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American Journal of Obstetrics and Gynecology
Journal Prestige (SJR): 2.7
Citation Impact (citeScore): 4
Number of Followers: 210  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0002-9378
Published by Elsevier Homepage  [3163 journals]
  • Sildenafil crosses the placenta at therapeutic levels in a dually perfused
           human cotyledon model
    • Abstract: Publication date: Available online 5 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Francesca M. Russo, Sigrid Conings, Karel Allegaert, Tim van Mieghem, Jaan Toelen, Kristel van Calsteren, Pieter Annaert, Jan Deprest BackgroundSildenafil is already administered during gestation in patients with pulmonary hypertension and is under evaluation as a treatment for several pregnancy complications, such as pre-eclampsia and intrauterine growth restriction. Animal studies have shown a potential therapeutic effect of the drug in fetuses with congenital diaphragmatic hernia, rescuing peripheral pulmonary vasculature and airway phenotype. When considering this drug for evaluation in a clinical trial, data on effective human placental drug passage are required.ObjectiveWe quantified transplacental passage of sildenafil in the ex vivo dually perfused cotyledon model.Study DesignSix placentas were collected after term delivery from healthy volunteers, cannulated and dually perfused. Sildenafil citrate was added to the maternal circulation at two different concentrations: 500 ng/mL, representing the maximum tolerated concentration (N=3) and 50 ng/mL, representing the therapeutic concentration (N=3). Samples were collected from both the fetal and the maternal reservoir at 0, 6, 30, 60, 90, 120, 150 and 180 minutes, and the concentrations of sildenafil and its metabolite desmethyl-sildenafil were determined using high performance liquid chromatography. The fetal/maternal concentration ratio was calculated for each time-point. Transfer clearance was calculated as the rate of maternal to fetal passage/maternal concentration.ResultsSildenafil crossed the placenta at both maximal and therapeutic concentrations. Maternal and fetal levels reached a plateau at 90-120 minutes. Transfer clearance was the highest during the first hour of perfusion, being 3.15 (range 2.14-3.19) mL/min for the maximum tolerated concentration and 3.07 (range 2.75-3.42) mL/min for the therapeutic concentration (NS). The feto-maternal concentration ratio significantly increased over time, up to 0.91 ± 0.16 for the maximal concentration and 0.95 ± 0.22 for the therapeutic concentration at the end of the perfusion (NS). Desmethyl-sildenafil was not detected in any sample.ConclusionSildenafil crosses the term placenta at a relatively high rate ex vivo, suggesting that there is sufficient placental transfer to reach clinically active fetal drug levels at the currently used maternal doses.
       
  • Medicaid Savings from the Contraceptive CHOICE Project: a Cost Savings
           Analysis
    • Abstract: Publication date: Available online 5 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Tessa Madden, Abigail R. Barker, Kelsey Huntzberry, Gina M. Secura, Jeffrey F. Peipert, Timothy D. Mcbride BackgroundForty-five percent of U.S. births are unintended, and the costs of unintended pregnancy and birth are substantial. Clinical and policy interventions that increase access to the most effective reversible contraceptive methods, intrauterine devices and contraceptive implants, have potential to generate significant cost savings. Evidence of cost savings for these interventions is needed.ObjectiveTo conduct a cost savings analysis of the Contraceptive CHOICE Project, which provided counseling and no-cost conception, to demonstrate the value of investment in enhanced contraceptive care to the Missouri Medicaid program.Study DesignThe CHOICE Project was a prospective cohort study of 9,256 reproductive-age women, enrolled between 2007 and 2011 and followed until October 2013. This analysis includes 5,061 CHOICE Project participants who were current Missouri Medicaid beneficiaries or uninsured and reported household incomes less than 201% of the federal poverty line. We created a simulated comparison group of women receiving care through the Missouri Title X program and modeled the contraception and pregnancy outcomes that would have occurred in the absence of the CHOICE Project. Data about contraceptive use for the comparison group (N=5,061) were obtained from the Missouri Title X program and adjusted based on age, race, ethnicity, and income. To make an accurate comparison accounting for difference in the two populations, we used our simulation model to estimate total CHOICE Project costs and total comparison group costs. We reported all costs in $2013 to account for inflation.ResultsAmong the CHOICE Project participants included, the uptake of intrauterine devices and implants was 76.1% compared to 4.8% among the comparison group. The estimated contraceptive cost for the simulated CHOICE Project group was $4.0 million versus $2.3 million for the comparison group. The estimated numbers of unintended pregnancies and births averted among the simulated CHOICE Project group compared to the comparison group were 927 and 483 respectively, representing a savings in pregnancy and maternity care of $6.7 million. We estimated that the total cost savings for the state of Missouri attributable to the CHOICE Project was $5.0 million (40.7%) over the project duration.ConclusionsA program providing counseling and no-cost contraception yields substantial cost savings due to increased uptake of highly effective contraception and consequent averted unintended pregnancy and birth.
       
  • Reply to Letter # L18-115AR1
    • Abstract: Publication date: Available online 17 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Christopher A. Enakpene, Laura DiGiovanni, Micaela Della Torre
       
  • Diversity of vaginal microbiota in sub-Saharan Africa and its effects on
           HIV transmission and prevention
    • Abstract: Publication date: Available online 12 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Lois Bayigga, David P. Kateete, Deborah J. Anderson, Musa Sekikubo, Damalie Nakanjako The vaginal microbial community (“microbiota”) is a key component of the reproductive health of women, providing protection against urogenital infections. In Sub-Saharan Africa, there is a high prevalence of bacterial vaginosis (BV), a condition defined by bacterial overgrowth and a shift away from a lactobacillus-dominated profile towards increased percentages of strict anaerobic species. BV is associated with an increased risk of HIV acquisition and transmission, as well as an increased risk of acquiring other sexually transmitted infections , pre-term births and pelvic inflammatory disease. Vaginal microbiota, rich in taxa of strict anaerobic species, disrupts the mucosal epithelial barrier through secretion of metabolites and enzymes that mediate inflammation. Advancements in next-generation sequencing technologies such as whole genome sequencing have led to deeper profiling of the vaginal microbiome and further study of its potential role in HIV pathogenesis and treatment. Until recently data on the composition of the vaginal microbiome in sub-Saharan Africa has been limited, however a number of studies have been published that highlight the critical role of vaginal microbiota in disease and health in African women. This article reviews these recent findings and identifies gaps in knowledge about variations in female genital commensal bacteria that could provide vital information to improve the effectiveness of interventions to prevent HIV and other sexually transmitted infections. In addition, we review the effects of pregnancy, contraception and sexual practices on vaginal microbiome and the potential of vaginal microbiota on HIV transmission and prevention. A better understanding of the role of vaginal microbiota in host susceptibility to HIV infection and its prevention among African women, could inform the development of novel local and systemic interventions to minimize new HIV infections among high risk women.
       
  • Risk of Severe Maternal Morbidity by Maternal Fertility Status: A US Study
           in Eight States
    • Abstract: Publication date: Available online 12 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Barbara Luke, Morton B. Brown, Ethan Wantman, Valerie L. Baker, Kevin J. Doody, David B. Seifer, Logan G. Spector BackgroundOver the past two decades the characteristics of women giving birth in the United States and the nature of the births themselves have changed dramatically, with increases in older maternal age, plural births, cesarean deliveries, and conception from infertility treatment.ObjectiveTo evaluate the risk of severe maternal morbidity by maternal fertility status, and for IVF pregnancies, by oocyte source and embryo state combinations.Study DesignWomen in eight States who underwent in vitro fertilization (IVF) cycles resulting in a live birth during 2004-13 were linked to their infant’s birth certificates; a 10:1 sample of births from non-IVF deliveries were selected for comparison; those with an indication of infertility treatment on the birth certificate were categorized as subfertile, all others were categorized as fertile. IVF pregnancies were additionally categorized by oocyte source (autologous vs donor) and embryo state (fresh vs thawed). Maternal morbidity was identified from the birth certificate, modeled using logistic regression, and reported as adjusted odds ratios and 95% confidence intervals [AOR (95% CI)]. The reference group was fertile women.ResultsThe study population included 1,477,522 pregnancies (1,346,118 fertile, 11,298 subfertile, 80,254 IVF autologous-fresh, 21,964 IVF autologous-thawed, 13,218 IVF donor-fresh and 4,670 IVF donor-thawed pregnancies); 1,420,529 singleton, 54,573 twin, and 2,420 triplet+ pregnancies. Compared to fertile women, subfertile and the four groups of IVF-treated women had increased risks for blood transfusion and 3rd or 4th degree perineal laceration (subfertile, 1.58 [1.23, 2.02] and 2.08 [1.79, 2.43]; autologous-fresh, 1.33 [1.14, 1.54] and 1.37 [1.26, 1.49]; autologous-thawed, 1.94 [1.60, 2.36] and 2.10 [1.84, 2.40]; donor-fresh 2.16 [1.69, 2.75] and 2.11 [1.66, 2.69]; and donor-thawed, 2.01 [1.38, 2.92] and 1.28 [0.79, 2.08]). Also compared to fertile women, the risk of unplanned hysterectomy was increased for IVF-treated women in the autologous-thawed group (2.80, [1.96, 4.00]), donor-fresh group (2.14 [1.33, 3.44], and the donor-thawed group (2.46 [1.33, 4.54]). The risk of ruptured uterus was increased for IVF-treated women in the autologous-fresh group (1.62 [1.14, 2.29]).Among women with a prior birth, the risk of blood transfusion after a vaginal birth was increased for subfertile women (2.91 [1.38, 6.15]), and women in all four IVF groups (autologous-fresh, 1.93 [1.23, 3.01]; autologous-thawed, 2.99 [1.78, 5.02]; donor-fresh, 5.13 [2.39, 11.02]; and donor-thawed, 5.20 [1.83, 14.82]; the risk after a cesarean delivery was increased in the autologous-thawed group (1.74 [1.29, 2.33]) and the donor-fresh group (1.62 [1.07, 2.45]). Unplanned hysterectomy was increased in the autologous-thawed (2.31, [1.43, 3.71]) and donor-thawed groups (2.45 [1.06, 5.67]).ConclusionsThe risks of severe maternal morbidity are increased for subfertile and IVF births, particularly in pregnancies that are not from autologous, fresh cycles.
       
