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American Journal of Obstetrics and Gynecology
Journal Prestige (SJR): 2.7
Citation Impact (citeScore): 4
Number of Followers: 274  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0002-9378 - ISSN (Online) 1097-6868
Published by Elsevier Homepage  [3206 journals]
  • Fetal Growth Percentile Software: a tool to calculate estimated fetal
           weight percentiles for six standards
    • Abstract: Publication date: Available online 15 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Gaurav Bhatti, Roberto Romero, Kiran Cherukuri, Dereje W. Gudicha, Mahendra Kavdia, Lami Yeo, Adi L. Tarca
       
  • Delayed versus immediate pushing in the second stage of labor in women
           with neuraxial analgesia: a systematic review and meta-analysis of
           randomized controlled trials
    • Abstract: Publication date: Available online 15 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Daniele Di Mascio, Gabriele Saccone, Federica Bellussi, Huda B. Al-Kouatly, Roberto Brunelli, Pierluigi Benedetti Panici, Marco Liberati, Francesco D’Antonio, Vincenzo BerghellaAbstractObjectiveThe aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the effect of delayed versus immediate pushing in the second stage of labor on mode of delivery and other outcomes in women with neuraxial analgesia.Data sourcesThe research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library as electronic databases, from the inception of each database to August 2019. No restrictions for language or geographic location were applied.Study eligibility criteriaSelection criteria included only RCTs of pregnant women randomized to either delayed or immediate pushing during the second stage of labor.Study appraisal and synthesis methodsThe primary outcome was mode of delivery. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of DerSimonian and Laird. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity.ResultsTwelve RCTs, including 5,445 women with neuraxial analgesia randomized to delayed versus immediate pushing during the second stage of labor were included in the meta-analysis. Of the 5,445 women included in the meta-analysis, 2,754 were randomized to the delayed pushing group and 2,691 to the immediate pushing group. No significant difference between delayed and immediate pushing was found for spontaneous vaginal delivery (80.9% vs 78.3%; RR 1.05, 95% CI 1.00 to 1.10; 12 RCTs, 5,540 women), operative vaginal delivery (12.8% vs 14.6%; RR 0.89, 95% CI 0.75 to 1.08; 11 RCTs, 5,395 women), and cesarean delivery (6.9% vs 7.9%; RR 0.89, 95% CI 0.73 to 1.07; 11 RCTs; 5,395 women). Women randomized to the delayed pushing group had a significantly shorter length of active pushing (MD -27.54 minutes; 95% CI -43.04 to -12.04; 7 RCTs, 4,737 women) at the expense of a significantly longer overall duration of the second stage of labor (MD 46.17 minutes; 95% CI 32.63 to 59.71; 8 studies; 4,890 women). The incidence of chorioamnionitis (9.1% vs 6.6%; RR 1.37, 95% CI 1.04 to 1.81; 1 RCT, 2,404 women) and low umbilical cord pH (2.7% vs 1.3%; RR 2.00, 95% CI 1.30 to 3.07; 5 RCTs, 4,549 women) were significantly higher in the delayed pushing group.ConclusionsIn women with spontaneous or induced labor at term with neuraxial analgesia, delayed pushing in the second stage does not affect the mode of delivery, although it reduces the time of active pushing at the expense of a longer second stage. This prolongation of labor was associated with a higher incidence of chorioamnionitis and low umbilical cord pH. Based on these findings, delayed pushing cannot be routinely advocated for the management of the second stage.
       
  • Examining indicators of early menopause following opportunistic
           salpingectomy: A cohort study from British Columbia, Canada
    • Abstract: Publication date: Available online 15 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Gillian E. Hanley, Janice S. Kwon, Jessica N. McAlpine, David G. Huntsman, Sarah J. Finlayson, Dianne MillerAbstractBackgroundThe fallopian tube may often be the site of origin for the most common and lethal form of ovarian cancer, high-grade serous ovarian cancer. As a result, many Colleges of Obstetrics & Gynecology, including ACOG, are recommending surgical removal of the fallopian tube (bilateral salpingectomy) at the time of other gynecologic surgeries (particularly hysterectomy and tubal sterilization) in women at general population risk for ovarian cancer, collectively referred to as opportunistic salpingectomy. Previous research has illustrated no increased risk of complications following opportunistic salpingectomy. However, most studies examining potential hormonal consequences of opportunistic salpingectomy have had limited follow-up time and have focused on surrogate hormonal markers.ObjectivesWe examine whether there are differences in physician visits for menopause and filling a prescription for hormone replacement therapy among women undergoing opportunistic salpingectomy in the population of British Columbia, Canada.Study DesignWe identified all women who were 50 years of age and younger in British Columbia who underwent opportunistic salpingectomy between 2008 and 2014. We compared women undergoing opportunistic salpingectomy at hysterectomy with women undergoing hysterectomy alone and women undergoing opportunistic salpingectomy for sterilization with women undergoing tubal ligation. We used Cox Proportional hazards models to model time to physician visits for menopause as well as filling a prescription for hormone replacement therapy. We calculated adjusted hazards ratios for these outcomes adjusting for other gynecologic conditions, surgical approach and patient age. An age-stratified analysis (
       
  • A Comparative Carbon Footprint Analysis of Disposable and Reusable Vaginal
           Specula
    • Abstract: Publication date: Available online 15 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Laura M. Donahue, Stephen Hilton, Sarah G. Bell, Brent C. Williams, Gregory A. KeoleianSTRUCTURED ABSTRACTBackgroundHealthcare systems in the United States have increasingly turned toward the use of disposable medical equipment in an attempt to save time, lower costs, and reduce transmission of infections. However, the use of disposable instruments is associated with increased solid waste production and may have negative impacts on the environment, such as increased greenhouse gas emissions.Objective and Study DesignTo inform this discussion, we apply life cycle assessment methods to evaluate the carbon footprints of three vaginal specula: a single-use acrylic model and two reusable stainless steel models. The functional unit of the study was defined as the completion of 20 gynecologic exams by either type of speculum. The greenhouse gas emissions (e.g. carbon dioxide, methane, nitrous oxide) across all life cycle stages, including material production and manufacturing, transportation, use and reprocessing, and end-of-life, were analyzed using SimaPro life cycle assessment software and converted into carbon dioxide equivalents (CO2e).ResultsThe reusable stainless steel grade 304 speculum was found to have a lesser carbon footprint over multiple model scenarios (different reprocessing techniques, autoclave loading/efficiency, and number of uses) than either the reusable stainless steel grade 316 or the disposable acrylic specula. The material production and manufacturing phase contributed most heavily to the total life cycle carbon footprint of the acrylic speculum whereas the use and reprocessing phase contributed most to the carbon footprints of both stainless steel specula.ConclusionThe use of disposable vaginal specula is associated with increased greenhouse gas equivalents compared to reusable alternatives with no significant difference in clinical utility. These findings can be used to inform decision-making by healthcare systems, as they weigh a wide range of considerations in making final purchase decisions, and that similar analytic methods can and should be applied to other components of health systems’ waste streams.
       
  • The first glimpse of the endometrial microbiota in early pregnancy
    • Abstract: Publication date: Available online 10 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Inmaculada Moreno, Iolanda Garcia-Grau, Davide BAU, David Perez-Villaroya, Marta Gonzalez-Monfort, Felipe Vilella, Roberto Romero, Carlos SimonAbstractInvestigation of the microbial community in the female reproductive tract using sequencing techniques has revealed that endometrial samples obtained through a transvaginal catheter are dominated by Lactobacillus species. Dysbiotic changes in the endometrial microbiota may be associated with implantation failure or early spontaneous abortion in patients undergoing assisted reproductive technology (ART) treatment. Whether or not there is an endometrial microbiota in early pregnancy is unknown.Herein we describe, the human endometrial microbiota in a patient who subsequently had an 8th week spontaneous clinical miscarriage with euploid embryos in the next cycle and, for the first time, during a successful pregnancy in which the endometrial fluid was sampled at 4 weeks of gestation. The microbial profile found on the endometrial sample prior to the spontaneous abortion had higher bacterial diversity and lower Lactobacillus abundance than the endometrial fluid from the healthy pregnancy. Functional metagenomics detected different Lactobacillus species between the two samples. Lactobacillus crispatus was present in the endometrium prior to the spontaneous abortion, as were other bacteria involved in dysbiosis, which had an unstable functional pattern characterized by transposases and insertion elements.Lactobacillus iners was the most prevalent microbe found in the endometrium during early pregnancy, associating its presence with defense mechanisms and basal functions. These novel observations prompt future investigations to understand the potential implications of microbiology on healthy and pathologic human pregnancy.
       
  • The Next Frontier: Universal HCV Screening in pregnant women
    • Abstract: Publication date: Available online 8 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Sammy Saab, Ravina Kullar, Christina Amini, Prabhu GounderAbstractThere is worldwide enthusiasm for the elimination of hepatitis C (HCV). The availability of highly effective and safe direct acting anti-viral agents to treat almost everyone with HCV infection means that HCV elimination is now primarily a public health challenge. Making progress towards HCV elimination requires screening to increase the proportion of HCV-infected persons who are aware of their status, linking to and retaining them in care to achieve cure, and increasing access to harm reduction services to prevent new infections. Historically, the majority of HCV-infected persons were “baby boomers” born during 1945–1965. Since the Centers for Disease Control recommended one-time HCV screening of baby boomers in 2012, the HCV prevalence in that population has decline with many have been identified and treated. Concurrently, there has been an increase in HCV prevalence among young adults using injection drugs. An important consequence of this changing epidemiology has been an increase in the number of HCV-infected women of childbearing age and HCV-exposed infants. Developing comprehensive programs and policies to identify, treat, and prevent perinatal HCV-transmission will play an important role in achieving the public health goal of HCV elimination.
       
  • Cervical Pessary To Prevent Preterm Birth In Asymptomatic High-Risk Women:
           A Systematic Review And Meta-Analysis
    • Abstract: Publication date: Available online 3 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Agustin Conde-Agudelo, Roberto Romero, Kypros H. NicolaidesABSTRACTObjectiveTo evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women.Data SourcesMEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.Study Eligibility CriteriaRandomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth.Study Appraisal And Synthesis MethodsThe systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth
       
  • Antibiotics, Pregnancy, and Fetal Mental Illnesses: Where is the link'
    • Abstract: Publication date: Available online 1 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Sedigheh HANTOUSHZADEH, Roghayeh ANVARI ALIABAD, Amir Hossein NOROOZNEZHAD
       
  • Metformin use in Obese mothers is Associated with Improved Cardiovascular
           Profile in the Offspring
    • Abstract: Publication date: Available online 1 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Olga PANAGIOTOPOULOU, Argyro SYNGELAKI, Georgios GEORGIOPOULOS, John SIMPSON, Ranjit AKOLEKAR, Hassan SHEHATA, Kypros NICOLAIDES, Marietta CHARAKIDAAbstractBackgroundMaternal obesity increases the risk for pregnancy complications and adverse neonatal outcome and it has also been associated with long lasting adverse effects in the offspring, including increased body fat mass, insulin resistance and increased risk for premature cardiovascular disease. Lifestyle interventions in pregnancy have produced none or modest effects in reducing adverse pregnancy outcomes in obese mothers. Metformin use in Obese Pregnant women trial was associated with reduced adverse pregnancy outcomes and had no effect on birthweight. However, the long-term implications of metformin on the health of offspring remain unknown.ObjectiveThe purpose of this study was to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers.Study designIn 151 children from the Metformin use in Obese-Pregnant women trial we measured body composition, peripheral blood pressure and arterial pulse wave velocity. Central hemodynamics (central blood pressure and augmentation index) were estimated using the Vicorder device. Left ventricular cardiac function and structure were assessed by echocardiography.ResultsChildren were 3.9±1.0 years of age and 77 were exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness and body composition apart from gluteal and tricep circumferences which were lower in the metformin group (p
       
