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Journal Cover American Journal of Obstetrics and Gynecology
  [SJR: 2.255]   [H-I: 171]   [232 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9378
   Published by Elsevier Homepage  [3043 journals]
  • Association of resting energy expenditure with fat gain during pregnancy
    • Authors: Kathleen M. Rasmussen
      Pages: 387 - 388
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Kathleen M. Rasmussen


      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.031
       
  • Management of sexuality, intimacy, and menopause symptoms in patients with
           ovarian cancer
    • Authors: Margaret Whicker; Jonathan Black; Gary Altwerger; Gulden Menderes; Jacqueline Feinberg; Elena Ratner
      Pages: 395 - 403
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Margaret Whicker, Jonathan Black, Gary Altwerger, Gulden Menderes, Jacqueline Feinberg, Elena Ratner
      Issues of sexuality, intimacy, and early menopause significantly impact the quality of life of patients following the diagnosis and treatment of ovarian cancer. These are undertreated problems. Successful treatment requires the provider’s awareness of the problem, ability to identify it, and willingness to treat it. Unfortunately many providers do not address these issues in the pretreatment or perioperative period. Furthermore, patients do not often alert their providers to their symptoms. While systemic hormone therapy may improve many of the issues, they are not appropriate for all patients given their action on estrogen receptors. However, other nonhormonal treatments exist including selective serotonin reuptake inhibitors, antiepileptics, natural remedies, and pelvic floor physical therapy. In addition psychological care and the involvement of the partner can be helpful in managing the sexual health concerns of these patients. At the time of diagnosis or at initial consultation, women should be informed of the potential physiologic, hormonal, and psychosocial effects of ovarian cancer on sexuality and that there is a multimodal approach to dealing with symptoms.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.04.012
       
  • Why do we continue to overtreat stage Ia carcinoma of the cervix'
    • Authors: Tommy Buchanan; Jennifer Young Pierce; Whitney Graybill; Matthew Kohler; William Creasman
      Pages: 413 - 417
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Tommy Buchanan, Jennifer Young Pierce, Whitney Graybill, Matthew Kohler, William Creasman
      The current recommended treatment for stage Ia2 cervical cancer is a radical or modified radical hysterectomy. Although in the United States the incidence of cervical cancer is low and declining, almost 50% of the >4000 new cases will present in early stages. An estimated 2200 women each year will undergo radical hysterectomy and many will have both early- and late-onset complications. The purpose of this review is to examine if there is still a role for radical hysterectomy in the proper treatment of stage Ia2 cervical cancer given most recent data. Sufficient histological evidence suggests that although parametrial involvement and lymph node metastases can increase the risk for recurrence, they are relatively uncommon at early stages. Worldwide data that challenge radical hysterectomy as standard of care have shown that conservative management of stage Ia2 cervical cancer results in similar survival and recurrence rates. It is the recommendation based on all reviewed data that radical hysterectomy should no longer be considered standard of care in all cases of stage Ia2 cervical cancer.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.020
       
  • A profile of Alan H. DeCherney, MD
    • Authors: Roberto Romero
      Pages: 389.e1 - 389.e12
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Roberto Romero


      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.028
       
  • The environmental injustice of beauty: framing chemical exposures from
           beauty products as a health disparities concern
    • Authors: Ami R. Zota; Bhavna Shamasunder
      Pages: 418.e1 - 418.e6
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Ami R. Zota, Bhavna Shamasunder
      The obstetrics-gynecology community has issued a call to action to prevent toxic environmental chemical exposures and their threats to healthy human reproduction. Recent committee opinions recognize that vulnerable and underserved women may be impacted disproportionately by environmental chemical exposures and recommend that reproductive health professionals champion policies that secure environmental justice. Beauty product use is an understudied source of environmental chemical exposures. Beauty products can include reproductive and developmental toxicants such as phthalates and heavy metals; however, disclosure requirements are limited and inconsistent. Compared with white women, women of color have higher levels of beauty product–related environmental chemicals in their bodies, independent of socioeconomic status. Even small exposures to toxic chemicals during critical periods of development (such as pregnancy) can trigger adverse health consequences (such as impacts on fertility and pregnancy, neurodevelopment, and cancer). In this commentary, we seek to highlight the connections between environmental justice and beauty product–related chemical exposures. We describe racial/ethnic differences in beauty product use (such as skin lighteners, hair straighteners, and feminine hygiene products) and the potential chemical exposures and health risks that are associated with these products. We also discuss how targeted advertising can take advantage of mainstream beauty norms to influence the use of these products. Reproductive health professionals can use this information to advance environmental justice by being prepared to counsel patients who have questions about toxic environmental exposures from beauty care products and other sources. Researchers and healthcare providers can also promote health-protective policies such as improved ingredient testing and disclosure for the beauty product industry. Future clinical and public health research should consider beauty product use as a factor that may shape health inequities in women's reproductive health across the life course.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.07.020
       
  • A randomized trial of motivational interviewing and facilitated
           contraceptive access to prevent rapid repeat pregnancy among adolescent
           mothers
    • Authors: Jack Stevens; Robyn Lutz; Ngozi Osuagwu; Dana Rotz; Brian Goesling
      Pages: 423.e1 - 423.e9
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Jack Stevens, Robyn Lutz, Ngozi Osuagwu, Dana Rotz, Brian Goesling
      Background Most interventions designed to reduce teen pregnancy rates have not focused on pregnant and/or parenting adolescents. Therefore, a large randomized controlled trial was conducted regarding a motivational interviewing program entitled Teen Options to Prevent Pregnancy in a low-income sample of adolescent mothers. This program recommended monthly sessions between a participant and a registered nurse over 18 months. This program also featured facilitated birth control access through transportation assistance and a part-time contraceptive clinic. Objective The impact of this program on rapid repeat pregnancies at 18 months after enrollment was evaluated. Study Design Five hundred ninety-eight adolescent females were enrolled from 7 obstetrics-gynecology clinics and 5 postpartum units of a large hospital system in a Midwestern city. Each participant was enrolled at least 28 weeks pregnant or less than 9 weeks postpartum. Each participant was randomized to either the Teen Options to Prevent Pregnancy intervention or a usual-care control condition. Intervention participants averaged 4.5 hours of assistance. Participants were contacted by blinded research staff at 6 and 18 months to complete self-report surveys. Differences in outcomes between the intervention and control groups were assessed using ordinary least-squares regression. Results There was an 18.1% absolute reduction in self-reported repeat pregnancy in the intervention group relative to the control group (20.5% vs 38.6%%; P < .001). There was a 13.7% absolute increase in self-reported long-acting reversible contraception use in the intervention group relative to the control group (40.2% vs 26.5%, P = .002). There was no evidence of harmful effects of the intervention on sexual risk behaviors, such as having sexual intercourse without a condom or greater number of partners. Conclusion The Teen Options to Prevent Pregnancy program represents one of the few evidence-based interventions to reduce rapid repeat teen pregnancy. This relatively brief intervention may be a viable alternative to more time-intensive programs that adolescent mothers may be unable or unwilling to receive.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.010
       
  • Longitudinal associations between mental health conditions and overactive
           bladder in women veterans
    • Authors: Catherine S. Bradley; Ingrid E. Nygaard; Stephen L. Hillis; James C. Torner; Anne G. Sadler
      Pages: 430.e1 - 430.e8
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Catherine S. Bradley, Ingrid E. Nygaard, Stephen L. Hillis, James C. Torner, Anne G. Sadler
      Background One in 5 recently deployed US women veterans report overactive bladder symptoms. Mental health conditions such as depression and anxiety commonly co-occur in women with overactive bladder, but temporal relationships between these outcomes have not been well studied, and the mechanism behind this association is unknown. The Women Veterans Urinary Health Study, a nationwide longitudinal study in recently deployed women veterans, was designed to better understand relationships between overactive bladder and mental health conditions. Objective We sought to estimate the 1-year incidence and remission of overactive bladder and to identify the impact of depression, anxiety, posttraumatic stress disorder, and prior sexual assault on 1-year overactive bladder incidence and remission rates. Study Design Participants of this 1-year prospective cohort study were female veterans separated from military service who had returned from Iraq or Afghanistan deployment within the previous 2 years. Eligible women were identified through the Defense Manpower Data Center and recruited by mail and telephone. Telephone screening confirmed participants were ambulatory, community-dwelling veterans and excluded those with urinary tract fistula, congenital abnormality, or cancer; pelvic radiation; spinal cord injury; multiple sclerosis; Parkinson disease; stroke; or current/recent pregnancy. Data collection included computer-assisted telephone interviews performed at enrollment and 1 year later. The interview assessed demographic and military service characteristics; urinary symptoms and treatment; depression, anxiety, and posttraumatic stress disorder symptoms and treatment; and a lifetime history of sexual assault. Overactive bladder was identified if at least moderately bothersome urgency urinary incontinence and/or urinary frequency symptoms were reported on Urogenital Distress Inventory items. Exposures included depression, anxiety, posttraumatic stress disorder, and lifetime sexual assault, assessed at baseline using validated questionnaires (including the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist). Associations between exposures and overactive bladder incidence and remission were estimated using propensity score adjusted logistic regression models. Results In all, 1107 (88.0%) of 1258 eligible participants completed 1-year interviews. Median age was 29 (range 20-67) years and 53% were nulliparous. Overactive bladder was identified at baseline in 242 (22%), and 102 (9.2%), 218 (19.7%), 188 (17.0%), and 287 (25.9%) met criteria for baseline depression, anxiety, posttraumatic stress disorder, and lifetime sexual assault, respectively. At 1 year, overactive bladder incidence was 10.5% (95% confidence interval, 8.6–12.8%), and remission of overactive bladder was 36.9% (95% confidence interval, 30.8–43.4%). New overactive bladder occurred more often in women with baseline anxiety (21% vs 9%), posttraumatic stress disorder (19% vs 9%) and lifetime sexual assault (16% vs 9%) (all: P < .01). After adjustment, anxiety (odds ratio, 2.4; 95% confidence interval, 1.4–4.1) and lifetime sexual assault (odds ratio, 1.7; 95% confidence interval, 1.0–2.8) predicted 1-year incident overactive bladder. Overactive bladder remission occurred less often in those with baseline depression (19% vs 41%, P < .01) and anxiety (29% vs 42%, P = .03). After adjustment, depression decreased 1-year overactive bladder remission risk (odds ratio, 0.37; 95% confidence interval, 0.16–0.83). Overactive bladder treatment was uncommon and not associated with remission. Conclusion Anxiety, depression, and prior sexual assault–common postdeployment problems for women veterans–influence the natural history of overactive bladder. Providers should screen for mental health conditions and sexual assault in women with newly diagnosed or persistent overactive bladder.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.016
       