  • Savings with Expanding Use of the Levonorgestrel IUD and Fewer Benign
           Hysterectomies
    • Abstract: Publication date: Available online 12 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Daniel M. Morgan, Neil S. Kamdar, Vanessa K. Dalton, Carolyn W. Swenson, Michelle H. Moniz, Brahmajee Nallamothu
       
  • Contraction of the levator ani muscle during Valsalva maneuver
           (co-activation) is associated with a longer active second stage of labor
           in nulliparous women undergoing induction of labor
    • Abstract: Publication date: Available online 12 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Rasha Kamel, Elisa Montaguti, Kypros H. Nicolaides, Mahmoud Soliman, Maria Gaia Dodaro, Sherif Negm, Gianluigi Pilu, Mohamed Momtaz, Aly Youssef BackgroundThe Valsalva maneuver is normally accompanied by relaxation of the levator ani muscle, which stretches around the presenting part, but in some women the maneuver is accompanied by levator ani muscle contraction, which is referred to as levator ani muscle co-activation. The effect of such co-activation on labor outcome in women undergoing induction of labor has not been previously assessed.ObjectivesThe aim of the study was to assess the effect of levator ani muscle co-activation on labor outcome, in particular on the duration of the second and active second stage of labor, in nulliparous women undergoing induction of labor.Study designTransperineal ultrasound was used to measure the anteroposterior diameter of the levator hiatus, both at rest and at maximum Valsalva maneuver, in a group of nulliparous women undergoing induction of labor in two tertiary-level University hospitals. The correlation between anteroposterior diameter of the levator hiatus values and levator ani muscle co-activation with the mode of delivery and various labor durations was assessed.ResultsIn total, 138 women were included in the analysis. Larger anteroposterior diameter of the levator hiatus at Valsalva was associated with a shorter second stage (r = -0.230, P =0.021) and active second stage of labor (r=-0.338, P=0.001). Women with levator ani muscle co-activation had a significantly longer active second stage duration (60±56 vs. 28±16 minutes, P
       
  • Reply to L18-102AR1 Sandrim et al
    • Abstract: Publication date: Available online 10 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Catherine Cluver, Natalie Hannan, Stephen Tong
       
  • Esomeprazole to treat women with preeclampsia: possible implications in
           the nitric oxide homeostasis
    • Abstract: Publication date: Available online 10 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Valeria C. Sandrim, Mayara Caldeira-Dias, Marcelo F. Montenegro
       
  • Robson classification system applied to the Brazilian reality
    • Abstract: Publication date: Available online 10 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Daniela Ferreira D´Agostini Marin, Betine Pinto Moehlecke Iser
       
  • The Ten Group Classification System as a tool for changing the culture
           around cesarean delivery
    • Abstract: Publication date: Available online 10 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Mark P. Hehir, Alexander M. Friedman
       
  • Opioid prescribing patterns among postpartum women
    • Abstract: Publication date: Available online 10 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Yao Zhang, Alyssia Venna, Jie Zhou
       
  • Opioid prescribing patterns among postpartum women
    • Abstract: Publication date: Available online 10 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Nevert Badreldin, William A. Grobman, Katherine T. Chang, Lynn M. Yee
       
  • The increased activity of a transcription factor inhibits autophagy in
           diabetic embryopathy
    • Abstract: Publication date: Available online 9 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Cheng Xu, Xi Chen, E. Albert Reece, Wenhui Lu, Peixin Yang BackgroundMaternal diabetes induces neural tube defects (NTDs) and stimulates the activity of the transcription factor FoxO3a (forkhead box transcription factor O3a) in the embryonic neuroepithelium. We previously demonstrated that deleting the Foxo3a gene ameliorates maternal diabetes-induced NTDs. Macroautophagy (hereafter referred to as autophagy) is essential for neurulation. Rescuing autophagy suppressed by maternal diabetes in the developing neuroepithelium inhibits NTD formation in diabetic pregnancy. This evidence suggests a possible link between FoxO3a and impaired autophagy in diabetic embryopathy.ObjectiveWe aimed to determine whether maternal diabetes suppresses autophagy through FoxO3a, and if the transcriptional activity of FoxO3a is required for the induction of diabetic embryopathy.Study designWe used a well-established type 1 diabetic embryopathy mouse model, in which diabetes was induced by streptozotocin, for our in vivo studies. To determine if FoxO3a mediates the inhibitory effect of maternal diabetes on autophagy in the developing neuroepithelium, we induced diabetic embryopathy in Foxo3a gene knockout mice and FoxO3a dominant negative transgenic mice. Embryos were harvested at embryonic day 8.5 (E8.5) to determine FoxO3a and autophagy activity and at E10.5 for the presence of NTDs. We also examined the expression of autophagy related genes. C17.2 neural stem cells were used for in vitro examination of the potential effects of FoxO3a on autophagy.ResultsDeletion of the Foxo3a gene restored the autophagy markers, lipidation of microtubule-associated protein 1A/1B-light chain 3 I (LC3I) to LC3II, in neurulation stage embryos. Maternal diabetes-decreased LC3I-positive puncta number in the neuroepithelium, which was restored by deleting FoxO3a. Maternal diabetes also decreased the expression of positive regulators of autophagy (Ulk1, Beclin1 and Atg5) and the negative regulator of autophagy, p62. FoxO3a gene deletion abrogated the dysregulation of autophagy genes. In vitro data showed that the constitutively active form of FoxO3a mimicked high glucose in repressing autophagy. In cells cultured under high glucose conditions, overexpression of the dominant negative FoxO3a mutant blocked autophagy impairment. Dominant negative FoxO3a overexpression in the developing neuroepithelium restored autophagy and significantly reduced maternal diabetes-induced apoptosis and NTDs.ConclusionOur study revealed that diabetes-induced FoxO3a activation inhibited autophagy in the embryonic neuroepithelium. We also observed that FoxO3a transcriptional activity mediated the teratogenic effect of maternal diabetes because dominant negative FoxO3a prevents maternal diabetes-induced autophagy impairment and NTD formation. Our findings suggest that autophagy activators could be therapeutically effective in treating maternal diabetes-induced neural tube defects.
       
  • Hysterectomy status and all-cause mortality in a 21-year Australian
           population-based cohort study
    • Abstract: Publication date: Available online 9 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Louise F. Wilson, Nirmala Pandeya, Julie Byles, Gita D. Mishra BackgroundHysterectomy is a common surgical procedure, predominantly performed when women are between 30 and 50 years old. One in three women in Australia has had a hysterectomy by the time they are 60 years old, and 30% have both ovaries removed at the time of surgery. Given this high prevalence, it is important to understand the long-term effects of hysterectomy. In particular, women who have a hysterectomy/oophorectomy at younger ages are likely to be pre- or perimenopausal and may experience greater changes in hormone levels and a shortened reproductive lifespan than women who have a hysterectomy when they are older and postmenopausal. Use of menopausal hormone therapy after surgery may compensate for these hormonal changes. To inform clinical decisions about post-surgery management of women who have a hysterectomy prior to menopause (i.e. average age at menopause 50 years), it is useful to compare women with a hysterectomy to women with no hysterectomy and to stratify the hysterectomy status by whether or not women have had a bilateral oophorectomy, or used menopausal hormone therapy.ObjectivesTo investigate whether women who had a hysterectomy with ovarian conservation or a hysterectomy and bilateral oophorectomy before the age of 50 years were at a higher risk of premature all-cause mortality compared to women who did not have this surgery before the age of 50. To explore whether use of menopausal hormone therapy modified these associations.Study designWomen from the mid-cohort (born 1946-1951) of the Australian Longitudinal Study on Women’s Health were included in our study sample (n=13,541). Women who reported a hysterectomy (with and without both ovaries removed) before the age of 50 were considered exposure at risk and compared with women who did not report these surgeries before 50 years. To explore effect modification by use of menopausal hormone therapy we further stratified hysterectomy status by menopausal hormone therapy use. Risk of all-cause mortality was assessed using inverse-probability weighted Cox regression models.ResultsDuring a median follow-up of 21.5 years, there were 901 (6.7%) deaths in our study sample. Overall, there was no difference in all-cause mortality between women who reported a hysterectomy with ovarian conservation (hazard ratio 0.86; 95% confidence interval 0.72-1.02) or women who reported a hysterectomy and bilateral oophorectomy (hazard ratio 1.02; 95% confidence interval 0.78-1.34) and women with no hysterectomy. When stratified by menopausal hormone therapy use, women with hysterectomy and ovarian conservation before the age of 50, were not at higher risk of all-cause mortality compared to no hysterectomy, regardless of menopausal hormone therapy use status. In contrast, among non-users of menopausal hormone therapy only, women who reported a hysterectomy-bilateral oophorectomy before the age of 50 were at a higher risk of death compared to women with no hysterectomy (hazard ratio 1.81, 95% confidence interval 1.01-3.25).ConclusionsHysterectomy with ovarian conservation before the age of 50 did not increase risk of all-cause mortality. Among non-menopausal hormone therapy users only, hysterectomy and bilateral oophorectomy before the age of 50 was associated with a higher risk of death.
       
