American Journal of Obstetrics & Gynecology

2012-05-01

Information for readers

2012-05-01

AJOG on iPad announcement

2012-05-01

We would like to announce that the American Journal of Obstetrics & Gynecology (AJOG) is now even easier and more convenient for our readers with an Apple iPad (Apple, Cupertino, CA). The AJOG app, available in iTunes (Apple) is free to download and offers readers access to full issues from January 2011 to the present. In addition, readers can also access the most current AJOG content and Articles in Press. Once downloaded, content may be browsed or searched and there are additional in-app features to enhance the AJOG reading experience:

The New American Journal of Obstetrics and Gynecology, 5 Years Later: Looking back and moving forward

2012-03-15

Maternal-fetal care starts and ends with the mother

Britton D. Rink — 2012-02-23

Over the last several years, maternal-fetal intervention has rapidly evolved and challenged those who provide care to pregnant women in many ways. Although fetal treatment began in the 1960s with the introduction of intraperitoneal transfusions by obstetrician Dr A. William Liley, it has become a field largely managed by pediatricians. In an effort to facilitate the transition from intrauterine to neonatal life with instantaneous access to pediatric specialists, most fetal care centers are now located in pediatric hospitals that offer luxurious birthing facilities to families faced with the worst uncertainty of their lives after the prenatal diagnosis: ongoing pregnancy management and birth (usually by scheduled cesarean) of a child with a congenital condition. The focus has shifted from the mother to the fetus. As the physical location of maternal-fetal care has shifted to the pediatric setting, so has the control of maternal-fetal care. Obstetricians and maternal-fetal specialists have not offered much resistance to the shift from obstetric to pediatric decision making.

Progesterone and preterm birth prevention: translating clinical trials data into clinical practice

2012-03-19

Objective: We sought to provide evidence-based guidelines for using progestogens for the prevention of preterm birth (PTB). Methods: Relevant documents, in particular randomized trials, were identified using PubMed (US National Library of Medicine, 1983 through February 2012) publications, written in English, which evaluate the effectiveness of progestogens for prevention of PTB. Progestogens evaluated were, in particular, vaginal progesterone and 17-alpha-hydroxy-progesterone caproate. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Data were evaluated according to population studied, with separate analyses for singleton vs multiple gestations, prior PTB, or short transvaginal ultrasound cervical length (CL), and combinations of these factors. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. Results and Recommendations: Summary of randomized studies indicates that in women with singleton gestations, no prior PTB, and short CL ≤20 mm at ≤24 weeks, vaginal progesterone, either 90-mg gel or 200-mg suppository, is associated with reduction in PTB and perinatal morbidity and mortality, and can be offered in these cases. The issue of universal CL screening of singleton gestations without prior PTB for the prevention of PTB remains an object of debate. CL screening in singleton gestations without prior PTB cannot yet be universally mandated. Nonetheless, implementation of such a screening strategy can be viewed as reasonable, and can be considered by individual practitioners, following strict guidelines. In singleton gestations with prior PTB 20-36 6/7 weeks, 17-alpha-hydroxy-progesterone caproate 250 mg intramuscularly weekly, preferably starting at 16-20 weeks until 36 weeks, is recommended. In these women with prior PTB, if the transvaginal ultrasound CL shortens to <25 mm at <24 weeks, cervical cerclage may be offered. Progestogens have not been associated with prevention of PTB in women who have in the current pregnancy multiple gestations, preterm labor, or preterm premature rupture of membranes. There is insufficient evidence to recommend the use of progestogens in women with any of these risk factors, with or without a short CL.

Oversight of elective early term deliveries: avoiding unintended consequences

Steven L. Clark, Janet A. Meyers, Jonathan B. Perlin — 2011-08-22

The national movement to eliminate elective delivery at <39 weeks' gestation has engendered much enthusiasm and is a major step forward in the evolution of perinatal patient safety. Our experience with >1 million births in the past 5 years suggests the existence of a number of potential pitfalls that should be considered in policy development, enforcement, and compliance monitoring. Attention to these details will ensure continued patient benefit from these policies without endangering those fetuses in whom early term delivery is warranted medically.

Gynecologic care for breast cancer survivors: assisting in the transition to wellness

Ritu Salani, Barbara L. Andersen — 2011-10-24

Currently, there are >2 million survivors of breast cancer in the United States. Two years after cancer treatment, patients may transition to primary care providers and/or gynecologists. Many of these survivors may have difficulties with menopausal symptoms. If they do not know already, some of these women may want or need risk assessment for hereditary- or treatment-induced second cancers. At least 20% will also have significant psychologic, sexual, and/or relationship difficulties that require attention. All of the women will need assistance to learn and follow recommendations for surveillance, detecting recurrence, and promoting wellness. Thus, gynecologists play a critical role in helping these patients in their health care transitions. To assist the gynecologists, we have reviewed the evaluation and management of common sequelae of breast cancer diagnoses and treatments.

Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care

Elizabeth E. Krans, Matthew M. Davis — 2011-06-30

In 2010, Preventing Low Birthweight celebrated it 25th anniversary. The report, one of the most influential policy statements ever issued regarding obstetric health care delivery, linked prenatal care to a reduction in low birthweight (LBW). Medicaid coverage for prenatal care services was subsequently expanded and resulted in increased prenatal care utilization. However, the rate of LBW failed to decrease. This well-intentioned expansion of prenatal care services did not change the structure of prenatal care. A single, standardized prenatal care model, largely ineffective in the prevention of LBW, was expanded to a heterogeneous group of patients with a variety of medical and psychosocial risk factors. Reinventing prenatal care as a flexible model, with content, frequency, and timing tailored to maternal and fetal risk, may improve adverse birth outcomes. Risk-appropriate prenatal care may improve the effectiveness of prenatal care for high-risk patients and the efficiency of prenatal care delivery for low-risk patients.

The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries

2012-03-19

Objective: The objective of the study was to evaluate the frequency of obstetrical anal sphincter injuries (OASIS) in women undergoing operative vaginal deliveries (OVD) and to assess whether a mediolateral episiotomy is protective for developing OASIS in these deliveries. Study Design: We performed a retrospective cohort study. Maternal and obstetrical characteristics of the 2861 women who delivered liveborn infants by an OVD at term in the years 2001-2009 were extracted from a clinical obstetrics database and were analyzed in a logistic regression model. Results: The frequency of OASIS was 5.7%. Women with a mediolateral episiotomy were at significantly lower risk for OASIS compared with the women without a mediolateral episiotomy in case of an OVD (adjusted odds ratio, 0.17; 95% confidence interval, 0.12–0.24). Conclusion: We found a 6-fold decreased odds for developing OASIS when a mediolateral episiotomy was performed in OVD. Therefore, we advocate the use of a mediolateral episiotomy in all operative vaginal deliveries to reduce the incidence of OASIS.

Effects on (neuro)developmental and behavioral outcome at 2 years of age of induced labor compared with expectant management in intrauterine growth-restricted infants: long-term outcomes of the DIGITAT trial

2012-03-26

Objective: We sought to study long-term (neuro)developmental and behavioral outcome of pregnancies complicated by intrauterine growth restriction at term in relation to induction of labor or an expectant management. Study Design: Parents of 2-year-old children included in the Disproportionate Intrauterine Growth Intervention Trial at Term (DIGITAT) answered the Ages and Stages Questionnaire (ASQ) and Child Behavior Checklist (CBCL). Results: We approached 582 (89.5%) of 650 parents. The response rate was 50%. Of these children, 27% had an abnormal score on the ASQ and 13% on the CBCL. Results of the ASQ and the CBCL for the 2 policies were comparable. Low birthweight, positive Morbidity Assessment Index score, and admission to intermediate care increased the risk of an abnormal outcome of the ASQ. This effect was not seen for the CBCL. Conclusion: In women with intrauterine growth restriction at term, neither a policy of induction of labor nor expectant management affect developmental and behavioral outcome when compared to expectant management.

Prenatally diagnosed fetal conditions in the age of fetal care: does who counsels matter?

2012-02-16

Objective: We sought to characterize practices and attitudes of maternal-fetal medicine (MFM) and fetal care pediatric (FCP) specialists regarding fetal abnormalities. Study Design: This was a self-administered survey of 434 MFMs and FCPs (response rate: MFM 60.9%; FCP 54.2%). Results: For Down syndrome (DS), congenital diaphragmatic hernia (CDH), spina bifida: MFMs were more likely than FCPs to support termination (DS 52% vs 35%, P < .001; CDH 49% vs 36%, P < .001; spina bifida 54% vs 35%, P < .001), and consider offering termination options as highly important (DS 90% vs 70%, P < .001; CDH 88% vs 69%, P < .001; spina bifida 88% vs 70%, P < .001). For DS only, MFMs were less likely than FCPs to think that pediatric specialist consultation should be offered prior to a decision regarding termination (54% vs 75%, P < .001). MFMs reported report higher termination rates among patients only for DS (DS 51% vs 21%, P < .001). Conclusion: MFM and FCP specialists' counseling attitudes differ for fetal abnormalities.

A comparison of surface acquired uterine electromyography and intrauterine pressure catheter to assess uterine activity

Gabi Haran, Michal Elbaz, Moshe D. Fejgin, Tal Biron-Shental — 2011-12-26

Objective: Intrauterine pressure catheter (IUPC) is the primary device used to evaluate uterine activity. In contrast to the IUPC, electrical uterine myography (EUM) enables noninvasive measurement of frequency, intensity, and tone of contractions. The aim of this study was to determine the accuracy of EUM compared to IUPC. Study Design: EUM measured myometrial electrical activity using a multichannel amplifier and a noninvasive position sensor. In all, 47 women in labor were monitored simultaneously with an IUPC and EUM. We compared the frequency, intensity, and tone of uterine contractions between the methods. Results: The correlation of the frequency, intensity, and tone of contractions between uterine electromyography and IUPC was strong with significant r values of 0.808-1 (P < .0001). Conclusion: Electrical uterine electromyography yields information about uterine contractility comparable to that obtained with IUPC.

