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Journal Cover American Journal of Obstetrics and Gynecology
  [SJR: 2.255]   [H-I: 171]   [200 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9378
   Published by Elsevier Homepage  [3089 journals]
  • Giants in Obstetrics and Gynecology Series: A profile of Jennifer Niebyl,
           MD
    • Authors: Roberto Romero
      Pages: 627 - 632.e4
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Roberto Romero


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.10.021
       
  • The use of intrapartum ultrasound to diagnose malpositions and cephalic
           malpresentations
    • Authors: Federica Bellussi; Tullio Ghi; Aly Youssef; Ginevra Salsi; Francesca Giorgetta; Dila Parma; Giuliana Simonazzi; Gianluigi Pilu
      Pages: 633 - 641
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Federica Bellussi, Tullio Ghi, Aly Youssef, Ginevra Salsi, Francesca Giorgetta, Dila Parma, Giuliana Simonazzi, Gianluigi Pilu
      Fetal malpositions and cephalic malpresentations are well-recognized causes of failure to progress in labor. They frequently require operative delivery, and are associated with an increased probability of fetal and maternal complications. Traditional obstetrics emphasizes the role of digital examinations, but recent studies demonstrated that this approach is inaccurate and intrapartum ultrasound is far more precise. The objective of this review is to summarize the current body of literature and provide recommendations to identify malpositions and cephalic malpresentations with ultrasound. We propose a systematic approach consisting of a combination of transabdominal and transperineal scans and describe the findings that allow an accurate diagnosis of normal and abnormal position, flexion, and synclitism of the fetal head. The management of malpositions and cephalic malpresentation is currently a matter of debate, and individualized depending on the general clinical picture and expertise of the provider. Intrapartum sonography allows a precise diagnosis and therefore offers the best opportunity to design prospective studies with the aim of establishing evidence-based treatment. The article is accompanied by a video that demonstrates the sonographic technique and findings.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.07.025
       
  • Gestational weight gain
    • Authors: Michelle A. Kominiarek; Alan M. Peaceman
      Pages: 642 - 651
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Michelle A. Kominiarek, Alan M. Peaceman
      Prenatal care providers are advised to evaluate maternal weight at each regularly scheduled prenatal visit, monitor progress toward meeting weight gain goals, and provide individualized counseling if significant deviations from a woman’s goals occur. Today, nearly 50% of women exceed their weight gain goals with overweight and obese women having the highest prevalence of excessive weight gain. Risks of inadequate weight gain include low birthweight and failure to initiate breast-feeding whereas the risks of excessive weight gain include cesarean deliveries and postpartum weight retention for the mother and large-for-gestational-age infants, macrosomia, and childhood overweight or obesity for the offspring. Prenatal care providers have many resources and tools to incorporate weight and other health behavior counseling into routine prenatal practices. Because many women are motivated to improve health behaviors, pregnancy is often considered the optimal time to intervene for issues related to eating habits and physical activity to prevent excessive weight gain. Gestational weight gain is a potentially modifiable risk factor for a number of adverse maternal and neonatal outcomes and meta-analyses of randomized controlled trials report that diet or exercise interventions during pregnancy can help reduce excessive weight gain. However, health behavior interventions for gestational weight gain have not significantly improved other maternal and neonatal outcomes and have limited effectiveness in overweight and obese women.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.05.040
       
  • Ovarian mass–differentiating benign from malignant: the value of the
           International Ovarian Tumor Analysis ultrasound rules
    • Authors: Jacques S. Abramowicz; Dirk Timmerman
      Pages: 652 - 660
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Jacques S. Abramowicz, Dirk Timmerman
      Ovarian cancer, the fifth most common cause of cancer death among women, has the highest mortality rate of all gynecologic cancers. General survival rate is <50% but can reach 90% if disease is detected early. Ultrasound is presently the best modality to differentiate between benign and malignant status. The patient with a malignant mass should be referred to an oncology surgeon since results have been shown to be superior to treatment by a specialist. Several ultrasound-based scoring systems exist for assessing the risk of an ovarian tumor to be malignant. The International Ovarian Tumor Analysis group published 2 such systems: the ultrasound Simple Rules and the Assessment of Different NEoplasias in the adneXa model. The Simple Rules classifies a tumor as benign, malignant, or indeterminate and the Assessment of Different NEoplasias in the adneXa model determines the risk for a tumor to be benign or malignant and, if malignant, the risk of various stages. Sensitivity of the Simple Rules and Assessment of Different NEoplasias in the adneXa model (using a cut-off of 10% to predict malignancy) are 92% and 96.5%, respectively, and specificities are 96% and 71.3%, respectively. These models are the best predictive tests for the preoperative classification of adnexal tumors. Their intent is to help the specialist make management decisions when faced with a patient with a persistent ovarian mass. The models are simple, are easy to use, and have been validated in multiple reports but not in the United States. We suggest they should be validated and widely introduced into medical practice in the United States.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.07.019
       
  • Brief latency after premature rupture of the membranes at term:
           correction of a propagated error
    • Authors: Brian M. Mercer
      Pages: 663 - 664
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Brian M. Mercer


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.09.025
       
  • Abdominal wall endometriosis
    • Authors: Cristina Morales Martínez; Sonia Tejuca Somoano
      Pages: 701 - 702
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Cristina Morales Martínez, Sonia Tejuca Somoano


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.07.033
       
  • A pilot study in using deep learning to predict limited life expectancy in
           women with recurrent cervical cancer
    • Authors: Koji Matsuo; Sanjay Purushotham; Aida Moeini; Guangyu Li; Hiroko Machida; Yan Liu; Lynda D. Roman
      Pages: 703 - 705
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Koji Matsuo, Sanjay Purushotham, Aida Moeini, Guangyu Li, Hiroko Machida, Yan Liu, Lynda D. Roman


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.012
       
  • Trends in perception of risk of regular marijuana use among US pregnant
           and nonpregnant reproductive-aged women
    • Authors: Marian Jarlenski; Jonathan W. Koma; Jennifer Zank; Lisa M. Bodnar; Debra L. Bogen; Judy C. Chang
      Pages: 705 - 707
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Marian Jarlenski, Jonathan W. Koma, Jennifer Zank, Lisa M. Bodnar, Debra L. Bogen, Judy C. Chang


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.015
       
  • Postoperative maintenance levonorgestrel-releasing intrauterine system and
           endometrioma recurrence: a randomized controlled study
    • Authors: Haifeng Qiu; Zhongfu Yuan
      First page: 708
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Haifeng Qiu, Zhongfu Yuan


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.013
       
  • Ultrasound estimated fetal weight
    • Authors: Michael G. Ross
      Pages: 709 - 710
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Michael G. Ross


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.104
       
  • Assessing standards used to review online health information
    • Authors: Anna S. Miller; Phaedra Thomas; Jill R. Kavanaugh
      Pages: 710 - 711
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Anna S. Miller, Phaedra Thomas, Jill R. Kavanaugh


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.105
       
  • Hydroxychloroquine as additional treatment in pregnant patients with
           refractory APS
    • Authors: Sara De Carolis; Francesca Rizzo; Sara Tabacco
      Pages: 711 - 712
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Sara De Carolis, Francesca Rizzo, Sara Tabacco