  • Placental Transcriptional and Histological Subtypes of Normotensive Fetal
           Growth Restriction are Comparable to Preeclampsia
    • Abstract: Publication date: Available online 9 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Isaac Gibbs, Katherine Leavey, Samantha J. Benton, David Grynspan, Shannon A. Bainbridge, Brian J. Cox BackgroundInfants born small-for-gestational-age (SGA) due to pathological placenta-mediated fetal growth restriction (FGR) can be difficult to distinguish from those who are constitutionally small. Additionally, even amongst FGR pregnancies with evident placental pathology, considerable heterogeneity in clinical outcomes and long-term consequences has been observed. Gene expression studies of FGR placentas also have limited consistency in their findings, which is likely due to the presence of different molecular subtypes of pathology. In our prior study on preeclampsia (PE), another heterogeneous placenta-centric disorder of pregnancy, we found that by clustering placentas based only on their gene expression profiles, multiple subtypes of PE, including several with co-occurring suspected FGR, could be identified.ObjectivesTo discover placental subtypes of normotensive SGA pregnancies with suspected FGR using unsupervised clustering of placental gene expression data, and investigate their relationships with hypertensive suspected FGR placental subtypes.Study DesignA new dataset of 20 placentas from normotensive SGA pregnancies (birth weight
       
  • A first step to improving maternal mortality in a low literacy setting;
           the successful use of singing to improve knowledge regarding antenatal
           care
    • Abstract: Publication date: Available online 3 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Binod Bindu Sharma, Deborah Joanne Loxton, Henry Murray, Giavanna Louise Angeli, Christopher Oldmeadow, Simon Chiu, Roger Smith BackgroundPreventable maternal mortality is related to delays in recognizing the problem, transport to a facility and receiving appropriate care on arrival. Reducing maternal mortality in low literacy settings is particularly challenging. In the rural villages of Nepal, the maternal mortality rate is amongst the highest in the world; the reasons include illiteracy and lack of knowledge of the needs of pregnant women. Culturally, singing and dancing are part of Nepalese daily life and present an opportunity to transmit knowledge of antenatal care and care at birth with a view to reducing the first two delays.ObjectiveWe hypothesized that health messages regarding the importance of antenatal care and skilled birth assistance would be effectively transmitted by songs in the limited literacy environment of rural Nepal.Study designWe randomly grouped four rural Village Development Committees comprising 36 villages into two (intervention and control) clusters. In the intervention group, local groups were invited to write song lyrics incorporating key health messages regarding antenatal care to accompany popular melodies. The groups presented their songs and dances in a festival organized and judged by the community. The winning songs were performed by the local people in a song and dance progression through the villages, houses and fields. A wall chart with the key health messages was also provided to each household. Knowledge of household decision makers (senior men and women) was assessed before and after the intervention and at 12 months using a structured questionnaire in all households that also assessed behavior change.ResultsStructured interviews were conducted at baseline, immediately post-intervention in the control and intervention areas (intervention n=735 interviews, control n=775), and at 12-months in the intervention area only (n=867). Knowledge scores were recorded as the number of correct items out of 36 questions at baseline and post-intervention, and of 21 questions at follow-up. Post-intervention, test score doubled in the intervention group from a mean of 11·60/36 to 22·33/36 (P
       
  • Role of Bleeding Recognition and Evaluation in Black-White Disparities in
           Endometrial Cancer
    • Abstract: Publication date: Available online 3 October 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Kemi Doll, Sara Khor, Katherine Odem-Davis, Hao He, Erika Wolff, David Flum, Scott Ramsey, Barbara Goff BackgroundAdvanced stage at diagnosis is an independent, unexplained contributor to racial disparity in endometrial cancer (EC).ObjectivesTo investigate whether, prior to diagnosis, provider recognition of the cardinal symptom of EC, postmenopausal bleeding (PMB), differs by patient race.Study DesignBlack and White women diagnosed with EC (2001-2011) from SEER-Medicare who had at least two years of claims prior to diagnosis were identified. Bleeding diagnoses along with procedures done prior to diagnosis were captured via claims data. Multinomial logistic regression was used to evaluate the association of race with diagnostic work-up and multivariate models built to determine the association of appropriate diagnostic procedures with stage at diagnosis.Results4354 White and 537 Black women diagnosed with EC were included. Compared to White women, Black women were less likely to have guideline concordant care: PMB and appropriate diagnostic evaluation (70% vs. 79%, p
       
  • SMFM Consult Series #46: Evaluation and management of polyhydramnios
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Society for Maternal-Fetal Medicine (SMFM), Jodi S. Dashe, Eva K. Pressman, Judith U. HibbardPolyhydramnios, or hydramnios, is an abnormal increase in the volume of amniotic fluid. Identification of polyhydramnios should prompt a search for an underlying etiology. Although most cases of mild polyhydramnios are idiopathic, the 2 most common pathologic causes are maternal diabetes mellitus and fetal anomalies, some of which are associated with genetic syndromes. Other causes of polyhydramnios include congenital infection and alloimmunization. The purpose of this document is to provide guidance on the evaluation and management of polyhydramnios. The following are Society for Maternal-Fetal Medicine recommendations: (1) we suggest that polyhydramnios in singleton pregnancies be defined as either a deepest vertical pocket of ≥8 cm or an amniotic fluid index of ≥24 cm (GRADE 2C); (2) we recommend that amnioreduction be considered only for the indication of severe maternal discomfort, dyspnea, or both in the setting of severe polyhydramnios (GRADE 1C); (3) we recommend that indomethacin should not be used for the sole purpose of decreasing amniotic fluid in the setting of polyhydramnios (GRADE 1B); (4) we suggest that antenatal fetal surveillance is not required for the sole indication of mild idiopathic polyhydramnios (GRADE 2C); (5) we recommend that labor should be allowed to occur spontaneously at term for women with mild idiopathic polyhydramnios; that induction, if planned, should not occur at
       
  • Re: The past, present, and future of selective progesterone receptor
           modulators in the management of uterine fibroids
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Mei-An Middelkoop, Judith A.F. Huirne
       
  • Reply
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Lisa D. Levine, Katheryne L. Downes
       
  • Concerns regarding a validated calculator to estimate risk of cesarean
           delivery after an induction of labor with an unfavorable cervix
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Gustavo A. San Román
       
  • A validated calculator to estimate risk of cesarean after an induction of
           labor with an unfavorable cervix
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Cynthia Abraham
       
  • Prediction calculator for induction of labor: no Holy Grail yet!
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Sepand Alavifard, Kennedy Meier, Rohan D’Souza
       
  • Reply
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Samuel Parry
       
  • Uterine artery Doppler studies in the early second trimester to predict
           abnormal pregnancy outcome in nulliparous women
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Roger A. McMaster-Fay, Jonathan A. Hyett
       
  • Utilization of ovarian transposition for fertility preservation among
           young women with pelvic malignancies who undergo radiotherapy
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Jessica Selter, Lisa C. Grossman Becht, Yongmei Huang, Cande V. Ananth, Alfred I. Neugut, Dawn L. Hershman, Jason D. Wright
       
  • Surgical variance between postconceptional and preconceptional minimally
           invasive transabdominal cerclage placement
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Gaby N. Moawad, Paul Tyan, Charbel Awad, Elias D. Abi KhalilRecent data show that transabdominal cerclage placement via laparoscopy carries better obstetrical outcomes in comparison to transabdominal cerclage placement via laparotomy. In this surgical tutorial, we review the technique for minimally invasive abdominal cerclage and highlight the surgical differences between preconceptional and conceptional cerclage.
       
