American Journal of Obstetrics & Gynecology

2010-02-01

Information for Readers

2010-02-01

Reports of Major Impact

Thomas J. Garite — 2010-02-01

Periodically, studies with implications for important changes in clinical practice emerge. Such reports are most often presented at scientific meetings and then submitted for publication. Although this is usually the most expeditious method of communicating such important developments to the clinical and scientific community, this process has major limitations. The appropriate scientific meeting is often held only yearly. The immediate dissemination of this information is then limited to those attending the meeting and subsequent word-of-mouth communications. By the time the study is submitted for publication, there is substantial delay because of the necessity to write the article, the peer-review process, and journal-publishing delays. Few journals have the option of expedited review and publication devoted to articles with potential major clinical impact.

Change in policy for Basic Science articles

Thomas J. Garite — 2010-02-01

The American Journal of Obstetrics & Gynecology is altering the way it publishes basic science articles. Beginning in 2010, basic science original research articles will be published in their entirety online, and only the abstracts will be published in the print edition of the Journal.

Do fathers matter? Paternal contributions to birth outcomes and racial disparities

Dawn P. Misra, Cleopatra Caldwell, Alford A. Young, Sara Abelson — 2010-02-01

Studies have rarely considered the impact of paternal factors on perinatal outcomes generally or on racial differences therein. Shah et al have produced a literature review that begins to delve into the contribution of fathers to the risk of adverse birth outcomes. Paternal exposures that were selected for inclusion in their database search were father's age, anthropometry (eg, height, weight), self birthweight, occupational exposures, and education. After a systematic search of the literature, the authors identified the father's age, current weight, and his own birthweight as risk factors for low birthweight and suggest that paternal occupation and education may be important but have not consistently been reported to increase the risk of adverse birth outcomes.

Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS)

Kim A. Boggess — 2010-02-01

Preterm birth is one of the most complicated and challenging research issues in perinatal medicine. Despite decades of scientific inquiry, the preterm birth rate has remained constant or increased annually in the United States. Nearly 12% of all deliveries occur at <37 weeks of gestation. Spontaneous preterm birth is a complex and heterogeneous public health problem with multiple risk factors. Some of these risk factors are social (such as maternal race/ethnicity and poverty), and some are individual (such as underweight, tobacco use, and maternal infection). Many of these risk factors occur in combination, which complicates preventive strategies.

Paternal factors and low birthweight, preterm, and small for gestational age births: a systematic review

2010-02-01

A systematic review of the risks of a low birthweight (LBW), preterm, and small-for-gestational-age births in relation to paternal factors was performed. Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, and bibliographies of identified articles were searched for English-language studies. Study qualities were assessed according to a predefined checklist. Thirty-six studies of low-to-moderate risk of bias were reviewed for various paternal factors: age, height, weight, birthweight, occupation, education, and alcohol use. Extreme paternal age was associated with higher risk for LBW. Among infants who were born to tall fathers, birthweight was approximately 125-150 g higher compared with infants who were born to short fathers. Paternal LBW was associated with lower birthweight of the offspring. In conclusion, paternal characteristics including age, height, and birthweight are associated with LBW. Paternal occupational exposure and low levels of education may be associated with LBW; however, further studies are needed.

Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis

Rebecca U. Margulies, Mary A.M. Rogers, Daniel M. Morgan — 2010-02-01

This systematic review of uterosacral ligament suspension provides a metaanalysis of anatomic outcomes and a summary of subjective outcomes. A successful anatomic outcome was considered present when women had “optimal” or “satisfactory” (pelvic organ prolapse quantification system stage 0 or 1) outcomes. In the anterior, apical, and posterior compartments, the pooled rates for a successful outcome were 81.2% (95% confidence interval [CI], 67.5–94.5%), 98.3% (95% CI, 95.7–100%), and 87.4% (95% CI, 67.5–94.5%). In the anterior compartment, women with preoperative stage 2 prolapse were more likely than those with preoperative stage 3 prolapse to have a successful anatomic outcome (92.4% vs 66.8%; P = .06). Outcomes, with respect to subjective symptoms, were reassuring; however, it was not possible to pool data because of methodologic differences between studies.

Pregnancy: a “teachable moment” for weight control and obesity prevention

Suzanne Phelan — 2009-08-17

Excessive gestational weight gain has been shown to relate to high-postpartum weight retention and the development of overweight and obesity later in life. Because many women are concerned about the health of their babies during pregnancy and are in frequent contact with their healthcare providers, pregnancy may be an especially powerful “teachable moment” for the promotion of healthy eating and physical activity behaviors among women. Initial research suggests that helping women gain the recommended amount during pregnancy through healthy eating and physical activity could make a major contribution to the prevention of postpartum weight retention. However, more randomized controlled trials with larger sample sizes are needed to identify the most effective and disseminable intervention. Providers have the potential to prevent high postpartum weight retention and future obesity by monitoring weight gain during pregnancy and giving appropriate advice about recommended amounts of gestational weight gain.

Improving quality of care: development of a risk-adjusted perioperative morbidity model for vaginal hysterectomy

2009-08-19

Objective: We sought to develop and evaluate a risk-adjusted perioperative morbidity model for vaginal hysterectomy.Study Design: Medical records of women who underwent vaginal hysterectomy during 2004 and 2005 were retrospectively reviewed. Morbidity included hospital readmission, reoperation, and unplanned medical intervention or intensive care unit admission; urinary tract infections were excluded. Multivariate logistic regression identified factors associated with perioperative morbidity (adjusted for urinary tract infection). The resulting model was validated using a random 2006 sample.Results: Of 712 patients, 139 (19.5%) had morbidity associated with congestive heart failure or prior myocardial infarction, perioperative hemoglobin decrease >3.1 g/dL, preoperative hemoglobin <12.0 g/dL, and prior thrombosis (c-index = 0.68). Predicted morbidity was similar to observed rates in the validation sample.Conclusion: History of congestive heart failure or myocardial infarction, prior thrombosis, perioperative hemoglobin decrease >3.1 g/dL, or preoperative hemoglobin <12.0 g/dL were associated with increased perioperative complications. Quality improvement efforts should modify these variables to optimize outcomes.

