American Journal of Obstetrics & Gynecology

2009-01-01

Information for readers

2009-01-01

Information for authors

2009-01-01

Spatiotemporal electromyography during human labor to monitor propagation of the uterine contraction wave and diagnose dystocia

Catalin S. Buhimschi — 2009-01-01

Understanding the evolution and progress of uterine contractility during pregnancy is a major goal in biology. Despite decades of effort by reproductive biologists, the “puzzle” of what activates and sustains the powerful myometrial contractile machinery during human parturition still remains unresolved. In 1871, during his state of the art lecture, Sir James Y. Simpson Bar described natural labor simplistically as the physiologic process of expelling the fetus from the uterus in 3 stages: preparation and dilatation, expulsion of the child, separation and expulsion of the placenta. Thus, it was held for centuries that forceful myometrial contractions lead to the gradual opening of the os uteri followed by the slow descent of the fetal head into the pelvis. Unfortunately, expulsion of the fetus was not always accomplished via natural ways, and in the absence of compelling scientific evidence many labor concepts, including labor “dystocia,” remained intuitive rather than evidence based.

Saving lives and changing family histories: appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy

Robert L. Brent — 2009-01-01

Over the past 50 years, our laboratory has provided consultations dealing with the risks of various environmental toxicant exposures during pregnancy. These contacts were primarily by telephone or written communications. Since the year 2000, the primary source of consultations has been via the internet. In 2007, the pregnancy website of the Health Physics Society received 1,299,672 visits. The contacts who downloaded information totaled 620,035. After reading the website information, 1442 individuals who were still concerned contacted me directly. Unfortunately, we have learned that many physicians and other counselors are not prepared to counsel patients concerning radiation risks. Approximately, 8% of the website contacts, who had consulted a professional, were provided inaccurate information that could have resulted in an unnecessary interruption of a wanted pregnancy.Research from our and other investigators' laboratories has provided radiation risk data that are the basis for properly counseling contacts with radiation exposures. Mammalian animal research has been an important source of information that improves the quality and accuracy of estimating the reproductive and developmental risks of ionizing radiation in humans.What are the reproductive and developmental risks of in utero ionizing radiation exposure?1. Birth defects, mental retardation, and other neurobehavioral effects, growth retardation, and embryonic death are deterministic effects (threshold effects). This indicates that these effects have a no adverse effect level (NOAEL). Almost all diagnostic radiological procedures provide exposures that are below the NOAEL for these developmental effects.2. For the embryo to be deleteriously affected by ionizing radiation when the mother is exposed to a diagnostic study, the embryo has to be exposed above the NOAEL to increase the risk of deterministic effects. This rarely happens when the pregnant women have x-ray studies of the head, neck, chest or extremities.3. During the preimplantation and preorganogenesis stages of embryonic development, the embryo is least likely to be malformed by the effects of ionizing radiation because the cells of the very young embryo are omnipotential and can replace adjacent cells that have been deleteriously affected. This early period of development has been designated as “the all-or-none period.”4. Protraction and fractionation of exposures of ionizing radiation to the embryo decrease the magnitude of the deleterious effects of deterministic effects.5. The increased risk of cancer following high exposures to ionizing radiation exposure to adult populations has been demonstrated in the atomic bomb survivor population. Radiation-induced carcinogenesis is assumed to be a stochastic effect (nonthreshold effect) so that there is theoretically a risk at low exposures. Whereas there is no question that high exposures of ionizing radiation can increase the risk of cancer, the magnitude of the risk of cancer from embryonic exposures following diagnostic radiological procedures is very controversial. Recent publications and analyses indicate that the risk is lower for the irradiated embryo than the irradiated child, which surprised many scientists interested in this subject, and that there may be no increased carcinogenic risk from diagnostic radiological studies.Examples of appropriate and inappropriate counseling will be presented to demonstrate how counseling can save lives and change family histories. The reader is referred to the Health Physics Society website to obtain many examples of the answers to questions posed by women and men who have been exposed to radiation (www.hps.org). Then click on ATE (ask the expert).

To the point: reviews in medical education—the Objective Structured Clinical Examination

2009-01-01

This article, the eighth in the To the Point Series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, discusses the effectiveness of the Objective Structured Clinical Examination (OSCE) for assessment of learners' knowledge, skills, and behaviors. The OSCE has also been used for the appraisal of residents and physicians undergoing licensure examinations; herein we focus on its application to undergraduate medical education. We review evidence for best practices and recommendations on effective use of the OSCE and requirements for and challenges to its implementation, including creative ways to design an OSCE program with a limited budget. We discuss its role in providing formative and summative feedback and describe learner performance on the OSCE as the OSCE relates to subsequent testing, including US Medical Licensing Examination step 1. A representative case with assessment used at the authors' medical schools is included.

Oxytocin: new perspectives on an old drug

Steven L. Clark, Kathleen Rice Simpson, G. Eric Knox, Thomas J. Garite — 2009-01-01

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications “bearing a heightened risk of harm,” which may “require special safeguards to reduce the risk of error.” Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents

Cynthia S. Tsai, Bryan E. Shepherd, Sten H. Vermund — 2009-01-01

Objective: The objective of the study was to examine the association between douching and 4 sexually transmitted infections (STIs).Study Design: We followed up 411 high-risk human immunodeficiency virus-infected and uninfected female adolescents aged 12-19 years over a median 3-year period, both by time from study entry/first STI-free visit until an incident STI for participants who never, intermittently, and always douched and also by reported douching at a given STI-free visit and incidence of STI at the next visit, using adjusted Cox proportional hazards models to calculate hazard ratios (HR).Results: The time to STI was shorter for adolescents who always (HR, 2.1; 95% confidence interval [CI], 1.2-3.4) and intermittently (HR, 1.5; 95% CI, 1.0-2.2) douched, compared with never-douchers. An adjusted hazard for STI was 1.8 times larger for always-douchers (95% CI, 1.1-3.1) and 1.4 times larger for intermittent douchers (95% CI, 0.9-2.0), compared with never-douchers. When classifying by follow-up after an STI-free visit, always-douchers had a shorter STI-free time than never-douchers (HRadj, 2.1; 95% CI, 1.5-3.1).Conclusion: Counseling to discourage douching may reduce STI risk in adolescents.

Ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women

2009-01-01

Objective: Guidelines support ending cervical cancer screening in women aged 65-70 years and older with previous normal testing, but little is known about older women's attitudes and beliefs about ending screening.Study Design: We conducted face-to-face interviews with 199 women aged 65 and older in English, Spanish, Cantonese, or Mandarin.Results: Most interviewees were nonwhite (44.7% Asian, 18.1% Latina, and 11.6% African American). Most (68%) thought lifelong screening was either important or very important, a belief held more strongly by African American (77%) and Latina (83%) women compared with women in other ethnic groups (P < .01). Most (77%) had no plans to discontinue screening or had ever thought of discontinuing (69%). When asked if they would end screening if recommended by their physician, 68% responded “yes.”Conclusion: The majority of these women believe that lifelong cervical cancer screening is important. Many women, however, reported that they would end screening if recommended by their physician.

The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda

2009-01-01

Objective: The objective of the study was to assess effects of male circumcision on female genital symptoms and vaginal infections.Study Design: Human immunodeficiency virus (HIV)-negative men enrolled in a trial were randomized to immediate or delayed circumcision (control arm). Genital symptoms, bacterial vaginosis (BV), and trichomonas were assessed in HIV-negative wives of married participants. Adjusted prevalence risk ratios (adjPRR) and 95% confidence intervals (CIs) were assessed by multivariable log-binomial regression, intent-to-treat analyses.Results: A total of 783 wives of control and 825 wives of intervention arm men were comparable at enrollment. BV at enrollment was higher in control (38.3%) than intervention arm spouses (30.5%, P = .001). At 1 year follow-up, intervention arm wives reported lower rates of genital ulceration (adjPRR, 0.78; 95% CI, 0.63-0.97), but there were no differences in vaginal discharge or dysuria. The risk of trichomonas was reduced in intervention arm wives (adjPRR, 0.52; 95% CI, 0.05-0.98), as were the risks of any BV (adjPRR, 0.60; 95% CI, 0.38-0.94) and severe BV (prevalence risk ratios, 0.39; 95% CI, 0.24-0.64).Conclusion: Male circumcision reduces the risk of ulceration, trichomonas, and BV in female partners.

Three-dimensional power Doppler ultrasound scanning for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium

Juan Luis Alcazar, Rosendo Galvan — 2009-01-01

Objective: The purpose of this study was to evaluate the role of 3-dimensional power Doppler angiography (3D-PDA) to discriminate between benign and malignant endometrial disease in women with postmenopausal bleeding and thickened endometrium.Study Design: Ninety-nine postmenopausal women (median age, 63.1 years; range, 48-84 years) with uterine bleeding and a thickened endometrium (≥ 5 mm) at baseline transvaginal sonography were assessed by 3D-PDA before endometrial biopsy. Endometrial volume, vascularity index (VI), flow index, and vascularity-flow index were calculated with the virtual organ computer-aided analysis method.Results: Histologic diagnoses were endometrial cancer (44 cases), hyperplasia (13 cases), polyp (23 cases), cystic atrophy (14 cases), and submucous myoma (5 cases). Endometrial volume, VI, and vascularity-flow index were significantly higher in malignant vs benign conditions. Receiver operating characteristic analysis revealed that VI was the best parameter for the prediction of endometrial cancer.Conclusion: The findings show that 3D-PDA may be useful for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium at baseline sonography.

Maternal thrombophilia and the risk of recurrence of preeclampsia

2009-01-01

Objective: The aim of this prospective study was to determine the impact of thrombophilia on the recurrence of preeclampsia.Study Design: In a multicenter, observational, cohort design, 172 white patients with a previous pregnancy complicated by preeclampsia were observed in the next pregnancy. They were evaluated for heritable thrombophilia (factor V Leiden and factor II G20210A mutations, protein S, protein C, and antithrombin deficiency), hyperhomocystinemia, lupus anticoagulant, and anticardiolipin antibodies. Development of preeclampsia and maternal complications and both gestational age at delivery and birthweight were recorded.Results: Sixty women (34.9%) showed the presence of a thrombophilic defect. They had a higher risk for the recurrence of preeclampsia (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.2-5.1), compared to patients without thrombophilia. Similar findings were observed considering only heritable thrombophilia. Thrombophilic patients were at increased risk for the occurrence of very early preterm delivery (< 32 weeks; OR, 11.6; 95% CI, 3.4-43.2).Conclusion: When counseling white women with a history of preeclampsia, screening for thrombophilia can be useful for preconceptional counseling and pregnancy management.

Obstetricians' choice of cesarean delivery in ambiguous cases: is it influenced by risk attitude or fear of complaints and litigation?

Dorthe Fuglenes, Pål Øian, Ivar Sønbø Kristiansen — 2009-01-01

Objective: The aim of this study was to test the hypothesis that obstetricians' choice of delivery method is influenced by their risk attitude and perceived risk of complaints and malpractice litigation.Study Design: The choice of delivery method in ambiguous cases was studied in a nationwide survey of Norwegian obstetricians (n = 716; response rate, 71%) using clinical scenarios. The risk attitude was measured by 6 items from the Jackson Personality Inventory-Revised.Results: The proportion of obstetricians consenting to the cesarean request varied both within and across the scenarios. The perceived risk of complaints and malpractice litigation was a clear determinant of obstetricians' choice of cesarean in all of the clinical scenarios, whereas no impact was observed for risk attitude.Conclusion: Obstetricians' judgments about cesarean request in ambiguous clinical cases vary considerably. Perceived risk of complaints and litigation is associated with compliance with the requested cesarean.