  • The uterus as venous overflow reservoir: one result of chronic iliac vein
           occlusion
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Fabiola C. Cardozo, Charles A. Ritchie, Christopher C. DeStephano
       
  • January 2018 Supplement (vol. 218, no. 1, pages S493-4)
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s):
       
  • Timing of gestational exposure to Zika virus is associated with postnatal
           growth restriction in a murine model
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Gregory C. Valentine, Maxim D. Seferovic, Stephanie W. Fowler, Angela M. Major, Rodion Gorchakov, Rebecca Berry, Alton G. Swennes, Kristy O. Murray, Melissa A. Suter, Kjersti M. AagaardBackgroundVertical transmission of Zika virus leads to infection of neuroprogenitor cells and destruction of brain parenchyma. Recent evidence suggests that the timing of infection as well as host factors may affect vertical transmission. As a result, congenital Zika virus infection may only become clinically apparent in the postnatal period.ObjectiveWe sought to develop an outbred mouse model of Zika virus vertical transmission to determine if the timing of gestational Zika virus exposure yields phenotypic differences at birth and through adolescence. We hypothesized that later gestational inoculations would only become apparent in adolescence.Study DesignTo better recapitulate human exposures, timed pregnant Swiss-Webster dams (n = 15) were subcutaneously inoculated with 1 × 104 plaque-forming units of first passage contemporary Zika virus HN16 strain or a mock injection on embryonic day 4, 8, or 12 with bioactive antiinterferon alpha receptor antibody administered in days preceding and proceeding inoculation. The antibody was given to prevent the robust type I interferon signaling cascade that make mice inherently resistant to Zika virus infection. At birth and adolescence (6 weeks of age) offspring were assessed for growth, brain weight, and biparietal head diameters, and Zika virus viral levels by reverse transcription–polymerase chain reaction or in situ hybridization.ResultsPups of Zika virus–infected dams infected at embryonic days 4 and 8 but not 12 were growth restricted (P < .003). Brain weights were significantly smaller at birth (P = .01) for embryonic day 8 Zika virus–exposed offspring. At 6 weeks of age, biparietal diameters were smaller for all Zika virus–exposed males and females (P < .05), with embryonic day 8–exposed males smallest by biparietal diameter and growth-restriction measurements (weight>2 SD, P = .0007). All pups and adolescent mice were assessed for Zika virus infection by reverse transcription–polymerase chain reaction. Analysis of all underweight pups reveled 1 to be positive for neuronal Zika virus infection by in situ hybridization, while a second moribund animal was diffusely positive at 8 days of age by Zika virus infectivity throughout the brain, kidneys, and intestine.ConclusionThese findings demonstrate that postnatal effects of infection occurring at single time points continue to be detrimental to offspring in the postnatal period in a subset of littermates and subject to a window of gestational susceptibility coinciding with placentation. This model recapitulates frequently encountered clinical scenarios in nonendemic regions, including the majority of the United States, where travel-related exposure occurs in short and well-defined windows of gestation. Our low rate of infection and relatively rare evidence of congenital Zika syndrome parallels human population-based data.
       
  • Low-dose aspirin is associated with reduced spontaneous preterm birth in
           nulliparous women
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Maria Andrikopoulou, Stephanie E. Purisch, Roxane Handal-Orefice, Cynthia Gyamfi-BannermanBackgroundPreterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor.ObjectiveOur objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities.Study DesignThis is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss
       
  • Implementation and validation of a retroperitoneal dissection curriculum
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Aisha A. Yousuf, Helena Frecker, Abheha Satkunaratnam, Eliane M. ShoreBackgroundCompetency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency.ObjectiveOur goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance.Study DesignA comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3–5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation.ResultsThirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5–7.25) precurriculum to 8 (7–9) postcurriculum (P < .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23–28.25) precurriculum to 30 (29.75–32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27–32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r = 0.53, P = .01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26).ConclusionA comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.
       
  • December 2017 (vol. 217, no. 6, page 725, Abstract 8)
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s):
       
  • Supplement to January 2018 (vol. 218, no. 1, pages S217-8)
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s):
       
  • Reply
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Sukhbir S. Singh, Liane Belland, Nicholas Leyland, Sarah von Riedemann, Ally Murji
       
  • Atraumatic normal vaginal delivery: how many women
           get what they want'
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Jessica Caudwell-Hall, Ixora Kamisan Atan, Rodrigo Guzman Rojas, Susanne Langer, Ka Lai Shek, Hans Peter DietzBackgroundTrauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage.ObjectiveIn this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery.Study DesignThis is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by>20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of>30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma.ResultsA total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035).ConclusionThe prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33–40%) of primiparous women achieved an atraumatic normal vaginal delivery.
       
  • A cautionary response to SMFM statement: pharmacological treatment of
           gestational diabetes
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Linda A. Barbour, Christina Scifres, Amy M. Valent, Jacob E. Friedman, Thomas A. Buchanan, Donald Coustan, Kjersti Aagaard, Kent L. Thornburg, Patrick M. Catalano, Henry L. Galan, William W. Hay, Antonio E. Frias, Kartik Shankar, Rebecca A. Simmons, Robert G. Moses, David A. Sacks, Mary R. LoekenUse of oral agents to treat gestational diabetes mellitus remains controversial. Recent recommendations from the Society for Maternal-Fetal Medicine assert that metformin may be a safe first-line alternative to insulin for gestational diabetes mellitus treatment and preferable to glyburide. However, several issues should give pause to the widespread adoption of metformin use during pregnancy. Fetal concentrations of metformin are equal to maternal, and metformin can inhibit growth, suppress mitochondrial respiration, have epigenetic modifications on gene expression, mimic fetal nutrient restriction, and alter postnatal gluconeogenic responses. Because both the placenta and fetus express metformin transporters and exhibit high mitochondrial activity, these properties raise important questions about developmental programming of metabolic disease in offspring. Animal studies have demonstrated that prenatal metformin exposure results in adverse long-term outcomes on body weight and metabolism. Two recent clinical randomized controlled trials in women with gestational diabetes mellitus or polycystic ovary syndrome provide evidence that metformin exposure in utero may produce a metabolic phenotype that increases childhood weight or obesity. These developmental programming effects challenge the conclusion that metformin is equivalent to insulin. Although the Society for Maternal-Fetal Medicine statement endorsed metformin over glyburide if oral agents are used, there are few studies directly comparing the 2 agents and it is not clear that metformin alone is superior to glyburide. Moreover, it should be noted that prior clinical studies have dosed glyburide in a manner inconsistent with its pharmacokinetic properties, resulting in poor glycemic control and high rates of maternal hypoglycemia. We concur with the American Diabetes Association and American Congress of Obstetricians and Gynecologists, which recommend insulin as the preferred agent, but we believe that it is premature to embrace metformin as equivalent to insulin or superior to glyburide. Due to the uncertainty of the long-term metabolic risks of either metformin or glyburide, we call for carefully controlled studies that optimize oral medication dosing according to their pharmacodynamic and pharmacokinetic properties in pregnancy, appropriately target medications based on individual patterns of hyperglycemia, and follow the offspring long-term for metabolic risk.
       
  • Sexism in obstetrics and gynecology: not just a “women’s issue”
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Francine Hughes, Peter S. BernsteinWomen in medicine have made strides towards equality and yet the gender gap continues to exist. Despite being the specialty dedicated to the promotion of women’s health, obstetrics and gynecology is also marred by gender disparity. Obstetrician-gynecologists who are women continue to face barriers to advancement to leadership positions and earn $36,000 per year less than men in obstetrics and gynecology according to a recent study. Similarly, men in obstetrics and gynecology may be negatively affected by unconscious bias and socially prescribed roles for men and women, resulting in patient preferences for providers who are women. Both men and women have a vested interest in promoting greater gender parity in obstetrics and gynecology, and participation of men is critical for realization of this goal. For the obstetrician-gynecologist, sexism is not just a “women’s issue”.
       