  • Clinicopathologic and molecular markers in cervical carcinoma: a
           prospective cohort study
    • Authors: Mari Kyllesø Halle; Akinyemi I. Ojesina; Hilde Engerud; Kathrine Woie; Ingvild Løberg Tangen; Frederik Holst; Erling Høivik; Kanthida Kusonmano; Ingfrid S. Haldorsen; Olav K. Vintermyr; Jone Trovik; Bjørn I. Bertelsen; Helga B. Salvesen; Camilla Krakstad
      Pages: 432.e1 - 432.e17
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Mari Kyllesø Halle, Akinyemi I. Ojesina, Hilde Engerud, Kathrine Woie, Ingvild Løberg Tangen, Frederik Holst, Erling Høivik, Kanthida Kusonmano, Ingfrid S. Haldorsen, Olav K. Vintermyr, Jone Trovik, Bjørn I. Bertelsen, Helga B. Salvesen, Camilla Krakstad
      Background Cervical cancer is a major health problem worldwide. Identification of effective clinicopathologic and molecular markers is vital to improve treatment stratification. Objectives The purpose of this study was to validate a set of well-defined clinicopathologic features in a large population-based, prospectively collected cervical cancer cohort to support their use in the clinic. Further, we explored p53 and human epidermal growth factor receptor 2 as potential prognostic markers in cervical cancer. Study Design Tissue was collected from 401 patients with cervical cancer. Clinical data that included follow-up evaluations were collected from patient journals. Histopathologic data were evaluated and revised by an expert pathologist. The prognostic impact of selected clinicopathologic variables was analyzed in the whole cohort. Tissue microarrays were prepared from 292 carcinomas, and p53 and human epidermal growth factor receptor 2 protein levels were evaluated by immunohistochemistry. Fresh frozen samples from overlapping cervical carcinomas previously were subjected to human papilloma virus typing (n=94), whole exome (n=100) and RNA (n=79) sequencing; the results were available for our analyses. Results Among the clinicopathologic variables, vascular space invasion, histologic type, and tumor size were verified as strong independent prognostic markers. High p53 protein levels were associated significantly with markers for aggressive phenotype and survival, also in multivariate survival analysis, but did not reflect TP53 mutational status. High human epidermal growth factor receptor 2 protein levels were identified in 21% of all tumors. ERBB2 amplification was associated with poor outcome (P=.003); human epidermal growth factor receptor 2 protein level was not. Conclusions Our findings support that the Féderation Internationale de Gynécologie et d’Obstétrique s guidelines should include vascular space invasion and tumor size 2–4 cm and that careful selection of histologic type is essential for stratification of patient risk groups. High p53 levels independently predict poor survival yet do not reflect mutational status in cervical cancer. Amplified ERBB2 significantly links to poor survival, while HercepTest does not. With optimal stratification, human epidermal growth factor receptor 2–based therapy may improve cervical cancer treatment.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.068
       
  • Trends in end-of-life care and health care spending in women with
           uterine cancer
    • Authors: Benjamin Margolis; Ling Chen; Melissa K. Accordino; Grace Clarke Hillyer; June Y. Hou; Ana I. Tergas; William M. Burke; Alfred I. Neugut; Cande V. Ananth; Dawn L. Hershman; Jason D. Wright
      Pages: 434.e1 - 434.e10
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Benjamin Margolis, Ling Chen, Melissa K. Accordino, Grace Clarke Hillyer, June Y. Hou, Ana I. Tergas, William M. Burke, Alfred I. Neugut, Cande V. Ananth, Dawn L. Hershman, Jason D. Wright
      Background High-intensity care including hospitalizations, chemotherapy, and other interventions at the end of life is costly and often of little value for cancer patients. Little is known about patterns of end-of-life care and resource utilization for women with uterine cancer. Objective We examined the costs and predictors of aggressive end-of-life care for women with uterine cancer. Study Design In this observational cohort study the Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify women age ≥65 years who died from uterine cancer from 2000 through 2011. Resource utilization in the last month of life including ≥2 hospital admissions, >1 emergency department visit, ≥1 intensive care unit admission, or use of chemotherapy in the last 14 days of life was examined. High-intensity care was defined as the occurrence of any of the above outcomes. Logistic regression models were developed to identify factors associated with high-intensity care. Total Medicare expenditures in the last month of life are reported. Results Of the 5873 patients identified, the majority had stage IV cancer (30.2%), were white (79.9%), and had endometrioid tumors (47.6%). High-intensity care was rendered to 42.5% of women. During the last month of life, 15.0% had ≥2 hospital admissions, 9.0% had a hospitalization >14 days, 15.3% had >1 emergency department visits, 18.3% had an intensive care unit admission, and 6.6% received chemotherapy in the last 14 days of life. The percentage of women who received high-intensity care was stable over the study period. Characteristics of younger age, black race, higher number of comorbidities, stage IV disease, residence in the eastern United States, and more recent diagnosis were associated with high-intensity care. The median Medicare payment during the last month of life was $7645. Total per beneficiary Medicare payments remained stable from $9656 (interquartile range $3190-15,890) in 2000 to $9208 (interquartile range $3309-18,554) by 2011. The median health care expenditure was 4 times as high for those who received high-intensity care compared to those who did not (median $16,173 vs $4099). Conclusion Among women with uterine cancer, high-intensity care is common in the last month of life, associated with substantial monetary expenditures, and does not appear to be decreasing.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.07.006
       
  • Urine leakage during sexual activity among ethnically diverse,
           community-dwelling middle-aged and older women
    • Authors: Nagambika Munaganuru; Stephen K. Van Den Eeden; Jennifer Creasman; Leslee L. Subak; Lisa Strano-Paul; Alison J. Huang
      Pages: 439.e1 - 439.e8
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Nagambika Munaganuru, Stephen K. Van Den Eeden, Jennifer Creasman, Leslee L. Subak, Lisa Strano-Paul, Alison J. Huang
      Background Urinary incontinence is associated with decreased female sexual function, but little is known about the prevalence, predictors, and impact of urine leakage during sexual activity among women in the community. Objective The purpose of this study was to evaluate the prevalence and impact of urine leakage during sex in ethnically diverse, community-dwelling midlife and older women. Study Design Urinary incontinence and sexual function were assessed by structured questionnaire in a multiethnic, community-based cohort of women enrolled in Kaiser Permanente Northern California, an integrated healthcare delivery system in California. All women were aged 40–80 years and sampled from 1 of 4 racial/ethnic groups (20% black, 20% Latina, 20% Asian, and 40% non-Latina white). Differences in frequency, bother, and fear of urine leakage during sexual activity were examined among women with monthly, weekly, and daily urinary incontinence and across different types of urinary incontinence (stress, urgency, mixed, and other type urinary incontinence), with the use of chi-square tests. Independent risk factors for urine leakage during sexual activity were identified through multivariable logistic regression. Results Of the 509 women who reported being sexually active and having at least monthly urinary incontinence, 127 of them (25%) reported experiencing any urine leakage during sex during the past 3 months. Nineteen percent of the women reported being subjectively bothered by leakage during sex, and 16% of them reported restricting sexual activity because of fear of leakage. Women with more frequent underlying urinary incontinence were more likely to report experiencing or being bothered by leakage during sex and restricting sexual activity because of fear of leakage (P<.001 for all). Participants with predominantly stress or mixed type urinary incontinence were more likely to report experiencing leakage during sex and being subjectively bothered by this leakage (P<.002 for all). Factors independently associated with leakage during sex were depression (odds ratio,1.96; 95% confidence interval, 1.20–3.20), symptomatic pelvic organ prolapse (odds ratio, 2.10; 95% confidence interval, 1.11–3.98), mixed vs urgency type urinary incontinence (odds ratio, 3.16; 95% confidence interval, 1.70–5.88), stress vs urgency type urinary incontinence (odds ratio, 1.94; 95% confidence interval, 1.01–3.70), and frequency of sexual activity (odds ratio, 1.6395% confidence interval, 1.05–2.55), but not age or race/ethnicity. Conclusions Up to a quarter of women with at least monthly urinary incontinence in the community may experience urine leakage during sexual activity. Many incontinent women who leak urine during sex remain sexually active, which indicates that the preservation of sexual function should still be a priority in this population. Among incontinent women, depression, pelvic organ prolapse, and stress mixed-type urinary incontinence may be associated with urine leakage during sexual activity.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.069
       
  • Evidence that fetal death is associated with placental aging
    • Authors: Kaushik Maiti; Zakia Sultana; Robert J. Aitken; Jonathan Morris; Felicity Park; Bronwyn Andrew; Simon C. Riley; Roger Smith
      Pages: 441.e1 - 441.e14
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Kaushik Maiti, Zakia Sultana, Robert J. Aitken, Jonathan Morris, Felicity Park, Bronwyn Andrew, Simon C. Riley, Roger Smith
      Background The risk of unexplained fetal death or stillbirth increases late in pregnancy, suggesting that placental aging is an etiological factor. Aging is associated with oxidative damage to DNA, RNA, and lipids. We hypothesized that placentas at >41 completed weeks of gestation (late-term) would show changes consistent with aging that would also be present in placentas associated with stillbirths. Objective We sought to determine whether placentas from late-term pregnancies and unexplained stillbirth show oxidative damage and other biochemical signs of aging. We also aimed to develop an in vitro term placental explant culture model to test the aging pathways. Study Design We collected placentas from women at 37-39 weeks’ gestation (early-term and term), late-term, and with unexplained stillbirth. We used immunohistochemistry to compare the 3 groups for: DNA/RNA oxidation (8-hydroxy-deoxyguanosine), lysosomal distribution (lysosome-associated membrane protein 2), lipid oxidation (4-hydroxynonenal), and autophagosome size (microtubule-associated proteins 1A/1B light chain 3B, LC3B). The expression of aldehyde oxidase 1 was measured by real-time polymerase chain reaction. Using a placental explant culture model, we tested the hypothesis that aldehyde oxidase 1 mediates oxidative damage to lipids in the placenta. Results Placentas from late-term pregnancies show increased aldehyde oxidase 1 expression, oxidation of DNA/RNA and lipid, perinuclear location of lysosomes, and larger autophagosomes compared to placentas from women delivered at 37-39 weeks. Stillbirth-associated placentas showed similar changes in oxidation of DNA/RNA and lipid, lysosomal location, and autophagosome size to placentas from late-term. Placental explants from term deliveries cultured in serum-free medium also showed evidence of oxidation of lipid, perinuclear lysosomes, and larger autophagosomes, changes that were blocked by the G-protein-coupled estrogen receptor 1 agonist G1, while the oxidation of lipid was blocked by the aldehyde oxidase 1 inhibitor raloxifene. Conclusion Our data are consistent with a role for aldehyde oxidase 1 and G-protein-coupled estrogen receptor 1 in mediating aging of the placenta that may contribute to stillbirth. The placenta is a tractable model of aging in human tissue.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.015
       