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.113
       
  • Impact of metronidazole on clearance of anaerobes in women with acute
           pelvic inflammatory disease: the ACE trial
    • Authors: H. Wiesenfeld; S. Hillier; L. Meyn; L. Rabe; I. Macio; C. Priest; T. Darville
      First page: 714
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): H. Wiesenfeld, S. Hillier, L. Meyn, L. Rabe, I. Macio, C. Priest, T. Darville


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.081
       
  • Neisseria gonorrhoeae biofilm contributes to antibiotic resistance
    • Authors: L.-C. Wang; Q. Yu; J. Qiu; D.C. Stein; W. Song
      First page: 714
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): L.-C. Wang, Q. Yu, J. Qiu, D.C. Stein, W. Song


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.082
       
  • Susceptibility of trichomonas vaginalis clinical isolates to secnidazole
           and metronidazole
    • Authors: A. Ghosh; C. Aycock; J. Schwebke
      Pages: 714 - 715
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): A. Ghosh, C. Aycock, J. Schwebke


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.083
       
  • Results from a phase 2, randomized, double-blind, placebo-controlled, dose
           ranging study to evaluate the efficacy and safety of VT 1161 oral tablets
           in the treatment of patients with recurrent vulvovaginal candidiasis
    • Authors: J.D. Sobel; S.R. Brand; T.P. Degenhardt; K. Person; P. Nyirjesy; R.J. Schotzinger; A. Tavakkol
      First page: 715
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): J.D. Sobel, S.R. Brand, T.P. Degenhardt, K. Person, P. Nyirjesy, R.J. Schotzinger, A. Tavakkol


      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.084
       
  • Management of premature rupture of membranes at term: the need to
           correct a recurring mistake in articles, chapters, and recommendations
           of professional organizations
    • Authors: Eyal Krispin
      Pages: 661.e1 - 661.e3
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Eyal Krispin
      Recommendations about the management of premature rupture of membranes at term are based, in part, on a large, randomized controlled trial published in 1996: the TERMPROM trial. The original article contained an error in Table 1, in which “Interval from membrane rupture to delivery” was listed instead of “Interval from membrane rupture to study entry.” While the authors and journal corrected this error, the mistake published in the original paper has made its way into subsequent publications and even in guidelines or practice bulletins issued by professional organizations, textbooks, and other publications around the world. The mistake, that half of women with premature rupture of membranes at term who were managed expectantly delivered within 5 hours and 95% delivered within 28 hours of membrane rupture, should be replaced with the actual fact that half of women with premature rupture of membranes at term who were managed expectantly delivered within 33 hours, and 95% delivered within 94–107 hours of membrane rupture. Correcting this error in contemporary health care information and publications is important to counsel patients accurately and to optimize the clinical care of women with premature rupture of membranes at term.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.111
       
  • Condom use and incident sexually transmitted infection after initiation of
           long-acting reversible contraception
    • Authors: Colleen P. McNicholas; Jessica B. Klugman; Qiuhong Zhao; Jeffrey F. Peipert
      Pages: 672.e1 - 672.e6
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Colleen P. McNicholas, Jessica B. Klugman, Qiuhong Zhao, Jeffrey F. Peipert
      Background Use of more effective contraception may lead to less condom use and increased incidence of sexually transmitted infection. Objective The objective of this study was to compare changes in condom use and incidence of sexually transmitted infection acquisition among new initiators of long-acting reversible contraceptives to those initiating non-long-acting reversible contraceptive methods. Study Design This is a secondary analysis of the Contraceptive CHOICE Project. We included 2 sample populations of 12-month continuous contraceptive users. The first included users with complete condom data (baseline, and 3, 6, and 12 months) (long-acting reversible contraceptive users: N = 2371; other methods: N = 575). The second included users with 12-month sexually transmitted infection data (long-acting reversible contraceptive users: N = 2102; other methods: N = 592). Self-reported condom use was assessed at baseline and at 3, 6, and 12 months following enrollment. Changes in condom use and incident sexually transmitted infection rates were compared using χ2 tests. Risk factors for sexually transmitted infection acquisition were identified using multivariable logistic regression. Results Few participants in either group reported consistent condom use across all survey time points and with all partners (long-acting reversible contraceptive users: 5.2%; other methods: 11.3%; P < .001). There was no difference in change of condom use at 3, 6, and 12 months compared to baseline condom use regardless of method type (P = .65). A total of 94 incident sexually transmitted infections were documented, with long-acting reversible contraceptive users accounting for a higher proportion (3.9% vs 2.0%; P = .03). Initiation of a long-acting reversible contraceptive method was associated with increased sexually transmitted infection incidence (odds ratio, 2.0; 95% confidence ratio, 1.07–3.72). Conclusion Long-acting reversible contraceptive initiators reported lower rates of consistent condom use, but did not demonstrate a change in condom use when compared to preinitiation behaviors. Long-acting reversible contraceptive users were more likely to acquire a sexually transmitted infection in the 12 months following initiation.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.09.009
       
  • Postplacental intrauterine device expulsion by 12 weeks:
           a prospective cohort study
    • Authors: Lisa M. Goldthwaite; Jeanelle Sheeder; Jennifer Hyer; Kristina Tocce; Stephanie B. Teal
      Pages: 674.e1 - 674.e8
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Lisa M. Goldthwaite, Jeanelle Sheeder, Jennifer Hyer, Kristina Tocce, Stephanie B. Teal
      Background An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly. Objective We sought to compare expulsion rates by 12 weeks’ postpartum for the levonorgestrel intrauterine system and copper intrauterine device. Study Design We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English- or Spanish-speaking, with singleton vaginal delivery at ≥35 weeks’ gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator’s hand. Intrauterine device location was evaluated via abdominal ultrasound at 24-48 hours’ postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion. Results We enrolled 123 women ages 18-40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12-week follow-up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99–6.55; P = .05). At 24 hours’ postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks’ postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P = .14). Conclusion Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.001
       
  • Measurement of uterine natural killer cell percentage in
           the periimplantation endometrium from fertile women and women with
           recurrent reproductive failure: establishment of a reference range
    • Authors: Xiaoyan Chen; Najat Mariee; Lingming Jiang; Yingyu Liu; Chi Chiu Wang; Tin Chiu Li; Susan Laird
      Pages: 680.e1 - 680.e6
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Xiaoyan Chen, Najat Mariee, Lingming Jiang, Yingyu Liu, Chi Chiu Wang, Tin Chiu Li, Susan Laird
      Background Uterine natural killer cells are the major leukocytes present in the periimplantation endometrium. Previous studies have found controversial differences in uterine natural killer cell percentage in women with recurrent reproductive failure compared with fertile controls. Objective We sought to compare the uterine natural killer cell percentage in women with recurrent reproductive failure and fertile controls. Study Design This was a retrospective study carried out in university hospitals. A total of 215 women from 3 university centers participated in the study, including 97 women with recurrent miscarriage, 34 women with recurrent implantation failure, and 84 fertile controls. Endometrial biopsy samples were obtained precisely 7 days after luteinization hormone surge in a natural cycle. Endometrial sections were immunostained for CD56 and cell counting was performed by a standardized protocol. Results were expressed as percentage of positive uterine natural killer cell/total stromal cells. Results The median uterine natural killer cell percentage in Chinese ovulatory fertile controls in natural cycles was 2.5% (range 0.9-5.3%). Using 5th and 95th percentile to define the lower and upper limits of uterine natural killer cell percentage, the reference range was 1.2-4.5%. Overall, the groups with recurrent reproductive failure had significantly higher uterine natural killer cell percentage than the controls (recurrent miscarriage: median 3.2%, range 0.6-8.8%; recurrent implantation failure: median 3.1%, range 0.8-8.3%). However, there was a subset of both groups (recurrent miscarriage: 16/97; recurrent implantation failure: 6/34) that had lower uterine natural killer cell percentage compared to fertile controls. Conclusion A reference range for uterine natural killer cell percentage in fertile women was established. Women with recurrent reproductive failure had uterine natural killer cell percentages both above and below the reference range.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.09.010
       
