for the same factors known to affect fetal growth.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.229
       
  • 08: Prevalence of new persistent opioid use among opioid naive women
           undergoing hysterectomy
    • Authors: C.W. Swenson; K. Seiler; N. Kamdar; D. Morgan
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2
      Author(s): C.W. Swenson, K. Seiler, N. Kamdar, D. Morgan


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.192
       
  • Prevention of spontaneous preterm birth: universal cervical length
           assessment and vaginal progesterone in women with a short cervix: time
           for action!
    • Authors: Stuart Campbell
      Pages: 151 - 158
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Stuart Campbell


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.222
       
  • Professional responsibility of transparency of obstetricians practicing in
           religious hospitals
    • Authors: Frank A. Chervenak; Laurence B. McCullough
      Pages: 159 - 160
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Frank A. Chervenak, Laurence B. McCullough


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.216
       
  • Vaginal progesterone for preventing preterm birth and adverse perinatal
           outcomes in singleton gestations with a short cervix: a meta-analysis of
           individual patient data
    • Authors: Roberto Romero; Agustin Conde-Agudelo; Eduardo Da Fonseca; John M. O’Brien; Elcin Cetingoz; George W. Creasy; Sonia S. Hassan; Kypros H. Nicolaides
      Pages: 161 - 180
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Roberto Romero, Agustin Conde-Agudelo, Eduardo Da Fonseca, John M. O’Brien, Elcin Cetingoz, George W. Creasy, Sonia S. Hassan, Kypros H. Nicolaides
      Background The efficacy of vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix has been questioned after publication of the OPPTIMUM study. Objective To determine whether vaginal progesterone prevents preterm birth and improves perinatal outcomes in asymptomatic women with a singleton gestation and a midtrimester sonographic short cervix. Study Design We searched MEDLINE, EMBASE, LILACS, and CINAHL (from their inception to September 2017); Cochrane databases; bibliographies; and conference proceedings for randomized controlled trials comparing vaginal progesterone vs placebo/no treatment in women with a singleton gestation and a midtrimester sonographic cervical length ≤25 mm. This was a systematic review and meta-analysis of individual patient data. The primary outcome was preterm birth <33 weeks of gestation. Secondary outcomes included adverse perinatal outcomes and neurodevelopmental and health outcomes at 2 years of age. Individual patient data were analyzed using a 2-stage approach. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology. Results Data were available from 974 women (498 allocated to vaginal progesterone, 476 allocated to placebo) with a cervical length ≤25 mm participating in 5 high-quality trials. Vaginal progesterone was associated with a significant reduction in the risk of preterm birth <33 weeks of gestation (relative risk, 0.62; 95% confidence interval, 0.47–0.81; P = .0006; high-quality evidence). Moreover, vaginal progesterone significantly decreased the risk of preterm birth <36, <35, <34, <32, <30, and <28 weeks of gestation; spontaneous preterm birth <33 and <34 weeks of gestation; respiratory distress syndrome; composite neonatal morbidity and mortality; birthweight <1500 and <2500 g; and admission to the neonatal intensive care unit (relative risks from 0.47-0.82; high-quality evidence for all). There were 7 (1.4%) neonatal deaths in the vaginal progesterone group and 15 (3.2%) in the placebo group (relative risk, 0.44; 95% confidence interval, 0.18–1.07; P = .07; low-quality evidence). Maternal adverse events, congenital anomalies, and adverse neurodevelopmental and health outcomes at 2 years of age did not differ between groups. Conclusion Vaginal progesterone decreases the risk of preterm birth and improves perinatal outcomes in singleton gestations with a midtrimester sonographic short cervix, without any demonstrable deleterious effects on childhood neurodevelopment.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.11.576
       
  • Giants in Obstetrics and Gynecology Series: A profile of John C. Hobbins,
           MD
    • Authors: Roberto Romero
      Pages: 181 - 187.e4
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Roberto Romero


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.12.008
       
  • To the point: medical education, technology, and the millennial learner
    • Authors: Laura Hopkins; Brittany S. Hampton; Jodi F. Abbott; Samantha D. Buery-Joyner; LaTasha B. Craig; John L. Dalrymple; David A. Forstein; Scott C. Graziano; Margaret L. McKenzie; Archana Pradham; Abigail Wolf; Sarah M. Page-Ramsey
      Pages: 188 - 192
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Laura Hopkins, Brittany S. Hampton, Jodi F. Abbott, Samantha D. Buery-Joyner, LaTasha B. Craig, John L. Dalrymple, David A. Forstein, Scott C. Graziano, Margaret L. McKenzie, Archana Pradham, Abigail Wolf, Sarah M. Page-Ramsey
      This article, from the “To The Point” series that was prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides an overview of the characteristics of millennials and describes how medical educators can customize and reframe their curricula and teaching methods to maximize millennial learning. A literature search was performed to identify articles on generational learning. We summarize the importance of understanding the attitudes, ideas, and priorities of millennials to tailor educational methods to stimulate and enhance learning. Where relevant, a special focus on the obstetrics and gynecology curriculum is highlighted.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.06.001
       
  • Perioperative pain management: an update for obstetrician-gynecologists
    • Authors: Georgine Lamvu; Jessica Feranec; Emily Blanton
      Pages: 193 - 199
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Georgine Lamvu, Jessica Feranec, Emily Blanton
      The opioid epidemic in the United States is unprecedented and continues to worsen. Many opioid abusers obtain their pills through legitimate prescriptions, directly or indirectly, from a medical provider. While practitioners have a responsibility to treat pain, it is now becoming clear that aggressive opioid prescription practices contribute to an epidemic of abuse. The medical community has to balance the unintended consequences of opioid misuse and abuse with the need to provide adequate pain control. Additionally, providers are being held accountable by the legal system and professional organizations for their prescribing practices. Responsible use of opioids is paramount and pain control does not supersede safety. Effective and safe pain management requires that providers perform risk assessments, understand medication risks, avoid excessive reliance on opioids, and adequately monitor and educate patients. Obstetricians and gynecologists are uniquely positioned to influence pain management practices as primary care providers and surgeons who regularly manage both acute and chronic pain conditions. Therefore, the objective of this publication was to familiarize obstetricians and gynecologists with contemporary concepts in pain management and summarize recent guidelines in a manner that is applicable to our specialty. We focus on perioperative pain management, which is the time period immediately before, during, and after surgery. Topics reviewed include proper risk assessment to evaluate a patient’s potential for poor pain control or development of chronic pain or misuse of opioids; multimodal pain management with nonpharmacological, nonopioid alternatives, safe opioid-use strategies; education and documentation; and special considerations for women, veterans, and lactation concerns.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.06.021
       