  • A mouse model of antepartum stillbirth
    • Authors: Anum Rahman; Lindsay S. Cahill; Yu-Qing Zhou; Johnathan Hoggarth; Monique Y. Rennie; Mike Seed; Christopher K. Macgowan; John C. Kingdom; S. Lee Adamson; John G. Sled
      Pages: 443.e1 - 443.e11
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Anum Rahman, Lindsay S. Cahill, Yu-Qing Zhou, Johnathan Hoggarth, Monique Y. Rennie, Mike Seed, Christopher K. Macgowan, John C. Kingdom, S. Lee Adamson, John G. Sled
      Background Many stillbirths of normally formed fetuses in the third trimester could be prevented via delivery if reliable means to anticipate this outcome existed. However, because the etiology of these stillbirths is often unexplained and although the underlying mechanism is presumed to be hypoxia from placental insufficiency, the placentas often appear normal on histopathological examination. Gestational age is a risk factor for antepartum stillbirth, with a rapid rise in stillbirth rates after 40 weeks’ gestation. We speculate that a common mechanism may explain antepartum stillbirth in both the late-term and postterm periods. Mice also show increasing rates of stillbirth when pregnancy is artificially prolonged. The model therefore affords an opportunity to characterize events that precede stillbirth. Objective The objective of the study was to prolong gestation in mice and monitor fetal and placental growth and cardiovascular changes. Study Design From embryonic day 15.5 to embryonic day 18.5, pregnant CD-1 mice received daily progesterone injections to prolong pregnancy by an additional 24 hour period (to embryonic day 19.5). To characterize fetal and placental development, experimental assays were performed throughout late gestation (embryonic day 15.5 to embryonic day 19.5), including postnatal day 1 pups as controls. In addition to collecting fetal and placental weights, we monitored fetal blood flow using Doppler ultrasound and examined the fetoplacental arterial vascular geometry using microcomputed tomography. Evidence of hypoxic organ injury in the fetus was assessed using magnetic resonance imaging and pimonidazole immunohistochemistry. Results At embryonic day 19.5, mean fetal weights were reduced by 14% compared with control postnatal day 1 pups. Ultrasound biomicroscopy showed that fetal heart rate and umbilical artery flow continued to increase at embryonic day 19.5. Despite this, the embryonic day 19.5 fetuses had significant pimonidazole staining in both brain and liver tissue, indicating fetal hypoxia. Placental weights at embryonic day 19.5 were 21% lower than at term (embryonic day 18.5). Microcomputed tomography showed no change in quantitative morphology of the fetoplacental arterial vasculature between embryonic day 18.5 and embryonic day 19.5. Conclusion Prolongation of pregnancy renders the murine fetus vulnerable to significant growth restriction and hypoxia because of differential loss of placental mass rather than any compromise in fetoplacental blood flow. Our data are consistent with a hypoxic mechanism of antepartum fetal death in human term and postterm pregnancy and validates the inability of umbilical artery Doppler to safely monitor such fetuses. New tests of placental function are needed to identify the late-term fetus at risk of hypoxia to intervene by delivery to avoid antepartum stillbirth.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.009
       
  • Variations in resting energy expenditure: impact on gestational
           weight gain
    • Authors: E.K. Berggren; P. O’Tierney-Ginn; S. Lewis; L. Presley; S. Hauguel De-Mouzon; P.M. Catalano
      Pages: 445.e1 - 445.e6
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): E.K. Berggren, P. O’Tierney-Ginn, S. Lewis, L. Presley, S. Hauguel De-Mouzon, P.M. Catalano
      Background There are significant variations in gestational weight gain, with many women gaining in excess of the Institute of Medicine guidelines. Unfortunately, efforts to improve appropriate gestational weight gain have had only limited success. To date, interventions have focused primarily on decreasing energy intake and/or increasing physical activity. Maternal resting energy expenditure, which comprises ∼60% of total energy expenditure compared with the ∼20% that comes from physical activity, may be an important consideration in understanding variations in gestational weight gain. Objective Our objective was to quantify the changes in resting energy expenditure during pregnancy and their relationship to gestational weight gain and body composition changes among healthy women. We hypothesized that greater gestational weight gain, and fat mass accrual in particular, are inversely related to variations in resting energy expenditure. Study Design We conducted a secondary analysis of a prospective cohort studied before conception and late pregnancy (34–36 weeks). Body composition (estimated using hydrodensitometry) and resting energy expenditure (estimated using indirect calorimetry) were measured. The relationship between the changes in resting energy expenditure and gestational weight gain and the change in fat mass and fat-free mass were quantified. Resting energy expenditure was expressed as kilocalories per kilogram of fat-free mass per day (kilocalories per kilogram of fat-free mass–1/day–1) and kilocalories per day. Correlations are reported as r. Results Among 51 women, preconception body mass index was 23.0 (4.7) kg/m2; gestational weight gain was 12.8 (4.7) kg. Preconception and late pregnancy resting energy expenditure (kilocalories per day) correlated positively with the change in fat-free mass (r = 0.37, P = .008; r = 0.51, P = .001). Late-pregnancy resting energy expenditure (kilocalories per kilogram of fat-free mass–1/day–1) was inversely associated with the change in fat mass (r = –0.34, P = .02) and gestational weight gain (r = –0.29, P = .04). From before pregnancy through late gestation, the increase in resting energy expenditure (kilocalories per day) correlated positively with the change in fat-free mass (r = 0.44, P = .002) and negatively with the change in fat mass (r = –0.27, P = .06). Conclusion The change in resting energy expenditure from before conception through late gestation correlated positively with changes in fat-free mass but negatively with fat mass accrual. Women with smaller increases in resting energy expenditure across pregnancy had greater gestational weight gain, specifically more adipose tissue. These data suggest that resting energy expenditure is an important factor in gestational weight gain, particularly excess fat mass accrual. Future lifestyle intervention studies need to consider clinically feasible means of estimating resting energy expenditure and, in response, tailor nutrient intake and composition recommendations. Implementing and testing such interventions would be a novel approach to improve compliance with gestational weight gain guidelines.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.054
       
  • Objectively measured short sleep duration and later sleep midpoint in
           pregnancy are associated with a higher risk of gestational diabetes
    • Authors: Francesca L. Facco; William A. Grobman; Kathryn J. Reid; Corette B. Parker; Shannon M. Hunter; Robert M. Silver; Robert C. Basner; George R. Saade; Grace W. Pien; Shalini Manchanda; Judette M. Louis; Chia-Ling Nhan-Chang; Judith H. Chung; Deborah A. Wing; Hyagriv N. Simhan; David M. Haas; Jay Iams; Samuel Parry; Phyllis C. Zee
      Pages: 447.e1 - 447.e13
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Francesca L. Facco, William A. Grobman, Kathryn J. Reid, Corette B. Parker, Shannon M. Hunter, Robert M. Silver, Robert C. Basner, George R. Saade, Grace W. Pien, Shalini Manchanda, Judette M. Louis, Chia-Ling Nhan-Chang, Judith H. Chung, Deborah A. Wing, Hyagriv N. Simhan, David M. Haas, Jay Iams, Samuel Parry, Phyllis C. Zee
      Background Experimental and epidemiologic data suggest that among nonpregnant adults, sleep duration may be an important risk factor for chronic disease. Although pregnant women commonly report poor sleep, few studies objectively evaluated the quality of sleep in pregnancy or explored the relationship between sleep disturbances and maternal and perinatal outcomes. Objective Our objective was to examine the relationship between objectively assessed sleep duration, timing, and continuity (measured via wrist actigraphy) and maternal cardiovascular and metabolic morbidity specific to pregnancy. Study Design This was a prospective cohort study of nulliparous women. Women were recruited between 16 0/7 and 21 6/7 weeks’ gestation. They were asked to wear a wrist actigraphy monitor and complete a daily sleep log for a period of 7 consecutive days. The primary sleep exposure variables were the averages of the following over the total valid nights (minimum 5, maximum 7 nights): short sleep duration during the primary sleep period (<7 h/night), late sleep midpoint (midpoint between sleep onset and sleep offset >5 am), and top quartile of minutes of wake time after sleep onset and sleep fragmentation index. The primary outcomes of interest were a composite of hypertensive disorders of pregnancy (mild, severe, or superimposed preeclampsia; eclampsia; or antepartum gestational hypertension) and gestational diabetes mellitus. We used χ2 tests to assess associations between sleep variables and categorical baseline characteristics. Crude odds ratios and 95% confidence intervals were estimated from univariate logistic regression models to characterize the magnitude of the relationship between sleep characteristics and hypertensive disorders of pregnancy and gestational diabetes. For associations significant in univariate analysis, multiple logistic regression was used to explore further the association of sleep characteristics with pregnancy outcomes. Results In all, 901 eligible women consented to participate; 782 submitted valid actigraphy studies. Short sleep duration and a later sleep midpoint were associated with an increased risk of gestational diabetes (odds ratio, 2.24; 95% confidence interval, 1.11–4.53; and odds ratio, 2.58; 95% confidence interval, 1.24–5.36, respectively) but not of hypertensive disorders. A model with both sleep duration and sleep midpoint as well as their interaction term revealed that while there was no significant interaction between these exposures, the main effects of both short sleep duration and later sleep midpoint with gestational diabetes remained significant (adjusted odds ratio, 2.06; 95% confidence interval, 1.01–4.19; and adjusted odds ratio, 2.37; 95% confidence interval, 1.13–4.97, respectively). Additionally, after adjusting separately for age, body mass index, and race/ethnicity, both short sleep duration and later sleep midpoint remained associated with gestational diabetes. No associations were demonstrated between the sleep quality measures (wake after sleep onset, sleep fragmentation) and hypertensive disorders or gestational diabetes. Conclusion Our results demonstrate a relationship between short sleep duration and later sleep midpoint with gestational diabetes. Our data suggest independent contributions of these 2 sleep characteristics to the risk for gestational diabetes in nulliparous women.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.066
       