  • Midtrimester amniotic fluid from healthy pregnancies has no microorganisms
           using multiple methods of microbiologic inquiry
    • Abstract: Publication date: Available online 1 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Yu Liu, Xiang Li, Baoli Zhu, Haijuan Zhao, Qubo Ai, Yulong Tong, Shengtang Qin, Ye Feng, Yutong Wang, Shuxian Wang, Jingmei Ma, Huixia YangAbstractBackgroundThere is controversy about whether the amniotic fluid contains bacteria. Using sequencing-based methods, recent studies report that the amniotic fluid is colonized by microorganisms. However, background-contaminating DNA might lead to false-positive findings when such a low microbial biomass sample is examined.ObjectiveTo determine whether the midtrimester amniotic fluid of patients who subsequently had normal pregnancy outcomes contains a microbial signature.Study designIn this prospective cohort study, 42 amniotic fluid samples were collected from 37 pregnancies (5 twin and 32 singletons) during genetic amniocentesis in the midtrimester. The subsequent pregnancy outcomes of all the participants were followed. Multiple methods were used to detect the presence of microorganisms in this study, including cultivation, quantitative real-time polymerase chain reaction (qPCR) and 16S ribosomal RNA (rRNA) gene sequencing. Multiple positive controls (n=16) served as quality controls, including 3 adult fecal samples, 4 vaginal swabs and 9 artificial bacterial communities, and run in parallel with negative controls (n=12), including 4 from the hospital operating room and 8 from the laboratory, to account for background-contaminating DNA during each step of the experiments.Results(1) No bacteria under anaerobic or aerobic conditions or genital mycoplasmas were cultured from any of the amniotic fluid samples. (2) Quantitative PCR did not reveal greater copy numbers of 16S rRNA gene in amniotic fluid samples than in negative controls. (3) 16S rRNA gene sequencing did not indicate significant difference in the microbial richness or community structures between amniotic fluid and negative controls.ConclusionWith multiple methods of microbiologic inquiry, no microorganisms were identified in the midtrimester amniotic fluid of healthy pregnancies with a normal pregnancy outcome.
       
  • Cerclage in twin pregnancies with short cervical length: more level 1 data
           is needed
    • Abstract: Publication date: Available online 1 February 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Amanda Roman, Vincenzo Berghella
       
  • Micronized vaginal progesterone to prevent miscarriage: a critical
           evaluation of randomized evidence
    • Abstract: Publication date: Available online 31 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Arri Coomarasamy, Adam J. Devall, Jan J. Brosens, Siobhan Quenby, Mary D. Stephenson, Sony Sierra, Ole B. Christiansen, Rachel Small, Jane Brewin, Tracy E. Roberts, Rima Dhillon-Smith, Hoda Harb, Hannah Noordali, Argyro Papadopoulou, Abey Eapen, Matt Prior, Gian Carlo Di Renzo, Kim Hinshaw, Ben W. Mol, Mary Ann LumsdenProgesterone is essential for the maintenance of pregnancy. Several small trials have suggested that progesterone supplementation may reduce the risk of miscarriage in women with recurrent or threatened miscarriage. Cochrane Reviews summarized the evidence and found that the trials were small with substantial methodologic weaknesses. Since then, the effects of first-trimester use of vaginal micronized progesterone have been evaluated in 2 large, high-quality, multicenter placebo-controlled trials, one targeting women with unexplained recurrent miscarriages (the PROMISE [PROgesterone in recurrent MIScarriagE] trial) and the other targeting women with early pregnancy bleeding (the PRISM [PRogesterone In Spontaneous Miscarriage] trial). The PROMISE trial studied 836 women from 45 hospitals in the United Kingdom and the Netherlands and found a 3% greater live birth rate with progesterone but with substantial statistical uncertainty. The PRISM trial studied 4153 women from 48 hospitals in the United Kingdom and found a 3% greater live birth rate with progesterone, but with a P value of .08. A key finding, first observed in the PROMISE trial, and then replicated in the PRISM trial, was that treatment with vaginal micronized progesterone 400 mg twice daily was associated with increasing live birth rates according to the number of previous miscarriages. Prespecified PRISM trial subgroup analysis in women with the dual risk factors of previous miscarriage(s) and current pregnancy bleeding fulfilled all 11 conditions for credible subgroup analysis. For the subgroup of women with a history of 1 or more miscarriage(s) and current pregnancy bleeding, the live birth rate was 75% (689/914) with progesterone vs 70% (619/886) with placebo (rate difference 5%; risk ratio, 1.09, 95% confidence interval, 1.03–1.15; P=.003). The benefit was greater for the subgroup of women with 3 or more previous miscarriages and current pregnancy bleeding; live birth rate was 72% (98/137) with progesterone vs 57% (85/148) with placebo (rate difference 15%; risk ratio, 1.28, 95% confidence interval, 1.08–1.51; P=.004). No short-term safety concerns were identified from the PROMISE and PRISM trials. Therefore, women with a history of miscarriage who present with bleeding in early pregnancy may benefit from the use of vaginal micronized progesterone 400 mg twice daily. Women and their care providers should use the findings for shared decision-making.
       
  • The role of second stage cesarean delivery in contributing to preterm
           delivery
    • Abstract: Publication date: Available online 31 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Sevan A. Vahanian, Anthony M. Vintzileos
       
  • Based on currently-available evidence, cerclage in patients with twin
           pregnancies and a short cervix should be avoided
    • Abstract: Publication date: Available online 31 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Luis Sanchez-Ramos
       
  • Letter to the editor
    • Abstract: Publication date: Available online 31 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Bradley S. de Vries, Joanne P. Ludlow, Angela Cong
       
  • Prediction of vaginal birth after cesarean deliveries using machine
           learning
    • Abstract: Publication date: Available online 30 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Michal Lipschuetz, Joshua Guedalia, Amihai Rottenstreich, Michal Novoselsky Persky, Ms. Sarah M. Cohen, Doron Kabiri, Gabriel Levin, Simcha Yagel, Ron Unger, Yishai SompolinskyAbstractBackgroundEfforts to reduce cesarean delivery rates to 12-15% have been undertaken worldwide. Special focus has been directed towards parturients undergoing a trial of labor after cesarean delivery, in order to reduce the burden of repeated cesarean deliveries. Complication rates are lowest when a vaginal birth is achieved and highest when an unplanned cesarean is performed, emphasizing the need to assess in advance the likelihood of a successful vaginal birth after cesarean.Vaginal birth after cesarean delivery calculators were developed in different populations, however, some limitations to their implementation into clinical practice were described.Machine learning methods enable investigation of large-scale datasets with input combinations that traditional statistical analysis tools have difficulty processing.ObjectiveThe aim of this study was to evaluate the feasibility of using machine-learning methods to predict a successful vaginal birth after cesarean delivery.Study designThe electronic medical records of singleton, term labors during a 12-year period in a tertiary referral center were analyzed. Using gradient boosting, models incorporating multiple maternal and fetal features were created to predict successful vaginal birth in parturients undergoing a trial of labor after cesarean delivery. One model was created to provide a personalized risk score for vaginal birth after cesarean delivery using features available as early as the first antenatal visit, additionally, a second model was created that reassesses this score after adding features available only in proximity to delivery.ResultsA cohort of 9,888 parturients with one previous cesarean delivery was identified, in which 75.6% (n=7,473) of parturients attempted a trial of labor, with a success rate of 88%. A machine learning based model to predict when vaginal delivery would be successful was developed. When using features available at the first antenatal visit, the model showed a receiver operating characteristic curve with area under the curve of 0.745 (95% confidence interval 0.728-0.762) which increased to 0.793 (95% confidence interval 0.778-0.808) when features available in proximity to the delivery process were added.Additionally, for the later model, a risk stratification tool was built to allocate parturients into low, medium and high-risk groups for failed trial of labor after cesarean delivery. The low and medium risk groups (42.4% and 25.6% of parturients, respectively) showed a success rate of 97.3% and 90.9% respectively. The high-risk group (32.1%) had a vaginal delivery success rate of 73.3%.Applying the model to a cohort of parturients who elected a repeat cesarean delivery (n=2145) demonstrated that 31% of these parturients would have been allocated to the low- and medium risk group, had a trial of labor been attempted.ConclusionTrial of labor after cesarean delivery is safe for most parturients. Success rates are high even in a population with high rates of trial of labor after cesarean. Applying a machine learning algorithm to assign a personalized risk score for a successful vaginal birth after cesarean delivery may help in decision making and contribute to a reduction in cesarean delivery rates. Parturient allocation to risk groups may help delivery process management.
       
  • Minimizing Surgical Blood Loss at Cesarean Hysterectomy for Placenta
           Previa with evidence of Placenta Increta or Placenta Percreta: The State
           of Play in 2020
    • Abstract: Publication date: Available online 30 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): John C. Kingdom, Sebastian R. Hobson, Ally Murji, Lisa Allen, Rory C. Windrim, Evelyn Lockhart, Sally L. Collins, Hooman Soleymani Majd, Moiad Alazzam, Feras Naaisa, Alireza A. Shamshirsaz, Michael A. Belfort, Karin A. FoxAbstractThe evolution of multidisciplinary team-based care for women with placenta accreta spectrum (PAS) disorder has delivered step-wise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care, and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy in order to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless a subset of women have the most severe form of PAS, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infra-renal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe PAS disorder.
       
  • Information for Readers
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s):
       
  • Reply
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Lina Youssef, Fatima Crispi, Fatima Crispi
       
  • Delayed interval delivery when the presenting fetus is in breech
           presentation
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Ka Wang Cheung, Mimi Tin Yan Seto, Mark D. Kilby
       
  • Comment on: “Effect of delayed interval delivery of remaining fetus(es)
           in multiple pregnancies on survival: a systematic review and
           meta-analysis”
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Sara Lazzarin, Sabrina Cozzolino, Patrizia Vergani
       
  • Rates of recognized pregnancy in women with disabilities in Ontario,
           Canada
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(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
       
  • The effect of temperature on bacterial growth in the presence of
           nonsterile ultrasound coupling gel
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Samantha Ricci, Michael G. Pinette, Joseph R. Wax, Wendy Craig, Lisa Forrest, Catherine Dragoni
       
  • An aberrant collateral vessel in a woman with a history of uterine artery
           embolization
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Toma Mizoguchi, Ryuichi Shimaoka, Ken-ichirou Morishige
       
  • Noninvasive prenatal detection of hemoglobin Bart hydrops fetalis via
           maternal plasma dispensed with parental haplotyping using the
           semiconductor sequencing platform
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Jiexia Yang, Chun-fang Peng, Yiming Qi, Xing-qiang Rao, Fangfang Guo, Yaping Hou, Wei He, Jing Wu, Yang-yi Chen, Xin Zhao, Yu-nan Wang, Haishan Peng, Dongmei Wang, Li Du, Ming-yong Luo, Quan-fei Huang, Hai-liang Liu, Aihua YinBackgroundThalassemia is one of the most common monogenetic diseases in the south of China and Southeast Asia. Hemoglobin Bart’s hydrops fetalis syndrome was caused by a homozygous Southeast Asian deletion (–/–) in the HBA gene. Few studies have proved the potential of screen for Bart's hydrops fetalis using fetal cell-free DNA. However, the number of cases is still relatively small. Clinical trials of large samples would be needed.ObjectiveIn this study, we aimed to develop a noninvasive method of target-captured sequencing and genotyping by the Bayesian method using cell-free fetal DNA to identify the fetal genotype in pregnant women who are at risk of having hemoglobin Bart hydrops fetalis in a large-scale study.Study DesignIn total, 192,173 couples from 30 hospitals were enrolled in our study and 878 couples were recruited, among whom both the pregnant women and their husbands were detected to be carriers of Southeast Asian type (–/αα) of α-thalassemia. Prenatal diagnosis was performed by chorionic villus sampling, amniocentesis, or cordocentesis using gap–polymerase chain reaction considered as the golden standard.ResultsAs a result, we found that the sensitivity and specificity of our noninvasive method were 98.81% and 94.72%, respectively, in the training set as well as 100% and 99.31%, respectively, in the testing set. Moreover, our method could identify all of 885 maternal samples with the Southeast Asian carrier and 36 trisomy samples with 100% of sensitivity in T13, T18, and T21 and 99.89% (1 of 917) and 99.88% (1 of 888) of specificity in T18 and T21, respectively.ConclusionOur method opens the possibility of early screening for maternal genotyping of α-thalassemia, fetal aneuploidies in chromosomes 13/18/21, and hemoglobin Bart hydrops fetalis detection in 1 tube of maternal plasma.
       
