Journal Cover
American Journal of Obstetrics and Gynecology
Journal Prestige (SJR): 2.7
Citation Impact (citeScore): 4
Number of Followers: 266  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0002-9378
Published by Elsevier Homepage  [3181 journals]
  • Preeclampsia: a defect in decidualization is associated with deficiency of
           Annexin A2
    • Abstract: Publication date: Available online 15 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Tamara Garrido-Gomez, Alicia Quiñonero, Francisco Dominguez, Laura Rubert, Alfredo Perales, Katherine Amberson Hajjar, Carlos Simon BackgroundDecidualization defects in the endometrium have been demonstrated at the time of delivery in women with severe preeclampsia (sPE) and linger for years, suggesting a maternal contribution to the pathogenesis of this condition. Global transcriptional profiling reveals alterations in gene expression, including downregulation of Annexin A2 (ANXA2) in sPE patients with decidualization resistance.ObjectiveWe investigated the functional role of ANXA2 deficiency during endometrial decidualization and its potential contribution to shallow trophoblast invasion during implantation and subsequent placentation using in vitro and in vivo modeling.Study DesignANXA2 gene and protein levels were assessed during in vitro decidualization of human endometrial stromal cells (hESCs) isolated from biopsies collected from women with previous severe preeclampsia (sPE) (n=5) or normal obstetric outcomes (n=5). Next, ANXA2 was inhibited with small interference RNA (siRNA) in control hESC cells isolated from endometrial biopsies (n=15) as an in vitro model to analyze decidualization defects at the morphological level as well as secretion of prolactin (PRL) and insulin-like growth binding protein-1 (IGFPB1). ANXA2-inhibited cells were used to evaluate motility and promotion of embryo invasion. Decidualization and placentation defects of ANXA2 deficiency were confirmed using an ANXA2-null mouse model.ResultsANXA2 gene and protein levels were downregulated during in vitro decidualization of hESCs from women with prior sPE compared to control individuals. To assess its role in the endometrial stroma, we inhibited ANXA2 expression and detected decidualization failure as evidenced by impaired morphological transformation, which was associated with altered actin polymerization and low PRL and IGFBP1 secretions. Functionally, in vitro models demonstrated that ANXA2 inhibition failed to support embryo invasion. This finding was corroborated by reduced trophoblast spreading through hESCs, lack of motility of these cells, and reduced trophoblast invasion in the presence of conditioned media from ANXA2-inhibited cells. Extending our discovery to an animal model, we detected that ANXA2-null mice have a functional deficiency in decidualization and placentation that impairs fetal growth as a feature associated with sPE.ConclusionsTogether, in vitro and in vivo results suggest that endometrial defects in ANXA2 expression impair decidualization of endometrial stromal cells as well as the uterine microenvironment that promotes embryo implantation and placentation. Our findings highlight the maternal contribution to the pathogenesis of sPE and suggest that evaluation of ANXA2 may provide a novel strategy to assess a woman’s risk of developing this pathology and perhaps discover therapeutic interventions to improve decidualization.
       
  • Response to letter: Scientific pathophysiology of intrapartum fetal
           hypoxaemia and cardiotocography pattern recognition
    • Abstract: Publication date: Available online 13 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Jessica M. Turner, Murray D. Mitchell, Sailesh Kumar
       
  • Scientific pathophysiology of intrapartum fetal hypoxemia and
           cardiotocography pattern-recognition.
    • Abstract: Publication date: Available online 13 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Shashikant L. Sholapurkar
       
  • THE COMPETING RISK APPROACH FOR PREDICTION OF PREECLAMPSIA
    • Abstract: Publication date: Available online 13 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): David Wright, Alan Wright, Kypros H. Nicolaides The established method of assessing the risk for development of preeclampsia (PE) is to identify risk factors from maternal demographic characteristics and medical history; in the presence of such factors the patient is classified as high-risk and in their absence as low-risk. Although this approach is simple to perform, it has poor performance of predicting PE and does not provide patient-specific risks. This review describes a new approach which allows estimation of patient-specific risks of delivery with PE before any specified gestational age by maternal demographic characteristics and medical history with biomarkers obtained either individually or in combination at any stage in pregnancy. In the competing risks approach every woman has a personalized distribution of gestational age at delivery with PE and whether she develops PE or not before a specified gestational age depends on competition between delivery before or after development of PE. The personalized distribution comes from the application of Bayes theorem to combine a prior distribution, determined from maternal factors, with likelihoods from biomarkers. As new data become available, what were posterior probabilities take the role as the prior and data collected at different stages are combined by repeating the application of Bayes theorem to form a new posterior at each stage allowing for dynamic prediction of PE. The competing risk model can be used for precision medicine and risk stratification at different stages of pregnancy. In the first-trimester, the model has been applied to identify a high-risk group that would benefit from preventative therapeutic interventions. In the second-trimester, the model has been used to stratify the population into high- intermediate- and low-risk groups in need of different intensities of subsequent monitoring thereby minimizing unexpected adverse perinatal events. The competing risks model can also be used in surveillance of women presenting to specialist clinics with signs or symptoms of hypertensive disorders; combination of maternal factors and biomarkers provide patient-specific risks for PE leading to personalized stratification of the intensity of monitoring with risks updated on each visit on the basis of biomarker measurements.
       
  • Association between Neuraxial Analgesia and Postpartum Opioid Use
           following Vaginal Delivery
    • Abstract: Publication date: Available online 13 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Nevert Badreldin, William A. Grobman, Lynn M. Yee
       
  • A new methodologic approach for clinico-pathologic correlations in
           invasive placenta previa accreta
    • Abstract: Publication date: Available online 12 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Eric Jauniaux, Ahmed M. Hussein, Nurit Zosmer, Rana M. Elbarmelgy, Rasha A. Elbarmelgy, Hizbullah Shaikh, Graham J. Burton BackgroundThe development of new management strategies for women presenting with placenta accreta spectrum requires quality epidemiology data which have so far been limited by the high variability in clinical and histopathologic data confirming the diagnosis at birth.ObjectiveTo evaluate the role of a new methodologic approach for the correlation of clinical and pathological data for women with a history of prior cesarean delivery diagnosed prenatally with placenta previa accreta.Study DesignA modified pathologic technique for gross examination of hysterectomy specimens with placenta in-situ consisting of intra-operative examination, immediate post-operative examination and guided histologic sampling was used prospectively in a cohort of 24 patients with singleton pregnancies complicated by placenta low-lying/placenta previa accreta. The maternal characteristics, detailed ultrasound findings, surgical outcomes and histopathologic examination were compared with those of a group of 24 patients with similar clinical characteristics where a standard pathologic examination method was used.ResultsThe median reporting time for obtaining the complete histopathology results including the microscopic examination was significantly shorter (7 vs 15 days; P
       
  • Chronic Hypertension in Pregnancy
    • Abstract: Publication date: Available online 9 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Ashley N. Battarbee, Rachel G. Sinkey, Lorie M. Harper, Suzanne Oparil, Alan T.N. Tita Chronic hypertension and associated cardiovascular disease are among the leading causes of maternal and perinatal morbidity and mortality in the United States. Chronic hypertension in pregnancy is associated with a host of adverse outcomes, including preeclampsia, cesarean delivery, cerebrovascular accidents, fetal growth restriction, preterm birth, and maternal and perinatal mortality. There are several key issues related to the diagnosis and management of chronic hypertension in pregnancy where data are limited and further research is needed. These challenges and recent guidelines for the management of chronic hypertension are reviewed. Well-timed pregnancies are of utmost importance to reduce the risks of chronic hypertension and long-acting reversible contraceptive options are preferred. Specifically, blood pressure thresholds for diagnosis and treatment in order to optimize short- and long-term maternal and perinatal outcomes should be prioritized along with interventions to reduce extant racial and ethnic disparities.
       
  • Survival Outcomes for Robotic-Assisted Laparoscopy Versus Traditional
           Laparoscopy in Clinical Stage I Epithelial Ovarian Cancer
    • Abstract: Publication date: Available online 9 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Benjin Facer, Fei Wang, Carlos G. Grijalva, Ronald D. Alvarez, Xiao-Ou Shu BackgroundThe Food and Drug Administration recently called for studies addressing long-term survival after robotic-assisted laparoscopy in oncologic settings. Long-term clinical outcomes of robotic-assisted laparoscopy among ovarian cancer patients are understudied.Objective(s)To investigate the long-term mortality of robotic-assisted laparoscopy compared to traditional laparoscopy for clinical stage I epithelial ovarian cancer.Study DesignUsing data from the National Cancer Database, we identified a total of 1,901 patients who received minimally invasive surgery (i.e., robotic-assisted laparoscopy or traditional laparoscopy) for clinical stage I epithelial ovarian cancer between 2010 and 2014. Multivariable logistic or linear regression analyses were conducted to evaluate the short-term outcomes, including conversion-to-open surgery, number of lymph nodes examined, length of hospitalization, unplanned 30-day readmission and 30- and 90-day mortality. Multivariable Cox proportional hazards models were used to derive adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for 1-, 3- and 5-year total mortality associated with surgical approaches. Covariates adjusted for included age, tumor size and upstaging, number of lymph nodes evaluated, time from diagnosis to surgery, length of hospitalization, histologic subtype, insurance status, region, distance to care, surgical procedure type, and hospital experience with these procedures.ResultsCompared to traditional laparoscopy, robotic-assisted laparoscopy was less likely to result in conversion-to-open surgery (conversion rate: 7.2% vs 17.9%, P
       
  • Tuberculosis in term pregnancy
    • Abstract: Publication date: Available online 7 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Fang Long, Cirenji, Zhen Xiao
       
  • Obesity, smoking, and risk of vasomotor menopausal symptoms: a pooled
           analysis of eight cohort studies
    • Abstract: Publication date: Available online 6 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Debra J. Anderson, Hsin-Fang Chung, Charrlotte A. Seib, Annette J. Dobson, Diana Kuh, Eric J. Brunner, Sybil L. Crawford, Nancy E. Avis, Ellen B. Gold, Gail A. Greendale, Ellen S. Mitchell, Nancy F. Woods, Toyoko Yoshizawa, Gita D. Mishra BackgroundFrequent and severe vasomotor symptoms during menopause are linked with adverse health outcomes. Understanding modifiable lifestyle factors for the risk of vasomotor menopausal symptoms is important to guide preventive strategies.ObjectiveWe investigated the associations between body mass index and smoking, and their joint effects with the risk of vasomotor symptoms, and whether the associations differed by menopausal stage.Study DesignThe International Collaboration for a Life Course Approach to Reproductive Health and Chronic Disease Events pooled data on 21,460 midlife women from eight studies (median age 50 years, interquartile range 49–51 years) for the cross-sectional analysis. Four studies provided data for the prospective analysis (n=11,986). Multinomial logistic regression models with four categories of frequency/severity for the outcome of vasomotor symptoms were used to estimate relative risk ratios (RRR) and 95% confidence intervals (CI) adjusted for within-study correlation and covariates.ResultsAt baseline, nearly 60% of the women experienced vasomotor symptoms. Half of them were overweight (30%) or obese (21%), and 17% were current smokers. Cross-sectional analyses showed that a higher body mass index and smoking more cigarettes with longer duration and earlier initiation were all associated with more frequent or severe vasomotor symptoms. Never smokers who were obese had a 1.5-fold (RRR, 1.52; 95% CI, 1.35–1.73) higher risk of often/severe vasomotor symptoms, compared with never smokers who were of normal-weight. Smoking strengthened the association as the risk of often/severe vasomotor symptoms was much greater among smokers who were obese (RRR, 3.02; 95% CI, 2.41–3.78). However, smokers who quit before 40 years of age were at similar levels of risk as never smokers. Prospective analyses showed a similar pattern, but the association attenuated markedly after adjustment for baseline vasomotor symptoms. Furthermore, we found that the association between body mass index and vasomotor symptoms differed by menopausal status. Higher body mass index was associated with increased risk of vasomotor symptoms in pre- and perimenopause but with reduced risk in postmenopause.ConclusionHigh body mass index (≥25 kg/m2) and cigarette smoking substantially increased women’s risk for experiencing frequent or severe vasomotor symptoms in a dose-response manner, and smoking intensified the effect of obesity. However, the effect of body mass index on the risk vasomotor symptoms was opposite among postmenopausal women. Maintaining a normal weight before the menopausal transition and quitting smoking before age 40 years may mitigate the excess risk of VMS in midlife.
       
