American Journal of Obstetrics & Gynecology

2010-03-01

Information for Readers

2010-03-01

Latest research from the 2010 meeting of the Society for Maternal-Fetal Medicine

Jay D. Iams — 2010-03-01

This month's issue includes 8 articles that describe research presented at the 2010 meeting of the Society for Maternal-Fetal Medicine (SMFM) in Chicago on February 4-6. From 1256 abstracts submitted, 86 were selected by the Society for oral presentation. Authors of these 86 abstracts were invited to submit their manuscripts through the “Fast-Track” process, in which AJOG reviewers provided rapid reviews in time to allow revision to meet the deadline for inclusion in this issue. These fast-track articles are easily identified by the checkered racing flags on the first page of each as well as next to their titles in the Contents section. We hope our readers will enjoy reading these articles based on oral presentations at the SMFM meeting and those that will appear in upcoming issues of the Journal.

Elective delivery before 39 weeks: reason for caution

George A. Macones — 2010-03-01

This issue includes 8 Fast-Track articles given as oral presentations at the Annual Meeting of the Society for Maternal-Fetal Medicine in February 2010. Three of these articles focus on an important issue in obstetrics: elective delivery <39 completed weeks of gestation.

What is the value for money of prenatal carrier screening for spina muscular atrophy? Too soon to say

Scott D. Grosse — 2010-03-01

Little et al pose an important question: would the universal offer of carrier screening for spinal muscular atrophy (SMA) during prenatal care be cost-effective, ie, provide good value for money spent? The rapid expansion of the availability of molecular genetic tests for rare disorders, with approximately 1700 tests currently available, poses a challenge to health care providers and payers. We as a society do not have sufficient funds to pay for all possible genetic tests, and prioritization in some form must be undertaken. Little et al and the American College of Obstetricians and Gynecologists are to be commended for addressing the balance of technological opportunity in genetic testing and opportunity cost of scarce health care resources implicit in the concept of cost-effectiveness.

Health disparities: definitions and measurements

2010-03-01

An article in this issue of the Journal, titled “Family Planning Disparities,” is the first in a series of 4 articles to address disparities in the area of obstetrics and gynecology. The remaining articles will appear in subsequent issues and will address disparities in reproductive endocrinology and infertility, obstetrics, and gynecology. Because the field of health disparities research is evolving rapidly and is conceptually complex, in this editorial we provide a background of the definitions and current understanding of health disparities to serve as a foundation for understanding this series.

Disparities in family planning

2010-03-01

Prominent racial/ethnic and socioeconomic disparities in rates of unintended pregnancy, abortion, and unintended births exist in the United States. These disparities can contribute to the cycle of disadvantage experienced by specific demographic groups when women are unable to control their fertility as desired. In this review we consider 3 factors that contribute to disparities in family planning outcomes: patient preferences and behaviors, health care system factors, and provider-related factors. Through addressing barriers to access to family planning services, including abortion and contraception, and working to ensure that all women receive patient-centered reproductive health care, health care providers and policy makers can substantially improve the ability of women from all racial/ethnic and socioeconomic backgrounds to make informed decisions about their fertility.

Menstrual cycle-related exacerbation of disease

JoAnn V. Pinkerton, Christine J. Guico-Pabia, Hugh S. Taylor — 2010-03-01

Exacerbation of common medical and mental health disorders at specific phases of the menstrual cycle is a prevalent phenomenon. Although the precise cause is unclear, studies implicate complex interactions between the immune and neuroendocrine systems. The menstrual cycle also is a trigger for the onset of depressive disorders, including premenstrual dysphoric disorder, a disorder specific to the luteal phase of the menstrual cycle, and depression associated with the transition to menopause. This article discusses common mental health problems exacerbated by the menstrual cycle, with a particular focus on premenstrual dysphoric disorder and perimenopausal depression. Throughout the reproductive lifespan, routine screening and assessment for the presence of common psychiatric disorders are critical for accurate diagnosis and provision of effective treatment. Management options include referral or consultation with a primary care provider or psychiatrist; treatment options for premenstrual dysphoric disorder and perimenopausal depression include pharmacotherapy with antidepressant agents and/or psychotherapy. Hormones may be helpful.

Maternal activity restriction and the prevention of preterm birth

Anthony C. Sciscione — 2009-09-23

Activity restriction is 1 of the most common interventions used in obstetrics. Although it is used for many reasons, 1 of the most common is to prevent preterm birth in those at risk. This review of the literature describes the potential advantages, disadvantages, and efficacy of activity restriction for the prevention of preterm birth.

Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery

2009-12-21

Objective: We sought to describe relationships of clinically relevant nerves and vessels of the anterior abdominal wall.Study Design: The ilioinguinal and iliohypogastric nerves and inferior epigastric vessels were dissected in 11 unembalmed female cadavers. Distances from surface landmarks and common incision sites were recorded. Additional surface measurements were taken in 7 other specimens with and without insufflation.Results: The ilioinguinal nerve emerged through the internal oblique: mean (range), 2.5 (1.1–5.1) cm medial and 2.4 (0–5.3) cm inferior to the anterior superior iliac spine (ASIS). The iliohypogastric emerged 2.5 (0–4.6) cm medial and 2.0 (0–4.6) cm inferior. Inferior epigastric vessels were 3.7 (2.6–5.5) cm from midline at the level of the ASIS and always lateral to the rectus muscles at a level 2 cm superior to the pubic symphysis.Conclusion: Risk of anterior abdominal wall nerve and vessel injury is minimized when lateral trocars are placed superior to the ASISs and >6 cm from midline and low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles.

Electronic prescribing influence on calcium supplementation: a randomized controlled trial

D. Ashley Hill, Michael Cacciatore, Georgine M. Lamvu — 2009-12-31

Objective: The purpose of this study was to determine whether an electronic prescription for over-the-counter calcium supplements increases compliance.Study Design: Two hundred forty-five patients from 19-50 years of age who underwent annual gynecologic examinations were assigned randomly to either verbal counseling about the use of a calcium carbonate with vitamin D supplement (n = 122) or verbal counseling and an electronic prescription (n = 123). Telephone interviews at 3 and 6 months determined compliance.Results: Women who received the electronic prescription were significantly more likely to use calcium supplementation than control subjects at both 3 and 6 months. At 3 months, 66.0% of women who received an electronic prescription reported compliance (P = .001). At 6 months, 57.0% of the participants were compliant (P = .001). At 6 months, women who were given the electronic prescription were 2.2 times more likely to report having taken the calcium than were control subjects (95% confidence interval, 1.5–3.1).Conclusion: An electronic prescription for over-the-counter calcium supplements is associated with a significant increase in compliance, compared with verbal counseling alone.

