American Journal of Obstetrics & Gynecology

2012-02-01

Information for Readers

2012-02-01

Decision to incision: time to reconsider

Frank H. Boehm — 2011-09-20

The fifth edition of Standards for Obstetrics and Gynecology published in 1982 stated that, “An obstetric service that generally cares for high-risk patients should be staffed and equipped to handle emergencies and to be able to begin cesarean delivery within 15 minutes.” However, in 1987, Shiono et al reported that in a survey of 538 hospitals almost all hospitals had the ability to perform an emergency cesarean section within 30 minutes; and therefore the 15-minute rule was changed in 1988 to a 30-minute rule in the sixth edition of the American College of Obstetricians and Gynecologists (ACOG) Standards for Obstetric Services as well in the second edition of the Guidelines for Perinatal Care. Since then, labor and delivery units all across the United States have been held to this 30-minute time interval, referred to as the decision to incision rule, although there are virtually no evidence-based medical studies supporting such a rule. As happened in 1988, it is time for revision once again.

Making sense of preterm birth

William A. Grobman — 2011-11-09

Categorization, such as that represented by the taxonomy of Linnaeus and periodic table of Mendeleev, can help us make sense of and understand the world around us. The success of systems such as these underscores the lack of accepted categories and the corresponding dearth of insight that we have with regard to preterm birth, despite the fact that it remains one of our major public health problems.

Vaginal progesterone for asymptomatic cervical shortening and the case for universal screening of cervical length

C. Andrew Combs — 2011-12-19

A short cervix detected in midpregnancy by transvaginal sonography carries a high risk of early preterm birth (PTB). The shorter the transvaginal cervical length (TVCL) and the earlier in pregnancy a short cervix is detected, the higher the risk. The strong association between cervical shortening and early PTB raises 2 critical but independent clinical questions:

Achievement of the 30-minute standard in obstetrics–can it be done?

Michael P. Nageotte, Beverly Vander Wal — 2011-09-20

One standard by which obstetrical practice is measured is the ability to achieve a time line of ≤30 minutes from decision for surgery to time of surgical incision for women in labor for whom a cesarean delivery is indicated due to fetal intolerance to labor. We reviewed our institution's performance regarding this standard and identified an initial rate of 25% of cases actually meeting this standard. Using a program of continuous quality improvement, various systematic and individual barriers were identified and overcome resulting in a significant change in performance. This is a report of the various processes and identified areas of challenge encountered to improve on the ability to achieve this important standard of care.

Challenges in defining and classifying the preterm birth syndrome

2011-10-28

In 2009, the Global Alliance to Prevent Prematurity and Stillbirth Conference charged the authors to propose a new comprehensive, consistent, and uniform classification system for preterm birth. This first article reviews issues related to measurement of gestational age, clinical vs etiologic phenotypes, inclusion vs exclusion of multifetal and stillborn infants, and separation vs combination of pathways to preterm birth. The second article proposes answers to the questions raised here, and the third demonstrates how the proposed system might work in practice.

The preterm birth syndrome: issues to consider in creating a classification system

2011-10-28

A comprehensive classification system for preterm birth requires expanded gestational boundaries that recognize the early origins of preterm parturition and emphasize fetal maturity over fetal age. Exclusion of stillbirths, pregnancy terminations, and multifetal gestations prevents comprehensive consideration of the potential causes and presentations of preterm birth. Any step in parturition (cervical softening and ripening, decidual-membrane activation, and/or myometrial contractions) may initiate preterm parturition, and should be recorded for every preterm birth, as should the condition of the mother, fetus, newborn, and placenta, before a phenotype is assigned.

The preterm birth syndrome: a prototype phenotypic classification

2011-10-28

Preterm birth is a syndrome with many causes and phenotypes. We propose a classification that is based on clinical phenotypes that are defined by ≥1 characteristics of the mother, the fetus, the placenta, the signs of parturition, and the pathway to delivery. Risk factors and mode of delivery are not included. There are 5 components in a preterm birth phenotype: (1) maternal conditions that are present before presentation for delivery, (2) fetal conditions that are present before presentation for delivery, (3) placental pathologic conditions, (4) signs of the initiation of parturition, and (5) the pathway to delivery. This system does not force any preterm birth into a predefined phenotype and allows all relevant conditions to become part of the phenotype. Needed data can be collected from the medical records to classify every preterm birth. The classification system will improve understanding of the cause and improve surveillance across populations.

Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data

2011-12-12

Objective: To determine whether the use of vaginal progesterone in asymptomatic women with a sonographic short cervix (≤25 mm) in the midtrimester reduces the risk of preterm birth and improves neonatal morbidity and mortality. Study Design: Individual patient data metaanalysis of randomized controlled trials. Results: Five trials of high quality were included with a total of 775 women and 827 infants. Treatment with vaginal progesterone was associated with a significant reduction in the rate of preterm birth <33 weeks (relative risk [RR], 0.58; 95% confidence interval [CI], 0.42–0.80), <35 weeks (RR, 0.69; 95% CI, 0.55–0.88), and <28 weeks (RR, 0.50; 95% CI, 0.30–0.81); respiratory distress syndrome (RR, 0.48; 95% CI, 0.30–0.76); composite neonatal morbidity and mortality (RR, 0.57; 95% CI, 0.40–0.81); birthweight <1500 g (RR, 0.55; 95% CI, 0.38–0.80); admission to neonatal intensive care unit (RR, 0.75; 95% CI, 0.59–0.94); and requirement for mechanical ventilation (RR, 0.66; 95% CI, 0.44–0.98). There were no significant differences between the vaginal progesterone and placebo groups in the rate of adverse maternal events or congenital anomalies. Conclusion: Vaginal progesterone administration to asymptomatic women with a sonographic short cervix reduces the risk of preterm birth and neonatal morbidity and mortality.

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

2011-08-12

Objective: The purpose of this study was to estimate US rates of postpartum intrauterine device (IUD) insertion and postpartum tubal sterilization. Study Design: Data from the 2001-2008 Nationwide Inpatient Sample were used to identify delivery hospitalizations with IUD insertion or tubal sterilization procedure codes. Results: Estimated rates of postpartum IUD insertion and postpartum tubal sterilization were 0.27 and 770.67 per 10,000 deliveries, respectively. Although the rate of IUD insertion was similar across age groups, the rate of tubal sterilization increased with age. Nonetheless, 15% of tubal sterilizations occurred among women who were ≤24 years old. IUD insertion was more likely among women who delivered at teaching hospitals (odds ratio, 3.02; 95% confidence interval, 1.43–6.37); tubal sterilization was more likely among women without private insurance (odds ratio, 2.04; 95% confidence interval, 1.97–2.11). Conclusion: Among US postpartum women, IUD insertion occurs considerably less frequently than tubal sterilization, even among younger women for whom poststerilization regret is a concern.

Naproxen or estradiol for bleeding and spotting with the levonorgestrel intrauterine system: a randomized controlled trial

2011-09-26

Objective: The purpose of this study was to evaluate whether oral naproxen or transdermal estradiol decreases bleeding and spotting in women who are initiating the levonorgestrel-releasing intrauterine system. Study Design: We conducted a randomized controlled trial of naproxen, estradiol, or placebo that was administered over the first 12 weeks of levonorgestrel-releasing intrauterine system use. Participants completed a written bleeding diary. We imputed missing values and performed an intention-to-treat analysis. Results: There were 129 women who were assigned randomly to naproxen (n = 42 women), estradiol (n = 44 women), or placebo (n = 43 women). The naproxen group was more likely to be in the lowest quartile of bleeding and spotting days compared with placebo (42.9% vs 16.3%; P = .03). In the multivariable analysis, the naproxen group had a 10% reduction in bleeding and spotting days (adjusted relative risk, 0.90; 95% confidence interval, 0.84–0.97) compared with placebo. More frequent bleeding and spotting was observed in the estradiol group (adjusted relative risk, 1.25; 95% confidence interval, 1.17–1.34). Conclusion: The administration of naproxen resulted in a reduction in bleeding and spotting days compared with placebo.

Obstetrician-gynecologists' beliefs about when pregnancy begins

2011-11-09

Objective: The purpose of this study was to assess obstetrician-gynecologists' regarding their beliefs about when pregnancy begins and to measure characteristics that are associated with believing that pregnancy begins at implantation rather than at conception. Study Design: We mailed a questionnaire to a stratified, random sample of 1800 practicing obstetrician-gynecologists in the United States. The outcome of interest was obstetrician-gynecologists' views of when pregnancy begins. Response options were (1) at conception, (2) at implantation of the embryo, and (3) not sure. Primary predictors were religious affiliation, the importance of religion, and a moral objection to abortion. Results: The response rate was 66% (1154/1760 physicians). One-half of US obstetrician-gynecologists (57%) believe pregnancy begins at conception. Fewer (28%) believe it begins at implantation, and 16% are not sure. In multivariable analysis, the consideration that religion is the most important thing in one's life (odds ratio, 0.5; 95% confidence interval, 0.2–0.9) and an objection to abortion (odds ratio, 0.4; 95% confidence interval, 0.2–0.9) were associated independently and inversely with believing that pregnancy begins at implantation. Conclusion: Obstetrician-gynecologists' beliefs about when pregnancy begins appear to be shaped significantly by whether they object to abortion and by the importance of religion in their lives.

Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions

2011-11-09

Objective: We sought to define the prevalence, trends, and outcomes of primary and secondary chronic hypertension in a population-based sample of deliveries. Study Design: An estimated 56,494,634 deliveries were identified from the 1995 through 2008 Nationwide Inpatient Sample. The association of primary and secondary chronic hypertension with adverse fetal and maternal outcomes was evaluated using regression modeling and adjusted population-attributable fractions were calculated. Results: During the study period, the prevalence of primary and secondary hypertension increased from 0.90% in 1995 through 1996 to 1.52% in 2007 through 2008 (P for trend < .001) and from 0.07% to 0.24% (P for trend < .001), respectively. The population-attributable fraction for chronic hypertension was considerable for many maternal adverse outcomes, including acute renal failure (21%), pulmonary edema (14%), preeclampsia (11%), and in-hospital mortality (10%). Conclusion: Primary and secondary chronic hypertension were both strongly associated with adverse pregnancy outcomes and accounted for a substantial fraction of maternal morbidity. Prioritizing research efforts in this area is needed.

Obstructive sleep apnea and the risk of adverse pregnancy outcomes

2011-09-16

Objective: We examined the risk of adverse pregnancy outcomes, including low birthweight (LBW), preterm birth, small for gestational age (SGA), cesarean section (CS), low Apgar score (at 5 minutes after delivery), and preeclampsia in pregnant women with and without obstructive sleep apnea (OSA). Study Design: Our subjects included 791 women with OSA and 3955 randomly selected women without OSA. We performed conditional logistic regression analyses to examine the risks of adverse pregnancy outcomes between women with and without OSA. Results: Compared with women without OSA, adjusted odds ratios for LBW, preterm birth, SGA infants, CS, and preeclampsia in women with OSA were 1.76 (95% confidence interval [CI], 1.28–2.40), 2.31 (95% CI, 1.77–3.01), 1.34 (95% CI, 1.09–1.66), 1.74 (95% CI, 1.48–2.04), and 1.60 (95% CI, 2.16–11.26), respectively. Conclusion: Pregnant women with OSA are at increased risk for having LBW, preterm, and SGA infants, CS, and preeclampsia, compared with pregnant women without OSA.

Morbidity following primary cesarean delivery in the Danish National Birth Cohort

2011-09-26

Objective: Cesarean delivery rates are on the rise in many countries, including the United States. There is mounting evidence that cesarean delivery is associated with adverse reproductive outcomes in subsequent pregnancies. The purpose of this article is to review those outcomes in a well-defined cohort of pregnant women. Study Design: In a cohort of primigravid women from the Danish National Birth Cohort with known baseline exposure characteristics, we stratified women by method of first delivery, vaginal or cesarean, and evaluated for appearance of adverse reproductive events in subsequent pregnancies. Results: After adjusting for age, body mass index, alcohol, smoking, and socioeconomic status, women who underwent cesarean delivery at first birth were at increased risk in their subsequent pregnancy for anemia (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3–3.4), placental abruption (OR, 2.3; 95% CI, 1.5–3.6), uterine rupture (OR, 268; 95% CI, 65.6–999), and hysterectomy (OR, 28.8; 95% CI, 3.1–263.8). Conclusion: Women who deliver their first baby with a cesarean are at increased risk of adverse reproductive outcomes in subsequent pregnancies and should be counseled accordingly.

Long-term neurodevelopmental outcome after intrauterine transfusion for hemolytic disease of the fetus/newborn: the LOTUS study

2011-09-26

Objective: To determine the incidence and risk factors for neurodevelopmental impairment (NDI) in children with hemolytic disease of the fetus/newborn treated with intrauterine transfusion (IUT). Study Design: Neurodevelopmental outcome in children at least 2 years of age was assessed using standardized tests, including the Bayley Scales of Infant Development, the Wechsler Preschool and Primary Scale of Intelligence, and the Wechsler Intelligence Scale for Children, according to the children's age. Primary outcome was the incidence of neurodevelopmental impairment defined as at least one of the following: cerebral palsy, severe developmental delay, bilateral deafness, and/or blindness. Results: A total of 291 children were evaluated at a median age of 8.2 years (range, 2–17 years). Cerebral palsy was detected in 6 (2.1%) children, severe developmental delay in 9 (3.1%) children, and bilateral deafness in 3 (1.0%) children. The overall incidence of neurodevelopmental impairment was 4.8% (14/291). In a multivariate regression analysis including only preoperative risk factors, severe hydrops was independently associated with neurodevelopmental impairment (odds ratio, 11.2; 95% confidence interval, 1.7–92.7). Conclusion: Incidence of neurodevelopmental impairment in children treated with intrauterine transfusion for fetal alloimmune anemia is low (4.8%). Prevention of fetal hydrops, the strongest preoperative predictor for impaired neurodevelopment, by timely detection, referral and treatment may improve long-term outcome.