An alternative monitoring protocol for single-dose methotrexate therapy in ectopic pregnancy

Andrea Ries Thurman, Melani Cornelius, Jeffrey E. Korte, Donald L. Fylstra — 2009-12-04

Objective: We sought to determine the sensitivity and specificity of alternative monitoring regimens in predicting the need for a second methotrexate (MTX) dose in women undergoing medical therapy for ectopic pregnancy.Study Design: We reviewed 187 women who received MTX for ectopic pregnancy.Results: We defined MTX treatment success as a clinically stable patient whose day-7 beta human chorionic gonadotropin (β-hCG) level decreased by ≥50%, compared with the day-of-treatment (DOT) β-hCG. In comparison to the standard MTX monitoring protocol, this model was 100% sensitive and 57.4% specific in predicting the need for a second MTX dose in women whose DOT β-hCG was <2000 mIU/mL and was 100% sensitive and 37.9% specific in women whose DOT β-hCG was ≥2000 mIU/mL.Conclusion: This model is an alternative to the traditional MTX monitoring regimen.

Does intraoperative spillage of benign ovarian mucinous cystadenoma increase its recurrence rate?

2009-12-21

Objective: To report a higher than estimated recurrence rate of benign mucinous cystadenomas after complete resection of the first one, and to assess potential risk factors for recurrence after complete surgical excision.Study Design: We retrospectively reviewed all cases of women who underwent either laparoscopic or laparotomic removal of benign mucinous adnexal cysts by either adnexectomy or cystectomy in our institution between 1996 and 2006.Results: Included were the data of 42 women who fulfilled study entry criteria. Three of them (7.1%) underwent a second operation because of a recurrence of the lesion. A significantly higher rate of women who had cyst recurrence had undergone cystectomy as opposed to adnexectomy (P < .05). Intraoperative rupture of cysts during cystectomy was also significantly associated with cyst recurrence (P < .03).Conclusion: Mucinous cystadenoma recurrence is apparently not as rare as reported in the literature. Intraoperative cyst rupture and cystectomy instead of adnexectomy emerged as being two risk factors for recurrence.

Comparing uterine fibroids treated by myomectomy through traditional laparotomy and 2 modified approaches: ultraminilaparotomy and laparoscopically assisted ultraminilaparotomy

Kuo-Chang Wen, Yi-Jen Chen, Pi-Lin Sung, Peng-Hui Wang — 2009-12-25

Objective: We sought to compare myomectomy performed by laparotomy (LT), and 2 other modified approaches: ultraminilaparotomy (UMLT) and laparoscopically assisted UMLT for uterine fibroids with a size <8 cm and the number <5.Study Design: A cohort study, including 79 (35.3%) women in the LT group, 71 (31.7%) in the UMLT group, and 74 (33.0%) in the laparoscopically assisted UMLT group, was conducted. The outcome was measured by comparing surgical parameters, immediate postoperative recovery, and therapeutic outcomes.Results: The median follow-up was 52 months with similar recurrence rates in the 3 groups. The modified approaches had advantages not only in the surgical parameters, but also in postoperative recovery, compared to LT (all P < .05).Conclusion: UMLT and laparoscopically assisted UMLT can be used successfully in place of LT in the management of uterine fibroids.

Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS)

2010-02-01

Objective: The purpose of this study was to test whether treating periodontal disease (PD) in pregnancy will reduce the incidence of spontaneous preterm delivery (SPTD) at ≤35 weeks of gestation.Study Design: A multicenter, randomized clinical trial was performed. Subjects with PD were randomized to scaling and root planing (active) or tooth polishing (control). The primary outcome was the occurrence of SPTD at <35 weeks of gestation.Results: We screened 3563 subjects for PD; the prevalence of PD was 50%. Seven hundred fifty-seven subjects were assigned randomly; 378 subjects were assigned to the active group, and 379 subjects were assigned to the placebo group. Active treatment did not reduce the risk of SPTD at <35 weeks of gestation (relative risk, 1.19; 95% confidence interval [CI], 0.62–2.28) or composite neonatal morbidity (relative risk, 1.30; 95% CI, 0.83–2.04). There was a suggestion of an increase in the risk of indicated SPTD at <35 weeks of gestation in those subjects who received active treatment (relative risk, 3.01; 95% CI, 0.95–4.24).Conclusion: Treating periodontal disease does not reduce the incidence of SPTD.

Peripartum hysterectomy and arterial embolization for major obstetric hemorrhage: a 2-year nationwide cohort study in the Netherlands

Joost J. Zwart, Pieter D. Dijk, Jos van Roosmalen — 2009-11-18

Objective: The purpose of this study was to assess the incidence, case fatality rates, and risk factors of peripartum hysterectomy and arterial embolization for major obstetric hemorrhage.Study Design: This was a 2-year prospective nationwide population-based cohort study. All pregnant women in the Netherlands during the same period acted as reference cohort (n = 371,021).Results: We included 205 women; the overall incidence was 5.7 per 10,000 deliveries. Arterial embolization was performed in 114 women (incidence, 3.2 per 10,000; case fatality rate, 2.0%). Peripartum hysterectomy was performed in 108 women (incidence, 3.0 per 10,000; case fatality rate, 1.9%). Seventeen women underwent hysterectomy after failure of embolization. Cesarean delivery (relative risk, 6.6; 95% confidence interval, 5.0–8.7) and multiple pregnancy (relative risk, 6.6; 95% confidence interval, 4.2–10.4) were the most important risk factors in univariable analysis.Conclusion: The rate of obstetric hemorrhage that necessitates hysterectomy or arterial embolization in the Netherlands is 5.7 per 10,000 deliveries; fertility is preserved in 46% of women by successful arterial embolization.

Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births

Joseph R. Wax, Michael G. Pinette, Angelina Cartin, Jacquelyn Blackstone — 2009-12-14

Objective: We sought to evaluate perinatal morbidity by delivery location (hospital, freestanding birth center, and home).Study Design: Selected 2006 US birth certificate data were accessed online from the Centers for Disease Control and Prevention. Low-risk maternal and newborn outcomes were tabulated and compared by birth facility.Results: A total of 745,690 deliveries were included, of which 733,143 (97.0%) occurred in hospital, 4661 (0.6%) at birth centers, and 7427 (0.9%) at home. Compared with hospital deliveries, home and birthing center deliveries were associated with more frequent prolonged and precipitous labors. Home births experienced more frequent 5-minute Apgar scores <7. In contrast, home and birthing center deliveries were associated with less frequent chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, neonatal intensive care unit admission, and birthweight <2500 g.Conclusion: Home births are associated with a number of less frequent adverse perinatal outcomes at the expense of more frequent abnormal labors and low 5-minute Apgar scores.

Prediction of spontaneous preterm birth in asymptomatic twin pregnancies using the change in cervical length over time

2009-10-21

Objective: We sought to evaluate the change in cervical length (CL) as a predictor of preterm birth in asymptomatic twin pregnancies.Study Design: We studied a historical cohort of 121 twin pregnancies with CL testing between 18-24 weeks who had a follow-up CL 2-6 weeks after the initial CL.Results: A total of 19 patients had their CL decrease by ≥20% (shortened CL group) and 102 patients' CL decreased by less, or not at all (stable CL group). The shortened CL group had a significantly higher rate of spontaneous preterm birth <28 weeks, <30 weeks, <32 weeks, and <34 weeks. This remained true even when excluding patients with a short CL (≤25 mm) on the repeated CL.Conclusion: In twin pregnancies, a CL that decreases by 20% over 2 measurements is a significant predictor of very preterm birth, even in the setting of a normal CL. Serial CL measurements should be considered in twin pregnancies, starting <24 weeks.

Appraisal of the selectivity index in a cohort of patients treated with laser surgery for twin–twin transfusion syndrome

Luminita S. Crisan, Eftichia V. Kontopoulos, Rubén A. Quintero — 2009-10-21

Objective: The selectivity index (SI) has been proposed as a measure of technical success in laser surgery for twin–twin transfusion syndrome. Surgeries with an index >–0.25 have been considered highly selective. The purpose of this study was to evaluate the applicability of this index in our patient population.Study Design: The SI was assessed in 314 consecutive laser surgeries and correlated with perinatal survival.Results: A total of 310 patients (98.7%) underwent a completely selective procedure. The SI was 0.8 in the selective laser photocoagulation of communicating vessels group vs 0.3 in the nonselective laser photocoagulation of communicating vessels group (P = .001). In the selective group perinatal survival of at least 1 twin (92.6% vs 50%) and survival of the donor (75.4% vs 0%) was significantly better (P = .05).Conclusion: The SI as originally proposed is misleading and of limited use as it does not differentiate selective from nonselective procedures. We propose instead using a ratio of selective/nonselective procedures, and selectively coagulated/total number of coagulated vessels to appraise center-specific and patient-specific surgical performance of laser surgery for twin–twin transfusion syndrome.

Examining the effectiveness of an opt-in approach to prenatal human immunodeficiency virus screening

2009-10-21

Objective: We sought to determine the prenatal human immunodeficiency virus (HIV) screening rate when using an opt-in policy and to find variables predictive of screening.Study Design: This was a case-control study examining gravid women with a prenatal visit and a delivery at our hospital in 2005. Cases were defined as women who did not undergo HIV screening during the first or second prenatal visit. Our institution used an opt-in approach to HIV screening.Results: Overall, 71% (291/412) of women underwent HIV screening at the first or second prenatal visit. Patient refusal was the most common reason for not being screened (15%; 62/412). Women who were ≤25 years old, were unmarried, and received care from maternal-fetal medicine attendings or family practitioners were more likely to undergo HIV screening.Conclusion: With an opt-in approach, 29% of women were not screened for HIV during their early prenatal care. An opt-in policy also leads to screening rates that are provider dependent.

An automated method for the determination of the sFlt-1/PIGF ratio in the assessment of preeclampsia

2009-10-22

Objective: The angiogenic and antiangiogenic factors soluble fms-like tyrosine kinase (sFlt)-1 and placental growth factor (PIGF) have been implicated in the mechanisms of disease responsible for preeclampsia (PE). Moreover, it has been proposed that the concentrations of these markers in maternal serum/plasma may have predictive value. This study evaluates a newly developed Elecsys (Roche, Penzberg, Germany) assay for sFlt-1 and PIGF and tests the value of the sFlt-1/PIGF ratio in the assessment of PE.Study Design: This multicenter case-control study included 351 patients: 71 patients with PE and 280 gestational age-matched control subjects from 5 European study centers. A total of 595 serum samples were measured for sFlt-1 and PIGF using an automated platform.Results: Maternal serum concentrations of sFlt-1 and PIGF significantly separated healthy women and women with PE. The sFlt-1/PIGF ratio had an area under the receiver operating characteristic curve of 0.95. The best performance was obtained in the identification of early-onset PE (area under the receiver operating characteristic curve of 0.97).Conclusion: Measurement of sFlt-1 and PIGF and calculation of sFlt-1/PIGF ratio can be performed quickly and in a platform available in clinical laboratories. This is a substantial step forward in bringing the determination of these analytes to clinical practice in obstetrics. We propose that sFlt-1, PIGF, and sFlt-1/PIGF ratio may be of value in the prediction of PE and in the differential diagnosis of patients with atypical presentations of PE, and perhaps in the differential diagnosis of women with chronic hypertension suspected to develop superimposed PE.

