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American Journal of Obstetrics and Gynecology
Journal Prestige (SJR): 2.7
Citation Impact (citeScore): 4
Number of Followers: 200  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0002-9378
Published by Elsevier Homepage  [3163 journals]
  • Postpartum intrauterine devices: Clinical and programmatic review
    • Abstract: Publication date: Available online 19 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Lisa M. Goldthwaite, Erica P. Cahill, Amy J. Voedisch, Paul D. Blumenthal The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long acting reversible contraception, including insertion of an intrauterine device (IUD). The use of the IUD in the postpartum period is a safe practice with few contraindications and many benefits. While an IUD placed during the postpartum period is more likely to expel compared to one placed at the postpartum visit, women initiating IUDs at the time of delivery are also more likely to continue to use an IUD compared to women planning to follow up for an interval IUD insertion. This review will focus on the most recent clinical and programmatic updates on postpartum IUD practice. We discuss postpartum IUD expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum IUDs and encourage those involved in the health care system to remove barriers to this worthwhile practice.
  • Expanding Phenotypes of Intrauterine Growth Restriction
    • Abstract: Publication date: Available online 17 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Christie L. Walker, Audrey A. Merriam, Cynthia Gyamfi-Bannerman, Kristina M. Adams Waldorf
  • The effect of customization and use of a fetal growth standard on the
           association between birthweight percentile and adverse perinatal
           outcome: methodologic issues
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Saeid Safiri
  • Response to Letter to the Editor for: Racial difference in postpartum
           hemorrhage outcome: Pathophysiological, clinical, and social
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Alexander Friedman, Cynthia Gyamfi-Bannerman
  • Vaginal delivery within 24 hours of labor induction as a primary outcome
           – what's the rush'
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Lena Sagi-Dain, Shlomi Sagi
  • Do Pregnant Inmates have a Constitutional Right to Opioid Replacement
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Joseph B. Williams Changes in the national drug laws have resulted in a marked increase in the number of individuals incarcerated in the US over the past several decades, and women have not been exempt from this trend. Incarcerated women who are pregnant and at risk of experiencing opioid withdrawal often lack access to opioid replacement therapy while in jails and prisons, and this treatment is necessary to prevent significant acute withdrawal which can be detrimental to maternal-fetal health. I contend that pregnant inmates who are at risk of experiencing opioid withdrawal possess a constitutional right to receive opioid replacement therapy while incarcerated, and failure to provide this treatment represents a violation of the Eighth Amendment’s protection against cruel and unusual punishment.
  • Sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome
           with a non-surgical neo-vagina
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Stephanie Both, Kirsten Kluivers, Marianne Ten Kate-Booij, Philomeen Weijenborg BackgroundSexual dysfunction is prevalent in women with Mayer-Rokitansky-Küster-Hauser syndrome after creation of a neo-vagina. Insight into the physiological response of the neo-vagina during sexual arousal is lacking, while this would help in the understanding of sexual function of these patients. The physiological sexual response of the vagina can be objectively measured by vaginal photoplethysmography assessing vaginal blood flow.Objective(s)Testing whether the physiological and subjective sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome with a neo-vagina differs from the response in women with a natal vagina.Study designVaginal blood flow (Vaginal Pulse Amplitude) and subjective sexual responses during neutral and erotic film viewing were assessed in pre-menopausal Mayer-Rokitansky-Küster-Hauser women with a non-surgically created neo-vagina (n = 15), and were compared with responses of an age-matched control group (n = 21).ResultsAll Mayer-Rokitansky-Küster-Hauser women had created their neo-vagina themselves by dilation. Mayer-Rokitansky-Küster-Hauser women showed a significantly smaller vaginal pulse amplitude compared to controls during neutral film viewing (p = .002). In both groups, vaginal pulse amplitude increased significantly during erotic film viewing, but this increase was significantly smaller in the Mayer-Rokitansky-Küster-Hauser group (p’s < .005). Levels of subjective sexual arousal did not significantly differ between the two groups (p’s> .2).ConclusionsMayer-Rokitansky-Küster-Hauser women with a non-surgically created neo-vagina showed a weaker vaginal blood flow response during visual sexual stimulation, and poorer basal blood flow compared to controls. The differences in vaginal blood flow may be related to less vascularization and innervation of the neo-vagina compared to the natal vagina. The weaker vaginal sexual response can play a role in sexual dysfunction, although, despite the weaker vaginal response, Mayer-Rokitansky-Küster-Hauser women did not differ in their level of subjective sexual arousal. Future studies may compare vaginal blood flow and subjective sexual response of Mayer-Rokitansky-Küster-Hauser women with non-surgically and surgically created vaginas.
  • Sexism in Obstetrics & Gynecology: Not just a “women’s
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Francine Hughes, Peter S. Bernstein Women 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”.
  • Femur-Sparing Pattern of Fetal Growth After Maternal Zika Virus Infection
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Sora Yasri, Viroj Wiwanitkit
  • Cervical Cerclage for Singleton Pregnant Patients on Vaginal Progesterone
           with Progressive Cervical Shortening
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Christopher A. Enakpene, Laura DiGiovanni, Tiffany N. Jones, Megan Marshalla, Dimitrios Mastrogiannis, Micaela Della Torre
  • Racial difference in postpartum hemorrhage outcome: Pathophysiological,
           clinical, and social significance'
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Shigeki Matsubara, Hironori Takahashi, Akihide Ohkuchi
  • Reply to Letter # L18-061AR1
    • Abstract: Publication date: Available online 11 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Alison M. Bauer, Justin R. Lappen, David N. Hackney
  • December 2017 (vol. 217, no. 6, page 725, Abstract 8)
    • Abstract: Publication date: Available online 3 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s):
  • Implementation and Validation of a Retroperitoneal Dissection Curriculum
    • Abstract: Publication date: Available online 3 July 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Aisha A. Yousuf, Helena Frecker, Abheha Satkunaratnam, Eliane M. Shore BackgroundCompetency-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 (LRD), 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.ObjectivesOur goal was to validate a comprehensive curriculum for LRD 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 (PGY 3-5) were recruited. Participants completed pre- and post- curriculum multiple-choice questionnaires (MCQ) to evaluate a didactic component. Pre- and post- performance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform LRD using the simulation model. Participants were then video-recorded performing LRD in the operating room (OR) within 3 months of the curriculum. All videos were blindly assessed by an expert using the objective structured assessment of technical skills (OSATS) 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 (MCQ score median and interquartile (IQR)) still significantly increased from 7 (5-7.25) pre-curriculum to 8 (7-9) post-curriculum (p < 0.001). The median (IQR) technical OSATS score increased significantly from 24.5 (23-28.25) pre-curriculum to 30 (29.75-32) post-curriculum (p < 0.001). Video recordings were completed for 23 participants performing LRD in the OR. Intraoperative OSATS scores (median of 29 (27-32)) correlated with post-curriculum OSATS scores on the model (r=0.53, p = 0.01). 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 felt that this model would be useful to enhance skills acquisition prior to performing the skill in the OR (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 OR. In addition to the objective measures, residents felt that their skills acquisition was improved following course completion.
  • Retraction notice to 647: Compliance of federally-funded maternal fetal
           medicine and neonatology studies to federally-mandated trial registration
           requirements: Am J Obstet Gynecol 2018;218:S385.
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Vanessa C. Nunes, Alexandria Wells, Germaine Y. Noukelak, Menachem Miodovnik, Tonse N.K. RajuThis article has been retracted: please see Elsevier Policy on Article Withdrawal ( abstract has been retracted at the request of the
      Authors .All authors did not have the opportunity to review and approve the abstract prior to submission. As a result, the abstract was published with errors.
  • Retraction notice to 633: Sex differences in mesolimbic dopamine
           signaling, catecholamine synthesis, and offspring weight in a mouse model
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Andrea G. Edlow, Chang Xue, Emmanuel N. PothosThis article has been retracted: please see Elsevier Policy on Article Withdrawal ( abstract has been retracted at the request of the
      Authors . This abstract was withdrawn by the authors prior to publication and published in error.