Occupational factors and risk of preterm birth in nurses

2009-01-01

Objective: We evaluated first-trimester exposures and the risk of preterm birth in the most recent pregnancy of participants of the Nurses' Health Study II.Study Design: Log binomial regression was used to estimate the relative risk (RR) for preterm birth in relation to occupational risk factors, such as work schedule, physical factors, and exposures to chemicals and x-rays, adjusted for age and parity.Results: Part-time work (≤ 20 hours a week) was associated with a lower risk of preterm birth [RR, 0.7; 95% confidence interval [CI], 0.6-0.9]. Working nights was associated only with early preterm birth (< 32 weeks of gestation) (RR, 3.0; 95% CI, 1.4-6.2). Although based on only 11 exposed preterm cases, self-reported exposure to sterilizing agents was associated with an increased risk (RR, 1.9; 95% CI, 1.1-3.4).Conclusion: These data suggest that night work may be related to early but not late preterm birth, whereas physically demanding work did not strongly predict risk.

Spatiotemporal electrohysterography patterns in normal and arrested labor

2009-01-01

Objective: The purpose of this study was to investigate the spatiotemporal patterns of uterine electrical activity in normal and arrested labors.Study Design: From a database of electrohysterograms, 12 subjects who underwent cesarean delivery for active-phase arrest were each matched with 2 vaginally delivered controls. Using 30-minute segments of the electrohysterogram during the arrest, or the same dilation in controls, the center of uterine electrical activity was derived. The vertical motion of this center of uterine activity was determined for each contraction and the frequencies of movement patterns analyzed.Results: Predominantly upward movement of the center of uterine activity (longer and/or stronger contraction at the fundus) was more common with normal dilation (P = .003). Receiver operating characteristic curve analysis gave an area under the curve of 0.91 for predicting outcome (vaginal vs cesarean delivery).Conclusion: There is a significant correlation between upward movement of the center of uterine activity (fundal dominance) and current labor progress.

Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor?

2009-01-01

Objective: The objective of the study was to determine whether a model for predicting vaginal birth after cesarean (VBAC) can also predict the probabilty of morbidity associated with a trial of labor (TOL).Study Design: Using a previously published prediction model, we categorized women with 1 prior cesarean by chance of VBAC. Prevalence of maternal and neonatal morbidity was stratfied by probability of VBAC success and delivery approach.Results: Morbidity became less frequent as the predicted chance of VBAC increased among women who underwent TOL (P < .001) but not elective repeat cesarean section (ERCS) (P > .05). When the predicted chance of VBAC was less than 70%, women undergoing a TOL were more likely to have maternal morbidity (relative risk [RR], 2.2; 95% confidence interval [CI], 1.5-3.1) than those who underwent an ERCS; when the predicted chance of VBAC was at least 70%, total maternal morbidity was not different between the 2 groups (RR, 0.8; 95% CI, 0.5-1.2). The results were similar for neonatal morbidity.Conclusion: A prediction model for VBAC provides information regarding the chance of TOL-related morbidity and suggests that maternal morbidity is not greater for those women who undergo TOL than those who undergo ERCS if the chance of VBAC is at least 70%.

A history of preeclampsia identifies women who have underlying cardiovascular risk factors

2009-01-01

Objective: The objective of this study was to prospectively assess physical and biochemical cardiovascular risk markers in women who had developed preeclampsia (PE) at 1 year postpartum.Study Design: Following an overnight fast, previously PE (n = 70) and normotensive women (n = 70) had weight and blood pressure recorded and levels of morning blood for insulin, glucose, C-reactive protein, lipids, cholesterol, and urine for microalbumin and creatinine measured. Body mass index, homeostatic model assessment index, and incidence of metabolic syndrome were determined.Results: At 1 year postpartum, markers of cardiovascular disease were different between the groups. There were also differences in the number of women with abnormal values. Mathematical modeling of cardiovascular event risk suggests that PE increases the risk by 2- to 3-fold; the risk was greatest for women with severe PE.Conclusion: The development of PE is 1 of the earliest clinically identifiable markers of a woman's heightened risk of cardiovascular disease.

Assessment of the peak systolic velocity of the middle cerebral artery in twin-twin transfusion syndrome. Part I: preoperative assessment

Eftichia V. Kontopoulos, Rubén A. Quintero — 2009-01-01

Objective: We sought to assess the incidence of an elevated peak systolic velocity of the middle cerebral artery (MCA-PSV) in twin-twin transfusion syndrome prior to laser surgery and its prognostic value for intrauterine fetal demise 24 hours after surgery (IUFD-24).Study Design: An elevated MCA-PSV was defined as a velocity > .5 multiples of the median by transabdominal pulsed Doppler. Gestational age, Quintero stage, and number and/or type of placental vascular anastomoses were assessed as risk factors for an elevated MCA-PSV. Risk of IUFD-24 was assessed relative to an elevated MCA-PSV.Results: An elevated MCA-PSV was present in 4.2% of donors, 3.2% of recipients (P = .5), and 1.5% of both twins in 189 patients with twin-twin transfusion syndrome. An elevated MCA-PSV was unrelated to gestational age, stage, and number or type of anastomoses. An elevated MCA-PSV in the recipient twin was associated with an increased risk of IUFD-24 of this fetus (P = .01).Conclusions: An elevated MCA-PSV is present in < 5% of donor and recipient twins. An elevated MCA-PSV is a risk factor for IUFD-24 of the recipient twin.

Preeclampsia and subsequent risk of cancer: update from the Jerusalem Perinatal Study

2009-01-01

Objective: The purpose of this study was to examine the association between preeclampsia and cancer incidence.Study Design: The Jerusalem Perinatal Study is a population-based cohort of all births to 41,206 residents of Western Jerusalem from 1964-76. Cancer incidence to 2004 was assessed by linkage of the cohort with the Israel Cancer Registry. Cox's proportional hazards models were constructed to estimate the hazard ratio for cancer among women who had had preeclampsia.Results: Preeclampsia was associated with a 1.23-fold increased risk of cancer at all sites, a 37% increased risk of breast cancer, and more than a doubling of ovarian cancer risk. Analysis by morphologic condition yielded significantly increased risks for malignancies that were classed as cystic mucinous and serous (relative risk, 1.96; 95% CI, 1.00-3.83) and for ductal, lobular, and medullary carcinomas (relative risk, 1.40; 95% CI, 1.07-1.83). No differential association was observed by sex of offspring.Conclusion: Our study suggests that the previously described protective effect of preeclampsia on cancer is not universal.