Increased risk of low birthweight, infants small for gestational age, and preterm delivery for women with peptic ulcer

Yi-Hua Chen, Herng-Ching Lin, Horng-Yuan Lou — 2010-02-01

Objective: The objective of the study was to determine whether maternal peptic ulcer disease (PUD) is associated with increased risk of adverse pregnancy outcomes, using a nationwide population-based dataset.Study Design: We identified a total of 2120 women who gave birth from 2001 to 2003 with a diagnosis of PUD during pregnancy. Then 10,600 unaffected pregnant women were matched with cases in age and year of delivery. Multivariate logistic regression analyses were performed for estimation.Results: We found that PUD was independently associated with a 1.18-fold risk of low birthweight (95% confidence interval [CI], 1.01–1.30), a 1.20-fold risk of preterm delivery (95% CI, 1.02–1.41), and a 1.25-fold (95% CI, 1.11–1.41) higher risk of babies small for gestational age, compared with unaffected mothers, after adjusting for potential confounders. In further examining women with treated PUD, improved effects of PUD medication on the risks of adverse neonate outcomes were not identified.Conclusion: We document increased risk of adverse birth outcomes for women with PUD during pregnancy.

Effect of antenatal betamethasone on maternal and fetal amino acid concentration

2009-12-21

Objective: To determine the concentration of amino acids in women receiving the first course of antenatal betamethasone and to evaluate the umbilical venous and arterial amino acid concentrations at the time of elective cesarean section after betamethasone administration.Study Design: Blood samples were collected from 34 pregnant women at risk of premature delivery before and 24 and 48 hours after the first course of betamethasone. In addition, maternal and cord blood samples were collected in 13 women undergoing an elective cesarean section between 24 and 192 hours after betamethasone.Results: Maternal amino acid concentrations were significantly increased after the first dose of betamethasone. Overall total amino nitrogen increased 17.5% 24 hours after betamethasone administration and 20.5% after 48 hours. The concentration of most amino acids was increased both in the umbilical vein and artery after maternal betamethasone administration.Conclusion: The concentration of maternal and fetal amino acids increases significantly after betamethasone administration.

Drospirenone and cardiovascular risk in lean and obese polycystic ovary syndrome patients: a pilot study

2009-11-16

Objective: We sought to verify if an oral contraceptive (OC) containing drospirenone affects the cardiovascular risk of patients with polycystic ovary syndrome (PCOS).Study Design: A total of 28 women with PCOS (16 lean [group A] and 12 overweight [group B]) were assessed at baseline and after 6 months therapy with an OC. Leptin, homocysteine, endothelin-1, and flow-mediated dilatation of brachial artery were measured.Results: The brachial artery diameter and the pulsatility index, after the reactive hyperemia, did not change in group A; it improved significantly in group B after 6 months of treatment. At baseline and after therapy the plasma levels of homocysteine and endothelin-1 did not differ among the groups. Leptin was significantly lower at baseline in group A compared to group B.Conclusion: The OC containing drospirenone does not seem to affect the surrogate markers of cardiovascular risk in lean patients with PCOS.

Eszopiclone improves insomnia and depressive and anxious symptoms in perimenopausal and postmenopausal women with hot flashes: a randomized, double-blinded, placebo-controlled crossover trial

2009-12-25

Objective: Menopause-associated insomnia is commonly associated with other symptoms (hot flashes, depression, anxiety). Given frequent symptom cooccurrence, therapies targeting sleep may provide an important approach to treatment during midlife.Study Design: Peri/postmenopausal women (40-65 years old) with sleep-onset and/or sleep-maintenance insomnia cooccurring with hot flashes and depressive and/or anxiety symptoms were randomized to eszopiclone 3 mg orally or placebo in a double-blinded, crossover 11 week trial. Changes in the Insomnia Severity Index (ISI) scale and secondary outcomes (diary-based sleep parameters, depression/anxiety, hot flashes, quality of life) were analyzed using repeated-measure linear models.Results: Of 59 women, 46 (78%) completed the study. Eszopiclone reduced ISI scores by 8.7 ± 1.4 more points than placebo (P < .0001). Eszopiclone improved (P < .05) all sleep parameters, depressive symptoms, anxiety symptoms, quality of life, and nighttime but not daytime hot flashes.Conclusion: Eszopiclone treats insomnia and cooccurring menopause-related symptoms. Our results provide evidence that hypnotic therapies may improve multiple domains of well-being during midlife.

Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy

2009-11-23

Objective: On the basis of outcome data from concurrent chemoradiotherapy (CCRT) for locally advanced cervical squamous cell carcinoma, the authors developed a nomogram for predicting survival outcome.Study Design: Two hundred fifty-one eligible patients with International Federation of Gynecology and Obstetrics stage IIB-IVA squamous cell carcinoma of the uterine cervix who underwent CCRT were included for the construction of the nomogram. Predictor variables included age, serum squamous cell carcinoma antigen, tumor size, parametrium invasion, hydronephrosis, bladder/rectum invasion, and lymph node metastases. Internal validation of the nomogram was performed.Results: A nomogram for predicting the 5 year overall survival for these patients was constructed on the basis of a Cox regression model from 7 parameters. The concordance index was 0.69.Conclusion: This nomogram is a predictive tool, upon external validation, that can be used to counsel patients in predicting outcomes. The discriminatory ability of the nomogram indicates that this population should not be considered homogeneous with respect to risk of death.