  • December 2017 (vol. 217, no. 6, pages 678.e1-9)
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s):
  • Infant outcome after complete uterine rupture
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Iqbal Al-Zirqi, Anne Kjersti Daltveit, Siri VangenBackgroundComplete uterine rupture is a rare peripartum complication often associated with a catastrophic outcome for both mother and child. However, little has been written based on large data sets about maternal and infant outcome after complete ruptures. This is partly due to the rarity of the event and the serious maternal and infant outcome; it is also partly due to the use of international diagnostic codes that do not differentiate between the less catastrophic partial rupture and more catastrophic complete uterine rupture. As uterine rupture is expected to increase due to increased cesarean delivery rates worldwide, it is important to know more completely about the outcome following complete uterine rupture.ObjectiveWe sought to explore risk factors associated with poor infant outcome in cases of complete uterine rupture.Study DesignThis population-based study used data from the Medical Birth Registry of Norway, the Patient Administration System, and medical records. We included births with complete uterine rupture after start of labor in all maternity units in Norway during the period 1967 through 2008 (n = 244 births), identified among 2,455,797 births. Uterine ruptures were identified and further studied through a review of medical records. We estimated the associations between infant outcomes and demographic and labor risk factors using logistic regression analyses. Odds ratios with 95% confidence intervals for each risk factor were determined after adjustment for demographic factors and period of birth. The main outcome measure was infant outcome: healthy infant, intrapartum/infant deaths, hypoxic ischemic encephalopathy, and admission to the neonatal intensive care unit.ResultsWe identified 109 (44.7%) healthy infants, 56 (23.0%) infants needing neonatal intensive care unit admission, 64 (26.2%) intrapartum/infant deaths, and 15 (6.1%) infants with hypoxic ischemic encephalopathy. The highest number of intrapartum/infant deaths occurred in 1967 through 1977 (51.6%) and the fewest in 2000 through 2008 (15.0%). Unscarred uterine ruptures did not significantly increase intrapartum/infant deaths compared to scarred uterine ruptures. Placental separation and/or fetal extrusion had the highest odds ratio for intrapartum/infant deaths (odds ratio, 17.9; 95% confidence interval, 7.5–42.4). Time-to-delivery interval 30 minutes vs 30 minutes and placental separation and/or fetal extrusion had the highest association with intrapartum/infant deaths after complete uterine rupture. Time to delivery
  • Opioid prescribing patterns among postpartum women
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Nevert Badreldin, William A. Grobman, Katherine T. Chang, Lynn M. YeeBackgroundWomen commonly receive opioid prescriptions following hospitalization. The rise of the opioid epidemic in the United States underscores the importance of a better understanding of prescribing patterns. Although delivery is the most frequent reason for hospitalization in the United States, there is inadequate knowledge regarding opioid prescribing at postpartum hospital discharge.ObjectiveWe sought to describe opioid prescribing patterns at the time of discharge following delivery in a large, diverse cohort, and to describe the relationship of these patterns with objective and subjective measures of pain prior to discharge.Study DesignThis is a retrospective cohort study of all deliveries at a single, high-volume tertiary care center over a 1-year period. Women were excluded from analysis if they had evidence of recent opioid use, or their labor, delivery, or postpartum course was notable for rare, nonroutine events anticipated to increase pain. Medical records were queried for demographic and clinical data, including whether an opioid prescription was provided at discharge, and if so, details of that prescription. The primary outcome was amount of opioid morphine milligram equivalents prescribed at discharge, described separately for women after vaginal and cesarean deliveries. Among women who received a prescription, we additionally assessed associations between prescription quantity and subjective (patient-reported pain score) and objective (inpatient opioid requirement during the final 24 hours of hospitalization) assessments of pain. Descriptive and bivariable analyses were performed.ResultsOf the total 12,611 women, 12,326 were eligible for inclusion. Of 9038 women postvaginal delivery and 3288 women postcesarean delivery, 30.4% and 86.7% received an opioid prescription at discharge, respectively. Of women receiving discharge opioid prescriptions, median morphine milligram equivalents received was 200 (interquartile range: 120–300) following vaginal and 300 (interquartile range: 200–300) following cesarean delivery. Nearly half (45.7%) of women postvaginal delivery and 18.5% of women postcesarean delivery who received an opioid prescription used 0 morphine milligram equivalent during the final hospital day. Similarly, 26.5% and 18.5% of women after vaginal and cesarean delivery, respectively, reported a pain score of 0 of 10 prior to discharge. Regardless of delivery mode, the amount of opioids prescribed did not differ between those who reported a pain score of 0 of 10 and those who reported a pain score of>0 of 10 immediately prior to discharge. Similarly, for women who underwent cesarean delivery, the morphine milligram equivalents prescribed did not differ between those who used 0 morphine milligram equivalents and those who used>0 in the 24 hours prior to hospital discharge.ConclusionPostpartum women are commonly prescribed opioids at the time of postpartum hospital discharge. There is a wide range of morphine milligram equivalents prescribed at hospital discharge following delivery, highlighting a lack of standardization. Furthermore, regardless of objective and subjective measures of pain prior to discharge, women received similar amounts of prescription morphine milligram equivalents following either vaginal or cesarean deliveries.
  • Infection-induced thrombin production: a potential novel mechanism for
           preterm premature rupture of membranes (PPROM)
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Liping Feng, Terrence K. Allen, William P. Marinello, Amy P. MurthaBackgroundPreterm premature rupture of membranes is a leading contributor to maternal and neonatal morbidity and death. Epidemiologic and experimental studies have demonstrated that thrombin causes fetal membrane weakening and subsequently preterm premature rupture of membranes. Although blood is suspected to be the likely source of thrombin in fetal membranes and amniotic fluid of patients with preterm premature rupture of membranes, this has not been proved. Ureaplasma parvum is emerging as a pathogen involved in prematurity, which includes preterm premature rupture of membranes; however, until now, prothrombin production that has been induced directly by bacteria in fetal membranes has not been described.ObjectiveThis study was designed to investigate whether Ureaplasma parvum exposure can induce prothrombin production in fetal membranes cells.Study DesignPrimary fetal membrane cells (amnion epithelial, chorion trophoblast, and decidua stromal) or full-thickness fetal membrane tissue explants from elective, term, uncomplicated cesarean deliveries were harvested. Cells or tissue explants were infected with live Ureaplasma parvum (1×105, 1×106 or 1×107 colony-forming units per milliliter) or lipopolysaccharide (Escherichia coli J5, L-5014; Sigma Chemical Company, St. Louis, MO; 100 ng/mL or 1000 ng/mL) for 24 hours. Tissue explants were fixed for immunohistochemistry staining of thrombin/prothrombin. Fetal membrane cells were fixed for confocal immunofluorescent staining of the biomarkers of fetal membrane cell types and thrombin/prothrombin. Protein and messenger RNA were harvested from the cells and tissue explants for Western blot or quantitative reverse transcription polymerase chain reaction to quantify thrombin/prothrombin protein or messenger RNA production, respectively. Data are presented as mean values ± standard errors of mean. Data were analyzed using 1-way analysis of variance with post hoc Dunnett’s test.ResultsProthrombin production and localization were confirmed by Western blot and immunostainings in all primary fetal membrane cells and tissue explants. Immunofluorescence observations revealed a perinuclear localization of prothrombin in amnion epithelial cells. Localization of prothrombin in chorion and decidua cells was perinuclear and cytoplasmic. Prothrombin messenger RNA and protein expression in fetal membranes were increased significantly by Ureaplasma parvum, but not lipopolysaccharide, treatments in a dose-dependent manner. Specifically, Ureaplasma parvum at a dose of 1×107 colony-forming units/mL significantly increased both prothrombin messenger RNA (fold changes in amnion: 4.1±1.9; chorion: 5.7±4.2; decidua: 10.0±5.4; fetal membrane: 9.2±3.0) and protein expression (fold changes in amnion: 138.0±44.0; chorion: 139.6±15.1; decidua: 56.9±29.1; fetal membrane: 133.1±40.0) compared with untreated control subjects. Ureaplasma parvum at a dose of 1×106 colony-forming units/mL significantly up-regulated prothrombin protein expression in chorion cells (fold change: 54.9±5.3) and prothrombin messenger RNA expression in decidua cells (fold change: 4.4±1.9).ConclusionOur results demonstrate that prothrombin can be produced directly by fetal membrane amnion, chorion, and decidua cells. Further, prothrombin production can be stimulated by Ureaplasma parvum exposure in fetal membranes. These findings represent a potential novel underlying mechanism of Ureaplasma parvum–induced rupture of fetal membranes.
