Obstetrical and Gynecological Survey (OBSTET GYNECOL SURV)

Publications in this journal

• Article: Vitamin D and Risk of Cognitive Decline in Elderly Persons

  David J. Llewellyn, Iain A. Lang, Kenneth M. Langa, Graciela Muniz-Terrera, Caroline L. Phillips, Antonio Cherubini, Luigi Ferrucci, David Melzer
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  ABSTRACT: The findings of a report published in 2007 suggested that over 40% of older, community-living adults in the United States and Europe were vitamin D deficient. There is clinical evidence for a relationship between low serum 25-hydroxyvitamin D (25[OH]D) levels and cognitive dysfunction with aging. Although data in several small clinical studies showing such an association were equivocal, 3 of 4 large population-based cross-sectional studies reported a relationship between levels of serum 25(OH)D and cognitive dysfunction in the elderly. No prior prospective population-based studies have investigated the possible association between vitamin D status and incident dementia or cognitive decline. This prospective population-based study was designed to determine whether low serum levels of 25(OH)D were associated with an increased risk of substantial cognitive decline in an elderly population. Data were obtained from a sample of elderly individuals enrolled in the InCHIANTI study, a large, prospective cohort study conducted in Italy to identify risk factors for late-life disability. The study participants were 858 adults aged 65 years or older who had completed 1 or more follow-up cognitive assessment between 1998 and 2006, with follow-up every 3 years. Cognitive decline was assessed using 2 tests of cognitive function: the Mini-Mental State Examination (MMSE) and the Trail-Making Tests A and B; both were administered at baseline, with follow-up at 3 and 6 years. Substantial cognitive decline was defined with MMSE as a decrease in score of 3 or more points, and with Trails A and Trails B as scoring in the worst 10% of cognitive decline or having the testing discontinued. In multivariate logistic regression fully adjusted models, the relative risk (RR) of substantial cognitive decline on the MMSE among participants who were severely 25(OH)D deficient was 60% greater compared with those who were 25(OH)D sufficient (RR, 1.60; 95% confidence interval [CI], 1.19–2.00; P value for linear trend < 0.02). In fully adjusted random-effects models, the MMSE score declined by an additional 0.3 points per year more among severely 25(OH)D deficient participants compared with those who were 25(OH)D sufficient. With the Trails B, severely vitamin D deficient participants were 31% more likely of having a substantial decline in cognitive performance scores compared to those with sufficient levels of vitamin D; the RR was 1.31, with a 95% CI of 1.03–1.51 (P value for linear trend < 0.04). No significant association was found between 25(OH)D levels and cognitive performance on Trails A. These findings are the first to show in a prospective study that low levels of vitamin D are associated with increased risk of substantial cognitive decline in an elderly population. The data suggest that tests of cognitive function may be useful in future prospective trials of vitamin D supplementation in the elderly.
  Obstetrical and Gynecological Survey 05/2011; 66(6):354-355.
• Article: Adverse Obstetric and Perinatal Outcomes in Subfertile Women Conceiving Without Assisted Reproductive Technologies

  Alice M. Jaques, David J. Amor, H. W. Gordon Baker, David L. Healy, Obioha C. Ukoumunne, Sue Breheny, Claire Garrett, Jane L. Halliday
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  ABSTRACT: It is unclear whether assisted reproductive technologies (ART) or factors associated with infertility contribute to adverse perinatal outcomes in subfertile women who undergo in vitro fertilization. Some investigators have suggested that specific effects of ART due to the laboratory procedures are largely responsible for adverse perinatal outcomes. Others believe that procedures involved with in vitro fertilization are not causative, but factors related to the health of the infertile woman are responsible. This cohort study compared the prevalence of adverse perinatal birth outcomes among subfertile women who conceived and delivered without ART and women from the general population (controls). The study subjects were 2171 subfertile women who registered at 2 fertility clinics and subsequently conceived and gave birth to singleton infants without ART. A total of 4363 controls, matched by maternal age and year of infant's birth were selected randomly from birth records. The primary study outcome measures were adverse obstetric and perinatal outcomes. Multivariable analysis was used to adjust for known confounders. Compared with controls, there were increased odds among subfertile women of hypertension or preeclampsia (adjusted odds ratio [aOR],1.29; 95% confidence interval [CI], 1.02–1.61); antepartum hemorrhage (aOR, 1.41; 95% CI, 1.05–1.89); preterm birth < 37 weeks (aOR, 1.32; 95% CI, 1.05–1.67) or < 31 weeks (aOR; 2.37; 95% CI, 1.35–4.13); low birth weight (aOR,1.44; 95% CI, 1.11–1.85); perinatal death (aOR, 2.19; 95% CI, 1.10–4.36); and cesarean delivery (aOR, 1.56; 95% CI, 1.37–1.77; P values for all these comparisons were <0.05). Only weak evidence was found in subfertile women for increased risk of gestational diabetes (aOR, 1.25; 95% CI, 0.96–1.63; P < 0.09) or birth defects (aOR, 1.30; 95% CI, 0.98–1.72; P < 0.07). There was no increased risk for prelabor rupture of membranes, small for gestational age, or postpartum hemorrhage. These findings show that subfertile singleton women who conceive without ART are at increased risk of several adverse perinatal outcomes. These data suggest more careful monitoring of subfertile women during antenatal care.
  Obstetrical and Gynecological Survey 03/2011; 66(4):203-204.
• Article: Effectiveness of a Regional Prepregnancy Care Program in Women With Type 1 and Type 2 Diabetes: Benefits Beyond Glycemic Control