  • The duration of fetal antenatal steroid exposure determines the durability
           of preterm ovine lung maturation
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Matthew W. Kemp, Masatoshi Saito, Augusto F. Schmidt, Haruo Usuda, Shimpei Watanabe, Shinichi Sato, Takushi Hanita, Yusaku Kumagai, Tsukasa Takahashi, Gabrielle C. Musk, Lucy Furfaro, Lisa Stinson, Erin L. Fee, Peter J. Eddershaw, Matthew S. Payne, Kiara Smallwood, James Bridges, John P. Newnham, Alan H. JobeBackgroundAntenatal corticosteroids (ACS) are the standard of care for maturing the fetal lung and improving outcomes for preterm infants. Antenatal corticosteroid dosing remains nonoptimized, and there is little understanding of how different treatment-to-delivery intervals may affect treatment efficacy. The durability of a lung maturational response is important because the majority of women treated with antenatal corticosteroids do not deliver within the widely accepted 1- to 7-day window of treatment efficacy.ObjectiveWe used a sheep model to test the duration of fetal exposures for efficacy at delivery intervals from 1 to 10 days.Materials and MethodsFor infusion studies, ewes with single fetuses were randomized to receive an intravenous bolus and maintenance infusion of betamethasone phosphate to target 1–4 ng/mL fetal plasma betamethasone for 36 hours, with delivery at 2, 4 ,or 7 days posttreatment or sterile saline solution as control. Animals receiving the clinical treatment were randomised to receive either a single injection of 0.25 mg/kg with a 1:1 mixture of betamethasone phosphate + betamethasone acetate with delivery at either 1 or 7 days posttreatment, or 2 treatments of 0.25 mg/kg betamethasone phosphate + betamethasone acetate spaced at 24 hours (giving ∼48 hours of fetal steroid exposure) with delivery at 2, 5, 7, or 10 days posttreatment. Negative control animals were treated with saline solution. All lambs were delivered at 121 ± 3 days gestational age and ventilated for 30 minutes to assess lung function.ResultsPreterm lambs delivered at 1 or 2 days post–antenatal corticosteroid treatment had significant improvements in lung maturation for both intravenous and single-dose intramuscular treatments. After 2 days, the efficacy of 36-hour betamethasone phosphate infusions was lost. The single dose of 1:1 betamethasone phosphate + betamethasone acetate also was ineffective at 7 days. In contrast, animals treated with 2 doses had significant improvements in lung maturation at 2, 5, and 7 days, with treatment efficacy reduced by 10 days.ConclusionIn preterm lambs, the durability of antenatal corticosteroids treatment depends on the duration of fetal exposure and is independent of the intravenous or intramuscular maternal route of administration. For acute 24- to 48-hour posttreatment deliveries, a 24-hour fetal antenatal corticosteroids exposure was sufficient for lung maturation. A fetal exposure duration of at least 48 hours was necessary to maintain long-term treatment durability. A single-dose ACS treatment should be sufficient for women delivering within
       
  • Specific birth defects in pregnancies of women with diabetes: National
           Birth Defects Prevention Study, 1997–2011
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Sarah C. Tinker, Suzanne M. Gilboa, Cynthia A. Moore, D. Kim Waller, Regina M. Simeone, Shin Y. Kim, Denise J. Jamieson, Lorenzo D. Botto, Jennita Reefhuis, National Birth Defects Prevention StudyBackgroundDiabetes is associated with an increased risk for many birth defects and is likely to have an increasing impact on birth defect prevalence because of the rise in diabetes in the United States in recent decades. One of the first analyses in which specific birth defects were assessed for their relationship with both pregestational and gestational diabetes used data from the initial 6 years of the National Birth Defects Prevention Study. That analysis reported strong associations for pregestational diabetes with several birth defects, but few exposures among some of the less common birth defects led to unstable estimates with wide confidence intervals. Since that analysis, the study continued to collect data for another 8 years, including information on approximately 19,000 additional cases and 6900 additional controls.ObjectiveOur objective was to use data from the National Birth Defects Prevention Study, the largest population-based birth defects case-control study in the United States, to provide updated and more precise estimates of the association between diabetes and birth defects, including some defects not previously assessed.Study DesignWe analyzed data on deliveries from October 1997 through December 2011. Mothers of case and control infants were interviewed about their health conditions and exposures during pregnancy, including diagnosis of pregestational (type 1 or type 2) diabetes before the index pregnancy or gestational diabetes during the index pregnancy. Using logistic regression, we separately assessed the association between pregestational and gestational diabetes with specific categories of structural birth defects for which there were at least 3 exposed case infants. For birth defect categories for which there were at least 5 exposed case infants, we calculated odds ratios adjusted for maternal body mass index, age, education, race/ethnicity, and study site; for defect categories with 3 or 4 exposed cases, we calculated crude odds ratios.ResultsPregestational diabetes was reported by 0.6% of mothers of control infants (71 of 11,447) and 2.5% of mothers of case infants (775 of 31,007). Gestational diabetes during the index pregnancy was reported by 4.7% of mothers of control infants (536 of 11,447) and 5.3% of mothers of case infants (1,653 of 31,007). Pregestational diabetes was associated with strong, statistically significant odds ratios (range, 2.5–80.2) for 46 of 50 birth defects considered. The largest odds ratio was observed for sacral agenesis (adjusted odds ratio, 80.2; 95% confidence interval, 46.1–139.3). A greater than 10-fold increased risk was also observed for holoprosencephaly (adjusted odds ratio, 13.1; 95% confidence interval, 7.0–24.5), longitudinal limb deficiency (adjusted odds ratio, 10.1; 95% confidence interval, 6.2–16.5), heterotaxy (adjusted odds ratio, 12.3; 95% confidence interval, 7.3–20.5), truncus arteriosus (adjusted odds ratio, 14.9; 95% confidence interval, 7.6–29.3), atrioventricular septal defect (adjusted odds ratio, 10.5; 95% confidence interval, 6.2–17.9), and single ventricle complex (adjusted odds ratio, 14.7; 95% confidence interval, 8.9–24.3). For gestational diabetes, statistically significant odds ratios were fewer (12 of 56) and of smaller magnitude (range, 1.3– 2.1; 0.5 for gastroschisis).ConclusionPregestational diabetes is associated with a markedly increased risk for many specific births defects. Because glycemic control before pregnancy is associated with a reduced risk for birth defects, ongoing quality care for persons with diabetes is an important opportunity for prevention.
       
  • Intrauterine growth discordance across gestation and birthweight
           discordance in dichorionic twins
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Melissa M. Amyx, Paul S. Albert, Alaina M. Bever, Stefanie N. Hinkle, John Owen, William A. Grobman, Roger B. Newman, Edward K. Chien, Robert E. Gore-Langton, Germaine M. Buck Louis, Katherine L. GrantzBackgroundAlthough intertwin size difference is an important measure of fetal growth, the appropriate cut point to define discordance is unclear. Few studies have assessed intertwin differences in estimated fetal weight longitudinally or in relation to size differences at birth.ObjectivesThe objectives of the study were to estimate the magnitude of percentage differences in estimated fetal weight across gestation in dichorionic twins in relation to a fixed discordance cut point and compare classification of aberrant fetal growth by different measures (estimated fetal weight differences, birthweight discordance, small for gestational age).Study DesignWomen aged 18–45 years from 8 US centers with dichorionic twin pregnancies at 8 weeks 0 days to 13 weeks 6 days gestation planning to deliver in participating hospitals were recruited into the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies–Dichorionic Twins study and followed through delivery (n = 140; 2012–2013). Ultrasounds were conducted at 6 targeted study visits to obtain fetal biometrics and calculate estimated fetal weight. Percent estimated fetal weight and birthweight differences were calculated: ([weightlarger – weightsmaller]/weightlarger)*100; discordance was defined as ≥18% for illustration. Birth sizes for gestational age (both, 1, or neither small for gestational age) were determined; twins were categorized into combined birthweight plus small for gestational age groups: birthweight discordance ≥18% (yes, no) with both, 1, or neither small for gestational age. Linear mixed-models estimated percentiles of estimated fetal weight percent differences across gestation and compared estimated fetal weight differences between combined birthweight discordance and small for gestational age groups. A Fisher exact test compared birthweight discordance and small for gestational age classifications.ResultsMedian estimated fetal weight percentage difference increased across gestation (5.9% at 15.0, 8.4% at 38.0 weeks), with greater disparities at higher percentiles (eg, 90th percentile: 15.6% at 15.0, 26.3% at 38.0 weeks). As gestation advanced, an increasing percentage of pregnancies were classified as discordant using a fixed cut point: 10% at 27.0, 15% at 34.0, and 20% at 38.0 weeks. Birthweight discordance and small for gestational age classifications differed (P = .002); for birthweight discordance ≥18% vs
       
  • Incomplete excision of cervical intraepithelial neoplasia as a predictor
           of the risk of recurrent disease—a 16-year follow-up study
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Susanna Alder, David Megyessi, Karin Sundström, Ellinor Östensson, Miriam Mints, Karen Belkić, Marc Arbyn, Sonia AnderssonBackgroundWomen treated for high-grade cervical intraepithelial neoplasia (grade 2 or 3) are at elevated risk for developing cervical cancer. Suggested factors identifying women at highest risk for recurrence post-therapeutically include incomplete lesion excision, lesion location, size and severity, older age, treatment modality, and presence of high-risk human papilloma virus after treatment. This question has been intensively investigated over decades, but there is still substantial debate as to which of these factors or combination of factors most accurately predict treatment failure.ObjectiveIn this study, we examine the long-term risk of residual/recurrent high-grade cervical intraepithelial neoplasia among women previously treated for cervical intraepithelial neoplasia 2/3 and how this varies according to margin status (considering also location), as well as comorbidity (conditions assumed to interact with high-risk human papilloma virus acquisition and/or cervical intraepithelial neoplasia progression), posttreatment presence of high-risk human papilloma virus, and other factors.Materials and MethodsThis prospective study included 991 women with histopathologically confirmed cervical intraepithelial neoplasia 2/3 who underwent conization in 2000–2007. Information on the primary histopathologic finding, treatment modality, comorbidity, age, and high-risk human papilloma virus status during follow-up, and residual/recurrent high-grade cervical intraepithelial neoplasia was obtained from the Swedish National Cervical Screening Registry and medical records. Cumulative incidence of residual/recurrent high-grade cervical intraepithelial neoplasia was plotted on Kaplan–Meier curves, with determinants assessed by Cox regression.ResultsDuring a median of 10 years and maximum of 16 years of follow-up, 111 patients were diagnosed with residual/recurrent high-grade cervical intraepithelial neoplasia or worse. Women with positive/uncertain margins had a higher risk of residual/recurrent high-grade cervical intraepithelial neoplasia or worse than women with negative margins, adjusting for potential confounders (hazard ratio, 2.67; 95% confidence interval, 1.81–3.93). The risk of residual/recurrent high-grade cervical intraepithelial neoplasia or worse varied by anatomical localization of the margins (endocervical: hazard ratio, 2.72; 95% confidence interval, 1.67–4.41) and both endo- and ectocervical (hazard ratio, 4.98; 95% confidence interval, 2.85–8.71). The risk did not increase significantly when only ectocervical margins were positive or uncertain. The presence of comorbidity (autoimmune disease, human immunodeficiency viral infection, hepatitis B and/or C, malignancy, diabetes, genetic disorder, and/or organ transplant) was also a significant independent predictor of residual/recurrent high-grade cervical intraepithelial neoplasia or worse. In women with positive high-risk human papilloma virus findings during follow-up, the hazard ratio of positive/uncertain margins for recurrent/residual high-grade cervical intraepithelial neoplasia or worse increased significantly compared to that in women with positive high-risk human papilloma virus findings but negative margins.ConclusionPatients with incompletely excised cervical intraepithelial neoplasia 2/3 are at increased risk for residual/recurrent high-grade cervical intraepithelial neoplasia or worse. Margin status combined with high-risk human papilloma virus results and consideration of comorbidity may increase the accuracy for predicting treatment failure.
       