  • Progestogens in singleton gestations with preterm prelabor rupture of
           membranes: a systematic review and metaanalysis of randomized controlled
           trials
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Johanna Quist-Nelson, Pamela Parker, Neggin Mokhtari, Rossana Di Sarno, Gabriele Saccone, Vincenzo BerghellaObjective DataPreterm prelabor rupture of membranes occurs in 3% of all pregnancies. Neonatal benefit is seen in uninfected women who do not deliver immediately after preterm prelabor rupture of membranes. The purpose of this study was to evaluate whether the administration of progestogens in singleton pregnancies prolongs pregnancy after preterm prelabor rupture of membranes.StudySearches were performed in MEDLINE, OVID, Scopus, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials with the use of a combination of keywords and text words related to “progesterone,” “progestogen,” “prematurity,” and “preterm premature rupture of membranes” from the inception of the databases until January 2018. We included all randomized controlled trials of singleton gestations after preterm prelabor rupture of membranes that were randomized to either progestogens or control (either placebo or no treatment). Exclusion criteria were trials that included women who had contraindications to expectant management after preterm prelabor rupture of membranes (ie, chorioamnionitis, severe preeclampsia, and nonreassuring fetal status) and trials on multiple gestations. We planned to include all progestogens, including but not limited to 17-α hydroxyprogesterone caproate, and natural progesterone.Study Appraisal and Synthesis MethodsThe primary outcome was latency from randomization to delivery. Metaanalysis was performed with the use of the random effects model of DerSimonian and Laird to produce relative risk with 95% confidence interval. Analysis was performed for each mode of progestogen administration separately.ResultsSix randomized controlled trials (n=545 participants) were included. Four of the included trials assessed the efficacy of 17-α hydroxyprogesterone caproate; 1 trial assessed rectal progestogen, and 1 trial had 3 arms that compared 17-α hydroxyprogesterone caproate, rectal progestogen, and placebo. The mean gestational age at time randomization was 26.9 weeks in the 17-α hydroxyprogesterone caproate group and 27.3 weeks in the control group. 17-α Hydroxyprogesterone caproate administration was not found to prolong the latency period between randomization and delivery (mean difference, 0.11 days; 95% confidence interval, –3.30 to 3.53). There were no differences in mean gestational age at delivery, mode of delivery, or maternal or neonatal outcomes between the 2 groups. Similarly, there was no difference in latency for those women who received rectal progesterone (mean difference, 4.00 days; 95% confidence interval, –0.72 to 8.72).ConclusionProgestogen administration does not prolong pregnancy in singleton gestations with preterm prelabor rupture of membranes.
       
  • Perinatal anxiety: approach to diagnosis and management in the
           obstetric setting
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Katie R. Thorsness, Corey Watson, Elizabeth M. LaRussoAnxiety is common in women during the perinatal period, manifests with various symptoms and severity, and is associated with significant maternal morbidity and adverse obstetric and neonatal outcomes. Given the intimate relationship and frequency of contact, the obstetric provider is positioned optimally to create a therapeutic alliance and to treat perinatal anxiety. Time constraints, absence of randomized controlled trials, mixed quality of data, and concern for potential adverse reproductive outcomes all limit the clinician’s ability to initiate informed risk-benefit discussions. Clear understanding of the role of the obstetric provider in the identification, stabilization, and initiation of medication and/or referral to psychotherapy for women with perinatal anxiety disorders is critical to maternal and neonatal wellbeing. Informed by our clinical practice as perinatal psychiatric providers, we have provided a concise summary of current research on the approach to the treatment of perinatal anxiety disorders in the obstetric setting that includes psychotherapy and supportive interventions, primary and adjuvant psychiatric medication, and general prescribing pearls. Medications that we examined include antidepressants, benzodiazepines, sedative-hypnotics, antihistamines, quetiapine, buspirone, propranolol, and melatonin. Further research into management of perinatal anxiety, particularly psychopharmacologic management, is warranted.
       
  • Successful in utero transesophageal pacing for severe drug-resistant
           tachyarrhythmia
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Julien Stirnemann, Alice Maltret, Ayman Haydar, Bertrand Stos, Damien Bonnet, Yves VilleSustained fetal tachyarrhythmia can evolve into a life-threatening condition in 40% of cases when hydrops develops, with a 27% risk of perinatal death. Several antiarrhythmic drugs can be given solely or in combination to the mother to achieve therapeutic transplacental concentrations. Therapeutic failure could lead to progressive cardiac insufficiency and restrict therapeutic options to either elective delivery or direct fetal administration of antiarrhythmic drugs, which may increase the risk of death. We report for the first time successful fetal transesophageal pacing to treat a hydropic fetus with drug-resistant tachyarrhythmia.
       
  • Systematic screening and treatment of toxoplasmosis during pregnancy: is
           the glass half full or half empty'
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s): Jose G. Montoya
       
  • Information for Readers
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s):
       
  • SMFM Divider Page
    • Abstract: Publication date: October 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 4Author(s):
       
  • National Mosaic Embryo Transfer Practices: A Survey
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Tesia G. Kim, Michael F. Neblett, Lisa M. Shandley, Kenan Omurtag, Heather S. Hipp, Jennifer F. Kawwass BackgroundThe growing use of preimplantation genetic testing (PGT) with in-vitro fertilization has provided clinicians with more information about the genetics of embryos. Embryos, however, sometimes result with a mixed composition of both aneuploid and euploid cells, called “mosaic embryos.” The interpretation of these results has varied, leading some clinicians to transfer mosaic embryos and some opt not to. In addition, labs providing PGT for aneuploidy have differing thresholds for determining an embryo aneuploid, mosaic, or euploid. Overall practice patterns for mosaic embryo transfer practices in the United States are unknown.Objective(s)To characterize national mosaic embryo transfer practices, including the use of PGT for aneuploidy, prior history of transferring mosaic embryos, thresholds for determining mosaicism, and willingness to transfer mosaic embryos among assisted reproductive technology (ART) clinics in the United States (U.S.).Study DesignA 14-question online survey assessing current use of preimplantation genetic testing for aneuploidy (PGT-A), thresholds for determining mosaicism, and clinic experience and willingness to transfer mosaic embryos was emailed to 417 ART clinics across the United States. Descriptive statistics and logistic regression were used to analyze survey responses and identify clinic factors associated with reporting having ever transferred a mosaic embryo.ResultsOf the 417 U.S. ART clinics contacted, 264 (63.3%) completed a survey, including 167 (63.3%) private, 55 (20.8%) academic, and 42 (15.9%) hybrid clinics. Most (174, 65.9%) clinics reported conducting PGT-A on less than 50% of all IVF cycles. The most common type of PGT-A technology used was next generation sequencing at 88.6%. Ninety-five (36.0%) clinics receive mosaicism data on their PGT-A report; the most common thresholds for determining embryo aneuploidy and euploidy by clinics’ primary genetics labs were 80% normal (44.2%), respectively. Forty (42.1%) of the 95 have transferred and 60 (63.2%) would transfer a mosaic embryo. Nearly 40% of clinics were unsure about their thresholds for mosaic transfer and one-fourth of clinics reported they had no threshold. Private (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.6, 2.0) and hybrid (OR 0.9, 95% CI 0.4, 2.2) clinics were just as likely as academic clinics to report having transferred a mosaic embryo. Clinics in the northeastern U.S. were more likely to have transferred a mosaic embryo than clinics in other regions (OR 1.7, 95% 0.9, 2.9). Most clinics (76.9%) report they do not have a unique consent for transfer of mosaic embryos.Conclusion(s)There is uncertainty and variability in the transfer practices of mosaic embryos and classification of mosaicism among U.S. ART clinics. These findings provide an opportunity to establish mosaicism thresholds and create standardized guidelines for transferring mosaic embryos.
       
  • Gross and Histologic Relationships of the Retropubic Urethra to Lateral
           Pelvic Sidewall and Anterior Vaginal Wall in Female Cadavers: Clinical
           Applications to Retropubic Surgery
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Jennifer J. Hamner, Kelley S. Carrick, Denise M.O. Ramirez, Marlene M. Corton BackgroundKnowledge of the retropubic space anatomy is essential for safe entry and surgical applications within this space.ObjectivesThe objectives of this study were to examine the gross and histologic anatomy of the retropubic urethra, paraurethral tissue and urethrovaginal space and to correlate findings to retropubic procedures.Study DesignAnatomic relationships of the retropubic urethra were examined grossly in unembalmed female cadavers. Measured distances included: lateral urethral wall to arcus tendineus fascia pelvis at the level of urethrovesical junction and at 1 cm distal. Other measurements included retropubic urethral length and distances from internal urethral opening to each ureteric orifice. Microscopic examination was performed at the same levels examined grossly in separate nulliparous specimens. Descriptive statistics were used for data analyses.ResultsTwenty-five cadavers were examined grossly. Median distance from lateral urethral wall to arcus tendineus fascia pelvis at the level of urethrovesical junction was 25 mm (range, 13-38 mm). At 1 cm distal, the median distance from aforementioned structures was 14 mm (10-26 mm). Median length of the retropubic urethra was 23 mm (range 15-30 mm). Four nulliparous specimens, ages 12 weeks, 34, 47 and 52 years, were examined histologically. No histologic evidence of a discrete fascial layer between bladder/urethra and anterior vagina was noted at any level examined. Tissue between the urethra and the pelvic sidewall skeletal muscle was composed of dense fibrous tissue, smooth muscle bundles, scant adipose tissue, blood vessels, and nerves. The smooth muscle fibers of the vaginal muscularis interdigitated with skeletal muscle fibers in the pelvic sidewall at both levels examined. No histologic evidence of “pubourethral ligaments” within the paraurethral tissue was noticed.ConclusionsA 2 cm “zone of safety” exists between the urethra and arcus tendineus fascia pelvis at the urethrovesical junction level. Suture or graft placement within this region should minimize injury to the urethra, pelvic sidewall muscles, and bladder. Knowledge that the shortest length of retropubic urethra was 1.5 cm and shortest urethra to arcus tendineus fascia pelvis distance was 1 cm highlights the importance of maintaining dissection and trocar entry site close to pubic bone to avoid bladder and/or urethral injury. Histologic analysis of paraurethral tissue supports the nonexistence of “pubourethral ligaments”.
       
