American Journal of Obstetrics & Gynecology

2010-09-01

Information for Readers

2010-09-01

Changes

Thomas J. Garite, Moon Kim — 2010-09-01

It is with both sadness and delight that The Editorial Board of the American Journal of Obstetrics and Gynecology announces the resignation of Dr Steven Gabbe and the appointment of Drs William Grobman and Samuel Parry as Associate Editors.

Using birth certificate data to determine medically indicated induction rates

William M. Callaghan — 2010-09-01

Induction of labor is increasing in the United States; the most recent national estimate is that approximately 1 in 5 births follow a labor that was medically induced. Although the reasons for this increase are not entirely clear, labor induction when there is no medical indication to effect delivery may play a role in this increase. The issue of elective induction is particularly important for deliveries at late preterm and early term gestations. Late preterm births (34-36 weeks of gestation) make up 71% of all preterm births in the United States. Although infants who are born at 37-38 weeks of gestation traditionally are considered to be “term,” neonatal morbidity continues to decrease with each week of gestation until 39 weeks. Hence, the American College of Obstetricians and Gynecologists clinical management guidelines require that there be documentation of gestational age of at least 39 weeks at the time of induction in the absence of maternal and/or fetal indications for delivery. In this context, it is an important public health issue to be able to track late preterm and early term births accurately after induced labor where there is no apparent medical reason for delivery and to use that information to inform clinical policy.

Scheduling the first prenatal visit: a missed opportunity

Arnold W. Cohen — 2010-09-01

As obstetricians we have always stressed the importance of prenatal care. The Centers for Disease Control and Prevention reported that delayed entry into prenatal care was associated with adverse outcomes for the mother and baby. We also know that the earlier in the pregnancy that a patient receives prenatal care, the better the chance for the obstetrics caregiver to establish the gestational age, address the issues that can affect the pregnancy such as preexisting medical diseases or issues related to previous pregnancies, avoidance of teratogenic medications, and modification of lifestyle issues such as smoking, drugs, alcohol, and excessive weight gain. It also allows the provider of care to develop and implement an obstetrics treatment plan best suited to the patient. Prenatal care has always been assumed to start when the pregnant mom is first examined by her obstetrics provider. Unfortunately in many cases, this “start” is after organogenesis has occurred and is too late to avoid adverse outcomes for the mother and fetus.

von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment

2010-04-26

von Willebrand disease is caused by either a quantitative or qualitative defect in von Willebrand factor (VWF). Patients may have extensive mucosal bleeding (because of platelet dysfunction) and prolonged bleeding after surgery (because of factor VIII deficiency). Up to 6 different subtypes of the disease have been described, and diagnosis is based on clinical suspicion and laboratory confirmation. Accurate diagnosis is of paramount importance because therapy will vary according to the subtype. Bleeding complications during pregnancy are more frequent when levels of the von Willebrand ristocetin cofactor assay and factor VIII levels are <50 IU/dL. In such cases, therapy before any invasive procedure or delivery must be instituted. The mainstays of therapy are desmopressin and plasma concentrates that contain von Willebrand factor. Delayed postpartum hemorrhage may occur, despite adequate prophylaxis. Frequent monitoring and continued prophylaxis and/or treatment are recommended for at least 2 weeks after delivery.

The diagnosis of polycystic ovary syndrome in adolescents

Enrico Carmina, Sharon E. Oberfield, Rogerio A. Lobo — 2010-05-04

In women, the definition of polycystic ovary syndrome (PCOS) has become broad and includes several possible phenotypes. Because several features of PCOS may be in evolution in adolescents, we suggest that only firm criteria should be used to make a diagnosis of PCOS during adolescence. Hyperandrogenism, oligomenorrhea, and ovarian morphology change during adolescence and are discussed individually. Adolescents with incomplete criteria for a firm diagnosis of PCOS should be followed up carefully and may be diagnosed at a later time.

A new approach to professional liability reform: placing obligations of stakeholders ahead of their interests

Judith L. Chervenak, Frank A. Chervenak, Laurence B. McCullough — 2010-05-10

The authors utilize stakeholder theory to provide a new analysis of the professional liability crisis, by identifying the major stakeholders in our current system of professional liability, their respective obligations and self-interests, and how these interests are advanced and constrained by the current system. This stakeholder analysis reveals a core ethical obligation of all stakeholders: the preservation of the integrity of our current judicial system. The adverse impact of the pursuit of stakeholder self-interests, rather than fulfillment of their core, shared ethical obligation, on achievement of the goals of the current system, the deterrence of unsafe practice and compensation of injured patients, is then identified. The authors argue that approaches to reform of professional liability in obstetrics be based upon the common obligation of the stakeholders to fulfill the goals of the system, because attempts to align the myriad self-interests of the stakeholders will be futile.

Scheduling the first prenatal visit: office-based delays

Mary D. Nettleman, Jennifer Brewer, Misty Stafford — 2010-07-20

Objective: The purpose of this study was to evaluate the office-based component of delayed entry into prenatal care.Study Design: Phone numbers for all obstetrics offices in a single state were obtained from a commercial list. A research assistant who posed as a newly pregnant, fully insured woman asked each clinic when she should come in for her first prenatal visit.Results: Information was provided by 239 of the 279 (86%) offices. The recommended appointment times ranged from immediately (4 weeks of gestation) to 10.6 weeks, which averaged 6.37 weeks. Twenty-five percent of clinics recommended a first appointment at ≥8 weeks. Scheduling calls were not a source of prenatal advice: <5% of clinics asked about smoking, alcohol, or medical condition; 88% of clinics did not mention vitamins.Conclusion: Office-based delays in scheduling the first prenatal visit occur in a substantial proportion of clinics, even for fully insured women. There is a need for a standard source of advice in early pregnancy.

Reproductive outcomes in subsequent pregnancies after a pregnancy complicated by open maternal-fetal surgery (1996–2007)

2010-05-31

Objective: The reproductive and gynecologic outcomes for women after the pregnancy complicated by open maternal-fetal surgery (OMFS) were evaluated.Study Design: The retrospective review identified 93 women with OMFS from a single institution (1996–2007). Consent and questionnaires were sent to women. Institutional review board approval was obtained from the Committee for Protection of Human Subjects.Results: The total return rate was 57.3%. Total pregnancies reported were 47, with 36 delivering after 20 weeks' gestation. The uterine dehiscence and rupture rates were 14% and 14%, respectively. Fetal anomalies occurred in 4 subsequent pregnancies. Normal conception occurred in 98% of subsequent pregnancies. Gynecologic issues were reported by 8 women, with infertility, abdominal pain, and ovarian and uterine factors.Conclusion: The reproductive outcomes of uterine dehiscence (14%) and rupture (14%) in a subsequent pregnancy continue to be a major counseling issue for OMFS. Fertility and gynecologic factors do not appear to be increased for women undergoing OMFS.