Recurrence and long-term maternal health risks of hypertensive disorders of pregnancy: a population-based study

2011-10-07

Objective: The purpose of this study was to investigate the recurrence risk of hypertensive disorders in subsequent pregnancies and to explore the associations among hypertensive disorders of pregnancy and maternal cardiovascular risk factor profile and the development of cardiovascular diseases later in life. Study Design: We used population-based, cross-sectional data from the fourth survey of the Tromsø Study. Results: Preeclampsia in the first pregnancy increased the risk of recurrence in later pregnancies (relative risk, 6.6; 95% confidence interval, 5.5–7.9) compared with a normotensive first pregnancy. Women with a history of preeclampsia or nonproteinuric hypertension had an unfavorable cardiovascular risk profile. Hypertension was prevalent in 25% and 28% of the women, respectively. The carotid artery intima-media thickness and total carotid plaque area were significantly larger in women with previous preeclampsia. Conclusion: A strong association between hypertensive disorders of pregnancy and an increased risk of atherosclerosis and cardiovascular diseases was demonstrated by the assessment of risk factors that can be potentially modified.

The antibiotic treatment of PPROM study: systemic maternal and fetal markers and perinatal outcomes

2011-09-09

Objective: We sought to correlate maternal and cord blood cytokine and intercellular adhesion molecule-1 levels with antibiotic exposure and perinatal outcomes after conservatively managed preterm premature rupture of the membranes. Study Design: Conservatively managed women with preterm premature rupture of the membranes at 24-32 weeks had blood sampling at randomization (n = 222) and delivery (n = 121). Plasma from these, and umbilical cord blood (n = 196), was stored at –70°C. Interleukin (IL)-6, IL-10, granulocyte colony-stimulating factor (G-CSF), tumor necrosis factor-α, and intercellular adhesion molecule-1 levels were assessed for associations with antibiotic treatment, latency, amnionitis, neonatal sepsis, pneumonia, and composite neonatal morbidity. Results: Cord blood IL-6 and G-CSF were higher than maternal levels. Antibiotic treatment lowered only maternal G-CSF (P = .01). Elevated maternal cytokine levels were associated with delivery within 7 days and with development of chorioamnionitis. All umbilical cord blood markers were increased with amnionitis (P ≤ .01 for each). No maternal marker was associated with neonatal morbidities. Cord G-CSF and IL-6 were increased with neonatal sepsis within 72 hours of birth (P = .004 for both), and with composite neonatal morbidity (P = .001 and .002, respectively). Maternal and umbilical cord cytokine levels demonstrated low predictive values for perinatal outcomes. Conclusion: Umbilical cord blood cytokine values are higher than maternal levels, suggesting significant fetal/placental contribution. Maternal and umbilical cord cytokine levels are not adequately predictive to be used clinically.

Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events

2011-10-07

Objective: To examine perinatal morbidity and rate of hypoxic-ischemic encephalopathy in infants exposed to intrapartum sentinel events. Study Design: Retrospective cohort study from 2000-2005. Perinatal mortality, perinatal morbidity and rate of hypoxic-ischemic encephalopathy were compared in 3 groups of infants exposed to different risk factors for perinatal asphyxia (sentinel events, nonreassuring fetal status, elective cesarean section). Results: Five hundred eighty-six infants were studied. Perinatal mortality was 6% in the sentinel event group and 0.3% in the nonreassuring fetal status group (relative risk, 2.4; 95% confidence interval, 1.95–2.94). Perinatal morbidity was 2-6 times more frequent in infants exposed to sentinel events; the incidence of hypoxic-ischemic encephalopathy was 10%, compared with 2.5% in the nonreassuring fetal status group (relative risk, 1.93; 95% confidence interval, 1.49–2.52). No infant in the elective cesarean section group died, had perinatal morbidity, or developed encephalopathy. Conclusion: Intrapartum sentinel events are associated with a high incidence of perinatal morbidity and hypoxic-ischemic encephalopathy.