  • FIRST TRIMESTER SERUM ANGIOGENIC AND ANTI-ANGIOGENIC FACTORS IN WOMEN WITH
           CHRONIC HYPERTENSION FOR THE PREDICTION OF PREECLAMPSIA
    • Abstract: Publication date: Available online 6 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Diane Nzelu, Dan Biris, Theodoros Karampitsakos, Kypros K. Nicolaides, Nikos A. Kametas BackgroundAn imbalance between angiogenic and antiangiogenic factors is thought to be a central pathogenetic mechanism in preeclampsia. In pregnancies that subsequently develop preeclampsia the maternal serum concentration of the angiogenic placental growth factor (PLGF) is decreased from as early as the first trimester of pregnancy and the concentration of the antiangiogenic soluble fms-like tyrosine kinase-1 (sFLT-1) is increased in the last few weeks before the clinical presentation of the disease. Chronic hypertension, which complicates 1-2% of pregnancies, is the highest risk factor for development of preeclampsia among all other factors in maternal demographic characteristics and medical history. Two previous studies in women with chronic hypertension reported that first-trimester serum PLGF and sFLT-1 were not significantly different between those that developed superimposed preeclampsia and those that did not, whereas a third study reported that concentrations of PLGF were decreased.ObjectiveTo investigate whether in women with chronic hypertension serum concentrations of PLGF and sFLT-1 and sFLT-1/PLGF ratio at 11+0 to 13+6 weeks’ gestation are different between those that developed superimposed preeclampsia and those that did not and to compare these values to those in normotensive controls.Study designThe study population comprised of 650 women with chronic hypertension, including 202 that developed superimposed preeclampsia and 448 that did not develop preeclampsia, and 142 normotensive controls. Maternal serum concentration of PLGF and sFLT-1 were measured by an automated biochemical analyzer and converted into multiples of the expected median (MoM) using multivariate regression analysis in the control group. Comparisons of PLGF, sFLT-1 and sFLT-1/PLGF ratio in MoM values between the two groups of chronic hypertension and the controls were made by the ANOVA or the Kruskal-Wallis test.ResultsIn the group of chronic hypertension that developed preeclampsia, compared to those that did not develop preeclampsia, there were significantly lower median concentrations of serum PLGF MoM (0.904, interquartile range (IQR) 0.771-1.052 vs. 0.948, IQR 0.814-1.093; p=0.014) and sFLT-1 MoM (0.895, IQR 0.760-1.033 vs 0.938, IQR 0.807-1.095; p=0.013) and they were both lower than in the normotensive controls (1.009, IQR 0.901-1.111 and 0.991, IQR 0.861-1.159, respectively; P
       
  • The worst of both worlds—combined deliveries in twin gestations: a
           subanalysis of the Twin Birth Study, a randomized, controlled, prospective
           study
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): Amir Aviram, Hayley Lipworth, Elizabeth V. Asztalos, Elad Mei-Dan, Xingshan Cao, Nir Melamed, Arthur Zaltz, Hannah B. Anastasio, Vincenzo Berghella, Jon F.R. BarrettObjectiveThe reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study.Study designThe Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries.ResultsOf the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P = 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4–124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score
       
  • An arm-based network meta-analysis on treatments for vulvar lichen
           sclerosus and a call for development of core outcome sets: Treatment
           options for vulvar lichen sclerosus
    • Abstract: Publication date: Available online 5 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Vasilios Pergialiotis, Ioannis Bellos, Eirini-Chrysovalantou Biliou, Panagiota Varnava, Dimitra Mitsopoulou, Stergios K. Doumouchtsis ObjectiveThe purpose of the present systematic review is to evaluate the available medical treatments for vulvar lichen sclerosus, using an arm based network meta-analysis protocol.Data sourcesWe searched Medline (1966–2019), Scopus (2004–2019), Cochrane Central Register of Controlled Trials CENTRAL (1999-2019) and Clinicaltrials.gov (2008–2019) databases. Google Scholar (2004-2019) database, along with the reference list of all included studies.Study eligibility criteriaAll observational, randomized and single arm studies that evaluated medical treatments for vulvar lichen sclerosus were considered eligible for inclusion in the present systematic review.Study appraisalNetwork meta-analysis was carried-out in R-3.4.3 using the “pcnetmeta” package which uses a Bayesian hierarchical model (based in Markov Chain Monte Carlo Convergence (MCMC) simulation).ResultsSixteen studies were included in this present meta-analysis which recruited 954 women with vulvar lichen sclerosus. Their quality was evaluated with the JADAD, Cochrane risk of bias and ROBINS-I tools. Clobetasol treatment ranked as the best treatment for disease remission after evaluating rank probabilities [40% chance of ranking 1st compared to tacrolimus (38%)]. However, the density plot revealed partial overlapping with tacrolimus. The lowest probability of experiencing a relapse was observed with pimecrolimus (15% [2-48%]); however, the density plot revealed significant overlapping with mometasone furoate, testosterone and clobetasol.ConclusionRobust evidence concerning the superiority of potent steroids at least over calcineurin inhibitors is still lacking in the field of vulvar lichen sclerosus. On the other hand, the gross heterogeneity in terms of selected population, duration of treatment, administered regimen, outcome reporting and selection of outcome measures leaves several fields unanswered.
       
  • September 2019 (vol. 221, no. 3, page 175)
    • Abstract: Publication date: Available online 5 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s):
       
  • Fetal hypertension and abnormal fetal cardiac morphology.
    • Abstract: Publication date: Available online 4 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Yan Qiu Wang, Hui Juan Zhang, M.J. Quinn
       
  • Fetal cardiac structure and function in preeclampsia and/or fetal growth
           restriction
    • Abstract: Publication date: Available online 4 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Lina Youssef, Fatima Crispi
       
  • Rates of recognized pregnancy in women with disabilities in Ontario,
           Canada
    • Abstract: Publication date: Available online 2 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Hilary K. Brown, Simon Chen, Astrid Guttmann, Susan M. Havercamp, Susan Parish, Joel G. Ray, Lesley A. Tarasoff, Simone N. Vigod, Adele Carty, Yona Lunsky
       
  • Preeclampsia resolution after fetal death in multifetal gestation: A
           systematic literature review
    • Abstract: Publication date: Available online 2 November 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Amelie Pham, Emily Rosenthal, Amanda Roman, Mona Makhamreh, Vincenzo Berghella, Farnaz Farhi, Huda B. Al-Kouatly
       
  • Learning curve of robot-assisted laparoscopic sacrocolpo(recto)pexy: a
           cumulative sum analysis
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Femke van Zanten, Steven E. Schraffordt Koops, Pieternel C.M. Pasker-De Jong, Egbert Lenters, Henk W.R. SchreuderBackgroundDetermination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves in robot-assisted laparoscopic pelvic floor surgery.ObjectiveThe purpose of this study was to assess the learning curve in robot-assisted laparoscopic pelvic floor surgery.Study DesignWe conducted a prospective cohort study. Consecutive patients who underwent robot-assisted laparoscopic sacrocolpopexy or sacrocolporectopexy were included (n=372). Patients were treated in a teaching hospital with a tertiary referral function for gynecologic/multicompartment prolapse. Procedures were performed by 2 experienced conventional laparoscopic surgeons (surgeons A and B). Baseline demographics were scored per groups of 25 consecutive patients. The primary outcome was the determination of proficiency, which was based on intraoperative complications. Cumulative sum control chart analysis allowed us to detect small shifts in a surgeon’s performance. Proficiency was obtained when the first acceptable boundary line of cumulative sum control chart analysis was crossed. Secondary outcomes that were examined were shortening and/or stabilization of surgery time (measured with the use of cumulative sum control chart analysis and the moving average method).ResultsSurgeon A performed 242 surgeries; surgeon B performed 137 surgeries (n=7 surgeries were performed by both surgeons). Intraoperative complications occurred in 1.9% of the procedures. The learning curve never fell below the unacceptable failure limits and stabilized after 23 of 41 cases. Proficiency was obtained after 78 cases for both surgeons. Surgery time decreased after 24–29 cases in robot-assisted sacrocolpopexy (no distinct pattern for robot-assisted sacrocolporectopexy). Limitations were the inclusion of 2 interventions and concomitant procedures, which limited homogeneity. Furthermore, analyses treated all complications in cumulative sum as equal weight, although there are differences in the clinical relevance of complications.ConclusionAfter 78 cases, proficiency was obtained. After 24–29 cases, surgery time stabilized for robot-assisted sacrocolpopexy. In this age of rapidly changing surgical techniques, it can be difficult to determine the learning curve of each procedure. Cumulative sum control chart analysis can assist with this determination and prove to be a valuable tool. Training programs could be individualized to improve both surgical performance and patient benefits.
       
  • Micrognathia
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • Paramedian Orofacial Cleft
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • Absent nasal bone
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • SMFM Fetal Anomalies Consult Series #1: Facial Anomalies
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine (SMFM), Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • The Society for Maternal-Fetal Medicine (SMFM) Fetal Anomalies Consult
           Series
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Joanne E. Stone, Jeffrey A. Kuller, Mary E. Norton, Alfred Abuhamad
       
  • SMFM Divider Page
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s):
       
  • Reply
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Koji Matsuo, Alexander Melamed, Jason D. Wright
       
  • Minimally invasive surgery for early-stage cervical cancer: is the uterine
           manipulator a risk factor'
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Anna Dietl, Maximilian Klar, Konrad Aumann
       
  • Magnetic resonance imaging for placenta accreta: hope for the future
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Grace Lim, Marc Lim, Jeanne M. Horowitz
       
  • Uterine legacy of open maternal–fetal surgery: preterm uterine
           rupture
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Ramen H. Chmait, Eftichia V. Kontopoulos, Rubén A. Quintero
       
  • Reply
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): David Wright, Kypros H. Nicolaides
       
  • Incorporating the probability of competing event(s) into the preeclampsia
           competing risk algorithm
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): David A. Krantz, Terrence W. Hallahan
       
  • Strengthening opioid use disorder training among
           obstetrician-gynecologists: Hollander et al’s call to action
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Gregory T. Woods, Stephanie L. Lim, Julia R. Salinaro
       
  • Compliance with cervical cancer screening guidelines in young female
           patients: rates and trends of screening in New Haven County, CT
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Carlos R. Oliveira, Hillary Hosier, Blake Pate, Linda M. Niccolai, Sangini S. Sheth, Alla Vash-Margita
       
  • Routine screening of pregnant women for Zika virus in the setting of local
           transmission—Miami−Dade County, Florida, 2016–2017
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Teresa Logue, Nicole Muse, Álvaro Mejia-Echeverry, Guoyan Zhang, Marie Etienne, Mercedes Rojas, Elizabeth Timoszyk, Danielle Fernandez, Stephanie Calle, Cynthia Goldberg, Amena Arshad, Edhelene Rico, Pedro Noya-Chaveco, Reynald Jean, Lillian Rivera, Rafael Mendoza, Stephen White, Leah D. Gillis, Lea Heberlein-Larson, Yesenia Villalta
       
  • Feasibility and acceptability of home use of a smartphone-based urine
           testing application among women in prenatal care
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Anne E. Burke, Katrina M. Thaler, Mika Geva, Yonatan Adiri
       
  • Surgical management of neuroproliferative-associated vestibulodynia:
           a tutorial on vestibulectomy with vaginal advancement flap
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Catherine Wu, Andrew Goldstein, Jordan S. Klebanoff, Gaby N. MoawadProvoked vestibulodynia is an often underdiagnosed and mismanaged medical condition that impacts the lives of many women. When symptoms are due to a dramatically increased density of pain fibers in the vestibular endoderm, the condition is referred to as neuroproliferative-associated vestibulodynia. Unfortunately, assessment of pain fiber density can only be performed after surgery during histologic examination. First-line therapies for this condition often include topical or oral medications targeting hyperalgesia and allodynia at the vulvar vestibule. However, in the setting of refractory disease, surgical treatment should be considered. The surgical video (Video 1) highlights anatomical landmarks as well as key surgical steps when performing a vulvar vestibulectomy with a vaginal advancement flap for the treatment of neuroproliferative-associated vestibulodynia. Surgeons should have a thorough understanding of pertinent vulvar anatomical landmarks before performing this procedure (Figure 1). The goal of vulvar vestibulectomy, as described in this video, is to excise the entirety of the vestibule containing the pathologic density of afferent pain fibers. This tutorial serves to identify key anatomical landmarks including Hart’s line as well as outline the meticulous dissection required for successful completion of this procedure. We describe our surgical instrumentation as well as provide insight into steps that can be taken to minimize postoperative morbidity.
       