An international trial of antioxidants in the prevention of preeclampsia (INTAPP)

2010-03-01

Objective: We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women.Study Design: In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions.Results: Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78–1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes.Conclusion: Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.

Agricultural-related chemical exposures, season of conception, and risk of gastroschisis in Washington State

Sarah A. Waller, Kathleen Paul, Suzanne E. Peterson, Jane E. Hitti — 2010-03-01

Objective: We sought to determine if periconceptional exposure to agrichemicals was associated with the development of gastroschisis.Study Design: We conducted a retrospective, case-controlled study using Washington State Birth Certificate and US Geological Survey databases. Cases included all live-born singleton infants with gastroschisis. Distance between a woman's residence and site of elevated exposure to agrichemicals was calculated. Multivariate regression was used to estimate the association between surface water concentrations of agrichemicals and the risk of gastroschisis.Results: Eight hundred five cases and 3616 control subjects were identified. Gastroschisis occurred more frequently among those who resided <25 km from a site of high atrazine concentration (odds ratio, 1.6). Risk was related inversely to the distance between the maternal residence and the closest toxic atrazine site. In multivariate analysis, nulliparity, tobacco use, and spring conception remained significant predictive factors for gastroschisis.Conclusion: Maternal exposure to surface water atrazine is associated with fetal gastroschisis, particularly in spring conceptions.

A statewide initiative to reduce inappropriate scheduled births at 360/7–386/7 weeks' gestation

The Ohio Perinatal Quality Collaborative Writing Committee — 2010-03-01

Objective: We sought to reduce scheduled births between 360/7-386/7 weeks that lack appropriate medical indication.Study Design: Twenty Ohio maternity hospitals collected baseline data for 60 days and then selected locally appropriate Institute for Healthcare Improvement Breakthrough Series interventions to reduce the incidence of scheduled births. Deidentified birth data were analyzed centrally. Rates of scheduled births without a documented indication, birth certificate data, and implementation issues were shared regularly among sites.Results: The rate of scheduled births between 360/7-386/7 weeks without a documented medical indication declined from 25% to <5% (P < .05) in participating hospitals. Birth certificate data showed inductions without an indication declined from a mean of 13% to 8% (P < .0027). Dating criteria were documented in 99% of charts.Conclusion: A statewide quality collaborative was associated with fewer scheduled births lacking a documented medical indication.

Maternal and neonatal outcomes by labor onset type and gestational age

2010-03-01

Objective: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age.Study Design: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age.Results: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28–0.53), sepsis (OR, 0.36; 95% CI, 0.26–0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48–0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08–9.54) with elective induction, 1.16 (95% CI, 0.24–5.58) with indicated induction, and 6.57 (95% CI, 1.78–24.30) with cesarean without labor compared to spontaneous labor.Conclusion: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry

2010-03-01

Objective: We sought to evaluate number and timing of elective cesarean sections at term and to assess perinatal outcome associated with this timing.Study Design: We conducted a recent retrospective cohort study including all elective cesarean sections of singleton pregnancies at term (n = 20,973) with neonatal follow-up. Primary outcome was defined as a composite of neonatal mortality and morbidity.Results: More than half of the neonates were born at <39 weeks of gestation, and they were at significantly higher risk for the composite primary outcome than neonates born thereafter. The absolute risks were 20.6% and 12.5% for birth at <38 and 39 weeks, respectively, as compared to 9.5% for neonates born ≥39 weeks. The corresponding adjusted odds ratios (95% confidence interval) were 2.4 (2.1–2.8) and 1.4 (1.2–1.5), respectively.Conclusion: More than 50% of the elective cesarean sections are applied at <39 weeks, thus jeopardizing neonatal outcome.

The cost-effectiveness of prenatal screening for spinal muscular atrophy

2010-03-01

Objective: We sought to investigate the cost-effectiveness of prenatal screening for spinal muscular atrophy (SMA).Study Design: A decision analytic model was created to compare a policy of universal SMA screening to that of no screening. The primary outcome was incremental cost per maternal quality-adjusted life year. Probabilities, costs, and outcomes were estimated through literature review. Univariate and multivariate sensitivity analyses were performed to test the robustness of our model to changes in baseline assumptions.Results: Universal screening for SMA is not cost-effective at $4.9 million per quality-adjusted life year. In all, 12,500 women need to be screened to prevent 1 case of SMA, at a cost of $5.0 million per case averted. Our results were most sensitive to the baseline prevalence of disease.Conclusion: Universal prenatal screening for SMA is not cost-effective. For populations at high risk, such as those with a family history, SMA testing may be a cost-effective strategy.

Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: preeclampsia

2010-03-01

Objective: The purpose of this study was to examine associations of fasting C-peptide, body mass index (BMI), and maternal glucose with the risk of preeclampsia in a multicenter multinational study.Study Design: We conducted a secondary analysis of a blinded observational cohort study. Subjects underwent a 75-g oral glucose tolerance test at 24-32 weeks' gestation. Associations of preeclampsia with fasting C-peptide, BMI, and maternal glucose were assessed with the use of multiple logistic regression analyses and adjustment for potential confounders.Results: Of 21,364 women who were included in the analyses, 5.2% had preeclampsia. Adjusted odds ratios for preeclampsia for 1 SD higher fasting C-peptide (0.87 ug/L), BMI (5.1 kg/m2), and fasting (6.9 mg/dL), 1-hour (30.9 mg/dL), and 2-hour plasma glucose (23.5 mg/dL) were 1.28 (95% confidence interval [CI], 1.20–1.36), 1.60 (95% CI, 1.60–1.71), 1.08 (95% CI, 1.00–1.16), 1.19 (95% CI, 1.11–1.28), and 1.21 (95% CI,1.13–1.30), respectively.Conclusion: Results indicate strong, independent associations of fasting C-peptide and BMI with preeclampsia. Maternal glucose levels (below diabetes mellitus) had weaker associations with preeclampsia, particularly after adjustment for fasting C-peptide and BMI.

Graded classification of fetal heart rate tracings: association with neonatal metabolic acidosis and neurologic morbidity

Colm Elliott, Philip A. Warrick, Ernest Graham, Emily F. Hamilton — 2009-08-31

Objective: The objective of the study was to measure the performance of a 5-tier, color-coded graded classification of electronic fetal monitoring (EFM).Study Design: We used specialized software to analyze and categorize 7416 hours of EFM from term pregnancies. We measured how often and for how long each of the color-coded levels appeared in 3 groups of babies: (A) 60 babies with neonatal encephalopathy (NE) and umbilical artery base deficit (BD) levels were greater than 12 mmol/L; (I) 280 babies without NE but with BD greater than 12 mmol/L; and (N) 2132 babies with normal gases.Results: The frequency and duration of EFM abnormalities considered more severe in the classification method were highest in group A and lowest in group N. Detecting an equivalent percentage of cases with adverse outcomes required only minutes spent with marked EFM abnormalities compared with much longer periods with lesser abnormalities.Conclusion: Both degree and duration of tracing abnormality are related to outcome. We present empirical data quantifying that relationship in a systematic fashion.

Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy

Judette M. Louis, Dennis Auckley, Robert J. Sokol, Brian M. Mercer — 2009-12-14

Objective: The objective of the study was to estimate the maternal and neonatal morbidities associated with obstructive sleep apnea (OSA) in pregnancy.Study Design: Women delivering between 2000–2008 with confirmed OSA in an academic center were included. Normal-weight and obese controls were randomly selected at a 2:1 ratio. Maternal and neonatal morbidities were compared between the groups. Multivariate analyses were performed to evaluate maternal morbidity and preterm birth (PTB).Results: The analysis included 57 pregnancies complicated by OSA. Compared with normal-weight (n = 114) controls, OSA patients had more preeclampsia (PET) (19.3% vs 7.0%; P = .02) and PTB (29.8% vs 12.3%; P = .007). Controlling for comorbid conditions, OSA was associated with an increased risk of PTB (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.02–6.6), mostly secondary to PET (63%). Cesarean delivery (OR, 8.1; 95% CI, 2.9–22.1) and OSA were associated with maternal morbidity (OR, 4.6; 95% CI, 1.5–13.7).Conclusion: Pregnancies complicated by OSA are at increased risk for preeclampsia, medical complications, and indicated PTB.

The effect of maternal body mass index on neonatal outcome in women receiving a single course of antenatal corticosteroids

2009-12-21

Objective: The aim of this study was to determine the effect of maternal body mass index on the incidence of neonatal prematurity morbidities in those who receive corticosteroids.Study Design: This was a secondary analysis of a trial of corticosteroids in women at risk for preterm birth. Women receiving a single course of corticosteroids were classified by their prepregnancy body mass index (<25 and ≥25) and compared on a composite outcome comprised of several neonatal morbidities and on each individual outcome.Results: Of 183 eligible women, 96 (52.5%) had a body mass index of <25 and 87 (47.5%) had a body mass index of ≥25. The composite outcome occurred more frequently in the body mass index of ≥25 group (28.7%), compared with those with a body mass index of <25 (18.8%), although this was not statistically significant (odds ratio, 1.75; 95% confidence interval, 0.83–3.72). Body mass index was not associated with outcomes after adjusting for confounding.Conclusion: Maternal body mass index did not affect neonatal prematurity morbidities in those receiving corticosteroids.

Effects of recommended levels of physical activity on pregnancy outcomes

2009-12-21

Objective: We sought to examine the relation between recommended levels of physical activity during pregnancy and pregnancy outcomes.Study Design: We conducted an observational study with energy expenditure, aerobic fitness, and sleeping heart rate measured in 44 healthy women in late pregnancy. Medical records were examined for pregnancy outcome.Results: Active women, who engaged in ≥30 minutes of moderate physical activity per day, had significantly better fitness and lower sleeping heart rate compared to the inactive. Duration of second stage of labor was 88 and 146 minutes in the active vs inactive women, respectively (P = .05). Crude odds ratio of operative delivery in the inactive vs the active was 3.7 (95% confidence interval, 0.87–16.08). Birthweight, maternal weight gain, and parity adjusted odds ratio was 7.6 (95% confidence interval, 1.23–45.8). Neonatal condition and other obstetric outcomes were similar between groups.Conclusion: Active women have better aerobic fitness as compared to inactive women. The risk for operative delivery is lower in active women compared to inactive, when controlled for birthweight, maternal weight gain, and parity. Further studies with larger sample size are required to confirm the association between physical activity and pregnancy outcomes.

Spontaneous labor onset: is it immunologically mediated?

Robert J. Biggar, Gry Poulsen, Mads Melbye, Jennifer Ng, Heather A. Boyd — 2010-01-04

Objective: The investigators tested the hypothesis that maternal-fetal immune interactions could be important in initiating spontaneous labor onset by examining if labor was delayed when fetuses share maternal HLA antigen types.Study Design: HLA antigen types A, B, and DR in 200 Danish mother-infant pairs delivering in 42–44 weeks (postterm) were compared with 195 mother-infant pairs delivering in 37–40 weeks (term).Results: Sharing of HLA A and B antigens was more common than expected in postterm deliveries. Odds ratios were 1.54 (95% confidence interval [CI], 1.01–2.35) and 1.75 (95% CI, 0.87–3.52), respectively (risk per shared antigen: 1.40 [95% CI, 1.04–1.90] per unit increase). Adding stringent birth-length criteria for postmaturity (92 cases; 168 controls) strengthened risks associated with antigen sharing to 1.57 (95% CI, 0.90–2.74) and 2.60 (95% CI, 1.15–5.88), respectively (risk per shared antigen: 1.60 (95% CI, 1.10–2.32).Conclusion: Postterm-delivered infants had more HLA A and B antigens in common with their mothers, suggesting that recognition of HLA antigen differences by adaptive immunity may have a role in triggering labor onset.

Clinical differences between early-onset HELLP syndrome and early-onset preeclampsia during pregnancy and at least 6 months postpartum

2009-12-21

Objective: We sought to evaluate whether clinical and laboratory variables differ between former patients who had HELLP syndrome and former patients who had preeclampsia (PE) without HELLP.Study Design: We compared early-onset HELLP (n = 75) with early-onset PE (n = 40) with respect to clinical features during the hypertensive complication and to metabolic, hemodynamic, and hemostatic variables determined at least 6 months postpartum.Results: HELLP differed from PE by a borderline higher frequency of eclampsia (13% vs 3%) during the complication, and by a lower prevalence of hypertension (19% vs 33%), proteinuria (2% vs 23%), thrombophilia (6% vs 27%), obesity (9% vs 33%), hypertriglyceridemia (1% vs 15%), hyperglycemia (0% vs 11%), and elevated levels of fasting homocysteine (6% vs 21%) at least 6 months postpartum.Conclusion: Women with HELLP had fewer signs of abnormalities consistent with the metabolic syndrome and a 4-fold lower prevalence of thrombophilia as compared with PE women without HELLP.

Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system

2010-01-04

Objective: We sought to examine the difference in use of labor epidural analgesia among women from different neighborhood socioeconomic groups.Study Design: Neighborhood socioeconomic variables from the 2001 Canadian Census were linked to singleton vaginal births from the Niday perinatal database (2004–2006) in Ontario, Canada. Births were divided into income and education groups by quintiles. Generalized estimating equations were employed to evaluate the association between labor epidural and neighborhood socioeconomic status. Supplementary analysis was conducted after stratifying data by hospital types.Results: Compared with those from the richest neighborhood, women from the poorest quintile were the least likely to receive labor epidural analgesia (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.58–0.61). The differences were smallest in teaching hospitals (OR, 0.73; 95% CI, 0.67–0.79) and largest in small community hospitals (OR, 0.57; 95% CI, 0.50–0.64). Similar association was found in neighborhood education quintiles.Conclusion: The use of labor epidural analgesia is decreased with decreasing neighborhood economic and education levels.

The effect of a chlorhexidine-based surgical lubricant during pelvic examination on the detection of group B Streptococcus

Ora I. Schwope, Katherine T. Chen, Isha Mehta, Margaret Re, Larry Rand — 2009-12-21

Objective: The objective of the study was to estimate whether surgical lubricant used during pelvic examination alters the detection of group B Streptococcus (GBS).Study Design: We conducted a prospective cohort study of patients undergoing GBS screening at the prenatal clinics of a New York City public hospital. Two specimens were collected from each patient, before and after a pelvic examination with Surgilube (Fougera and Co, Melville, NY), a bacteriostatic surgical lubricant. Test performance indices using GBS status pre-pelvic examination as the reference were calculated.Results: Over 10 months, 168 patients were enrolled in the study. Twenty of 168 patients (11.9%; 95% confidence interval, 7.4–17.8%) tested GBS positive before the pelvic examination. Of the initial 20 GBS-positive patients, 10 tested GBS positive after the pelvic examination with surgical lubricant. The sensitivity of detecting GBS after the examination with surgical lubricant was 50%.Conclusion: Because pelvic examination with surgical lubricant may decrease the detection of GBS, obstetric practitioners should collect GBS screening cultures before the use of surgical lubricant.

Endometrial sampling diagnosis of FIGO grade 1 endometrial adenocarcinoma with a background of complex atypical hyperplasia and final hysterectomy pathology

2009-12-21

Objective: The purpose of this study was to determine posthysterectomy pathologic findings in patients with a preoperative endometrial sampling diagnosis of International Federation of Gynecology and Obstetrics (FIGO) grade 1 endometrial adenocarcinoma with a background of complex atypical hyperplasia (CAH).Study Design: We reviewed 1423 consecutive cases of endometrial cancer to identify cases with a preoperative endometrial biopsy that demonstrated FIGO grade 1 endometrial adenocarcinoma. Final uterine pathologic findings were grouped into low- and high-risk based on FIGO and Gynecologic Oncology Group criteria.Results: We identified 123 cases with a background of CAH and 367 cases without a background of CAH. FIGO grade in the hysterectomy specimen was more than FIGO grade 1 in 11 of 123 cases (8.9%) with a background of CAH, compared with 60 of 359 cases (16.7%) without a background of CAH (P = .04).Conclusion: An endometrial sampling diagnosis of FIGO grade 1 endometrial adenocarcinoma with a background of CAH is more likely to correlate with final posthysterectomy grade than a diagnosis not arising with a background of CAH.

Aberrant DNA methylation of apoptotic signaling genes in patients responsive and nonresponsive to therapy for cervical carcinoma

2010-02-01

Objective: We sought to investigate CpG-island methylation profiling of apoptotic genes apoptotic protease activating factor 1, caspase 8, death-associated protein kinase (DAPK), tumor necrosis factor receptor superfamily member 6 (FAS), Survivin, and tumor necrosis factor-related apoptosis-inducing ligand receptor-1 and its role in resistance to therapy in cervical cancer (CXCA).Study Design: Methylation status was performed in 85 CXCA patients comprising therapeutic nonresponses and responses using methylation-specific polymerase chain reaction.Results: Methylation frequency of DAPK and FAS showed a statistically significant difference between therapeutic nonresponses and responses. Concurrent methylation of multiple apoptotic genes was a preferential event in CXCA. Moreover, concerted methylation of pair genes was observed in DAPK, FAS, and tumor necrosis factor-related apoptosis-inducing ligand receptor-1 and found only in nonresponses.Conclusion: Aberrant methylation of apoptotic signaling genes results in acquired resistance to therapy. Detection of methylation in apoptotic signaling genes is potentially useful as a molecular predictive marker for strategic planning of treatment efficacy and evaluation of therapeutic outcome in CXCA, leading to an improvement of patients' survival.

Smoking behavior in women with locally advanced cervical carcinoma: a Gynecologic Oncology Group study

Steven E. Waggoner, Kathleen M. Darcy, Chunqiao Tian, Rachelle Lanciano — 2009-12-31

Objective: The purpose of this study was to assess cigarette use and environmental smoke exposure in women with cervical cancer.Study Design: Smoking behavior was recorded prospectively in a clinical trial of women with locally advanced cervical carcinoma.Results: Of 315 participants, 133 women (42%) were current smokers; 72 women (23%) were former smokers, and 110 women (35%) were never smokers. Current smokers began smoking earlier (16 vs 18 years; P = .009), for more years (29 vs 24 years; P = .005), and in greater amounts (20 vs 11 cigarettes/d; P < .001) than former smokers. Active smokers lived more often with another smoker (63.3%), compared with former smokers (35.0%; P < .001) or never-smokers (28.7%; P < .001). Agreement between self-report and urine cotinine level was high (kappa = 0.872; P < .001). A significant decrease in cotinine level during treatment occurred in 5.2% of current smokers.Conclusion: Prevalence of smoking and tobacco consumption was twice that of the North American female population. Few smokers quit or decreased consumption during treatment.

Pelvic pain and surgeries in women before interstitial cystitis/painful bladder syndrome

2009-12-21

Objective: The objective of the study was to compare subjects with interstitial cystitis/painful bladder syndrome (IC/PBS) with controls on prior surgeries.Study Design: IC/PBS subjects were compared with matched controls on surgeries and possible surgical indications prior to their index dates.Results: Adjusted for demographic variables, logistic regression showed subjects exceeded controls in surgeries longer than 12 months and less than 1 month before the index date. However, addition of possible surgical indications showed chronic pelvic pain (CPP) to have a strong association with IC/PBS, whereas associations with surgeries were reduced to nonsignificance.Conclusion: Although women with IC/PBS were more likely to have experienced prior surgeries than controls, the apparent indications for surgeries, not the surgeries themselves, were stronger risk factors for IC/PBS. In particular, a prior history of CPP had a strong association with IC/PBS. Several features of study design, including extensive medical record review, suggest that prior CPP was not undiagnosed IC/PBS. Further investigation of CPP may yield insight into the pathogenesis of IC/PBS.