  • The prediction of fetal death with a simple maternal blood test at 20-24
           weeks: a role for angiogenic index-1 (PlGF/sVEGFR-1 ratio)
    • Authors: Tinnakorn Chaiworapongsa; Roberto Romero; Offer Erez; Adi L. Tarca; Agustin Conde-Agudelo; Piya Chaemsaithong; Chong Jai Kim; Yeon Mee Kim; Jung-Sun Kim; Bo Hyun Yoon; Sonia S. Hassan; Lami Yeo; Steven J. Korzeniewski
      Pages: 682.e1 - 682.e13
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Tinnakorn Chaiworapongsa, Roberto Romero, Offer Erez, Adi L. Tarca, Agustin Conde-Agudelo, Piya Chaemsaithong, Chong Jai Kim, Yeon Mee Kim, Jung-Sun Kim, Bo Hyun Yoon, Sonia S. Hassan, Lami Yeo, Steven J. Korzeniewski
      Background Fetal death is an obstetrical syndrome that annually affects 2.4 to 3 million pregnancies worldwide, including more than 20,000 in the United States each year. Currently, there is no test available to identify patients at risk for this pregnancy complication. Objective We sought to determine if maternal plasma concentrations of angiogenic and antiangiogenic factors measured at 24-28 weeks of gestation can predict subsequent fetal death. Study Design A case-cohort study was designed to include 1000 randomly selected subjects and all remaining fetal deaths (cases) from a cohort of 4006 women with a singleton pregnancy, enrolled at 6-22 weeks of gestation, in a pregnancy biomarker cohort study. The placentas of all fetal deaths were histologically examined by pathologists who used a standardized protocol and were blinded to patient outcomes. Placental growth factor, soluble endoglin, and soluble vascular endothelial growth factor receptor-1 concentrations were measured by enzyme-linked immunosorbent assays. Quantiles of the analyte concentrations (or concentration ratios) were estimated as a function of gestational age among women who delivered a live neonate but did not develop preeclampsia or deliver a small-for-gestational-age newborn. A positive test was defined as analyte concentrations (or ratios) <2.5th and 10th centiles (placental growth factor, placental growth factor/soluble vascular endothelial growth factor receptor-1 [angiogenic index-1] and placental growth factor/soluble endoglin) or >90th and 97.5th centiles (soluble vascular endothelial growth factor receptor-1 and soluble endoglin). Inverse probability weighting was used to reflect the parent cohort when estimating the relative risk. Results There were 11 fetal deaths and 829 controls with samples available for analysis between 24-28 weeks of gestation. Three fetal deaths occurred <28 weeks and 8 occurred ≥28 weeks of gestation. The rate of placental lesions consistent with maternal vascular underperfusion was 33.3% (1/3) among those who had a fetal death <28 weeks and 87.5% (7/8) of those who had this complication ≥28 weeks of gestation. The maternal plasma angiogenic index-1 value was <10th centile in 63.6% (7/11) of the fetal death group and in 11.1% (92/829) of the controls. The angiogenic index-1 value was <2.5th centile in 54.5% (6/11) of the fetal death group and in 3.7% (31/829) of the controls. An angiogenic index-1 value <2.5th centile had the largest positive likelihood ratio for predicting fetal death >24 weeks (14.6; 95% confidence interval, 7.7–27.7) and a relative risk of 29.1 (95% confidence interval, 8.8–97.1), followed by soluble endoglin >97.5th centile and placental growth factor/soluble endoglin <2.5th, both with a positive likelihood ratio of 13.7 (95% confidence interval, 7.3–25.8) and a relative risk of 27.4 (95% confidence interval, 8.2–91.2). Among women without a fetal death whose plasma angiogenic index-1 concentration ratio was <2.5th centile, 61% (19/31) developed preeclampsia or delivered a small-for-gestational-age neonate; when the 10th centile was used as the cut-off, 37% (34/92) of women had these adverse outcomes. Conclusion (1) A maternal plasma angiogenic index-1 value <2.5th centile (0.126) at 24-28 weeks of gestation carries a 29-fold increase in the risk of subsequent fetal death and identifies 55% of subsequent fetal deaths with a false-positive rate of 3.5%; and (2) 61% of women who have a false-positive test result will subsequently experience adverse pregnancy outcomes.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.10.001
       
  • Altered angiogenesis as a common mechanism underlying preterm birth, small
           for gestational age, and stillbirth in women living with HIV
    • Authors: Andrea L. Conroy; Chloe R. McDonald; Joel L. Gamble; Peter Olwoch; Paul Natureeba; Deborah Cohan; Moses R. Kamya; Diane V. Havlir; Grant Dorsey; Kevin C. Kain
      Pages: 684.e1 - 684.e17
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Andrea L. Conroy, Chloe R. McDonald, Joel L. Gamble, Peter Olwoch, Paul Natureeba, Deborah Cohan, Moses R. Kamya, Diane V. Havlir, Grant Dorsey, Kevin C. Kain
      Background Angiogenic processes in the placenta are critical regulators of fetal growth and impact birth outcomes, but there are limited data documenting these processes in HIV-infected women or women from low-resource settings. Objective We sought to determine whether angiogenic factors are associated with adverse birth outcomes in HIV-infected pregnant women started on antiretroviral therapy. Study Design This is a secondary analysis of samples collected as part of a clinical trial randomizing pregnant women and adolescents infected with HIV to lopinavir/ritonavir-based (n = 166) or efavirenz-based (n = 160) antiretroviral therapy in Tororo, Uganda. Pregnant women living with HIV were enrolled between 12-28 weeks of gestation. Plasma samples were evaluated for angiogenic biomarkers (angiopoietin-1, angiopoietin-2, vascular endothelial growth factor, soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin) by enzyme-linked immunosorbent assay between: 16-<20, 20-<24, 24-<28, 28-<32, 32-<36, 36-<37 weeks of gestation. The primary outcome was preterm birth. Results In all, 1115 plasma samples from 326 pregnant women and adolescents were evaluated. There were no differences in angiogenic factors according to antiretroviral therapy group (P > .05 for all). The incidence of adverse birth outcomes was 16.9% for spontaneous preterm births, 25.6% for small-for-gestational-age births, and 2.8% for stillbirth. We used linear mixed effect modelling to evaluate longitudinal changes in angiogenic factor concentrations between birth outcome groups adjusting for gestational age at venipuncture, maternal age, body mass index, gravidity, and the interaction between treatment arm and gestational age. Two angiogenic factors–soluble endoglin and placental growth factor–were associated with adverse birth outcomes. Significantly higher concentrations of soluble endoglin throughout gestation were found in study participants destined to deliver preterm [likelihood ratio test, χ2(1) = 12.28, P < .0005] and in those destined to have stillbirths [χ2(1) = 5.67, P < .02]. By contrast, significantly lower concentrations of placental growth factor throughout gestation were found in those destined to have small-for-gestational-age births [χ2(1) = 7.89, P < .005] and in those destined to have stillbirths [χ2(1) = 21.59, P < .0001]. Conclusion An antiangiogenic state in the second or third trimester is associated with adverse birth outcomes, including stillbirth in women and adolescents living with HIV and receiving antiretroviral therapy.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.10.003
       