  • Chemotherapy alone for patients 75 years and older with epithelial ovarian
           cancer—is interval cytoreductive surgery still needed'
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): David A. Klein, Amandeep K. Mann, Alexandra H. Freeman, Cheng-I Liao, Daniel S. Kapp, John K. ChanBackgroundPatients ≥75 years old with ovarian cancer experience high perioperative morbidity, but recruitment into prospective trials to assess the role of surgery continues to be challenging.ObjectiveTo compare overall survival for patients ≥75 years old with ovarian cancer after chemotherapy alone vs neoadjuvant chemotherapy with interval cytoreductive surgery.Study DesignData were extracted from the National Cancer Data Base from 2004 to 2014. Kaplan–Meier and Cox proportional hazards models were used for statistical analyses.ResultsOf 1661 patients (median age: 79 years), most were white (88%) and had stage III–IV disease (95%), and 51% had serous histology. Of those who did not receive primary surgery, 58% had chemotherapy alone and the remainder had neoadjuvant chemotherapy with interval cytoreductive surgery. The use of neoadjuvant chemotherapy with interval cytoreductive surgery increased from 28% to 50% in years 2004–2007 to 2012–2014 (P
       
  • Inherited susceptibility to miscarriage: a nested case-control study of
           31,565 women from an intergenerational cohort
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Andrea M.F. Woolner, Edwin Amalraj Raja, Siladitya Bhattacharya, Peter Danielian, Soh BhattacharyaBackgroundMiscarriage can be a devastating outcome for couples, and most miscarriages are unexplained. Many adverse obstetric outcomes (such as preeclampsia, preterm birth, and growth restriction) are thought to be inherited. It is possible that these conditions could share similar pathophysiologic mechanisms (such as endothelial dysfunction) with miscarriage. Therefore, it was hypothesized that there could be a susceptibility to miscarriage transmitted from mother to daughter.ObjectiveThis study aimed to investigate the association between a maternal history of miscarriage and the risk of miscarriage in daughters.Study DesignA case-control study nested within an intergenerational cohort was conducted. Mother-daughter pairs were identified from the intergenerational cohort within the Aberdeen Maternity and Neonatal Databank, United Kingdom. A mother’s history of miscarriage was the exposure. The primary outcome was miscarriage in daughters. There were 31,565 mother-daughter pairs who were eligible for inclusion. A population average model that used generalized estimating equations with robust standard errors was used to estimate the odds of a mother’s history of miscarriage in daughters with a miscarriage compared with daughters with only livebirths. This method accounted for clustering of daughters within mothers, and multiadjusted analyses were performed to include confounders at the daughter’s pregnancy level.ResultsDaughters who miscarried had 11% greater odds of being born to mothers with a history of miscarriage (adjusted odds ratio, 1.11; 95% confidence interval, 1.01–1.22). Daughters with recurrent miscarriage (≥2) were also more likely to be born to a mother with a history of miscarriage (adjusted odds ratio, 1.25; 95% confidence interval, 1.04–1.49).ConclusionThere may be an inherited predisposition to miscarriage transmitted from mother to daughter. Future research should investigate genetic or familial environmental factors that may predispose women to miscarriage.
       
  • The natural history of urinary incontinence subtypes in the Nurses’
           Health Studies
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Vatche A. Minassian, Kaitlin A. Hagan, Elisabeth Erekson, Andrea M. Austin, Donald Carmichael, Julie P.W. Bynum, Francine GrodsteinBackgroundUrinary incontinence subtypes often differ by symptom severity and treatment profiles; in particular, mixed urinary incontinence is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence subtypes, which could help to better identify and treat patients prior to development of more intractable disease.ObjectiveTo evaluate the onset of urinary incontinence subtypes, and transitions between subtypes over 8 years, using 2 large cohorts of middle-aged and older women with incident urinary incontinence.Materials and MethodsWe identified 10,349 women with incident urinary incontinence (stress, urgency, and mixed subtypes) from the Nurses’ Health Study and the Nurses’ Health Study II who were 41–83 years of age, using repeated mailed questionnaires. We defined stress urinary incontinence as leakage with coughing, sneezing, or activity; urgency urinary incontinence as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed urinary incontinence when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of urinary incontinence subtypes 4 years and 8 years after urinary incontinence onset, we used multivariable-adjusted generalized estimating equations with a multinomial outcome.ResultsAt urinary incontinence onset in 2004–2005, 56% of women reported stress urinary incontinence symptoms, 23% reported urgency urinary incontinence symptoms, and 21% reported mixed urinary incontinence symptoms. Women with stress urinary incontinence or urgency urinary incontinence at onset were likely to report the same urinary incontinence type 4 and 8 years later (stress urinary incontinence at onset: 70% and 60% reported stress urinary incontinence at years 4 and 8, respectively; urgency urinary incontinence at onset: 68% and 64% reported urgency urinary incontinence at years 4 and 8, respectively). Nonetheless, for both stress and urgency urinary incontinence, women with more severe symptoms at onset were more likely to progress to mixed urinary incontinence. Women with mixed urinary incontinence at onset had more variation over time, although the largest subset continued to report mixed urinary incontinence (45% reported mixed urinary incontinence at year 4; 43% reported mixed urinary incontinence at year 8). Few women across all urinary incontinence subtypes reported resolution of symptoms over 4–8 years of follow-up (4–12%). When considering the likelihood of remaining with or progressing to mixed urinary incontinence over follow-up, according to age, body mass index, and urinary incontinence severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed urinary incontinence (eg, women
       
  • Association between adjuvant posterior repair and success of native tissue
           apical suspension
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Gary Sutkin, Halina M. Zyczynski, Amaanti Sridhar, J. Eric Jelovsek, Charles R. Rardin, Donna Mazloomdoost, David D. Rahn, John N. Nguyen, Uduak U. Andy, Isuzu Meyer, Marie G. Gantz, NICHD Pelvic Floor Disorders NetworkBackgroundPosterior repairs and perineorrhaphies are often performed in prolapse surgery to reduce the size of the genital hiatus. The benefit of an adjuvant posterior repair at the time of sacrospinous ligament fixation or uterosacral ligament suspension is unknown.ObjectiveWe aimed to determine whether an adjuvant posterior repair at transvaginal apical suspension is associated with improved surgical success.Materials and MethodsThis secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial compared 24-month outcomes in 190 participants who had a posterior repair (posterior repair group) and 184 who did not (no posterior repair group) at the time of sacrospinous ligament fixation or uterosacral ligament suspension. Concomitant posterior repair was performed at the surgeon’s discretion. Primary composite outcome of “surgical success” was defined as no prolapse beyond the hymen, point C ≤ –2/3 total vaginal length, no bothersome bulge symptoms, and no retreatment at 24 months. The individual components were secondary outcomes. Propensity score methods were used to build models that balanced posterior repair group and the no posterior repair group for ethnographic factors and preoperative Pelvic Organ Prolapse Quantification values. Adjusted odds ratios were calculated to predict surgical success based on the performance of a posterior repair. Groups were also compared with unadjusted χ2 analyses. An unadjusted probability curve was created for surgical success as predicted by preoperative genital hiatus.ResultsWomen in the posterior repair group were less likely to be Hispanic or Latina, and were more likely to have had a prior hysterectomy and to be on estrogen therapy. The groups did not differ with respect to preoperative Pelvic Organ Prolapse Quantification stage; however, subjects in the posterior repair group had significantly greater preoperative posterior wall prolapse. There were no group differences in surgical success using propensity score methods (66.7% posterior repair vs 62.0% no posterior repair; adjusted odds ratio, 1.07; 95% confidence interval, 0.56–2.07; P = 0.83) or unadjusted test (66.2% posterior repair vs 61.7% no posterior repair; P = 0.47). Individual outcome measures of prolapse recurrence (bothersome bulge symptoms, prolapse beyond the hymen, or retreatment for prolapse) also did not differ by group. Similarly, there were no differences between groups in anatomic outcomes of any individual compartment (anterior, apical, or posterior) at 24 months. There was high variation in performance of posterior repair by surgeon (interquartile range, 15–79%). The unadjusted probability of overall success at 24 months, regardless of posterior repair, decreased with increasing genital hiatus, such that a genital hiatus of 4.5 cm was associated with 65.8% success (95% confidence interval, 60.1–71.1%).ConclusionConcomitant posterior repair at sacrospinous ligament fixation or uterosacral ligament suspension was not associated with surgical success after adjusting for baseline covariates using propensity scores or unadjusted comparison. Posterior repair may not compensate for the pathophysiology that leads to enlarged preoperative genital hiatus, which remains prognostic of prolapse recurrence.
       
  • Impact of oral metronidazole treatment on the vaginal microbiota and
           correlates of treatment failure
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Marijn C. Verwijs, Stephen K. Agaba, Alistair C. Darby, Janneke H.H. M. van de WijgertBackgroundMetronidazole is the first-line treatment for bacterial vaginosis, but cure rates are suboptimal and recurrence rates high.ObjectivesTo evaluate the impact of a standard course of oral metronidazole treatment (500 mg twice per day for 7 days) on the vaginal microbiota of Rwandan bacterial vaginosis patients using microscopy and 16S rRNA gene sequencing, and to evaluate correlates of treatment failure.Study DesignHIV-negative, nonpregnant women aged 18–45 years with bacterial vaginosis and/or Trichomonas vaginalis (N=68) were interviewed and sampled before and after metronidazole treatment. They were also screened, and treated if applicable, for other urogenital infections. The vaginal microbiota was assessed by Gram stain Nugent scoring, Illumina 16S rRNA HiSeq sequencing (relative abundances), and BactQuant 16S gene quantitative polymerase chain reaction (estimated concentrations). Only women with a pretreatment Nugent score of 7–10 and a valid posttreatment Nugent score (N=55) were included in metronidazole treatment failure analyses, with treatment failure defined as a posttreatment Nugent score of 4–10.ResultsThe bacterial vaginosis cure rate by Nugent scoring was 54.5%. The mean total vaginal bacterial concentration declined from 6.59 to 5.85 log10/μL (P
       