  • Intravesical pregnancy due to vesicouterine fistula
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Sandro Santos Fenelon, Públio Cesar Cavalcante Viana, Guilherme Orpinelli Ramos do Rego
       
  • A novel measurement of pelvic floor cross-sectional area in older and
           younger women with and without prolapse
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Anne G. Sammarco, David D. Sheyn, Tessa E. Krantz, Cedric K. Olivera, Antonio A. Rodrigues, Ms. Emily K. Kobernik, Mariana Masteling, John O. DelanceyBackgroundAn increase in size of the aperture of the pelvis that must be spanned by pelvic floor support structures translates to an increase in the force on these structures. Prior studies have measured the bony dimensions of the pelvis, but the effect of changes in muscle bulk that may affect the size of this area are unknown.ObjectivesTo develop a technique to evaluate the aperture size in the anterior pelvis at the level of the levator ani muscle attachments, and to identify age-related changes in women with and without prolapse.Materials and MethodsThis was a technique development and pilot case-control study evaluating pelvic magnetic resonance imaging from 30 primiparous women from the Michigan Pelvic Floor Research Group MRI Data Base: 10 younger women with normal support, 10 older women with prolapse, and 10 older menopausal women without prolapse. Anterior pelvic area measurements were made in a plane that included the bilateral ischial spines and the inferior pubic point, approximating the level of the arcus tendineus fascia pelvis. Measurements of the anterior pelvic area, obturator internus muscles, and interspinous diameter were made by 5 independent raters from the Society of Gynecologic Surgeons Pelvic Anatomy Group who focused on developing pelvic imaging techniques, and evaluating interrater reliability. Demographic characteristics were compared across groups of interest using the Wilcoxon rank sum test, χ2, or Fisher exact test where appropriate. Multiple linear regression models were created to identify independent predictors of anterior pelvic area.ResultsPer the study design, groups differed in age and prolapse stage. There were no differences in race, height, body mass index, gravidity, or parity. Patients with prolapse had a significantly longer interspinous diameter, and more major (>50% of the muscle) levator ani defects when compared to both older and younger women without prolapse. Interrater reliability was high for all measurements (intraclass correlation coefficient = 0.96). The anterior pelvic area (cm2) was significantly larger in older women with prolapse compared to older (60 ± 5.1 vs 53 ± 4.9, P = .004) and younger (60 ± 5.1 vs 52 ± 4.6, P = .001) women with normal support. The younger and older women with normal support did not differ in anterior pelvic area (52 ± 4.6 vs 53 ± 4.9, P = .99). After adjusting for race and body mass index, increased anterior pelvic area was significantly associated with the following: being an older woman with prolapse (β = 6.61 cm2, P = .004), and interspinous diameter (β = 4.52 cm2, P = .004).ConclusionOlder women with prolapse had the largest anterior area, suggesting that the anterior pelvic area is a novel measure to consider when evaluating women with prolapse. Interspinous diameter, and being an older woman with prolapse, were associated with a larger anterior pelvic area. This suggests that reduced obturator internus muscle size with age may not be the primary factor in determining anterior pelvic area, but that pelvic dimensions such as interspinous diameter could play a role. The measurements were highly repeatable. The high intraclass correlation coefficient indicates that all raters were able to successfully learn the imaging software and to perform measurements with high reproducibility.
       
  • Anatomy, histology, and nerve density of clitoris and associated
           structures: clinical applications to vulvar surgery
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Lindsey A. Jackson, Adam M. Hare, Kelley S. Carrick, Denise M.O. Ramirez, Jennifer J. Hamner, Marlene M. CortonBackgroundA precise understanding of structures comprising the female external genitalia is essential in obstetric and gynecologic practice.ObjectiveTo further characterize the anatomy, histology, and nerve density of the clitoris and associated structures, and to provide clinical correlations to vulvar surgery.Materials and MethodsUnembalmed female cadavers were examined. The length and width of the body, glans, and crura of the clitoris were measured. Distances from the glans to the urethra and from the dorsal surface of the clitoral body to the mid pubic arch were recorded. The path of the dorsal nerve of the clitoris was examined, and the nerve width was measured as it emerged from the lateral surface of crura and at the distal clitoral body. Distances from where the dorsal nerve emerged from the perineal membrane to the posterior surface of the membrane and to mid pubic arch were measured. Connective tissue layers associated with the clitoris were examined. Tissue was harvested from additional unembalmed cadavers, and nerve density of the labia minora, glans, and clitoral body were analyzed. Histological examination was performed on vulvar structures to clarify tissue composition. Descriptive statistics were used for data analyses.ResultsA total of 27 cadavers (aged 48–96 years) were examined, 22 grossly and 5 histologically. The median length and width of clitoral body were 29 mm (range, 13–59 mm) and 9 mm (range, 5–14 mm), respectively. The glans was 8 mm (range, 5–12 mm) long and 4 mm (range, 3–10 mm) wide. The length of the crura was 50 mm (range, 25–68 mm), and the width at the anterior portion was 9 mm (range, 2–13 mm). The closest distance from the glans to the urethra was 25 mm (range, 14–37 mm) and from the clitoral body to the mid pubic arch was 29 mm (range, 14–46 mm). The widths of the dorsal nerve at the lateral crura and at the distal clitoral body were 3 mm (range, 2–4 mm) and 1 mm (range, 1–2 mm), respectively. The distance from the dorsal nerve as it emerged from the perineal membrane to the mid pubic arch was 34 mm (range, 20–48 mm) and to the posterior surface of the membrane was 20 mm (range, 8–31 mm). The dorsal nerve and artery of the clitoris coursed adjacent to the medial surface of the inferior pubic ramus surrounded by a dense fibrous capsule adherent to the periosteum. The nerve and artery then coursed deep to dense connective tissue layers, which were contiguous with the suspensory ligament and fascia of the clitoris. Histologic examination revealed the presence of erectile tissue in the clitoral body, crura, and vestibular bulbs, but such tissue was absent in the glans and labia minora. Nerve density analysis revealed statistically significant greater density in the dorsal compared with ventral half of the clitoral body. Although not statistically significant, there was increased nerve density in the distal compared to the proximal half of the labia minora.ConclusionPrecise knowledge of clitoral anatomy and associated neurovascular structures is essential to safely complete partial vulvectomies, clitoral and vulvar reconstructive procedures, anti-incontinence surgeries, and repair of obstetric lacerations. Understanding the range of anatomic variations and awareness of the areas of increased nerve density is important during counseling and surgical planning. Although the dorsal nerve of the clitoris courses deep to dense connective tissue layers, inadvertent injury may occur in the setting of deep dissection or suture placement. The dorsal nerve seems most vulnerable with surgical entry or lacerations that extend from the midline of the prepuce to the inferior pubic rami.
       
  • A randomized, double-blind, placebo-controlled trial of onabotulinumtoxin
           A trigger point injections for myofascial pelvic pain
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Sybil G. Dessie, Emily Von Bargen, Michele R. Hacker, Miriam J. Haviland, Eman ElkadryBackgroundPelvic pain is estimated to effect 15% of women, and onabotulinumtoxin A is used to treat a variety of pain disorders. However, the data on the use of onabotulinumtoxin A for the treatment of women with myofascial pelvic pain are limited.ObjectiveThe objective of the study was to compare the effect of onabotulinumtoxin A vs placebo injections to the pelvic floor muscles in women with myofascial pelvic pain.Study DesignThis was a double-blind, randomized, placebo-controlled trial in women with myofascial pelvic pain. Women ≥18 years were eligible if they reported pain ≥6 on a 10 point visual analog scale ≥50% of the time and had pain on palpation ≥6 on the visual analog scale in ≥1 of 6 pelvic floor muscle groups. Participants were randomly allocated to a pelvic floor injection of 200 units of onabotulinumtoxin A or 20 mL of saline. All participants started 8 weeks of physical therapy 4 weeks after the injection. Participants completed validated questionnaires at baseline, 2, 4, and 12 weeks after injection. At each visit, a urogynecologist who was blinded to treatment arm performed a clinical examination with palpation of the left and right sides of 6 pelvic floor muscle groups. The primary outcome was change in participant-reported pain on palpation of the most painful pelvic floor muscle at 2 weeks. Analyses were intention to treat.ResultsWe consented 60 women. One participant was lost to follow-up after she was consented; therefore, we randomized 59 women. The groups had similar demographic and clinical characteristics. With regard to the primary outcome, there was no significant difference between the intervention and placebo groups in the change in participant-reported pain on palpation of the most painful pelvic floor muscle at 2 weeks. There were no significant differences in participant-reported pain on palpation for any muscle group at 4 or 12 weeks. At 4 and 12 weeks, participants in the intervention group reported greater declines in overall pelvic pain on the visual analog scale compared with the placebo group, although these differences were not statistically significant (both P = .16). Using the Patient Global Impression of Improvement index, participants in the intervention group were more likely to report their symptoms were improved at 4 and 12 weeks compared with the placebo group, although this difference was significant only at 4 weeks (P = .03 and P = .10, respectively). At 2 weeks, the placebo group had a significant improvement in the Pelvic Floor Distress Inventory score compared with the intervention group (P = .01); however, this difference did not persist at 4 (P = .19) or 12 weeks (P = .11). At 2 weeks, the most common adverse event was constipation in the intervention and placebo groups, with 10.1% reporting de novo constipation. This was followed by urinary incontinence in the intervention group (22%) and urinary tract infection (9%) in the placebo group.ConclusionPelvic floor onabotulinumtoxin A injections for myofascial pelvic pain were not more effective than saline injections at decreasing muscle pain on palpation. Despite this, participants who received onabotulinumtoxin A were more likely than those who received saline to report improvement, albeit not statistically significant, in their overall pelvic floor pain at 4 and 12 weeks.
       
  • Assessing the impact of procedure-specific opioid prescribing
           recommendations on opioid stewardship following pelvic organ prolapse
           surgery
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Brian J. Linder, John A. Occhino, Sheila R. Wiest, Christopher J. Klingele, Emanuel C. Trabuco, John B. GebhartBackgroundNationally, there is increasing concern regarding the volume of opioid medications prescribed postoperatively and the rate of prescription opioid−related adverse events. In evaluation of this, several reports have identified significant variability in postoperative opioid-prescribing patterns, including quantities exceeding patient’s needs, especially after minor surgical procedures. However, data regarding patient’s postoperative opioids needs following surgery for pelvic organ prolapse are sparse.ObjectiveTo design procedure-specific opioid-prescribing recommendations for pelvic organ prolapse surgeries and evaluate their impact on opioid stewardship.Study DesignWe prospectively evaluated opioid-prescribing patterns, patient use, medication refills, and patient satisfaction in women undergoing prolapse surgery (ie, vaginal, abdominal, or robotic) during an 8-month time period. Two cohorts of women, stratified by whether they had surgery before or after implementation of procedure-specific opioid-prescribing recommendations, were evaluated. Postoperative opioid usage (assessed via pill count), medication refills, and satisfaction with pain management after hospital dismissal were evaluated by telephone call 2 weeks after surgery. Postoperative opioid prescribing and use were recorded after conversion to oral morphine equivalents.ResultsOverall, 96 women were included, 57 in the initial baseline cohort, and 39 following implementation of the prescribing recommendations. In the initial cohort, 32.8% of the prescribed oral morphine equivalents (3607/11,007 mg) were consumed. Following implementation of the prescribing recommendations, median oral morphine equivalents prescribed decreased from 200 mg oral morphine equivalents (interquartile range 150, 225) to 112.5 mg oral morphine equivalents (interquartile range 22.5, 112.5; P
       