Intraamniotic infection with genital mycoplasmas exhibits a more intense inflammatory response than intraamniotic infection with other microorganisms in patients with preterm premature rupture of membranes

2010-08-05

Objective: The objective of the study was to compare the intensity of inflammatory responses between intraamniotic infection with genital mycoplasmas and intraamniotic infection with other microorganisms.Study Design: We examined the intensity of intraamniotic and maternal inflammatory responses in 99 patients with preterm premature rupture of membranes and a positive amniotic fluid (AF) culture. AF was obtained by transabdominal amniocentesis or at the time of cesarean delivery. Patients were divided according to the recovered microorganisms: (1) genital mycoplasmas (n = 62); (2) other microorganisms (n = 31); or (3) mixed infection (n = 6).Results: The median AF white blood cell (WBC) count, maternal blood WBC count, and plasma C-reactive protein concentrations were significantly higher in patients with intraamniotic infection with genital mycoplasmas than in those with intraamniotic infection with other microorganisms (P < .05 for each).Conclusion: Intraamniotic and maternal inflammatory responses are more intense in intraamniotic infection with genital mycoplasmas than in intraamniotic infection with other microorganisms in patients with preterm premature rupture of membranes.

The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester

2010-06-04

Objective: The aim of this study was to document the mortality of twin reversed arterial perfusion (TRAP) sequence from the first trimester to planned intervention at 16-18 weeks.Study Design: A retrospective review was performed of the outcome of monochorionic twin pregnancies diagnosed with twin reversed arterial perfusion sequence in the first trimester.Results: Twenty-six pregnancies were diagnosed with twin reversed arterial perfusion sequence in the first trimester: 2 opted for termination of pregnancy and 24 opted for prophylactic intervention to arrest the reversed flow, which was planned at 16-18 weeks. In 8 of 24 (33%) pregnancies, spontaneous death of the pump twin occurred between diagnosis and planned intervention. In 5 of 24 (21%), there was a spontaneous arrest of flow; whereas, in 11 (46%) there was persistent flow toward the acardiac twin at 16-18 weeks.Conclusion: Twin reversed arterial perfusion carries a high mortality between the first and early second trimester.

Seasonal variation in pregnancy hypertension is correlated with sunlight intensity

2010-05-31

Objective: To examine seasonality of pregnancy hypertension rates, and whether they related to sunlight levels around conception.Study Design: Data were obtained for 424,732 singleton pregnancies conceived from 2001 through 2005 in Australia. We analyzed monthly rates of pregnancy hypertension and preeclampsia in relation to monthly solar radiation.Results: Pregnancy hypertension rates, by month of conception, were lowest in autumn (7.3%) and highest in spring (8.9%). Higher sunlight intensity before delivery, but not around conception, was associated with decreased pregnancy hypertension (r = −0.67). Increased sunlight around conception may correlate with decreased rates of early-onset preeclampsia (r = −0.51; P = .09).Conclusion: The correlation between sunlight after conception and pregnancy hypertension was opposite to that hypothesized; however, sunlight levels before delivery did correlate with lower hypertension rates. For sunlight or ambient temperature to explain seasonal variation, the plausible exposure window is the period before delivery, but this may not apply to early-onset preeclampsia.

Computational modeling approach to study the effects of fetal head flexion during vaginal delivery

2010-05-17

Objective: The purpose of this study was to investigate the influence of fetal head flexion during vaginal delivery with a 3-dimensional computational finite element model.Study Design: A finite element model of the pelvic skeletal structure, pelvic floor, and fetus was developed. The movements of the fetus during birth were simulated in engagement, descent, flexion, internal rotation, and extension of the fetal head. The opposite forces against the fetal descendent and the stress of the pelvic floor muscles were obtained on simulations with different degrees of head flexion.Results: The simulated increase in fetal head flexion is associated with lower values of opposite forces against the fetal descent. The descending fetus with abnormal head flexion also meets resistance in later stations. Lower stress on the pelvic floor was demonstrated with simulated increase in fetal head flexion during vaginal delivery.Conclusion: This analytic evidence suggests that the fetal head flexion during vaginal delivery may facilitate birth and protect the pelvic floor.

The effect of plurality and obesity on betamethasone concentrations in women at risk for preterm delivery

2010-06-28

Objective: Antenatal corticosteroids (ACS) decrease respiratory distress syndrome in singleton gestations. Twin data are less clear. Obesity and body mass index (BMI) also affect medication distribution volume. We evaluated whether maternal or neonatal cord betamethasone concentrations differed in twin gestations or obese patients.Study Design: Participants receiving betamethasone in a randomized controlled trial of weekly ACS were identified. We analyzed maternal delivery and cord serum betamethasone concentrations comparing singletons with twins and obese (BMI ≥30 kg/m2) with nonobese women.Results: Fifty-five maternal and 45 cord blood samples were available. Unadjusted median maternal serum concentrations appeared paradoxically higher in both twin gestations and the obese. However, after controlling for confounders, there were no differences in betamethasone concentrations in maternal serum or cord blood between singletons and twins (P = .61 vs P = .14) or nonobese and obese women (P = .67 vs .12).Conclusion: Maternal and umbilical cord blood serum betamethasone concentrations are not different in twin gestations or obese women.

Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy

2010-05-31

Objective: We sought to determine whether emergent cesarean supracervical hysterectomy is associated with reduced risk of complications compared to total hysterectomy.Study Design: We conducted a cohort study of 150 women who underwent emergent cesarean hysterectomy at our medical center from 1991 through 2008. We compared the risk factors and indications, and intraoperative and postoperative complications associated with the 2 surgical procedures.Results: During the study period, a total of 164 cesarean hysterectomies were performed; 91% (n = 150) of these cases were performed emergently of which 53.3% were total and 46.7% were supracervical. There was a significant decline in the relative frequency of total hysterectomy: 71%, 56%, and 24% during 1991–1996, 1997–2002, and 2003–2008, respectively (P < .001). Risk factors, indications for surgery, operative variables, and postoperative complication rates were independent of the type of hysterectomy.Conclusion: Using a cohort of 150 cases from our institution, we found no evidence of increased surgical time or complications associated with total hysterectomy.