Green tea extract inhibits proliferation of uterine leiomyoma cells in vitro and in nude mice

2010-01-14

Objective: The purpose of this study was to investigate the effect of epigallocatechin gallate (EGCG) on rat leiomyoma (ELT3) cells in vitro and in a nude mice model.Study Design: ELT3 cells were treated with various concentrations of EGCG. Cell proliferation, proliferation cell nuclear antigen (PCNA), and cyclin-dependent kinase 4 (Cdk4) protein levels were evaluated. ELT3 cells were inoculated subcutaneously in female athymic nude mice. Animals were fed 1.25 mg EGCG (in drinking water)/mouse/day. Tumors were collected and evaluated at 4 and 8 weeks after the treatment.Results: Inhibitory effect of EGCG (200 μmol/L) on ELT3 cells was observed after 24 hours of treatment (P < .05). At ≥50 μmol/L, EGCG significantly decreased PCNA and Cdk4 protein levels (P < .05). In vivo, EGCG treatment dramatically reduced the volume and weight of tumors at 4 and 8 weeks after the treatment (P < .05). The PCNA and Cdk4 protein levels were significantly reduced in the EGCG-treated group (P < .05).Conclusion: EGCG effectively inhibits proliferation and induces apoptosis in rat ELT3 uterine leiomyoma cells in vitro and in vivo.

Magnesium sulfate reduces inflammation-associated brain injury in fetal mice

Irina Burd, Kelsey Breen, Alexander Friedman, Jinghua Chai, Michal A. Elovitz — 2010-03-01

Objective: The purpose of this study was to investigate whether magnesium sulfate (MgSO4) prevents fetal brain injury in inflammation-associated preterm birth (PTB).Study Design: Using a mouse model of PTB, lipopolysaccharide (LPS) or normal saline solution (NS)–exposed mice were randomized to intraperitoneal treatment with MgSO4 or NS by intrauterine injection. From the 4 treatment groups (NS + NS; LPS + NS; LPS + MgSO4; and NS + MgSO4), fetal brains were collected for quantitative polymerase chain reaction studies and primary neuronal cultures. Messenger RNA expression of cytokines, cell death, and markers of neuronal and glial differentiation were assessed. Immunocytochemistry and confocal microscopy were performed.Results: There was no difference between the LPS + NS and LPS + MgSO4 groups in the expression of proinflammatory cytokines, cell death markers, and markers of prooligodendrocyte and astrocyte development (P > .05 for all). Neuronal cultures from the LPS + NS group demonstrated morphologic changes; this neuronal injury was prevented by MgSO4 (P < .001).Conclusion: Amelioration of neuronal injury in inflammation-associated PTB may be a key mechanism by which MgSO4 prevents cerebral palsy.

Turning placenta into brain: placental mesenchymal stem cells differentiate into neurons and oligodendrocytes

2010-01-08

Objective: We aimed to induce neural stem (NSC) and progenitor cells (NPC) from human placental tissues.Study Design: Placental stem cells from first-trimester placental chorionic villi and term chorion were isolated. Neural differentiation was initiated with plating on collagen, retinoic acid, and/or human brain-derived neurotrophic factor and epidermal and fibroblast growth factor. Differentiation into neurons, oligodendrocytes, and astrocytes was monitored by immunohistochemistry. Two-dimensional polyacrylamide gel electrophoresis, high-performance liquid chromatography, and tandem mass spectrometry were used to identify proteins involved in the differentiation.Results: Differentiated cells were mostly immediately postmitotic with some more but not fully mature postmitotic neurons. Neurons had dopaminergic or serotonergic character. Some cells differentiated into predominantly immature oligodendrocytes. Upon differentiation, neuron-specific proteins were up-regulated, whereas placental proteins were reduced.Conclusion: Stem cells derived from human placenta can be differentiated into neural progenitors.

Human cytomegalovirus reinfection is associated with intrauterine transmission in a highly cytomegalovirus-immune maternal population

2010-01-08

Objective: To determine contribution of reinfection with new strains of cytomegalovirus in cytomegalovirus seromimmune women to incidence of congenital cytomegalovirus infection.Study Design: In 7848 women studied prospectively for congenital cytomegalovirus infection from a population with near universal cytomegalovirus seroimmunity, sera from 40 mothers of congenitally infected infants and 109 mothers of uninfected newborns were analyzed for strain-specific anticytomegalovirus antibodies.Results: All women were cytomegalovirus seroimmune at first prenatal visit. Reactivity for 2 cytomegalovirus strains was found in 14 of 40 study mothers and in 17 of 109 control mothers at first prenatal visit (P = .009). Seven of 40 (17.5%) study women and 5 of 109 (4.6%) controls (P = .002) acquired antibodies reactive with new cytomegalovirus strains during pregnancy. Evidence of infection with more than 1 strain of cytomegalovirus before or during current pregnancy occurred in 21 of 40 study mothers and 22 of 109 controls (P < .0001).Conclusion: Maternal reinfection by new strains of cytomegalovirus is a major source of congenital infection in this population.

Early-pregnancy soluble Fas levels in idiopathic small-for-gestational-age pregnancies

2010-03-01

Objective: We sought to determine first- and second-trimester serum soluble Fas (sFas) and placental growth factor (PlGF) levels in idiopathic small-for-gestational-age (SGA) pregnancies.Study Design: We measured sFas and PlGF levels in women who delivered SGA infants uncomplicated by preeclampsia and in control subjects. For sFas there were 34 cases and 318 control subjects in the first trimester and 9 cases and 11 control subjects in the second trimester. For PlGF there were 31 cases and 281 control subjects in the first trimester and 8 cases and 11 control subjects in the second trimester.Results: SGA pregnancies had lower sFas levels than control subjects in the second trimester (3703 ± 209 pg/mL vs 4562 ± 241 pg/mL; P = .015), but not in the first trimester (4892 ± 191 pg/mL vs 4971 ± 177 pg/mL; P = .68). There was no difference in PlGF levels between SGA and normal pregnancies in both trimesters.Conclusion: Serum sFas levels were lower in idiopathic SGA pregnancies in the second trimester, but not in the first. There was no difference in serum PlGF levels in either trimester.

The time in your life: use it wisely

Dennis J. Lutz — 2010-03-01

The privilege of serving a year as president of the Central Association of Obstetricians and Gynecologists is accompanied by the prerogative of selecting both the theme of the Annual Scientific Meeting and the topic for the presidential address. Topics traditionally have ranged from historical to scientific to futuristic to self-reflective. After nearly a quarter century as chair of an academic department of obstetrics and gynecology, I find myself more and more drawn to topics that are vitally important to successful career development but which formal education traditionally either neglects or omits entirely.