  • Sacral neuromodulation versus onabotulinumtoxinA for refractory urgency
           urinary incontinence: impact on fecal incontinence symptoms and sexual
           function
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Uduak U. Andy, Cindy L. Amundsen, Emily Honeycutt, Alayne D. Markland, Gena Dunivan, Keisha Y. Dyer, Nicole B. Korbly, Megan Bradley, Sandip Vasavada, Donna Mazloomdoost, Sonia Thomas, NICHD Pelvic Floor Disorders NetworkBackgroundWomen with refractory urgency urinary incontinence can be treated with onabotulinumtoxinA or sacral neuromodulation. Little data exists on the comparative effects of treatment of refractory urgency urinary incontinence on other pelvic floor complaints, such as bowel and sexual function.ObjectiveThe objective of this study was to compare the impact of these treatments on fecal incontinence and sexual symptoms.MethodsThis was a planned supplemental analysis of a randomized trial in women with refractory urgency urinary incontinence treated with onabotulinumtoxinA (n = 190) or sacral neuromodulation (n = 174). Fecal incontinence and sexual symptoms were assessed at baseline and at 6, 12, and 24 months. Fecal incontinence symptoms were measured using the St Mark’s (Vaizey) Fecal Incontinence severity scale. Sexual symptoms were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The PISQ-IR allows measurement of sexual symptoms in both sexually active and non–sexually active adults. Primary outcomes were change in Vaizey and PISQ-12 scores between baseline and 6 months. Secondary outcomes were change in PISQ-IR total and subscores between baseline and 6 months and change in Vaizey, PISQ-12, and PISQ-IR scores between baseline and 12 and 24 months. Intent-to-treat analysis was performed using repeated measures mixed model to estimate change in all parameters from baseline while adjusting for the baseline score. A subgroup analysis of women with clinically significant bowel symptoms was conducted based on baseline Vaizey score of ≥12.ResultsAt baseline, mean Vaizey scores were indicative of mild fecal incontinence symptoms and were not different between onabotulinumtoxinA and sacral neuromodulation groups (7.6 ± 5.3 vs 6.6 ± 4.9, P = .07). The proportion of sexually active women (56% vs 63%, P = .25), mean PISQ-12 score (33.4 ± 7.5 vs 32.7 ± 6.7, P = .55), or PISQ-IR subscores were also not different between the onabotulinumtoxinA and sacral neuromodulation groups at baseline. There was no difference between women treated with onabotulinumtoxinA and those treated with sacral neuromodulation at 6 months in terms of improvement in fecal incontinence symptom score (Vaizey: -1.9, 95% confidence interval -2.6 to -1.2 vs -0.9, 95% confidence interval -1.7 to -0.2, P = .07) or sexual symptoms score (PISQ-12: 2.2, 95% confidence interval 0.7 to 3.7 vs 2.2, 95% confidence interval 0.7 to 3.7, P = .99). There was no difference in improvement between groups in the sexual symptom subscores in sexually active and non–sexually active women at 6 months. Similar findings were noted at 12 and 24 months. In a subgroup (onabotulinumtoxinA = 33 and sacral neuromodulation = 22) with clinically significant fecal incontinence at baseline (Vaizey score ≥12), there was a clinically meaningful improvement in symptoms in both groups from baseline to 6 months, with no difference in improvement between the onabotulinumtoxinA and sacral neuromodulation groups (-5.1, 95% confidence interval -7.3 to -2.8 vs -5.6, 95% confidence interval -8.5 to -2.6, P = .8).ConclusionThere were no differences in improvement of fecal incontinence and sexual symptoms in women with urgency urinary incontinence treated with onabotulinumtoxinA or sacral neuromodulation. Women with significant fecal incontinence symptoms at baseline had clinically important improvement in symptoms, with no difference between the treatments. Our findings can help clinicians counseling women considering treatment for refractory urgency urinary incontinence.
       
  • Multimodal opioid-sparing postoperative pain regimen compared with the
           standard postoperative pain regimen in vaginal pelvic reconstructive
           surgery: a multicenter randomized controlled trial
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Andrey Petrikovets, David Sheyn, Helen H. Sun, Graham C. Chapman, Sangeeta T. Mahajan, Robert R. Pollard, Sherif A. El-Nashar, Adonis K. Hijaz, Jeffrey MangelBackgroundPostoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use.ObjectiveThe objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery.Study DesignThis was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power).ResultsThirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P < .001) and received fewer narcotics during the entire hospitalization (55.7 vs 91.2, P < .001). At 96 hour follow up, patients in the ice packs, Tylenol, and Toradol group used 4.9 ketorolac tablets compared with 4.6 oxycodone/acetaminophen tablets in the standard group (P = .81); however, ice packs, Tylenol, and Toradol patients required more acetaminophen than ibuprofen by patients in the standard arm (10.7 vs 6.2 tablets, P = .012). There were no differences in Quality of Recovery Questionnaire or satisfaction scores either in the morning after surgery or at 96 hour follow up.ConclusionThe ice packs, Tylenol, and Toradol multimodal pain regimen offers improved pain control the morning after surgery and 96 hours postoperatively compared with the standard regimen with no differences in patient satisfaction and quality of recovery. Ice packs, Tylenol, and Toradol can significantly limit postoperative inpatient narcotic use and eliminate outpatient narcotic use in patients undergoing vaginal pelvic reconstructive surgery.
       
  • Characterizing anxiety at the first encounter in women presenting to the
           clinic: the CAFÉ study
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Thythy T. Pham, Yufan B. Chen, William Adams, Birte Wolff, Megan Shannon, Elizabeth R MuellerBackgroundClinically based anxiety questionnaires measure 2 forms of anxiety that are known as state anxiety and trait anxiety. State anxiety is temporary and is sensitive to change; trait anxiety is a generalized propensity to be anxious.ObjectiveOur study aims to characterize the reasons for anxiety among women about the initial consultation for their pelvic floor disorders to measure change in participant state anxiety after the visit and to correlate improvement in anxiety with visit satisfaction.Study DesignAll new patients at our tertiary urogynecology clinic were invited to participate. After giving consent, participants completed pre- and postvisit questionnaires. Providers were blinded to pre- and postvisit questionnaire responses. The previsit questionnaires included the Pelvic Floor Distress Inventory, the Generalized Anxiety Disorder-7, and the 6-item short form of the Spielberg State Trait Anxiety Inventory. Participants were also asked to list their previsit anxieties. The postvisit questionnaires comprised of the Spielberg State Trait Anxiety Inventory, patient global impression of improvement of participant anxiety, patient satisfaction, and the participant’s perception of whether her anxiety was addressed during the visit. The anxieties listed by participants were then reviewed independently and categorized by 2 of the authors. A separate panel arbitrated when there were disagreements among anxiety categories.ResultsFifty primarily white (66%) women with a median age of 53 years (interquartile range, 41–66) completed the study. The visit diagnoses included stress urinary incontinence (54%), urge urinary incontinence (46%), myofascial pain (28%), pelvic organ prolapse (20%), and recurrent urinary tract infection (12%). Less than one-quarter of participants (22%) had a history of anxiety diagnosis. The average previsit Spielberg State Trait Anxiety Inventory score was 42.9 (standard deviation, 11.98) which decreased by an average of 12.60 points in the postvisit (95% confidence interval, –16.56 to –8.64; P
       
  • A cost-minimization analysis of treatment options for postmenopausal women
           with dysuria
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Megan S. Bradley, Richard H. Beigi, Jonathan P. ShepherdBackgroundEmpiric therapy for urinary tract infection is difficult in postmenopausal women because of the higher rates of confounding lower urinary tract symptoms and differential resistance profiles of uropathogens in this population.ObjectiveThe objective of the study was to determine the least costly strategy for treatment of postmenopausal women with the primary complaint of dysuria.Study DesignWe performed a cost minimization analysis modeling the following clinical options: (1) empiric antibiotic therapy followed by urine culture, (2) urinalysis with empiric antibiotic therapy only if positive nitrites and leukocyte esterase, or (3) waiting for culture prior to initiating antibiotics. For all strategies we included nitrofurantoin, trimethoprim/sulfamethoxazole, fosfomycin, ciprofloxacin, or cephalexin. Pathogens included Escherichia coli, Enterococcus faecalis, Klebsiella pneumonaie, or Proteus mirabalis. Pathogens, resistance, treatment success, and medication side effects were specific to postmenopausal women.ResultsCost minimization modeling with TreeAge Pro assumed 73.4% of urinary tract infections were caused by Escherichia coli with 24.4% resistance to nitrofurantoin, trimethoprim/sulfamethoxazole. With our assumptions, empiric antibiotics with nitrofurantoin, trimethoprim/sulfamethoxazole was the least costly approach ($89.64/patient), followed by waiting for urine culture ($97.04/patient). Except for empiric antibiotics with fosfomcyin, empiric antibiotics was always less costly than using urinalysis to discriminate antibiotic use. This is due to the cost of urinalysis ($38.23), high rate of both urinary tract infection (91%), and positive urinalysis (69.3%) with dysuria in postmenopausal women and resultant high rate of antibiotic use with or without urinalysis. Options with fosfomycin were the most expensive because of the highest drug costs ($98/dose), and tornado analyses showed fosfomycin cost was the most impactful variable for model outcomes. Sensitivity analyses showed empiric fosfomycin became the least costly option if drug costs were $25.80, a price still more costly than almost all modeled baseline drug costs. This outcome was largely predicated on low resistance to fosfomycin. Conversely, ciprofloxacin was never the least costly option because of higher resistance and side effect cost, even if the drug cost was $0. We modeled 91% positive urine culture rate in postmenopausal women with dysuria; waiting for the urine culture prior to treatment would be the least costly strategy in a population with a predicted positive culture rate of
       
  • February 2019 (vol. 220, no. 2, pages 199.e1-13)
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s):
       
  • Ferguson KK, McElrath TF, Chen Y-H, et al. Repeated measures of urinary
           oxidative stress biomarkers during pregnancy and preterm birth. Am J
           Obstet Gynecol 2015;212:208.e1-8.
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s):
       
  • Cyclic-recombinase-reporter mouse model to determine exosome communication
           and function during pregnancy
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Samantha Sheller-Miller, Kyungsun Choi, Chulhee Choi, Ramkumar MenonBackgroundDuring pregnancy, feto-maternal communication can be mediated through extracellular vesicles, specifically exosomes, 30- to 150-nm particles released from each cell. Exosomes carry cellular signals, and traffic between fetal and maternal tissues to produce functional changes in recipient cells. Exosomes may function as a biomarker indicative of the physiologic status of their tissue of origin. These properties of exosomes during pregnancy are not well studied.ObjectiveTo test exosome trafficking and function, we used a transgenic mouse model containing membrane-targeted, red fluorescent protein tdTomato and enhanced green fluorescent protein cyclic recombinase−reporter construct expressed only in fetal tissues. This model allows fetal tissues and their exosomes to express tdTomato under normal conditions or green fluorescent protein if fetal tissues are exposed to cyclic recombinase that will excise tdTomato. As maternal tissue remains negative for this construct, tdTomato/green fluorescent protein expression and their switching can be used to determine fetal-specific cell and exosome trafficking.Materials and MethodstdTomato/green fluorescent protein−homozygous male mice were mated with wild-type females to have all fetal tissues express the tdTomato/green fluorescent protein allele. Red fluorescence due to tdTomato expression of the tdTomato/green fluorescent protein allele in fetal tissues (placenta, fetal membranes) was confirmed by confocal microscopy on embryonic day 16. Localization of fetal exosomes in maternal uterine tissues were performed by immunostaining for exosome marker CD81 and tdTomato expression followed by confocal microscopy. Fetal exosomes (tdTomato−positive) in maternal plasma were immunoprecipitated using anti−red fluorescent protein tdTomato, followed by confirmation with flow cytometry. To further illustrate the fidelity of fetal exosomes in maternal samples, exosomes bioengineered to contain cyclic recombinase (1.0 × 1010 exosomes) were injected intraperitoneally on embryonic day 13. On embryonic day 16, fetal (placenta and fetal membranes) tissues were imaged to show tdTomato−to−green fluorescent protein transition. The green fluorescent protein−expressing exomes were localized in maternal tissues (confocal microscopy) and plasma (flow cytometry).ResultsMating between a male with the tdTomato/green fluorescent protein construct and a null female resulted in fetal tissues and their exosomes expressing tdTomato positivity. Total fetal exosomes in maternal plasma was about 35%. tdTomato−positive exosomes were isolated from maternal plasma and immunostaining localized tdTomato−positive exosomes in maternal uterine tissues. Maternal intraperitoneal injection of cyclic recombinase−enriched exosomes crossed placenta, excised tdTomato from the tdTomato/green fluorescent protein construct in the fetal tissues, and caused green fluorescent protein expression in fetal cells. Furthermore, green fluorescent protein−positive exosomes released from fetal cells were isolated from maternal blood.ConclusionIn this pilot study, we report feto-maternal and maternal−fetal trafficking of exosomes indicative of paracrine signaling during pregnancy. Exosomes from the maternal side can produce functional changes in fetal tissues. Trafficking of exosomes suggests their potential role in pregnancy as biomarkers of fetal functions and usefulness as a carrier of drugs and other cargo to the fetal side during pregnancy. Isolation and characterization of fetal exosomes can advance fetal research without performing invasive procedures.
       