Pregnancy with Friedreich ataxia: a retrospective review of medical risks and psychosocial implications

2010-05-17

Objective: Friedreich ataxia (FRDA) is an autosomal recessive, neurodegenerative disease. Recent medical advances have improved the average life expectancy, and as such, many female patients are contemplating pregnancy. However, little research exists exploring the medical or psychosocial complications that arise from pregnancy with this disease.Study Design: In this study, we retrospectively examined 31 women with FRDA who had 65 pregnancies, resulting in 56 live offspring.Results: FRDA did not appear to increase the risk of spontaneous abortion, preeclampsia, or preterm birth. Despite the sensory and proprioceptive loss that occurs in FRDA, nearly four fifths of births were vaginal. Of babies, 94.4% were discharged home with their mothers. Equal numbers of women reported that pregnancy made their disease symptoms worse, better, or unchanged.Conclusion: This study demonstrates that women with FRDA can have uncomplicated pregnancies that do not uniformly complicate disease symptomatology.

Evaluation of the labor curve in nulliparous Japanese women

Ritsuko Suzuki, Shigeko Horiuchi, Hiroshi Ohtsu — 2010-05-24

Objective: We sought to compare Japanese nulliparous labor progression with Friedman's classic 1955 curve and Zhang's 2002 curve.Study Design: We developed a labor curve using retrospective record reviews of 2369 Japanese nulliparas, at term, spontaneous labor onset and singleton vertex deliveries of normal birth weight infants.Results: The new Japanese Suzuki-Horiuchi labor curve with slower cervical dilation in the active phase was like Zhang's and differed from Friedman's curve. Labor length was approximately 5 hours occurring between 4-10 cm compared with Friedman's 2.5 hours and Zhang's 5.5 hours. Even at 10-cm dilation, labor lasted >2 hours at the 95th percentile of time interval.Conclusion: Similar to Zhang's curve, the Suzuki-Horiuchi curve was smooth and more gradually sloped than Friedman's curve. Appraise “arrested or protracted labor” with these slower labor curves in mind using Friedman's curve cautiously.

Comparison of a novel multiple marker assay vs the Risk of Malignancy Index for the prediction of epithelial ovarian cancer in patients with a pelvic mass

2010-05-17

Objective: We sought to compare the Risk of Malignancy Index (RMI) to the Risk of Ovarian Malignancy Algorithm (ROMA) to predict epithelial ovarian cancer (EOC) in women with a pelvic mass.Study Design: In all, 457 women with imaging results from ultrasound, computed tomography, magnetic resonance imaging, and serum HE4 and CA125 determined prior to surgery for pelvic mass were evaluable. RMI values were determined using CA125, imaging score, and menopausal status. ROMA values were determined using HE4, CA125, and menopausal status.Results: At a set specificity of 75%, ROMA had a sensitivity of 94.3% and RMI had a sensitivity of 84.6% for distinguishing benign status from EOC (P = .0029). In patients with stage I and II disease, ROMA achieved a sensitivity of 85.3% compared with 64.7% for RMI (P < .0001).Conclusion: The dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA value achieves a significantly higher sensitivity for identifying women with EOC than does RMI.

Expression of soluble interleukin-6 receptor in malignant ovarian tissue

2010-05-17

Objective: The objective of the study was to investigate interleukin-6 receptor (IL6R) isoforms and sheddases in the ovarian tumor microenvironment.Study Design: Expression of IL6R and sheddases was measured in tissue samples of papillary serous ovarian carcinomas and benign ovaries by real-time polymerase chain reaction and immunohistochemistry. Murine xenograft samples were tested by enzyme-linked immunosorbent assay to discriminate and evaluate tumor and host contributions of IL6R.Results: IL6R expression was increased in malignant ovarian tumors and localized to epithelial cells. Expression of a soluble splice variant of IL6R was increased in malignant tumors, as were the sheddases for the full-length isoform. An in vivo xenograft model showed that host IL6R expression is also increased and regulated by tumor-associated inflammation.Conclusion: IL6R is overexpressed in epithelial ovarian malignancies because of increases in a soluble IL6R variant, in the sheddases for full-length IL6R and host IL6R expression. Soluble IL6R may be an efficacious target for reducing IL6-mediated ovarian tumor progression.

Are endometrial polyps true cancer precursors?

2010-05-17

Objective: The purpose of this study was to assess whether endometrial polyps (EMPs) represent cancer precursors.Study Design: Age standardized incidence ratios (SIRs) of histologically verified endometrial cancers (EmCas) were estimated in women with EMPs and in women with uterine leiomyomata, which is a condition that is unrelated to endometrial carcinogenesis. SIRs were calculated as the ratio of observed to expected EmCas based on age-specific incidence rates for female Montreal residents during the same period.Results: Of 1467 women with EMPs, 125 (8.5%) had EmCa. Of 1138 patients with uterine leiomyomata, 133 (11.7%) had EmCa. The SIRs of EmCa for women with EMPs (odds ratio, 8.0; 95% confidence interval, 6.6–9.5) were significantly lower than that in women with leiomyomata (odds ratio, 19.1; 95% confidence interval, 16.0–22.6). Abnormal uterine bleeding was the main reason for evaluating patients with EMP with or without associated EmCa.Conclusion: The findings of higher EmCa incidence are consistent with enhanced detection opportunity rather than with the endometrial cancer precursor potential of EMPs.

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up

2010-05-24

Objective: The objective of the study was to compare anterior colporrhaphy with and without a mesh.Study Design: Two hundred two women with anterior prolapse were assigned to undergo colporrhaphy alone or reinforced with a tailored polypropylene mesh. Before and 2, 12, 24, and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of anterior vaginal prolapse. Secondary outcomes were symptom resolution, reoperation, and mesh exposure.Results: Recurrences of anterior vaginal prolapse were noted in 40 of the 97 (41%) in the colporrhaphy group and 14 of 105 (13%) in the mesh group (P < .0001). The number needed to treat was thus 4. The proportion of symptomatic patients, including those with dyspareunia, did not differ between the groups. The mesh erosion rate was 19%.Conclusion: At 3 year follow-up, anterior colporrhaphy with mesh reinforcement significantly reduced anatomic recurrences of anterior vaginal prolapse, but no difference in symptomatic recurrence were noted and the mesh erosion rate was high. The use of mesh was not associated with an increase in dyspareunia.

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia

2010-07-20

Objective: The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC.Study Design: This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program.Results: Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively.Conclusion: Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.