  • Defining the relationship between vaginal and urinary microbiomes
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Yuko M. Komesu, Darrell L. Dinwiddie, Holly E. Richter, Emily S. Lukacz, Vivian W. Sung, Nazema Y. Siddiqui, Halina M. Zyczynski, Beri Ridgeway, Rebecca G. Rogers, Lily A. Arya, Donna Mazloomdoost, Josh Levy, Benjamin Carper, Marie G. Gantz, National Institute of Child Health and Human Development Pelvic Floor Disorders NetworkBackgroundAlthough the vaginal and urinary microbiomes have been increasingly well-characterized in health and disease, few have described the relationship between these neighboring environments. Elucidating this relationship has implications for understanding how manipulation of the vaginal microbiome may affect the urinary microbiome and treatment of common urinary conditions.ObjectiveTo describe the relationship between urinary and vaginal microbiomes using 16S rRNA gene sequencing. We hypothesized that the composition of the urinary and vaginal microbiomes would be significantly associated, with similarities in predominant taxa.Study DesignThis multicenter study collected vaginal swabs and catheterized urine samples from 186 women with mixed urinary incontinence enrolled in a parent study and 84 similarly aged controls. Investigators decided a priori that if vaginal and/or urinary microbiomes differed between continent and incontinent women, the groups would be analyzed separately; if similar, samples from continent and incontinent women would be pooled and analyzed together. A central laboratory sequenced variable regions 1–3 (v1–3) and characterized bacteria to the genus level. Operational taxonomic unit abundance was described for paired vaginal and urine samples. Pearson’s correlation characterized the relationship between individual operational taxonomic units of paired samples. Canonical correlation analysis evaluated the association between clinical variables (including mixed urinary incontinence and control status) and vaginal and urinary operational taxonomic units, using the Canonical correlation analysis function in the Vegan package (R version 3.5). Linear discriminant analysis effect size was used to find taxa that discriminated between vaginal and urinary samples.ResultsUrinary and vaginal samples were collected from 212 women (mean age 53±11 years) and results from 197 paired samples were available for analysis. As operational taxonomic units in mixed urinary incontinence and control samples were related in canonical correlation analysis and since taxa did not discriminate between mixed urinary incontinence or controls in either vagina or urine, mixed urinary incontinence and control samples were pooled for further analysis. Canonical correlation analysis of vaginal and urinary samples indicated that that 60 of the 100 most abundant operational taxonomic units in the samples largely overlapped. Lactobacillus was the most abundant genus in both urine and vagina (contributing on average 53% to an individual’s urine sample and 64% to an individual’s vaginal sample) (Pearson correlation r=0.53). Although less abundant than Lactobacillus, other bacteria with high Pearson correlation coefficients also commonly found in vagina and urine included: Gardnerella (r=0.70), Prevotella (r=0.64), and Ureaplasma (r=0.50). Linear discriminant analysis effect size analysis identified Tepidimonas and Flavobacterium as bacteria that distinguished the urinary environment for both mixed urinary incontinence and controls as these bacteria were absent in the vagina (Tepidimonas effect size 2.38, P
       
  • Universal access to contraception: women, families, and communities
           benefit
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Laurel W. Rice, Eve Espey, Dee E. Fenner, Kimberly D. Gregory, Jacquelyn Askins, Charles J. LockwoodUniversal access to contraception benefits society: unintended pregnancies, maternal mortality, preterm birth, abortions, and obesity would be reduced by increasing access to affordable contraception. Women should be able to choose when and whether to use contraception, choose which method to use, and have ready access to their chosen method. State and national government should support unrestricted access to all contraceptives. As obstetrician-gynecologists, we have a critical mandate, based on principle and mission, to step up with leadership on this vital medical and public health issue, to improve the lives of women, their families, and society. The field of Obstetrics and Gynecology must provide the leadership for moving forward. The American Gynecological and Obstetrical Society (AGOS), representing academic and public policy leaders from across all disciplines of Obstetrics and Gynecology, is well positioned to serve as a unifying organization, focused on developing a strong unified advocacy voice to fight for accessible contraception for all in the United States.
       
  • Contraception across the transmasculine spectrum
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Chance Krempasky, Miles Harris, Lauren Abern, Frances GrimstadThe field of transgender health continues to expand rapidly, including research in the area of family planning. While much attention has been given to fertility preservation and the parenting intentions of transgender individuals, far less has been paid to pregnancy prevention and contraceptive needs of people along the transmasculine gender spectrum (transgender men and gender-nonbinary persons who were assigned female at birth). Existing research illustrates that many clinicians and transmasculine individuals falsely believe that there is no risk of pregnancy while amenorrheic. These studies also show inconsistent counseling practices provided to transmasculine persons surrounding contraception and pregnancy while falling short of providing robust clinical guidance for improvement. Clinicians report a lack of adequate training in transgender reproductive health, and consequently, many do not feel comfortable treating transgender patients. The aim of this publication is to consolidate the findings of these prior studies and build upon them to offer comprehensive clinical guidance for managing contraception in transmasculine patients. To do so, it reviews the physiologic effects of testosterone on the sex steroid axis and current understanding of why ovulation and pregnancy may still occur while amenorrheic. Gender-inclusive terminology and a suggested script for eliciting a gender-affirming sexual history are offered. Common concerns (such as the effects on gender dysphoria and gender affirmation) and side effects of available contraceptive methods are subsequently addressed and how these may have a unique impact on transmasculine persons as compared with cisgender women. Lastly, a model is provided for approaching contraceptive counseling in the transmasculine population to assist clinicians and patients in determining the need for and selection of the type of contraception. To center transmasculine voices, the development of this publication’s guidelines have been led by reproductive care clinicians of transgender experience.
       
  • Intimate partner violence during pregnancy and risk of fetal and
           neonatal death: a meta-analysis with socioeconomic context indicators
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Guadalupe Pastor-Moreno, Isabel Ruiz-Pérez, Jesús Henares-Montiel, Dafina PetrovaObjectiveThe objective of the study was to summarize the results from observational studies examining the risk of fetal and neonatal death (perinatal death) as a function of the experience of intimate partner violence during pregnancy and examine the influence of socioeconomic context indicators on this association.Data SourcesBibliographic searches were conducted in PubMed, EMBASE, CINAHL, and LILACS until March 2019.Study Eligibility CriteriaWe considered observational studies that provided data on the association between intimate partner violence during pregnancy and perinatal death.Study Appraisal and Synthesis MethodsInformation collected included study characteristics, type, and prevalence of intimate partner violence and the reported association between intimate partner violence and perinatal death. Quality of the included studies was assessed using the Newcastle-Ottawa scale. Two reviewers independently conducted all review procedures; disagreements were resolved by a third reviewer. Meta-analyses were conducted based on the specific type of intimate partner violence (physical, psychological, sexual, unspecified) and also based on any type of intimate partner violence, considering 1 effect size per study, regardless of the type of intimate partner violence analyzed. Meta-regression analyses were performed to assess the possible effects of socioeconomic context. The proportion of deaths attributable to the exposure of intimate partner violence based on the crude data from the 3 cohort studies available also was calculated.ResultsSeventeen studies were included. The random-effects model showed a statistically significant increase in the odds of perinatal death among women exposed to unspecified intimate partner violence (odds ratio, 3.18; 95% confidence interval, 1.88–5.38), physical intimate partner violence (odds ratio, 2.46; 95% confidence interval, 1.76–3.44), and any type of intimate partner violence during pregnancy (odds ratio, 2.89; 95% confidence interval, 2.03–4.10). Meta-regression analysis showed stronger associations in countries with higher gross domestic product (odds ratio, 1.03; 95% confidence interval, 1.02–1.04) and a higher percentage of health expenditure (odds ratio, 1.27; 95% confidence interval, 1.09–1.46). The proportion of deaths attributable to exposure to intimate partner violence in cohort studies was attributable proportion, 60%; 95% confidence interval, 15–81%.ConclusionPregnant women who experience intimate partner violence during pregnancy may be about 3 times more likely to suffer perinatal death compared with women who do not experience intimate partner violence. It should be a priority to include intimate partner violence screenings or other detection strategies in pregnancy monitoring or family-planning programs because these could help avoid preventable perinatal deaths.
       
  • Noncandidal vaginitis: a comprehensive approach to diagnosis and
           management
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Chemen M. Neal, Lauren H. Kus, Linda O. Eckert, Jeffrey F. PeipertVaginitis is one of the most common causes of patient visits to gynecologists, primary care providers, and urgent care centers. However, many women leave without a clear diagnosis or experience recurrent symptoms despite treatment. The 3 most common etiologies of vaginitis are trichomonas, bacterial vaginosis, and vulvovaginal candidiasis, which account for an estimated 70% of cases. The remaining 30% may be related to other causes of vaginitis, including atrophic vaginitis, desquamative inflammatory vaginitis, and vaginal erosive disease. The purpose of this review is to describe the noncandidal causes of acute and recurrent vaginitis, with the goal of improving the likelihood of accurate diagnosis as well as efficient and effective therapy. We excluded candidal vaginitis from our review because there was a recently published review on this topic in the Journal. The clinical presentation and evaluation of patients with symptoms of vaginitis can be triaged into 1 of 2 diagnostic pathways: noninflammatory and inflammatory vaginitis. The most common noninflammatory cause is bacterial vaginosis. Features such as irritation, purulent discharge, and the presence of polymorphonuclear neutrophils are more suggestive of an inflammatory process. Trichomoniasis is the most common cause of inflammatory vaginitis. Other well-described forms of inflammatory vaginitis include atrophic vaginitis, desquamative inflammatory vaginitis, and erosive disease. We present a review of the pathogenesis, symptoms, examination findings, diagnostic testing, and treatment for each of these causes of noncandidal vaginitis.
       
  • Management of genitourinary syndrome of menopause in female cancer
           patients: a focus on vaginal hormonal therapy
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Katie K. Crean-Tate, Stephanie S. Faubion, Holly J. Pederson, Jennifer A. Vencill, Pelin BaturGenitourinary syndrome of menopause is a condition describing the hypoestrogenic effects on the female genitals and lower urinary tract leading to symptoms such as vaginal dryness, vulvar and vaginal burning, dyspareunia and dysuria. Genitourinary syndrome of menopause is experienced by over half of postmenopausal women, and is even more pervasive in women with cancer. Due to treatments such as surgery, chemotherapy, radiation, and hormonal therapy, women may experience early menopause resulting in earlier and more severe symptoms. Understanding the scope of this issue in female breast and gynecologic cancer survivors and identifying treatment options for this complex patient population are paramount. Tailored patient treatments include nonhormonal therapies (vaginal moisturizers, lubricants, pelvic floor physical therapy, dilator therapy, counseling), systemic and local hormonal therapies. Consensus recommendations by medical societies and associated evidence are reviewed, with emphasis on safety and efficacy of local vaginal hormonal therapies, and management variations noted depending on cancer type and characteristics. With knowledge and understanding of the unmet need associated with under-recognition and under-treatment of genitourinary syndrome of menopause, providers caring for women with cancer are in a position to improve the quality of life of their patients by providing safe and effective treatments.
       
  • Delayed hysterectomy: a laparotomy too far'
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Sally L. Collins, Löic Sentilhes, Frederic Chantraine, Eric Jauniaux
       
  • AJOG MFM Table of Contents
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s):
       
  • The placement of a cerclage in patients with twin pregnancies and a short
           cervix is associated with increased risk of preterm birth and adverse
           perinatal outcome
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Luis Sanchez-Ramos
       
  • Fetal hypertension and abnormal fetal cardiac morphology
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 2Author(s): Yan Qiu Wang, Hui Juan Zhang, M.J. Quinn
       
  • Management of Stillbirth
    • Abstract: Publication date: Available online 29 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Jeanette SmithAbstractStillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depends on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.
       
  • Serum HE4 and diagnosis of ovarian cancer in postmenopausal women with
           adnexal masses
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Aleksandra Gentry-Maharaj, Matthew Burnell, James Dilley, Andy Ryan, Chloe Karpinskyj, Richard Gunu, Susan Mallett, Jon Deeks, Stuart Campbell, Ian Jacobs, Sudha Sundar, Usha MenonBackgroundTransvaginal ultrasound and serum CA125 are routinely used for differential diagnosis of pelvic adnexal mass. Use of human epididymis 4 was approved in the United States in 2011. However, there is scarcity of studies evaluating the additional value of human epididymis 4.ObjectiveThe objective of the study was to evaluate the performance characteristics of transvaginal ultrasound, CA125, and human epididymis 4 for differential diagnosis of ovarian cancer in postmenopausal women with adnexal masses.Study DesignThis was a cohort study nested within the screen arms of the multicenter randomized controlled trial, United Kingdom Collaborative Trial of Ovarian Cancer Screening, based in England, Wales, and Northern Ireland. In United Kingdom Collaborative Trial of Ovarian Cancer Screening, 48,230 women randomized to transvaginal ultrasound screening and 50,078 to multimodal screening (serum CA125 interpreted by Risk of Ovarian Cancer Algorithm with second line transvaginal ultrasound) underwent the first (prevalence) screen. Women with adnexal lesions and/or persistently elevated risk were clinically assessed and underwent surgery or follow-up for a median of 10.9 years. Banked samples taken within 6 months of transvaginal ultrasound from all clinically assessed women were assayed for human epididymis 4 and CA125. Area under the curve and sensitivity for diagnosing ovarian cancer of multiple penalized logistic regression models incorporating logCA125, log human epididymis 4, age, and simple ultrasound features of the adnexal mass were compared.ResultsOf 1590 (158 multimodal, 1432 ultrasound) women with adnexal masses, 78 were diagnosed with ovarian cancer (48 invasive epithelial ovarian, 14 type I, 34 type II; 24 borderline epithelial; 6 nonepithelial) within 1 year of scan. The area under the curve (0.893 vs 0.896; P = .453) and sensitivity (74.4% vs 75.6% ;P = .564) at fixed specificity of 90% of the model incorporating age, ultrasound, and CA125 were similar to that also including human epididymis 4. Both models had high sensitivity for invasive epithelial ovarian (89.6%) and type II (>91%) cancers.ConclusionOur population cohort study suggests that human epididymis 4 adds little value to concurrent use of CA125 and transvaginal ultrasound in the differential diagnosis of adnexal masses in postmenopausal women.
       