  • Cervical pessary to reduce preterm birth
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Laia Pratcorona, Maria Goya, Carme Merced, Carlota Rodó, Elisa Llurba, Teresa Higueras, Luis Cabero, Elena Carreras, Silvia Arévalo, Mayte Avilés, Inés Calero, Manel Casellas, Marina Folch, Andrea Gascón, Manel Mendoza, Mª Angeles Sanchez, Anna SuyBackgroundTo date, no intervention has proved effective in reducing the spontaneous preterm birth rate in singleton pregnancies following an episode of threatened preterm labor and short cervix remaining.ObjectiveThis study was designed to ascertain whether cervical pessaries could be useful in preventing spontaneous preterm birth in women with singleton pregnancies and a short cervix after a threatened preterm labor episode.Study DesignThis open randomized controlled trial was conducted in 357 pregnant women (between 240–336 weeks) who had not delivered 48 hours after a threatened preterm labor episode and had a short cervix remaining (≤25 mm at 240–296 weeks; ≤15 mm at 300–336 weeks). Patients were randomly assigned to cervical pessary (179) or routine management (178). The primary outcome was the spontaneous preterm birth rate
  • The Comparing Options for Management: PAtient-centered REsults for Uterine
           Fibroids (COMPARE-UF) registry: rationale and design
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Elizabeth A. Stewart, Barbara L. Lytle, Laine Thomas, Ganesa R Wegienka, Vanessa Jacoby, Michael P. Diamond, Wanda K. Nicholson, Raymond M. Anchan, Sateria Venable, Kedra Wallace, Erica E. Marsh, George L. Maxwell, Bijan J. Borah, William H. Catherino, Evan R. MyersBackgroundUterine fibroids are common in premenopausal women, yet comparative effectiveness research on uterine fibroid treatments is rare.ObjectiveThe purpose of this study was to design and establish a uterine fibroid registry based in the United States to provide comparative effectiveness data regarding uterine fibroid treatment.Study DesignWe report here the design and initial recruitment for the Comparing Options for Management: Patient-centered REsults for Uterine Fibroids (COMPARE-UF) registry (, NCT02260752), funded by the Agency for Healthcare Research and Quality in collaboration with the Patient-Centered Outcomes Research Institute. COMPARE-UF was designed to help answer critical questions about treatment options for women with symptomatic uterine fibroids. Women who undergo a procedure for uterine fibroids (hysterectomy, myomectomy [abdominal, hysteroscopic, vaginal, and laparoscopic/robotic], endometrial ablation, radiofrequency fibroid ablation, uterine artery embolization, magnetic resonance–guided focused ultrasound, or progestin-releasing intrauterine device insertion) at 1 of the COMPARE-UF sites are invited to participate in a prospective registry with 3 years follow up for postprocedural outcomes. Enrolled participants provide annual follow-up evaluation through an online portal or through traditional phone contact. A central data abstraction center provides information obtained from imaging, operative or procedural notes, and pathology reports. Women with uterine fibroids and other stakeholders are a key part of the COMPARE-UF registry and participate at all points from study design to dissemination of results.ResultsWe built a network of 9 clinical sites across the United States with expertise in the care of women with uterine fibroids to capture geographic, racial, ethnic, and procedural diversity. Of the initial 2031 women who were enrolled in COMPARE-UF, 42% are self-identified as black or African American, and 40% are ≤40 years old, with 16% of participants
  • Abdominal skeletal muscle activity precedes spontaneous menstrual cramping
           pain in primary dysmenorrhea
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Folabomi A. Oladosu, Frank. F. Tu, Saaniya Farhan, Ellen F. Garrison, Nicole D. Steiner, Genevieve E. Roth, Kevin M. HellmanBackgroundDysmenorrhea is a pervasive pain condition that affects 20–50% of reproductive-aged women. Distension of a visceral organ, such as the uterus, could elicit a visceromotor reflex, resulting in involuntary skeletal muscle activity and referred pain. Although referred abdominal pain mechanisms can contribute to visceral pain, the role of abdominal muscle activity has not yet been investigated within the context of menstrual pain.ObjectiveThe goal of this study was to determine whether involuntary abdominal muscle activity precedes spontaneous episodes of menstrual cramping pain in dysmenorrheic women and whether naproxen administration affects abdominal muscle activity.Study DesignAbdominal electromyography activity was recorded from women with severe dysmenorrhea (n = 38) and healthy controls (n = 10) during menses. Simultaneously, pain was measured in real time using a squeeze bulb or visual analog rheostat. Ninety minutes after naproxen administration, abdominal electromyography activity and menstrual pain were reassessed. As an additional control, women were also recorded off menses, and data were analyzed in relation to random bulb squeezes. Because it is unknown whether mechanisms of menstrual cramps are different in primary or secondary dysmenorrhea/chronic pelvic pain, the relationship between medical history and abdominal muscle activity was examined. To further examine differences in nociceptive mechanisms, pressure pain thresholds were also measured to evaluate changes in widespread pain sensitivity.ResultsAbdominal muscle activity related to random-bulb squeezing was rarely observed in healthy controls on menses (0.9 ± 0.6 episodes/hour) and in dysmenorrhea participants off menses (2.3 ± 0.6 episodes/hour). In dysmenorrheic participants during menses, abdominal muscle activity frequently preceded bulb squeezing indicative of menstrual cramping pain (10.8 ± 3.0 episodes/hour; P < .004). Whereas 45% of the women with dysmenorrhea (17 of 38) had episodes of abdominal muscle activity associated pain, only 13% (5 of 38) had episodes after naproxen (P = .011). Women with the abdominal muscle activity–associated pain were less likely to have a diagnosis for secondary dysmenorrhea or chronic pelvic pain (2 of 17) than women without this pain phenotype (10 of 21; P = .034). Similarly, women with the abdominal muscle activity–associated pain phenotype had less nonmenstrual pain days per month (0.6 ± 0.5) than women without the phenotype (12.4 ± 0.3; P = .002). Women with abdominal muscle activity–associated pain had pressure pain thresholds (22.4 ± 3.0 N) comparable with healthy controls (22.2 ± 3.0 N; P = .967). In contrast, women without abdominal muscle activity–associated pain had lower pressure pain thresholds (16.1 ± 1.9 N; P = .039).ConclusionAbdominal muscle activity may contribute to cramping pain in primary dysmenorrhea but is resolvable with naproxen. Dysmenorrheic patients without cramp-associated abdominal muscle activity exhibit widespread pain sensitivity (lower pressure pain thresholds) and are more likely to also have a chronic pain diagnosis, suggesting their cramps are linked to changes in central pain processes. This preliminary study suggests new tools to phenotype menstrual pain and supports the hypothesis that multiple distinct mechanisms may contribute to dysmenorrhea.
  • Reply
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Lindsey J. Graham, Brendan C. Graham, Carl H. Rose, Jeffrey L. Winters
  • Identification of experimental bladder sensitivity among dysmenorrhea
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Kevin M. Hellman, Avisek Datta, Nicole D. Steiner, Julia N. Kane Morlock, Ellen F. Garrison, Daniel J. Clauw, Frank F. TuBackgroundDysmenorrhea is a common risk factor for chronic pain conditions including bladder pain syndrome. Few studies have formally evaluated asymptomatic bladder pain sensitivity in dysmenorrhea, and whether this largely reflects excess pelvic symptom reporting due to comorbid psychological dysfunction.ObjectiveWe sought to determine whether bladder hypersensitivity is more common among women reporting moderate or greater dysmenorrhea, without chronic pain elsewhere, after accounting for anxiety and depression. Demonstrating this would suggest that dysmenorrhea might be an early clue for visceral or widespread pain hypersensitivity and improve understanding of potential precursors to bladder pain syndrome.Study DesignWe compared cohorts of regularly menstruating women, without symptoms of chronic pain elsewhere, reporting (1) moderate-to-severe dysmenorrhea (n = 98) and (2) low levels or no menstrual pain (n = 35). Participants underwent rapid bladder filling following a standard water ingestion protocol, serially rating bladder pain and relative urgency during subsequent distension. Potential differences in bladder volumes were controlled for by sonographic measurement at standard cystometric thresholds. Bladder sensitivity was also measured with complementary measures at other times separately including a simplified rapid filling test, palpation of the bladder wall, and through ambulatory self-report. Anxiety and depression were evaluated with the National Institutes of Health Patient-Reported Outcomes Measurement Information System measures.ResultsWomen with moderate-to-severe dysmenorrhea reported more urinary symptoms than controls and had a lower maximum capacity (498 ± 18 mL vs 619 ± 34 mL, P < .001) and more evoked bladder filling pain (0–100 visual analog scale: 25 ± 3 vs 12 ± 3, P < .001). The dysmenorrhea-bladder capacity relationship remained significant irrespective of menstrual pain severity, anxiety, depression, or bladder pain (R2 = 0.13, P = .006). Severity of menstrual pain predicted evoked bladder pain (R2 = 0.10, P = .008) independent of anxiety (P = .21) and depression (P = .21). Women with moderate-to-severe dysmenorrhea exhibiting provoked bladder pain (24/98, 24%) also reported higher pain during the screening rapid bladder test (P < .001), in response to transvaginal bladder palpation (P < .015), and on prospective daily diaries (P < .001) than women with dysmenorrhea without provoked bladder pain.ConclusionWomen experiencing moderate-to-severe dysmenorrhea also harbor a higher pain response to naturally evoked bladder distension. Noninvasive bladder provocation needs to be tested further longitudinally in those with dysmenorrhea to characterize the course of visceral sensitivity and determine if it may help predict individuals at risk for developing subsequent pain in the bladder or elsewhere.
  • Perioperative pregnancy interval, contraceptive counseling experiences,
           and contraceptive use in women undergoing bariatric surgery
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Biftu M. Mengesha, Jonathan T. Carter, Christine E. Dehlendorf, Amanda J. Rodriguez, Jody E. SteinauerBackgroundReproductive-aged women represent about half of those undergoing bariatric surgery in the United States. Obstetric and bariatric professional societies recommend that women avoid pregnancy for 12-18 months postoperatively due to concern for increased pregnancy risks, and that providers should counsel women about these recommendations and their contraceptive options. However, knowledge about women’s experience with perioperative counseling and postoperative contraceptive use is limited.ObjectiveWe sought to: (1) determine prevalence of perioperative contraceptive and pregnancy interval discussions among women who have recently undergone bariatric surgery; and (2) describe postoperative contraceptive use within the first year of surgery in this population.Study DesignWe performed a cross-sectional study of US women, aged 18-45 years and recruited through Facebook, who underwent bariatric surgery within the last 24 months.ResultsWe enrolled 363 geographically diverse women. Three-quarters recalled perioperative pregnancy or contraceptive discussions, the majority with a bariatric provider. Half felt it was “very important” to discuss these issues perioperatively, and 41% of those who reported discussions wished they had had more. Of the 66% of women who reported using contraception in the first 12 months postoperatively, 27% used oral contraceptives and 26% used an intrauterine device. One third of contraceptive users who had undergone Roux-en-Y gastric bypass, a combined restrictive-malabsorptive procedure, were using oral contraceptives. Perioperative contraceptive or pregnancy discussions were independently associated with increased postoperative contraceptive use (odds ratios, 2.5; 95% confidence interval, 1.5–4.3, P < .001).ConclusionA substantial proportion of women who had undergone bariatric surgery reported having had no perioperative pregnancy or contraception counseling, and many women who had felt the discussions were insufficient. Those who had had perioperative discussions were more likely to use contraception postoperatively. Reproductive-aged women should be routinely counseled perioperatively about pregnancy and contraception in the context of their reproductive desires, so they can make informed decisions about perioperative pregnancy prevention and contraceptive method use.