Assessment of intraoperative judgment during gynecologic surgery using the Script Concordance Test

2010-05-24

Objective: We sought to develop a valid, reliable assessment of intraoperative judgment by residents during gynecologic surgery based on Script Concordance Theory.Study Design: This was a multicenter prospective study involving 5 obstetrics and gynecology residency programs. Surgeons from each site generated case scenarios based on common gynecologic procedures. Construct validity was evaluated by correlating scores to training level, in-service examinations, and surgical skill and experience using a Global Rating Scale of Operative Performance and case volumes.Results: A final test that included 42 case scenarios was administered to 75 residents. Internal consistency (Cronbach alpha = 0.73) and test-retest reliability (Lin correlation coefficient = 0.76) were good. There were significant differences between test scores and training levels (P = .002) and test scores correlated with in-service examination scores (r = 0.38; P = .001). There was no association between test scores and total number of cases or technical skills.Conclusion: The Script Concordance Test appears to be a reliable, valid assessment tool for intraoperative decision-making during gynecologic surgery.

Co-expression of GPR30 and ERβ and their association with disease progression in uterine carcinosarcoma

2010-06-04

Objective: We sought to evaluate the expression of G protein-coupled receptor 30 (GPR30) and estrogen receptor (ER)β in uterine carcinosarcoma (CS).Study Design: Immunohistochemistry was performed using antibodies to GPR30, ERβ, ERα, and progesterone receptor (PR). The staining intensity and percentage of positive cells were scored for each tissue section. Expression levels were compared using the Wilcoxon rank sum test. Correlation was evaluated by Spearman rho and logistic regression.Results: Compared with normal endometrium, CS had lower ERα and PR expression (both P < .01) but higher GPR30 epithelial expression (P = .03). Advanced-stage CS had higher GPR30 (P < .01) and ERβ (P = .02) epithelial expression compared with early-stage CS. Expression of GPR30 and ERβ correlated with each other (P < .01), and not with ERα or PR.Conclusion: In uterine CS, GPR30 and ERβ are coordinately overexpressed and expression levels increase in advanced-stage disease, supporting the involvement of alternative ERs in disease progression.

Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis

2010-07-02

Objective: We sought to systematically review the medical literature on the maternal and newborn safety of planned home vs planned hospital birth.Study Design: We included English-language peer-reviewed publications from developed Western nations reporting maternal and newborn outcomes by planned delivery location. Outcomes' summary odds ratios with 95% confidence intervals were calculated.Results: Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates.Conclusion: Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.

Association of midgestation paraoxonase 1 activity and pregnancies complicated by preterm birth

Arthur M. Baker, Sina Haeri, Richard L. Klein, Kim Boggess — 2010-06-14

Objective: The objective of the study was to determine whether an association exists between low paraoxonase 1 activity and dyslipidemia at midgestation and preterm birth.Study Design: We conducted a case-control study of 30 women with preterm birth and 90 women with uncomplicated term deliveries. Maternal serum collected at 15-20 weeks was used to measure lipid concentrations and paraoxonase 1 activity using 2 substrates: paraoxon and phenylacetate (arylesterase activity).Results: The groups did not differ with respect to maternal demographics. Paraoxonase 1 activity (paraoxon) was significantly lower in women delivering preterm compared with controls (12.9 ± 6.1 vs 16.6 ± 7.7 dA/min; P = .02). Arylesterase activity and serum lipid concentrations were similar between women with preterm birth and controls.Conclusion: Midgestation paraoxonase 1 activity is lower in women who later experience spontaneous preterm birth compared with women who have term deliveries. Prospective studies are needed to determine the significance of paraoxonase 1 in the pathogenesis of preterm birth.

Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: a double-blind, randomized clinical trial

2010-09-01

Objective: To test whether 17 alpha-hydroxyprogesterone caproate (17P) will reduce neonatal morbidity by increasing gestational age at delivery in triplet pregnancies.Study Design: Double-blind, randomized clinical trial. Mothers carrying trichorionic-triamniotic triplets were randomly assigned (in a 2:1 ratio) to weekly injections of 250 mg of 17P or placebo, starting at 16-22 weeks and continued until 34 weeks. Primary outcome was composite neonatal morbidity.Results: Fifty-six women were randomized to 17P and 25 to placebo. Composite neonatal morbidity occurred with similar frequency in the 17P and placebo groups (38% vs 41%, respectively; P = .71). Mean gestational age at delivery was not affected by 17P (31.9 vs 31.8 weeks; P = .36). There were 13 midtrimester fetal losses with 17P vs none with placebo (P < .02).Conclusion: In triplet pregnancy, prophylactic treatment with 17P did not reduce neonatal morbidity or prolong gestation but was associated with increased midtrimester fetal loss.

Cost-effective standardization of preterm labor evaluation

2010-09-01

Objective: The purpose of this study was to determine the effect of a standardized evidence-based protocol for preterm labor evaluation on resource use and obstetrics outcomes.Study Design: We conducted a retrospective 12-month observational study of patients with symptoms of preterm labor at the Mayo Clinic. All patients underwent triage evaluation per a standardized protocol with a combination of cervical length measurement with contingent fetal fibronectin assay.Results: Of 201 patients who underwent evaluation, 3 women delivered within 7 days, and only 1 woman delivered after a negative evaluation. Mean gestational age at evaluation was 29 weeks 1 day, and delivery was at 38 weeks 3 days of gestation, with an average interval of 57.4 days until delivery. The rate of hospital admission was reduced by 56%, compared with the previous year; an estimated annual cost saving was $39,900.Conclusion: Implementation of a standardized protocol for evaluation of preterm labor reduces the rate of unnecessary hospital admissions for observation with consequent significant reduction in expenses.

Does sildenafil citrate affect myometrial contractile response to nifedipine in vitro?

2010-06-14

Objective: We sought to test the hypothesis that sildenafil citrate (SC) at low concentrations potentiates the tocolytic effects of nifedipine in vitro.Study Design: Myometrial biopsies were obtained from 22 term nonlaboring women undergoing scheduled cesarean delivery. Tissue strips were suspended in organ chambers for isometric tension recording, and incubated for 30 minutes with either SC at 231 ng/mL or solvent. The effects of cumulative doses (10–10 to 10–5 mol/L) of nifedipine on spontaneous and oxytocin-induced uterine contractility were then determined. Areas under the contraction curve were compared using 1-way analysis of variance with Tukey post hoc test (significance: P < .05).Results: Nifedipine significantly inhibited spontaneous and oxytocin-induced myometrial contractility. Preincubation with SC increased response to nifedipine and significantly potentiated its inhibitory effect at 10–8 mol/L, without affecting oxytocin-induced contractile response.Conclusion: At concentrations within a therapeutic window, SC increases myometrial sensitivity to nifedipine.