  • Assessment of ventricular contractility in fetuses with an estimated fetal
           weight less than the tenth centile
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Greggory R. DeVore, Diane L. Gumina, John C. HobbinsObjectiveTo determine whether abnormal global, transverse, and longitudinal ventricular contractility of the heart in fetuses with an estimated fetal weight
       
  • Size and shape of the four-chamber view of the fetal heart in fetuses with
           an estimated fetal weight less than the tenth centile
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): John C. Hobbins, Diane L. Gumina, Michael V. Zaretsky, Camille Driver, Annabelle Wilcox, Greggory R. DeVoreBackgroundFetuses with an estimated fetal weight below the 10th centile have an increased risk of adverse perinatal and long-term outcomes as well as increased rates of cardiac dysfunction, which often alters cardiac size and shape of the 4-chamber view and the individual ventricles. As a result, a simple method has emerged to screen for potential cardiac dysfunction in fetuses with estimated fetal weights
       
  • Characteristics and mode of inheritance of pathogenic copy number variants
           in prenatal diagnosis
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Matthew Hoi Kin Chau, Ye Cao, Yvonne Ka Yin Kwok, Samantha Chan, Yiu Man Chan, Huilin Wang, Zhenjun Yang, Hoi Kin Wong, Tak Yeung Leung, Kwong Wai ChoyBackgroundMicrodeletions and microduplications can occur in any pregnancy independent of maternal age. The spectrum and features of pathogenic copy number variants including the size, genomic distribution, and mode of inheritance are not well studied. These characteristics have important clinical implications regarding expanding noninvasive prenatal screening for microdeletions and microduplications.ObjectivesThe aim was to investigate the spectrum and characteristics of pathogenic copy number variants in prenatal genetic diagnosis and to provide recommendations for expanding the scope of noninvasive prenatal screening for microdeletions and microduplications.Study DesignThis was a retrospective study of 1510 pregnant women who underwent invasive prenatal diagnostic testing by chromosomal microarray analysis. Prenatal samples were retrieved by amniocentesis or chorionic villus sampling and sent to our prenatal genetic diagnosis laboratory for chromosomal microarray analysis. The risk of carrying a fetus with pathogenic copy number variants is stratified by the patients’ primary indication for invasive testing. We searched the literature for published prenatal chromosomal microarray data to generate a large cohort of 23,865 fetuses. The characteristics and spectrum of pathogenic copy number variants including the type of aberrations (gains or losses), genomic loci, sizes, and the mode of inheritance were studied.ResultsOverall, 375 of 23,865 fetuses (1.6%) carried pathogenic copy number variants for any indication for invasive testing, and 44 of them (11.7%) involve 2 or more pathogenic copy number variants. A total of 428 pathogenic copy number variants were detected in these fetuses, of which 280 were deletions and 148 were duplications. Three hundred sixty (84.1%) were less than 5 Mb in size and 68 (15.9%) were between 5 and 10 Mb. The incidence of carrying a pathogenic copy number variant in the high-risk group is 1 in 36 and the low-risk group is 1 in 125. Parental inheritance study results were available for 311 pathogenic copy number variants, 71 (22.8%) were maternally inherited, 36 (11.6%) were paternally inherited, and 204 (65.6%) occurred de novo.ConclusionCollectively, pathogenic copy number variants are common in pregnancies. High-risk pregnancies should be offered invasive testing with chromosomal microarray analysis for the most comprehensive investigation. Detection limits on size, parental inheritance, and genomic distribution should be carefully considered before implementing copy number variant screening in expanded noninvasive prenatal screening.
       
  • Association between stillbirth ≥23 weeks gestation and acute psychiatric
           illness within 1 year of delivery
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Adam K. Lewkowitz, Joshua I. Rosenbloom, Matt Keller, Julia D. López, George A. Macones, Margaret A. Olsen, Alison G. CahillBackgroundStillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known.ObjectiveThe purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth.Study DesignThis retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13–54 years old from 2005–2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at ≥23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model.ResultsA total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20– 2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99–2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63–4.04), although the risk remained high during the 4–12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13–2.76).ConclusionCoding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.
       
  • Maternal drug-related death and suicide are leading causes of postpartum
           death in California
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Sidra Goldman-Mellor, Claire E. MargerisonBackgroundReducing maternal mortality is a priority in the United States and worldwide. Drug-related deaths and suicide may account for a substantial and growing portion of maternal deaths, yet information on the incidence of and sociodemographic variation in these deaths is scarce.ObjectiveWe sought to examine incidence of drug-related and suicide deaths in the 12 months after delivery, including heterogeneity by sociodemographic factors. We also explored maternal decedents’ health care utilization prior to death.Study DesignThis retrospective, population-based cohort study followed up 1,059,713 women who delivered a live-born infant in California hospitals during 2010–2012 to ascertain maternal death. Analyses were conducted using statewide, all-payer, longitudinally-linked hospital and death data.ResultsA total of 300 women died during follow-up, a rate of 28.33 deaths per 100,000 person-years. The leading cause of death was obstetric-related problems (6.52 per 100,000 person-years). Drug-related deaths were the second leading cause of death (3.68 per 100,000 person-years), and suicide was the seventh leading cause (1.42 per 100,000 person-years); together these deaths comprised 18% of all maternal deaths. Non-Hispanic white women, Medicaid-insured women, and women residing in micropolitan areas were especially likely to die from drugs/suicide. Two thirds of women who died, including 74% of those who died by drugs/suicide, made ≥1 emergency department or hospital visit between their delivery and death.ConclusionDeaths caused by drugs and suicide are a major contributor to mortality in the postpartum period and warrant increased clinical attention, including recognition by physicians and Maternal Mortality Review Committees as a medical cause of death. Importantly, emergency department and inpatient hospital visits may serve as a point of identification of, and eventually prevention for, women at risk for these deaths.
       
  • The transition from latent to active labor and adverse obstetrical
           outcomes
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Joshua I. Rosenbloom, Candice L. Woolfolk, Leping Wan, Molly J. Stout, Methodius G. Tuuli, George A. Macones, Alison G. CahillBackgroundRecommendations on preventing primary cesarean delivery removed the previously defined time limits for latent labor (defined as ending at 6 cm) and urged clinicians to avoid cesarean delivery for labor abnormalities in the latent phase. However, relatively little is known about the implications of labor curve abnormalities from 4 to 6 cm and subsequent outcomes.ObjectiveTo examine the association between length of time for dilation from 4 to 6 cm, delivery outcomes, and maternal and neonatal morbidity.Study DesignThis is a secondary analysis of a prospective cohort study of patients at ≥37 weeks presenting in spontaneous or induced labor with a nonanomalous living singleton in vertex presentation. Patients with a history of cesarean delivery or who did not achieve 6-cm dilation were excluded. We used interval censored regression to determine the 90th percentile for dilation time from 4 to 6 cm and used logistic regression to estimate the odds ratios and 95% confidence intervals for adverse outcomes for patients above this cutoff percentile compared with those at or below. Analyses were adjusted for obesity, nulliparity, race, hypertension, diabetes, and type of labor (induced vs spontaneous/augmented). Outcomes included cesarean delivery, maternal morbidity (composite of postpartum fever, wound infection, hemorrhage), and neonatal morbidity (composite of neonatal death, hypothermic therapy, mechanical ventilation, respiratory distress, meconium aspiration syndrome, seizure, or treatment of sepsis). In addition, we created receiver operator characteristic curves to predict cesarean delivery, and maternal and neonatal morbidity based on time to dilate from 4 to 6 cm. The cutoff for time for each outcome was identified using the Youden index to maximize sensitivity and specificity, and test characteristics were computed.ResultsThere were 7355 patients eligible for analysis, 728 (10%) had dilation times from 4 to 6 cm>10.3 hours, which was the 90th percentile, and 6627 (90%) had dilation times ≤10.3 hours. Having dilation time from 4 to 6 cm above the 90th percentile (10.3 hours) was associated with cesarean delivery (adjusted odds ratio, 2.05; 95% confidence interval, 1.67–2.52), composite maternal morbidity (adjusted odds ratio, 1.48; 95% confidence interval, 1.10–2.00), and composite neonatal morbidity (adjusted odds ratio 1.92; 95% confidence interval 1.52–2.4). The area under the receiver operator characteristic curve for predicting cesarean delivery was 0.73 (95% confidence interval, 0.71–0.75). The test characteristics for the cutoff of 9.75 hours were sensitivity 68.3% (95% confidence interval, 64.8%–71.7%), specificity 66.2% (95% confidence interval, 55.0%–67.3%), positive predictive value 18.5% (95% confidence interval, 17.1%–20.0%), and negative predictive value 94.9% (95% confidence interval, 94.2%–95.5%). For composite maternal morbidity, the cutoff was 6.98 hours and the area under the curve was 0.62 (95% confidence interval, 0.59–0.65), whereas for composite neonatal morbidity it was 5.5 hours (area under the curve 0.69; 95% confidence interval, 0.67–0.71).ConclusionsPatients whose dilation time from 4 to 6 cm exceeds the 90th percentile have increased odds of cesarean delivery and postpartum complications. Prolonged dilation time has moderate predictive ability for adverse outcomes. Future studies should investigate at what point, if any, intervention is warranted during this period to reduce these risks.
       
  • Hypertelorism
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann S. Bromley, Angie C. Jelin
       
  • The relationship of defecation symptoms and posterior vaginal wall
           prolapse in women undergoing pelvic organ prolapse surgery
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Päivi K. Karjalainen, Nina K. Mattsson, Kari Nieminen, Anna-Maija Tolppanen, Jyrki T. JalkanenBackgroundDefecation symptoms are common among women with pelvic organ prolapse. However, the relationship between posterior vaginal wall prolapse and defecation symptoms remains debatable. Even though there is a plausible biomechanical rationale for posterior wall prolapse to cause obstructed defecation, previous studies have drawn contradictory conclusions regarding the association.ObjectiveWe aimed to examine the association between posterior vaginal wall prolapse and defecation symptoms by assessing the following: (1) does prevalence of defecation symptoms increase along with posterior wall prolapse severity, (2) is postoperative symptom improvement greater in women who underwent posterior compartment procedures in comparison with those who did not, and (3) is symptom improvement related to the symptom’s correlation with the degree of prolapse'Study DesignWe used data from a nationwide longitudinal cohort study with 3515 women undergoing pelvic organ prolapse surgery. We measured the prevalence of 9 defecation symptoms at baseline and at 6 and 24 months after surgery using the short form of the Pelvic Floor Distress Inventory. Baseline degree of prolapse was categorized in stages as defined by the Pelvic Organ Prolapse Quantification System. The relationship between the degree of posterior wall prolapse and prevalence of bothersome defecation symptoms was studied with logistic regression and adjusted for patient characteristics and severity of anterior wall and apical prolapse. Generalized estimating equations were used to assess the longitudinal change in symptom prevalence in groups of participants with and without repair for posterior vaginal compartment. Correlations between symptom improvement and symptom dependency on the degree of prolapse was assessed by calculating Pearson’s correlation coefficient.ResultsThe stage of posterior wall prolapse (stage 2 vs stage 0) correlated with splinting, straining, incomplete evacuation, fecal incontinence of liquid stool, pain during defecation, fecal urgency, and anorectal prolapse (adjusted odds ratios, 2.7, 2.1, 2.0, 1.5, 2.1, 1.4, and 2.2, respectively; P ≤ .007 for all). Flatal incontinence and fecal incontinence of solid stool were not associated with the severity of posterior vaginal wall prolapse. Obstructed defecation symptoms (splinting, straining, and incomplete evacuation) improved more in women undergoing posterior compartment surgery compared with women undergoing repair for other compartments. The greatest improvement at follow-up was observed for those symptoms that showed strongest association with the degree of prolapse at baseline.ConclusionObstructed defecation symptoms are dependent on the posterior wall anatomy. Women presenting with posterior wall prolapse, and these symptoms can expect to improve after surgery. Other defecation symptoms also improve after pelvic organ prolapse surgery, but they are not as specific to posterior wall anatomy as obstructed defecation symptoms.
       