The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population

2012-05-01

Objective: The purpose of this study was to evaluate the impact of group prenatal care on rates of preterm birth. Study Design: We conducted a retrospective cohort study of 316 women in group prenatal care that was compared with 3767 women in traditional prenatal care. Women self-selected participation in group care. Results: Risk factors for preterm birth were similar for group prenatal care vs traditional prenatal care: smoking (16.9% vs 20%; P = .17), sexually transmitted diseases (15.8% vs 13.7%; P = .29), and previous preterm birth (3.2% vs 5.4%; P = .08). Preterm delivery (<37 weeks' gestation) was lower in group care than traditional care (7.9% vs 12.7%; P = .01), as was delivery at <32 weeks' gestation (1.3% vs 3.1%; P = .03). Adjusted odds ratio for preterm birth for participants in group care was 0.53 (95% confidence interval, 0.34–0.81). The racial disparity in preterm birth for black women, relative to white and Hispanic women, was diminished for the women in group care. Conclusion: Among low-risk women, participation in group care improves the rate of preterm birth compared with traditional care, especially among black women. Randomized studies are needed to eliminate selection bias.

Maternal superobesity and perinatal outcomes

2012-03-09

Objective: The purpose of this study was to determine the effect of maternal superobesity (body mass index [BMI], ≥50 kg/m2) compared with morbid obesity (BMI, 40-49.9 kg/m2) or obesity (BMI, 30-39.9 kg/m2) on perinatal outcomes. Study Design: We conducted a retrospective cohort study of birth records that were linked to hospital discharge data for all liveborn singleton term infants who were born to obese Missouri residents from 2000-2006. We excluded major congenital anomalies and women with diabetes mellitus or chronic hypertension. Results: There were 64,272 births that met the study criteria, which included 1185 superobese mothers (1.8%). Superobese women were significantly more likely than obese women to have preeclampsia (adjusted relative risk [aRR], 1.7; 95% confidence interval [CI], 1.4–2.1), macrosomia (aRR, 1.8; 95% CI, 1.3–2.5), and cesarean delivery (aRR, 1.8; 95% CI, 1.5–2.1). Almost one-half of all superobese women (49.1%) delivered by cesarean section, and 33.8% of superobese nulliparous women underwent scheduled primary cesarean delivery. Conclusion: Women with a BMI of ≥50 kg/m2 are at significantly increased risk for perinatal complications compared with obese women with a lower BMI.

Changes in labor patterns over 50 years

S. Katherine Laughon, D. Ware Branch, Julie Beaver, Jun Zhang — 2012-03-12

Objective: The objective of the study was to examine differences in labor patterns in a modern cohort compared with the 1960s in the United States. Study Design: Data from pregnancies at term, in spontaneous labor, with cephalic, singleton fetuses were compared between the Collaborative Perinatal Project (CPP, n = 39,491 delivering 1959-1966) and the Consortium on Safe Labor (CSL; n = 98,359 delivering 2002-2008). Results: Compared with the CPP, women in the CSL were older (26.8 ± 6.0 vs 24.1 ± 6.0 years), heavier (body mass index 29.9 ± 5.0 vs 26.3 ± 4.1 kg/m2), had higher epidural (55% vs 4%) and oxytocin use (31% vs 12%), and cesarean delivery (12% vs 3%). First stage of labor in the CSL was longer by a median of 2.6 hours in nulliparas and 2.0 hours in multiparas, even after adjusting for maternal and pregnancy characteristics, suggesting that the prolonged labor is mostly due to changes in practice patterns. Conclusion: Labor is longer in the modern obstetrical cohort. The benefit of extensive interventions needs further evaluation.

Fetal male gender and the benefits of treatment of mild gestational diabetes mellitus

2012-03-26

Objective: We evaluated whether improvements in pregnancy outcomes after treatment of mild gestational diabetes mellitus differed in magnitude on the basis of fetal gender. Study Design: This is a secondary analysis of a masked randomized controlled trial of treatment for mild gestational diabetes mellitus. The results included preeclampsia or gestational hypertension, birthweight, neonatal fat mass, and composite adverse outcomes for both neonate (preterm birth, small for gestational age, or neonatal intensive care unit admission) and mother (labor induction, cesarean delivery, preeclampsia, or gestational hypertension). After stratification according to fetal gender, the interaction of gender with treatment status was estimated for these outcomes. Results: Of the 469 pregnancies with male fetuses, 244 pregnancies were assigned randomly to treatment, and 225 pregnancies were assigned randomly to routine care. Of the 463 pregnancies with female fetuses, 233 pregnancies were assigned randomly to treatment, and 230 pregnancies were assigned randomly to routine care. The interaction of gender with treatment status was significant for fat mass (P = .04) and birthweight percentile (P = .02). Among women who were assigned to the treatment group, male offspring were significantly more likely to have both a lower birthweight percentile (50.7 ± 29.2 vs 62.5 ± 30.2 percentile; P < .0001) and less neonatal fat mass (487 ± 229.6 g vs 416.6 ± 172.8 g; P = .0005,) whereas these differences were not significant among female offspring. There was no interaction between fetal gender and treatment group with regard to other outcomes. Conclusion: The magnitude of the reduction of a newborn's birthweight percentile and neonatal fat mass that were related to the treatment of mild gestational diabetes mellitus appears greater for male neonates.