Betamethasone in pregnancy: influence of maternal body weight and multiple gestation on pharmacokinetics

Micaela Della Torre, Judith U. Hibbard, Hyunyoung Jeong, James H. Fischer — 2010-09-01

Objective: The goals of the study were to estimate the pharmacokinetic parameters of standard dose betamethasone in a large obstetrics population and evaluate the effect of maternal body size and multiple gestation on the pharmacokinetic parameters and their observed variability.Study Design: This was a prospective pharmacokinetic study. Liquid chromatography mass spectrometry was used to measure betamethasone plasma concentrations. Pharmacokinetic parameters and significant clinical covariates were estimated with mixed effect modeling. Bootstrap analysis confirmed validity of the model.Results: Two hundred seventy-four blood samples from 77 patients were obtained. The greatest effect on pharmacokinetic variability was observed with maternal lean body weight (LBW). The relationship between the pharmacokinetic parameters and LBW remained linear over a wide range of maternal body sizes. Multiple gestations did not affect the pharmacokinetic parameters.Conclusion: Individualization of betamethasone dosing by maternal LBW reduces variability in drug exposure. Mutiple gestations do not require betamethasone dosing adjustment, because pharmacokinetics are the same as singleton gestations.

Impact of prior gestational age at preterm delivery on effectiveness of 17-alpha-hydroxyprogesterone caproate in practice

2010-08-05

Objective: We sought to examine if 17-alpha-hydroxyprogesterone caproate (17OHPC) effectiveness is dependent on the earliest gestational age (GA) at prior spontaneous preterm birth (SPTB) when administered in the clinical setting.Study Design: Women enrolled for outpatient services with current singleton gestation and ≥1 prior SPTB between 20-36.9 weeks were identified. Data were divided into 3 groups according to earliest GA of prior SPTB (20-27.9, 28-33.9, and 34-36.9 weeks). We compared GA at delivery of current pregnancy and incidence of recurrent SPTB between women enrolled in outpatient 17OHPC administration program (n = 2978) and women receiving other outpatient services without 17OHPC (n = 1260).Results: Rates of recurrent SPTB for those with and without 17OHPC prophylaxis, respectively, according to GA at earliest SPTB were: 20-27.9 weeks at earliest SPTB, 32.2% vs 40.7%, P = .025; 28-33.9 weeks at earliest SPTB, 34.1% vs 45.5%, P < .001; and 34-36.9 weeks at earliest SPTB, 29.3% vs 38.8%, P < .001.Conclusion: 17OHPC given to prevent recurrent SPTB is effective regardless of GA at earliest SPTB.

Cervical funneling: effect on gestational length and ultrasound-indicated cerclage in high-risk women

2010-09-01

Objective: The purpose of this study was to assess funnel type and pregnancy duration in women with previous spontaneous preterm birth and cervical length <25 mm.Study Design: We performed a secondary analysis of a multicenter randomized trial of cerclage. At the randomization scan that documented short cervix, the presence and type of funnel (U or V) were recorded.Results: One hundred forty-seven of 301 women (49%) had funneling: V-shaped funnel, 99 women; U-shaped funnel, 48 women. U-shaped funnel was associated significantly with preterm birth at <24, <28, <35, and <37 weeks of gestation. In multivariable models that controlled for randomization cervical length and cerclage, women with U-shaped funnel delivered earlier than women with either V-shaped funnel or no funnel. Interaction between cerclage and U-shaped funnel was observed, and analyses that were stratified by cerclage showed that women with a U-shaped funnel and cerclage delivered at a mean of 33.8 ± 6.6 weeks of gestation, compared with women who did not receive cerclage (28.9 ± 6.9 weeks of gestation).Conclusion: U-shaped funnels in high-risk women with a short cervix are associated with earlier birth.

Effect of maternal body mass index on in vitro response to tocolytics in term myometrium

2010-07-15

Objective: We sought to investigate the effect of body mass index (BMI) on in vitro response to tocolytics.Study Design: Myometrial biopsies were obtained at the time of scheduled cesarean deliveries from term nonlaboring women with BMI ≤29.9 (26.3 ± 1.3; n = 7), 30-34.9 (31.8 ± 1.2; n = 16), and ≥35 (39.5 ± 4.9; n = 9). Tissue strips were suspended in organ chambers for isometric tension recording. The effects of cumulative doses (10−10 to 10−5 mol/L) of nifedipine or indomethacin on spontaneous uterine contractility were determined. Areas under the contraction curve were compared using 1-way analysis of variance with Tukey post hoc test.Results: Myometrial response to tocolytics did not differ between the BMI groups. Nifedipine, but not indomethacin, significantly inhibited myometrial contractility independent of BMI.Conclusion: BMI does not affect uterine response to tocolytics in isolated uterine tissue from term nonlaboring women.

The maternal body mass index: a strong association with delivery route

2010-08-05

Objective: We sought to assess body mass index (BMI) effect on cesarean risk during labor.Study Design: The Consortium on Safe Labor collected electronic data from 228,668 deliveries. Women with singletons ≥37 weeks and known BMI at labor admission were analyzed in this cohort study. Regression analysis generated relative risks for cesarean stratifying for parity and prior cesarean while controlling for covariates.Results: Of the 124,389 women, 14.0% had cesareans. Cesareans increased with increasing BMI for nulliparas and multiparas with and without a prior cesarean. Repeat cesareans were performed in >50% of laboring women with a BMI >40 kg/m2. The risk for cesarean increased as BMI increased for all subgroups, P < .001. The risk for cesarean increased by 5%, 2%, and 5% for nulliparas and multiparas with and without a prior cesarean, respectively, for each 1-kg/m2 increase in BMI.Conclusion: Admission BMI is significantly associated with delivery route in term laboring women. Parity and prior cesarean are other important predictors.

Lipoxygenase and cyclooxygenase inhibitors reveal a complementary role of arachidonic acid derivatives in pregnant human myometrium

Stéphanie Corriveau, Eric Rousseau, Maryse Berthiaume, Jean-Charles Pasquier — 2010-08-05

Objective: The aim of this study was to assess the involvement of lipoxygenase (LOX) metabolic pathways in uterine tissues from pregnant women as well as the combined inhibition of LOX and cyclooxygenase (COX) on contractile activity.Study Design: Uterine biopsies were performed from consenting women undergoing elective caesarean sections at term (n = 24). Western blot analysis and isometric tension measurements were performed in vitro on fresh human myometrial strips. Concentration-response curves to arachidonic acid (AA) 861 and baicalein (5- and 12-LOX inhibitors, respectively) were performed. The combined effects of baicalein and indomethacin were also assessed. Contractile activities were quantified by calculating both amplitude and the area under the curve over 20 minute periods.Results: 5- and 12-LOX were present in all tested tissues. Addition of AA861 or baicalein resulted in tocolytic effects (P < .05). Finally, the combined inhibition of both COX and 12-LOX pathways resulted in additive tocolytic effects.Conclusion: 5- and 12-LOX pathways modulate human myometrium contractility.