  Helen R. Murphy, Jonathan M. Roland, Timothy C. Skinner
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  ABSTRACT: A large number of studies have demonstrated that prepregnancy care for women with preconceptional diabetes improves glycemic control and reduces adverse pregnancy outcomes. However, only 2 regional centers, both nearly 20 years ago, have described the benefits of implementing prepregnancy care programs. A large study in the United Kingdom reported that relatively few maternity units provided prepregnancy care clinics for women with diabetes and that only 10% of diabetic women attended such clinics. In the absence of prepregnancy care, a majority of women with type 1 and 2 diabetes are at increased risk of potentially preventable poor pregnancy outcomes. This prospective cohort study investigated the implementation and effectiveness of a regional prepregnancy care program on pregnancy preparation, glycemic control, and pregnancy outcomes in women with type 1 and type 2 diabetes at 10 regional maternity units. The study population comprised 680 pregnancies of women with type 1 and type 2 diabetes. Primary outcomes examined included adverse pregnancy outcome (miscarriage, congenital fetal malformation, stillbirth, neonatal death) and indicators of pregnancy preparation (folic acid supplementation, and glycemic control [HgbA1c]). A historical cohort of 613 pregnancies from the same units during 1999–2004 served as the control. Overall, 27% (181/680) of the women with diabetes attended prepregnancy care and 73% did not. On comparison with the controls, women who attended prepregnancy care presented earlier (6.7 vs. 7.7 weeks; P < 0.0001), were more likely to use 5 mg preconception folic acid (88.2% vs. 26.7%; P < 0.0001), achieved lower HgbA1c levels (6.9% vs. 7.6%; P < 0.0001), and were less likely to conceive while on potentially harmful ACE inhibitors (1.1% vs. 4.6%; P < 0.05) and/or statins (0% vs. 7.6%; P< 0.0003). Overall, attendees had fewer adverse pregnancy outcomes (1.3% vs. 7.8%; P = 0.009). Multivariate logistic regression analysis showed that independent predictors of adverse outcome were glycemic control at booking (odds ratio, 1.46; 95% confidence interval, 1.16–1.85; P = 0.001 per 1% HgbA1c increase) and lack of prepregnancy care (odds ratio, 0.2; 95% confidence interval, 0.05–0.89; P = 0.03). Neither maternal age, parity, obesity, ethnicity nor socioeconomic deprivation was independent predictors of adverse outcome. Notable differences in pregnancy outcomes during 2006–2009 compared with 1999–2004 included an increase in folic acid supplementation (40.7% vs. 32.5%; P = 0.006) and fewer congenital malformations (4.3% vs. 7.3%; P = 0.04). These findings show that implementation in routine care of a regional prepregnancy care program is associated with improved glycemic control and reduced risk of adverse pregnancy outcome in pregnancies of women with type 1 and type 2 diabetes.
  Obstetrical and Gynecological Survey 03/2011; 66(4):189-191.
• Article: Incidence of Intra-Abdominal Adhesions in a Continuous Series of 1000 Laparoscopic Procedures

  Jean Dubuisson, Revaz Botchorishvili, Sandrine Perrette, Nicolas Bourdel, Kris Jardon, Benoît Rabischong, Michel Canis, Gérard Mage
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  ABSTRACT: Intra-abdominal adhesions occurring after intraperitoneal surgery are responsible for a substantial proportion of cases of intestinal obstruction (74%), chronic pelvic pain (20%–50%), and female infertility (15%–20%). They increase the risk of bowel injuries during subsequent surgery. This prospective monocentric study investigated the incidence of intra-abdominal adhesions and their relationship to previous abdominal surgery for a continuous series of 1000 gynecologic laparoscopic procedures. The study was conducted between 2006 and 2007 at a university hospital in France. Data on individual patient history were obtained on the number of prior abdominal surgeries, the indications for surgery, abdominal cavity access, and type of incision. The primary study outcome was the presence of intra-abdominal adhesions. Over 60% (637/1000) of the laparoscopic procedures were performed in patients with a history of 1 or more abdominal surgery; 35% of these cases (350/1000) had only 1 prior abdominal surgery. The presence of intraoperative adhesions were noted in 21.1% (211/1000) of the cases; 28% (59/211) of these involved bowel loops. There was a significant increase in the rate of intestinal adhesions with increasing number of prior abdominal surgeries (1 [6.29%], 2 [8.29%], 3 [16.9%], and >3 [74%]; P < 0.001). The rate of intestinal adhesions was significantly higher among patients with a history of midline incision compared with the other incisions (P < 0.012). These findings indicate that evaluation of the risk of adhesion formation requires extensive preoperative knowledge of prior surgery. Adhesion formation does not appear to be influenced by the prior indication for surgery.
  Obstetrical and Gynecological Survey 03/2011; 66(4):205-206.
• Article: Generation of Viable Male and Female Mice From 2 Fathers