Cerclage for cervical shortening at fetoscopic laser photocoagulation in twin-twin transfusion syndrome

2012-03-01

Objective: The purpose of this study was to evaluate the benefit of cervical cerclage for cervical length ≤25 mm at the time of fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome. Study Design: A multicenter, retrospective cohort study was conducted with 163 patients with a short cervix before FLP for twin-twin transfusion syndrome. Seventy-nine of the patients (48%) had cerclage placement at the surgeon's discretion. The outcome measures that were compared were gestational age at delivery and perinatal mortality rates for patients with cerclage and those who were treated conservatively. Outcomes were evaluated with the use of comparative statistics. Results: There were no differences in the preoperative variables, except cerclage was performed more frequently for a cervical length of ≤15 mm (P < .001). There were no differences in the gestational age at delivery (28.8 ± 5.4 vs 29.1 ± 5.6 weeks with and without cerclage, respectively; P = .15); perinatal mortality rates were similar between the 2 groups. Conclusion: The benefit of cerclage for patients with short cervix before FLP remains questionable.

Prepregnancy obesity and complement system activation in early pregnancy and the subsequent development of preeclampsia

2012-03-09

Objective: We hypothesized that women who are obese before they become pregnant and also have elevations of complement Bb and C3a in the top quartile in early pregnancy would have the highest risk of preeclampsia compared with a referent group of women who were not obese and had levels of complement less than the top quartile. Study Design: This was a prospective study of 1013 women recruited at less than 20 weeks' gestation. An EDTA-plasma sample was obtained, and complement fragments were measured using enzyme-linked immunosorbent assays. The data were analyzed using univariable and multivariable logistic regression analysis. Results: Women who were obese with levels of Bb or C3a in the top quartile were 10.0 (95% confidence interval, 3.3–30) and 8.8 (95% confidence interval, 3–24) times, respectively, more likely to develop preeclampsia compared with the referent group. Conclusion: We demonstrate a combined impact of obesity and elevated complement on the development of preeclampsia.

Improving patient understanding of preeclampsia: a randomized controlled trial

Whitney B. You, Michael S. Wolf, Stacy C. Bailey, William A. Grobman — 2012-03-13

Objective: We developed a standardized educational tool to inform women about preeclampsia. The objective of this study was to assess whether exposure to this tool led to superior understanding of the syndrome. Study Design: This was a randomized controlled trial in which 120 women were assigned to (1) a newly developed preeclampsia educational tool, (2) a standard pamphlet addressing preeclampsia that had been created by the American College of Obstetricians and Gynecologists, or (3) no additional information. Preeclampsia knowledge was assessed with the use of a previously validated questionnaire. Results: There were no demographic differences among the groups. Patients who received the tool scored significantly better on the preeclampsia questionnaire than those who received the American College of Obstetricians and Gynecologists pamphlet or no additional information (71%, 63%, 49%, respectively; P < .05). This improved understanding was evident equally among women with and without adequate health literacy (interaction: P > .05). Conclusion: Patients who were exposed to a graphics-based educational tool demonstrated superior preeclampsia-related knowledge, compared with those patients who were exposed to standard materials or no education.

Cost minimization analysis of laparoscopic sacral colpopexy and total vaginal mesh

Christopher F. Maher, Luke B. Connelly — 2011-12-19

Objective: The objective of the study was a cost minimization analysis of the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM). Study Design: Primary clinical costs were derived from our randomized control trial comparing LSC and TVM and were compared using prices from privately- and publicly-conducted procedures. Womens' opportunity cost of time were added to these estimates to produce estimates of the primary economic costs of the procedures. Reoperation costs were added to estimate the economic cost per subject. Results: LSC has lower mean primary clinical cost as compared with the TVM in both the public (mean difference, $1102.96; 95% confidence interval [CI], 468.52–1737.385) and private models (mean difference, $1176.68; 95% CI, 1116.85–1236.51), respectively. Mean total economic costs were significantly lower in the LSC group as compared with the TVM ($4013.07; 95% CI, 3107.77–4918.37). Labor costs were significantly greater in the LSC but were offset by lower consumable, inpatient, opportunity, and reoperation costs as compared with the TVM. Conclusion: The LSC has lower economic cost than TVM.

Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy

Nazema Y. Siddiqui, Elizabeth J. Geller, Anthony G. Visco — 2012-02-10

Objective: The purpose of this study was to compare symptomatic and anatomic outcomes 1 year after robotic vs abdominal sacrocolpopexy. Study Design: Our retrospective cohort study compared women who underwent robotic sacrocolpopexy (RSC) with 1 surgeon to those who underwent abdominal sacrocolpopexy (ASC) as part of the Colpopexy and Urinary Reduction Efforts trial. Our primary outcome was a composite measure of vaginal bulge symptoms or repeat surgery for prolapse. Results: We studied 447 women (125 with RSC and 322 with ASC). Baseline characteristics were similar. There were no significant differences in surgical failures 1 year after surgery based on our primary composite outcome (7/86 [8%] vs 12/304 [4%]; P = .16). When we considered anatomic failure, there were also no significant differences between RSC and ASC (4/70 [6%] vs 16/289 [6%]; P = .57). Conclusion: One year after sacrocolpopexy, women who underwent RSC have similar symptomatic and anatomic success compared with those women who underwent ASC.

Effect of surgical approach on physical activity and pain control after sacral colpopexy

Sarah A. Collins, Paul K. Tulikangas, David M. O'Sullivan — 2012-02-10

Objective: We sought to compare recovery of activity and pain control after robotic (ROB) vs abdominal (ABD) sacral colpopexy. Study Design: Women undergoing ROB and ABD sacral colpopexy wore accelerometers for 7 days preoperatively and the first 10 days postoperatively. They completed postoperative pain diaries and Short Form-36 questionnaires before and after surgery. Results: At 5 days postoperatively, none of the 14 subjects in the ABD group and 4 of 28 (14.3%) in the ROB group achieved 50% total baseline activity counts (P = .283). At 10 days, 5 of 14 (35.7%) in the ABD group and 8 of 26 (30.8%) in the ROB group (P = .972) achieved 50%. Postoperative pain was similar in both groups. Short Form-36 vitality scores were lower (P = .017) after surgery in the ABD group, but not in the ROB group. Conclusion: Women undergoing ROB vs ABD sacral colpopexy do not recover physical activity faster, and pain control is not improved.

Outcomes and predictors of failure of trocar-guided vaginal mesh surgery for pelvic organ prolapse

Alfredo L. Milani, Mariella I.J. Withagen, Mark E. Vierhout — 2012-02-10

Objective: The objective of the study was to compare the 1 year conventional and composite outcomes of trocar-guided vaginal mesh surgery and the identification of the predictors of failure. Study Design: This was a prospective observational cohort study. Failure outcome definitions were as follows: I, prolapse stage II or greater in mesh treated compartments; II, overall prolapse stage II or greater; III, composite outcome of overall prolapse greater than the hymen and the presence of bulge symptoms or repeat surgery. We used logistic regression to identify predictors of failure. Results: The results of the study were 1 year follow-up of 433 patients. Treated compartment failure (I) was 15% (95% confidence interval [CI], 12–19). Overall prolapse failure (II) was 41% (95% CI, 36–45). Composite failure (III) was 9% (95% CI, 7–13). Predictor of failure in all outcomes was the combined anterior/posterior mesh with the uterus in situ. Conclusion: Outcome of prolapse surgery depends on outcome definition. The mesh treated compartment failure outcome (I) and the composite failure outcome (III) appeared not to be statistically different. Consistent factor for failure in all outcomes was the combined anterior/posterior mesh insertion with the uterus in situ.

Interrater reliability of the International Continence Society and International Urogynecological Association (ICS/IUGA) classification system for mesh-related complications

Elena Tunitsky, Sara Abbott, Matthew D. Barber — 2012-03-12

Objective: We sought to assess interrater reliability of the International Continence Society (ICS)/International Urogynecological Association (IUGA) classification system of vaginal mesh-related complications and compare this with several other available complication classification systems. Study Design: This was a retrospective analysis of mesh-related complications in patients presenting after pelvic organ prolapse or incontinence surgery. The complications were classified by 2 independent reviewers using the ICS/IUGA classification system as well as 3 other available classification systems. Interrater reliability was assessed using percent agreement and the weighted κ statistic. Results: The ICS/IUGA mesh complication classification system was found to have poor interrater reliability (κ = 0.15-0.78). The other systems yielded a κ that ranged from 0.18-0.60, but were too general or could only be applied to 68% of the complications. Conclusion: The complexity of the ICS/IUGA mesh complication system, the large number of categories, and lack of clarity likely contribute to its poor interrater reliability.

Pharmacologic treatment for urgency-predominant urinary incontinence in women diagnosed using a simplified algorithm: a randomized trial

2012-03-12

Objective: The purpose of this study was to evaluate clinical outcomes associated with the initiation of treatment for urgency-predominant incontinence in women diagnosed by a simple 3-item questionnaire. Study Design: We conducted a multicenter, double-blinded, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence in ambulatory women diagnosed by the simple 3-item questionnaire. Participants (N = 645) were assigned randomly to fesoterodine therapy (4-8 mg daily) or placebo. Urinary incontinence was assessed with the use of voiding diaries; postvoid residual volume was measured after treatment. Results: After 12 weeks, women who had been assigned randomly to fesoterodine therapy reported 0.9 fewer urgency and 1.0 fewer total incontinence episodes/day, compared with placebo (P ≤ .001). Four serious adverse events occurred in each group, none of which was related to treatment. No participant had postvoid residual volume of ≥250 mL after treatment. Conclusion: Among ambulatory women with urgency-predominant incontinence diagnosed with a simple 3-item questionnaire, pharmacologic therapy resulted in a moderate decrease in incontinence frequency without increasing significant urinary retention or serious adverse events, which provides support for a streamlined algorithm for diagnosis and treatment of female urgency-predominant incontinence.