  • Aspirin for Evidence-Based Preeclampsia Prevention trial: influence of
           compliance on beneficial effect of aspirin in prevention of preterm
           preeclampsia
    • Authors: David Wright; Liona C. Poon; Daniel L. Rolnik; Argyro Syngelaki; Juan Luis Delgado; Denisa Vojtassakova; Mercedes de Alvarado; Evgenia Kapeti; Anoop Rehal; Andrea Pazos; Ilma Floriana Carbone; Vivien Dutemeyer; Walter Plasencia; Nikos Papantoniou; Kypros H. Nicolaides
      Pages: 685.e1 - 685.e5
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): David Wright, Liona C. Poon, Daniel L. Rolnik, Argyro Syngelaki, Juan Luis Delgado, Denisa Vojtassakova, Mercedes de Alvarado, Evgenia Kapeti, Anoop Rehal, Andrea Pazos, Ilma Floriana Carbone, Vivien Dutemeyer, Walter Plasencia, Nikos Papantoniou, Kypros H. Nicolaides
      Background The Aspirin for Evidence-Based Preeclampsia Prevention trial was a multicenter study in women with singleton pregnancies. Screening was carried out at 11-13 weeks’ gestation with an algorithm that combines maternal factors and biomarkers (mean arterial pressure, uterine artery pulsatility index, and maternal serum pregnancy-associated plasma protein A and placental growth factor). Those with an estimated risk for preterm preeclampsia of >1 in 100 were invited to participate in a double-blind trial of aspirin (150 mg/d) vs placebo from 11-14 until 36 weeks’ gestation. Preterm preeclampsia with delivery at <37 weeks’ gestation, which was the primary outcome, occurred in 1.6% (13/798) participants in the aspirin group, as compared with 4.3% (35/822) in the placebo group (odds ratio in the aspirin group, 0.38; 95% confidence interval, 0.20 to 0.74). Objective We sought to examine the influence of compliance on the beneficial effect of aspirin in prevention of preterm preeclampsia in the Aspirin for Evidence-Based Preeclampsia Prevention trial. Study Design This was a secondary analysis of data from the trial. The proportion of prescribed tablets taken was used as an overall measure of compliance. Logistic regression analysis was used to estimate the effect of aspirin on the incidence of preterm preeclampsia according to compliance of <90% and ≥90%, after adjustment for the estimated risk of preterm preeclampsia at screening and the participating center. The choice of cut-off of 90% was based on an exploratory analysis of the treatment effect. Logistic regression analysis was used to investigate predictors of compliance ≥90% among maternal characteristics and medical history. Results Preterm preeclampsia occurred in 5/555 (0.9%) participants in the aspirin group with compliance ≥90%, in 8/243 (3.3%) of participants in the aspirin group with compliance <90%, in 22/588 (3.7%) of participants in the placebo group with compliance ≥90%, and in 13/234 (5.6%) of participants in the placebo group with compliance <90%. The odds ratio in the aspirin group for preterm preeclampsia was 0.24 (95% confidence interval, 0.09–0.65) for compliance ≥90% and 0.59 (95% confidence interval, 0.23–1.53) for compliance <90%. Compliance was positively associated with family history of preeclampsia and negatively associated with smoking, maternal age <25 years, Afro-Caribbean and South Asian racial origin, and history of preeclampsia in a previous pregnancy. Conclusion The beneficial effect of aspirin in the prevention of preterm preeclampsia appears to depend on compliance.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.08.110
       
  • Positive predictive value estimates for cell-free noninvasive prenatal
           screening from data of a large referral genetic diagnostic laboratory
    • Authors: Andrea K. Petersen; Sau Wai Cheung; Janice L. Smith; Weimin Bi; Patricia A. Ward; Sandra Peacock; Alicia Braxton; Ignatia B. Van Den Veyver; Amy M. Breman
      Pages: 691.e1 - 691.e6
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Andrea K. Petersen, Sau Wai Cheung, Janice L. Smith, Weimin Bi, Patricia A. Ward, Sandra Peacock, Alicia Braxton, Ignatia B. Van Den Veyver, Amy M. Breman
      Background Since its debut in 2011, cell-free fetal DNA screening has undergone rapid expansion with respect to both utilization and coverage. However, conclusive data regarding the clinical validity and utility of this screening tool, both for the originally included common autosomal and sex-chromosomal aneuploidies as well as the more recently added chromosomal microdeletion syndromes, have lagged behind. Thus, there is a continued need to educate clinicians and patients about the current benefits and limitations of this screening tool to inform pre- and posttest counseling, pre/perinatal decision making, and medical risk assessment/management. Objective The objective of this study was to determine the positive predictive value and false-positive rates for different chromosomal abnormalities identified by cell-free fetal DNA screening using a large data set of diagnostic testing results on invasive samples submitted to the laboratory for confirmatory studies. Study Design We tested 712 patient samples sent to our laboratory to confirm a cell-free fetal DNA screening result, indicating high risk for a chromosome abnormality. We compiled data from all cases in which the indication for confirmatory testing was a positive cell-free fetal DNA screen, including the common trisomies, sex chromosomal aneuploidies, microdeletion syndromes, and other large genome-wide copy number abnormalities. Testing modalities included fluorescence in situ hybridization, G-banded karyotype, and/or chromosomal microarray analysis performed on chorionic villus samples, amniotic fluid, or postnatally obtained blood samples. Positive predictive values and false-positive rates were calculated from tabulated data. Results The positive predictive values for trisomy 13, 18, and 21 were consistent with previous reports at 45%, 76%, and 84%, respectively. For the microdeletion syndrome regions, positive predictive values ranged from 0% for detection of Cri-du-Chat syndrome and Prader-Willi/Angelman syndrome to 14% for 1p36 deletion syndrome and 21% for 22q11.2 deletion syndrome. Detection of sex chromosomal aneuploidies had positive predictive values of 26% for monosomy X, 50% for 47,XXX, and 86% for 47,XXY. Conclusion The positive predictive values for detection of common autosomal and sex chromosomal aneuploidies by cell-free fetal DNA screening were comparable with other studies. Identification of microdeletions was associated with lower positive predictive values and higher false-positive rates, likely because of the low prevalence of the individual targeted microdeletion syndromes in the general population. Although the obtained positive predictive values compare favorably with those seen in traditional screening approaches for common aneuploidies, they highlight the importance of educating clinicians and patients on the limitations of cell-free fetal DNA screening tests. Improvement of the cell-free fetal DNA screening technology and continued monitoring of its performance after introduction into clinical practice will be important to fully establish its clinical utility. Nonetheless, our data provide valuable information that may aid result interpretation, patient counseling, and clinical decision making/management.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.10.005
       