  Jian Min Deng, Kei Satoh, Hao Chang, Zhaoping Zhang, M. David Stewart, Hongran Wang, Austin J. Cooney, Richard R. Behringer
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  ABSTRACT: During normal mating in mammals between males and females, fertilization of oocytes by spermatozoa produces progeny with alleles inherited from both parents. Pluripotent embryonic stem (ES) cells can differentiate into all adult cell types, including oocytes and sperm. In culture, genetically male mouse ES lines spontaneously lose the Y chromosome at a frequency of about 1%, resulting in genetically female XO cell lines that can produce viable fertile females. Previous studies have not shown that such XY-derived XO pluripotent stem cells can generate viable progeny with genetic information from 2 distinct fathers. This present study exploited this stem cell strategy (in vitro sex reversal) to generate viable male and female mice that combine the haploid genomes from 2 fathers. Manipulation of fibroblasts from somatic cells of a male (XY) mouse fetus produced induced pluripotent stem cell lines. Injection of these XY-derived XO ES cells into blastocysts from donor female mice produced functional oocytes in female chimeras. Natural mating of the female chimeras (from father 1) with genetically distinct males (father 2) resulted in live progeny with haploid genomes that were equally derived from both fathers. These findings demonstrate that use of induced pluripotent stem cell technology can generate male and female progeny by combining the alleles from 2 male mice. This new method of mammalian reproduction may have major implications for improving livestock breeds and preserving endangered species as well as for advancing assisted reproductive technology in humans.
  Obstetrical and Gynecological Survey 03/2011; 66(4):216-218.
• Article: Subjective Risk Versus Objective Risk Can Lead to Different Post-Cesarean Birth Decisions Based on Multi-Attribute Modeling

  Poonam S. Sharma, Karen B. Eden, Jeanne-Marie Guise, Holly B. Jimison, James G. Dolan
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  ABSTRACT: The choice of vaginal birth after cesarean or a repeat cesarean delivery is a complex decision. Both delivery methods have advantages as well as disadvantages and are associated with risks of maternal and neonatal morbidity. Vaginal birth after cesarean delivery is associated with shorter hospital stays for mother and infant, more rapid recovery postpartum, less thromboembolism, and lower rates of future pregnancy complications, but also leads to a higher rate of uterine rupture and a small risk of subsequent neonatal injury. The decision regarding mode of delivery for women with a prior cesarean is not only based on clinical evidence and priorities but is also influenced by several nonclinical patient priorities. Previously, recommendations for childbirth decisions were generated using decision tree models based on clinical data and the opinion of clinical experts. However, these models did not incorporate patient priorities. It was unclear how a pregnant woman's subjective prioritization of risk affected the shared birthing decision by patients and their providers. In the present study, the investigators created 2 different decision tree models, one subjective and the other objective, to help determine how risk assessment can affect a birth decision. The first was a subjective multi-attribute decision model based on patient prioritization of risks. This model used Analytic Hierarchy Process criteria to generate a recommendation from 96 postnatal women with a previous cesarean delivery based on their priorities for avoiding maternal and neonatal risks and priorities for the delivery experience. The second was an objective hybrid model that integrated aspects of Analytic Hierarchy Process and decision trees based on absolute risks (clinical data). The subjective model generated significantly more recommendations for an elective repeat cesarean compared with the hybrid model (73% vs. 18%, P < 0.001). In this model, women strongly prioritized avoiding any death/disability to the infant over all the other criteria, despite being presented information on the greater risk of repeat cesareans. The hybrid model favored a trial of labor recommendation for most women because a successful trial of labor led to overall lower health risks for the mother than an elective repeat cesarean. These findings show that some women make decisions on the method of delivery that may be strongly counterintuitive to the clinical evidence due to the weighting of priorities regarding outcomes. The data demonstrate the importance of effective risk communication between providers and patients to permit a shared birthing decision that reduces the risk of adverse outcomes among both mothers and infants.
  Obstetrical and Gynecological Survey 03/2011; 66(4):187-189.
• Article: Restoration of Ovarian Function After Allografting of Ovarian Cortex Between Genetically Nonidentical Sisters