  • Universal cystoscopy at the time of benign hysterectomy: a debate
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Lisa M. Peacock, Amy Young, Rebecca G. RogersInjury to the bladder and/or ureters is the cause of significant morbidity, and efforts to reduce these injuries are important. This debate presents arguments that both support, and refute, the value of routine cystoscopy at the time of benign hysterectomy. Proponents of routine cystoscopy state that injuries are more likely to be detected and repaired when cystoscopy is routinely performed. Dissenters counter that the available evidence does not support routine cystoscopy at the current rates of lower urinary tract injury, and the cystoscopy should be performed only when injury is suspected or when performing hysterectomy with concurrent procedures that increase the risk of lower urinary tract injury.
  • Antenatal corticosteroids: an assessment of anticipated benefits and
           potential risks
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Alan H. Jobe, Robert L. GoldenbergAntenatal corticosteroids are standard of care for pregnancies at risk of preterm delivery between 24-34 weeks’ gestational age. Recent trials demonstrate modest benefits from antenatal corticosteroids for late preterm and elective cesarean deliveries, and antenatal corticosteroids for periviable deliveries should be considered with family discussion. However, many women with threatened preterm deliveries receive antenatal corticosteroids but do not deliver until>34 weeks or at term. The net effect is that a substantial fraction of the delivery population will be exposed to antenatal corticosteroids. There are gaps in accurate assessments of benefits of antenatal corticosteroids because the randomized controlled trials were performed prior to about 1990 in pregnancies generally>28 weeks. The care practices for the mother and infant survival were different than today. The randomized controlled trial data also do not strongly support the optimal interval from antenatal corticosteroid treatment to delivery of 1-7 days. Epidemiology-based studies using large cohorts with>85% of at-risk pregnancies treated with antenatal corticosteroids probably overestimate the benefits of antenatal corticosteroids. Although most of the prematurity-associated mortality is in low-resource environments, the efficacy and safety of antenatal corticosteroids in those environments remain to be evaluated. The short-term benefits of antenatal corticosteroids for high-risk pregnancies in high-resource environments certainly justify antenatal corticosteroids as few risks have been identified over many years. However, cardiovascular and metabolic abnormalities have been identified in large animal models and cohorts of children exposed to antenatal corticosteroids that are consistent with fetal programming for adult diseases. These late effects of antenatal corticosteroids suggest caution for the expanded use of antenatal corticosteroids beyond at-risk pregnancies at 24-34 weeks. A way forward is to develop noninvasive fetal assessments to identify pregnancies across a wider gestational age that could benefit from antenatal corticosteroids.
  • Diagnosis and treatment of urinary tract infections across age groups
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Christine M. Chu, Jerry L. LowderUrinary tract infections are the most common outpatient infections, but predicting the probability of urinary tract infections through symptoms and test results can be complex. The most diagnostic symptoms of urinary tract infections include change in frequency, dysuria, urgency, and presence or absence of vaginal discharge, but urinary tract infections may present differently in older women. Dipstick urinalysis is popular for its availability and usefulness, but results must be interpreted in context of the patient’s pretest probability based on symptoms and characteristics. In patients with a high probability of urinary tract infection based on symptoms, negative dipstick urinalysis does not rule out urinary tract infection. Nitrites are likely more sensitive and specific than other dipstick components for urinary tract infection, particularly in the elderly. Positive dipstick testing is likely specific for asymptomatic bacteriuria in pregnancy, but urine culture is still the test of choice. Microscopic urinalysis is likely comparable to dipstick urinalysis as a screening test. Bacteriuria is more specific and sensitive than pyuria for detecting urinary tract infection, even in older women and during pregnancy. Pyuria is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms such as incontinence. Positive testing may increase the probability of urinary tract infection, but initiation of treatment should take into account risk of urinary tract infection based on symptoms as well. In cases in which the probability of urinary tract infection is moderate or unclear, urine culture should be performed. Urine culture is the gold standard for detection of urinary tract infection. However, asymptomatic bacteriuria is common, particularly in older women, and should not be treated with antibiotics. Conversely, in symptomatic women, even growth as low as 102 colony-forming unit/mL could reflect infection. Resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole. Most uropathogens still display good sensitivity to nitrofurantoin. First-line treatments for urinary tract infection include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are
  • Vaginal progesterone is as effective as cervical cerclage to prevent
           preterm birth in women with a singleton gestation, previous spontaneous
           preterm birth, and a short cervix: updated indirect comparison
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Agustin Conde-Agudelo, Roberto Romero, Eduardo Da Fonseca, John M. O’Brien, Elcin Cetingoz, George W. Creasy, Sonia S. Hassan, Offer Erez, Percy Pacora, Kypros H. NicolaidesBackgroundAn indirect comparison meta-analysis published in 2013 reported that both vaginal progesterone and cerclage are equally efficacious for preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic short cervix. The efficacy of vaginal progesterone has been challenged after publication of the OPPTIMUM study. However, this has been resolved by an individual patient-data meta-analysis (Am J Obstet Gynecol. 2018;218:161-180).ObjectiveTo compare the efficacy of vaginal progesterone and cerclage in preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix.Data SourcesMEDLINE, EMBASE, LILACS, and CINAHL (from their inception to March 2018); Cochrane databases, bibliographies, and conference proceedings.Study Eligibility CriteriaRandomized controlled trials comparing vaginal progesterone to placebo/no treatment or cerclage to no cerclage in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic cervical length
  • Vaginal progesterone is an alternative to cervical cerclage in women with
           a short cervix and a history of preterm birth
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Luis Sanchez-Ramos
  • The 10-Group Classification System–a new way of thinking
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Michael S. Robson
  • Information for Readers
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s):
  • SMFM Divider Page
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s):
  • Mild fetal ventriculomegaly: diagnosis, evaluation, and management
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Society for Maternal-Fetal Medicine (SMFM);, Nathan S. Fox, Ana Monteagudo, Jeffrey A. Kuller, Sabrina Craigo, Mary E. NortonVentriculomegaly is defined as dilation of the fetal cerebral ventricles and is a relatively common finding on prenatal ultrasound. The purpose of this document is to review the diagnosis, evaluation, and management of mild fetal ventriculomegaly. When enlargement of the lateral ventricles (≥10 mm) is identified, a thorough evaluation should be performed, including detailed sonographic evaluation of fetal anatomy, amniocentesis for karyotype and chromosomal microarray analysis, and a workup for fetal infection. In some cases, fetal magnetic resonance imaging may identify other central nervous system abnormalities and should be considered when this technology as well as expert interpretation is available. Follow-up ultrasound examination should be performed to assess for progression of the ventricular dilation. In the setting of isolated ventriculomegaly of 10–12 mm, the likelihood of survival with normal neurodevelopment is>90%. With moderate ventriculomegaly (13–15 mm), the likelihood of normal neurodevelopment is 75–93%. The following are Society for Maternal-Fetal Medicine recommendations: We suggest that ventriculomegaly be characterized as mild (10–12 mm), moderate (13–15 mm), or severe (>15 mm) for the purposes of patient counseling, given that the chance of an adverse outcome and potential for other abnormalities are higher when the ventricles measure 13–15 mm vs 10–12 mm (GRADE 2B); we recommend that diagnostic testing (amniocentesis) with chromosomal microarray analysis should be offered when ventriculomegaly is detected (GRADE 1B); we recommend testing for cytomegalovirus and toxoplasmosis when ventriculomegaly is detected, regardless of known exposure or symptoms (GRADE 1B); we suggest that magnetic resonance imaging be considered in cases of mild or moderate fetal ventriculomegaly when this modality and expert radiologic interpretation are available; magnetic resonance imaging is likely to be of less value if the patient has had a detailed ultrasound performed by an individual with specific experience and expertise in sonographic imaging of the fetal brain (GRADE 2B); we recommend that timing and mode of delivery be based on standard obstetric indications (GRADE 1C); we recommend that with isolated mild ventriculomegaly of 10–12 mm, after a complete evaluation, women be counseled that the outcome is favorable, and the infant is likely to be normal (GRADE 1B); we recommend that with isolated moderate ventriculomegaly of 13–15 mm, after a complete evaluation, women be counseled that the outcome is likely to be favorable but that there is an increased risk of neurodevelopmental disabilities (GRADE 1B).