Lymph node dissection in the surgical management of atypical endometrial hyperplasia

Jill S. Whyte, Elizabeth P. Gurney, John P. Curtin, Stephanie V. Blank — 2009-12-21

Objective: The aim of this study was to evaluate the effect of lymph node dissection in patients with atypical endometrial hyperplasia.Study Design: Patients undergoing surgical management of atypical endometrial hyperplasia during the study period were retrospectively identified. Clinical and pathologic information was analyzed.Results: Eighty-eight patients comprised our cohort. Median age was 54 years (range, 37–85 years). Sixty-seven patients had lymph node dissection at the time of surgery for atypical endometrial hyperplasia, whereas 21 did not. Twenty-five of 88 (28.4%) had endometrial carcinoma on final uterine pathology. Stages were as follows: 4 IA, 15 IB, 3 IC, 2 IIB, and 1 IIIC. Surgical outcomes were not statistically significant between staged and unstaged groups. Information from lymph node dissection influenced management decisions in 7 of the 25 (28%) cancer patients.Conclusion: Lymph node dissection did not adversely affect surgical outcomes in patients with atypical endometrial hyperplasia. Because many of these patients have concurrent endometrial cancer, we recommend consideration of lymph node dissection in atypical endometrial hyperplasia patients undergoing definitive surgical treatment.

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

2010-02-01

Objective: The aim of this study was to compare carcinomatosis scores, and to determine their relevance to predict resectability, morbidity, and outcome.Study Design: From 2005-2008, 61 patients underwent surgery for ovarian cancer. We compared International Federation Gynecology and Obstetrics (FIGO), peritoneal cancer index, Eisenkop, Aletti, Fagotti, and Fagotti-modified scores.Results: There was a strong correlation between the different scores. In predicting resectability, Fagotti-modified and peritoneal cancer index outperformed other scores. We demonstrated a strong association between the occurrence of postoperative complications and Aletti, peritoneal cancer index, and Eisenkop scores (P < .0001). For progression-free survival, we observed significant differences among FIGO, peritoneal cancer index, Eisenkop, Fagotti-modified, and Aletti stages (P < .05). For stage III/IV patients, only Aletti score remains significant to predict resectability. This suggests that complete respectability is more related to the surgical effort than to the extent of the disease.Conclusion: Alternative ranking systems provide additional information over FIGO for complete resectability, complications, and survival.

The effect of topical pimecrolimus on inflammatory infiltrate in vulvar lichen sclerosus

2009-11-05

Objective: Lichen sclerosus (LS) is a relatively common chronic inflammatory disorder of the skin and mucosal surfaces.Study Design: A total of 29 women with histologically confirmed, active LS were recruited to this study with 2 aims. First, we evaluated the effectiveness of pimecrolimus treatment to LS not responding to conventional corticosteroid treatment. The second aim in this study was to provide information of in vivo effects of topical pimecrolimus in acute LS lesions, especially the inflammatory cell infiltration.Results: In all, 25 of 29 women applied cream as recommended. After 2 months of treatment, 20 patients had reached partial or complete clinical remission. Histology showed decreased inflammatory lymphoid infiltrate with down-regulation of CD3+ T cells, CD8+ T cells, and CD57+ natural killer cells. Also macrophage marker CD68 staining showed down-regulation. There was no change in CD20+ B lymphocytes.Conclusion: We conclude that calcineurin inhibitors are an effective treatment for patients not responding to corticosteroid treatment.

Angiogenic dysfunction in molar pregnancy

2009-11-18

Objective: Molar pregnancy is associated with very early-onset preeclampsia. Since excessive circulating antiangiogenic factors may play a pathogenic role in preeclampsia, we hypothesized that molar placentas produce more antiangiogenic proteins than normal placentas.Study Design: This retrospective case-control study used a semiquantitative immunohistochemical technique to compare histologic sections of molar placentas to normal controls. Tissue slides were treated with 2 antisera: one recognized the antiangiogenic markers fms-like tyrosine kinase receptor 1 (Flt1) and its soluble form (sFlt1), while the other recognized vascular endothelial marker CD31. Stain intensity was graded from 1+ (strong focal staining) to 4+ (91-100% staining).Results: Molar placentas (n = 19) showed significantly more staining than controls (n = 16) for Flt/sFlt1 (P < .0001).Conclusion: There was a significant difference in Flt1/sFlt1 immunostaining intensity when molar placentas were compared to controls. This supports a hypothesis that the phenotype of preeclampsia in molar pregnancy may result from trophoblasts overproducing at least 1 antiangiogenic protein.

Dose-response effects of betamethasone on maturation of the fetal sheep lung

2009-12-21

Objective: Glucocorticoid administration to women in preterm labor improves neonatal mortality and morbidity. Fetal exposure to glucocorticoid levels higher than those appropriate to the current gestational stage has multiple organ system effects. Some, eg, fetal hypertension, are maximal at lower than the clinical dose. We hypothesized that the clinical dose has supramaximal lung maturational effects.Study Design: We evaluated the full, half, and quarter clinical betamethasone dose (12 mg/70 kg or 170 μg/kg intramuscularly twice 24 hours apart) on fetal sheep lung pressure volume curves (PVC) after 48 hours' exposure at 0.75 gestation. We measured key messenger RNAs and protein products that affect lung function and total lung dipalmitoyl phosphatidyl choline.Results: Full and half doses had similar PVC and total lung dipalmitoyl phosphatidyl choline effects. Messenger RNA for surfactant proteins A, B, and D and elastin increased in a dose-dependent fashion.Conclusion: Half the clinical betamethasone dose produces maximal PVC improvement in fetal sheep at 0.75 gestation.