Mortality and morbidity in preterm small-for-gestational-age infants: a population-based study

2011-08-29

Objective: We sought to evaluate the impact of severity of growth restriction on mortality and major neonatal morbidity among very-low-birthweight small-for-gestational-age infants. Study Design: This was a population-based observational study using data collected by the Israel National Very-Low-Birth-Weight Infant Database 1995 through 2007 including infants 24-31 weeks' gestation, with birthweight (BW) ≤50th percentile without major malformations. Four BW percentile groups were considered: <3rd, 3rd-<10th, 10th-<25th, and a reference group 25th-50th percentile. Univariate and multivariable logistic regression analyses were performed. Results: Infants of BW 3rd-<10th percentile were at increased risk for grades 3-4 retinopathy of prematurity (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.54–2.78), bronchopulmonary dysplasia (OR, 2.52; 95% CI, 2.03–3.12), necrotizing enterocolitis (OR, 1.32; 95% CI, 1.04–1.68), and mortality (OR, 2.37; 95% CI, 1.94–2.90). The risk was further increased among infants of BW <3rd percentile. Conclusion: Growth restriction severity may serve as a clinical marker of degree of risk for neonatal mortality and various morbidities.

Assessing obstetric risk factors for maternal morbidity: congruity between medical records and mothers' reports of obstetric exposures

Deirdre Gartland, Nirosha Lansakara, Margaret Flood, Stephanie J. Brown — 2011-10-28

Objective: We sought to assess congruity between data abstracted from medical records with answers to self-administered questionnaires. Study Design: This was a multicenter prospective nulliparous pregnancy cohort. Results: A total of 1507 women enrolled. Analyses were reported for 1296 with medical record data and 3-month postpartum follow-up. There was near-perfect agreement (κ ≥0.80) between maternal report and abstracted data for reproductive history, induction/augmentation method, epidural/spinal analgesia, method of birth, perineal repair, infant birthweight, and gestation. Agreement was poor to moderate for maternal position in second stage and duration of pushing. Conclusion: Maternal report of pregnancy, labor, and birth factors was very reliable and considered more accurate in relation to maternal position in labor and birth, smoking, prior terminations, and miscarriages. Use of routine birthing outcome summaries may introduce measurement error as hospitals differ in their definitions and reporting practices. Using primary data sources (eg, partograms) with clearly defined prespecified criteria will provide the most accurate obstetric exposure and outcome data.

Gestational age of previous twin preterm birth as a predictor for subsequent singleton preterm birth

Timothy J. Rafael, Matthew K. Hoffman, Benjamin E. Leiby, Vincenzo Berghella — 2011-10-17

Objective: We sought to determine an optimal gestational-age cutoff of preterm twin deliveries for predicting subsequent singleton preterm birth (PTB). Study Design: We performed a retrospective study of women with a spontaneous twin delivery who subsequently had a singleton gestation. Univariate and multivariate analyses determined the risk of a spontaneous singleton PTB after a PTB of a twin gestation. Different gestational-age cutoffs of the previous twin PTB were evaluated. Results: Among 255 women, previous twin PTB at <34 weeks' gestation was associated with an increased risk of singleton PTB (odds ratio, 9.67; 95% confidence interval, 3.07–30.47). Every twin gestational age cutoff at <34 weeks' gestation had a significantly higher risk of subsequent singleton PTB, which was no longer significant at ≥34 weeks' gestation (odds ratio, 1.68; 95% confidence interval, 0.23–12.19). Conclusion: In women with a previous spontaneous twin PTB at <34 weeks' gestation, there is an increased risk of subsequent singleton PTB. A twin birth at ≥34 weeks' gestation is not associated with an increased risk for a subsequent singleton PTB.

Prevention of mother-to-child transmission of infections during pregnancy: implementation of recommended interventions, United States, 2003-2004

2011-09-09

Objective: The objective of the study was to describe prenatal screening, positive test rates, and the administration of indicated interventions for hepatitis B, rubella, syphilis, group B streptococcus (GBS), chlamydia, and gonorrhea in the United States using 2 population-based surveys. Study Design: Both surveys abstracted demographic, prenatal, and delivery data from a representative sample of delivering women in 10 states. Analyses accounted for the complex sampling design. Results: Among the 7691 and 19,791 women in the 2 studies, screened proportions before delivery were more than 90% for hepatitis B and rubella, 80% for syphilis, 72-85% for GBS, and less than 80% for chlamydia and gonorrhea. Inadequate prenatal care was the strongest factor associated with no screening. Administration of interventions indicated by positive test results was variable but generally low. Conclusion: Improved prenatal screening and administration of indicated treatments or interventions, particularly for syphilis, GBS, chlamydia, and gonorrhea, will further protect newborns from infection.

Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound

2011-10-28

Objective: During labor, transperineal sonography is increasingly used to evaluate fetal head descent. The aim of this study was to compare the angle of progression assessed by open magnetic resonance imaging (MRI) vs transperineal ultrasound. Study Design: A total of 31 pregnant women at term (>37 weeks), who were not in labor, underwent MRI in an open 1.0-T system. A midsagittal plane of the maternal pelvis was stored. Immediately after, without changing the supine position, a transperineal ultrasound was performed. The angle of progression was measured offline by transperineal ultrasound and MRI. Results: The angles of progression measured by transperineal ultrasound (mean, 79.05 degrees; SD 11.44) and MRI (mean, 80.48 degrees; SD 11.06) correlated significantly (P < .001). The intraclass correlation coefficient between the 2 methods was 0.89 (95% confidence interval, 0.78–0.94). Conclusion: The angle of progression measurements obtained by transperineal ultrasound and open MRI showed very good agreement.

Can placental growth factor in maternal circulation identify fetuses with placental intrauterine growth restriction?

2011-09-26

Objective: We investigated whether decreased concentrations of placental growth factor (PlGF) in maternal circulation differentiated placental intrauterine growth restriction (IUGR) from constitutionally small fetuses. Excluding congenital syndromes, infection, and aneuploidy, we assumed IUGR with an abnormal placental pathology to be of placental origin. Study Design: The study design included a single site, case-control study of 16 cases (9 placental IUGR, 7 constitutionally small) and 79 normal controls with singleton pregnancies. Plasma PlGF was measured by Triage PlGF immunoassay according to the product insert. A positive PlGF test was defined as a concentration less than the fifth percentile for gestational age for normal pregnancy. Results: A positive PlGF test was found in 9 of 9 placental IUGR cases, 1 of 7 constitutionally small fetuses, and 4 of 79 controls (P < .0001). PlGF identified placental IUGR from constitutionally small fetuses with 100% sensitivity and 86% specificity (P = .0009). Conclusion: These preliminary data suggest PlGF may identify placental IUGR antenatally.

FOXP3 gene polymorphisms in preeclampsia

Torri D. Metz, Lesa M. Nelson, Gregory J. Stoddard, Robert M. Silver — 2011-09-16

Objective: To determine whether polymorphisms in the FOXP3 gene are associated with preeclampsia. Study Design: Case-control study in which 120 women with preeclampsia were compared with 120 healthy normotensive controls. Genetic variants (single nucleotide polymorphisms and microsatellites) in the FOXP3 gene were analyzed. Polymorphisms were chosen based on studies of the FOXP3 gene in other autoimmune disorders. Correction of P values for multiple comparisons was performed by using the Benjamini-Hochberg procedure. Results: There were no differences in the genotypes or allele frequencies in the single nucleotide polymorphisms between cases and controls. The FOXP3 GT microsatellite allele at 266 bp was less common in cases than controls (1.0% vs 5.2%, P = .0264). However, this did not remain significant after correction for multiple comparisons. Conclusion: Preeclampsia is not associated with FOXP3 gene polymorphisms that have been associated with other autoimmune disorders.

Efficacy and safety of oxybutynin chloride topical gel for women with overactive bladder syndrome

2011-08-16

Objective: This subgroup analysis of a phase-3 study evaluated the efficacy and safety of oxybutynin chloride topical gel (OTG) in women with overactive bladder syndrome (OAB). Study Design: Women (n = 704) with urgency-predominant urinary incontinence received OTG or placebo for 12 weeks. The primary endpoint was change from baseline to last observation in number of daily incontinence episodes. Treatments were compared with the use of analysis of covariance. Results: OTG significantly reduced the number (mean ± standard deviation) of daily incontinence episodes (OTG, −3.0 ± 2.8 episodes; placebo, −2.5 ± 3.0 episodes; P < .0001), reduced urinary frequency (P = .0013), increased voided volume (P = .0006), and improved select health-related quality-of-life domains (P ≤ .0161) vs placebo. Dry mouth was the only drug-related adverse event significantly more common with OTG (7.4%) than with placebo (2.8%; P = .0062). Conclusion: OTG was well tolerated and provided significant improvement in urinary symptoms and health-related quality of life in women with OAB.