  • How shall we transfuse Hippolyta' The same way whether on or off the
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Mark H. Yazer, Shawn C. Nessen, Andrew P. Cap
  • Reply
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Alison Paquette, Nathan D. Price, Stephen J. Lye
  • The preterm labor associated ADAMTS2 gene is induced by
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Alasdair W. Jubb, Thomas P. Hofer, David A. Hume, Loems Ziegler-Heitbrock
  • Genitourinary syndrome of menopause: corrections and comments by a
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Karen L. Miller
  • Reply
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Spencer G. Kuper, Alan T. Tita
  • Prevention of adverse pulmonary, neurological, and ocular perinatal
           outcomes by supplementing omega-3 fatty acids during pregnancy
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Lorenzo Ferro Desideri, Fabio Barra, Simone Ferrero
  • Reply
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Maria P. Ruiz, Yongmei Huang, Cande V. Ananth, Jason D. Wright
  • All-cause death in young women with endometrial cancer who receive
           progesterone therapy
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Andreas Obermair, Monika Janda, Val Gebski
  • Optimal aspirin dosing for preeclampsia prevention
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Anna Lene Seidler, Lisa Askie, Joel G. Ray
  • Placenta increta after high-intensity-focused ultrasound for the treatment
           of a uterine leiomyoma
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Chin-Ru Ker, Cheng-Yu Long, Ching-Ju Shen
  • Maternal pomegranate juice attenuates maternal inflammation–induced
           fetal brain injury by inhibition of apoptosis, neuronal nitric oxide
           synthase, and NF-κB in a rat model
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Yuval Ginsberg, Nizar Khatib, Noor Saadi, Michael G. Ross, Zeev Weiner, Ron BelooseskyBackgroundMaternal inflammation is a risk factor for neonatal brain injury and future neurological deficits. Pomegranates have been shown to exhibit anti-inflammatory, anti-apoptotic and anti-oxidant activities.ObjectiveWe hypothesized that pomegranate juice (POM) may attenuate fetal brain injury in a rat model of maternal inflammation.Study DesignPregnant rats (24 total) were randomized for intraperitoneal lipopolysaccharide (100 μg/kg) or saline at time 0 at 18 days of gestation. From day 11 of gestation, 12 dams were provided ad libitum access to drinking water, and 12 dams were provided ad libitum access to drinking water with pomegranate juice (5 mL per day), resulting in 4 groups of 6 dams (saline/saline, pomegranate juice/saline, saline/lipopolysaccharide, pomegranate juice/lipopolysaccharide). All dams were sacrificed 4 hours following the injection and maternal blood and fetal brains were collected from the 4 treatment groups. Maternal interleukin-6 serum levels and fetal brain caspase 3 active form, nuclear factor-κB p65, neuronal nitric oxide synthase (phosphoneuronal nitric oxide synthase), and proinflammatory cytokine levels were determined by enzyme-linked immunosorbent assay and Western blot.ResultsMaternal lipopolysaccharide significantly increased maternal serum interleukin-6 levels (6039 ± 1039 vs 66 ± 46 pg/mL; P < .05) and fetal brain caspase 3 active form, nuclear factor-κB p65, phosphoneuronal nitric oxide synthase, and the proinflammatory cytokines compared to the control group (caspase 3 active form 0.26 ± 0.01 vs 0.20 ± 0.01 U; nuclear factor-κB p65 0.24 ± 0.01 vs 0.1 ± 0.01 U; phosphoneuronal nitric oxide synthase 0.23 ± 0.01 vs 0.11 ± 0.01 U; interleukin-6 0.25 ± 0.01 vs 0.09 ± 0.01 U; tumor necrosis factor-α 0.26 ± 0.01 vs 0.12 ± 0.01 U; chemokine (C-C motif) ligand 2 0.23 ± 0.01 vs 0.1 ± 0.01 U). Maternal supplementation of pomegranate juice to lipopolysaccharide-exposed dams (pomegranate juice/lipopolysaccharide) significantly reduced maternal serum interleukin-6 levels (3059 ± 1121 pg/mL, fetal brain: caspase 3 active form (0.2 ± 0.01 U), nuclear factor-κB p65 (0.22 ± 0.01 U), phosphoneuronal nitric oxide synthase (0.19 ± 0.01 U) as well as the brain proinflammatory cytokines (interleukin-6, tumor necrosis factor-α and chemokine [C-C motif] ligand 2) compared to lipopolysaccharide group.ConclusionMaternal pomegranate juice supplementation may attenuate maternal inflammation–induced fetal brain injury. Pomegranate juice neuroprotective effects might be secondary to the suppression of both the maternal inflammatory response and inhibition of fetal brain apoptosis, neuronal nitric oxide synthase, and nuclear factor-κB activation.
  • Abortion training in US obstetrics and gynecology residency programs
    • Abstract: Publication date: July 2018Source: American Journal of Obstetrics and Gynecology, Volume 219, Issue 1Author(s): Jody E. Steinauer, Jema K. Turk, Tali Pomerantz, Kristin Simonson, Lee A. Learman, Uta LandyBackgroundNearly 15 years ago, 51% of US obstetrics and gynecology residency training program directors reported that abortion training was routine, 39% reported training was optional, and 10% did not have training. The status of abortion training now is unknown.ObjectiveWe sought to determine the current status of abortion training in obstetrics and gynecology residency programs.Study DesignThrough surveying program directors of US obstetrics and gynecology residency training programs, we conducted a cross-sectional study on the availability and characteristics of abortion training. Training was defined as routine if included in residents’ schedules with individuals permitted to opt out, optional as not in the residents’ schedules but available for individuals to arrange, and not available. Findings were compared between types of programs using bivariate analyses.ResultsIn all, 190 residency program directors (79%) responded. A total of 64% reported routine training with dedicated time, 31% optional, and 5% not available. Routine, scheduled training was correlated with higher median numbers of uterine evacuation procedures. While the majority believed their graduates to be competent in first-trimester aspiration (71%), medication abortion (66%), and induction termination (67%), only 22% thought graduates were competent in dilation and evacuation. Abortion procedures varied by clinical indication, with some programs limiting cases to pregnancy complication, fetal anomaly, or demise.ConclusionAbortion training in obstetrics and gynecology residency training programs has increased since 2004, yet many programs graduate residents without sufficient training to provide abortions for any indication, as well as dilation and evacuation. Professional training standards and support for family planning training have coincided with improved training, but there are still barriers to understand and overcome.
  • Association between depression, symptom experience and quality of life in
           polycystic ovary syndrome
    • Abstract: Publication date: Available online 30 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Eleni A. Greenwood, Lauri A. Pasch, Marcelle I. Cedars, Richard S. Legro, Heather G. Huddleston, NICHD Reproductive Medicine NetworkStructured BackgroundClinical stigmata of polycystic ovary syndrome include hirsutism, obesity, menstrual disturbances and infertility. These symptoms impair health-related quality of life. Depression is also common. The relationship between depression, symptom self-perception and quality of life in polycystic ovary syndrome is poorly understood.ObjectiveTo investigate the relationship between health-related quality of life and depression in women with polycystic ovary syndromeStudy DesignWe conducted a secondary analysis of a multicenter, randomized clinical trial (Pregnancy in Polycystic Ovary Syndrome II, NCT00719186) comparing clomiphene citrate versus letrozole in the treatment of infertility. Subjects included 732 women ages 18-40 with polycystic ovary syndrome by modified Rotterdam criteria. The validated Polycystic Ovary Syndrome Health-Related Quality of Life survey was self-administered, assessing the following domains: emotions, body hair, body weight, menstrual problems and infertility; scores range from 1-7, with lower numbers indicating poorer quality of life. Depression was evaluated via the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire. Quality of life scores were compared between Depressed and Non-depressed women in unadjusted regression analyses. Multivariate linear regression models analyzed the association between depression and quality of life scores, controlling for age, body mass index, hirsutism score and duration of infertility.ResultsSixty-four women (8.4%) met criteria for depression. Depressed women reported reduced quality of life in all domains compared to Non-depressed women: mood (3.1 vs 4.6, p
  • A Cautionary Response to SMFM Statement: Pharmacological Treatment of
           Gestational Diabetes
    • Abstract: Publication date: Available online 28 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Linda A. Barbour, Christina Scifres, Amy M. Valent, Jacob E. Friedman, Thomas Buchanan, Donald Coustan, Kjersti Aagaard, Kent L. Thornburg, Patrick M. Catalano, Henry Galan, William W. Hay, Antonio E. Frias, Kartik Shankar, Rebecca A. Simmons, Robert G. Moses, David A. Sacks, Mary R. Loeken Use of oral agents to treat gestational diabetes mellitus (GDM) remains controversial. Recent recommendations from the Society for Maternal Fetal Medicine (SMFM) assert that metformin may be a safe first line alternative to insulin for GDM 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 GDM or polycystic ovary syndrome (PCOS) 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 SMFM statement endorsed metformin over glyburide if oral agents are used, there are few studies directly comparing the two 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 (ADA) and American College of Obstetricians and Gynecologists (ACOG), who 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.
  • Physical examination techniques for the assessment of pelvic floor
           myofascial pain: a systematic review
    • Abstract: Publication date: Available online 28 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Melanie R. Meister, Nishkala Shivakumar, Siobhan Sutcliffe, Theresa Spitznagle, Jerry Lowder BackgroundMyofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles in men and women. Pelvic floor myofascial pain in the absence of local or referred pain has also been observed in patients with lower urinary tract symptoms (LUTS), and we have found that many patients report an improvement in these symptoms after receiving myofascial-targeted pelvic floor physical therapy.ObjectiveTo systematically review the literature for examination techniques used to assess pelvic floor myofascial pain in women.Study DesignWe performed a systematic literature search using strategies for the concepts of pelvic floor disorders, myofascial pain, and diagnosis in Ovid Medline 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Database of s of Reviews of Effects, and Cochrane Database of Systematic Reviews. Articles were screened by three authors and included if they contained a description of a pelvic myofascial physical examination.ResultsFifty-five studies met our inclusion criteria. Overall, examination components varied significantly among the included studies and were frequently undefined. A consensus examination guideline was developed based on the available data and includes use of a single digit (62%, 34/55) to perform transvaginal palpation (75%, 41/55) of the levator ani (LA; 87%, 48/55) and obturator internus (OI; 45%, 25/55) muscles with a patient-reported scale to assess the level of pain to palpation (51%, 28/55).ConclusionsPhysical examination methods to evaluate pelvic musculature for presence of myofascial pain varied significantly and were often undefined. Given the known role of pelvic floor myofascial pain in chronic pelvic pain and link between pelvic floor myofascial pain and lower urinary tract symptoms, physicians should be trained to evaluate for pelvic floor myofascial pain as part of their physical examination in patients presenting with these complaints. Therefore, the development and standardization of a reliable and reproducible examination is needed.