  • Are amniotic fluid neutrophils in women with intraamniotic infection
           and/or inflammation of fetal or maternal origin'
    • Authors: Nardhy Gomez-Lopez; Roberto Romero; Yi Xu; Yaozhu Leng; Valeria Garcia-Flores; Derek Miller; Suzanne M. Jacques; Sonia S. Hassan; Jonathan Faro; Adham Alsamsam; Ali Alhousseini; Hunter Gomez-Roberts; Bogdan Panaitescu; Lami Yeo; Eli Maymon
      Pages: 693.e1 - 693.e16
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Nardhy Gomez-Lopez, Roberto Romero, Yi Xu, Yaozhu Leng, Valeria Garcia-Flores, Derek Miller, Suzanne M. Jacques, Sonia S. Hassan, Jonathan Faro, Adham Alsamsam, Ali Alhousseini, Hunter Gomez-Roberts, Bogdan Panaitescu, Lami Yeo, Eli Maymon
      Background Neutrophils are the most abundant white blood cells found in the amniotic cavity of women with intraamniotic infection and/or inflammation. The current belief is that these neutrophils are of fetal origin. However, abundant neutrophils have been found in the amniotic fluid of women with a severe acute maternal inflammatory response but without a severe fetal inflammatory response in the placenta, suggesting that these innate immune cells can also be of maternal origin or a mixture of both fetal and maternal neutrophils. Objective We sought to investigate the origin of amniotic fluid neutrophils from women with intraamniotic infection and/or inflammation and to correlate these findings with acute histologic maternal and fetal inflammatory responses in the placenta. Study Design Amniotic fluid was collected from 15 women with suspected intraamniotic infection and/or inflammation (positive microbiological cultures and/or interleukin-6 concentrations ≥2.6 ng/mL). Amniotic fluid neutrophils were purified by fluorescence-activated cell sorting, DNA was extracted, and DNA fingerprinting was performed. DNA fingerprinting was also performed in the umbilical cord and maternal blood DNA. Fluorescence in situ hybridization was assayed in women with male neonates. Blinded placental histopathological evaluations were conducted. Results First, DNA fingerprinting revealed that 43% (6/14) of women who underwent a single amniocentesis had mostly fetal neutrophils in the amniotic fluid. Second, DNA fingerprinting showed that 36% (5/14) of the women who underwent a single amniocentesis had predominantly maternal neutrophils in the amniotic fluid. Third, DNA fingerprinting indicated that 21% (3/14) of the women who underwent a single amniocentesis had an evident mixture of fetal and maternal neutrophils in the amniotic fluid. Fourth, DNA fingerprinting revealed that a woman who underwent 2 amniocenteses (patient 15) had fetal neutrophils first, and as infection progressed, abundant maternal neutrophils invaded the amniotic cavity. Fifth, fluorescence in situ hybridization confirmed DNA fingerprinting results by showing that both fetal and maternal neutrophils were present in the amniotic fluid. Sixth, most of the women who had predominantly amniotic fluid neutrophils of fetal origin at the time of collection delivered extremely preterm neonates (71% [5/7]). Seventh, all of the women who had predominantly amniotic fluid neutrophils of maternal origin at the time of collection delivered term or late preterm neonates (100% [6/6]). Eighth, 2 of the women who had an evident mixture of fetal and maternal neutrophils in the amniotic fluid at the time of collection delivered extremely preterm neonates (67% [2/3]), and the third woman delivered a term neonate (33% [1/3]). Finally, most of the women included in this study presented acute maternal and fetal inflammatory responses in the placenta (87% [13/15]). Conclusion Amniotic fluid neutrophils can be either predominantly of fetal or maternal origin, or a mixture of both fetal and maternal origin, in women with intraamniotic infection and/or inflammation. The findings herein provide evidence that both fetal and maternal neutrophils can invade the amniotic cavity, suggesting that both the fetus and the mother participate in the host defense mechanisms against intraamniotic infection.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.09.013
       
  • In an in-vitro model using human fetal membranes,
           17-α hydroxyprogesterone caproate is not an optimal progestogen for
           inhibition of fetal membrane weakening
    • Authors: Deepak Kumar; Robert M. Moore; Brian M. Mercer; Joseph M. Mansour; Sam Mesiano; Frederick Schatz; Charles J. Lockwood; John J. Moore
      Pages: 695.e1 - 695.e14
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Deepak Kumar, Robert M. Moore, Brian M. Mercer, Joseph M. Mansour, Sam Mesiano, Frederick Schatz, Charles J. Lockwood, John J. Moore
      Background The progestogen 17-α hydroxyprogesterone caproate (17-OHPC) is 1 of only 2 agents recommended for clinical use in the prevention of spontaneous preterm delivery, and studies of its efficacy have been conflicting. We have developed an in-vitro model to study the fetal membrane weakening process that leads to rupture in preterm premature rupture of the fetal membranes (pPROM). Inflammation/infection associated with tumor necrosis factor-α (TNF-α) induction and decidual bleeding/abruption associated thrombin release are leading causes of preterm premature rupture of the fetal membranes. Both agents (TNF-α and thrombin) cause fetal membrane weakening in the model system. Furthermore, granulocyte-macrophage colony-stimulating factor (GM-CSF) is a critical intermediate for both TNF-α and thrombin-induced fetal membrane weakening. In a previous report, we demonstrated that 3 progestogens, progesterone, 17-alpha hydroxyprogesterone (17-OHP), and medroxyprogesterone acetate (MPA), each inhibit both TNF-α– and thrombin-induced fetal membrane weakening at 2 distinct points of the fetal membrane weakening pathway. Each block both the production of and the downstream action of the critical intermediate granulocyte-macrophage colony-stimulating factor. Objective The objective of the study was to characterize the inhibitory effects of 17-OHPC on TNF-α– and thrombin-induced fetal membrane weakening in vitro. Study Design Full-thickness human fetal membrane fragments from uncomplicated term repeat cesarean deliveries were mounted in 2.5 cm Transwell inserts and cultured with/without 17-alpha hydroxyprogesterone caproate (10–9 to 10–7 M). After 24 hours, medium (supernatant) was removed and replaced with/without the addition of tumor necrosis factor-alpha (20 ng/mL) or thrombin (10 U/mL) or granulocyte-macrophage colony-stimulating factor (200 ng/mL). After 48 hours of culture, medium from the maternal side compartment of the model was assayed for granulocyte-macrophage colony-stimulating factor and the fetal membrane fragments were rupture strength tested. Results Tumor necrosis factor-alpha and thrombin both weakened fetal membranes (43% and 62%, respectively) and increased granulocyte-macrophage colony-stimulating factor levels (3.7- and 5.9-fold, respectively). Pretreatment with 17-alpha hydroxyprogesterone caproate inhibited both tumor necrosis factor-alpha– and thrombin-induced fetal membrane weakening and concomitantly inhibited the induced increase in granulocyte-macrophage colony-stimulating factor in a concentration-dependent manner. However, contrary to our prior reports regarding progesterone and other progestogens, 17-alpha hydroxyprogesterone caproate did not also inhibit granulocyte-macrophage colony-stimulating factor–induced fetal membrane weakening. Conclusion 17-Alpha hydroxyprogesterone caproate blocks tumor necrosis factor-alpha– and thrombin-induced fetal membrane weakening by inhibiting the production of granulocyte-macrophage colony-stimulating factor. However, 17-alpha hydroxyprogesterone caproate did not also inhibit granulocyte-macrophage colony-stimulating factor–induced weakening. We speculate that progestogens other than 17-alpha hydroxyprogesterone caproate may be more efficacious in preventing preterm premature rupture of the fetal membranes–related spontaneous preterm birth.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.10.004
       