  • Second primary anal and oropharyngeal cancers in cervical cancer survivors
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Katyayani Papatla, Michael T. Halpern, Enrique Hernandez, Jennifer Brown, Daniel Benrubi, Karen Houck, Christina Chu, Stephen RubinBackgroundHuman papilloma virus infection is responsible for approximately 31,500 new cancers in the United States annually. Almost all cervical cancers are linked to human papilloma virus infection. As early identification and treatment of cervical cancer improve, the incidence of cervical cancer has decreased and survival has improved. However, survivors continue to remain at risk for other human papilloma virus–related malignancies. The purpose of this study was to assess the risk of primary anal and oropharyngeal cancers among women with a history of squamous cell carcinoma of the cervix.Study DesignA population-based cohort of 21,060 women diagnosed with cervical squamous cell carcinoma from 1973 through 2014 was identified from the Surveillance, Epidemiology, and End Results Program-9 data. Standardized incidence ratios for anal and oropharyngeal cancers were calculated to estimate the risk of a second primary human papilloma virus–related malignancy based on incidence in the general population. Results were further stratified by age (20–53, 54 years old or older) and latency period (2–11, 12–59, 60–119, 120 months or longer). The number needed to screen for oropharyngeal and anal cancers was estimated using study results and Centers for Disease Control and Prevention–reported incidence rates.ResultsCervical squamous cell cancer survivors had a higher risk of being diagnosed with oropharyngeal cancer (standardized incidence ratio, 4.36, 95% confidence interval, 1.19–11.15) and anal cancer (standardized incidence ratio, 2.20, 95% confidence interval, 1.28–3.52). Patients diagnosed with cervical cancer between ages 20 and 53 years had an increased risk of anal cancer (standardized incidence ratio, 3.53, 95% confidence interval, 1.15–8.23). Age 54 years or older at cervical cancer diagnosis was associated with increased oropharyngeal cancer risk only (standardized incidence ratio, 5.04, 95% confidence interval, 1.37–12.91). Latency stratification was significant for increased OPC risk between 2–11 months and 12–59 months after diagnosis. At 120 months or longer, there was an increased risk of both oropharyngeal cancer (standardized incidence ratio, 7.97, 95% confidence interval, 2.17–20.42) and anal cancer (standardized incidence ratio, 2.60, 95% confidence interval, 1.34–4.54). The estimated number needed to screen for oropharyngeal cancer (number needed to screen for oropharyngeal cancer, 282) and anal cancer (number needed to screen for anal cancer, 1272) is significantly less than the number needed to screen for cervical cancer.ConclusionSquamous cell cervical cancer survivors have a substantially increased risk of anal and oropharyngeal cancers. This increased risk is significant 10 or more years after the cervical cancer diagnosis. Health care providers and survivors should be aware of this increased risk. The development of effective and economical surveillance methods for anal and oropharyngeal cancers in cervical cancer survivors is urgently needed.
       
  • National patterns of care and fertility outcomes for reproductive-aged
           women with endometrial cancer or atypical hyperplasia
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Ross F. Harrison, Weiguo He, Shuangshuang Fu, Hui Zhao, Charlotte C. Sun, Rudy S. Suidan, Terri L. Woodard, J. Alejandro Rauh-Hain, Shannon N. Westin, Sharon H. Giordano, Larissa A. MeyerBackgroundAlthough it is uncommon, the incidence of endometrial cancer and atypical hyperplasia among reproductive-aged women is increasing. The fertility outcomes in this population are not well described.ObjectiveWe aim to describe the patterns of care and fertility outcomes of reproductive-aged women with endometrial cancer or atypical hyperplasia.Materials and MethodsA cohort of women aged ≤45 years with endometrial cancer or atypical hyperplasia diagnosed in 2000 to 2014 were identified in Truven Marketscan, an insurance claims database of commercially insured patients in the United States. Treatment information, including use of progestin therapy, hysterectomy, and assisted fertility services, was identified and collected using a combination of Common Procedural Terminology codes, International Statistical Classification of Diseases and Related Health Problems codes, and National Drug Codes. Pregnancy events were identified from claims data using a similar technique. Patients were categorized as receiving progestin therapy alone, progestin therapy followed by hysterectomy, or standard surgical management with hysterectomy alone. Multivariable logistic regression was performed to assess factors associated with receiving fertility-sparing treatment.ResultsA total of 4007 reproductive-aged patients diagnosed with endometrial cancer or atypical hyperplasia were identified. The majority of these patients (n = 3189; 79.6%) received standard surgical management. Of the 818 patients treated initially with progestins, 397 (48.5%) subsequently underwent hysterectomy, whereas 421 (51.5%) did not. Patients treated with progestin therapy had a lower median age than those who received standard surgical management (median age, 36 vs 41 years; P < .001). The proportion of patients receiving progestin therapy increased significantly over the observation period, with 24.9% treated at least initially with progestin therapy in 2014 (P < .001). Multivariable analysis shows that younger age, a diagnosis of atypical hyperplasia diagnosis rather than endometrial cancer, and diagnosis later in the study period were all associated with a greater likelihood of receiving progestin therapy (P < .0001). Among the 421 patients who received progestin therapy alone, 92 patients (21.8%; 92/421) had 131 pregnancies, including 49 live births for a live birth rate of 11.6%. Among the 397 patients treated with progestin therapy followed by hysterectomy, 25 patients (6.3%; 25/397) had 34 pregnancies with 13 live births. The median age of patients who experienced a live birth following diagnosis during the study period was 36 years (interquartile range, 33−38). The use of some form of assisted fertility services was observed in 15.5% patients who were treated with progestin therapy. Among patients who experienced any pregnancy event following diagnosis, 54% of patients used some form of fertility treatment. For patients who experienced a live birth following diagnosis, 50% of patients received fertility treatment. Median time to live birth following diagnosis was 756 days (interquartile range, 525−1077). Patients treated with progestin therapy were more likely to experience a live birth if they had used assisted fertility services (odds ratio, 5.9; 95% confidence interval, 3.4−10.1; P < .0001).ConclusionThe number of patients who received fertility-sparing treatment for endometrial cancer or atypical hyperplasia increased over time. However, the proportion of women who experience a live birth following these diagnoses is relatively small.
       
  • Biomarker panel for early detection of endometrial cancer in the Prostate,
           Lung, Colorectal, and Ovarian cancer screening trial
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Christopher M. Tarney, Guisong Wang, Nicholas W. Bateman, Kelly A. Conrads, Ming Zhou, Brian L. Hood, Jeremy Loffredo, Chunqiao Tian, Kathleen M. Darcy, Chad A. Hamilton, Yovanni Casablanca, Anna Lokshin, Thomas P. Conrads, G. Larry MaxwellBackgroundEndometrial cancer is the most common gynecological cancer in the United States. However, no early detection test exists for asymptomatic women at average risk for endometrial cancer.ObjectiveWe sought to identify early detection biomarkers for endometrial cancer using prediagnostic serum.Study DesignWe performed a nested case-control study of postmenopausal women in the Prostate, Lung, Colorectal, and Ovarian cancer screening trial (n = 78,216), including 112 incident endometrial cancer cases and 112 controls. Prediagnostic serum was immunodepleted of high-abundance proteins and digested with sequencing grade porcine trypsin via pressure cycling technology. Quantitative proteomics and phosphoproteomics was performed using high-resolution liquid chromatography–tandem mass spectrometry and highly multiplexed isobaric mass tag combined with basic reversed-phase liquid chromatography. A set of proteins able to predict cancer status was identified with an integrated score assessed by receiver-operator curve analysis.ResultsMean time from blood draw to endometrial cancer diagnosis was 3.5 years (SD, 1.9 years). There were 47 differentially abundant proteins between cases and controls (P < .05). Protein alterations with high predictive potential were selected by regression analysis and compiled into an aggregate score to determine the ability to predict endometrial cancer. An integrated risk score of 6 proteins was directly related to disease incidence in cases with blood draw ≤2 years,>2 years to ≤5 years or>5 years prior to cancer diagnosis. The integrated score distinguished cases from controls with an area under the curve of 0.80 (95% confidence interval, 0.72–0.88).ConclusionAn integrated score of 6 proteins using prediagnostic serum from the Prostate, Lung, Colorectal, and Ovarian cancer screening trial distinguishes postmenopausal endometrial cancer cases from controls. Validation is needed to evaluate whether this test can improve prediction or detection of endometrial cancer among postmenopausal women.
       
  • Placental bed research: II. Functional and immunological investigations of
           the placental bed
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Lynda K. Harris, Marisa Benagiano, Mario M. D’Elios, Ivo Brosens, Giuseppe BenagianoResearch on the placenta as the interface between the mother and the fetus has been undertaken for some 150 years, and in 2 subsequent reviews, we attempted to summarize the situation. In the first part, we described the discovery of unique physiological modifications of the uteroplacental spiral arteries, enabling them to cope with a major increase in blood flow necessary to ensure proper growth of the fetus. These consist of an invasion of the arterial walls by trophoblast and a progressive disappearance of its normal structure. Researchers then turned to the pathophysiology of the placental bed and in particular to its maternal vascular tree. This yielded vital information for a better understanding of the so-called great obstetrical syndromes (preeclampsia, fetal growth restriction, premature labor and delivery, placenta accreta). Systematic morphological investigations of the uteroplacental vasculature showed that preeclampsia is associated with decreased or failed transformation of spiral arteries and the persistence of endothelial and smooth muscle cells in segments of their myometrial portion. Here we report on recent functional investigations of the placental bed, including in situ biophysical studies of uteroplacental blood flow and vascular resistance, and manipulation of uteroplacental perfusion. These new methodologies have provided a novel way of identifying pregnancies in which remodeling is impaired. In animals it is now possible to manipulate uteroplacental blood flow, leading to an enhancement of fetal growth; this opens the way to trials in abnormal human pregnancies. In this second part, we explored a new, extremely important area of research that deals with the role of specific subsets of leukocytes and macrophages in the placental bed. The human first-trimester decidua is rich in leukocytes called uterine natural killer cells. Both macrophages and uterine natural killer cells increase in number from the secretory endometrium to early pregnancy and play a critical role in mediating the process of spiral artery transformation by inducing initial structural changes. It seems therefore that vascular remodeling of spiral arteries is initiated independently of trophoblast invasion. Dysregulation of the immune system may lead to reproductive failure or pregnancy complications, and in this respect, recent studies have advanced our understanding of the mechanisms regulating immunological tolerance during pregnancy, with several mechanisms being proposed for the development of tolerance to the semiallogeneic fetus. In particular, these include several strategies by which the trophoblast avoids maternal recognition. Finally, an important new dimension is being explored: the likelihood that pregnancy syndromes and impaired uteroplacental vascular remodeling may be linked to future maternal and even the child’s cardiovascular disease risk. The functional evidence underlying these observations will be discussed.
       
  • Placental bed research: I. The placental bed: from spiral arteries
           remodeling to the great obstetrical syndromes
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Ivo Brosens, Patrick Puttemans, Giuseppe BenagianoThe term placental bed was coined to describe the maternal-fetal interface (ie, the area in which the placenta attaches itself to the uterus). Appropriate vascularization of this area is of vital importance for the development of the fetus; this is why systematic investigations of this area have now been carried out. Initially, the challenge was the identification and classification of the various successive branching of uterine arteries in this area. These vessels have a unique importance because failure of their physiological transformation is considered to be the anatomical basis for reduced perfusion to the intervillous space in women with preeclampsia, fetal growth restriction, preterm labor, preterm premature rupture of membranes, abruptio placentae, and fetal death. To investigate in depth the pathophysiology of the placental bed, some 60 years ago, a large number of placental bed biopsies, as well as of cesarean hysterectomy specimens with placenta in situ, from both early and late normotensive and hypertensive pregnancies, were carefully dissected and analyzed. Thanks to the presence of a series of specific physiological changes, characterized by the invasion and substitution of the arterial intima by trophoblast, this material allowed the identification in the placental bed of normal pregnancies of the main vessels, the uteroplacental arteries. It was then discovered that preeclampsia is associated with defective or absent transformation of the myometrial segment of the uteroplacental arteries. In addition, in severe hypertensive disease, atherosclerotic lesions were also found in the defective myometrial segment. Finally, in the basal decidua, a unique vascular lesion, coined acute atherosis, was also identified This disorder of deep placentation, coined defective deep placentation, has been associated with the great obstetrical syndromes, grouping together preeclampsia, intrauterine growth restriction, preterm labor, preterm premature rupture of membranes, late spontaneous abortion, and abruptio placentae. More recently, simplified techniques of tissue sampling have been also introduced: decidual suction allows to obtain a large number of decidual arteries, although their origin in the placental bed cannot be determined. Biopsies parallel to the surface of the basal plate have been more interesting, making possible to identify the vessels’ region (central, paracentral, or peripheral) of origin in the placental bed and providing decidual material for immunohistochemical studies. Finally, histochemical and electron microscopy investigations have now clarified the pathology and pathogenetic mechanisms underlying the impairment of the physiological vascular changes.
       