  • Changes in the burnout profile of chairs of academic departments of
           obstetrics and gynecology over the past 15 years
    • Abstract: Publication date: Available online 28 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Steven G. Gabbe, Monica Hagan Vetter, Michelle C. Nguyen, Susan Moffatt-Bruce, Jeffrey M. Fowler BackgroundWhile many studies have documented the high prevalence of burnout in practicing physicians and medical trainees, fewer reports describe burnout in academic leaders. In 2002, we observed a moderate-high to high level of burnout in 42.9% of chairs of academic departments of obstetrics and gynecology.ObjectiveThe purpose of this study was to identify trends in burnout and associated factors in today’s OB/GYN chairs as they face complex changes to the current health care environment.Study DesignThis was a cross-sectional study. A survey was developed based on the questionnaire used in our first investigation and sent electronically to all members of the Council of University Chairs of Obstetrics and Gynecology. Burnout was measured using an abbreviated Maslach Burnout Inventory-Human Sciences Survey. In addition to demographic data, we assessed perceived stressors, job satisfaction, spousal/partner support, self-efficacy, depression, suicidal ideation, and stress management.ResultsThe response rate was 60% (84/139). Almost 30% of chairs were women, increased from 7.6% in 2002. Hospital and department budget deficits and loss of key faculty remain major stressors noted by participants. The Maslach Burnout Inventory results have changed dramatically over the past 15 years. Today’s chairs demonstrated less burnout but with an “ineffective” profile. Subscale scores for emotional exhaustion and depersonalization were reduced but over 50% reported low personal accomplishment. Spousal support remained important in preventing burnout.ConclusionsChairs of academic departments of obstetrics and gynecology continue to face significant job-related stress. Burnout has decreased; however, personal accomplishment scores have also declined most likely due to administrative factors which are beyond the chairs’ perceived control.
  • Implementation of an Urogynecology-Specific Enhanced Recovery After
           Surgery (ERAS) Pathway
    • Abstract: Publication date: Available online 18 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Charelle M. Carter-Brooks, Angela L. Du, Kristine M. Ruppert, Anna L. Romanova, Halina M. Zyczynski ObjectivesERAS protocols were developed for colorectal surgery to hasten post-op recovery. Variations of the protocol are being adopted for gynecologic procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate if implementation of an ERAS pathway would facilitate reduced length of admission in an urogynecology population.Materials and MethodsIn this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons we compared same day discharge, length of admission and post-op complications before and after implementation of an ERAS pathway at a tertiary-care hospital. Groups were compared using χ2 and t-tests. Candidate variables that could impact patient outcomes with p < .2 were included in multivariable logistic regression models. Satisfaction with surgical experience was assessed using a phone administered questionnaire the day after discharge.ResultsMean age and BMI of 258 women (137 pre-ERAS and 121 ERAS) were 65.5±11.3 years and 28.2±5.0 kg/m2. The most common diagnosis was pelvic organ prolapse (n=242, 93.8%) including stage III POP (n=61, 65.1%). Apical suspension procedures included: 58 (25.1%) transvaginal, 112 (48.8%) laparoscopic/robotic and 61 (26.4%) obliterative. Hysterectomy was performed in 57.4% of women. Demographic and surgical procedures were similar in both groups. Compared to pre-ERAS, the ERAS group had a higher proportion of same day discharge (25.9% vs 91.7%, p
  • Low dose aspirin is associated with reduced spontaneous preterm birth in
           nulliparous women
    • Abstract: Publication date: Available online 18 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Maria Andrikopoulou, Stephanie E. Purisch, Roxane Handal-Orefice, Cynthia Gyamfi-Bannerman BackgroundPreterm birth (PTB) is one of the leading causes of perinatal morbidity and mortality. Clinical data suggests that low dose aspirin may decrease the rate of overall PTB, but investigators have speculated that this is likely due to a decrease in medically indicated PTB through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low dose aspirin may also impact the mechanism of spontaneous preterm labor.ObjectiveOur objective was to determine whether low dose aspirin reduces the rate of spontaneous PTB in nulliparous women without medical co-morbidities.Study DesignThis is a secondary analysis of a randomized, placebo-controlled trial of low dose aspirin for 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, non-anomalous gestations. Women were eligible if they had prior pregnancy terminations, but not prior spontaneous pregnancy loss
  • Randomized Controlled Trial of Belladonna and Opiate Suppository during
           Intravesical Onabotulinum Toxin A Injection
    • Abstract: Publication date: Available online 11 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Edgar L. Leclaire, Jennifer Duong, Rachel M. Wykes, Kevin E. Miller, Tessa L. Winterton, Milan BimaliStructured BackgroundIntravesical injection with onabotulinum toxin A (BTX-A) injection can be performed in-office under local anesthesia. Rectally administered pain medication presents a potentially feasible and previously uninvestigated adjunct to office-based anesthesia protocols.ObjectivesThe primary aim of this study was to determine whether adding a belladonna and opiate (BO) suppository to standard lidocaine instillation resulted in reduction of bladder injection pain during BTX-A injection procedure.Study DesignThis was a prospective, randomized, double-blind, placebo-controlled study of patients undergoing BTX-A bladder injection at a single clinic. Patients 18 years or older, met clinical criteria for invasive treatment of refractory urinary symptoms, had previously documented post-void residual (PVR) volumes less than 150ml, and elected for in-office intravesical BTX-A injection were eligible to participate. Participants were randomized by computer generated block randomization to receive a BO (belladonna alkaloid with morphine 16.2/7.5mg) or placebo suppository. Suppositories were placed immediately prior to lidocaine-based anesthesia, which all participants received. All participants underwent a standardized injection procedure using the same rigid cystoscope, needle type, and injection pattern (20 injections total). A 0-10 numeric rating scale was used to assess pain intensity before anesthesia and suppository (P0), 40 minutes after administration of anesthesia and suppository (PA), after first 10 bladder injections (P10), and immediately after completion of 20 injections (P20). Pain increase during procedure was calculated using the difference between PA and P10. PVR were measured immediately post-procedure and two weeks later. Patient satisfaction with pain control was measured using a Likert scale. Our primary outcome was change in pain level from anesthetic baseline to mid-procedure (P10-PA). A final sample size of 26 patients was needed to have 80% power (alpha = 0.05) to detect a 50% reduction in bladder injection pain during the procedure as defined by our primary outcome. An intent-to-treat approach was used for all analyses.ResultsTwenty-six participants were enrolled and randomized with 13 in each study arm. Participants in the treatment group were slightly older than in the placebo group (p=0.05); there were no statistically significant differences in medical comorbidities. Median P10-PA for the placebo group and treatment group was 4 (range 1,10) and 5 (range 0,9), respectively (p=0.94). Median P20 scores for the placebo group and treatment group were 3 (range 0,10) and 2 (range 0,8), respectively (p=0.29). There were no significant differences in pre-injection pain scores reported at P0 and PA. Post-procedure PVR greater than 200ml was noted in 5 (38%) of the placebo group and 3 (23%) of the treatment group (p=0.67). Two week post-procedure PVR greater than 200ml was noted in 3 (25%) of the placebo group and 2 (15%) of the treatment group (p=0.64) for an overall rate of 20%. Eleven (84%) participants in each group reported being “mostly satisfied” or “very much satisfied” with pain control.ConclusionsBO suppository use did not significantly reduce bladder injection pain, or increase risk of urinary retention immediately post-procedure or two weeks later. Satisfaction with pain control among BTX-A injection patients is high.