  • Hospital Variation in Utilization and Success of Trial of Labor after A
           Prior Cesarean
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Xiao Xu, Henry C. Lee, Haiqun Lin, Lisbet S. Lundsberg, Katherine H. Campbell, Heather S. Lipkind, Christian M. Pettker, Jessica L. Illuzzi BackgroundTrial of labor after cesarean delivery (TOLAC) is an effective and safe option for women without contraindications.ObjectivesTo examine hospital variation in utilization and success of TOLAC and identify associated institutional characteristics and patient outcomes.Study DesignUsing linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with one prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized rates of TOLAC utilization and success were estimated for each hospital after accounting for differences in patient case-mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of TOLAC and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals’ TOLAC utilization and success rates.ResultsIn the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, rate of TOLAC use and success varied considerably across hospitals with a median of 35.2% (10th-to-90th percentile range: 10.2-67.1%) and 40.5% (10th-to-90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of TOLAC demonstrated an inverted U-shaped relationship such that low or excessively high TOLAC use was associated with lower success rate. Compared to other births, those delivered at hospitals with above-the-median TOLAC use and success rates had a higher risk for uterine rupture (adjusted risk ratio [aRR] = 2.74, p
       
  • The clinical heterogeneity of preeclampsia is related to both placental
           gene expression and placental histopathology
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Samantha J. Benton, Katherine Leavey, David Grynspan, Brian J. Cox, Shannon A. Bainbridge BackgroundPreeclampsia (PE) is a life-threatening disorder of pregnancy, demonstrating a high degree of heterogeneity in clinical features such as presentation, disease severity and outcomes. This heterogeneity suggests distinct pathophysiological mechanisms may be driving the placental disease underlying this disorder. Our group recently reported distinct clusters of placental gene expression in PE and control pregnancies, allowing for the identification of at least three clinically relevant gene expression-based subtypes of PE. Histopathological examination of a small number of samples from two of the gene expression-based subtypes revealed placental lesions consistent with their gene expression phenotype, suggesting that detailed placental histopathology may provide further insight into the pathophysiology underlying these distinct gene expression-based subtypes.ObjectivesTo assess histopathological lesions in the placentas of patients belonging to each identified gene expression-based subtype of PE, characterised in our previous study. Our goal is to further understand the pathophysiologies defining these gene expression-based subtypes by integrating gene expression with histopathological findings, possibly identifying additional subgroups of PE patients.Study DesignParaffin-embedded placental biopsies from patients included in the gene expression profiling study (n=142/157, 90.4%) were sectioned, H&E stained and imaged. An experienced perinatal pathologist, blinded to gene expression findings and clinical information, assessed the presence and severity of histological lesions using a comprehensive, standardized data collection form. The frequency and severity scores of observed histopathological lesions were compared amongst gene expression-based subtypes as well as within each subtype using using Fisher’s exact tests, Kruskal-Wallis tests, and hierarchical clustering. The histological findings of the placental samples were visualized using t-distributed stochastic neighbor embedding (t-SNE) and phylogenetic trees. Concordance and discordance between gene expression findings and histopathology was also investigated and visualized using principal component analysis (PCA).ResultsSeveral histological lesions were found to be characteristic of each gene expression-based PE subtype. The overall concordance between gene expression and histopathology for all samples was 65% (93/142), with characteristic placental lesions for each gene expression-based subtype complementing prior gene enrichment findings (ex. placentas with enrichment of hypoxia-associated genes showed severe lesions of maternal vascular malperfusion). Concordant samples were located in the central area of each gene expression-based cluster when viewed on a PCA plot. Interestingly, discordant samples (gene expression and histopathology not reflective of one another) were generally found to lie at the periphery of the gene expression-based clusters, and tended to border the group of patients with phenotypically similar histopathology.ConclusionsOur findings demonstrates a high degree of concordance between placental lesions and gene expression across subtypes of PE. Additionally, novel integrative analysis of scored placental histopathology severity and gene expression findings allowed for the identification of patients with intermediate phenotypes of PE not apparent through gene expression profiling alone. Future investigations should examine the temporal relationship between these two modalities, as well as consider the maternal and fetal contributions to these subtypes of disease.
       
  • Addressing Maternal Mortality: The Pregnant Cardiac Patient
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Diana S. Wolfe, Afshan B. Hameed, Cynthia C. Taub, Ali N. Zaidi, Anna E. Bortnick Over the last three years, multiple reports have been published in the United States demonstrating the upward trends in maternal mortality [1] [2] [3]. This increase in maternal death rate is greatly driven by the cardiovascular disease related deaths. Cardiovascular disease accounted for 15.5% of maternal deaths in the USA between years 2011-2013. The United Nations Millennium Development Goal of a 75% reduction in maternal mortality has not been achieved. This may be explained by the increasing number of women with congenital heart disease (CHD) reaching reproductive age and a higher prevalence of chronic medical diseases that puts women at risk for cardiac complications, as pregnancy is a physiologic stress test [1]. A number of experts in the field of Obstetrics & Gynecology (OB/GYN) recommend a call to action by the medical community to address the rise in maternal mortality [4]. In order to achieve this goal, it is imperative that models of care are created and sustained for a standardized approach to management of high complexity pregnant patients. It mandates investment from institutions and stakeholders along with resources for outcomes research. We propose a triad solution for this problem that includes cardiovascular screening, patient education, and multidisciplinary team planning.
       
  • Purinergic, P2X3 positive cells in amniotic membranes
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Zhi Yang Zhou, Xin Xin Xu, Xue Qing Wu, M.J. Quinn;
       
  • Reply
    • Abstract: Publication date: Available online 29 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Liping Feng
       
  • Tackling poorly selected, collected, and reported outcomes in obstetrics
           and gynecology research
    • Abstract: Publication date: Available online 28 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): James M.N. Duffy, Sue Ziebland, Peter von Dadelszen, Richard J. McManus Clinical research should ultimately improve patient care. To enable this, randomized controlled trials must select, collect, and report outcomes which are both relevant to clinical practice and genuinely reflect the perspectives of key stakeholders including healthcare professionals, researchers, and patients. Unfortunately, many randomized controlled trials fall short of this requirement. Complex issues, including a failure to take into account the perspectives of key stakeholders when selecting outcomes, variations in outcome definitions and measurement instruments, and outcome reporting bias make research evidence difficult to interpret, undermining the translation of research into clinical practice. Problems with poor outcome selection, measurement, and reporting can be addressed by developing, disseminating, and implementing core outcome sets. A core outcome set represents a minimum data set of outcomes developed using robust consensus science methods engaging diverse stakeholders including healthcare professionals, researchers, and patients. Core outcomes should be routinely utilized by researchers, collected in a standardized manner, and reported consistently in the final publication. They are currently being developed across our specialty including infertility, endometriosis, and preeclampsia. Recognizing poorly-selected, -collected, and -reported outcomes as serious hindrances to progress in our specialty, over 80 journals including the American Journal of Obstetrics and Gynecology, have come together to support the Core Outcomes in Women’s and Newborn Health (CROWN) initiative. The consortium supports researchers to develop, disseminate, and implement core outcome sets. Implementing core outcome sets could make a profound contribution to addressing poorly-selected, -collected, and -reported outcomes. Implementation should ensure future randomized controlled trials hold the necessary reach and relevance to inform clinical practice, enhance patient care, and improve patient outcomes.
       