  • Prophylactic negative-pressure wound therapy after cesarean is associated
           with reduced risk of surgical site infection: a systematic review and
           meta-analysis
    • Authors: Lulu Yu; Ryan J. Kronen; Laura E. Simon; Carolyn R.T. Stoll; Graham A. Colditz; Methodius G. Tuuli
      Pages: 200 - 210.e1
      Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2
      Author(s): Lulu Yu, Ryan J. Kronen, Laura E. Simon, Carolyn R.T. Stoll, Graham A. Colditz, Methodius G. Tuuli
      Objective The objective of the study was to assess the effect of prophylactic negative-pressure wound therapy on surgical site infections and other wound complications in women after cesarean delivery. Data Sources We searched Ovid Medline, Embase, SCOPUS, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. Study Eligibility Criteria We included randomized controlled trials and observational studies comparing prophylactic negative-pressure wound therapy with standard wound dressing for cesarean delivery. Study Appraisal and Synthesis Methods The primary outcome was surgical site infection after cesarean delivery. Secondary outcomes were composite wound complications, wound dehiscence, wound seroma, endometritis, and hospital readmission. Heterogeneity was assessed using Higgin’s I2. Relative risks with 95% confidence intervals were calculated using random-effects models. Results Six randomized controlled trials and 3 cohort studies in high-risk mostly obese women met inclusion criteria and were included in the meta-analysis. Six were full-text articles, 2 published abstracts, and 1 report of trial results in ClinicalTrials.gov. Studies were also heterogeneous in the patients included and type of negative-pressure wound therapy device. The risk of surgical site infection was significantly lower with the use of prophylactic negative-pressure wound therapy compared with standard wound dressing (7 studies: pooled risk ratio, 0.45; 95% confidence interval, 0.31–0.66; adjusted risk ratio, –6.0%, 95% confidence interval, –10.0% to –3.0%; number needed to treat, 17, 95% confidence interval, 10–34). There was no evidence of significant statistical heterogeneity (I2 = 9.9%) or publication bias (Egger P = .532). Of the secondary outcomes, only composite wound complications were significantly reduced in patients receiving prophylactic negative-pressure wound therapy compared with standard dressing (9 studies: pooled risk ratio, 0.68, 95% confidence interval, 0.49–0.94). Conclusion Studies on the effectiveness of prophylactic negative-pressure wound therapy at cesarean delivery are heterogeneous but suggest a reduction in surgical site infection and overall wound complications. Larger definitive trials are needed to clarify the clinical utility of prophylactic negative-pressure wound therapy after cesarean delivery.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2017.09.017
       
  • Pelvic Muscles’ Mechanical Response to Strains in the Absence and
           Presence of Pregnancy-Induced Adaptations in a Rat Model
    • Authors: Tatiana Catanzarite; Shannon Bremner; Caitlin L. Barlow; Laura Bou-Malham; Shawn O’Connor; Marianna Alperin
      Abstract: Publication date: Available online 9 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Tatiana Catanzarite, Shannon Bremner, Caitlin L. Barlow, Laura Bou-Malham, Shawn O’Connor, Marianna Alperin
      Background Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles’ mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect. Objectives 1. To determine the mechanical impact of parturition-related strains on pelvic floor muscles’ microstructure. 2. To test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery. Study Design 3-month-old Sprague-Dawley late-pregnant (N=20) and non-pregnant (N=22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and non-pregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in the intrapartum rats (N=4), sacrificed during fetal delivery. Data were compared with repeated measures and two-way analysis of variance, followed by pairwise comparisons, with significance set at P<0.05. Results Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to the intrapartum sarcomere lengths in all muscles (P>0.4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in non-pregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P<0.0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles. Conclusions Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.02.001
       
  • Optimizing Research in Symptomatic Uterine Fibroids with Development of a
           Computable Phenotype for Use with Electronic Health Records
    • Authors: Sarah R. Hoffman; Anissa I. Vines; Jacqueline R. Halladay; Emily Pfaff; Lauren Schiff; Daniel Westreich; Aditi Sundaresan; La-Shell Johnson; Wanda K. Nicholson
      Abstract: Publication date: Available online 9 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Sarah R. Hoffman, Anissa I. Vines, Jacqueline R. Halladay, Emily Pfaff, Lauren Schiff, Daniel Westreich, Aditi Sundaresan, La-Shell Johnson, Wanda K. Nicholson
      Background Symptomatic uterine fibroids, due to menorrhagia, pelvic pain, bulk symptoms or infertility, are a source of substantial morbidity for reproductive-age women. Comparing Treatment Options for Uterine Fibroids (COMPARE-UF) is a multi-site registry study to compare the effectiveness of hormonal or surgical fibroid treatments on women’s perceptions of their quality of life. Electronic health record (EHR)-based algorithms are able to identify large numbers of women with fibroids, but additional work is needed to develop EHR algorithms that can identify women with symptomatic fibroids to optimize fibroid research. Objective To develop an efficient electronic health record (EHR)-based algorithm that can identify women with symptomatic uterine fibroids in a large health care system for recruitment into large-scale observational and interventional research in fibroid management. Study Design We developed and assessed the accuracy of three algorithms to identify patients with symptomatic fibroids using an iterative approach. The data source was the Carolina Data Warehouse for Health, a repository for the health system’s EHR data. In addition to ICD-9 diagnosis and procedure codes and clinical characteristics, text data mining software was used to derive information from imaging reports to confirm the presence of uterine fibroids. Results of each algorithm were compared with expert manual review to calculate the positive predictive values (PPVs) for each algorithm. Results Algorithm 1 was composed of the following criteria: i) age 18-54 AND ii) either ≥ 1 ICD-9 diagnosis codes for uterine fibroids or mention of fibroids using text-mined key words in imaging records or documents AND iii) no ICD-9 or CPT codes for hysterectomy and no reported history of hysterectomy. The PPV was 47% (95% CI: 39%-56%). Algorithm 2 required i) ≥ 2 ICD-9 diagnosis codes for fibroids AND positive text mined key words and had a PPV of 65% (95% CI: 50%-79%). In Algorithm 3, further refinements included ≥ 2 ICD-9 diagnosis codes for fibroids on separate outpatient visit dates, the exclusion of women who had a positive pregnancy test within three months of their fibroid-related visit, and exclusion of incidentally detected fibroids during prenatal or emergency department visits. Algorithm 3 achieved a PPV of 76% (95% CI: 71%-81%). Conclusion An EHR-based algorithm is capable of identifying cases of symptomatic uterine fibroids with moderate positive predictive value and may be an efficient approach for large-scale study recruitment.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.02.002
       