  Jacques Donnez, Jean Squifflet, Céline Pirard, Pascale Jadoul, Marie-Madeleine Dolmans
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  ABSTRACT: Premature ovarian failure (POF) and loss of reproductive function usually occur in women with cancer following the use of aggressive chemotherapy and radiotherapy. The options available to preserve fertility in such patients include oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation. When none of these options are available or were not implemented at the time of treatment, ovarian allotransplantation from the previous bone marrow donor is now possible. A previous study described 6 cases of successful kidney transplantation between HLA-compatible sisters who previously underwent bone marrow transplantation (BMT), with the kidney donor being the BMT donor in all cases. This present report describes 3 cases of orthotopic allotransplantation of fresh ovarian tissue between 2 genetically nonidentical sisters. None of the above options could be proposed when these 3 patients were treated and each experienced iatrogenic POF. The recipients (20, 15, and 12 years of age) had undergone chemotherapy and total body irradiation before BMT, with the donor in each case being the HLA-compatible sister. HLA group analysis performed years later revealed complete chimerism (full HLA compatibility) between the 2 genetically nonidentical sisters in each case. Ovarian allografting was performed, with the ovarian tissue donor being the sister who had already donated bone marrow to the recipient sister with POF. No immunosuppressive therapy was required, and there was no sign of rejection. There was successful restoration of ovarian function in all 3 cases; the time interval between implantation of cortical tissue and follicular development for all 3 was between 3.5 and 6 months. Primordial follicle density of donor ovarian tissue appears to be associated with the timing of the first estradiol peaks and the persistence of ovarian function. These findings show restoration of ovarian function following ovarian cortex allografting between genetically different sisters for cases in which the sisters are HLA-compatible with full chimerism due to previous BMT, eliminating the threat of rejection.
  Obstetrical and Gynecological Survey 02/2011; 66(3):147-148.
• Article: Treatment of Hyperthyroidism in Pregnancy and Birth Defects

  Maurizio Clementi, Elena Di Gianantonio, Matteo Cassina, Emanuele Leoncini, Lorenzo D. Botto, Pierpaolo Mastroiacovo, The SAFE-Med Study Group
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  ABSTRACT: The reported prevalence of clinical hyperthyroidism in pregnancy is 0.1% to 0.4%. For several decades, pregnant women with this disorder have been treated with suppressive thyrostatic agents to prevent many potential complications of hyperthyroidism in pregnancy. The antithyroid drugs used include propylthiouracil and methimazole/carbimazole. For many years, physicians have been concerned about the fetal risks of these 2 drugs. Previous reports suggested an association between prenatal exposure to methimazole/carbimazole and congenital malformations or an embryopathy. The limited data available on the association between prenatal exposure to propylthiouracil and major congenital anomalies are conflicting. The aim of this study was to investigate the association of exposure to propylthiouracil and methimazole/carbimazole in the first trimester and congenital malformations. Data were obtained from the Surveillance of Adverse Fetal Effects of Medications Study, which was, a study conducted within the framework of the International Clearinghouse for Birth Defects Surveillance and Research. A total of 18,131 infants (cases) with malformations and reported first-trimester exposure to any medication were evaluated using a case versus affected control analysis. Malformations were analyzed for 52 major groups. A total of 127 infants were identified whose mothers had known exposure in the first-trimester to antithyroid drugs. Among the 52 groups of malformations analyzed, there was a significant association between prenatal exposure to methimazole/carbimazole and the occurrence of choanal atresia (4 cases) and omphalocele (6 cases; P < 0.01). Malformations associated with prenatal exposure to propylthiouracil included situs inversus ± dextrocardia (3 cases), isolated unilateral kidney agenesis/dysgenesis (2 cases), and cardiac outflow tract defects (5 cases). These findings show a significant association between prenatal exposure to methimazole or carbimazole and the occurrence of omphalocele and choanal atresia, and are consistent with previous studies. The possible associations between propylthiouracil and birth defects are difficult to interpret primarily because of the low number of affected cases.
  Obstetrical and Gynecological Survey 02/2011; 66(3):135-137.
• Article: 5. Association between maternal sleep practices and risk of late stillbirth: A case-control study. Stacey, T., Thompson, J. M. D., Mitchell, E. A., Ekeroma, A. J., Zuccollo, J. M., & McCowan, L. M. E. (2011). Obstetrical and Gynecological Survey, 66(10), 601-602. doi:10.1097/OGX.0b013e31823d8532

  Stacey, Thompson, Mitchell, Ekeroma, Zuccollo, McCowan
  Obstetrical and Gynecological Survey 01/2011;
• Article: High Incidence of Invasive Group B Streptococcal Infections in Human Immunodeficiency Virus-Exposed Uninfected Infants

  Cristina Epalza, Tessa Goetghebuer, Marc Hainaut, Fany Prayez, Patricia Barlow, Anne Dediste, Arnaud Marchant, Jack Levy
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  ABSTRACT: Several reports from resource poor African and Latin American countries suggest an increased susceptibility of human immunodeficiency virus (HIV)-exposed uninfected (HEU) infants to infection as compared with their HIV-unexposed counterparts. Many of these studies were conducted in sub-Saharan Africa, where access to adequate prophylactic antiretroviral therapy is limited. Increased susceptibility of HEU infants to infection is unlikely in more affluent, high-resource countries. This report compared the clinical presentation and incidence of severe group B streptococcal (GBS) infections during the first months of life in a cohort of infants born to HIV-infected and -uninfected mothers at a university hospital in Belgium. The hospital database and microbiology laboratory records were used to identify all HEU infants born between 2001 and 2008 with invasive GBS infections at follow-up. The control group consisted of infants born to HIV-uninfected mothers. Invasive GBS infections developed in 5 (1.55%) of HEU infants who were born to the 322 HIV-uninfected mothers, and in only 16 (0.08%) of the control infants born to 20, 158 HIV-uninfected mothers. Moreover, late-onset infection occurred more frequently among HEU infants (HEU group: 5 of 6 [83%] vs. control group: 2 of 16 [13%], P < 0.04). Infections were more severe in HEU infants: septic shock or sepsis occurred in 5 of 6 HEU infants versus 10 of 16 controls, and leukopenia occurred more frequently at onset of infection in HEU infants (66% vs. 13%). One HEU infant presenting with a recurrent GBS infection 28 days after the completion of treatment for the first episode developed septic shock with meningitis resulting in death. The findings show that HEU infants have a significantly higher incidence of GBS infection and more late-onset and severe disease as compared with the infants born to HIV-uninfected mothers. These are the first data obtained from a developed country suggesting an increased susceptibility of HEU infants to GBS infection.
  Obstetrical and Gynecological Survey 12/2010; 66(1):6-7.
• Article: Cerebral Palsy Among Term and Post-term Births