Extended antibiotic prophylaxis for prevention of surgical-site infections in morbidly obese women who undergo combined hysterectomy and medically indicated panniculectomy: a cohort study

2010-03-01

Objective: The purpose of this study was to compare surgical-site infection rates in obese women who had extended prophylactic antibiotic (EPA) vs standard prophylactic antibiotic.Study Design: An electronic records-linkage system identified 145 obese women (body mass index, >30 kg/m2) who underwent combined hysterectomy and panniculectomy from January 1, 2005, through December 31, 2008. The EPA cohort received standard antibiotics (cefazolin, 2 g) and continued oral antibiotic (ciprofloxacin) until removal of drains. Regression models were used to adjust for known confounders.Results: The mean age was 56.0 ± 12.1 years, and mean body mass index was 42.6 ± 8.4 kg/m2 (range, 30–86.4 kg/m2). The EPA cohort experienced fewer surgical-site infections (6 [5.9%] vs 12 [27.9%]; P < .001; adjusted odds ratio, 0.16; 95% confidence interval, 0.04–0.51; P < .001), had lower probability of incision and drainage (3 [2.9%] vs 5 [11.6%]; P = .05), and required fewer infection-related admissions (5 [4.9%] vs 6 [13.9%]; P = .08).Conclusion: Extended antibiotic prophylaxis can reduce surgical-site infections in obese women after combined hysterectomy and panniculectomy.

The association of innate immune response gene polymorphisms and puerperal group A streptococcal sepsis

Sarah M. Davis, Erin A.S. Clark, Lesa T. Nelson, Robert M. Silver — 2010-03-01

Objective: The objective of the study was to determine whether single-nucleotide polymorphisms (SNPs) that influence the maternal innate immune response are associated with puerperal group A streptococcal sepsis.Study Design: Subjects with confirmed puerperal group A streptococal infection were prospectively identified in 2 tertiary care hospitals over 18 years. Controls were racially matched subjects with term, uncomplicated deliveries. Thirty-eight polymorphisms associated with the innate immune response to bacterial infection were analyzed. Allele and genotype frequencies for subjects and controls were compared.Results: Forty-eight women with puerperal group A streptococcal infection were identified. DNA was obtained for 28 subjects and 54 controls. Allele frequencies were significantly different between subjects and controls for polymorphisms in Toll-like receptor (TLR) 9-1486 (P = .03) and heat shock protein (HSP) 70-2 1267 (P = .003). Genotype frequencies were significantly different between subjects and controls for TLR9-1486 (P = .025), HSP70-2 1267 (P = .02), and interleukin (IL)-1β-511 (P = .016).Conclusion: Puerperal group A streptococcal sepsis may be associated with innate immune response gene polymorphisms in TLR9, HSP70-2, and IL1β.

Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial

2010-03-01

Objective: The objective of the study was to determine whether vaginal preparation with povidone iodine before cesarean delivery decreased the risk of postoperative maternal morbidities.Study Design: The design of the study was a randomized, controlled trial in women undergoing cesarean delivery with subjects assigned to have a preoperative vaginal cleansing with povidone iodine or to a standard care group (no vaginal wash). The primary outcome was a composite of postoperative fever, endometritis, sepsis, readmission, wound infection, or complication.Results: There were 155 vaginal cleansing subjects and 145 control subjects. Overall, 9.0% developed the composite outcome, with fewer women in the cleansing group (6.5%) compared with the control group (11.7%), although the difference was not statistically significant (relative risk, 0.55; 95% confidence interval, 0.26–1.11; P = .11). Length of surgery, being in labor, and having a dilated cervix were all associated with the composite morbidity outcome.Conclusion: Vaginal cleansing with povidone iodine before cesarean delivery may decrease postoperative morbidities, although the reduction is not statistically significant.

Barriers to mental health treatment among obstetric patients at risk for depression

2010-03-01

Objective: The objective of the study was to examine mental health referrals outcomes among obstetric patients at risk for depression.Study Design: Fifty-one perinatal women who were offered mental health referrals were queried about their behaviors at 4 steps in the treatment engagement process and factors facilitating or impeding each step.Results: Although 59% of at-risk women accepted mental health referrals, only 27% ultimately engaged in treatment. Women who proactively sought help via a hotline were more likely to accept referrals (P < .001), contact a referred provider (P < .001), and engage in treatment (P < .05) than those who received unsolicited referrals after screening at-risk for depression. Barriers to successful treatment linkage were identified at the patient, provider, and system levels.Conclusion: Only a minority of women who are at risk for perinatal depression and receive mental health referrals ultimately engage in treatment. Successful linkage may be enhanced via interventions targeting identified barriers; such interventions require prospective evaluation.

Hysterectomy and perioperative morbidity in women who have undergone renal transplantation

Christine A. Heisler, Elizabeth R. Casiano, John B. Gebhart — 2010-03-01

Objective: The purpose of this study was to compare complications from vaginal hysterectomy with abdominal hysterectomy in renal transplant recipients.Study Design: Women who underwent renal transplantation then hysterectomy from 1966-2008 at Mayo Clinic, Rochester, MN, were identified. Data were collected about preoperative, intraoperative, and postoperative events. Main outcome measure was loss of allograft function; secondary outcomes included types of complications and treatment methods.Results: Of 58 women with renal transplants, 42 women (72.4%) underwent abdominal hysterectomy. The most common indication for hysterectomy was menorrhagia (n = 20; 34.5%). Overall, 24 women (41.4%) had complications, the most common of which were infection (n = 15) and transfusion (n = 8). Women who underwent abdominal hysterectomy were no more likely to have perioperative complications than were women who underwent vaginal hysterectomy (odds ratio, 1.25; 95% confidence interval, 0.38–4.08).Conclusion: Although patients with renal transplants had perioperative complications, none of these complications led to renal graft loss. Hysterectomy can be considered in these patients when accompanied by diligent postoperative care.

Fetal heart rate tracings and neonatal metabolic acidosis: Elliott et al

Alison G. Cahill, Anthony Shanks, Methodius Tuuli, Molly Stout, Kathleen O'Neill — 2010-03-01

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:Elliott C, Warrick PA, Graham E, et al. Graded classification of fetal heart rate tracings: association with neonatal metabolic acidosis and neurologic morbidity. Am J Obstet Gynecol 2010;202:258.e1-8.The full discussion appears at www.AJOG.org, pages e1-4.

Left behind: The patient's secondary infertility was traced to a previous pregnancy

Sunesh Kumar, Prerna Gupta, Murali Subbaiah — 2009-10-05

A 28-year-old woman had a 6-year history of secondary infertility. Her first pregnancy was a normal delivery at term 8 years earlier. This was followed by a second-trimester loss at 14 weeks of gestation that required surgical evacuation. The patient had regular menstrual cycles after the procedure.