  • Lost and Found – Advocacy during Residency
    • Authors: Olivia H. Chang
      Abstract: Publication date: Available online 7 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Olivia H. Chang


      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.047
       
  • The impact of a daily smartphone-based feedback system among women with
           gestational diabetes on compliance, glycemic control, satisfaction, and
           pregnancy outcome: a randomized controlled trial
    • Authors: Hadas Miremberg; Tal Ben-Ari; Tal Betzer; Hagit Raphaeli; Rose Gasnier; Giulia Barda; Jacob Bar; Eran Weiner
      Abstract: Publication date: Available online 7 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Hadas Miremberg, Tal Ben-Ari, Tal Betzer, Hagit Raphaeli, Rose Gasnier, Giulia Barda, Jacob Bar, Eran Weiner
      Background Patient compliance and tight glycemic control have been demonstrated to improve pregnancy outcome in pregnancies complicated by gestational diabetes mellitus (GDM). The use of advanced technological tools, including smartphone-based platforms, to improve medical care and outcomes has been demonstrated in various fields of medicine, but only few small studies were performed with GDM patients. Objective We aimed to study the impact of introducing a smartphone-based daily feedback and communication platform between GDM patients and their physicians, on patient compliance, glycemic control, pregnancy outcome, and patient satisfaction. Study design This is a prospective, single-center, randomized controlled trial. Newly diagnosed GDM patients presenting to our multidisciplinary diabetes-in-pregnancy clinic were randomized to: (1) routine bi-weekly prenatal clinic care (control group) or (2) an additional daily detailed feedback on their compliance and glycemic control from the clinic team via an application installed on their smartphone (smartphone group). The primary outcome was patient compliance defined as the actual blood glucose measurements/instructed measurements X100. The secondary outcomes included diabetes-control parameters, pregnancy, and neonatal outcomes. The study was adequately powered to detect a 20% difference in patient compliance, based on a preliminary phase that demonstrated 70% baseline compliance to glucose measurements. Results A total of 120 newly diagnosed GDM patients were analyzed. The two groups did not differ in terms of age, parity, education, body mass index (BMI), family history, maternal comorbidities, oral glucose tolerance test (OGTT) values, and hemoglobin A1C (HbA1C) at randomization. The smartphone group demonstrated higher level of compliance (84 ± 0.16% vs. 66 ± 0.28%, p<0.001), lower mean blood glucose (105.1 ± 8.6 mg/dL vs. 112.6 ± 7.4 mg/dL, p<0.001), lower rates of off-target measurements both fasting (4.7 ± 0.4 % vs. 8.4 ± 0.6%, p<0.001) and 1 hour post-prandial (7.7 ± 0.8% vs. 14.3 ± 0.8%, p<0.001), and a lower rate of pregnancies requiring insulin treatment (13.3% vs. 30.0%, p=0.044). The rates of macrosomia, neonatal hypoglycemia, shoulder dystocia and other delivery and neonatal complications did not differ between the groups. Patients in the smartphone group reported excellent satisfaction from the use of the application and from their overall prenatal care. Conclusion Introduction of a smartphone-based daily feedback and communication platform between GDM patients and the multidisciplinary diabetes-in-pregnancy clinic team, improved patient compliance, glycemic control, and lowered the rate of insulin treatment.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.044
       
  • A Prospective Study of the Natural History of Urinary Incontinence in
           Women
    • Authors: Kaitlin A. Hagan; Elisabeth Erekson; Andrea Austin; Vatche A. Minassian; Mary K. Townsend; Julie PW. Bynum; Francine Grodstein
      Abstract: Publication date: Available online 6 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Kaitlin A. Hagan, Elisabeth Erekson, Andrea Austin, Vatche A. Minassian, Mary K. Townsend, Julie PW. Bynum, Francine Grodstein
      Background Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long-term. Objective To delineate the course of urinary incontinence symptoms over time, using two large cohorts of middle-age and older women, with data collected over 10 years. Study Design We studied 9,376 women from the Nurses’ Health Study, age 56-81 years at baseline, and 7,491 women from Nurses’ Health Study II, age 39-56 years, with incident urinary incontinence in 2002-3. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models. Results Among women age 39-56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56-81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow-up; few (3-11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75-81 versus 56-60 years, odds ratio=1.84, 95% confidence interval: 1.51, 2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio=2.37, 95% confidence interval: 2.00, 2.81 body mass index ≥30 vs. < 25 kg/m2; older women: odds ratio=1.93, 95% confidence interval: 1.62, 2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio=0.86, 95% confidence interval: 0.71, 1.03, highest vs. lowest quartile of activity; older women: odds ratio=0.68, 95% confidence interval: 0.59, 0.80). Conclusions Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.045
       