  • Trends in pregnancy-associated mortality involving opioids in the United
           States, 2007-2016
    • Abstract: Publication date: Available online 28 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Alison Gemmill, Mathew V. Kiang, Monica J. Alexander
       
  • Interpersonal trauma and aging-related genitourinary dysfunction in a
           national sample of older women
    • Abstract: Publication date: Available online 28 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Carolyn J. Gibson, Nadra E. Lisha, Louise C. Walter, Alison J. Huang BackgroundAmong reproductive-aged women, exposure to interpersonal trauma is associated with genitourinary symptoms. Little is known about the relationship between these exposures and the genitourinary health of older women, who tend to experience different and more prevalent genitourinary symptoms due to menopause and aging.ObjectivesIn this study, we examined relationships between common types of interpersonal trauma and aging-related genitourinary dysfunction among older women.Study DesignWe analyzed data from the National Social Life, Health, and Aging Project, a national area probability sample of older community-dwelling adults born between 1920-1947. We used cross-sectional data from home-based study visits conducted in 2005-2006 to examine interpersonal violence exposures (any lifetime sexual assault, past-year emotional and physical abuse), and past-year genitourinary symptoms (urinary incontinence, other urinary problems, and vaginal pain/lubrication problems with sexual intercourse) among women participants. Multivariable logistic regression models were used to relate interpersonal violence and genitourinary symptoms, adjusting for age, race/ethnicity, body mass index, education, marital status, parity, hormone therapy, depressive and anxiety symptoms, and self-reported health. In exploratory models, we further adjusted for vaginal maturation, a tissue-specific marker of aging-related urogenital atrophy obtained from vaginal self-swabs.ResultsIn this national sample of 1,551 older women (mean age 69 ± 2 years), 9% reported sexual assault, 23% reported emotional abuse, and
       
  • Early Preterm Preeclampsia Outcomes by Intended Mode of Delivery
    • Abstract: Publication date: Available online 28 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Elizabeth M. Coviello, Sara N. Iqbal, Katherine L. Grantz, Chun-Chih Huang, Helain J. Landy, Uma M. Reddy BackgroundThe optimal route of delivery in early onset preeclampsia before 34 weeks is debated, as many clinicians are reluctant to proceed with induction for perceived high risk of failure.ObjectiveOur objective was to investigate labor induction success rates and compare maternal and neonatal outcomes, by intended mode of delivery in women with early preterm preeclampsia.MethodsWe identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n=460) and planned cesarean delivery (n=454) and women with successful induction of labor (n=214) and unsuccessful induction of labor (n=246). We calculated relative risks (RRs) and 95% confidence intervals (CIs) to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birth weight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance and marital status and steroid use.ResultsAmong the 460 (50%) women with induction, 46% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7 and 32 to 33 6/7 the induction of labor success rates were 38% (12/32), 39% (70/180) and 54% (132/248), respectively. Induction of labor compared to planned cesarean delivery was less likely to be associated with placental abruption (aRR 0.33; 95% CI 0.16-0.67), wound infection or separation (aRR 0.23; 95% CI 0.06-0.85) and neonatal asphyxia (0.12; 95% CI 0.02-0.78). Women with vaginal delivery compared to those with failed induction of labor had decreased maternal morbidity (aRR 0.27; 95% CI 0.09-0.82) and no different in neonatal outcomes.ConclusionAbout half of women with preterm preeclampsia who attempted an induction, had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high risk population of women.
       
  • Regenerative medicine as a therapeutic option for fecal incontinence: a
           systematic review of preclinical and clinical studies
    • Abstract: Publication date: Available online 26 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Wiep R. de Ligny, Manon H. Kerkhof, Alejandra M. Ruiz-Zapata ObjectiveThis systematic review aims to perform a quality assessment and to give a critical overview of the current research available on regenerative medicine as a treatment for fecal incontinence.Data sourcesA systematic search strategy was applied in PubMed, Cochrane Library, EMBASE, Medline, Web of Science and Cinahl from inception until March of 2018.Study eligibility criteriaStudies were found relevant when the animals or patients in the studied group had objectively determined or induced fecal incontinence, and the intervention must use any kind of cells, stem cells or biocompatible material, with or without the use of trophic factors.Study appraisal and synthesis methodsStudies were screened on title and consecutively on abstract for relevance by two independent investigators. The risk of bias of preclinical studies was assessed using the SYRCLE’s risk of bias tool for animal studies, and for clinical studies the Cochrane Risk of Bias tool for randomized trials was used.ResultsThirty-four preclinical studies and five clinical studies were included. Animal species, type of anal sphincter injury, intervention and outcome parameters were heterogenous. Therefore, a meta-analysis could not be performed. The overall risk of bias of the included studies was high.ConclusionThe efficacy of regenerative medicine to treat fecal incontinence could not be determined due to the high risk of bias and heterogenicity of the available preclinical and clinical studies. The findings of this systematic review may result in improved study design of future studies which could help the translation of regenerative medicine to the clinic as an alternative to current treatments for fecal incontinence.
       
  • Welcoming Transgender and Non-binary Patients: Expanding the Language of
           “Women’s Health”
    • Abstract: Publication date: Available online 26 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Daphna Stroumsa, Justine P. Wu In this article, we consider the impact of gendered language on our ability to provide inclusive care and to address health disparities experienced by transgender and non-binary people. We posit that while obstetrician gynecologists and others trained in women’s health are already well-positioned to extend care to this population, we can improve this care through simple adjustments in the framing and language we use.
       
  • The importance of access to comprehensive reproductive health care,
           including abortion: A statement from women’s health professional
           organizations
    • Abstract: Publication date: Available online 26 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Eve Espey, Uta Landy, Amanda Dennis Barriers to women’s reproductive healthcare access, particularly for termination of pregnancy, are increasing at the local, regional, and national levels through numerous institutional, legislative, and regulatory restrictions. Lack of access to reproductive healthcare has negative consequences for women’s health. Twelve women’s healthcare organizations affirm their support for access to comprehensive reproductive healthcare, including abortion.
       
  • Reply to Manuscript # L18-092AR1 “ A clinician’s concerns about motor
           functions Outcomes of fetal Surgery for Myelomeningocele.”
    • Abstract: Publication date: Available online 21 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Diana L. Farmer, N. Scott Adzick
       
  • Reply
    • Abstract: Publication date: Available online 19 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Carolyn M. Zelop, Sharon Einav, Jill M. Mhyre, Stephanie Martin
       
  • Uterine and fetal placental Doppler indices are associated with maternal
           cardiovascular function
    • Abstract: Publication date: Available online 19 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Jasmine Tay, Giulia Masini, Carmel M. McEniery, Dino A. Giussani, Caroline J. Shaw, Ian B. Wilkinson, Phillip R. Bennett, Christoph C. Lees Background and ObjectivesThe mechanism underlying fetal-placental Doppler changes in pre-eclampsia and/or fetal growth restriction are unknown though both are associated with maternal cardiovascular dysfunction. We sought to investigate whether there was a relationship between maternal cardiac output and vascular resistance and feto-placental Doppler in healthy and complicated pregnancy.Study DesignWomen with healthy (n= 62), PE (Pre eclampsia) (n=13), PE+FGR (Pre eclampsia with fetal growth restriction) (n=15) or FGR (Fetal growth restriction) (n=17) pregnancies from 24-40 weeks were included. All underwent measurement of cardiac output (CO) using an inert gas rebreathing technique, and derivation of peripheral vascular resistance (PVR). Uterine and fetal Doppler indices were recorded: the latter were z-scored to account for gestation. Associations were determined by polynomial regression analyses.ResultsMean uterine artery pulsatility index (PI) was higher in FGR (Fetal growth restriction) (1.37, p=0.026) and PE+FGR (Pre eclampsia with fetal growth restriction) (1.63, p=0.001) but not PE (Pre eclampsia) (0.92, p=1) compared to controls (0.8). There was a negative relationship between uterine PI and CO (r2=0.101; p=0.025) and umbilical PI z-score and CO (r2=0.078; p=0.015), and positive associations between uterine PI and PVR (r2=0.150; p=0.003) and umbilical PI z-score and PVR (r2= 0.145; p=0.001). There was no significant relationship between CO and PVR with cerebral Doppler.ConclusionsUterine artery Doppler is abnormally elevated in FGR with and without PE, but not in PE: this may explain the limited sensitivity of uterine artery Doppler for all these complications considered in aggregate. Furthermore, impedance within feto-placental arterial vessels is at least in part associated with maternal cardiovascular function. This relationship may have important implications for fetal surveillance and would inform therapeutic options in those pathological pregnancy conditions currently-and perhaps erroneously- attributed purely to placental mal-development.Uterine and fetal placental Doppler indices are significantly associated with maternal cardiovascular function. The classical description of uterine and fetal Doppler changes being initiated by placental maldevelopment is a less plausible explanation for the pathogenesis of the conditions than that relating to maternal cardiovascular changes.
       