Comprehensive analysis of LAMC1 genetic variants in advanced pelvic organ prolapse

2012-02-10

Objective: We sought to comprehensively evaluate the association of laminin gamma-1 (LAMC1) and advance pelvic organ prolapse. Study Design: We conducted a candidate gene association of patients (n = 239) with stages III-IV prolapse and controls (n = 197) with stages 0-I prolapse. We used a linkage disequilibrium (LD)–tagged approach to identify single-nucleotide polymorphisms (SNPs) in LAMC1 and focused on non-Hispanic white women to minimize population stratification. Additive and dominant multivariable logistic regression models were used to test for association between individual SNPs and advanced prolapse. Results: Fourteen SNPs representing 99% coverage of LAMC1 were genotyped. There was no association between SNP rs10911193 and advanced prolapse (P = .34). However, there was a trend toward significance for SNPs rs1413390 (P = .11), rs20563 (P = .11), and rs20558 (P = .12). Conclusion: Although we found that the previously reported LAMC1 SNP rs10911193 was not associated with nonfamilial prolapse, our results support further investigation of this candidate gene in the pathophysiology of prolapse.

A novel bridge between oxidative stress and immunity: the interaction between hydrogen peroxide and human leukocyte antigen G in placental trophoblasts during preeclampsia

Xue Zhou, Guo-ying Zhang, Jue Wang, Shou-lian Lu, Jun Cao, Li-zhou Sun — 2012-03-22

Objective: The aim of this study was to investigate a possible association between hydrogen peroxide and human leukocyte antigen G (HLA-G) in preeclampsia. Study Design: We explored the correlation between HLA-G and hydrogen peroxide in preeclamptic (n = 30) and normotensive (n = 30) placentas, which was confirmed by in vitro experiments. Furthermore, RNA interference was used to explore the influence of HLA-G on the proliferation, apoptosis and invasion of HTR-8/SVneo cells when exposed to hydrogen peroxide. Results: We found an inverse correlation between hydrogen peroxide and HLA-G expression in preeclamptic placentas. High levels of hydrogen peroxide could down-regulate HLA-G expression in HTR-8/SVneo. Compared with HLA-G knockdown HTR-8/SVneo, increased proliferation inhibition, higher apoptosis, and decreased cell invasion were found in the cell expressing HLA-G when exposed to hydrogen peroxide. Conclusion: Our findings highlight that high levels of hydrogen peroxide can down-regulate HLA-G expression in trophoblasts during preeclampsia and trophoblasts expressing HLA-G are vulnerable to oxidative stress.

The impact of drug metabolizing enzyme polymorphisms on outcomes after antenatal corticosteroid use

2012-02-29

Objective: To determine the impact of maternal and fetal single nucleotide polymorphisms in key betamethasone pathways on neonatal outcomes. Study Design: DNA was obtained from women given betamethasone and their infants. Samples were genotyped for 73 exploratory drug metabolism and glucocorticoid pathway single nucleotide polymorphisms. Clinical variables and neonatal outcomes were obtained. Logistic regression analysis using relevant clinical variables and genotypes to model for associations with neonatal respiratory distress syndrome was performed. Results: One hundred nine women delivering 117 infants were analyzed. Sixty-four infants (49%) developed respiratory distress syndrome. Multivariable analysis revealed that respiratory distress syndrome was associated with maternal single nucleotide polymorphisms in CYP3A5 (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16–2.30) and the glucocorticoid resistance (OR, 0.28; 95% CI, 0.08–0.95) and fetal single nucleotide polymorphisms in ADCY9 (OR, 0.17; 95% CI, 0.03–0.80) and CYP3A7*1E (rs28451617; OR, 23.68; 95% CI, 1.33–420.6). Conclusion: Maternal and fetal genotypes are independently associated with neonatal respiratory distress syndrome after treatment with betamethasone for preterm labor.

SOD1 suppresses maternal hyperglycemia-increased iNOS expression and consequent nitrosative stress in diabetic embryopathy

Hongbo Weng, Xuezheng Li, E. Albert Reece, Peixin Yang — 2012-02-23

Objective: Hyperglycemia induces oxidative stress and increases inducible nitric oxide synthase (iNOS) expression. We hypothesized that oxidative stress is responsible for hyperglycemia-induced iNOS expression. Study Design: iNOS-luciferase activities, nitrosylated protein, and lipid peroxidation markers 4-hydroxynonenal and malondialdehyde were determined in parietal yolk sac-2 cells exposed to 5 mmol/L glucose or high glucose (25 mmol/L) with or without copper zinc superoxide dismutase 1 (SOD1) treatment. Levels of iNOS protein and messenger RNA, nitrosylated protein, and cleaved caspase-3 and -8 were assessed in wild-type embryos and SOD1-overexpressing embryos from nondiabetic and diabetic dams. Results: SOD1 treatment diminished high glucose–induced oxidative stress, as evidenced by 4-hydroxynonenal and malondialdehyde reductions, and it blocked high glucose–increased iNOS expression, iNOS-luciferase activities, and nitrosylated protein. In vivo SOD1 overexpression suppressed hyperglycemia-increased iNOS expression and nitrosylated protein, and it blocked caspase-3 and -8 cleavage. Conclusion: We conclude that oxidative stress induces iNOS expression, nitrosative stress, and apoptosis in diabetic embryopathy.