  • Robotic-Assisted Sacrocolpopexy: Early Postoperative Outcomes after
           Surgical Reduction of Enlarged Genital Hiatus
    • Authors: Megan S. Bradley; Amy L. Askew; Monique H. Vaughan; Amie Kawasaki; Anthony G. Visco
      Abstract: Publication date: Available online 6 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Megan S. Bradley, Amy L. Askew, Monique H. Vaughan, Amie Kawasaki, Anthony G. Visco
      Background Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy is not standardized. Objective To compare anatomic failure after robotic-assisted sacrocolpopexy among three groups of patients categorized by their pre- and post-operative genital hiatus size. Study Design We performed a retrospective cohort study of women who underwent robotic-assisted sacrocolpopexy, from 1/2013 to 9/2016. We defined a wide GH as ≥4cm and a normal GH as <4cm. We compared three groups: 1) Wide Pre- and Post-operative GH (Persistently Wide); 2) Wide Pre- and Normal Post-op GH (Improved); and 3) Normal Pre- and Post-operative GH (Stably Normal). Our primary outcome was composite anatomic failure defined as either recurrent prolapse in any compartment past the hymen or retreatment for prolapse with either surgery or pessary. Our data were analyzed using one-way ANOVA and chi-square test. Logistic regression was performed to evaluate for independent risk factors for anatomic failure between the three groups. P<0.05 was considered significant. Results Our study population consisted of 452 women with a mean age of 59.3±10.0 years and a mean body mass index of 27.8±5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The genital hiatus groups were distributed as follows: 57 (12.6%) were Persistently Wide, 296 (65.5%) were Improved and 99 (21.9%) were Stably Normal. The Stably Normal group had less advanced preoperative prolapse (≥Stage 3) than the other groups (p<0.01). A similar percentage of patients among groups had a concomitant posterior repair/perineoplasty (p=0.09) with a total of 84 (18.6%) women undergoing this procedure. There was a statistically significant difference in overall composite anatomic failure among the groups (p=0.03). There was an increase in failure in the Persistently Wide group (14.0%) compared to the Improved Group (5.7%, p=0.04) and compared to the Stably Normal Group (4.0%, p=0.03). In a logistic regression model, controlling for number of vaginal deliveries and posterior repair/perineoplasty, there was a 5.3-fold increased odds of composite anatomic failure in the Persistently Wide group (adjusted OR 5.3, 95% CI 1.4, 19.1; p=0.01) compared to the Stably Normal group. In a sub-analysis of failure by compartment, there was an increase in failure of the posterior compartment in the Persistently Wide Group compared to the Improved group (8.8% v. 2.0%, p<0.01), but not the Stably Normal group (3.0%, p=0.12). There was not a statistically significant difference in failure of the combined apical and anterior compartments among groups (p=0.29). Conclusion Surgical reduction of an enlarged pre-operative genital hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of GH to postoperative GH are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.046
       
  • A randomized clinical trial of knotless barbed suture vs conventional
           suture for closure of the uterine incision at Cesarean delivery
    • Authors: David Peleg; Ronan Said Ahmad; Steven L. Warsof; Naama Marcus-Braun; Yael Sciaky-Tamir; Inbar Ben Shachar
      Abstract: Publication date: Available online 5 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): David Peleg, Ronan Said Ahmad, Steven L. Warsof, Naama Marcus-Braun, Yael Sciaky-Tamir, Inbar Ben Shachar
      Background Knotless barbed sutures are monofilament sutures with barbs cut into them. These sutures self-anchor, maintaining tissue approximation without the need for surgical knots. Objective The hypothesis of this study was that knotless barbed suture could be used on the myometrium to close the hysterotomy at cesarean delivery. The objective was to compare uterine closure time, need for additional sutures, and blood loss between this and a conventional suture. Study Design This was a prospective unblinded randomized controlled trial conducted at the Ziv Medical Center, Zefat, Israel. The primary outcome was the length of time needed to close the uterine incision, which was measured from the start of the first suture on the uterus until obtaining uterine hemostasis. To minimize provider bias, women were randomized by sealed envelopes that were opened in the operating room just prior to uterine closure with either a bidirectional knotless barbed suture or conventional suture. Secondary outcomes included number of additional hemostatic sutures needed and blood loss during incision closure. Results Patients were enrolled from August 2016 until March 2017. 102 women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesareans. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 min 43 sec (P<0.001, 95% CI 67.69 – 138.47 sec). Knotless barbed sutures were associated with a lower need for hemostatic sutures (median 0 versus 1, P<0.001) and blood loss measured during incision closure was significantly lower (mean 221 ml versus 268 ml, P<0.005). Conclusions The use of a knotless barbed suture is a reasonable alternative to conventional sutures since it reduced closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.043
       
  • Neonatal morbidity associated with vaginal delivery of non-cephalic second
           twins
    • Authors: Thomas Schmitz; Diane Korb; Catherine Battie; Anne-Gaël Cordier; Céline De Carne Carnavalet; Céline Chauleur; Véronique Equy; Bassam Haddad; Delphine Lemercier; Christophe Poncelet; Luc Rigonnot; François Goffinet
      Abstract: Publication date: Available online 5 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Thomas Schmitz, Diane Korb, Catherine Battie, Anne-Gaël Cordier, Céline De Carne Carnavalet, Céline Chauleur, Véronique Equy, Bassam Haddad, Delphine Lemercier, Christophe Poncelet, Luc Rigonnot, François Goffinet
      Background Management of non-cephalic second twin delivery rests on the results of population-based retrospective studies of twin births that have shown higher neonatal mortality and morbidity for second twins with non-cephalic, compared with cephalic, presentations after vaginal delivery of the first twin. Because these studies are flawed by data of questionable validity, do not report the obstetrical practices at delivery and do not allow collection of potential confounding variables, we performed a national prospective study specially designed to evaluate the management of twins’ delivery. Objective To assess neonatal mortality and morbidity according to second twin presentation after vaginal birth of the first twin. Study design The JUMODA study was a nationwide prospective population-based cohort study of twin deliveries performed in 176 maternity units in France from February 2014 to March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Neonatal outcomes of second twins born at or after 32 weeks of gestation after vaginal delivery of the first cephalic or breech twin were compared according to the non-cephalic or cephalic second twin presentation. Multivariable logistic regression models controlled for potential confounders. Subgroup analyses were conducted according to the breech or transverse presentation of the non-cephalic second twin, and gestational age at delivery, before or after 37 weeks of gestation. Results Among 3903 second twins enrolled in the study, 2384 (61.1%) were in cephalic and 1519 (38.9%) in non-cephalic presentations, of whom 999 (25.6%) were in breech and 520 (13.3%) in transverse presentation. Composite neonatal mortality and morbidity did not differ between the non-cephalic and cephalic group (47/1519 (3.1%) vs 59/2384 (2.5%); adjusted odds ratio 1.23; 95% CI, 0.81-1.85). No significant difference between groups was shown for the primary outcome in subgroup analyses according to type of non-cephalic second twin presentation or gestational age at delivery. Cesarean delivery rates for the second twin were lower in the breech than in the cephalic group (14/999 (1.4%) vs 75/2384 (3.1%), P=0.003) and lower in the cephalic than in the transverse group (75/2384 (3.1%) vs 35/520 (6.7%), P<0.001). Conclusions Non-cephalic and cephalic second twin presentations after vaginal delivery of the first twin at or after 32 weeks of gestation are associated with similar low composite neonatal mortality and morbidity. Vaginal delivery of non-cephalic second twin is a reasonable option.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.023
       