Abnormal endothelium-dependent microvascular dilator reactivity in pregnancies complicated by normotensive intrauterine growth restriction

2009-01-01

Objective: Normotensive intrauterine growth restriction and preeclampsia share a similar placenta pathophysiology, whereas maternal clinical manifestations differ. Clinical symptoms of preeclampsia are partly attributed to vascular endothelial dysfunction, but it is unclear whether this phenomenon plays a role in intrauterine growth restriction. Therefore, we investigated microvascular endothelial function in women with intrauterine growth restriction.Study Design: Laser Doppler fluxmetry was used combined with iontophoresis of acetylcholine and sodium nitroprusside, namely, endothelium-dependent and endothelium-independent vasodilators. We studied 12 women with intrauterine growth restriction and 16 controls in the third trimester of pregnancy. All women had prepregnancy body mass indexes < 26.Results: Acetylcholine-mediated vasodilatation was significantly increased in women with intrauterine growth restriction compared with controls (743% ± 120% vs 390% ± 67%, P = .01); sodium nitroprusside-mediated vasodilatation was not different (360% ± 55% vs 363% ± 65%, P > .99).Conclusion: Nonobese women with normotensive intrauterine growth restriction show abnormal endothelium-dependent microvascular vasodilatation, suggesting endothelial dysfunction as in preeclampsia. Obviously, for the clinical manifestation of preeclampsia additional factors are required, and a role of metabolic syndrome and obesity has been suggested.

Therapeutic cerclage may be more efficacious in women who develop cervical insufficiency after a term delivery

2009-01-01

Objective: Our objective was to determine whether obstetric history affects the efficacy of therapeutic cerclage.Study Design: Data were gathered prospectively on patients receiving therapeutic cerclage, defined as midtrimester presentation with a cervical length less than 2.5 cm and prior preterm delivery or cervical dilatation with visible membranes on sterile speculum exam. Delivery outcomes based on cerclage type were compared between women with (n = 31) vs without prior term birth (n = 33).Results: Patients with a history of a term birth were older than those without such history (P = .05) but otherwise similar with regard to ethnicity, body mass index, prior preterm birth, genitourinary infection, prior cervical surgery, gestational age at cerclage placement, and cerclage indication. Women with a therapeutic cerclage and a history of a prior term delivery were significantly more likely to deliver after 35 weeks (90% vs 48%, P < .001) and their babies were significantly larger (2942 ± 812 g vs 1966 ± 1069 g, P < .001) than women with no prior term delivery.Conclusion: Patients who develop cervical insufficiency after a term delivery may have better perinatal outcomes following therapeutic cerclage than those without a history of term delivery.

High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome

Susie Lim, Mona R. Prasad, Philip Samuels, Debra K. Gardner, Leandro Cordero — 2009-01-01

Objective: The purpose of this study was to examine high-dose methadone in pregnant women and its effect on the duration of neonatal abstinence syndrome.Study Design: This was a retrospective chart review of 68 neonates and their mothers who received methadone therapy during pregnancy. The last dosage of maternal methadone just before delivery and the length of treatment for neonatal abstinence syndrome were examined with an analysis of variance model.Results: When the data were analyzed for methadone dosages as a continuous variable, each 1-mg increase in the last maternal methadone dosage before delivery was associated with an additional 0.18 days of infant treatment for neonatal abstinence syndrome (P < .001; 95% CI, 0.112-0.255). In other words, every increase of 5.5 mg of methadone in the mother was associated statistically with 1 additional day of neonatal abstinence syndrome treatment for the infant. Gestational age at delivery and birthweight were not statistically significant.Conclusion: Higher doses of maternal methadone were associated with an increase in diagnosis and longer duration of neonatal abstinence syndrome.

Breast cancer incidence after hormonal infertility treatment in Sweden: a cohort study

2009-01-01

Objective: To assess the impact of infertility treatment with causes of infertility on incidence of breast cancer.Study Design: Historical prospective cohort study of 1135 women attending major university clinics for treatment of infertility in Sweden, 1961-1976. Women were classified as users of clomiphene citrate or gonadotropins, or a combination of both therapies. Standardized incidence ratios were calculated to estimate relative risk of breast cancer.Results: We observed 54 cases of breast cancer during 1961-2004, which did not significantly exceed those expected. Users of high-dose clomiphene citrate had an almost 2-fold increased risk (standardized incidence ratio, 1.90; 95% confidence interval, 1.08-3.35). This association was more pronounced among women referred for nonovulatory factors, with 3-fold increased risk (standardized incidence ratio, 3.00; 95% confidence interval, 1.35-6.67).Conclusion: No overall increased risk for breast cancer was shown with infertility treatment. Women with nonovulatory causes treated with high-dose clomiphene citrate therapy may have an elevated risk for breast cancer.

Generation of CA125-specific cytotoxic T lymphocytes in human leukocyte antigen-A2.1-positive healthy donors and patients with advanced ovarian cancer

2009-01-01

Objective: To identify potential immunogenic peptides derived from CA125.Study Design: A bioinformatics approach was used to identify peptides derived from CA125 that bind to human leukocyte antigen A2.1 and elicit peptide-specific human cytotoxic T-lymphocyte responses in healthy individuals and patients with ovarian carcinoma.Results: CD8+ cytotoxic T-lymphocyte populations generated against 4 CA125-derived peptides were able to induce lysis of autologous peptide-loaded target cells. CA125 YTLDrDSLYV peptide-specific cytotoxic T lymphocytes were found to effectively kill ovarian tumors expressing CA125. Cytotoxicity was inhibited by antihuman leukocyte antigen A2.1 (BB7-2) and antihuman leukocyte antigen class I (W6/32) antibodies, whereas natural killer-sensitive targets were not lysed. YTLDrDSLYV peptide-specific cytotoxic T lymphocyte precursor frequency was low in peripheral blood leukocytes of normal donors and patients with ovarian cancer as determined by interferon-gamma production in ELISPOT assays. Intracellular cytokine expression measured by flow cytometry showed a type 1 cytokine profile in YTLDrDSLYV peptide-specific cytotoxic T lymphocytes.Conclusion: The CA125 YTLDrDSLYV peptide is an immunogenic epitope and may represent an attractive target for immunotherapy of ovarian cancer.