  Dag Moster, Allen J. Wilcox, Stein Emil Vollset, Trond Markestad, Rolv Terje Lie
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  ABSTRACT: Preterm birth is a strong predictor of cerebral palsy (CP), with risk of CP increasing with earlier delivery. There is a lower individual risk of CP among infants born at term, but even so, most infants with CP are born after 36 weeks of gestation. Little data are available within this range of term births on the association between risk of CP and gestational age in infants born at term. This population-based study investigated whether risk of CP is associated with timing of birth in the term and post-term period. Information obtained from the national health and insurance registries in Norway was used to identify 1,682,441 singleton live births between 1967 and 2001 with a gestational age of 37 to 44 weeks. Linkage to other national registries provided follow-up data for this cohort through 2005. The primary study outcome measure was the absolute and relative risk (RR) of CP among children who survived to at least 4 years of age. The gestational age was estimated using information based on the last menstrual period. Data from the Norwegian compulsory health insurance system identified 1938 term and post-term children with CP (1.15/1000 births). The lowest risk of CP was found among infants delivered at 40 weeks; the prevalence was 0.99/1000, with a 95% confidence interval (CI) of 0.90–1.08. Compared with term delivery, CP risk was higher with both earlier or later delivery: prevalence at 37 weeks was 1.91/1000 (95% CI, 1.58–2.25) with a RR of 1.9 (95% CI, 1.6–2.4); at 38 weeks, 1.25/1000 (95% CI, 1.07–1.42) with a RR of 1.3 (95% CI, 1.1–1.6); at 42 weeks, 1.36/1000 (95% CI, 1.19–1.53) with a RR of 1.4 (95% CI, 1.2–1.6); and after 42 weeks, 1.44 (95% CI, 1.15–1.72) with a RR of 1.4 (95% CI, 1.1–1.8). The association of CP risk with gestational age was even stronger with ultrasound-based gestational age than with last menstrual period for infant subgroups born at 37 weeks (prevalence, 1.17/1000 [95% CI, 0.30–2.04] with a RR of 3.7 [95% CI, 1.5–9.1]) and at 42 weeks (prevalence, 0.85/1000 [95% CI, 0.33–1.38] with a RR of 2.4 [95% CI, 1.1–5.3]). The RRs for gestational age were unaffected by adjustment for infant gender, maternal age, and several socioeconomic measures. These findings show that risk of CP is lowest at 40 weeks of gestation and is higher before and after this.
  Obstetrical and Gynecological Survey 12/2010; 66(1):8-9.
• Article: The Effect of Plurality and Obesity on Betamethasone Concentrations in Women at Risk for Preterm Delivery

  Cynthia Gyamfi, Lisa Mele, Ronald J. Wapner, Catherine Y. Spong, Alan Peaceman, Yoram Sorokin, Donald J. Dudley, Francee Johnson, Kenneth J. Leveno, Steve N. Caritis, Brian M. Mercer, John M. Jr. Thorp, Mary J. O'Sullivan, Susan M. Ramin, Marshall Carpenter, Dwight J. Rouse, Menachem Miodovnik, Baha Sibai
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  ABSTRACT: Administration of antenatal corticosteroids to women who are at risk for preterm delivery and carry singletons decreases the incidence of respiratory distress syndrome in their prematurely born infants. However, it is unclear whether antenatal corticosteroids decrease the incidence of respiratory distress syndrome in women with multiple gestations. The effect of maternal obesity on the volume of distribution of betamethasone has not been evaluated, and some investigators are concerned that the concentration of drug available to the fetus may be different in an obese mother as compared with a nonobese mother. This study was designed to determine whether the concentration of betamethasone in maternal serum or fetal cord blood differed between singleton and twin pregnancies and between obese and nonobese women. Data were obtained from analysis of biological fluids collected within a randomized, double-blinded, placebo-controlled clinical trial. All participants receiving weekly doses of betamethasone were identified. Univariate analysis was used to compare betamethasone concentrations in singleton versus twin gestations and in obese (body mass index, <30 kg/m2) versus normal weight (body mass index, <30 kg/m2) women. A total of 100 samples were analyzed (45 cord blood and 55 maternal blood). In univariate analysis, there was a significant increase in median cord blood betamethasone concentrations among twin gestations (4.4 ng/mL, interquartile range [IQR], 2.5–8.2, vs. singletons, 1.4 ng/mL; IQR, 1.0–3.0 [P = 0.002]) and a nonsignificant increase in median maternal serum betamethasone concentrations among obese (5.0 ng/mL; IQR, 2.7–7.6) versus nonobese (4.3 ng/mL; IQR, 3.0–6.1) women (P = 0.74). However, after adjustment for possible confounders, no differences were noted in concentrations of betamethasone in maternal serum and cord blood between singletons and twins or between nonobese and obese women. These findings fail to support that there is a significant association between serum betamethasone concentrations and either plurality or obesity.
  Obstetrical and Gynecological Survey 12/2010; 66(1):1-2.
• Article: Use of Cryobanked Oocytes in an Ovum Donation Program: A Prospective, Randomized, Controlled Clinical Trial