  • Nonmedically indicated induction in morbidly obese women is not
           associated with an increased risk of cesarean delivery
    • Authors: Tetsuya Kawakita; Sara N. Iqbal; Chun-Chih Huang; Uma M. Reddy
      Pages: 451.e1 - 451.e8
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Tetsuya Kawakita, Sara N. Iqbal, Chun-Chih Huang, Uma M. Reddy
      Background The prevalence of morbid obesity (body mass index ≥40 kg/m2) in women aged 20-39 years was 7.5% in 2009 through 2010. Morbid obesity is associated with an increased risk of stillbirth compared with normal body mass index, especially >39 weeks’ gestation. The data regarding increased risk of cesarean delivery associated with nonmedically indicated induction of labor compared to expectant management in morbidly obese women are limited. Objective We sought to compare the cesarean delivery rate of nonmedically indicated induction of labor with expectant management in morbidly obese women without other comorbidity. Study Design This was a retrospective cohort study from the Consortium on Safe Labor of morbidly obese women with singleton, cephalic gestations without previous cesarean, chronic hypertension, or gestational or pregestational diabetes between 37 0/7 and 41 6/7 weeks’ gestation. We examined maternal outcomes including cesarean delivery, operative delivery, third- or fourth-degree laceration, postpartum hemorrhage, and composite maternal outcome (any of: transfusion, intensive care unit admission, venous thromboembolism). We also examined neonatal outcomes including shoulder dystocia, macrosomia (>4000 g), neonatal intensive care unit admission, and composite neonatal outcome (5-min Apgar score <5, stillbirth, neonatal death, or asphyxia or hypoxic-ischemic encephalopathy). Adjusted odds ratios with 95% confidence intervals were calculated, controlling for maternal characteristics, hospital type, and simplified Bishop score. Analyses were conducted at early and full term (37 0/7 to 38 6/7 and 39 0/7 to 40 6/7 weeks’ gestation, respectively). Women who delivered between 41 0/7 and 41 6/7 weeks’ gestation were included as expectant management group. Results Of 1894 nulliparous and 2455 multiparous morbidly obese women, 429 (22.7%) and 791 (32.2%) had nonmedically indicated induction, respectively. In nulliparas, nonmedically indicated induction was not associated with increased risks of cesarean delivery and was associated with decreased risks of macrosomia (2.2% vs 11.0%; adjusted odds ratio, 0.24; 95% confidence interval, 0.05–0.70) at early term and decreased neonatal intensive care unit admission (5.1% vs 8.9%; adjusted odds ratio, 0.59; 95% confidence interval, 0.33–0.98) at full term compared with expectant management. In multiparas, nonmedically indicated induction compared with expectant management was associated with a decreased risk of macrosomia at early term (4.2% vs 14.3%; adjusted odds ratio, 0.30; 95% confidence interval, 0.13–0.60), cesarean delivery at full term (5.4% vs 7.9%; adjusted odds ratio, 0.64; 95% confidence interval, 0.41–0.98), and composite neonatal outcome (0% vs 0.6%; adjusted odds ratio, 0.10; 95% confidence interval, <.01–0.89) at full term. Conclusion In morbidly obese women without other comorbidity, nonmedically indicated induction was not associated with an increased risk of cesarean delivery.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.048
       
  • Fractional fetal thigh volume in the prediction of normal and abnormal
           fetal growth during the third trimester of pregnancy
    • Authors: Louise E. Simcox; Jenny E. Myers; Tim J. Cole; Edward D. Johnstone
      Pages: 453.e1 - 453.e12
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Louise E. Simcox, Jenny E. Myers, Tim J. Cole, Edward D. Johnstone
      Background Currently, 2-dimensional ultrasound estimation of fetal size rather than fetal growth is used to define fetal growth restriction, but single estimates in late pregnancy lack sensitivity and may identify small for gestational age rather than growth restriction. Single or longitudinal measures of 3-dimensional fractional thigh volume may address this problem. Objective We sought to derive normal values for 3-dimensional fractional thigh volume in the third trimester, determine if fractional thigh volume is superior to 2-dimensional ultrasound biometry alone for detecting fetal growth restriction, and determine whether individualized growth assessment parameters have the potential to identify fetal growth restriction remote from term delivery. Study Design This was a longitudinal prospective cohort study of 115 unselected pregnancies in a tertiary referral unit (St Mary’s Hospital, Manchester, United Kingdom). Standard 2-dimensional ultrasound biometry measurements were obtained, along with fractional thigh volume measurements (based on 50% of the femoral diaphysis length). Measurements were used to calculate estimated fetal weight (Hadlock). Individualized growth assessment parameters and percentage deviations in longitudinally measured biometrics were determined using a Web-based system (iGAP; http://iGAP.research.bcm.edu). Small for gestational age was defined <10th and fetal growth restriction <3rd customized birthweight centile. Logistic regression was used to compare estimated fetal weight (Hadlock), estimated fetal weight (biparietal diameter–abdominal circumference–fractional thigh volume), fractional thigh volume, and abdominal circumference for the prediction of small for gestational age or fetal growth restriction at birth. Screening performance was assessed using area under the receiver operating characteristic curve. Results There was a better correlation between fractional thigh volume and estimated fetal weight ((biparietal diameter–abdominal circumference–fractional thigh volume) obtained at 34-36 weeks with birthweight than between 2-dimensional biometry measures such as abdominal circumference and estimated fetal weight (Hadlock). There was also a modest improvement in the detection of both small for gestational age and fetal growth restriction using fractional thigh volume–derived measures compared to standard 2-dimensional measurements (area under receiver operating characteristic curve, 0.86; 95% confidence interval, 0.79–0.94, and area under receiver operating characteristic curve, 0.92; 95% confidence interval, 0.85–0.99, respectively). Conclusion Fractional thigh volume measurements offer some improvement over 2-dimensional biometry for the detection of late-onset fetal growth restriction at 34-36 weeks.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.018
       
  • Cervical cerclage placement decreases local levels of proinflammatory
           cytokines in patients with cervical insufficiency
    • Authors: Stephany P. Monsanto; Silvia Daher; Erika Ono; Karen Priscilla Tezotto Pendeloski; Évelyn Trainá; Rosiane Mattar; Chandrakant Tayade
      Pages: 455.e1 - 455.e8
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Stephany P. Monsanto, Silvia Daher, Erika Ono, Karen Priscilla Tezotto Pendeloski, Évelyn Trainá, Rosiane Mattar, Chandrakant Tayade
      Background Cervical insufficiency is characterized by premature, progressive dilation and shortening of the cervix during pregnancy. If left unattended, this can lead to the prolapse and rupture of the amniotic membrane, which usually results in midtrimester pregnancy loss or preterm birth. Previous studies have shown that proinflammatory cytokines such as interleukin-1β, interleukin-6, interleukin-8, and tumor necrosis factor alpha are up-regulated in normal parturition but are also associated with preterm birth. Studies evaluating such markers in patients with cervical insufficiency have evaluated only their diagnostic potential. Even fewer studies have studied them within the context of cerclage surgery. Objectives(S) The objective of the study was to evaluate the impact of local and systemic inflammatory markers on the pathogenesis of cervical insufficiency and the effect of cerclage surgery on the local immune microenvironment of women with cervical insufficiency. Study Design We recruited 28 pregnant women (12–20 weeks’ gestation) diagnosed with insufficiency and referred for cerclage surgery and 19 gestational age–matched normal pregnant women as controls. Serum and cervicovaginal fluid samples were collected before and after cerclage surgery and during a routine checkup for normal women and analyzed using a targeted 13-plex proinflammatory cytokine assay. Results Before surgery, patients with cervical insufficiency had higher levels of interleukin-1β, interleukin-6, interleukin-12, monocyte chemoattractant protein-1 and tumor necrosis factor alpha in cervicovaginal fluid compared to controls, but after surgery, these differences disappeared. No differences were found in serum of insufficiency versus control women. In patients with insufficiency, the levels of interleukin-1β, interleukin-6, interleukin-8, monocyte chemoattractant protein-1, and interferon gamma in cervicovaginal fluid declined significantly after cerclage compared with before intervention, but these changes were not detected in serum. Conclusion Compared with normal women, patients with cervical insufficiency have elevated levels of proinflammatory cytokines in cervicovaginal fluid but not in serum, suggesting a dysregulation of the local immune environment. Cerclage intervention led to a significant decline in these proinflammatory cytokines, suggesting that cerclage may help reduce local inflammation in cervical insufficiency.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.024
       
  • Successful maintenance of key physiological parameters in preterm lambs
           treated with ex vivo uterine environment therapy for a period of 1 week
    • Authors: Haruo Usuda; Shimpei Watanabe; Yuichiro Miura; Masatoshi Saito; Gabrielle C. Musk; Judith Rittenschober-Böhm; Hideyuki Ikeda; Shinichi Sato; Takushi Hanita; Tadashi Matsuda; Alan H. Jobe; John P. Newnham; Sarah J. Stock; Matthew W. Kemp
      Pages: 457.e1 - 457.e13
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Haruo Usuda, Shimpei Watanabe, Yuichiro Miura, Masatoshi Saito, Gabrielle C. Musk, Judith Rittenschober-Böhm, Hideyuki Ikeda, Shinichi Sato, Takushi Hanita, Tadashi Matsuda, Alan H. Jobe, John P. Newnham, Sarah J. Stock, Matthew W. Kemp
      Background Extremely preterm infants born at the border of viability (22-24 weeks’ gestation) have high rates of death and lasting disability. Ex vivo uterine environment therapy is an experimental neonatal intensive care strategy that provides gas exchange using parallel membranous oxygenators connected to the umbilical vessels, sparing the extremely preterm cardiopulmonary system from ventilation-derived injury. Objective In this study, we aimed to refine our ex vivo uterine environment therapy platform to eliminate fetal infection and inflammation, while simultaneously extending the duration of hemodynamically stable ex vivo uterine environment therapy to 1 week. Study Design Merino-cross ewes with timed, singleton pregnancies were surgically delivered at 112-115 days of gestation (term is ∼150 days) and adapted to ex vivo uterine environment therapy (treatment group; n = 6). Physiological variables were continuously monitored; humerus and femur length, ductus arteriosus directional flow, and patency were estimated with ultrasound; serial blood samples were collected for hematology and microbiology studies; weight was recorded at the end of the experiment. Control group animals (n = 7) were euthanized at 122 days of gestation and analyzed accordingly. Bacteremia was defined by positive blood culture. Infection and fetal inflammation was assessed with white blood cell counts (including differential leukocyte counts), plasma and lung proinflammatory cytokine measurements, and lung histopathology. Results Five of 6 fetuses in the treatment group completed the 1-week study period with key physiological parameters, blood counts remaining within normal ranges, and no bacteremia detected. There were no significant differences (P > .05) in arterial blood oxygen content or lactate levels between ex vivo uterine environment therapy and control groups at delivery. There was no significant difference (P > .05) in birthweight between control and ex vivo uterine environment groups. In the ex vivo uterine environment group, we observed growth of fetal humerus (P < .05) and femur (P < .001) over the course of the 7-day experimental period. There was no difference in airway or airspace morphology or consolidation between control and ex vivo uterine environment animals, and there was no increase in the number of lung cells staining positive for T-cell marker CD3+. Conclusion Five preterm lambs were maintained in a physiologically stable condition for 1 week with significant growth and without clinically significant bacteremia or systemic inflammation. Although substantial further refinement is required, a life support platform based around ex vivo uterine environment therapy may provide an avenue to improve outcomes for extremely preterm infants.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.046
       