The prognostic value of molecular biomarkers in tissue removed by curettage from FIGO stage 1 and 2 endometrioid type endometrial cancer

2009-01-01

Objective: To analyze the prognostic value of molecular biomarkers in curettages of endometrioid endometrial cancer pathologic FIGO stages 1 and 2.Study Design: Population-based survival analysis in 258 patients of classical prognostic features and molecular biomarkers of cell cycle regulation, (anti)apoptosis, proliferation, squamous differentiation, and PTEN/Akt pathway.Results: With 74 months median follow-up (range, 1-209), 24 (9.3%) patients had metastases develop. Pathologic FIGO stage 2B (6% of all cases) and age > 68 years had independent multivariate prognostic value. Many molecular biomarkers were prognostic, particularly cell-cycle regulators p16, p21, p27, p53, p63, and the antiapoptosis marker survivin (which mostly stains mitoses). The strong prognostic value of a multivariate model with survivin, p21, and p53 overshadowed all other prognosticators in pathologic FIGO 1 and 2A.Conclusion: In pathologic FIGO stage 1 and 2A endometrioid endometrial cancer curettages, combined biomarkers survivin, p21, and p53 expression patterns are prognostically stronger than classical feature combinations.

A lower incidence of gynecologic adverse events and interventions with anastrozole than with tamoxifen in the ATAC trial

Sean R. Duffy, Wolfgang Distler, Anthony Howell, Jack Cuzick, Michael Baum — 2009-01-01

Objective: Results of the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial have shown that tamoxifen is associated with a significantly higher incidence of gynecologic adverse events than anastrozole.Study Design: This was a retrospective analysis of all gynecologic adverse events and interventions conducted in patients receiving anastrozole or tamoxifen in the main ATAC trial database.Results: Women taking tamoxifen experienced significantly more gynecologic adverse events than those taking anastrozole (34.2% vs 20.5%; P < .0001) and this led to more diagnostic and/or therapeutic interventions, including an almost 4-fold increase in the number of hysterectomies (5.1% vs 1.3%; P < .0001). The majority of the gynecologic adverse events with tamoxifen occurred during the first 2.5 years.Conclusion: The lower incidence of gynecologic adverse events and interventions with anastrozole and the early occurrence of these events provide further support for using anastrozole as the initial adjuvant treatment for early hormone receptor–positive breast cancer.

Laparoscopic management of early ovarian and fallopian tube cancers: surgical and survival outcome

2009-01-01

Objective: To evaluate the role of laparoscopy for staging of early ovarian cancers.Study Design: Case series conducted at the University Hospital with 36 patients who had presumed early-stage adnexal cancers. Laparoscopic staging/restaging was performed.Results: Cases included 20 invasive epithelial tumors, 11 borderline tumors, and 5 nonepithelial tumors. Mean number of peritoneal biopsies, paraaortic nodes, and pelvic nodes were 6, 12.23, and 14.84, respectively. Eighty-three percent of the patients had laparoscopic omentectomy. On final pathology, 7 patients were upstaged. Postoperative complications included 1 small bowel obstruction, 2 pelvic lymphoceles, and 1 lymphocele cyst. Mean duration of follow-up is 55.9 months. Three patients had recurrences. All patients are alive without evidence of the disease.Conclusion: This represents 1 of the largest series and longest follow-ups of laparoscopic staging for early-stage adnexal tumors. Laparoscopic staging of these cancers appears to be feasible and comprehensive without compromising survival when performed by gynecologic oncologists experienced with advanced laparoscopy.

Postmenopausal hormone therapy and incident urinary incontinence in middle-aged women

Mary K. Townsend, Gary C. Curhan, Neil M. Resnick, Francine Grodstein — 2009-01-01

Objective: The objective of the study was to examine the association of hormone therapy with incident urinary incontinence (UI) in postmenopausal women aged 37-54 years in the Nurses' Health Study II.Study Design: Participants reported use of hormone therapy, including hormone type, on biennial questionnaires from 1989 to 2001. Among 7341 postmenopausal women reporting no UI in 2001, we identified 1026 women who developed UI at least monthly between 2001 and 2003. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).Results: Women currently using hormone therapy had 1.39-fold (95% CI, 1.16-1.67) increased odds of incident UI, compared with women who never used hormone therapy. ORs were similar in current users of oral estrogen alone (OR, 1.35, 95% CI, 1.03-1.78) and oral estrogen with progestin (OR, 1.37, 95% CI, 1.13-1.67).Conclusion: These findings suggest an increased risk of UI associated with use of postmenopausal hormone therapy in younger postmenopausal women.

New pelvic symptoms are common after reconstructive pelvic surgery

Thythy Pham, Kimberly Kenton, Elizabeth Mueller, Linda Brubaker — 2009-01-01

Objective: The objective of the study was to determine the incidence of new pelvic symptoms after reconstructive pelvic surgery and its impact on surgical outcomes.Study Design: Women undergoing surgery for prolapse (POP) and/or urinary incontinence underwent preoperative and 3 month postoperative assessment: urodynamics, pelvic organ prolapse quantification, and Pelvic Floor Distress Inventory (PFDI-20). Postoperative assessment included Patient Global Impression of Improvement (PGI-I), satisfaction, and new symptom questionnaire.Results: Forty-two percent (33/79) reported new pelvic symptoms: incontinence (27%), urgency (25%), frequency (23%), difficult defecation (22%), voiding difficulty (10%), and POP (2%). Women with new symptoms differed from those without: higher postoperative mean PFDI-20 scores (P < .001 for Urinary Distress Inventory, P = .02 for Pelvic Organ Prolapse Distress Inventory, and P = .02 Colorectal-Anal Inventory); 58% vs 83% improved on PGI-I, compared with 83% (P = .01); 33% vs 83% completely satisfied (P ≤ .001).Conclusion: Women report high rates of new pelvic symptoms after surgery, which are associated with decreased self-reported improvement and satisfaction despite improvement on validated quality of life measures.