  Ana Cobo, Marcos Meseguer, José Remohí, Antonio Pellicer
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  ABSTRACT: The level of success of ovum donation programs is dependent on an efficient oocyte cryopreservation method to provide a well-synchronized replacement of good-quality embryos. Several strategies have been used for synchronization. Over the last 2 decades, clinical results of oocyte cryopreservation have been unreliable because of the poor track record of the methodology used to cryopreserve human oocytes. Although there is increasing evidence of good clinical outcomes after oocyte cryopreservation, no large, adequately designed, prospective studies have evaluated the effectiveness of oocyte cryobanking, especially methods of vitrification. This randomized, prospective, triple-blind, single-center, parallel-group controlled-clinical trial compared the ongoing pregnancy rates (OPR) of vitrified-banked oocytes and fresh oocytes. Between 2008 and 2009, 1032 potential recipients were screened for eligibility; 600 of these were randomized into 2 groups inseminated with either vitrified oocytes from an oocyte-bank (n = 300) or fresh oocytes (n = 300). To establish the superiority of the OPR of fresh versus vitrified cycles, a likelihood ratio-based test in logistic regression analysis was used. A possible conversion from superiority to noninferiority was set up based on a predefined noninferiority limit of 0.66 for the odds ratio of vitrified versus fresh oocytes. The primary study end-point was the OPR per randomized recipients according to intention-to-treat analysis. Secondary end-points analyzed included clinical pregnancy rate, implantation rate, fertilization rate, and embryo quality. There were no differences between the 2 groups in demographic baseline characteristics, ovarian stimulation parameters, ovum donation indications, or male factor contribution. No differences were found in the OPR per intention-to-treat of the 2 groups (vitrification group: 43.7 vs. fresh group: 41.7%). The odds ratio of ongoing pregnancy was 0.921 in favor of the vitrification group, but the 95% confidence interval (0.667–1.274) was above the predefined noninferiority limit of 0.66; demonstrating noninferiority of the vitrified group in relation to the fresh group (P = 0.744). Secondary endpoints were similar for patients receiving either vitrified or fresh oocytes: clinical pregnancy rate per cycle (50.2% vs. 49.8%; P = 0.933) or per embryo-transfer (55.4% vs. 55.6%; P = 0.974), and implantation rate (39.9% vs. 40.9%; P = 0.745). Moreover, there were no differences in the proportion of top-quality embryos between the egg-bank and fresh groups for day-2 (30.8% vs. 30.8%) and day-3 (36.1% vs. 37.7%) oocytes, respectively, and for day-2 (43.6% vs. 8%) and day-3 (58.4% vs. 60.7%) cleaved embryos, respectively (P = ns). These findings confirm the effectiveness of oocyte vitrification/egg-banked storage for a successful clinical outcome in oocyte donation programs and fail to demonstrate superiority of fresh oocytes over that of vitrified egg-banked oocytes with respect to OPR or fertilization and embryo developmental rates.
  Obstetrical and Gynecological Survey 11/2010; 65(12):775-777.
• Article: Vitamins C and E for Prevention of Preeclampsia in Women With Type 1 Diabetes (DAPIT): A Randomized Placebo-controlled Trial