  • An evidence-based recommendation to increase the dosing frequency of
           buprenorphine during pregnancy
    • Authors: Steve N. Caritis; Jaime R. Bastian; Hongfei Zhang; Hari Kalluri; Dennis English; Michael England; Stephanie Bobby; Raman Venkataramanan
      Pages: 459.e1 - 459.e6
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Steve N. Caritis, Jaime R. Bastian, Hongfei Zhang, Hari Kalluri, Dennis English, Michael England, Stephanie Bobby, Raman Venkataramanan
      Background Dose-adjusted plasma concentrations of buprenorphine are significantly decreased during pregnancy compared with the nonpregnant state. This observation suggests that pregnant women may need a higher dose of buprenorphine than nonpregnant individuals to maintain similar drug exposure (plasma concentrations over time after a dose). The current dosing recommendations for buprenorphine during pregnancy address the total daily dose of buprenorphine to be administered, but the frequency of dosing is not clearly addressed. Based on buprenorphine’s long terminal half-life, once-daily or twice-daily dosing has generally been suggested. Objective The objective of the study was to assess the impact of dosing frequency on buprenorphine plasma concentration time course during pregnancy. Study Design We utilized 3 data sources to determine an optimal frequency for dosing of buprenorphine during pregnancy: data from a pharmacokinetic study of 14 pregnant and postpartum women on maintenance buprenorphine in a supervised clinical setting; data from pregnant women attending a buprenorphine clinic; and data from a physiologically based pharmacokinetic modeling of buprenorphine pharmacokinetics in nonpregnant subjects. Results Among the 14 women participating in the pharmacokinetic study during and after pregnancy, plasma concentrations of buprenorphine were <1 ng/mL (the theoretical concentration required to prevent withdrawal symptoms) for 50–80% of the 12 hour dosing interval while at steady state. Among 62 women followed up in a opioid agonist treatment program, in which dosing frequency is determined in part by patient preference, 10 (16%) were on once-daily dosing, 10 (16%) were on twice-daily dosing, 28 (45%) were on thrice-daily dosing, and 14 (23%) were on four-times-daily dosing. A physiologically based pharmacokinetic model in nonpregnant subjects demonstrated that dosing frequency has an impact on the duration over which the plasma concentrations are below a specified plasma concentration threshold. Conclusion A more frequent dosing interval (ie, three-times-daily or four-times-daily dosing) may be required in pregnant women to sustain plasma concentrations above the threshold of 1 ng/mL to prevent withdrawal symptoms and to improve adherence.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.06.029
       
  • Neonatal outcomes in fetuses with cardiac anomalies and the impact of
           delivery route
    • Authors: Laura I. Parikh; Katherine L. Grantz; Sara N. Iqbal; Chun-Chih Huang; Helain J. Landy; Melissa H. Fries; Uma M. Reddy
      Pages: 469.e1 - 469.e12
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Laura I. Parikh, Katherine L. Grantz, Sara N. Iqbal, Chun-Chih Huang, Helain J. Landy, Melissa H. Fries, Uma M. Reddy
      Background Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. Objective We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. Study Design Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. Results Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85–3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77–1.27) cardiac anomalies. Conclusion Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2017.05.049
       
  • Impact of aspirin on fetal growth in diabetic pregnancies according to
           White classification
    • Authors: Katlynn Adkins; Amanda Allshouse; Torri Metz; Kent Heyborne
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Katlynn Adkins, Amanda A. Allshouse, Torri D. Metz, Kent D. Heyborne
      Background Current US Preventive Services Task Force and other guidelines recommend low-dose aspirin for all pregnant women with pregestational diabetes mellitus to prevent preeclampsia and small-for-gestational-age birth. The Maternal-Fetal Medicine Units High-Risk Aspirin trial did not show a reduction in either preeclampsia or small-for-gestational-age birth in diabetic women. Objective Our objective was to reassess the impact of aspirin on fetal growth in diabetic pregnancies overall and according to White classification. We hypothesized that aspirin improves fetal growth in pregnancies with vascular complications of diabetes at highest risk for poor fetal growth. Study Design We conducted secondary analysis of the cohort of diabetic women enrolled in the Maternal-Fetal Medicine Units High-Risk Aspirin trial. The impact of aspirin prophylaxis on birthweight was assessed in the overall cohort and in 2 groups categorized according to White classification as nonvascular (White class B, C, D) or vascular (White class R, F, RF). Birthweight was converted to Z-score normalized for gestational age at delivery and neonatal sex. Difference in birthweight Z-score between aspirin and placebo was tested with a 2-sample t test. The effect of vascular group, aspirin vs placebo randomization, and the interaction of the 2 on normalized birthweight percentile was estimated with linear regression with a multivariable model including covariates body mass index, tobacco use, race, and parity. The percentage of small and large-for-gestational-age newborns born to aspirin- vs placebo-treated women was compared between groups using Pearson exact χ2 analysis, and an adjusted model was estimated by logistic regression. Results All 444 women with pregestational diabetes and complete outcome data were included (53 vascular, 391 nonvascular). Aspirin was significantly associated with a higher birthweight Z-score (0.283; 95% confidence interval, 0.023–0.544) in the overall cohort (P = .03). In the adjusted model, the association of aspirin with higher birthweight Z-score was confined to neonates of women with nonvascular diabetes (0.341; 95% confidence interval, 0.677–0.006; P = .044). An opposite but nonsignificant effect was observed among neonates from women with vascular diabetes (–0.416; 95% confidence interval, –1.335 to 0.503; P = .6). This difference in the relationship of aspirin and birthweight Z-score by vascular group was significant at P = .046. Aspirin-randomized women with nonvascular diabetes had more large-for-gestational-age births than those treated with placebo (40.2 vs 26.6%; P = .005). Small-for-gestational-age births occurred at the same frequency with aspirin vs placebo randomization in the overall cohort (8% in each group) and in each vascular group. Conclusion Inconsistent with our hypothesis, aspirin did not reduce small-for-gestational-age births in the overall cohort or either group. The increased incidence of large-for-gestational-age infants in aspirin-treated diabetic gestations is of potential concern given the known increased maternal and neonatal morbidity associated with macrosomia.

      PubDate: 2017-09-29T05:51:21Z
      DOI: 10.1016/j.ajog.2016.11.230
       
  • Male Partner Reproductive Coercion among Women Veterans
    • Abstract: Publication date: Available online 19 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Elian A. Rosenfeld, Elizabeth Miller, Xinhua Zhao, Florentina E. Sileanu, Maria K. Mor, Sonya Borrero
      Background Male partner reproductive coercion is defined as male partners' attempts to promote pregnancy through interference with women’s contraceptive behaviors and reproductive decision making. Male partners may try to promote pregnancy through birth control sabotage such as taking away or destroying their partners' contraceptives, refusing to wear condoms, and/or verbally pressuring their partners to abstain from contraceptive use. Reproductive coercion is associated with an elevated risk for unintended pregnancy. Women experiencing intimate partner violence, racial/ethnic minorities and those of lower socioeconomic status, are more likely to experience reproductive coercion. Women veterans who use Veterans Affairs (VA) for health care may be particularly vulnerable to reproductive coercion as they are disproportionally from racial/ethnic minority groups and experience high rates of intimate partner violence. Objectives We sought to examine the prevalence, correlates, and impact of reproductive coercion among women veterans served by the VA healthcare system. Study Design We analyzed data from a national telephone survey of women veterans aged 18-44, with no history of sterilization or hysterectomy, who had received care within VA in the prior 12 months. Participants who had sex with men in the last year were asked if they experienced male partner reproductive coercion. Adjusted logistic regression was used to examine the relationship between participant characteristics and male partner reproductive coercion and the relationship between reproductive coercion and the outcomes of contraceptive method used at last sex, and pregnancy and unintended pregnancy in the last year. Results Among the 1,241 women veterans in our study cohort, 11% reported experiencing male partner reproductive coercion in the past year. Black women, younger women, and single women were more likely to report reproductive coercion than their white, older, and married counterparts. Women who experienced military sexual trauma were also more likely to report reproductive coercion compared to women who did not report military sexual trauma. In adjusted analyses, compared to women who did not experience reproductive coercion, those who did were less likely at last sex to have used any method of contraception (76% vs. 80%; aOR: 0.61, 95% CI: 0.38-0.96), prescription contraception (43% vs. 55%; aOR: 0.62, 95% CI: 0.43-0.91) and their ideal method of contraception (35% vs. 45%; aOR: 0.63, 95% CI: 0.43-0.93). Those who reported coercion were more likely to have had a pregnancy in the last year (14% vs. 10%; aOR: 2.07, 95% CI: 1.17-3.64); there were no significant differences in unintended pregnancy by coercion status (6% vs. 4%; aOR: 1.63, 95% CI: 0.71-3.76). Conclusion Eleven percent of women veterans in our sample experienced male partner reproductive coercion, which may impact their use of contraception and ability to prevent pregnancy.