  • Associations of Neighborhood-Level Racial Residential Segregation with
           Adverse Pregnancy Outcomes
    • Authors: Arturo D. Salow; Lindsay R. Pool; William A. Grobman; Kiarri N. Kershaw
      Abstract: Publication date: Available online 5 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Arturo D. Salow, Lindsay R. Pool, William A. Grobman, Kiarri N. Kershaw
      Background Previous analyses utilizing birth certificate data have shown environmental factors such as racial residential segregation may contribute to disparities in adverse pregnancy outcomes. However, birth certificate data are ill equipped to reliably differentiate between small for gestational age, spontaneous preterm birth and medically indicated preterm birth. Objective To utilize data from electronic medical records to determine whether residential segregation among black women is associated with an increased risk of adverse pregnancy outcomes. Study Design The study population is composed of 4,770 non-Hispanic black women who delivered during the years 2009 through 2013 at a single urban medical center. Addresses were geocoded at the level of census tract, and this tract was used to determine the degree of residential segregation for an individual’s neighborhood. Residential segregation was measured using the Gi* statistic, a z-score that measures the extent to which the neighborhood racial composition deviates from the composition of the larger surrounding area. The Gi* statistic z-scores were categorized as follows: low (z< 0), medium (z = 0 to 1.96), and high (z > 1.96). Adverse pregnancy outcomes included overall preterm birth, spontaneous preterm birth, medically-indicated preterm birth, and small for gestational age. Hierarchical logistic regression models accounting for clustering by census tract and repeated births among mothers were used to estimate odds ratios (OR) of adverse pregnancy outcomes associated with segregation. Results In high-segregation areas, the prevalence of overall preterm birth was significantly higher than that in low segregation areas (15.5% vs. 10.7%, respectively; p<0.001). Likewise, the prevalence of spontaneous preterm birth and medically-indicated preterm birth were higher in high (9.5% and 6.0%) vs. low (6.2% and 4.6%) segregation neighborhoods (p<0.001 and p=0.046, respectively). The associations of high segregation with overall preterm birth (OR: 1.31; 95% CI: 1.02, 1.69) and spontaneous preterm birth (OR: 1.37; 95% CI: 1.02, 1.85) remained significant with adjustment for maternal medical conditions (Table). Conclusions Among non-Hispanic black women in an urban area, high levels of segregation were independently associated with the higher odds of spontaneous preterm birth. These findings highlight one aspect of social determinants (i.e., segregation) through which adverse pregnancy outcomes may be influenced and points to a potential target for intervention.

      PubDate: 2018-02-15T07:39:50Z
      DOI: 10.1016/j.ajog.2018.01.022
       
  • Title Page
    • Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement


      PubDate: 2018-02-15T07:39:50Z
       
  • Letter from the SGS President
    • Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2


      PubDate: 2018-02-15T07:39:50Z
       
  • Information for Readers
    • Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2


      PubDate: 2018-02-15T07:39:50Z
       
  • 05: Withdrawn
    • Abstract: Publication date: February 2018
      Source:American Journal of Obstetrics and Gynecology, Volume 218, Issue 2, Supplement 2


      PubDate: 2018-02-15T07:39:50Z
       
  • Reply
    • Authors: Jiri Sonek; David McKenna David Krantz
      Abstract: Publication date: Available online 3 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Jiri Sonek, David McKenna, David Krantz


      PubDate: 2018-02-03T23:03:41Z
       
  • Placenta increta after high intensity-focused ultrasound for the treatment
           of a uterine leiomyoma
    • Authors: Chin-Ru Ker; Cheng-Yu Long; Ching-Ju Shen
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Chin-Ru Ker, Cheng-Yu Long, Ching-Ju Shen


      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.037
       
  • Post mortem microfocus computed tomography for early gestation fetuses: a
           validation study against conventional autopsy
    • Authors: John C. Hutchinson; Xin Kang; Susan Cheng Shelmerdine; Valerie Segers; Claudio M. Lombardi; Mieke M. Cannie; Neil J. Sebire; Jacques C. Jani; Owen J. Arthurs
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): John C. Hutchinson, Xin Kang, Susan Cheng Shelmerdine, Valerie Segers, Claudio M. Lombardi, Mieke M. Cannie, Neil J. Sebire, Jacques C. Jani, Owen J. Arthurs
      Background Perinatal autopsy provides useful clinical information in up to 40% of cases. However, there is a substantial unmet clinical need with regards to post mortem investigation of early gestation fetal loss for parents for whom standard autopsy is either not available or not acceptable. Parents dislike the invasive nature of autopsy, but current clinical imaging techniques do not provide high-enough imaging resolution in small fetuses. We hypothesized that microfocus computed tomography, a rapid, high resolution imaging technique, could give accurate diagnostic imaging following early gestation fetal loss. Objectives The objective of the study was to evaluate the diagnostic accuracy of microfocus computed tomography for non-invasive human fetal autopsy for early gestation fetuses, using conventional autopsy as the reference standard. Study design We compared iodinated whole body microfocus computed tomography in 20 prospectively recruited fetuses (11-21 weeks’ gestation; from two centers), to conventional autopsy in a double-blinded manner for (a) main diagnosis, and (b) findings in specific body organs. Fetuses were prepared using 10% formalin / potassium tri-iodide. Images were acquired using XT H 225 ST microfocus CT scanner, using size-appropriate parameters. Images were independently evaluated by two pediatric radiologists across 40 individual indices to reach consensus, blinded to formal perinatal autopsy results. The primary outcome was agreement between micro CT and conventional autopsy for overall diagnosis. Results Post-mortem whole body fetal micro CT gave non-invasive autopsy in minutes, at a mean resolution of 27μm, with high diagnostic accuracy in fetuses below 22 weeks gestation. Autopsy demonstrated 13/20 fetuses with structural abnormalities, 12 of which were also identified by micro CT (92.3%). Overall, micro CT agreed with overall autopsy findings in 35/38 diagnoses (15 true positive, 18 true negative; sensitivity 93.8% (95% CI: 71.7, 98.9%), specificity 100% (95% CI: 82.4, 100%)), with 100% agreement for body imaging diagnoses. Furthermore, following removal of non-diagnostic indices, there was agreement for 700 / 718 individual body organ indices assessed on micro CT and autopsy (agreement 97.5%; 95% CI 96.1, 98.4%), with no overall differences between fetuses ≤14 or >14 weeks gestation (agreement 97.2%, 97.9% respectively). Within first trimester fetal loss cases (below 14 weeks gestation), micro CT analysis yielded significantly fewer non-diagnostic indices than autopsy examination (22/440 vs 48/348 respectively; p<0.001). Conclusion Post mortem whole-body fetal micro CT gives non-invasive, detailed anatomical examinations, achieved in minutes, at high resolution. Micro CT may be preferable to MRI in early gestation fetuses and may offer an acceptable method of examination after fetal loss for parents who decline invasive autopsy. This will facilitate autopsy and subsequent discussions between medical professionals involved in patient care and counselling for future pregnancies.