The transplacental transport of essential amino acids in uncomplicated human pregnancies

2009-01-01

Objective: The purpose of this study was to assess the placental transport of the essential amino acids (EAAs) in normal pregnancies.Study Design: Nine (13C or 2H) EAAs were infused simultaneously as a bolus into the maternal circulation of 12 patients with uncomplicated pregnancy before cesarean delivery. Maternal samples were collected before and after the bolus; umbilical blood was collected at delivery. The fetal/maternal molar percent enrichment for each EAA was calculated for both the umbilical vein and artery. Plasma amino acids enrichments were analyzed by gas chromatography mass spectrometry and concentrations by high performance liquid chromatography. Data were analyzed with paired and unpaired t-test.Results: The umbilical arterial enrichments were significantly lower than the venous. Fetal/maternal ratios for leucine, isoleucine, methionine, and phenylalanine were > 0.80, with no significant differences among their molar percent enrichment ratios, whereas fetal/maternal ratios of the other 5 EAAs were significantly lower (< 0.60).Conclusion: The EAAs showed significant umbilical uptake and striking differences in their transport rates in vivo.

The adaptor protein MyD88 is essential for E coli–induced preterm delivery in mice

Yana Filipovich, Shi-Jiang Lu, Shizuo Akira, Emmet Hirsch — 2009-01-01

Objective: We used a mouse model of infection-induced preterm delivery to examine the roles of 2 adaptor proteins with central functions in Toll-like receptor signaling: MyD88 (myeloid differentiation primary-response gene 88) and TRIF (Toll/IL-1 receptor (TIR)-domain-containing adaptor protein-inducing IFN-β).Study Design: Mice deficient (KO) for MyD88, TRIF, both (DKO) or neither (WT) were inoculated into the uterus with killed Escherichia coli. Delivery outcomes, fetal status, serum progesterone, and nuclear translocation of the transcription factor nuclear factor κ B (NFκB) were determined.Results: Preterm birth (delivery in less than 48 hours) occurred in WT and TRIF-KO animals in a dose-dependent fashion, reaching 100% with 5-10 × 109 bacteria, while MyD88-KO and DKO animals were completely protected from delivery. Intrauterine fetal survival, maintenance of circulating progesterone levels, and nuclear translocation of NFκB were also dependent upon MyD88 but not TRIF. In contrast, induction of uterine interleukin (IL)-1β and tumor necrosis factor alpha (TNF-α) depends upon actions of both MyD88 and TRIF.Conclusion: E coli–induced preterm delivery in the mouse is completely dependent upon MyD88 but not TRIF.

Ureaplasma colonization of amniotic fluid and efficacy of antenatal corticosteroids for preterm lung maturation in sheep

2009-01-01

Objective: The objective of the study was to assess the efficacy of maternal betamethasone for improving preterm lung function in the presence of inflammation induced by amniotic fluid Ureaplasma colonization.Study Design: Ewes bearing single fetuses were randomized to receive an intraamniotic injection of Ureaplasma parvum (serovar 6; 2 × 107 colony-forming units) or vehicle at 86 ± 2 days of pregnancy (mean ± SD: term is 150 days), followed by maternal intramuscular betamethasone (0.5 mg/kg) or saline, either 2 or 7 days before delivery of lambs at 123 ± 1 d.Results: Amniotic fluid interleukin-8 was elevated by ureaplasmas (P = .049) but unaffected by betamethasone. Lung inflammation induced by ureaplasmas was not affected by betamethasone. Lung compliance was increased by Ureaplasma colonization (P = .009) and betamethasone (P = .042), and effects were additive. Lung surfactant was increased by Ureaplasma colonization (P < .001) and betamethasone 7 days (P = .001), but not 2 days, before delivery.Conclusion: Inflammation improves preterm lung function because of increases in surfactant. Antenatal corticosteroids further augment lung function through an apparently independent mechanism.

Quantification of cell free fetal DNA in maternal plasma in normal pregnancies and in pregnancies with placental dysfunction

2009-01-01

Objective: To assess the normal levels of free fetal DNA in maternal plasma through pregnancy compared with those in pregnancies complicated with placental dysfunction manifested by preeclampsia and/or fetal growth restriction.Study Design: Maternal blood samples from 138 singleton male pregnancies were divided into 3 groups; normal pregnancies (77), preeclampsia (49), and fetal growth restriction (12). Royston and Wright's methods were used to calculate gestational age-related reference limits of free fetal DNA in the 3 groups. The DYS14 gene of the Y chromosome was quantified and compared in maternal plasma by using real-time quantitative polymerase chain reaction.Results: Free fetal DNA in normal pregnancies increased with gestational age. Results were significantly higher in preeclampsia and fetal growth restriction groups than in normal pregnancy and were higher in severe preeclampsia than in milder disease.Conclusion: Free fetal DNA is a potential marker for placental dysfunction in pregnancy. Large prospective studies are now needed to investigate its role in the prediction of pregnancy complications and severity and or timing of delivery.

Cord immunoproteins as predictors of respiratory outcome in preterm infants

Tuula Kaukola, Jarno Tuimala, Riitta Herva, Stephen Kingsmore, Mikko Hallman — 2009-01-01

Objective: The purpose of this study was to evaluate the role of cord blood proteins and antenatal factors in the prediction of respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD).Study Design: The prospectively collected cohort included 163 infants. All infants were born between 1998-2002 in a single regional hospital before 32 weeks of gestation and survived the first hospitalization. Altogether, 107 cord blood proteins were analyzed. Twenty-two antenatal clinical factors were included in the data mining and logistic regression analyses.Results: The incidence of RDS was 64% and of BPD was 25%. Histologic chorioamnionitis protected from RDS (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11-0.53; P < .001). Besides the length of gestation, other clinical factors poorly predicted the outcomes. Matrix metalloproteinase-9 independently predicted RDS (OR, 8.3; 95% CI, 3.0-23.1; P < .001). Soluble glycoprotein 130 independently predicted BPD (OR, 6.07; 95%CI, 2.20-16.7; P < .001).Conclusion: Specific antenatal immunologic activation predicts either acute or chronic respiratory disease in very preterm infants.