Human amnion epithelial cells reduce ventilation-induced preterm lung injury in fetal sheep

2012-03-09

Objective: The objective of the study was to explore whether human amnion epithelial cells (hAECs) can mitigate ventilation-induced lung injury. Study Design: An established in utero ovine model of ventilation-induced lung injury was used. At day 110 of gestation, singleton fetal lambs either had sham in utero ventilation (IUV) (n = 4), 12 hours of IUV alone (n = 4), or 12 hours of IUV and hAEC administration (n = 5). The primary outcome, structural lung injury, was assessed 1 week later. Results: Compared with sham controls, IUV alone was associated with significant lung injury: increased collagen (P = .03), elastin (P = .02), fibrosis (P = .02), and reduced secondary-septal crests (P = .009). This effect of IUV was significantly mitigated by the administration of hAECs: less collagen (P = .03), elastin (P = .04), fibrosis (P = .02), normalized secondary-septal crests (P = .02). The hAECs were immunolocalized within the fetal lung and had differentiated into type I and II alveolar cells. Conclusion: The hAECs mitigate ventilation-induced lung injury and differentiated into alveolar cells in vivo.

A new method for assessing uterine activity: Haran et al

George A. Macones, Alison Cahill, David M. Stamilio, Anthony Odibo — 2012-03-26

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: Haran G, Elbaz M, Fejgin MD, et al. A comparison of surface acquired uterine electromyography and intrauterine pressure catheter to assess uterine activity. Am J Obstet Gynecol 2012;206:412.e1-5.

In the nick of time: Despite 2 treatments a cervical ectopic pregnancy continued to advance

Emily S. Miller, Kathryn Marko, Leeber Cohen, Jeffrey S. Dungan, Lee P. Shulman — 2012-01-30

A 36-year-old nulligravid woman, who had conceived by intrauterine insemination, was referred for a known cervical pregnancy. The ectopic pregnancy was initially diagnosed at 6 weeks 6 days of gestation. Asingle-dose intramuscular injection of systemic methotrexate, 50 mg/m2, was administered at 7 weeks' and again at 9 weeks' gestation at her local hospital, but these failed to successfully treat the ectopic gestation. The patient subsequently presented to our institution at 11 weeks 1 day for further management. Her human chorionic gonadotropin (hCG) level at that time was 26,861 IU/L. She denied any vaginal bleeding or pain.

Discussion: ‘A new method for assessing uterine activity’ by Haran et al

George A. Macones, Alison Cahill, David M. Stamilio, Anthony Odibo — 2012-03-29

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: Haran G, Elbaz M, Fejgin MD, et al. A comparison of surface acquired uterine electromyography and intrauterine pressure catheter to assess uterine activity. Am J Obstet Gynecol 2012;206:412.e1-5.

Decreased brachial plexus palsy after institution of shoulder dystocia protocol

Russ Jelsema — 2012-01-05

In the recent study evaluating outcomes after instituting a shoulder dystocia protocol that included 5 components, the authors describe a “reduced frequency of brachial plexus palsy when a shoulder dystocia occurred.” I have several questions for the authors:

Reply

William A. Grobman — 2012-01-05

We would like to thank Dr Jelsema for his interest in our article as well as the questions he has asked. During time periods A, B, and C of the study, the cesarean rates were 27.1%, 28.2%, and 29%, respectively. This change in the point estimate was not statistically significant (P = .12). Even if statistical significance had been reached, we do not believe this would explain a decrease in the frequency of brachial plexus palsy documented given the denominator for the frequency was “per shoulder dystocia,” and that the frequency of shoulder dystocia per delivery did not change over time. The protocol itself was focused upon the team response to the shoulder dystocia and did not convey specific maneuvers, or order of maneuvers, that should be employed in the management of the shoulder dystocia. Thus, providers' judgment was relied upon to determine what maneuvers and traction were employed.

Lymphadenectomy in endometrial cancer: what's the right question?

Stefano Basile, Maria Giovanna Salerno, Pierluigi Benedetti Panici — 2012-02-10

We read, with great interest, the article by Sharma et al, in which, in a large retrospective study on data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database, the authors analyzed women with stages I-II endometrioid adenocarcinomas of the uterine corpus treated between 1988 and 2006. Findings suggest that, especially among women with high- to intermediate-risk tumors, patients who undergo lymphadenectomy are less likely to receive external-beam radiation. According to the authors, data support lymphadenectomy for the majority of women with endometrial carcinoma, thus sparing radiation-related morbidity and costs.