  • Progestogens for the prevention of preterm birth and risk of developing
           gestational diabetes mellitus: a meta-analysis
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Vasilios Pergialiotis, Ioannis Bellos, Erifili Hatziagelaki, Aris Antsaklis, Dimitrios Loutradis, George DaskalakisBackgroundSeveral articles have implied that progestogen supplementation during pregnancy to reduce the risk of preterm birth may increase the risk for developing gestational diabetes mellitus.ObjectiveThe purpose of the present meta-analysis was to accumulate existing evidence concerning this correlation.Data SourcesWe searched Medline (1966–2019), Scopus (2004–2019), Clinicaltrials.gov (2008–2019), EMBASE (1980–2019), Cochrane Central Register of Controlled Trials CENTRAL (1999–2019), and Google Scholar (2004–2019) databases.Study Eligibility CriteriaRandomized trials and observational studies were considered eligible for inclusion in the present meta-analysis. To minimize the possibility of article losses, we avoided language, country, and date restrictions.Study Appraisal and Synthesis MethodsThe methodological quality of included studies was evaluated with the Cochrane risk of bias and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Meta-analysis was performed with the RevMan 5.3 and secondary analysis with the Open Meta-Analyst software. Trial sequential analysis was conducted with the trial sequential analysis program.ResultsOverall, 11 studies were included in the present meta-analysis that recruited 8085 women. The meta-analysis revealed that women who received 17-alpha hydroxyprogesterone caproate had increased the risk of developing gestational diabetes mellitus (risk ratio, 1.73, 95% confidence interval, 1.32–2.28), whereas women who received vaginal progesterone had a decreased risk, although the effect did not reach statistical significance because of the unstable estimate of confidence intervals (risk ratio, 0.82, 95% confidence interval, 0.50–1.12). Meta-regression analysis indicated that neither the methodological rationale for investigating the prevalence of gestational diabetes mellitus (incidence investigated as primary or secondary outcome) (coefficient of covariance, –0.36, 95% confidence interval, –0.85 to 0.13, P = .154) nor the type of investigated study (randomized controlled trial/observational) (coefficient of covariance –0.361, 95% confidence interval, –1.049 to 0.327, P = .304) significantly altered the results of the primary analysis. Trial sequential analysis suggested that the meta-analysis concerning the correlation of 17-alpha hydroxyprogesterone caproate was of adequate power to reach firm conclusions, whereas this was not confirmed in the case of vaginal progesterone.ConclusionThe results of the present meta-analysis clearly indicate that women who receive supplemental 17-alpha hydroxyprogesterone caproate for the prevention of preterm birth have an increased risk of developing gestational diabetes mellitus. On the other hand, evidence concerning women treated with vaginal progesterone remains inconclusive.
       
  • Placental colonization with periodontal pathogens: the potential missing
           link
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Lori A. Fischer, Ellen Demerath, Peter Bittner-Eddy, Massimo CostalongaObservational studies demonstrate that women with severe periodontitis have a higher risk of adverse pregnancy outcomes like preterm birth and low birthweight. Standard treatment for periodontitis in the form of scaling and root planing during the second trimester failed to reduce the risk of preterm or low birthweight. It is premature to dismiss the association between periodontitis and adverse pregnancy outcomes because one explanation for the failure of scaling and root planing to reduce the risk of adverse pregnancy outcomes is that periodontal pathogens spread to the placental tissue prior to periodontal treatment. In the placenta, orally derived organisms could cause direct tissue damage or mediate a maternal immune response that impairs the growth of the developing fetus. Sequencing studies demonstrate the presence of organisms derived from the oral microbiome in the placenta, but DNA-based sequencing studies should not be the only technique to evaluate the placental microbiome because they may not detect important shifts in the metabolic capability of the microbiome. In humans, polymerase chain reaction and histology have detected periodontal pathogens in placental tissue in association with multiple adverse pregnancy outcomes. We conclude that both placental and oral microbiomes may play a role in periodontitis-associated adverse pregnancy outcomes. However, the measure to determine the association between periodontal pathogens in the placenta and adverse pregnancy outcomes should be the amount and prevalence, not the mere presence of such microorganisms. Placental colonization with periodontal pathogens thus potentially represents the missing link between periodontitis and adverse pregnancy outcomes.
       
  • To the point: undergraduate medical education learner mistreatment issues
           on the learning environment in the United States
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Archana Pradhan, Samantha D. Buery-Joyner, Sarah Page-Ramsey, Susan Bliss, LaTasha B. Craig, Elise Everett, David A. Forstein, Scott Graziano, Laura Hopkins, Margaret McKenzie, Helen Morgan, Brittany S. HamptonThis article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is an overview of issues to consider regarding learner mistreatment and its effects on the undergraduate medical education learning environment in the United States. National data from the American Association of Medical Colleges Graduate Questionnaire and local data regarding learner mistreatment provide evidence that the learning environment at most medical schools needs to be improved. The American Association of Medical Colleges’ definition of learner mistreatment focuses on active mistreatment, but data on passive mistreatment also contribute to a negative learning environment. The lack of tolerance for active mistreatment issues such as public humiliation and sexual and racial harassment need to be made transparent through institutional and departmental policies. Additionally, reporting mechanisms at both levels need to be created and acted upon. Passive mistreatment issues such as unclear expectations and neglect can also be addressed at institutional and departmental levels through training modules and appropriate communication loops to address these concerns. To fully confront and solve this challenging issue regarding learner mistreatment at the undergraduate medical education level, solutions to need to be implemented for faculty, residents, and students in the institutional, departmental, and clerkship settings.
       
  • AJOG MFM Table of Contents
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s):
       
  • Information for Readers
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s):
       
  • Anophthalmia and Microphthalmia
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • Median Facial Cleft
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • Hypotelorism
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 5Author(s): Society for Maternal-Fetal Medicine, Beryl R. Benacerraf, Bryann Bromley, Angie C. Jelin
       
  • Short-term Quality of Life after Myomectomy for Uterine Fibroids from the
           Compare-UF Fibroid Registry
    • Abstract: Publication date: Available online 31 October 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Shannon K. Laughlin-Tommaso, Di Lu, Laine Thomas, Michael Diamond, Kedra Wallace, Ganesa Wegienka, Anissa Vines, Ray Anchan, Tracy Wang, G Larry Maxwell, Vanessa Jacoby, Erica E. Marsh, James B. Spies, Wanda Nicholson, Elizabeth A. Stewart, Evan Myers BackgroundUterine fibroids may decrease quality of life in a significant proportion of affected women. Myomectomy offers a uterine-sparing treatment option for patients with uterine fibroids that can be performed abdominally, laparoscopically (with or without robotic assistance), and by hysteroscopy. Quality of life using validated measures for different myomectomy routes, especially hysteroscopic myomectomy, is limited.ObjectiveTo compare women’s perception of their short-term health-related quality of life measures and reported time to return to usual activities and return to work for different routes of myomectomy.Study DesignComparing Options for Management: Patient-centered Results for Uterine Fibroids (Compare-UF) is a prospective nationwide fibroid registry study that enrolled premenopausal women seeking treatment for uterine fibroids at 8 clinical sites. For this analysis, we included women undergoing hysteroscopic, abdominal, or laparoscopic myomectomy who completed the post-procedure questionnaire scheduled between 6 and 12 weeks after surgery. Health-related quality of life outcomes, such as pain, anxiety, and return to usual activities were assessed for each route. The hysteroscopic myomectomy group had large differences in demographics, fibroid number, and uterine size, compared to the other groups; thus, a direct comparison of quality of life measures was done only for abdominal and laparoscopic approaches after propensity weighting. Propensity weighting was done using 24 variables that included demographics, quality of life baseline measures, and fibroid and uterine measurements.Results1,206 women from 8 Compare-UF sites underwent myomectomy (338 hysteroscopic, 519 laparoscopic, 349 abdominal). All women had substantial improvement in short-term health-related quality of life and symptom severity scores, which was not different among groups. Average symptom severity scores decreased about 30 points in each group. Return to usual activities averaged 0 days (IQR 0-14 days) for hysteroscopic myomectomy, 21 days (14-28 days) for laparoscopic myomectomy, and 28 days (IQR 14-35 days) for abdominal myomectomy. After propensity adjustment, quality of life outcomes in the laparoscopic and abdominal myomectomy groups were similar except more anxiety in the laparoscopic myomectomy group and slightly more pain in the abdominal myomectomy group. After propensity weighting, return to usual activities favored laparoscopic compared to abdominal procedures; median time was the same at 21 days but the highest quartile of women in the abdominal group needed an additional week of recovery ( IQR14.0-28.0 for laparoscopic versus (IQR14.0-35.0 for abdominal, p
       
  • Associations between the vaginal microbiome and Candida colonization in
           women of reproductive age
    • Abstract: Publication date: Available online 22 October 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Brett A. Tortelli, Warren G. Lewis, Jenifer E. Allsworth, Nadum Member-Meneh, Lynne R. Foster, Hilary E. Reno, Jeffrey F. Peipert, Justin C. Fay, Amanda L. LewisBackgroundThe composition of bacteria within the vaginal microbiome has garnered a lot of recent attention and has been associated with reproductive health and disease. Despite the common occurrence of yeast (primarily Candida) within the vaginal microbiome, there is still an incomplete picture of relationships between yeast and bacteria (especially lactobacilli), as well as how such associations are governed. Such relationships could be important to a more holistic understanding of the vaginal microbiome and its connection to reproductive health.ObjectiveTo perform molecular characterization of clinical specimens to define associations between vaginal bacteria (especially Lactobacillus species) and Candida colonization. In vitro studies were conducted to test the two most common dominant Lactobacillus species (Lactobacillus crispatus and Lactobacillus iners) in their ability to inhibit Candida growth and to examine the basis for such inhibition.Study DesignA nested cross-sectional study of reproductive age women from the Contraceptive CHOICE Project was conducted. Vaginal swabs from 299 women were selected to balance race and BV status, resulting in similar representation of black and white women in each of the three Nugent score categories [normal (0-3), intermediate (4-6), and bacterial vaginosis (7-10)]. Sequencing of the 16S ribosomal gene (V4 region) was used to determine the dominant Lactobacillus species present (primarily L. iners and L. crispatus), defined as>50% of the community. Subjects without dominance by a single Lactobacillus species were classified as Diverse. A Candida-specific qPCR targeting the internally transcribed spacer 1 (ITS1) was validated using vaginal samples collected from a second cohort of women and used to assess Candida colonization. 255 nonpregnant women with sufficient bacterial biomass for analysis were included in the final analysis. Generalized linear models were employed to evaluate associations between Lactobacillus dominance, sociodemographic and risk characteristics and vaginal Candida colonization. In separate in vitro studies, the potential of cell-free supernatants from L. crispatus and L. iners cultures to inhibit Candida growth was evaluated.ResultsForty-two women (16%) were vaginally colonized with Candida. Microbiomes characterized as Diverse (38%), L. iners-dominant (39%), and L. crispatus-dominant (20%) were the most common. The microbiome, race and Candida colonization co-varied with a higher prevalence of Candida among black women and L. iners-dominant communities compared to white women and L. crispatus-dominant communities. L. iners-dominant communities were more likely to harbor Candida than L. crispatus-dominant communities (OR = 2.85, 95% CI: 1.03 to 7.21; Fisher’s Exact, p = 0.048). In vitro, L. crispatus produced greater concentrations of lactic acid and exhibited significantly more pH-dependent growth inhibition of C. albicans, suggesting a potential mechanism for the clinical observations.ConclusionIn nonpregnant women, L. iners-dominant communities were significantly more likely to harbor Candida than L. crispatus-dominant communities, suggesting that Lactobacillus species have different relationships with Candida. In vitro experiments indicate that L. crispatus may impede Candida colonization more effectively than L. iners through a greater production of lactic acid.
       