  • Thyroid-stimulating hormone, anti–thyroid antibodies, and pregnancy
           outcomes
    • Authors: Torie C. Plowden; Enrique F. Schisterman; Lindsey A. Sjaarda; Neil J. Perkins; Robert Silver; Rose Radin; Keewan Kim; Noya Galai; Alan H. DeCherney; Sunni L. Mumford
      Pages: 697.e1 - 697.e7
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Torie C. Plowden, Enrique F. Schisterman, Lindsey A. Sjaarda, Neil J. Perkins, Robert Silver, Rose Radin, Keewan Kim, Noya Galai, Alan H. DeCherney, Sunni L. Mumford
      Background Overt thyroid dysfunction has been associated with adverse obstetric outcomes. However, less is known regarding subclinical hypothyroidism or thyroid autoimmunity and their relationship to pregnancy complications. Objective The purpose of this study was to examine the association between prepregnancy anti–thyroid antibodies and subclinical hypothyroidism and preterm delivery, gestational diabetes mellitus, and preeclampsia. Study Design We conducted a secondary analysis of a prospective cohort of 18- to 40-year-old women with 1–2 previous pregnancy losses (n=1193) who participated in a multicenter randomized, placebo-controlled trial of low-dose aspirin. Prepregnancy levels of thyroid-stimulating hormone, free thyroxine, thyroglobulin antibody, and thyroid peroxidase antibody were measured. Relative risks and 95% confidence intervals were estimated with the use of generalized linear models with adjustment for age and body mass index. Results Among women with an ongoing pregnancy of >20 weeks estimated gestational age, there was no association between prepregnancy thyroid-stimulating hormone level (>2.5 vs ≤2.5 mIU/L) and preterm delivery (adjusted relative risk, 0.77; 95% confidence interval, 0.40–1.47), gestational diabetes mellitus (adjusted relative risk, 1.28; 95% confidence interval, 0.54–3.04), or preeclampsia (adjusted relative risk, 1.20; 95% confidence interval, 0.71–2.04). Similarly, among women with thyroid antibodies, there was no increase in the likelihood of preterm delivery (relative risk, 1.26; 95% confidence interval, 0.65–2.45), gestational diabetes mellitus (relative risk, 1.33; 95% confidence interval, 0.51–3.49), or preeclampsia (relative risk, 1.02; 95% confidence interval, 0.54–1.92), compared with women without these antibodies. Conclusion Among women with 1–2 previous pregnancy losses, subclinical hypothyroidism and thyroid autoimmunity were not associated with an increased risk of preterm delivery, gestational diabetes mellitus, or preeclampsia. These data support current recommendations that low-risk asymptomatic women should not be screened routinely for thyroid dysfunction or autoimmunity.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.09.001
       
  • Emergency in the clinic: a simulation curriculum to improve outpatient
           safety
    • Authors: Eve Espey; Gillian Baty; John Rask; Michelle Chungtuyco; Brenda Pereda; Lawrence Leeman
      Pages: 699.e1 - 699.e13
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Eve Espey, Gillian Baty, John Rask, Michelle Chungtuyco, Brenda Pereda, Lawrence Leeman
      Background Emergency response skills are essential when events such as seizure, anaphylaxis, or hemorrhage occur in the outpatient setting. As services and procedures increasingly move outside the hospital, training to manage complications may improve outcomes. Objective The objective of this study was to evaluate a simulation-based curriculum in outpatient emergency management skills with the outcome measures of graded objective performance and learner self-efficacy. Study Design This pre- and postcurriculum study enrolled residents and fellows in Obstetrics and Gynecology and Family Medicine in a simulation-based, outpatient emergency management curriculum. Learners completed self-efficacy questionnaires and were videotaped managing 3 medical emergency scenarios (seizure, over-sedation/cardiopulmonary arrest, and hemorrhage) in the simulation laboratory both before and after completion of the curriculum. Evaluators who were blinded to training level scored the simulation performance videotapes using a graded rubric with critical action checklists. Scenario scores were assigned in 5 domains and globally. Paired t-tests were used to determine differences pre- and postcurriculum. Results Thirty residents completed the curriculum and pre- and postcurriculum testing. Subjects’ objective performance scores improved in all 5 domains (P<.05) in all scenarios. When scores were stratified by level of training, all participants demonstrated global improvement. When scores were stratified by previous outpatient simulation experience, subjects with previous experience improved in all but management of excess sedation. Pre- and postcurriculum self-efficacy evaluations demonstrated improvement in all 7 measured areas: confidence, use of appropriate resources, communication skills, complex airway management, bag mask ventilation, resuscitation, and hemorrhage management. Self-efficacy assessment showed improvement in confidence managing outpatient emergencies (P=.001) and ability to communicate well in emergency situations (P<.001). Conclusion A simulation-based curriculum improved both self-efficacy and objectively rated performance scores in management of outpatient medical emergencies. Simulation-based curricula should be incorporated into residency education.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.09.008
       