The effects of sildenafil citrate (Viagra) on uterine blood flow and well being in the intrauterine growth-restricted fetus

Suzanne L. Miller, Jan M. Loose, Graham Jenkin, Euan M. Wallace — 2009-01-01

Objective: This study examined whether the type-5 phosphodiesterase inhibitor sildenafil citrate (Viagra; Pfizer, New York, NY) could increase uterine blood flow in intrauterine growth restriction (IUGR), thereby improving fetal oxygenation and well being.Study Design: In fetal sheep, we induced IUGR at 105-110 days (0.7 gestation) using single umbilical artery ligation (SUAL). In SUAL and control animals, we measured uterine blood flow (UBF) and blood gases before and after sildenafil administration.Results: SUAL fetuses were hypoxemic compared with controls. Following sildenafil, UBF was significantly decreased in both SUAL and control ewes for ∼40 minutes. In response to sildenafil, pO2 was decreased in SUAL and control fetuses and both groups displayed significant hypotension and tachycardia. At postmortem SUAL fetal body weight was significantly reduced by 23% compared with controls.Conclusion: Sildenafil does not improve UBF or fetal well being in SUAL-induced IUGR pregnancies and should be used with caution in IUGR and healthy pregnancies because of its detrimental effects on uteroplacental perfusion and on the fetus.

Term labor is associated with a core inflammatory response in human fetal membranes, myometrium, and cervix

2009-01-01

Objective: Identify overlap of the transcriptome of myometrium and cervix in association with human labor.Study Design: The transcriptional profile of myometrial and cervical biopsies obtained from women in spontaneous labor at term (n = 9) and not in labor (n = 9) were characterized by Affymetrix v2 U133 plus 2 arrays. Common canonical pathways and functional groups were identified by Ingenuity Pathway Analysis.Results: One hundred ten genes (false discovery rate < 1%) were commonly up-regulated by myometrium and cervix in association with labor and 29 genes (false discovery rate < 1%) down-regulated. Fold change in expression of up-regulated genes was strongly correlated; myometrium vs cervix (r = 0.51; P < .001), with no relationship in down-regulated genes (r = 0.26; P = .16). Canonical pathway analysis established up-regulation of inflammatory pathway signaling, with greatest increases in cellular movement and immune response gene ontology groups.Conclusion: Gestational tissues exhibit a core inflammatory response in association with human parturition, with pathways regulating cellular trafficking dominating.

Is there an association between uterine leiomyomas and acid phosphatase locus 1 polymorphism?

2009-01-01

Objective: Platelet derived growth factor (PDGF) is involved in the development of leiomyomas. The low-molecular-weight phosphoprotein-tyrosine–phosphatase (LMWPTP), controlled by the highly polymorphic acid phosphatase locus 1 (ACP1), is able to dephosphorylate the PDGF receptor. Therefore, we searched for a possible association between ACP1 and leiomyomas.Study Design: We studied 172 women hospitalized for symptomatic leiomyomas requiring surgical intervention and 164 healthy women without clinical evidence of leiomyomas from the same white population. The χ2 test of independence, Pearson correlation, analysis of variance, and post hoc test for difference between means were performed.Results: The distribution of ACP1 genotypes among patients does not differ significantly from that of healthy women. However, leiomyoma size was negatively correlated with ACP1 F isoform concentrations. Leiomyoma size was smaller among carriers of the *B/*B genotype, which has the highest concentration of the F isoform, than among carriers of *A/*A, *C/*B, and *C/*C genotypes, which have the lowest concentration of the F isoform.Conclusion: High ACP1 F isoform concentration, through dephosphorylation of the PDGF receptor, may negatively regulate cell proliferation and growth of leiomyomas.

Douching and the risk for sexually transmitted disease: Tsai et al

2009-01-01

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:Tsai CS, Shepherd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Am J Obstet Gynecol 2009;200:38.e1-38.e8.The full discussion appears at www.AJOG.org, pages e11-e14.

Think outside the box: While investigating a patient's dyspnea, physicians made an unusual discovery

Ferga C. Gleeson, Lizhi Zhang, Michael J. Levy — 2009-01-01

A 73-year-old female presented with a 1-week history of progressive dyspnea. Six months earlier, she had been diagnosed with an International Federation of Gynecology and Obstetrics grade 3 uterine papillary serous carcinoma. Computed tomography (CT) of the thorax disclosed bilateral pulmonary emboli; a CT of the abdomen indicated retention of gastric contents, which suggested delayed gastric emptying (). While anticoagulation was being initiated, the patient became hemodynamically unstable. In addition, evidence of melena was noted.

Complex abdominal wall reconstruction after radiation therapy: A full-thickness defect was repaired with a rectus femoris myofasciocutaneous flap

2009-01-01

Usually, cervical cancer metastasizes to the pelvis or distant organs; on rare occasions, it recurs at the abdominal wall. In 1 such case, a 31-year-old woman was admitted with a bleeding tumor and enterocutaneous fistula of the abdominal wall. Two years earlier, she underwent radical abdominal hysterectomy followed by whole-pelvis radiation therapy (total dose, 60 Gy) for squamous cell carcinoma of the cervix. After treatment concluded, a painful abdominal nodule formed and grew rapidly. A period of intense pain was promptly relieved when an intestinal secretion was spontaneously discharged from the growth. At that time, the patient presented to the emergency department at another institution, where urgent surgery to correct the fistula was unsuccessful. A colostomy at the splenic flexure was done but was never functional.

Discussion: ‘Douching and the risk for sexually transmitted disease’ by Tsai et al

2009-01-01

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:Tsai CS, Shepherd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Am J Obstet Gynecol 2009;200:38.e1-38.e8.