  • Effect of regionalization of endometrial cancer care on site of care and
           patient travel
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Anne Knisely, Yongmei Huang, Alexander Melamed, Ana I. Tergas, Caryn M. St. Clair, June Y. Hou, Fady Khoury-Collado, Cande V. Ananth, Alfred I. Neugut, Dawn L. Hershman, Jason D. WrightBackgroundComplex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations.ObjectiveTo describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time.Study DesignWe used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed.ResultsWe identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from –16.7% in Syracuse (12 to 10 hospitals) to –76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from –45.2% in Buffalo (84–46 surgeons) to –77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8–60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4–18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8–60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4–18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P
       
  • Pelvic floor muscle strength and the incidence of pelvic floor disorders
           after vaginal and cesarean delivery
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Joan L. Blomquist, Megan Carroll, Alvaro Muñoz, Victoria L. HandaBackgroundPelvic floor disorders (including urinary and anal incontinence and pelvic organ prolapse) are associated with childbirth. Injury to the pelvic floor muscles during vaginal childbirth, such as avulsion of the levator ani muscle, is associated with weaker pelvic floor muscle strength. As weak pelvic floor muscle strength may be a modifiable risk factor for the later development of pelvic floor disorders, it is important to understand how pelvic floor muscle strength affects the course of pelvic floor disorders over time.ObjectiveTo investigate the association between pelvic floor muscle strength and the incidence of pelvic floor disorders, and to identify maternal and obstetrical characteristics that modify the association.Materials and MethodsThis is a longitudinal study investigating pelvic floor disorders after childbirth. Participants were recruited 5–10 years after their first delivery and were assessed for pelvic floor disorders annually for up to 9 years. Stress incontinence, overactive bladder, and anal incontinence were assessed at each annual visit using the Epidemiology of Prolapse and Incontinence Questionnaire. Pelvic organ prolapse was assessed on physical examination, and was defined as descent of the vaginal walls or cervix beyond the hymen during forceful Valsalva. The primary exposure of interest was pelvic floor muscle strength, defined as the peak pressure during a voluntary pelvic muscle contraction (measured with a perineometer). The relationship between pelvic floor muscle strength and the cumulative incidence (time to event) of each pelvic floor disorder was evaluated using lognormal models, stratified by vaginal vs cesarean delivery. The relative hazard for each pelvic floor disorder (among those women free of the disorder at enrollment and thus more than 5–10 years from first delivery), was estimated using semiparametric proportional hazard models as a function of delivery mode, pelvic floor muscle strength, and other covariates.ResultsOf 1143 participants, the median age was 40 (interquartile range, 36.6–43.7) years, and 73% were multiparous. On perineometry, women with at least 1 vaginal delivery were more likely to have a low peak pressure, defined as
       
  • Copper ions are novel therapeutic agents for uterine leiomyosarcoma
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Mamoru Kakuda, Shinya Matsuzaki, Yutaka Ueda, Mayu Shiomi, Satoko Matsuzaki, Toshihiro Kimura, Masami Fujita, Tomomi Egawa-Takata, Eiji Kobayashi, Satoshi Serada, Kiyoshi Yoshino, Tetsuji Naka, Tadashi KimuraBackgroundMultidrug resistance is a major concern in uterine leiomyosarcoma treatment. Development of effective chemotherapies and management of drug resistance in patients is necessary. The copper efflux transporter adenosine triphosphatase copper transporting beta is a member of the P-type adenosine triphosphatase family and is also known as a strong platinum efflux transporter. Various reports have shown the association between adenosine triphosphatase copper transporting beta and platinum resistance; however, suitable inhibitors or methods for inhibiting platinum efflux via adenosine triphosphatase copper transporting beta are not developed.ObjectiveOur study focused on platinum resistance in uterine leiomyosarcoma. The role of adenosine triphosphatase copper transporting beta in uterine leiomyosarcoma resistance to platinum drugs was investigated both in vitro and in vivo.Study DesignAdenosine triphosphatase copper transporting beta expression was investigated by Western blotting and the efficacy of copper sulfate pretreatment and cisplatin administration in adenosine triphosphatase copper transporting beta–expressing cells was investigated both in vitro and in vivo.ResultsWestern blot analysis of SK-LMS-1 cells (uterine leiomyosarcoma cell line) revealed strong adenosine triphosphatase copper transporting beta expression. A permanent SK-LMS-ATPase copper transporting beta–suppressed cell line (SK-LMS-7B cells) was generated, and cisplatin exhibited a significant antitumor effect in SK-LMS-7B cells, both in vitro (SK-LMS-1 cells, half-maximal inhibitory concentration, 17.2 μM; SK-LMS-7B cells, half-maximal inhibitory concentration, 4.2 μM, P < .01) and in xenografts compared with that in SK-LMS-1 cells (5.8% vs 62.8%, P < .01). Copper sulfate was identified as a preferential inhibitor of platinum efflux via adenosine triphosphatase copper transporting beta. In SK-LMS-1 cells pretreated with 15 μM copper sulfate for 3 hours, the cisplatin half-maximal inhibitory concentration decreased significantly compared with that in untreated cells and resulted in significantly increased intracellular platinum accumulation (1.9 pg/cell vs 8.6 pg/cell, P < .01). The combination of copper sulfate pretreatment with cisplatin administration was also effective in vivo and caused cisplatin to exhibit significantly increased antitumor effects in mice with SK-LMS-1 xenografts (3.1% vs 62.7%, P < .01).ConclusionOur study demonstrates that adenosine triphosphatase copper transporting beta is overexpressed in uterine leiomyosarcoma cells and that copper sulfate, which acts as an inhibitor of platinum efflux via adenosine triphosphatase copper transporting beta, may be a therapeutic agent in the treatment of uterine leiomyosarcoma.
       
  • Hyperglycosylated human chorionic gonadotropin as a predictor of ongoing
           pregnancy
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Paula C. Brady, Leslie V. Farland, Catherine Racowsky, Elizabeth S. GinsburgBackgroundHyperglycosylated human chorionic gonadotropin, the predominant human chorionic gonadotropin variant secreted following implantation, is associated with trophoblast invasion.ObjectiveTo determine whether the initial serum hyperglycosylated human chorionic gonadotropin differs between ongoing and failed pregnancies, and to compare it to total serum human chorionic gonadotropin as a predictor of ongoing pregnancy.Materials and MethodsWomen undergoing fresh/frozen in vitro fertilization cycles at a university-based infertility clinic with an autologous day 5 single embryo transfer resulting in serum human chorionic gonadotropin>3 mIU/mL (n = 115) were included. Human chorionic gonadotropin was measured 11 days after embryo transfer in a single laboratory (coefficient of variation
       
  • Evaluating the discordant relationship between Tarlov cysts and symptoms
           of pudendal neuralgia
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Victoria M. Lim, Rohit Khanna, Olga Kalinkin, Mario E. Castellanos, Michael HibnerBackgroundPudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms.ObjectiveTo evaluate the prevalence of S2–S4 Tarlov cysts at the pudendal nerve origin (S2–S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst.Study DesignA retrospective study was performed on 242 patients with pudendal neuralgia referred for pelvic magnetic resonance imaging from January 2010 to November 2012. Dedicated magnetic resonance imaging review evaluated for presence, level, site, and size of Tarlov cysts. Among those with demonstrable cysts, subsequent imaging data were collected and correlated with the patients’ clinical site of symptoms. Statistical analysis was performed using χ2, Pearson χ2, and Fisher exact tests to assess significance.ResultsThirty-nine (16.1%) patients demonstrated at least 1 sacral Tarlov cyst; and of the 38 patients with complete pain records, 31 (81.6%) had a mismatch in findings. A total of 50 Tarlov cysts were identified in the entire patient cohort. The majority of the Tarlov cysts were found at the S2–S3 level (32/50; 64%). Seventeen patients (44.7%) revealed unilateral discordant findings: unilateral symptoms on the opposite side as the Tarlov cyst. In addition, 14 (36.8%) patients were detected with bilateral discordant findings: 11 (28.9%) had bilateral symptoms with a unilateral Tarlov cyst, and 3 (7.9%) had unilateral symptoms with bilateral cysts. Concordant findings were only demonstrated in 7 patients (18.4%). No significant association was found between cyst size and pain laterality (P = .161), cyst volume and pain location (P = .546), or cyst size and unilateral vs bilateral pain (P = .997).ConclusionThe increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.
       
  • “New or not-so-new” labor management practices and cesarean delivery
           for arrest of progress
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): David B. Nelson, James M. Alexander, Donald D. McIntire, Kenneth J. LevenoBackgroundBecause nearly one-third of births in the United States are now achieved by cesarean delivery, comprising more than 1.27 million women each year, national organizations have recently published revised guidelines for the management of labor. These new guidelines stipulate that labor arrest should not be diagnosed unless ≥6 cm cervical dilatation has been reached or labor has been stimulated for at ≥6 hours.ObjectiveTo determine the cervical dilatation and hours of labor stimulation prior to cesarean delivery for arrest of dilatation.Materials and MethodsBetween January 1, 1999, andDecember 31, 2000, a prospective observational study of all primary cesarean deliveries was conducted at 13 university centers comprising the Eunice Kennedy Shriver National Institute for Child Health and Human Development, Maternal-Fetal Medicine Units Network. This secondary analysis includes all live-born, singleton, nonanomalous, cephalic gestations delivered by primary cesarean delivery at ≥37 weeks. A cesarean delivery was considered to have been performed for arrest of dilatation if the indication for the procedure was failure to progress, cephalopelvic disproportion, or failed induction. Augmentation was defined as stimulation after spontaneous labor had been previously diagnosed. Analysis included both the latent and active phases of labor. The active phase of labor was diagnosed when cervical dilatation was ≥4 cm in the presence of uterine contractions.ResultsA total of 13,269 primary cesarean deliveries were available for analysis, 8,546 (65%) of which were performed for inadequate progress of labor with cervical dilatation recorded at the time of cesarean delivery. Of these cesarean deliveries for labor arrest, a total of 719 (8%) were performed in the latent phase of labor and 7827 (92%) were performed when cervical dilatation was ≥4 cm (active phase). Approximately two-thirds (n = =5876; 69%) received intrauterine pressure monitoring. A total of 5636 women (66% of those reaching the active phase of labor) had reached ≥6 cm cervical dilatation before cesarean delivery was performed. Moreover, 7440 (95%) of the 7827 women in active labor had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation.ConclusionWomen undergoing primary cesarean delivery for arrest of dilatation 15 years before the recommendations of the Obstetrics Care Consensus had received bona fide efforts to achieve adequate labor consistent with the recommendations of the Consensus. Because 95% of these women had ≥6 cm dilatation or had received labor stimulation ≥6 hours prior to cesarean delivery for arrest of dilatation, these new recommendations are unlikely to change the cesarean delivery rates.
       