Continuous infusion of 17-hydroxyprogesterone caproate into either the fetoplacental or intervillous circulation of a placental cotyledon attenuates vasoconstriction of the fetoplacental arteries by thromboxane mimetic U46619

2009-12-14

Objective: The objective of the study was to determine whether pretreatment of fetal or maternal placental vasculature with 17-hydroxyprogesterone caproate (17-P) attenuates the vasoactive effect of the thromboxane mimetic U46619.Study Design: Two cotyledons were obtained from each placenta studied. For the first 5 placentas, the fetal artery of 1 cotyledon from each pair was infused with 17-P. After 30 minutes, a bolus dose of U46619 was administered to both cotyledons. An identical procedure was carried out on the next 5 placentas except that 17-P was infused into the intervillous space.Results: The pressure excursion caused by bolus administration of U46619 was less in the cotyledons infused with 17-P, both in the 5 cases in which the fetal vasculature was infused with 17-P (P = .0035) and in the 5 cases in which the maternal vasculature was infused with 17-P (P = .038).Conclusion: Pretreatment of either the fetal or maternal circuits of the placenta with 17-P attenuates U46619-mediated fetoplacental vasoconstriction.

Precipitated egg white as a sealant for iatrogenic preterm premature rupture of the membranes

Hector Mendez-Figueroa, Ramesha Papanna, David L. Berry, Kenneth J. Moise — 2009-11-27

Objective: The objective of the study was to investigate whether precipitated egg white could be used as a sealant for iatrogenic injury to fetal membranes.Study Design: Membranes were collected, washed, and affixed to the bottom of glass cylinders filled with second-trimester amniotic fluid. An iatrogenic defect with an 8-gauge needle was created in the test column, and precipitated egg white was added. Fluid levels in test and control columns were compared over a 14 day period. The amount of fluid added to columns was compared using the Wilcoxon rank sum test; P < .05 was considered significant.Results: Test columns (20/21) maintained seal integrity for 14 days and required less amniotic fluid to be added as compared with controls: median: 55.1 mL (range, 20–137 mL) vs 61.6 mL (range, 22–159 mL), respectively (P < .01).Conclusion: Precipitated egg white has the potential to seal iatrogenic membrane defects for up to 14 days' duration.

Multipotent mesenchymal stem cells from human placenta: critical parameters for isolation and maintenance of stemness after isolation

2009-12-25

Objective: This study was undertaken to isolate and characterize multipotent mesenchymal stem cells from term human placenta (placenta-derived mesenchymal stem cells, PD-MSCs).Study Design: Sequential enzymatic digestion was used to isolate PD-MSCs in which trypsin removes the trophoblast layer, followed by collagenase treatment of remaining placental tissue. Karyotype, phenotype, growth kinetics, and differentiability of PD-MSC isolates from collagenase digests were analyzed.Results: PD-MSC isolation was successful in 14 of 17 cases. Karyotyping of PD-MSC isolates from deliveries with a male fetus revealed that these cells are of maternal origin. Flow cytometry and immunocytochemistry confirmed the mesenchymal stem cell phenotype. Proliferation rates of PD-MSCs remained constantly high up to passage 20. These cells could be differentiated toward mesodermal lineage in vitro up to passage 20. Nonconfluent culture was critical to maintain the MSC stemness during long-term culture.Conclusion: Term placenta constitutes a rich, very reliable source of maternal mesenchymal stem cells that remain differentiable, even at high passage numbers.

Effect of corticosteroids and progesterone on adrenomedullin output and expression in human fetal membranes and placenta trophoblasts

2009-12-25

Objective: Plasma adrenomedullin (AM) concentrations are increased in fetal and maternal circulation in response to exogenous glucocorticoids administration. The role of corticosteroids and progesterone in regulating AM synthesis and secretion was investigated in amnion and chorion trophoblast cells of the fetal membranes and in placental trophoblast cells.Study Design: Cells were treated with betamethasone, hydrocortisone, and progesterone. Changes in AM output were measured with radioimmunoassay. Protein expression was evaluated with Western blot and immunohistochemistry.Results: Betamethasone stimulated AM secretion and protein expression in placental trophoblast cells and in amnion cells of the fetal membranes. Hydrocortisone and progesterone did not induce any effect either on secretion or protein expression in placenta and fetal membranes cells.Conclusion: Glucocorticoids regulate AM secretion and expression by human placenta thereby promoting increased AM concentration in maternal and fetal circulation in circumstances characterized by increased cortisol levels.

Albumin as an adjunct to tracheal occlusion in fetal rats with congenital diaphragmatic hernia: a placebo-controlled study

2009-12-25

Objective: We sought to investigate effects of intratracheal albumin injection prior to tracheal occlusion (TO) on lung proliferation in fetal rats with nitrofen-induced congenital diaphragmatic hernia.Study Design: On embryonic day 19, nitrofen-exposed fetuses underwent TO, TO and 50 μL of either intratracheal albumin 20% or saline, or remained untouched. Main outcome at embryonic day 21.5 was expression of the proliferation marker Ki-67. Secondary outcomes were lung-to-bodyweight ratio (LBWR), tropoelastin expression, density and spatial distribution of elastin, pulmonary/alveolar morphometry, and fetal survival.Results: TO increased Ki-67 messenger RNA and LBWR. Albumin further increased LBWR and density of Ki-67-positive cells but also fetal mortality. TO with or without adjuncts induced elastin deposits at the tips of arising secondary crests, increased air space size, and decreased septal thickness.Conclusion: TO had effects on lung proliferation and advanced the morphologic appearance. Addition of albumin increased density of proliferating cells and LBWR, yet at the expense of additional fetal loss.