  David R. McCance, Valerie A. Holmes, Michael J. A. Maresh, Christopher C. Patterson, James D. Walker, Donald W. M. Pearson, Ian S. Young, for the Diabetes and Preeclampsia Intervention Trial (DAPIT) Study Group
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  ABSTRACT: The hypothesis that oxidative stress plays a major role in the pathogenesis of preeclampsia has been the focus of considerable research in the last 2 decades. Evidence for such a role was provided in a small, randomized, placebo-controlled trial showing that supplementation with vitamins C and E was associated with more than a 50% reduction in the rate of preeclampsia among a population of women at high risk of developing the disorder. Subsequently, the results of several large trials investigating antioxidant treatment in both women at low and high risk of preeclampsia showed that vitamins C and E supplementation during pregnancy was not beneficial. Only 3 of these trials included subgroups of women with diabetes and these groups were small and poorly characterized. The rates of preeclampsia are 2 to 4 times higher in pregnant women with diabetes than in nondiabetic women. The possible benefits of antioxidants in pregnant women with diabetes at risk of preeclampsia are unknown. The Diabetes and Preeclampsia Intervention Trial was a multicenter, randomized, placebo-controlled study designed to investigate whether supplementation with vitamins C and E reduced the incidence of preeclampsia in women with type 1 diabetes. The study subjects were singleton pregnant women, aged 16 years or older, who had type 1 diabetes before pregnancy, and presented between 8 and 22 weeks of gestation at 25 antenatal metabolic clinics in the United Kingdom. Women were randomly assigned to receive 1000 mg vitamin C and 400 IU vitamin E (n = 379) or matched placebo (n = 383) daily from 8 and 22 weeks' gestation until delivery. The primary outcome measure was preeclampsia defined as gestational hypertension with proteinuria. There was no difference in the rates of preeclampsia between the vitamin (15%, 57/375) and placebo groups (19%, 70/374); the risk ratio was 0.81, with a 95% confidence interval of 0.59 to 1.12. No significant differences were noted between vitamin and placebo groups for any adverse clinical maternal or fetal outcome. These findings indicate that the daily supplementation with vitamins C and E from early to mid pregnancy does not reduce risk of preeclampsia, gestational hypertension, or low birth weight infants in women with type 1 diabetes.
  Obstetrical and Gynecological Survey 11/2010; 65(12):753-754.
• Article: Maternal or Infant Antiretroviral Drugs to Reduce HIV-1 Transmission

  R. L. Shapiro, M. D. Hughes, A. Ogwu, D. Kitch, S. Lockman, C. Moffat, J. Makhema, S. Moyo, I. Thior, K. McIntosh, [......], E. Moko, S. Souda, E. Lubega, M. Akhtar, C. Wester, R. Tuomola, W. Snowden, M. Martinez-Tristani, L. Mazhani, M. Essex
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  ABSTRACT: There is a critical need for effective highly active antiretroviral therapy (HAART) to prevent mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) through breast-feeding in low-resource areas of the world where replacement feeding is not feasible. The most effective HAART regimen to prevent HIV transmission during breast-feeding is unknown. This study compared different HAART regimens to determine whether they differ with respect to virologic suppression during pregnancy and breast-feeding, pregnancy outcomes, and adverse effects in mothers and infants. The participants—560 pregnant HIV-1 infected women with CD4+ cell counts of ≥200—were randomly assigned to receive either a coformulation of abacavir, zidovudine, and lamivudine (the nucleoside reverse-transcriptase inhibitor [NRTI] group) or a coformulation of lopinavir-ritonavir plus zidovudine-lamivudine (the protease inhibitor group). Both the regimens were administered between 26 and 34 weeks' gestation and were continued through planned weaning by 6 months postpartum. The observational group—170 women with CD4+ cell counts <200 cells—received standard-of-care treatment (nevirapine plus zidovudine-lamivudine). Infants were given single-dose nevirapine at birth and zidovudine from birth through 4 weeks. There was no significant difference between any of the 3 regimens in the rate of virologic suppression (decrease in plasma HIV-1 RNA level) to less than 400 copies per mL both at delivery (96% in the NRTI group, 93% in the protease inhibitor group, and 94% in the observational group) and throughout the breast-feeding period (92% in the NRTI group, 93% in the protease inhibitor group, and 95% in the observational group). At 6 months, the rates of mother-to-child transmission were low; only 1.1% (8/709) of live-born infants were infected (95% confidence interval, 0.5–2.2). Of the 8 infants infected at 6 months, 6 were infected in utero (4 in the NRTI group, 1 in the protease inhibitor group, and 1 in the observational group) and 2 infants were infected through late breast-feeding transmission (both in the NRTI group). Adverse events required modification of the HAART regimen in 2% of both intervention groups and 11% in the observational group. These findings show that all HAART regimens are highly effective for virologic suppression at delivery and throughout breast-feeding, with an overall rate of mother-to-child HIV transmission of 1.1% at 6 months.
  Obstetrical and Gynecological Survey 10/2010; 65(11):689-691.
• Article: Infection and Fetal Loss in the Mid-Second Trimester of Pregnancy