Spontaneous rectovaginal fistula during bevacizumab therapy for ovarian cancer: a case report

Elisabeth Chéreau, Dan Stefanescu, Frédéric Selle, Roman Rouzier, Emile Daraï — 2009-01-01

Recent studies have demonstrated efficacy of bevacizumab for recurrent ovarian cancer, but few data on its use and gastrointestinal potential complications when administered as adjuvant chemotherapy after cytoreductive surgery are available. In this study, we report the first case of a rectovaginal fistula in this indication.

Vulvar hematoma secondary to spontaneous rupture of the internal iliac artery: clinical review

Eleanor Egan, Philip Dundee, Nathan Lawrentschuk — 2009-01-01

Vulvar hematomas occur rarely outside the obstetric population but may present after other trauma to the pelvis or perineum. Spontaneous rupture of the internal iliac artery is described mostly in the presence of an aneurysm, with atherosclerosis, connective tissue disease, infection, and trauma as causative factors. It most often presents with abdominal pain and neurologic or urologic symptoms. We present an unusual case of a spontaneous rupture of the internal iliac artery that presented as a vulvar hematoma in a nulliparous woman that was successfully treated with selective arterial embolization and surgical evacuation. The literature is reviewed and management options discussed.

Endothelial progenitor cells and pregnancy

Carl A. Hubel — 2009-01-01

Savvidou et al reported a decline in endothelial progenitor cells (EPCs) in the maternal circulation with advancing gestation. The available literature on EPCs during pregnancy is conflicting, however, as appropriately acknowledged by the authors.

Reply

Qingzhong Xiao, Makrina D. Savvidou, Kypros H. Nicolaides — 2009-01-01

We thank Dr Hubel for his comments. The methodology to identify circulating endothelial progenitor cells (EPCs) used in our study has been described in detail. In many previous studies, EPCs are described as a peripheral blood mononuclear cell (PBMC) population expressing CD34, kinase insert domain receptor (KDR)/vascular endothelial growth factor receptor-2, and CD133/AC133 with adherent growth characteristics.

Can physiologic hyperlipidemia during pregnancy be the culprit for atherogenesis in utero?

Ahmet Basaran — 2009-01-01

We read the article by Liguori et al with great interest. However, there are some conflicting points that need to be clarified. The first thing that I want to mention is about the exclusion criteria that did not include gravids with polycystic ovary syndrome, diabetes, or gestational diabetes; patients with high body mass index or preterm labor; and smoking mothers.

Reply

Antonio Liguori, Wulf Palinski, Claudio Napoli — 2009-01-01

In his comment on our paper, Dr Basaran raises the question why we did not exclude some conditions associated with increased C-reactive protein (CRP) and the need to define hypercholesterolemia and elevated CRP in dependency of the trimester. An impairment of CRP levels is not described in the paper quoted by Dr Basaran.

American Journal of Obstetrics & Gynecology

Table of contents

Information for readers

Information for authors

Spatiotemporal electromyography during human labor to monitor propagation of the uterine contraction wave and diagnose dystocia

Saving lives and changing family histories: appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy

To the point: reviews in medical education—the Objective Structured Clinical Examination

Oxytocin: new perspectives on an old drug

Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents

Ending cervical cancer screening: attitudes and beliefs from ethnically diverse older women

The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda

Three-dimensional power Doppler ultrasound scanning for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium

Maternal thrombophilia and the risk of recurrence of preeclampsia

Obstetricians' choice of cesarean delivery in ambiguous cases: is it influenced by risk attitude or fear of complaints and litigation?

Occupational factors and risk of preterm birth in nurses

Spatiotemporal electrohysterography patterns in normal and arrested labor

Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor?

A history of preeclampsia identifies women who have underlying cardiovascular risk factors

Assessment of the peak systolic velocity of the middle cerebral artery in twin-twin transfusion syndrome. Part I: preoperative assessment

Preeclampsia and subsequent risk of cancer: update from the Jerusalem Perinatal Study

Abnormal endothelium-dependent microvascular dilator reactivity in pregnancies complicated by normotensive intrauterine growth restriction

Therapeutic cerclage may be more efficacious in women who develop cervical insufficiency after a term delivery

High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome

Breast cancer incidence after hormonal infertility treatment in Sweden: a cohort study

Generation of CA125-specific cytotoxic T lymphocytes in human leukocyte antigen-A2.1-positive healthy donors and patients with advanced ovarian cancer

The prognostic value of molecular biomarkers in tissue removed by curettage from FIGO stage 1 and 2 endometrioid type endometrial cancer

A lower incidence of gynecologic adverse events and interventions with anastrozole than with tamoxifen in the ATAC trial

Laparoscopic management of early ovarian and fallopian tube cancers: surgical and survival outcome

Postmenopausal hormone therapy and incident urinary incontinence in middle-aged women

New pelvic symptoms are common after reconstructive pelvic surgery

The transplacental transport of essential amino acids in uncomplicated human pregnancies

The adaptor protein MyD88 is essential for E coli–induced preterm delivery in mice

Ureaplasma colonization of amniotic fluid and efficacy of antenatal corticosteroids for preterm lung maturation in sheep

Quantification of cell free fetal DNA in maternal plasma in normal pregnancies and in pregnancies with placental dysfunction

Cord immunoproteins as predictors of respiratory outcome in preterm infants

The effects of sildenafil citrate (Viagra) on uterine blood flow and well being in the intrauterine growth-restricted fetus

Term labor is associated with a core inflammatory response in human fetal membranes, myometrium, and cervix

Is there an association between uterine leiomyomas and acid phosphatase locus 1 polymorphism?

Douching and the risk for sexually transmitted disease: Tsai et al

Think outside the box: While investigating a patient's dyspnea, physicians made an unusual discovery

Complex abdominal wall reconstruction after radiation therapy: A full-thickness defect was repaired with a rectus femoris myofasciocutaneous flap

Discussion: ‘Douching and the risk for sexually transmitted disease’ by Tsai et al

Spontaneous rectovaginal fistula during bevacizumab therapy for ovarian cancer: a case report

Vulvar hematoma secondary to spontaneous rupture of the internal iliac artery: clinical review

Endothelial progenitor cells and pregnancy

Reply

Can physiologic hyperlipidemia during pregnancy be the culprit for atherogenesis in utero?

Reply