Prevalence and demographic characteristics of vulvodynia in a population-based sample

2011-08-22

Objective: The objective of the study was to determine the prevalence and characteristics of vulvodynia among women in southeast Michigan. Study design: A population-based study of adult women was conducted, using telephone recruitment and completion of a self-administered survey. Weighted estimates of vulvodynia prevalence and characteristics were determined. Results: Over a year, 2542 women were recruited and 2269 (89.3%) completed the self-administered survey. The weighted prevalence of vulvodynia was 8.3% (95% confidence interval, 7.0–9.8) or approximately 101,000 women in the targeted population. Prevalence remained stable through age 70 years and declined thereafter. Among sexually active women, the prevalence was similar at all ages. Of 208 women meeting vulvodynia criteria, 101 (48.6%) had sought treatment, and only 3 (1.4%) had been diagnosed with vulvodynia (unweighted values). Previous vulvodynia symptoms had resolved in 384 women (16.9%) after a mean duration of 12.5 years. Conclusion: Vulvodynia is common, although rarely diagnosed. Prevalence remains high among sexually active women of any age.

Normative fetal brain growth by quantitative in vivo magnetic resonance imaging

2011-10-13

Objective: The objective of the study was to characterize total and regional volumetric brain growth in healthy fetuses during the second and third trimesters of pregnancy, using an automated method. Study Design: We developed and validated an automated method to quantify global and regional in vivo brain volumes using fetal magnetic resonance imaging. We then computed the percentage of growth for each brain structure in a cohort of 64 healthy fetuses (25.4-36.6 weeks' gestational age). Results: The cerebellum demonstrated the greatest maturation rate, with a 4-fold increase (384%) in volume between 25.4 and 36.6 weeks, and a relative growth rate of 12.87% per week. Both total brain and cerebral volumes increased by 230% and brain stem volume by 134% over the same gestational age period. Conversely, lateral ventricular volume decreased by 4.18% per week. Conclusion: The availability and ongoing validation of normative fetal brain growth trajectories will provide important tools for early detection of impaired fetal brain growth upon which to manage high-risk pregnancies.

Sleep apnea and adverse pregnancy outcomes: Chen et al

George A. Macones, Anthony Odibo, David M. Stamilio, Alison G. Cahill — 2011-12-23

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: Chen Y-H, Kang J-H, Lin C-C, et al. Obstructive sleep apnea and the risk of adverse pregnancy outcomes. Am J Obstet Gynecol 2012;206:136.e1-5. The full discussion appears at www.AJOG.org, pages e1-2.

A stitch in time: Layers of circular sutures can staunch postpartum hemorrhage

2011-12-19

When postpartum hemorrhage does not respond to medical treatment, arterial embolization or surgery is required. The surgical techniques of uterine compression or vascular ligation are attempted before resorting, if necessary, to hysterectomy. We have evaluated the efficacy of total uterine ligation, which is a new technique that combines vascular and uterine compression and avoids invasion of the uterine cavity, which can cause synechiae.

Discussion: ‘Sleep apnea and adverse pregnancy outcomes’ by Chen et al

George A. Macones, Anthony Odibo, David M. Stamilio, Alison G. Cahill — 2011-12-26

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: Chen Y-H, Kang J-H, Lin C-C, et al. Obstructive sleep apnea and the risk of adverse pregnancy outcomes. Am J Obstet Gynecol 2012;206:136.e1-5.

Proteomic identification of serum peptides predicting subsequent spontaneous preterm birth

Cicek Gercel-Taylor, Douglas D. Taylor, Shesh N. Rai — 2011-09-22

We read the article by Esplin et al on the proteomic identification of serum peptides that predict subsequent spontaneous preterm birth with great interest because it is a very relevant topic. However, there appears to be biased sample selection and incomplete statistical analysis that lead to results that need additional interpretation. In study 1, 40 cases (spontaneous preterm birth) and 40 control subjects were selected from 2929 women who were eligible with serum samples at 24 weeks' gestation. It is not clear whether the cases were matched with control subjects. In study 2, another 40 cases (spontaneous preterm birth) and another 40 control subjects were selected from 2929 women who were eligible with serum samples at 28 weeks gestation. Again, it does not appear that cases and control subjects were matched. Because control subjects were selected randomly, it is not clear how they were handled if the same control was selected for study 1 and study 2. Another question is the sample size of 40 cases and 40 control subjects, given such a large eligible cohort. In addition, it is not clear whether the samples that were used for model building were also used for validation, which would create additional bias. The rationale for the choice of markers is not provided in the article.

Reply

2011-09-22

We thank Dr Gercel-Taylor et al for their interest in our recent article. In the letter, they ask about the selection of the subjects who were included in the study. Subjects were selected from among 2929 women in the original study. Cases were selected randomly by an independent statistical center. Thereafter, control subjects were chosen by matching on maternal race, gestational age at sampling, and site of enrollment. Such selection of cases and matching of control subjects should eliminate these biases in the sample.

Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States

Jessica L. Illuzzi, Michael B. Bracken — 2011-10-13

Chen et al found decreased early neonatal mortality rates among infants who were recorded on birth certificates as having had electronic fetal monitoring (EFM) during labor compared with those who did not have EFM recorded on the birth certificate. The authors invoke the large size of this study as a major strength over RCTs comparing EFM and intermittent auscultation (IA). At first glance, this observational study would seem to affirm widely supported, validated recommendations to monitor the fetal heart rate during labor, but on closer examination many of its findings may be substantially biased.

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2011-10-13

We thank Drs Illuzzi and Bracken for their letter to the editor regarding our article which ascertained the association between the use of electronic fetal monitoring (EFM) and risk of adverse infant morbidity and mortality. We concur that one of the strengths of our investigation is the large sample size but there are other strengths as well. The first is the consistency of our findings with those previously reported, and subsequently corroborated by a large metaanalysis with respect to operative deliveries and perinatal mortality. The second is the number needed to treat (NNT) to avert 1 neonatal death in our analysis is similar to prior publications. The third is the biologic plausibility of our findings.

Appropriate cervical cancer screening remains essential: the case of women with inflammatory bowel disease

Ruby C. Greywoode, Sean D. Fine, Marie L. Borum — 2011-10-17

We read with interest the article by Dr de Bie and colleagues assessing the screening history of women with cervical cancer in which half were never screened before diagnosis. Given recent guideline revisions on cervical cancer screening, which no longer recommend routine annual examinations for all women, there is a need to promote the continued importance of screening, especially for women at increased risk. Women identified in guidelines as high-risk include women with human immunodeficiency virus or those previously treated for advanced cervical intraepithelial neoplasia. Although women with inflammatory bowel disease (IBD) are unnamed among the high-risk, numerous articles published in recent years support an increased risk of cervical abnormalities, largely attributed to the use of immunomodulators (eg, 6-mercaptopurine, antitumor necrosis factor), among these women.

American Journal of Obstetrics & Gynecology

Table of Contents

Information for Readers

Decision to incision: time to reconsider

Making sense of preterm birth

Vaginal progesterone for asymptomatic cervical shortening and the case for universal screening of cervical length

Achievement of the 30-minute standard in obstetrics–can it be done?

Challenges in defining and classifying the preterm birth syndrome

The preterm birth syndrome: issues to consider in creating a classification system

The preterm birth syndrome: a prototype phenotypic classification

Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

Naproxen or estradiol for bleeding and spotting with the levonorgestrel intrauterine system: a randomized controlled trial

Obstetrician-gynecologists' beliefs about when pregnancy begins

Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions

Obstructive sleep apnea and the risk of adverse pregnancy outcomes

Morbidity following primary cesarean delivery in the Danish National Birth Cohort

Long-term neurodevelopmental outcome after intrauterine transfusion for hemolytic disease of the fetus/newborn: the LOTUS study

Recurrence and long-term maternal health risks of hypertensive disorders of pregnancy: a population-based study

The antibiotic treatment of PPROM study: systemic maternal and fetal markers and perinatal outcomes

Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events

Mortality and morbidity in preterm small-for-gestational-age infants: a population-based study

Assessing obstetric risk factors for maternal morbidity: congruity between medical records and mothers' reports of obstetric exposures

Gestational age of previous twin preterm birth as a predictor for subsequent singleton preterm birth

Prevention of mother-to-child transmission of infections during pregnancy: implementation of recommended interventions, United States, 2003-2004

Angle of progression measurements of fetal head at term: a systematic comparison between open magnetic resonance imaging and transperineal ultrasound

Can placental growth factor in maternal circulation identify fetuses with placental intrauterine growth restriction?

FOXP3 gene polymorphisms in preeclampsia

Efficacy and safety of oxybutynin chloride topical gel for women with overactive bladder syndrome

Prevalence and demographic characteristics of vulvodynia in a population-based sample

Normative fetal brain growth by quantitative in vivo magnetic resonance imaging

Sleep apnea and adverse pregnancy outcomes: Chen et al

A stitch in time: Layers of circular sutures can staunch postpartum hemorrhage

Discussion: ‘Sleep apnea and adverse pregnancy outcomes’ by Chen et al

Proteomic identification of serum peptides predicting subsequent spontaneous preterm birth

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Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States

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Appropriate cervical cancer screening remains essential: the case of women with inflammatory bowel disease