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.040
       
  • CINE MRI During Spontaneous Cramps in Women with Menstrual Pain
    • Authors: Kevin M. Hellman; Caroline S. Kuhn; Frank F. Tu; Katlyn E. Dillane; Nathan A. Shlobin; Sangeeta Senapati; Xiaojie Zhou; Wei Li; Pottumarthi V. Prasad
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Kevin M. Hellman, Caroline S. Kuhn, Frank F. Tu, Katlyn E. Dillane, Nathan A. Shlobin, Sangeeta Senapati, Xiaojie Zhou, Wei Li, Pottumarthi V. Prasad
      Background The lack of non-invasive methods to study dysmenorrhea has resulted in poor understanding of the mechanisms underlying pain, insufficient diagnostic tests, and limited treatment options. To address this knowledge gap, we have developed an MRI-based strategy for continuously monitoring the uterus in relation to participants’ spontaneous pain perception. Objective The study objective was to evaluate whether MRI can detect real-time changes in myometrial activity during cramping episodes in women with dysmenorrhea, with a hand-held squeeze bulb for pain reporting. Study design Sixteen women with dysmenorrhea and ten healthy control women both on and off their menses were evaluated with MRI while not taking analgesic medication. Continuous MRI was acquired using single-shot HASTE sequence along with simultaneous reporting of pain severity with a squeeze bulb. Pearson’s coefficient was used to compare results between reviewers. Proportional differences between women with dysmenorrhea and controls on/off menses were evaluated with Fisher’s exact test. The temporal relationships between signal changes were evaluated with Monte Carlo simulations. Results Spontaneous progressive decreases in myometrial signal intensity were more frequently observed in women on their menses than in the absence of pain in the same women off their menses or participants without dysmenorrhea (p’s < 0.01). Women without reductions in myometrial signal intensity on their menses either had a history of endometriosis or were not in pain. Observations of myometrial events were consistently reported between two raters blinded to menstrual pain or day status (r=0.97, p<0.001). Episodes of cramping occurred either immediately before or 32-70s after myometrial signal change onset (p’s <0.05). Conclusions Transient decreases in myometrial uterine T2-weighted signal intensity can be reliably measured in women with menstrual pain. The directionality of signal change and temporal relationship to pain onset suggest that cramping pain may be caused by a combination of uterine pressure and hemodynamic dysfunction.

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.035
       
  • Combination Antimicrobial Prophylaxis for Hysterectomy… Harm without
           the Benefit'
    • Authors: Westyn Branch-Elliman; John Ripollone; William O’Brien; Kamal Itani; Judith Strymish; Kalpana Gupta.
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Westyn Branch-Elliman, John Ripollone, William O’Brien, Kamal Itani, Judith Strymish, Kalpana Gupta.


      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.032
       
  • SMFM Statement: Pharmacological treatment of gestational diabetes
    • Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): SMFM Publications Committee


      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.041
       
  • Structural, Functional, and Symptomatic Differences between Women with
           Rectocele versus Cystocele and Normal Support
    • Authors: Mitchell B. Berger; Giselle E. Kolenic; Dee E. Fenner; Daniel M. Morgan; John O.L. DeLancey
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Mitchell B. Berger, Giselle E. Kolenic, Dee E. Fenner, Daniel M. Morgan, John O.L. DeLancey
      Background Prolapse of the anterior and posterior vaginal walls has been generally associated with apical descent and levator ani muscle defects. However, the relative contributions of these factors to the pathophysiology of descent in the different vaginal compartments is not well understood. Furthermore, symptoms uniquely associated with prolapse in these compartments have not been well-characterized. Objectives Compare associations between: 1) apical support, 2) levator ani muscles, and 3) pelvic floor symptoms in women with posterior-predominant prolapse, anterior-predominant prolapse, and normal support. Study Design This is a cross-sectional study with two case arms: 60 women with posterior prolapse, 90 with anterior prolapse, and a referent control arm with 103 asymptomatic subjects with normal support, determined from pelvic organ prolapse quantification examinations. Levator muscle defects were graded from magnetic resonance imaging. Vaginal closure forces above resting were measured with an instrumented speculum during maximal contraction. Pelvic floor symptoms were measured via the Pelvic Floor Distress Inventory – Short Form. Results Mean Point C location in controls was -6.9 cm [1.5] (mean [standard deviation]); and was higher in posterior prolapse (-4.7 cm [2.7], 2.2 cm below controls) than the anterior prolapse group (-1.2 cm [4.1]; 5.6 cm below controls, p<0.001 for all comparisons). Normal-appearing muscles (i.e., muscle without a visible defect) occurred at similar frequencies in posterior prolapse (45%) and controls (51%, p=0.43), but less often in anterior prolapse (28%, p≤0.03 for pairwise comparisons). Major levator ani defects occurred at similar rates in women with posterior (33%) and anterior prolapse (42%, p=0.27), but less often in controls (16%, p≤0.012 for both pairwise comparisons). Similarly, there were significant differences in generated vaginal closure forces across the three groups, with the prolapse groups generating weaker closure forces than the control group (p=0.004), but the differences between the two prolapse groups were not significant after controlling for prolapse size (p=0.43). Pelvic floor symptoms were more severe for the posterior (mean Pelvic Floor Distress Inventory score 129) and anterior prolapse groups (128) than the controls (40.2, p<0.001 for both comparisons); the difference between the two prolapse groups was not significant (p=0.83). Conclusions Posterior-predominant prolapse involves almost 3-fold less apical descent below normal than anterior-predominant vaginal prolapse. Levator ani defects and muscle impairment are also less impacted. Pelvic floor symptoms reflect the presence and size of prolapse more than the predominant lax vaginal compartment.