Rates of labor induction without medical indication are overestimated when derived from birth certificate data

Jennifer L. Bailit, Ohio Perinatal Quality Collaborative — 2010-09-01

Objective: The purpose of this study was to determine the rates of late preterm inductions without a medical indication from birth certificate data and to compare them with rates that were obtained from medical charts.Study Design: The Ohio Perinatal Quality Collaborative, which comprises 20 hospitals in Ohio that came together in 2008 for the purpose of decreasing nonmedically indicated scheduled deliveries, abstracted data on all scheduled births between 36 weeks and 38 weeks 6 days of gestation. We compared labor inductions with “elective” documented or no indication documented in charts to birth certificate data for inductions with no maternal or fetal complications recorded.Results: Birth certificates overestimate rates of induction without medical indication compared with chart abstraction (11% vs 1%; P < .0001). The monthly difference between chart abstraction and birth certificates averages 10.1%.Conclusion: Birth certificates overestimate nonmedically indicated inductions by 11-fold. Until birth certificate data improve, nonmedically indicated induction rates that are calculated from birth certificates should be interpreted with caution.

Complications of cesarean delivery in the massively obese parturient

2010-08-05

Objective: The objective of the study was to determine predictors of cesarean delivery morbidity associated with massive obesity.Study Design: This was an institutional review board–approved retrospective study of massively obese women (body mass index, ≥50 kg/m2) undergoing cesarean delivery. Bivariable and multivariable analyses were used to assess the strength of association between wound complication and various predictors.Results: Fifty-eight of 194 patients (30%) had a wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after hospital discharge (median postoperative day, 8.5; interquartile range, 6–12). Subcutaneous drains and smoking, but not labor or ruptured membranes, were independently associated with wound complication after controlling for various confounders. Vertical abdominal incisions were associated with increased operative time, blood loss, and vertical hysterotomy.Conclusion: Women with a body mass index ≥50 kg/m2 have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

Maternal arterial stiffness in pregnancies complicated by gestational and type 2 diabetes mellitus

Makrina D. Savvidou, James M. Anderson, Christine Kaihura, Kypros H. Nicolaides — 2010-07-26

Objective: We sought to investigate whether maternal arterial stiffness is altered in pregnant women with gestational diabetes mellitus (GDM) and type 2 diabetes compared to normoglycemic women.Study Design: We conducted a cross-sectional study involving 34 women with GDM and their controls (n = 34), and 34 women with type 2 diabetes and their controls (n = 34). Maternal arterial stiffness was assessed using applanation tonometry.Results: In patients with GDM, compared to their controls, augmentation index (a measure of arterial wave reflection) was higher (13.1 ± 8.9% vs 0.7 ± 11.4%; P < .001) and pulse wave velocity (PWV) (arterial stiffness of the carotid-femoral) was marginally increased (6 ± 1.5 vs 5.4 ± 0.6 m/s; P = .07). In type 2 diabetics, compared to their controls, both augmentation index and PWV were increased (11.5 ± 11.4% vs 3.3 ± 12.5%; P = .006, and 6.8 ± 1.2 vs 5.6 ± 1 m/s; P < .001). When all groups were considered together, there was a significant trend of increasing augmentation index (P = .001) and PWV (P < .001) from controls to those with GDM to type 2 diabetes.Conclusion: Pregnancies complicated by GDM and type 2 diabetes are associated with increased maternal arterial stiffness.

Anesthesia complications during scheduled cesarean delivery for morbidly obese women

Laura K. Vricella, Judette M. Louis, Brian M. Mercer, Norman Bolden — 2010-08-05

Objective: We sought to estimate the morbidity associated with regional anesthesia in morbidly obese women undergoing scheduled cesarean delivery.Study Design: This was a retrospective cohort study of women undergoing elective scheduled cesarean delivery from September 2004 through December 2008.Results: A total of 142 morbidly obese, 251 overweight and obese, and 185 normal-weight women met inclusion criteria. Differences between groups were identified regarding: complicated placement (5.6%, 2.8%, and 0%, respectively; P = .007), failure to establish (2%, 0%, and 0%, respectively; P = .047), and insufficient duration (4%, 0%, and 0%, respectively; P = .02) of regional anesthesia. The groups differed in the frequency of general anesthesia (6%, 0%, and 0%, respectively; P = .003), intraoperative hypotension (3%, 0%, and 0%, respectively; P = .01), and overall anesthetic complications (8.4%, 0%, and 0%, respectively; P < .0001). Prepregnancy body mass index ≥40 kg/m2 (receiver operating characteristic area under the curve, 0.856; positive likelihood ratio, 4.0) and delivery body mass index ≥45 kg/m2 (receiver operating characteristic area under the curve, 0.877; positive likelihood ratio, 4.1) were predictive of anesthetic complications.Conclusion: Morbidly obese women have significant risk for anesthesia complications during cesarean delivery.

Gestational weight gain in consecutive pregnancies

2010-09-01

Objective: The purpose of this study was to examine the association between gestational weight gain (GWG) in a woman's first and second pregnancies.Study Design: We conducted a retrospective observational cohort study of 27,771 women with their first and second births in North Carolina's Pregnancy Nutrition Surveillance System database from 1996-2004. GWG was categorized as inadequate, appropriate, or excessive, according to 2009 Institute of Medicine guidelines. Covariate adjusted polytomous logistic regression was used to test the association between GWG category in the first and second pregnancy.Results: Compared with women with appropriate GWG in their first pregnancy, women with excessive GWG in their first pregnancy had an odds ratio of 2.6 (95% confidence interval, 2.4–2.7) for excessive GWG in their second pregnancy. Women with inadequate GWG in their first pregnancy were similarly likely to repeat this category in their subsequent pregnancy.Conclusion: GWG category in a woman's first pregnancy is a significant predictor of GWG category in her subsequent pregnancy.

Platelet reactivity and pregnancy loss

2010-08-05

Objective: We sought to critically evaluate platelet function in recurrent miscarriage (RM).Study Design: We conducted a prospective study comparing 30 patients with unexplained recurrent first-trimester pregnancy loss with 30 control subjects matched for age and serum progesterone level. Platelet function was determined using a modified assay of light transmission aggregometry with multiple agonists at different concentrations. Dose-response curves were created and half-maximal effective concentration values were calculated.Results: At test completion the half-maximal effective concentration values for arachidonic acid in the patients with RM were significantly less than in the control subjects (0.153 vs 0.230; P = .0099). The dose-response curves were tightly matched for the other agonists.Conclusion: This novel measurement of platelet function has demonstrated that patients with unexplained RM have significantly increased platelet aggregation in response to arachidonic acid. The enhanced response to this agonist provides an empirical rationale for the use of aspirin in management of this clinical condition.