Parametrial dissection during laparoscopic nerve-sparing radical hysterectomy: A new approach aims to improve patients' postoperative quality of life

2010-01-25

In recent years, nerve-sparing radical hysterectomy for cervical cancer has proven successful in reducing postoperative bladder, colorectal and sexual dysfunction. At our institution, we perform this procedure using a magnified laparoscopic view to better identify fibers and surgical landmarks; this improves dissection of the pars vasculosa from the pars nervosa of the parametrium.

Discussion: ‘Fetal heart rate tracings and neonatal metabolic acidosis’ by Elliott et al

Alison G. Cahill, Anthony Shanks, Methodius Tuuli, Molly Stout, Kathleen O'Neill — 2010-03-01

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:Elliott C, Warrick PA, Graham E, et al. Graded classification of fetal heart rate tracings: association with neonatal metabolic acidosis and neurologic morbidity. Am J Obstet Gynecol 2010;202:258.e1-8.

Rudimentary horn pregnancy with herniation into the main uterine cavity

Laura E. Fitzmaurice, Robert M. Ehsanipoor, Manuel Porto — 2010-03-01

We report a case of a rudimentary horn pregnancy with herniation of a fetal arm and umbilical cord into the main uterine cavity that presented as an incidental finding on a routine second-trimester ultrasound scan. We also review the literature that guides the diagnosis and management of these rare complicated pregnancies.

Vaginal evisceration after total laparoscopic radical hysterectomy in cervical cancer

Gun Oh Chong, Dae Gy Hong, Young Lae Cho, Il Soo Park, Yoon Soon Lee — 2010-01-28

A 50-year-old woman came to the emergency department with vaginal evisceration that occurred 7 months after a total laparoscopic radical hysterectomy. Vaginal evisceration was repaired by a laparoscopic-vaginal approach without a laparotomy. This is the first report of vaginal evisceration after a total laparoscopic radical hysterectomy.

What gestation cut-off should be used for magnesium sulfate treatment of women threatening to deliver preterm?

David B. Knight, Glenn J. Gardener — 2009-11-05

The recent Cochrane Review and similar metaanalysis by Conde-Agudelo and Romero establish a fetal neuroprotective role for antenatal magnesium sulfate (MgSO4) given to women at risk of preterm birth, with significant reductions in the risk of cerebral palsy (CP) and gross motor dysfunction. However, the upper gestational age that warrants treatment is not clear. CP is 20 times more common in babies born at <28 weeks' gestation (14.6% prevalence) than in those of 32-36 weeks (0.7% prevalence). Perinatal and neonatal factors are more prominent in the etiology of CP in less mature infants, suggesting that an intervention immediately predelivery is more likely to be effective the earlier the gestation. Thus the number needed to treat will increase significantly with advancing gestational age.

Reply

Roberto Romero, Agustin Conde-Agudelo — 2009-11-05

We thank Drs Knight and Gardener for their interest in our study and are pleased to respond to their comments. Overall, antenatal magnesium sulfate was associated with a statistically significant reduction in the risk of cerebral palsy for all 6 studies that recruited women at <34 weeks of gestation (relative risk [RR], 0.69; 95% confidence interval [CI], 0.55–0.88; 5357 infants). In addition, in a planned subgroup analysis designed to examine the effect of magnesium sulfate according to gestational age at which treatment was given, we found a reduction in the risk of cerebral palsy for the 3 studies that recruited women at <33 weeks of gestation (RR, 0.69; 95% CI, 0.54–0.88; 4374 infants) and for the 2 studies that recruited women at <32 weeks of gestation (RR, 0.69; 95% CI, 0.52–0.91; 3686 infants). The reduction in the risk of cerebral palsy was not statistically significant for the 2 studies that reported results for infants of mothers recruited at <30 weeks of gestation (RR, 0.86; 95% CI, 0.56–1.31; 1537 infants).

The role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium

Arthur McCausland, Vance McCausland — 2009-10-15

Dr Goldstein's review article on the role of transvaginal (TV) ultrasound (U/S) or endometrial biopsy in the evaluation of the menopausal endometrium is extremely important from a practical standpoint. He mentioned that one of the limitations of TV U/S was previous uterine surgery. In this context, the increasingly popular total or global endometrial ablation (GEA) to treat menorrhagia must be discussed since >400,000 GEAs are being performed annually in the United States. It is now evident that after a GEA, significant intrauterine scarring and contracture occur. There is concern that bleeding from persistent or regenerating endometrium behind this scarring could be obstructed and delay the diagnosis of endometrial cancer. Since cases of asymptomatic postablation endometrial cancers have already been reported, periodic postmenopausal TV U/S has been recommended to rule out obstructed endometrial growth. Unfortunately, if an abnormal endometrial echo complex (EEC) is found, it is difficult to evaluate for multiple reasons. It has not been determined what an abnormal EEC is after a patient has had an ablation. Sonographic artifact from the scar tissue may result in variations in U/S interpretation. It is not known if an endometrial thickness measuring <4 mm is also considered normal in patients who have had an ablation. Further, if an abnormal EEC is discovered, postablation scarring makes thorough evaluation of the intrauterine cavity difficult to impossible. Saline infusion sonograms, endometrial biopsies, and diagnostic hysteroscopy are also unreliable after an ablation. U/S-guided operative hysteroscopy is often necessary but dense intrauterine scarring can distort the intrauterine cavity making it difficult to access all endometrial tissue. Even if endometrial tissue is obtained, it is difficult to ascertain if the sample is complete. Often, a hysterectomy is necessary just to resolve this problem. This is becoming a major issue and we would like Dr Goldstein to suggest any solutions that will help resolve this dilemma.

Reply

Steven R. Goldstein — 2009-11-05

I so fully appreciate the interest and the input of Drs McCausland in their letter regarding “The role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium.” They must have been a “fly on the wall” during the past several years when I have spoken on this topic as an invited faculty member at various postgraduate courses. Invariably the question arises as to what to do about the patient who has undergone a previous global endometrial ablation (GEA), who now experiences postmenopausal bleeding. My answer virtually always expresses the concerns that they have expressed so nicely in their letter. Virtually all modalities that have been used in the past or can be used in such patients will often be compromised and suboptimal, including transvaginal ultrasound, sonohysterography, blind biopsy, or office or operative hysteroscopy. The best solution I can offer is better patient selection for GEA. Simply not wanting to be inconvenienced by periodic bleeding should not be an indication for GEA. Patients with known risk factors for endometrial hyperplasia or malignancy (obesity, diabetes, hypertension, nulliparity) should be offered GEA only when their symptoms are significant enough to offset potential risks. Beyond optimizing patient selection, unfortunately, at the current time I have very little to offer Drs McCausland in the way of solutions for this problem, which certainly is on the rise in clinical practice.