  • You Can Never be too Prepared: ECMO for MCA
    • Abstract: Publication date: Available online 19 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Atsushi Mizuno, Ayako Shibata, Akira Saito
       
  • September 2016 (vol. 215, no. 3; errors on page 316.e4)
    • Abstract: Publication date: Available online 19 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s):
       
  • A Clinician's Concerns about Motor Function Outcomes of Fetal Surgery for
           Myelomeningocele
    • Abstract: Publication date: Available online 19 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Gordon Worley
       
  • Reply to L18-083AR1
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Eliane M. Shore, Helena Frecker, Evan R. Tannenbaum
       
  • Female Pelvic Medicine and Reconstructive Surgery Fellows’ Exposure
           to Transgender Healthcare
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Olivia H. Chang, Miriam J. Haviland, Emily Von Bargen, Yvonne Gomez-Carrion, Michele R. Hacker, Janet Li
       
  • Medical education research in Obstetrics and Gynecology
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Martin G. Tolsgaard
       
  • Cesarean scar defect: A prospective study on risk factors
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Riitta M. Antila-Långsjö, Johanna U. Mäenpää, Heini S. Huhtala, Eija I. Tomás, Synnöve M. Staff BackgroundCesarean scar defect (isthmocele) is a known complication after cesarean delivery. It has become more common due to a rising cesarean delivery rate. Isthmocele has been associated with various gynecological and obstetric problems such as uterine rupture, cesarean scar pregnancy and bleeding disorders.ObjectiveTo prospectively investigate factors associated with the risk for isthmocele assessed by sonohysterography.Study designA prospective observational cohort study was conducted in 401 non-pregnant women who were recruited within three days of cesarean delivery. Women were evaluated with sonohysterography six months after cesarean delivery in order to detect a possible isthmocele. The ultrasonographer was blinded to any clinical information. The main outcome measure was the presence of isthmocele. Type of surgery (elective versus emergency), maternal background variables, and factors related to pregnancy, labor and post-operative recovery were analyzed in relation to isthmocele. A logistic regression model was used to assess independent risk factors from univariate analysis.ResultsThree hundred and seventy-one women were examined with sonohysterography resulting in a follow-up rate of 92.5%. The prevalence of isthmocele was 45.6%. Independent risk factors for isthmocele development were a history of gestational diabetes (OR 1.73 [95% CI 1.02–2.92]; P=0.042), previous cesarean delivery (OR 3.14 [95% CI 1.90–5.17]; P
       
  • Intrapartum Magnesium Sulphate is Associated with Neuroprotection in
           Growth Restricted Fetuses
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Elizabeth L. Stockley, Joseph Y. Ting, John Kingdom, Sarah D. McDonald, Jon Barrett, Anne Synnes, Luis Monterrosa, Prakesh S. Shah, Canadian Neonatal Network, Canadian Neonatal Follow-up Network and Canadian Preterm Birth Network Investigators BackgroundIntrapartum magnesium sulphate administration is recommended for fetal neuroprotection in women with imminent very preterm birth. However, previous studies have not included or separately analyzed the outcomes of pregnancies with fetal growth restriction that were treated with intrapartum magnesium sulphate.ObjectivesTo evaluate the neonatal and neurodevelopmental outcomes of growth restricted fetuses born before 29 weeks’ gestation and exposed to maternal intrapartum magnesium sulphate.Study DesignWe conducted a retrospective cohort study of infants born before 29 weeks’ gestation between 2010 and 2011, admitted to participating Canadian Neonatal Network units, and followed by the Canadian Neonatal Follow-up Network centers. Growth restriction was defined either as estimated fetal or actual neonatal birth weight
       
  • Guild Interests: An Insidious Threat to Professionalism in Obstetrics and
           Gynecology
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Frank A. Chervenak, Laurence B. McCullough, Ralph W. Hale Powerful incentives now exist that could subordinate professionalism to guild self-interest. How obstetrician-gynecologists respond to these insidious incentives will determine whether guild self-interests will define our specialty. We provide ethically justified, practical guidance to obstetrician-gynecologists to prevent this ethically unacceptable outcome. We describe and illustrate two major incentives to subordinating professionalism to guild self-interest: demands for productivity; and compliance and regulatory pressures. We then set out the professional responsibility model of ethics in obstetrics and gynecology to guide obstetrician-gynecologists in responding to these incentives [with the goal of preserving] so that they preserve professionalism. Obstetrician-gynecologists should identify guild interests affecting their group practices, set ethically justified limits on self-sacrifice, and prevent incremental drift toward dominance of guild self-interests over professionalism. Guild self-interests could succeed in undermining professionalism, but only if obstetrician-gynecologists allow this to happen. When guild self-interest becomes the deciding factor in patient care, professionalism withers and insidious incentives flourish.
       
  • Preventing Incremental Drift away from Professionalism in Graduate Medical
           Education
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Frank A. Chervenak, Laurence B. McCullough, Amos Grünebaum Professionalism is a core competency of graduate medical education programs, stipulated by Accreditation Council for Graduate Medical Education (ACGME). We identify an underappreciated challenge to professionalism in residency training, the risk of incremental drift from professionalism, and a preventive ethics response, which can occur in residency programs in countries with oversight similar to that of ACGME. Two major, welcome changes in graduate medical education – required duty hours and increased attending supervision – create incentives for drift from professionalism. This paper analyzes these incentives based on the ethical concept of medicine as a profession, introduced into the history of medical ethics in late eighteenth century Britain. This concept calls for physicians to make three commitments: to scientific and clinical competence; to the protection and promotion of the patient’s health-related interests; and to keeping individual and group self-interest systematically secondary. Some responses of programs and residents to these incentives can undermine professionalism, creating a subtle and therefore hard-to-detect drift away from professionalism that in its worst form results in infantilization of residents. Program directors and educators should prevent this drift from professionalism by implementing practices that promote professionally responsible responses to the incentives created by required duty hours and increased attending supervision.
       
  • Prediction of spontaneous preterm delivery in women presenting with
           premature labor: a comparison of placenta alpha microglobulin-1,
           phosphorylated insulin-like growth factor binding protein-1, and cervical
           length
    • Abstract: Publication date: Available online 18 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Tanja Nikolova, Jukka Uotila, Natasha Nikolova, Vyacheslav M. Bolotskikh, Vera Y. Borisova, Gian Carlo di Renzo BackgroundPlacental alpha microglobulin-1 (PAMG-1) and phosphorylated insulin-like growth factor-binding protein-1 (phIGFBP-1) have been studied in patients at risk for preterm birth with signs and symptoms of preterm labor. However, a direct comparison between these two biomarkers, alone or in combination with cervical length measurement with an adequate sample size, has been lacking to date.ObjectiveTo compare PAMG-1 test and the phIGFBP-1-1 test alone and in combination with cervical length measurement for the prediction of imminent spontaneous preterm birth of testing in pregnant women with symptoms of preterm labor in a tertiary care setting.Study Design403 patients with intact amniotic membranes and cervical dilation ≤ 3 cm, without recent intercourse or cerclage, between gestational weeks of 20+0 and 36+6 were prospectively recruited from three international centers. PAMG-1 and phIGFBP-1 tests were conducted prior to cervical length measurement via transvaginal ultrasound. Caregivers were blinded to the biomarker test results. Medically indicated deliveries within 14 days of testing were excluded. Standard performance statistics with 95% confidence intervals were calculated and compared based on pairwise estimates from a generalized model.ResultsOf 403 subjects enrolled in the study cohort 94% (383/403) met the inclusion criteria. Median gestational age and cervical length at presentation were 30+5 weeks and 27 mm, respectively. 6.8% (26/383) women had spontaneous birth ≤7 days from testing. PAMG-1 test was positive in 7.8% (30/383) women, whereas phIGFBP-1 test was positive in 29.5% (113/383). Positive predictive value for PAMG-1, phIGFBP-1, and cervical length
       
  • Screening extremely obese pregnant women for obstructive sleep apnea
    • Abstract: Publication date: Available online 11 September 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Jennifer E. Dominguez, Chad A. Grotegut, Mary Cooter, Andrew D. Krystal, Ashraf S. HabibStructured BackgroundObesity is prevalent among pregnant women in the United States; obstructive sleep apnea (OSA) is highly comorbid with obesity and is associated with adverse pregnancy outcomes. Screening for obstructive sleep apnea in pregnant women has remained a challenge due to a lack of validated screening tools.ObjectivesThe purpose of this study was to evaluate established OSA screening tools, a sleepiness scale, and their individual component items in a cohort of pregnant women with extreme obesity in mid-pregnancy using objective testing to determine OSA status, and to describe the prevalence of OSA among women with extreme obesity.Study designAdult pregnant subjects, between 24 and 35 weeks gestation with a body mass index (BMI) greater than or equal to 40 kg.m-2 at the time of enrollment completed OSA screening questionnaires (Berlin, American Society of Anesthesiologists checklist, and STOP-BANG), and the Epworth sleepiness scale; they also underwent physical examination of the neck, mouth, and airway. The OSA in pregnancy prediction score proposed by Facco et al. was calculated for each subject. OSA status for each subject was determined by the results of an overnight, unattended type III home sleep apnea test.Results24% of pregnant women with extreme obesity had OSA on home sleep apnea testing in mid-pregnancy [apnea-hypopnea index (AHI) > 5 events/hour]. Established OSA screening tools performed very poorly to screen for OSA in this cohort. Age, BMI, neck circumference, frequent witnessed apneas and highly likely to fall asleep while driving were most strongly associated with OSA status in this cohort.ConclusionsWe found that 24% of pregnant women with BMI greater than or equal to 40 kg.m-2 between 24 and 35 weeks gestation have OSA, defined as AHI > 5 events/hour on an overnight, type III home sleep apnea test. We found the Berlin questionnaire, American Society of Anesthesiologists checklist, STOP-BANG, OSA in pregnancy score by Facco et al., and the Epworth sleepiness scale were not useful screening tools for OSA in a cohort of obese pregnant women. However, age, BMI, neck circumference, frequent witnessed apneas and likely to fall asleep while driving were associated with OSA in this cohort and further studies are needed to adjust the criteria and thresholds within the available screening tools to better predict OSA in pregnant women with obesity.
       
 
 
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