  • The Management of Myelomeningocele Study: Full cohort 30 month pediatric
           outcomes
    • Abstract: Publication date: Available online 12 December 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Diana L. Farmer, Elizabeth A. Thom, John W. Brock, Pamela K. Burrows, Mark P. Johnson, Lori J. Howell, Jody A. Farrell, Nalin Gupta, N. Scott Adzick
      Background Previous reports from the Management of Myelomeningocele Study (MOMS) demonstrated that prenatal repair of myelomeningocele reduces hindbrain herniation, the need for cerebrospinal fluid shunting, and improves motor function in children with myelomeningocele. The trial was stopped for efficacy after 183 patients had been randomized, but 30-month outcomes were only available at the time of initial publication in 134 mother-child dyads. Data from the complete cohort for the 30-month outcomes are presented here. Maternal and 12-month neurodevelopmental outcomes for the full cohort have been reported previously. Objective The purpose of this study is to report the 30 month outcomes for the full cohort of patients randomized to either prenatal or postnatal repair of myelomeningocele in the original Management of Myelomeningocele Study (MOMS). Study Design Eligible women were randomly assigned to undergo standard postnatal repair or prenatal repair before 26 weeks gestation. We evaluated a composite of mental development and motor function outcome at 30 months for all enrolled patients as well as independent ambulation and the Bayley II Scales of Infant Development (BSID-II). We assessed whether there was a differential effect of prenatal surgery in subgroups defined by: fetal leg movements, ventricle size, presence of hindbrain herniation, gender, and location of the myelomeningocele lesion. Within the prenatal surgery group only, we evaluated these and other baseline parameters as predictors of 30-month motor and cognitive outcomes. We evaluated whether presence or absence of a shunt at 1 year was associated with 30-month motor outcomes. Results The data for the full cohort of 183 patients corroborates the original findings of MOMS, confirming that prenatal repair improves the primary outcome composite score of mental development and motor function (199.4 ± 80.5 versus 166.7 ± 76.7, p=0.004). Prenatal surgery also resulted in improvement in the secondary outcomes of independent ambulation (44.8% versus 23.9%, p = 0.004), WeeFim® Self-Care score (20.8 versus 19.0, p=0.006), functional level at least 2 better than anatomic level (26.4% versus 11.4%, p=0.02), and mean Bayley II Psychomotor Development Index (17.3% versus 15.1%, p=0.03), but does not affect cognitive development at 30 months. On subgroup analysis, there was a nominally significant interaction between gender and surgery, with boys demonstrating better improvement in functional level and PDI. For patients receiving prenatal surgery, the presence of in utero ankle, knee, and hip movement, absence of a sac over the lesion and a myelomeningocele lesion of L3 or lower were significantly associated with independent ambulation. Postnatal motor function showed no correlation with either prenatal ventricular size or postnatal shunt placement. Conclusion The full cohort data of 30-month cognitive development and motor function outcomes validate in utero surgical repair as an effective treatment for fetuses with myelomeningocele. Current data suggest that outcomes related to the need for shunting should be counseled separately from the outcomes related to distal neurologic functioning.

      PubDate: 2017-12-13T06:05:09Z
       
  • Risk of fetal death in growth-restricted fetuses with umbilical and/or
           ductus venosus absent or reversed end-diastolic velocities before 34
           weeks of gestation: a systematic review and meta-analysis
    • Authors: J. Caradeux; R.J. Martinez-Portilla; T.R. Basuki; T. Kiserud; F. Figueras
      Abstract: Publication date: Available online 9 December 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): J. Caradeux, R.J. Martinez-Portilla, T.R. Basuki, T. Kiserud, F. Figueras
      Objective The objective of the study was to establish the risk of fetal death in early-onset growth-restricted fetuses with absent or reversed end-diastolic velocities in the umbilical artery or ductus venosus. Data Sources A systematic search was performed to identify relevant studies published in English, Spanish, French, Italian, or German using the databases PubMed, ISI Web of Science, and SCOPUS, without publication time restrictions. Study Eligibility Criteria The study criteria included observational cohort studies and randomized controlled trials of early-onset growth-restricted fetuses (diagnosed before 34 weeks of gestation), with information on the rate of fetal death occurring before 34 weeks of gestation and absent or reversed end-diastolic velocities in the umbilical artery and/or ductus venosus. Study Appraisal and Synthesis Methods For quality assessment, 2 reviewers independently assessed the risk of bias using the Newcastle-Ottawa Scale for observational studies and the Cochrane Collaboration’s tool for randomized trials. For the meta-analysis, odds ratio for both fixed and random-effects models (weighting by inverse of variance) were used. Heterogeneity between studies was assessed using tau2, χ2 (Cochrane Q), and I2 statistics. Publication bias was assessed by a funnel plot for meta-analyses and quantified by the Egger method. Results A total of 31 studies were included in this meta-analysis. The odds ratios for fetal death (random-effects models) were 3.59 (95% confidence interval, 2.3–5.6), 7.27 (95% confidence interval, 4.6–11.4), and 11.6 (95% confidence interval, 6.3–19.7) for growth-restricted fetuses with umbilical artery absent end-diastolic velocities, umbilical artery reversed end-diastolic velocities, and ductus venosus absent or reversed end-diastolic velocities, respectively. There was no substantial heterogeneity among studies for any of the analyses. Conclusion Early-onset growth-restricted fetuses with either umbilical artery or ductus venosus absent or reserved end-diastolic velocities are at a substantially increased risk for fetal death.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.11.566
       
  • The role of aspirin, heparin, and other interventions in the prevention
           and treatment of fetal growth restriction
    • Authors: Katie M. Groom; Anna L. David
      Abstract: Publication date: Available online 8 December 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Katie M. Groom, Anna L. David
      Fetal growth restriction and related placental pathologies such as preeclampsia, stillbirth, and placental abruption are believed to arise in early pregnancy when inadequate remodeling of the maternal spiral arteries leads to persistent high-resistance and low-flow uteroplacental circulation. The consequent placental ischaemia, reperfusion injury, and oxidative stress are associated with an imbalance in angiogenic/antiangiogenic factors. Many interventions have centered on the prevention and/or treatment of preeclampsia with results pertaining to fetal growth restriction and small-for-gestational-age pregnancy often included as secondary outcomes because of the common pathophysiology. This renders the study findings less reliable for determining clinical significance. For the prevention of fetal growth restriction, a recent large-study level meta-analysis and individual patient data meta-analysis confirm that aspirin modestly reduces small-for-gestational-age pregnancy in women at high risk (relative risk, 0.90, 95% confidence interval, 0.81–1.00) and that a dose of ≥100 mg should be recommended and to start at or before 16 weeks of gestation. These findings support national clinical practice guidelines. In vitro and in vivo studies suggest that low-molecular-weight heparin may prevent fetal growth restriction; however, evidence from randomized control trials is inconsistent. A meta-analysis of multicenter trial data does not demonstrate any positive preventative effect of low-molecular-weight heparin on a primary composite outcome of placenta-mediated complications including fetal growth restriction (18% vs 18%; absolute risk difference, 0.6%; 95% confidence interval, 10.4–9.2); use of low-molecular-weight heparin for the prevention of fetal growth restriction should remain in the research setting. There are even fewer treatment options once fetal growth restriction is diagnosed. At present the only management option if the risk of hypoxia, acidosis, and intrauterine death is high is iatrogenic preterm birth, with the use of peripartum maternal administration of magnesium sulphate for neuroprotection and corticosteroids for fetal lung maturity, to prevent adverse neonatal outcomes. The pipeline of potential therapies use different strategies, many aiming to increase fetal growth by improving poor placentation and uterine blood flow. Phosphodiesterase type 5 inhibitors that potentiate nitric oxide availability such as sildenafil citrate have been extensively researched both in preclinical and clinical studies; results from the Sildenafil Therapy In Dismal Prognosis Early-Onset Intrauterine Growth Restriction consortium of randomized control clinical trials are keenly awaited. Targeting the uteroplacental circulation with novel therapeutics is another approach, the most advanced being maternal vascular endothelial growth factor gene therapy, which is being translated into the clinic via the doEs Vascular endothelial growth factor gene therapy safEly impRove outcome in seveRe Early-onset fetal growth reSTriction consortium. Other targeting approaches include nanoparticles and microRNAs to deliver drugs locally to the uterine arterial endothelium or trophoblast. In vitro and in vivo studies and animal models have demonstrated effects of nitric oxide donors, dietary nitrate, hydrogen sulphide donors, statins, and proton pump inhibitors on maternal blood pressure, uteroplacental resistance indices, and angiogenic/antiangiogenic factors. Data from human pregnancies and, in particular, pregnancies with fetal growth restriction remain very limited. Early research into melatonin, creatine, and N-acetyl cysteine supplementation in pregnancy suggests they may have potential as neuro- and cardioprotective agents in fetal growth restriction.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.11.565
       