A systematic technique using 3-dimensional ultrasound provides a simple and reproducible mode to evaluate the corpus callosum

2009-12-25

Objective: The aim of this study was to evaluate a rapid 3-dimensional ultrasound-assisted technique for evaluation of the corpus callosum as an integral part of the anatomic survey.Study Design: Transabdominal 3-dimensioal gray scale and power Doppler volumes of the fetal brain were acquired in 102 consecutive healthy fetuses at 20–23 postmenstrual weeks. Offline analysis was performed by 2 of the authors using a systematic approach of “volume manipulation.” Diagnostic-quality visualization of the corpus callosum and the pericallosal arteries on the median plane was recorded by the 2 examiners independently.Results: The median plane was easily obtained in all cases. Diagnostic-quality images of the corpus callosum were recorded in 93.1% and 99.0% and of the pericallosal arteries in 94.4% and 95.5% of the cases, by the 2 examiners, respectively.Conclusion: Three-dimensional ultrasound enables a rapid and easy evaluation of the corpus callosum that may facilitate its inclusion as an integral part of the routine anatomic survey.

Perioperative maternal morbidity model for vaginal hysterectomy: Heisler et al

Israel Zighelboim, Cindy Zhang, Lindsay Kuroki, Mallika Anand, Summer Dewdney — 2010-02-01

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:Heisler CA, Aletti GD, Weaver AL, et al. Improving quality of care: development of a risk-adjusted perioperative morbidity model for vaginal hysterectomy. Am J Obstet Gynecol 2010;202:137.e1-5.The full discussion appears at www.AJOG.org, pages e1-3.

It's not what you think: Pain in the genital area was followed by ulceration

Galit Zaidenberg-Israeli, Ayala Assia, Shimon Reif, Galia Grisaru-Soen — 2009-09-23

A generally healthy 15-year-old girl presented to the pediatric emergency department with genital ulcers. One week earlier, she developed fever (100.4°F; 38°C), dysuria, and genital pain and received a diagnosis of lichen planus at another hospital. Neither topical steroids nor amoxicillin clavulanate proved helpful. The patient was then referred to our hospital.

Discussion: ‘Perioperative morbidity model for vaginal hysterectomy’ by Heisler et al

Israel Zighelboim, Cindy Zhang, Lindsay Kuroki, Mallika Anand, Summer Dewdney — 2010-02-01

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:Heisler CA, Aletti GD, Weaver AL, et al. Improving quality of care: development of a risk-adjusted perioperative morbidity model for vaginal hysterectomy. Am J Obstet Gynecol 2010;202:137.e1-5.

Don't be fooled by Simcox CIRCLE

Jeff Andrews — 2009-11-05

Don't be fooled by Simcox's CIRCLE trial publication about cerclage. The randomization was between an objective measure as a determinant for an intervention vs individual clinical judgment—for which there were no prescribed criteria.

Reply

Andrew H. Shennan, Rachael Simcox — 2009-10-05

We believe Dr Andrews has missed the point of our study. Quoting the overall risk of our study population based on “history” is meaningless as the intervention was not selected on this basis. This is just an entry criterion of those who are scanned. We stand by the robustness of the methodology and the design, which are fit for purpose.

Episiotomy in the United States: has anything changed?

Shunji Suzuki, Misao Satomi — 2009-11-05

We read with interest the article by Frankman et al, who reported the significant decreases in episiotomy rates between 1979–2004 in the United States. Are pregnant women in the United States satisfied with the trends in episiotomy?

Reply

Jerry L. Lowder, Elizabeth A. Frankman — 2009-11-05

We thank Drs Suzuki and Satomi for their interest and comments regarding our study of national trends of episiotomy rates using the National Hospital Discharge Survey database, 1979-2004. The authors of the letter ask whether pregnant women in the United States seem to be satisfied with the trends in episiotomy. Unfortunately, we do not have an answer to this question. Upon review of the literature, we could not find a study assessing patient satisfaction with decreasing trends in episiotomy use in the United States. However, an association between lower episiotomy rate and higher patient satisfaction has been demonstrated in a non-US population. We speculate that women delivering in the United States would also be happy with a lower rate of episiotomy because the risk of anal sphincter laceration (ASL) decreases with a lower episiotomy rate. In a prior study at our institution, we found a significant increase in risk of ASL with use of episiotomy and, fortunately, a significant decrease in use of episiotomy from 1995 (59%) to 2002 (28%). An ongoing study we are conducting will shed light on maternal choice of subsequent delivery route after an ASL and satisfaction with their prior delivery.

Free thyroxine assays: no going back!

John E. Midgley, Nic D. Christofides — 2009-11-05

Lee et al have resurrected the free thyroxine index (FT4I) against modern analog-type (labeled analog/labeled antibody) free thyroxine (FT4) assays for diagnosis in pregnancy. This harkens back 40 years to a more innocent era, when shortcomings in thyroid hormone uptake methods were scarcely understood. All authentic FT4 assays must rigorously obey the law of mass action when measuring free hormone.