      PubDate: 2017-10-20T06:15:12Z
       
  • Predicting Risk of Pelvic Floor Disorders 12 and 20 Years after Delivery
    • Abstract: Publication date: Available online 19 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): J. Eric Jelovsek, Kevin Chagin, Maria Gyhagen, Suzanne Hagen, Don Wilson, Michael W. Kattan, Andrew Elders, Matthew D. Barber, Björn Areskoug, Christine MacArthur, Ian Milsom
      Background Little progress has been made in preventing pelvic floor disorders despite their significant health and economic impact. Identifying women at risk remains a key element in targeting prevention and planning health resource allocation strategies. Although events around the time of childbirth are clinically recognized as important predictors, it is difficult to counsel women and intervene around the time of childbirth due to an inability to accurately convey a patient’s risk in the presence of multiple risk factors and the long time lapse, often decades, between obstetric events and the onset of pelvic floor disorders later in life. Prediction models and scoring systems have been used in other areas of medicine to identify patients at risk for chronic diseases. Models have been developed for use before delivery that predict short-term risk of pelvic floor disorders after childbirth but no models predicting long-term risk exist. Objective To use variables known before and during childbirth to develop and validate prognostic models estimating risks of these disorders 12 and 20 years after delivery. Study Design Obstetric variables were collected from two cohorts: 1) women who gave birth in the United Kingdom and New Zealand (n=3763) and 2) women from the Swedish Medical Birth Register (n=4991). Pelvic floor disorders were self-reported 12 years after childbirth in the UK/NZ cohort and 20 years after childbirth in the Swedish Register. The cohorts were split so that data during the first half of the cohort’s time period were used to fit prediction models and validation was performed from the second half (temporal validation). As there is currently no consensus on how to best define pelvic floor disorders from a patient’s perspective, we chose to fit the data for each model using multiple outcome definitions for prolapse, urinary incontinence, fecal incontinence, 1 or more pelvic floor disorder and 2 or more pelvic floor disorders. Model accuracy was measured: 1) by ranking an individual’s risk among all subjects in the cohort (discrimination) using a concordance index and 2) by observing whether the predicted probability was too high or low (calibration) at a range of predicted probabilities using visual plots. Results Models were able to discriminate between women who developed bothersome symptoms or received treatment, at 12 and 20 years respectively, for: pelvic organ prolapse (concordance indices 0.570, 0.627), urinary incontinence (concordance indices 0.653, 0.689), fecal incontinence (concordance indices 0.618, 0.676), ≥1 pelvic floor disorders (concordance indices 0.639, 0.675) and ≥2 pelvic floor disorders (concordance indices 0.635, 0.619). The discriminatory ability of all models is shown in Table 2. Route of delivery and family history of each pelvic floor disorder were strong predictors in most models. Urinary incontinence before and during the index pregnancy was a strong predictor for developing all pelvic floor disorders in most models 12 years after delivery. The 12 and 20-year bothersome or treatment for prolapse models were accurate when providing predictions for risk from 0% to approximately 15%. The 12-year and 20-year primiparous model began to over-predict when risk rates reached 20%. When predicting bothersome symptoms or treatment for urinary incontinence, the 12-year models were accurate when predictions ranged from approximately 5% to 60% and 20-year primiparous models were accurate between 5% and 80%. For bothersome symptoms or treatment for fecal incontinence, the 12 and 20-year models were accurate between 1% and 15% risk and began to over-predict at rates above 15% and 20%, respectively. Conclusion Models may provide an opportunity before birth to identify women at low risk of developing pelvic floor disorders and institute prevention strategies such as pelvic floor muscle training, weight control or elective cesarean section for women at higher risk. Models are provided at: http://riskcalc.org/UR_CHOICE/
      PubDate: 2017-10-20T06:15:12Z
       
  • Risk of metachronous ovarian cancer after ovarian conservation in young
           women with stage I cervical cancer: Methodological issues
    • Abstract: Publication date: Available online 18 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Amir Almasi-Hashiani, Erfan Ayubi, Saeid Safiri


      PubDate: 2017-10-20T06:15:12Z
       
  • Surgical outcomes among elderly women with endometrial cancer treated by
           laparoscopic hysterectomy: A NRG/Gynecologic Oncology Group Study
    • Abstract: Publication date: Available online 14 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Erin A. Bishop, James J. Java, Kathleen N. Moore, Nick M. Spirtos, Michael L. Pearl, Oliver Zivanovic, David M. Kushner, Floor Backes, Chad A. Hamilton, Melissa A. Geller, Jean Hurteau, Cara Mathews, Robert M. Wenham, Pedro T. Ramirez, Susan Zweizig, Joan L. Walker
      Objective Tolerance of and complications due to minimally invasive hysterectomy and staging in the older endometrial cancer population is largely unknown despite the fact that this is the most rapidly growing age group in the United States. The objective of this retrospective review is to compare operative morbidity by age in patients on the Gynecologic Oncology Group (GOG) LAP2 trial. Methods This is a retrospective analysis of patients from GOG LAP2, a trial that included clinically early stage uterine cancer patients randomized to laparotomy vs. laparoscopy for surgical staging. Differences in the rates and types of intraoperative and perioperative complications were compared by age. Specifically complications between patients <60 vs ≥60 years old were compared due to toxicity analysis showing a sharp increase in toxicity starting at age 60 years old in the laparotomy group. Results LAP2 included 1,477 patients ≥60 years old. As expected, with increasing age there is worsening performance status and disease characteristics including higher rates of serous histology, high stage disease, and lymphovascular space invasion. There is no significant difference in lymph node dissection rate by age for the entire population or within the laparotomy or laparoscopy groups. Toxicity analysis shows a sharp increase in toxicity seen in patients ≥60 years old in the laparotomy group. Further analysis shows that when comparing laparotomy to laparoscopy in patients <60 years old vs ≥60 years old and controlling for race, body mass index, stage, grade, and performance status patients <60 years old undergoing laparotomy had more hospital stays >2 days (OR 17.48; 95% CI 11.71–27.00, p<0.001) compared to patients <60 years old undergoing laparoscopy. However, when comparing laparotomy to laparoscopy in patients ≥60 years old, in addition to hospital stay >2 days (OR 12.77; 95% CI 8.74–19.32, p<0.001), there were higher rates of the following postoperative complications: antibiotic administration (OR 1.63; 95% CI 1.24–2.14, p<0.001), ileus (OR 2.16; 95% CI 1.42–3.31, p<0.001), pneumonias (OR 2.36; 95% CI 1.01–5.66, p=0.048), deep vein thromboses (OR 2.87; 95% CI 1.08–8.03, p=0.035), and arrhythmias (OR 3.21; 95% CI 1.60–6.65, p=0.001) in the laparotomy group. Conclusion Laparoscopic staging for uterine cancer is associated with decreased morbidity in the immediate postoperative period in patients ≥60 years old. These results allow for more accurate preoperative counseling. A minimally invasive approach to uterine cancer staging may decrease morbidity that could affect long term survival.
      Teaser Laparoscopic staging for endometrial cancer patients ≥60 years old results in decreased morbidity in the immediate postoperative period.

      PubDate: 2017-10-20T06:15:12Z
       
  • A low angiogenic index-1 (PlGF/sVEGFR-1 ratio) at 24-28 weeks of gestation
           
    • 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
      Abstract: Publication date: Available online 13 October 2017
      Source:American Journal of Obstetrics and Gynecology
      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
      Objective To determine if maternal plasma concentrations of angiogenic and anti-angiogenic factors measured at 24-28 weeks of gestation can predict subsequent fetal death. Methods 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 (PlGF), soluble endoglin (sEng), and soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) concentrations were measured by ELISA assays. Quantiles of the analyte concentrations (or concentration ratios) were estimated as a function of gestational age among women who delivered live neonates but did not develop preeclampsia or deliver small-for-gestational–age (SGA) newborns. A positive test was defined as analyte concentrations (or ratios) <2.5th and 10th centiles [PlGF, PlGF/sVEGFR-1 (angiogenic index-1), and PlGF/sEng)] or >90th and 97.5th centiles (sVEGFR-1 and sEng). 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 prior to 28 weeks and eight at or after 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 before 28 weeks and 87.5% (7/8) of those who had this complication at or after 28 weeks of gestation. The maternal plasma angiogenic index-1 value was below the 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% CI, 7.7-27.7) and a relative risk of 29.1 (95% CI, 8.8-97.1), followed by sEng >97.5thcentile and PlGF/sEng <2.5th, both with a positive likelihood ratio of 13.7 (95% CI, 7.3-25.8) and a relative risk of 27.4 (95% CI, 8.2-91.2). Among women without a fetal death whose plasma angiogenic index-1 concentration ratio was below the 2.5th centile, 61% (19/31) developed preeclampsia or delivered an SGA neonate; when the 10th centile was used as the cut-off, 37% (34/92) of women had these adverse outcomes. Conclusions 1) A maternal plasma angiogenic index-1 value below the 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: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.10.001
       
  • 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
      Abstract: Publication date: Available online 13 October 2017
      Source:American Journal of Obstetrics and Gynecology
      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 (cffDNA) 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, has 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 post-test counseling, pre/perinatal decision making and medical risk assessment/management. Objective The objective of this study was to determine the positive predictive value (PPV) and false positive rates (FPR) for different chromosomal abnormalities identified by cffDNA screening using a large dataset 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 cffDNA screening result indicating high-risk for a chromosome abnormality. We compiled data from all cases where the indication for confirmatory testing was a positive cffDNA 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. PPVs and FPRs were calculated from tabulated data. Results The PPVs for trisomy 13, 18 and 21 were consistent with previous reports at 45, 76 and 84%, respectively. For the microdeletion syndrome regions, PPVs 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 PPVs of 26% for monosomy X, 50% for 47,XXX and 86% for 47,XXY. Conclusion The PPVs for detection of common autosomal and sex chromosomal aneuploidies by cffDNA screening were comparable to other studies. Identification of microdeletions was associated with lower PPVs and higher FPRs, likely due to the low prevalence of the individual targeted microdeletion syndromes in the general population. Although the obtained PPVs 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 cffDNA screening tests. Improvement of the cffDNA 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: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.10.005
       