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.033
       
  • High performance of maternal characteristics and assessment of uterine
           artery Doppler waveform for the prediction of early-onset preeclampsia
    • Authors: Lionel Carbillon
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Lionel Carbillon


      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.038
       
  • Pharmacy-level Barriers to Implementing Expedited Partner Therapy in
           Baltimore, Maryland
    • Authors: Jennifer Z. Qin; Clarissa P. Diniz; Jenell S. Coleman
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Jennifer Z. Qin, Clarissa P. Diniz, Jenell S. Coleman
      Background Addressing record high rates of Chlamydia trachomatis (Ct) incidence in the United States (U.S.) requires the utilization of effective strategies, such as expedited partner therapy (EPT), to reduce reinfection and further transmission. EPT, which can be given as a prescription or medication, is a strategy to treat the sexual partners of index patients diagnosed with a sexually transmitted infection (STI) without prior medical evaluation of the partners. Objective There are multiple steps in the prescription-EPT cascade and we sought to identify pharmacy-level barriers to implementing prescription-EPT for Ct treatment. Study Design We used spatial analysis and ArcGIS, a geographic information system, to map and assess geospatial access to pharmacies within Baltimore, Maryland neighborhoods with the highest rates of Ct (1180.25-4255.31 per 100,000 persons). EPT knowledge and practices were collected via a telephone survey of pharmacists employed at retail pharmacies located in these same neighborhoods. Cost of antibiotic medication in U.S. Dollars (USD) was collected. Results Census tracts with the highest Ct incidence rates had lower median pharmacy density than other census tracts (26.9 per 100,000 v. 31.4 per 100,000, P<.001). We identified 25 pharmacy deserts. Areas defined as pharmacy deserts had larger proportions of Black and Hispanic or Latino populations compared to non-Hispanic whites (93.1% v. 6.3%, P<.001) and trended toward higher median Ct incidence rates (1170.0 per 100,000 v. 1094.5 per 100,000, P=.110) than non-pharmacy desert areas. Of the 52 pharmacies identified, 96% (50/52) responded to our survey. Less than a fifth of pharmacists (18%, 9/50) were aware of EPT for Ct. Most pharmacists (59%, 27/46) confirmed they would fill an EPT prescription. The cost of a single dose of azithromycin (1 gram) ranged from 5-39.99 USD (median, 30 USD). Conclusion Limited geographic access to pharmacies, lack of pharmacist awareness of EPT, and wide variation in EPT medication cost are potential barriers to implementing prescription-EPT. Although most Baltimore pharmacists were unaware of EPT, they were generally receptive to learning about and filling EPT prescriptions. This finding suggests the need for wide dissemination of educational material targeted to pharmacists. In areas with limited geographic access to pharmacies, EPT strategies that do not depend on partners physically accessing a pharmacy merit consideration.
      Teaser A study of pharmacies in Baltimore, Maryland found barriers to prescription-EPT, including limited geographic access to pharmacies, pharmacist unawareness, and high medication cost.

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.036
       
  • Laparoscopic vs. Transvaginal Cuff Closure After Total Laparoscopic
           Hysterectomy: A Randomized Trial by the Italian Society of Gynecologic
           Endoscopy
    • Authors: Stefano Uccella; Mario Malzoni; Antonella Cromi; Renato Seracchioli; Giuseppe Ciravolo; Francesco Fanfani; Fevzi Shakir; Salvatore Gueli Alletti; Francesco Legge; Roberto Berretta; Giacomo Corrado; Lucia Casarella; Paolo Donarini; Margherita Zanello; Emanuele Perrone; Baldo Gisone; Enrico Vizza; Giovanni Scambia; Fabio Ghezzi
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Stefano Uccella, Mario Malzoni, Antonella Cromi, Renato Seracchioli, Giuseppe Ciravolo, Francesco Fanfani, Fevzi Shakir, Salvatore Gueli Alletti, Francesco Legge, Roberto Berretta, Giacomo Corrado, Lucia Casarella, Paolo Donarini, Margherita Zanello, Emanuele Perrone, Baldo Gisone, Enrico Vizza, Giovanni Scambia, Fabio Ghezzi
      Background Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event. Objective Aim of the present randomized study has been to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy (TLH), in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial. Study Design Patients undergoing TLH for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal (TV group) vs. laparoscopic approach (LPS group) using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a post-operative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after TLH. Results After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the post-operative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the TV group and 700 in the LPS group) were similar between groups. Patients in the TV group had a significantly higher incidence of vaginal dehiscence (2.7% vs. 1%; OR:2.78; 95%CI:1.16-6.63;p=0.01) and of any cuff complication (9.8% vs. 4.7%; OR:2.19; 95%CI:1.43-3.37;p=0.0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence. Conclusions Laparoscopic closure of the vaginal cuff at the end of TLH is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal re-suture and reintervention. Trial registration clinicaltrials.gov; protocol number NCT02453165