Risk of shoulder dystocia in second delivery: does a history of shoulder dystocia matter?

Shobha H. Mehta, Robert J. Sokol — 2009-11-05

We would like to bring to your readers' attention an issue with pregnancy management with history of shoulder dystocia (SD), as recommended by Overland et al in the Journal's May issue. In a large sample of vaginal deliveries during a 38-year period in Norway, the absolute risk of SD recurrence was 7.3%. They find that the most important risk factor for SD recurrence is very high birthweight (BW) and recommend planned cesarean for women with previous SD and estimated fetal weight (EFW) >4500g. This is based on recurrence rates of 19.9% (BW, 4500–5000 g) and 29.2% (BW, >5000 g).

Reply

Eva A. Overland, Anne Eskild — 2009-11-05

Shobha H. Mehta and Robert J. Sokol question our recommendations on mode of delivery in women with a history of shoulder dystocia. Our aim was to estimate the absolute and relative risk of shoulder dystocia recurrence. We had the opportunity to study this in a population with almost complete follow-up and a relatively low cesarean section rate. In populations with high cesarean section rate, and differential mode of delivery according to history of shoulder dystocia, the recurrence rate estimates are likely to be biased. In the Western world today, the level of obstetrical interventions is high and true recurrence risk estimates of any delivery complication are difficult to obtain.

The natural history of cervical and vulvar intraepithelial neoplasia

Ronald W. Jones — 2009-12-14

Lanneau et al commented that “despite the prevalence of HPV in younger patients with vulvar dysplasia, the likelihood of progression to vulvar carcinoma appears lower than the likelihood of cervical dysplasia progressing to cervical cancer. …”

Counseling and screening for chromosomal abnormalities

Kenneth R. Kahn, Glenna C.L. Bett — 2009-12-14

The recent article by Fang et al comparing Down syndrome screening in 2001 and 2007 reported a substantial increase in the number of women who screen positive for Down syndrome but declined invasive diagnostic genetic tests. In 2001, an estimated 46% of women who screened positive declined invasive diagnostic testing. In 2007, this number increased significantly to 66%. Even with the low false-positive rates reported for the quad screen, more than 90% of women who screen positive will not actually have a child with Down syndrome.

Reply

Yu Ming Victor Fang, James F.X. Egan, Peter Benn — 2009-12-14

We thank Drs Khan and Bett for their interest in our work. Improvements in Down syndrome screening between 2001 and 2007 are probably the major factor that accounts for the reduced use of invasive testing. These improvements include wider use of first trimester combined screening, changes from triple to quadruple serum markers in the second trimester, greater use of second-trimester ultrasound to modify risks, and use of other sequential strategies.

American Journal of Obstetrics & Gynecology

Table of contents

Information for Readers

Latest research from the 2010 meeting of the Society for Maternal-Fetal Medicine

Elective delivery before 39 weeks: reason for caution

What is the value for money of prenatal carrier screening for spina muscular atrophy? Too soon to say

Health disparities: definitions and measurements

Disparities in family planning

Menstrual cycle-related exacerbation of disease

Maternal activity restriction and the prevention of preterm birth

Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery

Electronic prescribing influence on calcium supplementation: a randomized controlled trial

An international trial of antioxidants in the prevention of preeclampsia (INTAPP)

Agricultural-related chemical exposures, season of conception, and risk of gastroschisis in Washington State

A statewide initiative to reduce inappropriate scheduled births at 360/7–386/7 weeks' gestation

Maternal and neonatal outcomes by labor onset type and gestational age

Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry

The cost-effectiveness of prenatal screening for spinal muscular atrophy

Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: preeclampsia

Graded classification of fetal heart rate tracings: association with neonatal metabolic acidosis and neurologic morbidity

Maternal and neonatal morbidities associated with obstructive sleep apnea complicating pregnancy

The effect of maternal body mass index on neonatal outcome in women receiving a single course of antenatal corticosteroids

Effects of recommended levels of physical activity on pregnancy outcomes

Spontaneous labor onset: is it immunologically mediated?

Clinical differences between early-onset HELLP syndrome and early-onset preeclampsia during pregnancy and at least 6 months postpartum

Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system

The effect of a chlorhexidine-based surgical lubricant during pelvic examination on the detection of group B Streptococcus

Endometrial sampling diagnosis of FIGO grade 1 endometrial adenocarcinoma with a background of complex atypical hyperplasia and final hysterectomy pathology

Aberrant DNA methylation of apoptotic signaling genes in patients responsive and nonresponsive to therapy for cervical carcinoma

Smoking behavior in women with locally advanced cervical carcinoma: a Gynecologic Oncology Group study

Pelvic pain and surgeries in women before interstitial cystitis/painful bladder syndrome

Green tea extract inhibits proliferation of uterine leiomyoma cells in vitro and in nude mice

Magnesium sulfate reduces inflammation-associated brain injury in fetal mice

Turning placenta into brain: placental mesenchymal stem cells differentiate into neurons and oligodendrocytes

Human cytomegalovirus reinfection is associated with intrauterine transmission in a highly cytomegalovirus-immune maternal population

Early-pregnancy soluble Fas levels in idiopathic small-for-gestational-age pregnancies

The time in your life: use it wisely

Extended antibiotic prophylaxis for prevention of surgical-site infections in morbidly obese women who undergo combined hysterectomy and medically indicated panniculectomy: a cohort study

The association of innate immune response gene polymorphisms and puerperal group A streptococcal sepsis

Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial

Barriers to mental health treatment among obstetric patients at risk for depression

Hysterectomy and perioperative morbidity in women who have undergone renal transplantation

Fetal heart rate tracings and neonatal metabolic acidosis: Elliott et al

Left behind: The patient's secondary infertility was traced to a previous pregnancy

Parametrial dissection during laparoscopic nerve-sparing radical hysterectomy: A new approach aims to improve patients' postoperative quality of life

Discussion: ‘Fetal heart rate tracings and neonatal metabolic acidosis’ by Elliott et al

Rudimentary horn pregnancy with herniation into the main uterine cavity

Vaginal evisceration after total laparoscopic radical hysterectomy in cervical cancer

What gestation cut-off should be used for magnesium sulfate treatment of women threatening to deliver preterm?

Reply

The role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium

Reply

Risk of shoulder dystocia in second delivery: does a history of shoulder dystocia matter?

Reply

The natural history of cervical and vulvar intraepithelial neoplasia

Counseling and screening for chromosomal abnormalities

Reply