  • Bowel Endometriosis: Diagnosis and Management
    • Authors: Camran Nezhat; Anjie Li; Rebecca Falik; Daniel Copeland; Gity Meshkat Razavi; Alexandra Shakib; Catalina Mihailide; Holden Bamford; Lucia DiFrancesco; Salli Tazuke; Pejman Ghanouni; Homero Rivas; Azadeh Nezhat; Ceana Nezhat; Farr Nezhat
      Abstract: Publication date: Available online 13 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Camran Nezhat, Anjie Li, Rebecca Falik, Daniel Copeland, Gity Meshkat Razavi, Alexandra Shakib, Catalina Mihailide, Holden Bamford, Lucia DiFrancesco, Salli Tazuke, Pejman Ghanouni, Homero Rivas, Azadeh Nezhat, Ceana Nezhat, Farr Nezhat
      The most common location of extra-genital endometriosis is the bowel. Medical treatment may not provide long-term improvement in patients who are symptomatic, and consequently most of these patients may require surgical intervention. Over the past century, surgeons have continued to debate the optimal surgical approach to treating bowel endometriosis, weighing the risks against the benefits. In this expert opinion we will describe how the recommended surgical approach depends largely on the location of disease, in addition to size and depth of the lesion. For lesions approximately 5-8cm from the anal verge, we encourage conservative surgical management over resection to decrease the risk of short and long-term complications.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.09.023
       
  • 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
      Abstract: Publication date: Available online 12 October 2017
      Source:American Journal of Obstetrics and Gynecology
      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 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 infected with HIV to lopinavir/ritonavir (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 (Ang-1), angiopoietin-2 (Ang-2), vascular endothelial growth factor (VEGF), soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and soluble endoglin (sEng)) by enzyme linked immunosorbent assay between: 16–20, >20–24, >24–28, >28–32, >32–36, and >36 –<37 weeks of gestation. The primary outcome was preterm birth. Results 1115 plasma samples from 326 pregnant women were evaluated. There were no differences in angiogenic factors according to antiretroviral therapy group (p>0.05 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— sEng and PlGF— were associated with adverse birth outcomes. Significantly higher concentrations of sEng throughout gestation were found in those women destined to deliver preterm (LR test, χ2(1)=12.28, p<0.0005) and in those destined to have stillbirths (χ2(1)=5.67, p<0.02). By contrast, significantly lower concentrations of PlGF throughout gestation were found in those destined to have small-for-gestational age births (χ2(1)=7.89, p<0.005) and in those destined to have stillbirths (χ2(1)=21.59, p<0.0001). Conclusions An anti-angiogenic state in the second or third trimester is associated with adverse birth outcomes, including stillbirth in women living with HIV and receiving antiretroviral therapy.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.10.003
       
  • 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
      Abstract: Publication date: Available online 12 October 2017
      Source:American Journal of Obstetrics and Gynecology
      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 one of only two 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 pPROM. 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 three progestogens, progesterone, 17α-hydroxyprogesterone (17-OHP), and medroxyprogesterone acetate (MPA) each inhibit both TNF-α and thrombin induced fetal membrane weakening at two distinct points of the fetal membrane weakening pathway. Each block both the production of, and also the downstream action of the critical intermediate GM-CSF. Objective 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 2.5cm Transwell inserts and cultured with/without 17-OHPC (10-9-10-7 M). After 24h, medium (supernatant) was removed and replaced with/without addition of TNF-α (20ng/ml) or thrombin (10U/ml) or GM-CSF (200ng/ml). After 48h culture, medium from the maternal side compartment of the model was assayed for GM-CSF and the fetal membrane fragments were rupture-strength tested. Results TNF-α and thrombin both weakened fetal membranes (43% and 62%, respectively) and increased GM-CSF levels (3.7 and 5.9 fold, respectively). Pretreatment with 17-OHPC inhibited both TNF-α and thrombin induced fetal membrane weakening and concomitantly inhibited the induced increase in GM-CSF in a concentration-dependent manner. However, contrary to our prior reports regarding progesterone and other progestogens, 17-OHPC did not also inhibit GM-CSF induced fetal membrane weakening. Conclusions 17-OHPC blocks TNF-α and thrombin induced fetal membrane weakening by inhibiting production of GM-CSF. However, 17-OHPC did not also inhibit GM-CSF induced weakening. We speculate that progestogens other than 17-OHPC may be more efficacious in preventing pPROM related spontaneous preterm birth.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.10.004
       
  • Refractory Urgency Urinary Incontinence Treatment in Women: Impact of Age
           on Outcomes and Complications
    • Authors: Yuko M. Komesu; Cindy L. Amundsen; Holly E. Richter; Stephen W. Erickson; Mary F. Ackenbom; Uduak U. Andy; Vivian W. Sung; Michael Albo; W. Thomas Gregory; Marie Fidela Paraiso; Dennis Wallace
      Abstract: Publication date: Available online 12 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Yuko M. Komesu, Cindy L. Amundsen, Holly E. Richter, Stephen W. Erickson, Mary F. Ackenbom, Uduak U. Andy, Vivian W. Sung, Michael Albo, W. Thomas Gregory, Marie Fidela Paraiso, Dennis Wallace
      Background Women with refractory urgency urinary incontinence (UUI) (i.e. unresponsive to behavioral and pharmacologic interventions) are treated with onabotulinumtoxinA or sacral neuromodulation. Objectives To compare treatment efficacy and adverse events (AEs) in women <65 and ≥65 years old treated with onabotulinumtoxinA or sacral neuromodulation (SNM). Study Design This study was a planned secondary analysis of a multi-center, randomized trial which enrolled community-dwelling women with refractory UUI to onabotulinumtoxinA or SNM treatments. The primary outcome: Change in mean daily UUI episodes (UUIEs) on bladder diary over 6 months. Secondary outcomes: ≥75% UUIE reduction, change in symptom severity/quality of life, treatment satisfaction and treatment-related AEs. Results Both age groups experienced improvement in mean UUIEs/day following each treatment. There was no evidence that mean daily UUIE reduction differed between age groups for onabotulinumtoxinA (adjusted coefficient, -0.127,95%CI -1.233, 0.979; P=0.821) or SNM (adjusted coefficient -0.698, 95% CI -1.832, 0.437; P=0.227). Among those treated with onabotulinumtoxinA, women < 65 had 3.3-fold greater odds of ≥ 75% resolution than women ≥ 65 (95% CI 1.56 –7.02). Women <65 had greater reduction in OABq-SF symptom bother scores compared to women ≥ 65 by 7.49 points (95% CI -3.23, -11.74), regardless of treatment group. There was no difference between quality of life improvement by age. Women ≥ 65 had more UTIs following onabotulinumtoxinA and SNM (OR 1.9, 95% CI 1.2-3.3). There was no evidence of age differences in SNM revision/removal or catheterization following onabotulinumtoxinA. Conclusion Younger women experienced greater absolute continence, symptom improvement, and fewer UTIs; both older and younger women had beneficial UUIE reduction, similar rates of other treatment adverse events and improved quality of life.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.10.006
       
  • Chronic pelvic pain in an interdisciplinary setting: 1 year prospective
           cohort
    • Authors: Catherine Allaire; Christina Williams; Sonja Bodmer-Roy; Sean Zhu; Kristina Arion; Kristin Ambacher; Jessica Wu; Ali Yosef; Fontayne Wong; Heather Noga; Susannah Britnell; Holly Yager; Mohamed A. Bedaiwy; Arianne Y. Albert; Sarka Lisonkova; Paul J. Yong
      Abstract: Publication date: Available online 12 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Catherine Allaire, Christina Williams, Sonja Bodmer-Roy, Sean Zhu, Kristina Arion, Kristin Ambacher, Jessica Wu, Ali Yosef, Fontayne Wong, Heather Noga, Susannah Britnell, Holly Yager, Mohamed A. Bedaiwy, Arianne Y. Albert, Sarka Lisonkova, Paul J. Yong
      Background Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities that are associated with changes in chronic pelvic pain severity over time. Objective To describe trends and factors associated with chronic pelvic pain severity over a 1 year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects. Methods Prospective 1 year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age>50. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was CPP severity at 1 year on a 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0-3, moderate 4-6, severe 7-10). Secondary outcomes included functional quality-of-life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year. Results Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10 to 4/10, p<0.001). There was also an improvement in functional quality-of-life (42% to 29% on the pain subscale of the Endometriosis Health Profile-30, p<0.001), and a reduction in subjects requiring a physician visit (73% to 36%, p<0.001) or emergency visit (24% to 11%, p<0.001) in the last 3 months. On multivariable ordinal regression for the primary outcome, chronic pelvic pain severity at 1 year was independently associated with a higher score on the Pain Catastrophizing Scale at baseline (OR=1.10, 95% CI=1.00-1.21, p=0.04), controlling for baseline pain, treatment effects (surgery), age and referral status. Conclusion Improvements in chronic pelvic pain severity, quality-of-life, and health care utilization were observed in a 1 year cohort in an interdisciplinary setting. Higher pain catastrophizing at baseline was associated with greater chronic pelvic pain severity at 1 year. Consideration should be given to stratifying pelvic pain patients by catastrophizing level (rumination, magnification, helplessness) in research studies and in clinical practice.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.10.002
       
  • SMFM Special Statement: Research to knowledge: Promoting the training of
           physician-scientists in the biology of pregnancy
    • Authors: Yoel Sadovky; Aaron B. Caughey; Michelle DiVito; Mary E. D’Alton; Amy P. Murtha
      Abstract: Publication date: Available online 7 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Yoel Sadovky, Aaron B. Caughey, Michelle DiVito, Mary E. D’Alton, Amy P. Murtha
      Common disorders of pregnancy, such as preeclampsia, preterm birth, and fetal growth abnormalities, continue to challenge perinatal biologists seeking insights into disease pathogenesis that will result in better diagnosis, therapy, and disease prevention. These challenges have recently been intensified with discoveries that associate gestational diseases with long-term maternal and neonatal outcomes. Whereas modern high-throughput investigative tools enable scientists and clinicians to non-invasively probe the maternal-fetal genome, epigenome, and other analytes, their implications for clinical medicine remain uncertain. Bridging these knowledge gaps depends on strengthening the existing pool of scientists with expertise in basic, translational, and clinical tools to address pertinent questions in the biology of pregnancy. Although PhD researchers are critical in this quest, physician-scientists would facilitate the inquiry by bringing togehter clinical challenges and investigative tools, promoting a culture of intellectual curiosity among clinical providers, and helping transform discoveries into relevant knowledge and clinical solutions. Uncertainties related to future administration of health care, federal support for research, attrition of physician-scientists, and an inadequate supply of new scholars may jeopardize our ability to address these challenges. New initiatives are necessary to attract current scholars and future generations of researchers seeking expertise in the scientific method and to support them, through mentorship and guidance, in pursuing a career that combines scientific investigation with clinical medicine. These efforts will promote breadth and depth of inquiry into the biology of pregnancy and enhance the pace of translation of scientific discoveries into better medicine and disease prevention.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.09.024
       