Reply

Charu Sharma, Israel Deutsch, Thomas J. Herzog, Jason D. Wright — 2012-02-10

We appreciate the interest of Dr Basile and his colleagues in our work. Utilizing a large population-based database of patients with endometrial cancer treated from 1988 to 2006, we noted that those women who underwent lymphadenectomy were less likely to receive adjuvant external beam radiotherapy than those who did not undergo nodal evaluation. The association between lymphadenectomy and avoidance of radiation was strongest for women with intermediate risk tumors (Fédération Internationale de Gynécologie et d'Obstétrique 1988 stage IB grades 2 and 3 and stage IC grades 1 and 2).

Safety and efficiency of multiple square sutures to avoid peripartum hysterectomy

Souhail Alouini, Louis Mesnard — 2012-02-16

Bateman et al reported an increased rate of hysterectomy for severe postpartum hemorrhage in the United States from 1994-2007. This study is pessimistic and does not reflect the high efficiency of new surgical procedures to stop severe postpartum hemorrhage. Indeed, the first publication on the very high success rate of multiple square sutures to control severe postpartum hemorrhage was in 2000; therefore, it is normal that the application of this technique in routine practice and its positive consequences appear many years later. This explains the reason that there is no drop in peripartum hysterectomy rates. Indeed, multiple square sutures are very efficient to control severe postpartum hemorrhage when they are applied correctly. The rate of success is >90% on uterine atony. Moreover, fertility is preserved after multiple square sutures, and subsequent pregnancies are possible.

Reply

Brian T. Bateman, William M. Callaghan, Elena V. Kuklina — 2012-03-12

We appreciate the interest of Drs Alouini and Mesnard in our study. We share the authors' enthusiasm for uterine compression sutures as a treatment of severe postpartum hemorrhage and agree that in many circumstances their use may prevent the need for peripartum hysterectomy.

Board Certification

2012-05-01

The following list contains 1115 Diplomates passing the 2011 Ob/Gyn Oral Examination on 11/07/2011, 12/09/2011, and 01/13/2012 Certificates valid through 12/31/2012

American Journal of Obstetrics & Gynecology

Table of Contents

Information for readers

AJOG on iPad announcement

The New American Journal of Obstetrics and Gynecology, 5 Years Later: Looking back and moving forward

Maternal-fetal care starts and ends with the mother

Progesterone and preterm birth prevention: translating clinical trials data into clinical practice

Oversight of elective early term deliveries: avoiding unintended consequences

Gynecologic care for breast cancer survivors: assisting in the transition to wellness

Preventing Low Birthweight: 25 years, prenatal risk, and the failure to reinvent prenatal care

The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries

Effects on (neuro)developmental and behavioral outcome at 2 years of age of induced labor compared with expectant management in intrauterine growth-restricted infants: long-term outcomes of the DIGITAT trial

Prenatally diagnosed fetal conditions in the age of fetal care: does who counsels matter?

A comparison of surface acquired uterine electromyography and intrauterine pressure catheter to assess uterine activity

The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population

Maternal superobesity and perinatal outcomes

Changes in labor patterns over 50 years

Fetal male gender and the benefits of treatment of mild gestational diabetes mellitus

Cerclage for cervical shortening at fetoscopic laser photocoagulation in twin-twin transfusion syndrome

Prepregnancy obesity and complement system activation in early pregnancy and the subsequent development of preeclampsia

Improving patient understanding of preeclampsia: a randomized controlled trial

Cost minimization analysis of laparoscopic sacral colpopexy and total vaginal mesh

Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy

Effect of surgical approach on physical activity and pain control after sacral colpopexy

Outcomes and predictors of failure of trocar-guided vaginal mesh surgery for pelvic organ prolapse

Interrater reliability of the International Continence Society and International Urogynecological Association (ICS/IUGA) classification system for mesh-related complications

Pharmacologic treatment for urgency-predominant urinary incontinence in women diagnosed using a simplified algorithm: a randomized trial

Comprehensive analysis of LAMC1 genetic variants in advanced pelvic organ prolapse

A novel bridge between oxidative stress and immunity: the interaction between hydrogen peroxide and human leukocyte antigen G in placental trophoblasts during preeclampsia

The impact of drug metabolizing enzyme polymorphisms on outcomes after antenatal corticosteroid use

SOD1 suppresses maternal hyperglycemia-increased iNOS expression and consequent nitrosative stress in diabetic embryopathy

Human amnion epithelial cells reduce ventilation-induced preterm lung injury in fetal sheep

A new method for assessing uterine activity: Haran et al

In the nick of time: Despite 2 treatments a cervical ectopic pregnancy continued to advance

Discussion: ‘A new method for assessing uterine activity’ by Haran et al

Decreased brachial plexus palsy after institution of shoulder dystocia protocol

Reply

Lymphadenectomy in endometrial cancer: what's the right question?

Reply

Safety and efficiency of multiple square sutures to avoid peripartum hysterectomy

Reply

Board Certification