Obesity and diabetes genetic variants associated with gestational weight gain

2010-09-01

Objective: We sought to determine whether genetic variants associated with diabetes and obesity predict gestational weight gain.Study Design: A total of 960 participants in the Pregnancy, Infection, and Nutrition cohorts were genotyped for 27 single-nucleotide polymorphisms (SNPs) associated with diabetes and obesity.Results: Among Caucasian and African American women (n = 960), KCNQ1 risk allele carriage was directly associated with weight gain (P < .01). In Bayesian hierarchical models among Caucasian women (n = 628), we found posterior odds ratios >3 for inclusion of TCF2 and THADA SNPs in our models. Among African American women (n = 332), we found associations between risk allele carriage and weight gain for the THADA and INSIG2 SNPs. In Bayesian variable selection models, we found an interaction between the TSPAN8 risk allele and pregravid obesity, with lower weight gain among obese risk allele carriers.Conclusion: We found evidence that diabetes and obesity risk alleles interact with maternal pregravid body mass index to predict gestational weight gain.

Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery

2010-09-01

Objective: The purpose of this study was to determine the wound complication rates and patient satisfaction for subcuticular suture vs staples for skin closure at cesarean delivery.Study Design: This was a randomized prospective trial. Subjects who underwent cesarean delivery were assigned randomly to stainless steel staples or subcuticular 4.0 Monocryl sutures. The primary outcomes were composite wound complication rate and patient satisfaction.Results: A total of 435 patients were assigned randomly. Staple closure was associated with a 4-fold increased risk of wound separation (adjusted odds ratio [aOR], 4.66; 95% confidence interval [CI], 2.07–10.52; P < .001). Having a wound complication was associated with a 5-fold decrease in patient satisfaction (aOR, 0.18; 95% CI, 0.09–0.37; P < .001). After confounders were controlled for, there was no difference in satisfaction between the treatment groups (aOR, 0.71; 95% CI, 0.34–1.50; P = .63).Conclusion: Use of staples for cesarean delivery closure is associated with an increased risk of wound complications. Occurrence of a wound complication is the most important factor that influenced patient satisfaction.

Scheduling the first prenatal visit: Nettleman et al

2010-09-01

The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed:Nettleman MD, Brewer J, Stafford M. Scheduling the first prenatal visit: office-based delays. Am J Obstet Gynecol 2010;203:207.e1-3.The full discussion appears at www.AJOG.org, pages e1-4.

Separated from birth: An initial examination suggested Asherman's syndrome

Meghan B. Oakes, Senait Fisseha — 2010-07-02

A 30-year-old woman (gravida 1, para 1) was evaluated for secondary infertility. Her first pregnancy was delivered by cesarean section 13 months earlier, and she had an unremarkable postpartum course. Hysteroscopy, a component of the infertility workup, revealed lower uterine synechiae, which is a condition known as Asherman's syndrome (). Concomitant ultrasonography detailed a normal-appearing upper cavity with tubal patency. Hysteroscopic adhesiolysis was recommended ().

Loop electrosurgical excision procedure with an intrauterine device in place

Amelia P. Bailey, Mixon M. Darracott — 2010-09-01

Abstract: Patients using an intrauterine device (IUD) who require a loop electrosurgical excision procedure (LEEP) for cervical dysplasia have traditionally had the IUD removed prior to the procedure. The only other options have been methods that lead to suboptimal sampling or risk cutting the strings. Our study suggests a procedure for performing the LEEP without removing the IUD, and review of the literature suggests that this method has not been reported before. The LEEP is performed using a conization electrode or a cone biopsy excisor. After noting that the IUD strings are of adequate length, a 0-polyglactin free tie is secured around the visible portion of the IUD strings without applying tension on the strings. A large, sterile absorbent-tipped applicator with a hollow handle becomes an 8 cm hollow plastic tube by removing the cotton tip with sterile scissors. The long end of the suture is threaded through the sterile tube. Without pulling on the IUD, the tube is then passed over the strings into the cervical canal approximately 2.5 cm to protect the strings from the excisor well into the cervical canal. Then, the LEEP is performed. After the specimen is removed, hemostasis can be obtained using a ball cautery electrode, keeping the protecting tube with the enclosed IUD strings out of the way. The tube is then carefully removed. The suture is now cut close to the polyglactin knot around the IUD strings, making certain not to shorten the IUD strings and making certain the visible length of the strings is the same as before the procedure. Ferric subsulfate is applied to the operative area to provide continued hemostasis. Follow-up for the LEEP is unchanged. This procedure may be performed on either levonorgestrel-releasing or copper IUDs.

Discussion: ‘Scheduling the first prenatal visit’ by Nettleman et al

2010-09-01

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed:Nettleman MD, Brewer J, Stafford M. Scheduling the first prenatal visit: office-based delays. Am J Obstet Gynecol 2010;203:207.e1-3.

Squamous cell carcinoma arising from a localized vulval lesion of Hailey-Hailey disease after tacrolimus therapy

2010-09-01

Hailey-Hailey disease (HHD) is a rare, autosomal dominant intraepidermal blistering disorder characterized by recurrent vesicles and erosions affecting mostly the intertriginous areas. We report a case of HHD affecting exclusively the vulva from which an invasive squamous cell carcinoma developed after tacrolimus therapy.

Assessing second-stage progress

Wayne R. Cohen, Barry S. Schifrin — 2010-07-23

In a recent editorial Caughey addressed the optimal timing of intervention when the second stage of labor is long. He stressed that the duration norms drawn from Emanuel Friedman's “notorious” research need reevaluation. Friedman, however, never advocated such use of durations as clinical norms. In fact, it was his enduring (and often corroborated) contribution that the feasibility of safe vaginal delivery is not determinable strictly from elapsed time in labor or contraction measurement, but is best realized by graphic analysis of dilatation and descent patterns.

Reply

Aaron B. Caughey — 2010-07-23

I would like to thank Drs Cohen and Schifrin for their letter. They underscore the importance of using clinical acumen and ongoing assessment of the laboring woman as opposed to arbitrary thresholds. I entirely agree, and this appears to hold true in both the first and second stage. Further, they point out that Dr Friedman had no intent of establishing norms to be utilized as absolute thresholds. While this is true, as we all know, his work has led to the establishment of thresholds that are used by both obstetricians and malpractice attorneys and has contributed to the current 32% cesarean delivery rate in the United States.