  • Should women with gestational diabetes be screened at delivery
           hospitalization for type 2 diabetes'
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Thaddeus P. Waters, Shin Y. Kim, Erika Werner, Cheryl Dinglas, Ebony B. Carter, Roshni Patel, Andrea J. Sharma, Patrick CatalanoBackgroundLess than one-half of women with gestational diabetes mellitus are screened for type 2 diabetes postpartum. Other approaches to postpartum screening need to be evaluated, including the role of screening during the delivery hospitalization.ObjectiveTo assess the performance of an oral glucose tolerance test administered during the delivery hospitalization compared with the oral glucose tolerance test administered at a 4- to 12-week postpartum visit.Study DesignWe conducted a combined analysis of patient-level data from 4 centers (6 clinical sites) assessing the utility of an immediate postpartum 75-g oral glucose tolerance test during the delivery hospitalization (PP1) for the diagnosis of type 2 diabetes compared with a routine 4- to 12-week postpartum oral glucose tolerance test (PP2). Eligible women underwent a 75-g oral glucose tolerance test at both PP1 and PP2. Sensitivity, specificity, and negative and positive predictive values of the PP1 test were estimated for diagnosis of type 2 diabetes, impaired fasting glucose, or impaired glucose tolerance.ResultsIn total, 319 women completed a PP1 screening, with 152 (47.6%) lost to follow-up for the PP2 oral glucose tolerance test. None of the women with a normal PP1 oral glucose tolerance test (n=73) later tested as having type 2 diabetes at PP2. Overall, 12.6% of subjects (n=21) had a change from normal to impaired fasting glucose/impaired glucose tolerance or a change from impaired fasting glucose/impaired glucose tolerance to type 2 diabetes. The PP1 oral glucose tolerance test had 50% sensitivity (11.8–88.2), 95.7% specificity (91.3–98.2%) with a 98.1% (94.5–99.6%) negative predictive value and a 30% (95% confidence interval, 6.7–65.3) positive predictive value for type 2 diabetes vs normal/impaired fasting glucose/impaired glucose tolerance result. The negative predictive value of having type 2 diabetes at PP2 compared with a normal oral glucose tolerance test (excluding impaired fasting glucose/impaired glucose tolerance) at PP1 was 100% (95% confidence interval, 93.5–100) with a specificity of 96.5% (95% confidence interval, 87.9–99.6).ConclusionA normal oral glucose tolerance test during the delivery hospitalization appears to exclude postpartum type 2 diabetes mellitus. However, the results of the immediate postpartum oral glucose tolerance test were mixed when including impaired fasting glucose or impaired glucose tolerance. As a majority of women do not return for postpartum diabetic screening, an oral glucose tolerance test during the delivery hospitalization may be of use in certain circumstances in which postpartum follow-up is challenging and resources could be focused on women with an abnormal screening immediately after the delivery hospitalization.
       
  • Fetal cardiac remodeling and dysfunction is associated with both
           preeclampsia and fetal growth restriction
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Lina Youssef, Jezid Miranda, Cristina Paules, Laura Garcia-Otero, Kilian Vellvé, Grigorios Kalapotharakos, Alvaro Sepulveda-Martinez, Francesca Crovetto, Olga Gomez, Eduard Gratacós, Fatima CrispiBackgroundPreeclampsia and fetal growth restriction share some pathophysiologic features and are both associated with placental insufficiency. Fetal cardiac remodeling has been described extensively in fetal growth restriction, whereas little is known about preeclampsia with a normally grown fetus.ObjectiveTo describe fetal cardiac structure and function in pregnancies complicated by preeclampsia and/or fetal growth restriction as compared with uncomplicated pregnancies.Study designThis was a prospective, observational study including pregnancies complicated by normotensive fetal growth restriction (n=36), preeclampsia with a normally grown fetus (n=35), preeclampsia with fetal growth restriction (preeclampsia with a normally grown fetus–fetal growth restriction, n=42), and 111 uncomplicated pregnancies matched by gestational age at ultrasound. Fetal echocardiography was performed at diagnosis for cases and recruitment for uncomplicated pregnancies. Cord blood concentrations of B-type natriuretic peptide and troponin I were measured at delivery. Univariate and multiple regression analysis were conducted.ResultsPregnancies complicated by preeclampsia and/or fetal growth restriction showed similar patterns of fetal cardiac remodeling with larger hearts (cardiothoracic ratio, median [interquartile range]: uncomplicated pregnancies 0.27 [0.23–0.29], fetal growth restriction 0.31 [0.26–0.34], preeclampsia with a normally grown fetus 0.31 [0.29–0.33), and preeclampsia with fetal growth restriction 0.28 [0.26–0.33]; P
       
  • The utility of MRI for measuring hematocrit in fetal anemia
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Jiawei Xu, An Qi Duan, Davide Marini, Jessie Mei Lim, Johannes Keunen, Sharon Portnoy, John G. Sled, Brian W. McCrindle, John Kingdom, Christopher K. Macgowan, Mike SeedBackgroundDoppler ultrasound measurements of the peak systolic velocity of the middle cerebral artery can be used to noninvasively diagnose fetal anemia but are less precise following fetal blood transfusion and in late gestation. We have previously demonstrated the feasibility of estimating fetal hematocrit in vitro using magnetic resonance imaging relaxation times. Here we report the use of magnetic resonance imaging as a noninvasive tool to accurately detect fetal anemia in vivo.ObjectivesThis study has 2 objectives: (1) to determine the feasibility and accuracy of magnetic resonance imaging in estimating hematocrit in anemic fetuses and (2) to compare magnetic resonance imaging and middle cerebral artery Doppler in detecting moderate to severe fetal anemia.Study DesignFetuses undergoing fetal blood sampling or transfusion underwent magnetic resonance imaging examinations prior to and following their procedures at 1.5 Tesla (Siemens Avanto). A modified Look-Locker inversion pulse sequence and T2 preparation sequence were applied for T1 and T2 mapping of the intrahepatic umbilical vein. Estimated fetal hematocrit was calculated using a combination of T1 and T2 values and compared with conventional hematocrit obtained from fetal blood samples and middle cerebral artery Doppler measurements.ResultsTwenty-three fetuses were assessed during 33 magnetic resonance imaging scans. The mean absolute difference between the laboratory and magnetic resonance imaging–estimated hematocrit was 0.06 ± 0.05 with a correlation of 0.77 (P < .001) determined by a multilevel, mixed-effects model adjusting for the repeated measurements from the same participants, multiple gestation pregnancies, and the scan type (ie, before or after transfusion scan). Bland-Altman analysis revealed a systematic bias of –0.03 between the magnetic resonance imaging and fetal blood sampling measurements. Magnetic resonance imaging and middle cerebral artery Doppler had similar sensitivities of approximately 90% to detect moderate to severe anemia. However, magnetic resonance imaging had a higher specificity (93% [13/14], 95% confidence interval, 66–100%) than Doppler (71% [10/14], 95% confidence interval, 42–92%).ConclusionModerate to severe fetal anemia can be detected noninvasively by magnetic resonance imaging with high sensitivity and specificity. Our results suggest an adjunct role for magnetic resonance imaging in fetuses with suspected anemia, particularly following previous transfusion and in late gestation.
       
  • Use of naltrexone in treating opioid use disorder in pregnancy
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Craig V. Towers, Emily Katz, Beth Weitz, Kevin ViscontiBackgroundThe mainstay of the management of opioid use disorder in pregnancy is with methadone or buprenorphine medication-assisted treatment. Methadone and buprenorphine are opioid agonist drugs. Naltrexone, an opioid antagonist, is also a medication-assisted treatment option; however, to date, only a few retrospective studies have reported its use in pregnancy.ObjectiveOur study objective was to evaluate prospectively obstetric and newborn outcomes and the maternal/fetal effects of the use of naltrexone as a medication-assisted treatment in pregnant patients with opioid use disorder.Study DesignWe performed a prospective cohort study collecting data on all pregnant women who were treated with naltrexone medication-assisted treatment compared with pregnant women who were treated with methadone or buprenorphine medication-assisted treatment. Based on a sample size calculation, it was determined that for a power of 90, a minimum of 160 study participants (80 in each group) was needed with an alpha of .01 and an expected 60% rate of newborn infants who were treated for neonatal abstinence syndrome in the methadone or buprenorphine medication-assisted treatment group compared with a 30% rate in the naltrexone medication-assisted treatment group. In a random subset of 20 maternal/newborn dyads, blood levels for naltrexone and 6-beta-naltrexol (an active metabolite) were analyzed at delivery.ResultsA total of 230 patients were studied: 121 patients with naltrexone medication-assisted treatment compared with 109 patients with methadone or buprenorphine medication-assisted treatment. No differences between groups were seen regarding demographics, the use of comedications/drugs, or obstetric outcomes. For newborn outcomes, the rate of neonatal abstinence syndrome in neonates>34 weeks gestation was significantly lower in the naltrexone medication-assisted treatment group (10/119 [8.4%] vs 79/105 [75.2%]; P60 hours before delivery.ConclusionThese study data demonstrate that, in pregnant women who choose to completely detoxify off opioid drugs during gestation, naltrexone, as a continued form of medication-assisted treatment, is a viable option for some pregnant patients who experience opioid use disorder. Naltrexone crosses the placenta, and maternal and fetal levels are concordant. Because naltrexone clears quickly from the maternal circulation, this rapid clearance needs to be addressed with patients. This is important because maternal relapse could occur in a short time-period if the oral drug is discontinued without the knowledge of their healthcare providers. Nonetheless, the drug is well-tolerated by both mother and fetus, and newborn infants do not experience symptoms of neonatal abstinence syndrome if naltrexone medication-assisted treatment is maintained to delivery.
       
  • October 2011 (vol. 205, no. 4, pages 362.e4-.e6)
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s):
       
  • Rare case of a massive uterine arteriovenous fistula
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Jacob M. Core, Aakriti R. Carrubba, Ricardo Paz-Fumagalli
       
  • Paternal bias: The impact of not accounting for paternal confounders in
           reproductive epidemiological studies
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Andrea Bellavia, Susanna D. Mitro, Russ Hauser, Tamarra James-Todd
       
  • The impact of induction of labor at 39 weeks in low-risk women on the
           incidence of stillbirth
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Gaia Po’, Emily A. Oliver, Uma M. Reddy, Robert M. Silver, Vincenzo Berghella
       
  • Barriers to care and reproductive considerations for transmasculine gender
           affirming surgery
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Monica Mendiola, Jennifer Chu, Miriam J. Haviland, Marybeth Meservey, Michele R. Hacker, Yvonne Gomez-Carrion
       
  • Hysterectomy and the risk of osteoporosis
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Abraham N. Morse
       
  • Reply
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Hyo Geun Choi, Suk Woo Lee
       
  • New horizons of sentinel lymph node technique in early ovarian cancer
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Víctor Lago, Santiago Domingo
       
  • Reply
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Stefano Uccella, Anna Fagotti, Giovanni Scambia
       
  • Formal assessment of the learning curve for minimally invasive methods is
           vital in retrospective cohort studies
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Gijs I. Van Boxel, B. Feike Kingma, Jelle P. Ruurda
       
  • Reply
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Maria C. Cusimano, Sarah E. Ferguson
       
  • Reduction in umbilical artery metabolic acidosis after implementation of
           intrapartum ST waveform analysis of the fetal electrocardiogram
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Vincenzo Zanardo, Michela Vettore, Gianluca Straface
       
  • Reply
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Anadeijda J.E.M.C. Landman, Anneke Kwee
       
  • Understanding gestational surrogacy in the United States: a primer for
           obstetricians/gynecologists
    • Abstract: Publication date: Available online 23 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Kate Swanson, Nina K. Ayala, Randall B. Barnes, Nidhi Desai, Marcy Miller, Lynn M. YeeAbstractAs gestational surrogacy (a process by which intended parents contract with a woman to carry a fetus that the intended parents will raise) increases across the United States (US), it is imperative that obstetrician/gynecologists understand the unique nuances of caring for patients who are gestational surrogates. Gestational surrogacy offers a route to parenthood for individuals and families who may otherwise have limited options. Understanding surrogacy requires multiple ethical considerations about the potential medical and psychosocial effects on gestational surrogates as well as the families built through surrogacy. There is a dearth of research on the subject, particularly in the US and other countries that practice compensated surrogacy. Here we seek to review the process of gestational surrogacy in the US including the legal landscape, current trends in gestational surrogacy utilization, and what is known about the medical and social effects of this process on all participants. We also aim to highlight the limitations of available data and identify topics for future research to provide optimal evidence-based and just care for these patients.
       