Reply

Richard H. Lee, Jorge H. Mestman, Carole A. Spencer — 2009-09-25

We thank Drs Midgley and Christofides for their insightful comments regarding free thyroxine (FT4) immunoassays. We would like to reiterate that we also believe it is important to establish pregnancy-specific reference ranges for FT4 immunoassays. However, such ranges may need to be specific to the population that is being studied, and this is not typically practical for clinical laboratories. Rather than debate the law of mass action and the validity of the free thyroxine index (FT4I), we want to emphasize that the purpose of the study was to evaluate the clinical utility of FT4 immunoassays when thyroid-stimulating hormone is not used as the primary test to assess thyroid function (ie, during anti–thyroid drug treatment for hyperthyroidism). This study was prompted in large part by the high number of referrals from obstetricians who asked us to evaluate patients with isolated hypothyroxinemia based on FT4 immunoassay results. We have observed, despite the controversy of whether thyroid function screening is necessary in pregnancy, that obstetricians routinely obtain complete thyroid function panels in their patients. We believe this practice is driven in part by the pressure exerted by the popular media that freely report associations of poor fetal outcome with abnormal thyroid function tests. Although the specifics regarding the superiority of 1 method vs another are left to debate, we believe our data reinforce the fact that the performance of these FT4 immunoassays is altered with pregnancy to a method-related degree. Until pregnancy-specific ranges are developed, history demonstrates that a normal FT4I or total T4 (with the use of an adjusted reference range for pregnancy) can be used to exclude the presence of hypothyroxinemia.

Common molecular causes for congenital heart defects and microcephaly

Christoph Bührer, Angela M. Kaindl — 2009-10-05

In their article, Barbu et al reported increased rates of microcephaly in neonates with congenital heart defects such as tetralogy of Fallot or coarctation/aortic arch hypoplasia. The authors interpret their findings as “strong evidence in support of intrauterine hypoxic central nervous system damage.” They thereby argue that it is heart defect–induced hypoxia that causes a developmental defect of the brain and thus microcephaly. Moreover, they call for “potential changes in prenatal management including aggressive antepartum surveillance and earlier delivery.”

Reply

Ray Bahado-Singh — 2009-11-05

We are deeply gratified by the interest of colleagues in our recent publication. Their response is thought provoking and worthy of consideration. As geneticists, we were particularly interested in the reference to neurotrophin-3 and connexin-43 gene mutations as potential explanations of our findings of increased rates of microcephaly in newborn infants with congenital heart disease. For the benefit of our readers it bears pointing out, however, that null mice for Cx 43 died at or within hours of birth because of cyanosis that resulted from congenital obstruction of the right ventricular out-flow tract. No brain abnormalities were identified. Similarly, neurotropin-3 mutations were associated with right out-flow tract abnormalities and pulmonary and valvular stenosis with pulmonary hemorrhage. Here again, no brain abnormalities were reported. The phenotypes described bear little resemblance to the cases we report.

American Journal of Obstetrics & Gynecology

Table of contents

Information for Readers

Reports of Major Impact

Change in policy for Basic Science articles

Do fathers matter? Paternal contributions to birth outcomes and racial disparities

Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS)

Paternal factors and low birthweight, preterm, and small for gestational age births: a systematic review

Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis

Pregnancy: a “teachable moment” for weight control and obesity prevention

Improving quality of care: development of a risk-adjusted perioperative morbidity model for vaginal hysterectomy

An alternative monitoring protocol for single-dose methotrexate therapy in ectopic pregnancy

Does intraoperative spillage of benign ovarian mucinous cystadenoma increase its recurrence rate?

Comparing uterine fibroids treated by myomectomy through traditional laparotomy and 2 modified approaches: ultraminilaparotomy and laparoscopically assisted ultraminilaparotomy

Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS)

Peripartum hysterectomy and arterial embolization for major obstetric hemorrhage: a 2-year nationwide cohort study in the Netherlands

Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births

Prediction of spontaneous preterm birth in asymptomatic twin pregnancies using the change in cervical length over time

Appraisal of the selectivity index in a cohort of patients treated with laser surgery for twin–twin transfusion syndrome

Examining the effectiveness of an opt-in approach to prenatal human immunodeficiency virus screening

An automated method for the determination of the sFlt-1/PIGF ratio in the assessment of preeclampsia

Increased risk of low birthweight, infants small for gestational age, and preterm delivery for women with peptic ulcer

Effect of antenatal betamethasone on maternal and fetal amino acid concentration

Drospirenone and cardiovascular risk in lean and obese polycystic ovary syndrome patients: a pilot study

Eszopiclone improves insomnia and depressive and anxious symptoms in perimenopausal and postmenopausal women with hot flashes: a randomized, double-blinded, placebo-controlled crossover trial

Prognostic nomogram for overall survival in stage IIB-IVA cervical cancer patients treated with concurrent chemoradiotherapy

Lymph node dissection in the surgical management of atypical endometrial hyperplasia

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

The effect of topical pimecrolimus on inflammatory infiltrate in vulvar lichen sclerosus

Angiogenic dysfunction in molar pregnancy

Dose-response effects of betamethasone on maturation of the fetal sheep lung

Continuous infusion of 17-hydroxyprogesterone caproate into either the fetoplacental or intervillous circulation of a placental cotyledon attenuates vasoconstriction of the fetoplacental arteries by thromboxane mimetic U46619

Precipitated egg white as a sealant for iatrogenic preterm premature rupture of the membranes

Multipotent mesenchymal stem cells from human placenta: critical parameters for isolation and maintenance of stemness after isolation

Effect of corticosteroids and progesterone on adrenomedullin output and expression in human fetal membranes and placenta trophoblasts

Albumin as an adjunct to tracheal occlusion in fetal rats with congenital diaphragmatic hernia: a placebo-controlled study

A systematic technique using 3-dimensional ultrasound provides a simple and reproducible mode to evaluate the corpus callosum

Perioperative maternal morbidity model for vaginal hysterectomy: Heisler et al

It's not what you think: Pain in the genital area was followed by ulceration

Discussion: ‘Perioperative morbidity model for vaginal hysterectomy’ by Heisler et al

Don't be fooled by Simcox CIRCLE

Reply

Episiotomy in the United States: has anything changed?

Reply

Free thyroxine assays: no going back!

Reply

Common molecular causes for congenital heart defects and microcephaly

Reply