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.029
       
  • In vivo Raman spectroscopy for biochemical monitoring of the cervix
           throughout pregnancy
    • Authors: Christine M. O’Brien; Elizabeth Vargis; Amy Rudin; James C. Slaughter; Giju Thomas; J Michael Newton; Jeff Reese; Kelly A. Bennett; Anita Mahadevan-Jansen
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Christine M. O’Brien, Elizabeth Vargis, Amy Rudin, James C. Slaughter, Giju Thomas, J Michael Newton, Jeff Reese, Kelly A. Bennett, Anita Mahadevan-Jansen
      Background The cervix must undergo significant biochemical remodeling to allow for successful parturition. This process is not fully understood, especially in instances of spontaneous preterm birth. In vivo Raman spectroscopy is an optical technique that can be used to investigate the biochemical composition of tissue longitudinally and non-invasively in humans, and has been utilized to measure physiology and disease states in a variety of medical applications. Objective The purpose of this study is to measure in vivo Raman spectra of the cervix throughout pregnancy in women, and to identify biochemical markers that change with the preparation for delivery and post-partum repair. Study Design Sixty-eight healthy pregnant women were recruited. Raman spectra were measured from the cervix of each patient monthly in the first and second trimesters, weekly in the third trimester, and at the six week post-partum visit. Raman spectra were measured using an in vivo Raman system with an optical fiber probe to excite the tissue with 785 nm light. A spectral model was developed to highlight spectral regions that undergo the most changes throughout pregnancy, which were subsequently used for identifying Raman peaks for further analysis. These peaks were analyzed longitudinally to determine if they underwent significant changes over the course of pregnancy (p<0.05). Finally, six individual components that comprise key biochemical constituents of the human cervix were measured to extract their contributions in spectral changes throughout pregnancy using a linear combination method. Patient factors including body mass index (BMI) and parity were included as variables in these analyses. Results Raman peaks indicative of extracellular matrix proteins (1248, 1254cm-1) significantly decreased (p<0.05), while peaks corresponding to blood (1233 and 1563 cm-1) significantly increased (p<0.0005) in a linear manner throughout pregnancy. In the post-partum cervix, significant increases in peaks corresponding to actin (1003, 1339, 1657 cm-1) and cholesterol (1447 cm-1) were observed when compared to late gestation, while signatures from blood significantly decreased. Post-partum actin signals were significantly higher than early pregnancy, whereas extracellular matrix (ECM) proteins and water signals were significantly lower than early weeks of gestation. Parity had a significant effect on blood and ECM protein signals, with nulliparous patients having significant increases in blood signals throughout pregnancy, and higher ECM protein signals in early pregnancy compared to patients with prior pregnancies. Body mass index significantly affected actin signal contribution, with low BMI patients showing decreasing actin contribution throughout pregnancy and high BMI patients demonstrating increasing actin signals. Conclusion Raman spectroscopy was successfully used to biochemically monitor cervical remodeling in pregnant women during prenatal visits. This foundational study has demonstrated sensitivity to known biochemical dynamics that occur during cervical remodeling, and identified patient variables that have significant effects on Raman spectra throughout pregnancy. Raman spectroscopy has the potential to improve our understanding of cervical maturation, and be used as a non-invasive preterm birth risk assessment tool to reduce the incidence, morbidity, and mortality caused by preterm birth.

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.030
       
  • Predictors of Sleep Disordered Breathing in Pregnancy
    • Authors: Judette M. Louis; Matthew A. Koch; Uma M. Reddy; Robert M. Silver; Corette B. Parker; Francesca L. Facco; Susan Redline; Chia-Ling Nhan-Chang; Judith H. Chung; Grace W. Pien; Robert C. Basner; William A. Grobman; Deborah A. Wing; Hyagriv N. Simhan; David M. Haas; Brian M. Mercer; Samuel Parry; Daniel Mobley; Benjamin Carper; George R. Saade; Frank P. Schubert; Phyllis C. Zee
      Abstract: Publication date: Available online 2 February 2018
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Judette M. Louis, Matthew A. Koch, Uma M. Reddy, Robert M. Silver, Corette B. Parker, Francesca L. Facco, Susan Redline, Chia-Ling Nhan-Chang, Judith H. Chung, Grace W. Pien, Robert C. Basner, William A. Grobman, Deborah A. Wing, Hyagriv N. Simhan, David M. Haas, Brian M. Mercer, Samuel Parry, Daniel Mobley, Benjamin Carper, George R. Saade, Frank P. Schubert, Phyllis C. Zee
      Background Sleep disordered breathing (SDB) is common in pregnancy, but there are limited data on predictors. Objectives The objective of this study was to develop predictive models of SDB during pregnancy. Study Design Nulliparous women completed validated questionnaires to assess for symptoms related to snoring, fatigue, excessive daytime sleepiness insomnia and restless leg syndrome. These included questions regarding the timing of sleep and sleep duration, work schedules (e.g., shift work, night work), sleep positions, and previously diagnosed sleep disorders. Frequent snoring was defined as self-reported snoring ≥3 days per week. Participants underwent in-home portable sleep studies for SDB assessment in early (6-15 weeks’) and mid-pregnancy (22-31 weeks’). SDB was characterized using an apnea hypopnea index (AHI) that included all apneas, plus hypopneas with ≥3% oxygen desaturation. For primary analyses, an AHI ≥5 events/hour was used to define SDB. Odds ratios and 95% confidence intervals (CIs) were calculated for predictor variables. Predictive ability of the logistic models was estimated using area under the receiver-operating-characteristic curves, along with sensitivities, specificities, and positive and negative predictive values and likelihood ratios. Results Among 3705 women who were enrolled, data were available for 3,264 and 2,512 women in early and mid-pregnancy, respectively. The corresponding prevalence of SDB was 3.6% and 8.3%. At each time point in gestation, frequent snoring, chronic hypertension, greater maternal age, BMI, neck circumference, and systolic blood pressure were most strongly associated with an increased risk of SDB. Logistic regression models that included current age, BMI, and frequent snoring predicted SDB in early pregnancy, SDB in mid-pregnancy, and new onset SDB in mid-pregnancy with 10-fold cross-validated AUCs of 0.870, 0.838, and 0.809. We provide a supplement with expanded tables, integrated predictiveness and classification curves, and an Excel predicted probability calculator. Conclusion(s) Among nulliparous pregnant women, logistic regression models with just three variables (i.e., age, BMI, and frequent snoring) achieved good prediction of prevalent and incident SDB. These results can help with screening for SDB in the clinical setting and for future clinical treatment trials.

      PubDate: 2018-02-03T23:03:41Z
      DOI: 10.1016/j.ajog.2018.01.031
       
 
 
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