  • Timing of Gestational Exposure to Zika Virus is Associated with Postnatal
           Growth Restriction in a Murine Model
    • Abstract: Publication date: Available online 11 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(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. Aagaard BackgroundVertical transmission of Zika virus (ZIKV) 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 ZIKV infection may only become clinically apparent in the postnatal period.ObjectivesWe sought to develop an outbred mouse model of ZIKV vertical transmission to determine if the timing of gestational ZIKV exposure yields phenotypic differences at birth and through adolescence. We hypothesized that later gestational inoculations would only become apparent in adolescence.MethodsTo better recapitulate human exposures, timed pregnant Swiss-Webster dams (n=15) were subcutaneously inoculated with 1x104 PFU of first passage contemporary ZIKV HN16 strain or a mock injection on embryonic day 4, 8, or 12 with bioactive anti-interferon 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 ZIKV infection. At birth and adolescence (6 weeks of age) offspring were assessed for growth, brain weight and biparietal head diameters (BPD), and ZIKV viral levels by RT-PCR or in situ hybridization.ResultsPups of ZIKV-infected dams infected at e4 and e8 but not e12 were growth restricted (p
  • Postponing Early intrauterine Transfusion with Intravenous immunoglobulin
           Treatment; the PETIT study on severe hemolytic disease of the fetus and
    • Abstract: Publication date: Available online 11 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Carolien Zwiers, Johanna G. van der Bom, Inge L. van Kamp, Nan Van Geloven, Enrico Lopriore, John Smoleniec, Roland Devlieger, Pauline E. Sim, Marie Anne Ledingham, Eleonor Tiblad, Kenneth J. Moise, Karl-Philip Gloning, Mark D. Kilby, Timothy G. Overton, Ditte S. Jørgensen, Katrine V. Schou, Bettina Paek, Martin Walker, Emma Parry, Dick Oepkes BackgroundIntrauterine transfusion for severe alloimmunization in pregnancy performed before 20 weeks’ gestation is associated with a higher fetal death rate. Intravenous immunoglobulins may prevent hemolysis and could therefore be a non-invasive alternative for early transfusions.Objective(s): We evaluated whether maternal treatment with intravenous immunoglobulins defers the development of severe fetal anemia and its consequences in a retrospective cohort to which 12 fetal therapy centers contributed.Study DesignWe included consecutive pregnancies of alloimmunized women with a history of severe hemolytic disease and by propensity analysis compared index pregnancies treated with intravenous immunoglobulins (n=24) with pregnancies managed without intravenous immunoglobulins (n=28),.ResultsIn index pregnancies with intravenous immunoglobulin treatment, fetal anemia developed on average 15 days later compared to previous pregnancies (8% less often before 20 weeks’ gestation). In pregnancies without intravenous immunoglobulin treatment anemia developed 9 days earlier compared to previous pregnancies (10% more before 20 weeks), an adjusted 4-day between-group difference in favor of the immunoglobulin group (95%CI -10 to 18, P=.564). In the subcohort in which immunoglobulin treatment was started before 13 weeks, anemia developed 25 days later and 31% less before 20 weeks’ gestation (54% compared to 23%) than in the previous pregnancy. Fetal hydrops occurred in 4% of immunoglobulin-treated pregnancies and in 24% of those without intravenous immunoglobulin treatment (OR 0.03, 95%CI 0 to 0.5, P=.011). Exchange transfusions were given to 9% of neonates born from pregnancies with and in 37% without immunoglobulin treatment (OR 0.1, 95%CI 0 to 0.5, P=.009).Conclusion(s)Intravenous immunoglobulin treatment in mothers pregnant with a fetus at risk for hemolytic disease seems to have a potential clinically relevant, beneficial effect on the course and severity of the disease. Confirmation in a multicenter randomized trial is needed.
  • Use of non-steroidal anti-inflammatory drugs during pregnancy and the risk
           of miscarriage
    • Abstract: Publication date: Available online 8 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): De-Kun LI, Jeannette R. Ferber, Roxana Odouli, Charles Quesenberry BackgroundNon-steroidal anti-inflammatory drugs (NSAIDs) remain one of the medications most widely used by pregnant women, and previous studies reported an increased risk of miscarriage associated with NSAID use during pregnancy. Although the findings have not always been consistent, there is a well-established mechanism for the association: NSAIDs inhibit the production of prostaglandin, which is essential for successful embryonic implantation. Abnormal implantation increases the risk of miscarriage.ObjectivesTo examine the impact of NSAID use in early pregnancy on the risk of miscarriage, especially regarding the timing and duration of use.Study DesignWe conducted a cohort study among pregnant members of Kaiser Permanente Northern California (KPNC), an integrated health care delivery system. Pregnant KPNC members (N=1,097) were recruited very early in pregnancy (median gestational age at enrollment was 39 days) to achieve optimal ascertainment of miscarriage, including early miscarriages, which are often missed in studies of miscarriages. Based on use of NSAIDs and acetaminophen, which has similar indication as NSAIDs, three cohorts were formed: women who used NSAIDs only, women who used acetaminophen only (to control for indication) and women who used neither NSAIDs nor acetaminophen (unexposed controls). Among all eligible women contacted, 63% participated in the study. Miscarriages were ascertained from both electronic medical record data and directly from interviews with participants. The Cox proportional hazards model with accommodation for left truncation was used to examine the risk of miscarriage associated with use of NSAIDs and acetaminophen during pregnancy while controlling for potential confounders.ResultsAfter adjusting for multiple confounders including maternal age, previous miscarriage, multivitamin use, caffeine drinking and smoking during pregnancy, NSAID use during pregnancy was associated with a statistically significant increased risk of miscarriage compared to both unexposed controls (adjusted hazard ratio (aHR)=1.59, 95% confidence interval (CI): 1.13 to 2.24) and acetaminophen users (indication controls) (aHR=1.45, 95% CI: 1.01 to 2.08). The risk was largely due to NSAID use around conception (aHR=1.89, 95% CI: 1.31 to 2.71) with a statistically significant dose-response relationship: aHR=1.37 (95% CI: 0.70 to 2.71) for NSAID use of 14 days or less, and aHR=1.85 (95% CI: 1.24 to 2.78) for NSAID use of 15 days or more. The association was stronger for early miscarriage (
  • Application of a preeclampsia screening algorithm in a low-risk
           nulliparous population
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Fionnuala Mone, Fergal D. Malone, Fionnuala M. Mcauliffe
  • Utilization of Ovarian Transposition for Fertility Preservation among
           Young Women with Pelvic Malignancies Who Undergo Radiotherapy
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Jessica Selter, Yongmei Huang, Lisa C. Grossman Becht, Cande V. Ananth, Alfred I. Neugut, Dawn L. Hershman, Jason D. Wright
  • Letter to the editor
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): T.K.J. Groenhof, W. Ganzevoort, A.T. Lely
  • Uterine arteriolar injuries in chronic hypertension
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Mj Quinn
  • Is fetal heart rate “deceleration-area” the silver bullet for
           detection of acidemia'
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Shashikant L. Sholapurkar
  • Reply
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Samuel Parry
  • Uterine artery Doppler studies in the early second trimester to predict
           abnormal pregnancy outcome in nulliparous women
    • Abstract: Publication date: Available online 6 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Roger A. Mcmaster-Fay, Jonathan A. Hyett
  • Six-month expulsion of postplacental copper intrauterine devices placed
           after vaginal delivery
    • Abstract: Publication date: Available online 2 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Elizabeth P. Gurney, Sarita Sonalkar, Arden Mcallister, Mary D. Sammel, Courtney A. Schreiber BackgroundImmediate placement of an intrauterine device (IUD) after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited.ObjectivesTo determine the proportion of TCu380A (copper) IUDs devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum. To determine risk factors for expulsion and partial expulsion.Study DesignIn this prospective, observational study, women who received a postplacental TCu380A IUD at vaginal delivery were enrolled postpartum. Participants returned for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded IUD outcomes and 6-month contraceptive use. Partial expulsion was defined as an IUD protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the IUD below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver-operating characteristics (ROC) curve was used to assess the ability of a string check to predict the correct placement of a postplacental IUD. The primary outcome was the proportion of IUDs expelled at 6 months.ResultsWe enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%, 95% CI 4.7%-13.4%), experienced complete expulsion and 26 (16.0%, 95% CI 11.1%-22.6%) partial expulsion (see Figure 1). Of 25 malpositioned IUDs (15.4%, 95% CI 10.2%-21.9%), 14 were not at the fundus (8.6%, 95% CI 5.2%-14.1%) and 11 were rotated within the uterus (6.8%, 95% CI 3.8%-11.9%). Multinomial logistic regression modeling indicated that higher parity (OR 2.05; 95% CI 1.21-3.50, p=0.008) was associated with expulsion. Provider specialty (Obstetrics vs. Family Medicine; OR 5.31, 95% CI 1.20-23.59; p=0.03) and gestational weight gain (normal vs. excess; OR 9.12, 95% CI 1.90-43.82; p=0.004) were associated with partial expulsion. Long-acting reversible contraceptive method use at 6 months was 80.9% (95% CI 74.0%-86.6%).At 6 weeks postpartum, 35 of 149 (23.5%, 95% CI 16.9%-31.1%) participants had no IUD strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the ROC curve of 0.5.ConclusionThis prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality.The proportion of partially expelled and malpositioned IUDs was high, and the area under the ROC curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental IUD should be counseled about the risk of position abnormalities, as well as the possibility of non-visible strings, which may complicate clinical follow-up. The clinical significance of IUD position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects.