  • Symptomatic pelvic organ prolapse in middle-aged women - a national
           matched cohort study on the influence of childbirth
    • Abstract: Publication date: Available online 19 October 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Sigvard Åkervall, Jwan Al-Mukhtar Othman, Mattias Molin, Maria Gyhagen BACKGROUNDThe relative impact of age, pregnancy and vaginal delivery on symptomatic pelvic organ prolapse is still an unresolved issue that involves the controversial question about the protective effect of cesarean section.OBJECTIVESThe purpose of this study was to compare the age-related prevalence of symptomatic genital prolapse in nulliparous, vaginal and cesarean delivered women aged 40 to 64 years.STUDY DESIGNThis Swedish, nationwide matched cohort study involved 14,335 women. Three restricted, randomly selected source cohorts of women (nulliparous women unexposed to childbirth (n = 9136), one-para cesarean delivered women, exposed to one pregnancy (n = 1412), and one-para women exposed to one pregnancy followed by vaginal delivery (n = 3787) were retrieved from The Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014. The surveys used a postal and internet-based questionnaire containing validated questions for pelvic floor disorders. Symptomatic prolapse was defined by the question “Do you have a sensation of tissue protrusion (a vaginal bulge) from your vagina'”. In this study the symptom frequencies “Sometimes and Often” were defined as a positive response. Parous women were all assessed 20 years postnatally. One-to-one matching with an age interval for pairing of three years and three units of body mass index (kg/m2) was used in women aged 40 to 64 years. The procedure succeeded in 2,635 out of 2,640 women (99.8%), resulting in an adequate distribution of age and body mass index (kg/m2) between matched groups. For comparison between groups Fisher’s exact test was used for categorical variables and the Mann–Whitney U test for continuous variables. Trend between matched groups was analysed with Mantel-Haenszel statistics. Estimated, age-related values of symptomatic prolapse were obtained by logistic regression analysis.RESULTSIn nulliparous and cesarean delivered women the prevalence of symptomatic prolapse was relatively similar and below 5% across ages 40 to 64 years. In contrast, in women after vaginal delivery, there was an accelerating increase in the prevalence of symptomatic genital prolapse up to 65 years of age. Estimated probability from the regression model increased fourfold from 3.8% at 40 years to 13.4% at 64 years of age. The observed induction period associated with one vaginal delivery seemed to be at least 20 years among women giving birth in their early twenties. At age 64 the estimated probability of symptomatic prolapse was twelve times higher after vaginal delivery compared to cesarean section [13.4 % (95% CI 9.4-18.9) versus 1.1 % (95% CI 0.4-2.5 ), P
       
  • From Molecular to Macro: The Key Role of the Apical Ligaments in
           Uterovaginal Support
    • Abstract: Publication date: Available online 19 October 2019Source: American Journal of Obstetrics and GynecologyAuthor(s): Caroline Kieserman-Shmokler, Carolyn W. Swenson, Luyun Chen, Lisa M. Desmond, James A. Ashton-Miller, John O. DeLancey In order to explain the pathophysiology of pelvic organ prolapse, we must first understand the complexities of the normal support structures of the uterus and vagina. In this review, we focus on the apical ligaments, which include the cardinal and uterosacral ligaments. The aims of this review are the following: 1) to provide an overview of the anatomy and histology of the ligaments; 2) to summarize the imaging and biomechanical studies of the ligament properties and the way they relate to anterior and posterior vaginal wall prolapse; and 3) to synthesize these findings into a conceptual model for the progression of prolapse.
       
  • Breastfeeding and pelvic floor disorders one to two decades after vaginal
           delivery
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): David A. Lovejoy, Jennifer L. Roem, Joan L. Blomquist, Prerna R. Pandya, Victoria L. HandaBackgroundPostpartum recovery from pelvic floor trauma associated with vaginal delivery may be impaired by the transient hypoestrogenic state associated with breastfeeding.ObjectiveThe aim of our study was to examine the association between exclusive breastfeeding and pelvic floor disorders 1–2 decades after the first vaginal delivery. We hypothesize that compared with women who did not breastfeed following vaginal delivery, women who breastfeed would have a higher proportion of pelvic floor disorders s, and those women who practiced sustained exclusive/unsupplemented breastfeeding would have the highest proportion.Study DesignThis is a secondary analysis of the Mothers’ Outcomes After Delivery study, a prospective cohort study of pelvic floor disorders after childbirth. Participants were recruited 5–10 years after their first delivery and followed up annually for up to 9 years. This analysis focused on participants who experienced at least 1 vaginal delivery. Each participant completed a self-administered questionnaire regarding breastfeeding. Based on questionnaire responses, breastfeeding status was classified into 3 ordinal categories: unexposed (did not breastfeed or breastfed
       
  • Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of
           a prospective multicentre study (SELLY)
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): Stefano Uccella, Camilla Nero, Enrico Vizza, Virginia Vargiu, Giacomo Corrado, Nicolò Bizzarri, Fabio Ghezzi, Francesco Cosentino, Luigi Carlo Turco, Anna Fagotti, Giovanni ScambiaBackgroundSystematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer.ObjectivesWe here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy.Study DesignThe Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I–II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled.ResultsThirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred.ConclusionOur data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.
       
  • The effect of childbirth on urinary incontinence: a matched cohort study
           in women aged 40–64 years
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): Maria Gyhagen, Sigvard Åkervall, Mattias Molin, Ian MilsomBackgroundThe relative impact of age, pregnancy and vaginal delivery on urinary incontinence is still an unresolved issue that involves the controversial question about the protective effect of cesarean delivery.ObjectiveThe purpose of this study was to estimate and compare the effect size of 1 pregnancy, 1 vaginal delivery, and the derived protective effect of cesarean delivery for different aspects of urinary incontinence in women 40–64 years old, all 20 years after birth.Study DesignThis Swedish nationwide matched cohort study involved 14,335 women. Data from 3 restricted, randomly selected, source cohorts of (1) nulliparous women who were unexposed to childbirth (n=9136), (2) primiparous women who had experienced cesarean delivery and who had been exposed to 1 pregnancy (n=1412), and (3) primiparous women who had been exposed to 1 pregnancy followed by vaginal delivery (n=3787) were retrieved from The Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014, respectively. Parous women were all assessed 20 years postnatally. One-to-one matching with an interval for pairing of 3 years and 3 body mass index units was used in women 40–64 years old with information about body mass index (kilograms/square meters) and urinary incontinence. The procedure succeeded in 2630 of 2635 women (99.8%) and resulted in an adequate distribution of age and body mass index between groups. The surveys used a postal- and an internet-based questionnaire with validated questions for various aspects of urinary incontinence. Fisher’s exact test and the Mann-Whitney U test were used for comparisons between matched groups; trend was analyzed with Mantel-Haenszel statistics. Predicted, age-related values of different aspects of urinary incontinence were obtained by logistic regression analysis.ResultsPregnancy increased the prevalence of urinary incontinence from 20.1–30.1% (odds ratio, 1.71; 95% confidence interval, 1.43–2.05; P
       
  • The differential diagnoses of uterine leiomyomas and leiomyosarcomas using
           DNA and RNA sequencing
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): Aymara Mas, Roberto Alonso, Tamara Garrido-Gómez, Patricia Escorcia, Beatriz Montero, Jorge Jiménez-Almazán, Julio Martín, Nuria Pellicer, Javier Monleón, Carlos SimónBackgroundAlthough uterine leiomyomas and leiomyosarcomas are considered biologically unrelated tumors, they share morphologic and histologic characteristics that complicate their differential diagnosis. The long-term therapeutic option for leiomyoma is laparoscopic myomectomy with morcellation, particularly for patients who wish to preserve their fertility. However, because of the potential dissemination of undiagnosed or hidden leiomyosarcoma from morcellation, there is a need to develop a preoperative assessment of malignancy risk.ObjectiveThrough an integrated comparative genomic and transcriptomic analysis, we aim to identify differential genetic targets in leiomyomas vs leiomyosarcomas using next-generation sequencing as the first step toward preoperative differential diagnosis.Study DesignTargeted sequencing of DNA and RNA coding regions for solid tumor–associated genes was performed on formalin-fixed paraffin-embedded samples from 13 leiomyomas and 13 leiomyosarcoma cases. DNA sequencing was used to identify copy number variations, single-nucleotide variants, and small insertions/deletions. RNA sequencing was used to identify gene fusions, splice variants, and/or differential gene expression profiles.ResultsIn leiomyosarcomas, tumor mutation burden was higher in terms of copy number variations, single nucleotide variants, small insertions/deletions, and gene fusions compared with leiomyomas. For copy number variations, 20 genes were affected by deletions in leiomyosarcomas, compared with 6 observed losses in leiomyomas. Gains (duplications) were identified in 19 genes in leiomyosarcomas, but only 3 genes in leiomyomas. The most common mutations (single-nucleotide variants and insertions/deletions) for leiomyosarcomas were identified in 105 genes of all analyzed leiomyosarcomas; 82 genes were affected in leiomyomas. Of note, 1 tumor previously diagnosed as leiomyosarcoma was established as inflammatory myofibroblastic tumor along this study with a novel ALK-TNS1 fusion. Finally, a differential transcriptomic profile was observed for 11 of 55 genes analyzed in leiomyosarcomas; 8.5% of initially diagnosed leiomyosarcomas showed high-confidence, novel gene fusions that were associated with these tumors.ConclusionThrough integrated comparative genomic and transcriptomic analyses, we identified novel differential genetic targets that potentially differentiate leiomyosarcomas and leiomyomas. This provides a new insight into the differential diagnosis of these myometrial tumors.
       
  • Assessing endometrial cancer risk among US women: long-term trends using
           hysterectomy-adjusted analysis
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): Kemi M. Doll, Aaron N. WinnBackgroundCommonly reported incidence rates for endometrial cancer fail to take into account both the large number of hysterectomies performed each year and the dynamic change in hysterectomy rate over the past decade. Large racial differences in premenopausal hysterectomy rates between Black and White women in the United States likely affect calculation of race-based risk.ObjectivesThe objectives of the study were to determine how the long-term trends in Black-White differences in endometrial cancer incidence and histology type have changed over time for women at risk.Study DesignUsing longitudinal Surveillance, Epidemiology, and End Results data from 1997 to 2014 and state-level hysterectomy prevalence from the Behavioral Risk Factor Surveillance System, we calculated hysterectomy-adjusted incidence rates of endometrial cancer and the proportion of high vs low-risk endometrial cancer, by race, over time.ResultsIn women older than 50 years who have not had a hysterectomy, endometrial cancer incidence is 87 per 100,000 from 1997 to 2014. Among White women endometrial cancer incidence changed from 102 (1997–2001) to 86 (2012–2014) cases per 100,000, with a nonsignificant decreasing linear trend (adjusted risk ratio, 0.95; 95% confidence interval, 0.91–1.00; p=0.05). In contrast, incidence for Black women was 88 (1997–2001), 101 (2002–2006), 100 (2007–2011), and 102 (2012–2014) cases per 100,000 with no decreasing trend (adjusted risk ratio, 1.02; 95% confidence interval, 0.96–1.10, P = .449). High-risk histology increased among both groups (White: adjusted risk ratio, 1.06; 95% confidence interval, 1.01–1.11; P = .015; Black: adjusted risk ratio, 1.06; 95% confidence interval, 1.02–1.10, P = .007). Racial difference in the proportion of high-risk disease remained stable.ConclusionUpdated hysterectomy-adjusted incidence demonstrates that endometrial cancer is the second most common cancer among women older than 50 years with a uterus and that endometrial cancer has been more common among Black women compared with White women in the United States since 2002. A clinical approach of proactive communication and routine screening for early symptoms in the perimenopausal and menopausal years, especially among Black women, is warranted. These findings can also inform equitable distribution of research funding for endometrial cancer and serve to promote public awareness of this common cancer.
       
  • Elective induction of labor at 39 weeks compared with expectant
           management: a meta-analysis of cohort studies
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): William A. Grobman, Aaron B. CaugheyBackgroundElective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain.ObjectiveTo perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes.Study DesignStudies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models.ResultsOf 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74–0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39–0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59–0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26–0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72–0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09–0.76).ConclusionThis meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.
       
  • Maternal self-harm deaths: an unrecognized and preventable outcome
    • Abstract: Publication date: October 2019Source: American Journal of Obstetrics and Gynecology, Volume 221, Issue 4Author(s): Kimberly Mangla, M. Camille Hoffman, Caroline Trumpff, Sinclaire O’Grady, Catherine MonkMaternal mortality continues to be a public health priority in national and international communities. Maternal death rates secondary to medical illnesses such as cardiovascular disease, preeclampsia, and postpartum hemorrhage are well documented. The rates of maternal death secondary to self-harm, including suicide and overdose, have been omitted from published rates of maternal mortality, despite growing attention to the prevalence of perinatal mood disorders, estimated at up to 15% of pregnant and postpartum women in the United States. Underlying psychiatric disorder, including depression, is consistently identified as a risk factor in substance abuse and suicide. The rate of opioid-associated morbidity and mortality has recently been deemed a national crisis. Pregnancy does not protect against these risks, and the postpartum period has been identified as a particularly vulnerable time. The lack of consistent and inclusive data on self-harm deaths in the pregnancy-postpartum period is alarming. This review will identify barriers to reporting and ascertainment of maternal suicide and overdose deaths, summarize geographic-specific data available, address potential social and psychological biases that have led to neglect of the topic of maternal self-harm deaths, and suggest recommendations that incorporate the whole woman in prenatal care and thus prevention of this devastating outcome.
       
 
 
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
 
About JournalTOCs
API
Help
News (blog, publications)
JournalTOCs on Twitter   JournalTOCs on Facebook

JournalTOCs © 2009-