17-alpha-hydroprogesterone caproate and cervical changes

Fabio Facchinetti — 2010-05-31

I read with interest the article of Durnwald et al. Contrary to our prospective evaluations, in a retrospective analysis they found that 17-alpha-hydroxyprogesterone (17P) caproate did not affect cervical length in the women who were enrolled in a preterm prevention clinic.

Reply

Celeste Durnwald, Courtney Lynch, Jay Iams — 2010-05-31

We appreciate Dr Facchinetti's comment on our recent publication, “The effect of treatment with 17-alpha-hydroxyprogesterone caproate on changes in cervical length over time.” In our retrospective analysis, there was no difference in the average weekly change in cervical length measurements over time in women who underwent 17-alpha-hydroxyprogesterone caproate (17 OHPC) treatment compared with those women who were not treated. Dr Facchinetti's study enrolled women in preterm labor that was defined as uterine contractions with either cervical shortening or dilation. We enrolled asymptomatic women with a history of preterm birth. In our study population, only 17 women had a cervical length <25 mm at their first measurement (mean gestational age, 20.5 weeks). In this subset of women, there was no difference in effectiveness of 17 OHPC between women who had a short cervical length (<25 mm) at baseline and those who had a cervical length ≥25 mm at baseline (P = .28), after adjustment for race/ethnicity and gestational age at earliest preterm birth. These results have to be interpreted with caution because of poor precision as a result of our small sample size (n = 17 women). Our findings may differ from those of Dr Facchinetti's because of the population of women who were studied (asymptomatic women vs those women who had been diagnosed with preterm labor), the dose of 17 OHPC given (250 vs 341 mg), or the frequency of the dosing (weekly vs every 4 days). We agree with Dr Facchinetti that other mechanisms of action could be hypothesized to explain the difference in the effectiveness of 17 OHPC that is given for symptomatic preterm labor compared with 17 OHPC that is given to asymptomatic women because of a history of preterm birth.

Comparison of peritoneal carcinomatosis scoring methods in predicting resectability and prognosis in advanced ovarian cancer

Anna Fagotti, Giuseppe Vizzielli, Francesco Fanfani, Giovanni Scambia — 2010-07-02

We have read with great interest the article by Chéreau et al regarding the comparison of peritoneal carcinomatosis scoring methods to identify patients with advanced ovarian cancer (AOC) for optimal cytoreductive surgery, and we would congratulate the authors for their effort to clarify the power of these different scores.

Reply

Elisabeth Chéreau, Emile Daraï, Roman Rouzier, Hopital Tenon — 2010-07-02

We have read with a great interest the letter by Fagotti et al that referred to our article “Comparison of peritoneal scoring methods in predicting resectability and prognosis in advanced ovarian cancer.”

American Journal of Obstetrics & Gynecology

Table of Contents

Information for Readers

Changes

Using birth certificate data to determine medically indicated induction rates

Scheduling the first prenatal visit: a missed opportunity

von Willebrand disease and pregnancy: a practical approach for the diagnosis and treatment

The diagnosis of polycystic ovary syndrome in adolescents

A new approach to professional liability reform: placing obligations of stakeholders ahead of their interests

Scheduling the first prenatal visit: office-based delays

Reproductive outcomes in subsequent pregnancies after a pregnancy complicated by open maternal-fetal surgery (1996–2007)

Intraamniotic infection with genital mycoplasmas exhibits a more intense inflammatory response than intraamniotic infection with other microorganisms in patients with preterm premature rupture of membranes

The outcome of twin reversed arterial perfusion sequence diagnosed in the first trimester

Seasonal variation in pregnancy hypertension is correlated with sunlight intensity

Computational modeling approach to study the effects of fetal head flexion during vaginal delivery

The effect of plurality and obesity on betamethasone concentrations in women at risk for preterm delivery

Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy

Pregnancy with Friedreich ataxia: a retrospective review of medical risks and psychosocial implications

Evaluation of the labor curve in nulliparous Japanese women

Comparison of a novel multiple marker assay vs the Risk of Malignancy Index for the prediction of epithelial ovarian cancer in patients with a pelvic mass

Expression of soluble interleukin-6 receptor in malignant ovarian tissue

Are endometrial polyps true cancer precursors?

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia

Assessment of intraoperative judgment during gynecologic surgery using the Script Concordance Test

Co-expression of GPR30 and ERβ and their association with disease progression in uterine carcinosarcoma

Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis

Association of midgestation paraoxonase 1 activity and pregnancies complicated by preterm birth

Failure of 17-hydroxyprogesterone to reduce neonatal morbidity or prolong triplet pregnancy: a double-blind, randomized clinical trial

Cost-effective standardization of preterm labor evaluation

Does sildenafil citrate affect myometrial contractile response to nifedipine in vitro?

Betamethasone in pregnancy: influence of maternal body weight and multiple gestation on pharmacokinetics

Impact of prior gestational age at preterm delivery on effectiveness of 17-alpha-hydroxyprogesterone caproate in practice

Cervical funneling: effect on gestational length and ultrasound-indicated cerclage in high-risk women

Effect of maternal body mass index on in vitro response to tocolytics in term myometrium

The maternal body mass index: a strong association with delivery route

Lipoxygenase and cyclooxygenase inhibitors reveal a complementary role of arachidonic acid derivatives in pregnant human myometrium

Rates of labor induction without medical indication are overestimated when derived from birth certificate data

Complications of cesarean delivery in the massively obese parturient

Maternal arterial stiffness in pregnancies complicated by gestational and type 2 diabetes mellitus

Anesthesia complications during scheduled cesarean delivery for morbidly obese women

Gestational weight gain in consecutive pregnancies

Platelet reactivity and pregnancy loss

Obesity and diabetes genetic variants associated with gestational weight gain

Randomized controlled trial of wound complication rates of subcuticular suture vs staples for skin closure at cesarean delivery

Scheduling the first prenatal visit: Nettleman et al

Separated from birth: An initial examination suggested Asherman's syndrome

Loop electrosurgical excision procedure with an intrauterine device in place

Discussion: ‘Scheduling the first prenatal visit’ by Nettleman et al

Squamous cell carcinoma arising from a localized vulval lesion of Hailey-Hailey disease after tacrolimus therapy

Assessing second-stage progress

Reply

17-alpha-hydroprogesterone caproate and cervical changes

Reply

Comparison of peritoneal carcinomatosis scoring methods in predicting resectability and prognosis in advanced ovarian cancer

Reply