  • A prospective cohort study of meat and fish consumption and endometriosis
    • Abstract: Publication date: Available online 2 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Ayae Yamamoto, Holly R. Harris, Allison F. Vitonis, Jorge E. Chavarro, Stacey A. Missmer BackgroundOnly two case-control studies have examined the associations between consumption of meat products and endometriosis risk with inconsistent results. Consumption of animal products has the potential to influence endometriosis risk through effects on steroid hormones levels.ObjectivesTo determine whether higher intake of red meat, poultry, fish, and seafood are associated with risk of laparoscopically-confirmed endometriosisStudy Design81,908 participants of the prospective Nurses’ Health Study II were followed from 1991-2013. Diet was assessed via food frequency questionnaire every 4 years. Cox proportional hazards models were used to calculate rate ratios (RR) and 95% confidence intervals (CIs).ResultsDuring 1,019,294 person-years of follow-up, 3,800 cases of incident laparoscopically-confirmed endometriosis were reported. Women consuming>2 servings/day of red meat/day had a 56% higher risk in endometriosis (95% CI=1.22-1.99; Ptrend
  • Human term amniotic fluid: A novel source of stem cells for regenerative
    • Abstract: Publication date: Available online 2 June 2018Source: American Journal of Obstetrics and GynecologyAuthor(s): Cara D. Dolin, Michael K. Chan, Ross S. Basch, Bruce K. Young
  • Liposomal bupivacaine to improve pain after retropubic sling placement
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Mark C. Kendall, Lucas J. Castro-Alves
  • Reply
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Ulla Sovio, Gordon C.S. Smith
  • Reply
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Donna Mazloomdoost, Rachel N. Pauls, Catrina C. Crisp
  • The diagnosis of chronic endometritis in infertile asymptomatic women: a
           comparative study of histology, microbial cultures, hysteroscopy, and
           molecular microbiology
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Inmaculada Moreno, Ettore Cicinelli, Iolanda Garcia-Grau, Marta Gonzalez-Monfort, Davide Bau, Felipe Vilella, Dominique De Ziegler, Leonardo Resta, Diana Valbuena, Carlos SimonBackgroundChronic endometritis is a persistent inflammation of the endometrial mucosa caused by bacterial pathogens such as Enterobacteriaceae, Enterococcus, Streptococcus, Staphylococcus, Mycoplasma, and Ureaplasma. Although chronic endometritis can be asymptomatic, it is found in up to 40% of infertile patients and is responsible for repeated implantation failure and recurrent miscarriage. Diagnosis of chronic endometritis is based on hysteroscopy of the uterine cavity, endometrial biopsy with plasma cells being identified histologically, while specific treatment is determined based on microbial culture. However, not all microorganisms implicated are easily or readily culturable needing a turnaround time of up to 1 week.ObjectiveWe sought to develop a molecular diagnostic tool for chronic endometritis based on real-time polymerase chain reaction equivalent to using the 3 classic methods together, overcoming the bias of using any of them alone.Study DesignEndometrial samples from patients assessed for chronic endometritis (n = 113) using at least 1 or several conventional diagnostic methods namely histology, hysteroscopy, and/or microbial culture, were blindly evaluated by real-time polymerase chain reaction for the presence of 9 chronic endometritis pathogens: Chlamydia trachomatis, Enterococcus, Escherichia coli, Gardnerella vaginalis, Klebsiella pneumoniae, Mycoplasma hominis, Neisseria gonorrhoeae, Staphylococcus, and Streptococcus. The sensitivity and specificity of the molecular analysis vs the classic diagnostic techniques were compared in the 65 patients assessed by all 3 recognized classic methods.ResultsThe molecular method showed concordant results with histological diagnosis in 30 samples (14 double positive and 16 double negative) with a matching accuracy of 46.15%. Concordance of molecular and hysteroscopic diagnosis was observed in 38 samples (37 double positive and 1 double negative), with an accuracy of 58.46%. When the molecular method was compared to microbial culture, concordance was present in 37 samples (22 double positive and 15 double negative), a matching rate of 56.92%. When cases of potential contamination and/or noncultivable bacteria were considered, the accuracy increased to 66.15%. Of these 65 patients, only 27 patients had consistent histological + hysteroscopic diagnosis, revealing 58.64% of nonconcordant results. Only 13 of 65 patients (20%) had consistent histology + hysteroscopy + microbial culture results. In these cases, the molecular microbiology matched in 10 cases showing a diagnostic accuracy of 76.92%. Interestingly, the molecular microbiology confirmed over half of the isolated pathogens and provided additional detection of nonculturable microorganisms. These results were confirmed by the microbiome assessed by next-generation sequencing. In the endometrial samples with concordant histology + hysteroscopy + microbial culture results, the molecular microbiology diagnosis demonstrates 75% sensitivity, 100% specificity, 100% positive and 25% negative predictive values, and 0% false-positive and 25% false-negative rates.ConclusionThe molecular microbiology method describe herein is a fast and inexpensive diagnostic tool that allows for the identification of culturable and nonculturable endometrial pathogens associated with chronic endometritis. The results obtained were similar to all 3 classic diagnostic methods together with a degree of concordance of 76.92% providing an opportunity to improve the clinical management of infertile patients with a risk of experiencing this ghost endometrial pathology.
  • Vaginal antimycotics and the risk for spontaneous abortions
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Sharon Daniel, Reut Rotem, Gideon Koren, Eitan Lunenfeld, Amalia LevyBackgroundSpontaneous abortions are the most common complication of pregnancy. Clotrimazole and miconazole are widely used vaginal-antimycotic agents used for the treatment of vulvovaginal candidiasis. A previous study has suggested an increased risk of miscarriage associated with these azoles, which may lead health professionals to refrain from their use even if clinically indicated.ObjectiveThe aim of the current study was to assess the risk for spontaneous abortions following first trimester exposure to vaginal antimycotics.Study DesignA historical cohort study was conducted including all clinically apparent pregnancies that began from January 2003 through December 2009 and admitted for birth or spontaneous abortion at Soroka Medical Center, Clalit Health Services, Beer-Sheva, Israel. A computerized database of medication dispensation was linked with 2 computerized databases containing information on births and spontaneous abortions. Time-varying Cox regression models were constructed adjusting for mother’s age, diabetes mellitus, hypothyroidism, obesity, hypercoagulable or inflammatory conditions, recurrent miscarriages, intrauterine contraceptive device, ethnicity, tobacco use, and the year of admission.ResultsA total of 65,457 pregnancies were included in the study: 58,949 (90.1%) ended with birth and 6508 (9.9%) with a spontaneous abortion. Overall, 3246 (5%) pregnancies were exposed to vaginal antimycotic medications until the 20th gestational week: 2712 (4.2%) were exposed to clotrimazole and 633 (1%) to miconazole. Exposure to vaginal antimycotics was not associated with spontaneous abortions as a group (crude hazard ratio, 1.11; 95% confidence interval, 0.96–1.29; adjusted hazard ratio, 1.11; 95% confidence interval, 0.96–1.29) and specifically for clotrimazole (adjusted hazard ratio, 1.05; 95% confidence interval, 0.89–1.25) and miconazole (adjusted hazard ratio, 1.34; 95% confidence interval, 0.99–1.80). Furthermore, no association was found between categories of dosage of vaginal antimycotics and spontaneous abortions.ConclusionExposure to vaginal antimycotics was not associated with spontaneous abortions.
  • Training contraceptive providers to offer intrauterine devices and
           implants in contraceptive care: a cluster randomized trial
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Kirsten M.J. Thompson, Corinne H. Rocca, Lisa Stern, Johanna Morfesis, Suzan Goodman, Jody Steinauer, Cynthia C. HarperBackgroundUS unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods.ObjectiveWe sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care.Study DesignWe measured the impact of a continuing medical education–accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1-year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference-in-differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later.ResultsOverall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1-year follow-up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow-up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13–5.4). Likewise, for the implant, the proportion increased from 57-77% in intervention, compared to 61-65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44–4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53-67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04–3.44), and for the implant increased more in intervention (41-62%) compared to control sites (48-50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28–4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77-0.86) 6% more over time compared to control sites (from 0.78-0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003–0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65-0.79) compared to control sites (0.67-0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09–0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71-87%, compared to in control sites, 76-82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02–3.80).ConclusionProfessional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.
  • The Conscience of an MFM
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Steven J. RalstonMuch has been written about conscience-based objections to the provision of reproductive abortion services. Nevertheless, conscience may drive providers in the other direction as well: OB/GYNs may, in fact, decide to provide these services because of their well-considered moral, ethical, and religious convictions.
  • Prevention of obesity and diabetes in pregnancy: is it an impossible
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Oded LangerThe obesity and diabetes epidemic is an unintended consequence of economic, social, and technological changes. In nonpregnancy, people identified as high risk to develop type 2 diabetes may delay progression by 30–70% with lifestyle interventions and pharmacological agents. In pregnancy, lifestyle interventions have been the primary focus to prevent fetal short- and long-term complications that may evolve into substantial weight gain and gestational diabetes mellitus. The dilemma for obstetricians is whether diabetes and obesity can be prevented and not simply treated after the fact. Interventions after women become pregnant may be too late to see the kinds of meaningful improvements in child and maternal health because there is a short interval from gestational diabetes mellitus diagnosis to delivery. Therefore, future efforts need to incorporate quality research, lifestyle interventions that designate time of initiation and duration during pregnancy, the preventative intervention of a prepregnant “fourth trimester,” coupled with the concept of precision medicine so that there is the potential to make the impossible dream a reality.
  • The past, present, and future of selective progesterone receptor
           modulators in the management of uterine fibroids
    • Abstract: Publication date: June 2018Source: American Journal of Obstetrics and Gynecology, Volume 218, Issue 6Author(s): Sukhbir S. Singh, Liane Belland, Nicholas Leyland, Sarah von Riedemann, Ally MurjiUterine fibroids are common in women of reproductive age and can have a significant impact on quality of life and fertility. Although a number of international obstetrics/gynecology societies have issued evidence-based clinical practice guidelines for the management of symptomatic uterine fibroids, many of these guidelines do not yet reflect the most recent clinical evidence and approved indication for one of the key medical management options: the selective progesterone receptor modulator class. This article aims to share the clinical experience gained with selective progesterone receptor modulators in Europe and Canada by reviewing the historical development of selective progesterone receptor modulators, current best practices for selective progesterone receptor modulator use based on available data, and potential future uses for selective progesterone receptor modulators in uterine fibroids and other gynecologic conditions.
School of Mathematical and Computer Sciences
Heriot-Watt University
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