  • Living uterus donation and transplantation: Experience of interest and
           screening in a single center in the United States
    • Authors: Liza Johannesson; Kristin Wallis; E. Colin Koon; Gregory J. Mckenna; Tiffany Anthony; Sara G. Leffingwell; Goran B. Klintmalm; Robert T. Gunby; Giuliano Testa
      Abstract: Publication date: Available online 6 December 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Liza Johannesson, Kristin Wallis, E. Colin Koon, Gregory J. Mckenna, Tiffany Anthony, Sara G. Leffingwell, Goran B. Klintmalm, Robert T. Gunby, Giuliano Testa
      Background Little is known about attitudes toward uterus donation and transplantation in society and the interest of the women the treatment is aimed to assist. Objective This study examined the interest of recipients and living donors in our uterus transplantation program; it describes the screening protocol we developed and the results of the screening and reports demographic data and characteristics of screened candidates. Study Design Initial screening and evaluation included physical examinations by a gynecologist and a transplant surgeon; psychological evaluation; imaging (x-ray, computed tomography, ultrasound); blood tests; immunological testing; viral, bacterial, and fungal testing; drug screen; hormonal testing; Pap smear; urinalysis; and electrocardiogram. For selected recipients, the process also included in vitro fertilization. Results A total of 351 women contacted our department with interest in participating in uterus transplantation; 272 were potential recipients and 79 were potential donors. Among these women, 179 potential recipients and 62 potential donors and continued the evaluation after the initial telephone screening. The mean age of the donor candidates was 40 years; all had completed their own family, and 80% were nondirected. Most recipient candidates (92%) had an anatomical lack of the uterus and, of these, 36% had a congenital malformation. The women with a congenital uterine absence were in general younger than the women in the group whose uterus had been removed (mean of 28 and 33 years, respectively). In every step of the initial screening and evaluation process there were donor and recipient candidates that chose not to continue the process. The reasons for self-withdrawal were after expressing interest, not returning phone calls or emails (17 donors and 76 recipients); after initial phone screening, no longer interested (1 donor and 9 recipients); in step 1, Health history questionnaire not returned after one reminder (10 donors and 9 recipients); step 2, not right in their current life situation (2 donors and 2 recipients) and in step 3, chose another way to achieve motherhood (1 recipient). Most donor and recipient candidates (52% and 78%, respectively) could be screened out (due to self-withdrawal or transplant team’s decision) during the noninvasive and cost-efficient initial screening. Conclusion Our initial experience shows a great interest in participating in a trial of uterus transplantation by both potential recipients and donors. It is the first study to show interest in nondirected donation. A sufficient but thoughtful screening process of living donors and recipients is essential and should aim both to assure donor/recipient safety and to provide good quality grafts.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.11.594
       
  • Religious hospital policies on reproductive care: What do patients want to
           know'
    • Authors: Lori R. Freedman; Luciana E. Hebert; Molly F. Battistelli; Debra B. Stulberg
      Abstract: Publication date: Available online 6 December 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Lori R. Freedman, Luciana E. Hebert, Molly F. Battistelli, Debra B. Stulberg
      Background Religious hospitals are a large and growing part of the American healthcare system. Patients who receive obstetric and other reproductive care in religious hospitals may face religiously-based restrictions on the treatment their doctor can provide. Little is known about patients’ knowledge or preferences regarding religiously restricted reproductive healthcare. Objective(s) We aimed to assess women’s preferences for knowing a hospital’s religion and religiously-based restrictions before deciding where to seek care and the acceptability of a hospital denying miscarriage treatment options for religious reasons, with and without informing the patient that other options may be available. Study Design We conducted a national survey of women ages 18-45. The sample was recruited from AmeriSpeak, a probability-based research panel of civilian non-institutionalized adults. Of 2,857 women invited to participate, 1,430 completed surveys online or over the phone, for a survey response rate of 50.1%. All analyses adjusted for the complex sampling design and were weighted in order to generate estimates representative of the population of U.S. adult reproductive age women. We used Chi squared tests and multivariable logistic regression to evaluate associations. Results One-third of women ages 18-45 (34.5%) feel it is somewhat or very important to know a hospital’s religion when deciding where to get care, but 80.7% feel it is somewhat or very important to know about a hospital’s religious restrictions on care. Being Catholic or attending religious services more frequently does not make one more or less likely to want this information. Compared to Protestant women who do not identify as Born-again, women of other religious backgrounds are more likely to consider it important to know a hospital’s religious affiliation. These include: religious minority women (AOR= 2.17; 95% CI: 1.11-4.27), those who reported no religion/atheist/agnostic (AOR=2.27; 95% CI: 1.19-4.34), and Born-again Protestants (AOR=2.38; 95% CI: 1.32-4.28). Religious minority women (AOR= 2.36; 95% CI: 1.01-5.51) and those who reported no religion/atheist/agnostic (AOR=3.16; 95% CI: 1.42-7.04) were more likely to want to know a hospital’s restrictions on care. More than two-thirds of women find it unacceptable for the hospital to restrict information and treatment options during miscarriage based on religion. Women who attended weekly religious services were significantly more likely to accept such restrictions (AOR=3.13; 95% CI: 1.70-5.76) and to consider transfer to another site an acceptable solution (AOR=3.22; 95% CI: 1.69-6.12). When asked, “When should a religious hospital be allowed to restrict care based on religion'” 52.3% responded “never;” 16.6%, “always;” and 31.1%, “under some conditions.” Conclusion(s) The vast majority of adult American women of reproductive age want information about a hospital’s religious restrictions on care when deciding where to go for ob/gyn care. Growth in the US Catholic healthcare sector suggests an increasing need for transparency about these restrictions, so that women can make informed decisions and, when needed, seek alternative providers.

      PubDate: 2017-12-10T05:40:22Z
      DOI: 10.1016/j.ajog.2017.11.595
       
  • Information for Readers
    • Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6


      PubDate: 2017-12-10T05:40:22Z
       
  • Reply
    • Authors: Yi-Jen Chen; Teh-Fu Hsu Peng-Hui Wang
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Yi-Jen Chen, Teh-Fu Hsu, Peng-Hui Wang


      PubDate: 2017-12-10T05:40:22Z
       
  • Reply
    • Authors: Martin Hirsch; Claire Barker James M.N. Duffy
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Martin Hirsch, Claire Barker, James M.N. Duffy


      PubDate: 2017-12-10T05:40:22Z
       
  • Reply
    • Authors: Gabriele Saccone; Vincenzo Berghella Giuseppe Maria Maruotti Pasquale Martinelli
      Abstract: Publication date: December 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 6
      Author(s): Gabriele Saccone, Vincenzo Berghella, Giuseppe Maria Maruotti, Pasquale Martinelli


      PubDate: 2017-12-10T05:40:22Z
       
 
 
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