  • Cesarean radical hysterectomy for cervical cancer in the United States: A
           national study of surgical outcomes
    • Abstract: Publication date: Available online 23 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Koji Matsuo, Rachel S. Mandelbaum, Shinya Matsuzaki, Ernesto Licon, Maximilian Klar, Brendan H. Grubbs, Lynda D. Roman
       
  • Post-operative urinary catheter removal for Enhanced Recovery After
           Cesarean protocols
    • Abstract: Publication date: Available online 23 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Alex F. Peahl, Joanna Kountanis, Roger D. Smith
       
  • A Low-Cost Approach to Salpingectomy at Cesarean Delivery
    • Abstract: Publication date: Available online 23 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Xiaoyue Mona Guo, Evelyn F. Hall, Liza Mazzullo, Miroslav DjordjevicAbstractThere is increasing adoption of opportunistic salpingectomy for ovarian cancer prevention at the time of gynecologic surgery, including the postpartum period. However, there is no consensus on an ideal surgical approach for the parturient vasculature. We describe a safe, low-cost and accessible approach for bilateral salpingectomy during cesarean section that we call the “Mesosalpinx Isolation Salpingectomy Technique” (MIST) which can guide institutions to standardize their postpartum salpingectomy procedures when advanced vessel-sealing devices are not available. In the MIST technique, avascular windows are created within the mesosalpinx close to the tubal vessels. The vasculature is thus fully skeletonized and isolated from the adjacent mesosalpinx prior to suture ligation, ensuring security of the free-tie to the individual vessels and avoiding sharp injury to the mesosalpinx. Not using vessel-sealing devices also eliminates the risk of thermal injury to the adjacent ovarian tissue and vasculature, and potentially achieves a cost savings for the hospital and patient. MIST has been performed in 141 cesarean deliveries in the past four years. There were no noted bleeding complications during the salpingectomy procedure, blood transfusions, or instances of postoperative surgical re-exploration. In our experience, a surgeon new to the procedure takes approximately 15 minutes to complete a bilateral salpingectomy. Those experienced in MIST need only 5 minutes. A video is included demonstrating the technique.
       
  • Quality of periconceptional dietary intake and maternal and neonatal
           outcomes
    • Abstract: Publication date: Available online 23 January 2020Source: American Journal of Obstetrics and GynecologyAuthor(s): Lynn M. Yee, Robert M. Silver, David M. Haas, Samuel Parry, Brian M. Mercer, Jay Iams, Deborah Wing, Corette B. Parker, Uma M. Reddy, Ronald J. Wapner, William A. GrobmanBackgroundPericonceptional diet quality is commonly suboptimal and sociodemographic disparities in diet quality exist. However, it is unknown whether individual periconceptional diet quality is associated with obstetric outcomes.ObjectiveOur objective was to assess differences in maternal and neonatal outcomes according to maternal periconceptional diet quality.Study DesignThis is a secondary analysis of a large, multicenter prospective cohort study of 10,038 nulliparous women receiving obstetrical care at 8 United States centers. Women underwent three antenatal study visits and had detailed maternal and neonatal data abstracted by trained research personnel. In the first trimester (between 6 and 13 weeks), women completed the modified Block 2005 Food Frequency Questionnaire, a semiquantitative assessment of usual dietary intake for the 3 months around conception. Responses were scored using the Healthy Eating Index-2010, which assesses adherence to the 2010 Dietary Guidelines for Americans. Higher scores on the Healthy Eating Index represent better adherence. Healthy Eating Index scores were analyzed by quartile; quartile 4 represents the highest dietary quality. Bivariable and multivariable analyses were performed to assess associations between diet quality and outcomes. A sensitivity analysis in which markers of socioeconomic status were included in the multivariable Poisson regression models was performed.ResultsIn the cohort of 8,259 women with Healthy Eating Index data, the mean Healthy Eating Index score was 63 (± 13) of 100. Women with the lowest quartile Healthy Eating Index scores were more likely to be younger, non-Hispanic black and Hispanic, publicly insured, low income, and tobacco users. They were more likely to have comorbidities (obesity, chronic hypertension, pregestational diabetes, mental health disorders), a higher pre-pregnancy body mass index, and less education. Women with lowest quartile scores experienced less frequent major perineal lacerations and more frequent postpartum hemorrhage requiring transfusion and hypertensive disorders of pregnancy, which persisted on multivariable analyses (controlling for age, body mass index, tobacco use, chronic hypertension, pregestational diabetes mellitus, and mental health disorders) comparing women in each quartile to quartile 4. Additionally, women in quartiles 1 and 2 experienced greater adjusted relative risk of cesarean delivery compared to women in quartile 4. Neonatal outcomes also differed by dietary quartile, with women in the lowest Healthy Eating Index quartile experiencing greater adjusted relative risk of preterm birth, neonatal intensive care unit admission, small for gestational age infant, and low birthweight, and lower risk of macrosomia; all neonatal findings also persisted in multivariable analyses. The sensitivity analysis with inclusion of markers of socioeconomic status (race/ethnicity, insurance status, marital status) in the multivariable models supported these findings.ConclusionsPericonceptional diet quality among women in the United States is poor. Poorer periconceptional dietary quality is associated with adverse maternal and neonatal outcomes even after controlling for potential comorbidities and body mass index, suggesting periconceptional diet may be an important social or biological determinant of health underlying existing health disparities.
       
  • Undetectable equals untransmittable (U = U): implications for
           preconception counseling for human immunodeficiency virus serodiscordant
           couples
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Shweta J. Bhatt, Nataki DouglasAlthough limited by society guidelines from the American Society for Reproductive Medicine and the Centers for Disease Control and Prevention in the past, many human immunodeficiency virus serodiscordant American couples who desired future childbearing were referred to reproductive endocrinology and infertility specialists for in vitro fertilization. The access to and cost of assisted reproductive technology created a significant barrier to reproductive care in this patient population. New evidence-based guidelines by the Centers for Disease Control and Prevention, however, endorse condomless intercourse timed to ovulation for human immunodeficiency virus serodiscordant couples with undetectable viral loads on antiretroviral therapy. In parallel, the Prevention Access Campaign’s undetectable equals untransmittable initiative advocates increasing awareness of the favorable prognosis of persons living with human immunodeficiency virus to remove the associated stigma of the disease and promote the safety of condomless intercourse in the setting of undetectable viral loads. With these new guidelines, human immunodeficiency virus serodiscordant couples may not require an automatic referral to the reproductive endocrinology and infertility specialist. Rather, providers of preconception care could recommend timed intercourse for these couples after confirmation of an undetectable viral load and discussion with the interdisciplinary team of health care professionals caring for persons living with human immunodeficiency virus.
       
  • Amniotic fluid embolism: principles of early clinical management
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Luis D. Pacheco, Steven L. Clark, Miranda Klassen, Gary D.V. HankinsAmniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism–related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of>150–200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.
       
  • The physiology of intrapartum fetal compromise at term
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Jessica M. Turner, Murray D. Mitchell, Sailesh S. KumarUterine contractions in labor result in a 60% reduction in uteroplacental perfusion, causing transient fetal and placental hypoxia. A healthy term fetus with a normally developed placenta is able to accommodate this transient hypoxia by activation of the peripheral chemoreflex, resulting in a reduction in oxygen consumption and a centralization of oxygenated blood to critical organs, namely the heart, brain, and adrenals. Providing there is adequate time for placental and fetal reperfusion between contractions, these fetuses will be able to withstand prolonged periods of intermittent hypoxia and avoid severe hypoxic injury. However, there exists a cohort of fetuses in whom abnormal placental development in the first half of pregnancy results in failure of endovascular invasion of the spiral arteries by the cytotrophoblastic cells and inadequate placental angiogenesis. This produces a high-resistance, low-flow circulation predisposing to hypoperfusion, hypoxia, reperfusion injury, and oxidative stress within the placenta. Furthermore, this renders the placenta susceptible to fluctuations and reduction in uteroplacental perfusion in response to external compression and stimuli (as occurs in labor), further reducing fetal capillary perfusion, placing the fetus at risk of inadequate gas/nutrient exchange. This placental dysfunction predisposes the fetus to intrapartum fetal compromise. In the absence of a rare catastrophic event, intrapartum fetal compromise occurs as a gradual process when there is an inability of the fetal heart to respond to the peripheral chemoreflex to maintain cardiac output. This may arise as a consequence of placental dysfunction reducing pre-labor myocardial glycogen stores necessary for anaerobic metabolism or due to an inadequate placental perfusion between contractions to restore fetal oxygen and nutrient exchange. If the hypoxic insult is severe enough and long enough, profound multiorgan injury and even death may occur. This review provides a detailed synopsis of the events that can result in placental dysfunction, how this may predispose to intrapartum fetal hypoxia, and what protective mechanisms are in place to avoid hypoxic injury.
       
  • Evolution of the human pelvis and obstructed labor: new explanations of an
           old obstetrical dilemma
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Mihaela Pavličev, Roberto Romero, Philipp MitteroeckerWithout cesarean delivery, obstructed labor can result in maternal and fetal injuries or even death given a disproportion in size between the fetus and the maternal birth canal. The precise frequency of obstructed labor is difficult to estimate because of the widespread use of cesarean delivery for indications other than proven cephalopelvic disproportion, but it has been estimated that at least 1 million mothers per year are affected by this disorder worldwide. Why is the fit between the fetus and the maternal pelvis so tight' Why did evolution not lead to a greater safety margin, as in other primates' Here we review current research and suggest new hypotheses on the evolution of human childbirth and pelvic morphology. In 1960, Washburn suggested that this obstetrical dilemma arose because the human pelvis is an evolutionary compromise between two functions, bipedal gait and childbirth. However, recent biomechanical and kinematic studies indicate that pelvic width does not considerably affect the efficiency of bipedal gait and thus is unlikely to have constrained the evolution of a wider birth canal. Instead, bipedalism may have primarily constrained the flexibility of the pubic symphysis during pregnancy, which opens much wider in most mammals with large fetuses than in humans. We argue that the birth canal is mainly constrained by the trade-off between 2 pregnancy-related functions: while a narrow pelvis is disadvantageous for childbirth, it offers better support for the weight exerted by the viscera and the large human fetus during the long gestation period. We discuss the implications of this hypothesis for understanding pelvic floor dysfunction. Furthermore, we propose that selection for a narrow pelvis has also acted in males because of the role of pelvic floor musculature in erectile function. Finally, we review the cliff-edge model of obstetric selection to explain why evolution cannot completely eliminate cephalopelvic disproportion. This model also predicts that the regular application of life-saving cesarean delivery has evolutionarily increased rates of cephalopelvic disproportion already. We address how evolutionary models contribute to understanding and decision making in obstetrics and gynecology as well as in devising health care policies.
       
  • Naltrexone use in pregnancy: a time for change
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s): Steve N. Caritis, Raman Venkataramanan
       
  • AJOG MFM Table of Contents
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s):
       
  • Information for Readers
    • Abstract: Publication date: January 2020Source: American Journal of Obstetrics and Gynecology, Volume 222, Issue 1Author(s):
       
 
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