  • Mercer response to Krispin 9-2017
    • Authors: Brian M. Mercer
      Abstract: Publication date: Available online 6 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Brian M. Mercer


      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.09.025
       
  • Validity of Utility Measures for Women with Pelvic Organ Prolapse
    • Authors: Heidi S. Harvie; Daniel D. Lee; Uduak U. Andy; Judy A. Shea; Lily A. Arya
      Abstract: Publication date: Available online 6 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Heidi S. Harvie, Daniel D. Lee, Uduak U. Andy, Judy A. Shea, Lily A. Arya
      Background Pelvic organ prolapse is a common condition that frequently co-exists with urinary and fecal incontinence. The impact of prolapse on quality of life is typically measured through condition-specific quality of life instruments. Utility preference scores are a standardized generic health related quality of life (HRQOL) measure that summarizes morbidity on a scale from 0 (death) to 1 (optimum health). Utility preference scores quantify disease severity and burden and are widely used in cost-effectiveness research. The validity of utility preference instruments in women with pelvic organ prolapse has not been established. Objective The objective of this study was to evaluate the construct validity of generic quality of life instruments for measuring utility scores in women with pelvic organ prolapse. Our hypothesis was that women with multiple pelvic floor disorders would have worse (lower) utility scores than women with pelvic organ prolapse only and that women with all three pelvic floor disorders would have the worst (lowest) utility scores. Study Design This was a prospective observational study of 286 women with pelvic floor disorders from a referral female pelvic medicine and reconstructive surgery practice. All women completed the following general health-related quality of life questionnaires: Health Utilities Index Mark 3, EuroQol, and Short Form 6D and a visual-analogue scale. Pelvic floor symptom severity and condition specific quality of life were measured using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, respectively. We measured the relationship between utility scores and condition-specific quality of life scores and also compared utility scores between four groups of women: 1) pelvic organ prolapse only, 2) pelvic organ prolapse and stress urinary incontinence, 3) pelvic organ prolapse and urgency urinary incontinence, and 4) pelvic organ prolapse, urinary incontinence and fecal incontinence. Results Of 286 women enrolled, 191 (67%) had pelvic organ prolapse, mean age was 59 and 73% were Caucasian. Among women with prolapse, 30 (16%) also had stress urinary incontinence, 39 (20%) had urgency urinary incontinence and 42 (22%) had fecal incontinence. For the Health Utilities Index Mark 3, EuroQol, and Short Form 6D, the pattern in utility scores was noted to be lowest (worst) in the prolapse + urinary incontinence + fecal incontinence group (0.73-0.76), followed by the prolapse + urgency urinary incontinence group (0.77-0.85) and utility scores were the highest (best) for the prolapse only group (0.80-0.86). Utility scores from all generic instruments except the visual analog scale were significantly correlated with the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire total scores (r-values -0.26 to -0.57), and prolapse, bladder, and bowel subscales (r-values -0.16 to -0.50). Utility scores from all instruments except the visual analog scale were highly correlated with each other (r = 0.53 to 0.69, p <0.0001). Conclusions The Health Utilities Index Mark 3, EuroQol, and Short Form 6D, but not the visual analogue scale, provide valid measurements for utility scores in women with pelvic organ prolapse and associated pelvic floor disorders and could potentially be used for cost-effectiveness research.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.09.022
       
  • Detailed muscular structure and neural control anatomy of the levator ani
           muscle. A study based on female human fetuses
    • Authors: Krystel Nyangoh Timoh; David Moszkowicz; Mazen Zaitouna; Cedric Lebacle; Jelena Martinovic; Djibril Diallo; Maud Creze; Vincent Lavoue; Emile Darai; Gérard Benoit; Thomas Bessede
      Abstract: Publication date: Available online 6 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Krystel Nyangoh Timoh, David Moszkowicz, Mazen Zaitouna, Cedric Lebacle, Jelena Martinovic, Djibril Diallo, Maud Creze, Vincent Lavoue, Emile Darai, Gérard Benoit, Thomas Bessede
      Background Injury to the levator ani muscle or pelvic nerves during pregnancy and vaginal delivery are responsible for pelvic floor dysfunction. Objective To demonstrate the presence of smooth muscular cell areas within the levator ani muscle and describe their localization and innervation. Study design Five female human fetuses were studied after approval from the French Biomedicine Agency. Specimens were serially sectioned and stained by Masson’s trichrome and immunostained for striated and smooth muscle, as well as for somatic, adrenergic, cholinergic, and nitriergic nerve fibers. Slides were digitized for 3D reconstruction. One fetus was reserved for electronic microscopy. We explored the structure and innervation of the levator ani muscle. Results Smooth muscular cell beams were connected externally to the anococcygeal raphe and the levator ani muscle and with the longitudinal anal muscle sphincter. The caudalmost part of the pubovaginal muscle was found to bulge between the rectum and the vagina. This bulging was a smooth muscular interface between the levator ani muscle and the longitudinal anal muscle sphincter. The medial (visceral) part of the levator ani muscle contained smooth muscle cells, in relation to the autonomic nerve fibers of the inferior hypogastric plexus. The lateral (parietal) part of the levator ani muscle contained striated muscle cells only and was innervated by the somatic nerve fibers of levator ani and pudendal nerves. The presence of smooth muscle cells within the medial part of the levator ani muscle was confirmed under electronic microscopy in one fetus. Conclusions We characterized the muscular structure and neural control of the levator ani muscle. The muscle consists of a medial part containing smooth muscle cells under autonomic nerve influence and a lateral part containing striated muscle cells under somatic nerve control. These findings could result in new postpartum rehabilitation techniques.

      PubDate: 2017-10-13T18:30:35Z
      DOI: 10.1016/j.ajog.2017.09.021
       
  • Contraception after medication abortion in the United States: Results from
           a cluster randomized trial
    • Authors: Corinne H. Rocca; Suzan Goodman; Daniel J. Grossman; Kara Cadwallader; Kirsten M.J. Thompson; Elizabeth Talmont; J. Joseph Speidel; Cynthia C. Harper
      Abstract: Publication date: Available online 3 October 2017
      Source:American Journal of Obstetrics and Gynecology
      Author(s): Corinne H. Rocca, Suzan Goodman, Daniel J. Grossman, Kara Cadwallader, Kirsten M.J. Thompson, Elizabeth Talmont, J. Joseph Speidel, Cynthia C. Harper
      Background Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered post-abortion contraceptive care. Objective To investigate differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients. Study Design This sub-analysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18-25 who did not desire pregnancy and followed them for one year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device (IUD) and subdermal implant initiation over one year. Results Overall, 26% (n=166) of participants had a medication abortion and 74% (n=477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on IUDs or the implant (55%), and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% IUD or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs. 57% aspiration), and condoms or no method (20% vs. 22%), within three months were not significantly different by abortion type. However, IUD initiation over a year was significantly lower post-medication than aspiration abortion (11/100 person-years versus 20/100 PY, adjusted hazard ratio=0.50; 95% CI: 0.28-0.89). Implant initiation rates were low and similar by abortion type (5/100 PY vs. 4/100 PY, aHR=2.41; 95% CI: 0.88-6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within three months. Neither differences in health insurance nor pelvic exam preferences by abortion type accounted for lower IUD use among medication abortion patients. Conclusions Despite similar contraceptive choices, fewer medication abortion than aspiration abortion patients initiated IUDs over one year follow-up. Interventions to help medication abortion patients to successfully return for IUD placement are warranted. New protocols for same-day implant placement may also help medication abortion patients desiring a long-acting method to receive one.

      PubDate: 2017-10-06T16:05:34Z
      DOI: 10.1016/j.ajog.2017.09.020
       
  • Information for Readers
    • Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4


      PubDate: 2017-09-29T05:51:21Z
       
  • Persistence of fimbrial tissue on the ovarian surface after salpingectomy
    • Authors: Carmen Gan; Rashna Chenoy Dhivya Chandrasekaran Elly Brockbank Antony Hollingworth
      Abstract: Publication date: October 2017
      Source:American Journal of Obstetrics and Gynecology, Volume 217, Issue 4
      Author(s): Carmen Gan, Rashna Chenoy, Dhivya Chandrasekaran, Elly Brockbank, Antony Hollingworth, Sotiris Vimplis, Alexandra C. Lawrence, Arjun R. Jeyarajah, David Oram, Nandita Deo, Jamna Saravanamuthu, Sarah S. Lam, Asma Faruqi, Naveena Singh, Ranjit Manchanda
      Background Salpingectomy is recommended as a risk-reducing strategy for epithelial tubo-ovarian cancer. The gold standard procedure is complete tubal excision. Objective The purpose of this study was to assess the presence of residual fimbrial/tubal tissue on ovarian surfaces after salpingectomy. Study Design Prospective analysis of patients who underwent salpingo-oophorectomy with or without hysterectomy for benign indications, early cervical cancer, or low-risk endometrial cancer at a UK National Health Service Trust. Salpingectomy with or without hysterectomy was performed initially, followed by oophorectomy within the same operation. Separately retrieved tubes and ovaries were sectioned serially and examined completely histologically. The main outcome measure was histologically identified fimbrial/ tubal tissue on ovarian surface. Chi-square/Fisher’s exact tests were used to evaluate categoric variables. Results Twenty-five consecutive cases (mean age, 54.8 ± 5.0 years) that comprised 41 adnexae (unilateral, 9; bilateral, 16) were analyzed. Seventeen (68.0%), 5 (20.0%), and 3 (12.0%) procedures were performed by consultant gynecologists, subspecialty/specialist trainees, and consultant gynecologic oncologists, respectively. Twelve of 25 procedures (48.0%) were laparoscopic, and 13 of 25 procedures (52.0%) involved laparotomy. Four of 25 patients (16.0%; 95% confidence interval, 4.5–36.1%) or 4 of 41 adnexae (9.8%; 95% confidence interval, 2.7–23.1%) showed residual microscopic fimbrial tissue on the ovarian surface. Tubes/ovaries were free of adhesions in 23 cases. Two cases had dense adnexal adhesions, but neither had residual fimbrial tissue on the ovary. Residual fimbrial tissue was not associated significantly with surgical route or experience (consultant, 3/20 [15%]; trainee, 1/5 [20%]; P=1.0). Conclusion Residual fimbrial tissue remains on the ovary after salpingectomy in a significant proportion of cases and could impact the level of risk-reduction that is obtained.

      PubDate: 2017-09-29T05:51:21Z
       
 
 
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