  Ben Allanson, Belinda Jennings, Angela Jacques, Adrian K. Charles, Anthony D. Keil, Jan E. Dickinson
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  ABSTRACT: Inflammation and infection are associated with spontaneous early preterm births. A common cause of second trimester pregnancy loss is chorioamnionitis, usually resulting from an infection ascending from the vagina. In a previous study, histological chorioamnionitis was present in 85% of preterm infants delivered at gestations <28 weeks. Few data are available on the prevalence of inflammation in midtrimester pregnancy loss. The aim of this study was to determine the frequency of chorioamnionitis in spontaneous pregnancy loss at previable gestations during the second trimester and to review the microbiology of chorioamnionitis associated with these very preterm losses. During the 3-year study period (2003–2005), 661 fetuses delivered at 16 to 22 weeks of gestation were identified from the hospital pathology database. Autopsy reports and pathology findings were reviewed, and maternal features including clinical symptoms, blood count, and vaginal microbiology culture results were analyzed. Medical chart review provided maternal clinical and laboratory data. Anomalous and macerated fetuses, multiple gestations, and fetuses without a complete examination were excluded, leaving 101 cases in the study group. The matched control group included 103 cases of medical terminations for fetal abnormalities during the same time period. Chorioamnionitis was defined by the presence of neutrophils. The cases and control groups had a similar mean gestational age (19.1 ± 2.1 vs. 19.3 ± 1.7 weeks, respectively, P = 0.22). Histological evidence of chorioamnionitis was noted in 77.2% (78/101) of the study group cases, but in none of the control group. There was a fetal reaction in 49.4% (38/77) of cases with chorioamnionitis; the frequency of fetal reaction increased during gestation from 5.3% at 16 weeks' gestation to 33.3% at 22 weeks' gestation. Of the 76 study cases with chorioamnionitis, 36 (47.4%) were culture positive, whereas only 4 of the 25 study cases (16%) without chorioamnionitis were culture positive. These findings demonstrate a strong association between spontaneous second trimester pregnancy loss and intrauterine infection among otherwise normal fetuses. The data show that a majority of cases of spontaneous pregnancy loss at 16 to 22 weeks' gestation are accompanied by chorioamnionitis. The intrauterine inflammatory response appears to predate the labor process and may be an important initiating factor in the pregnancy loss.
  Obstetrical and Gynecological Survey 09/2010; 65(10):613-614.
• Article: Infant Morbidity and Mortality Attributable to Prenatal Smoking in the United States

  Patricia M. Dietz, Lucinda J. England, Carrie K. Shapiro-Mendoza, Van T. Tong, Sherry L. Farr, William M. Callaghan
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  ABSTRACT: Despite the continuing reduction in the incidence of smoking during pregnancy in the United States, prenatal smoking is still one of the most prevalent and preventable causes of infant morbidity and mortality. Two previous studies estimated that 5% to 6% of all infant deaths during 1995 to 1997 were due to prenatal smoking. In 2004, the Surgeon General's report concluded that there was sufficient evidence to show a clear association between prenatal smoking and several causes of infant morbidity and mortality. This study provides updated estimates of the percentage of preterm deliveries, term low-birth-weight deliveries <2500 g, and infant deaths because of smoking—individual outcomes identified in the Surgeon General's report as causally related to prenatal smoking in the United States. The updated estimates were based on the most recent and complete US vital statistical data. The US Linked Birth/Infant Death Data Set, 2002 birth cohort included a final sample of 3,352,756 singleton live births. Live birth outcomes were grouped into 5 delivery groups: very preterm (27 completed weeks of gestation), moderately preterm (28–33 completed weeks), late preterm (34–36 completed weeks), term low birth weight (≥37 completed weeks and <2500 g), sudden infant death syndrome (SIDS), and infant deaths from preterm-related causes. Multiple logistic regression models estimated the proportion of adverse birth outcomes attributable to prenatal smoking. Of the 3,352,756 singleton live infants delivered in 2002, 11.5% (n = 386,262) were exposed to prenatal smoking. The percentage of all infant deaths attributable to prenatal smoking was estimated to be 2.8% to 4.1%. Prenatal smoking was associated with very (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.4–1.6); moderate (aOR, 1.4; 95% CI, 1.4–1.4); and late (aOR, 1.2; 95% CI, 1.2–1.3) preterm deliveries and term low-birth-weight deliveries (aOR, 2.3; 95% CI, 2.3–2.5) compared with term ≥2500 g deliveries. Prenatal smoking was also associated with SIDS (aOR, 2.7; 95% CI, 2.4–3.0) and preterm-related deaths (aOR, 1.5; 95% CI, 1.4–1.6). The percentage of adverse birth outcomes attributable to prenatal smoking and thereby, potentially avoidable was 5.3% to 7.7% of preterm deliveries, 13.1% to 19.0% of term low-birth-weight deliveries, 23.2% to 33.6% of SIDS, and 5.0% to 7.3% of preterm-related deaths. Provided that rates of prenatal smoking continued to decline, estimates for the fraction of preterm-related deaths and SIDS deaths attributed to prenatal smoking in 2009 were slightly lower (4.4%–6.3% for preterm-related deaths and 20.2%–29.3% for SIDS deaths). These findings demonstrate that despite the continuing decline in rates of prenatal smoking, a substantial proportion of avoidable cases of infant morbidity and mortality is associated with prenatal smoking.
  Obstetrical and Gynecological Survey 09/2010; 65(10):601-602.
• Article: Misoprostol as an Adjunct to Standard Uterotonics for Treatment of Postpartum Hemorrhage: A Multicentre, Double-Blind Randomized Trial

  Mariana Widmer, Jennifer Blum, G. Justus Hofmeyr, Guillermo Carroli, Hany Abdel-Aleem, Pisake Lumbiganon, Thi Nhu Ngoc Nguyen, Daniel Wojdyla, Jadsada Thinkhamrop, Mandisa Singata, Luciano E. Mignini, Mahmoud Ahmad Abdel-Aleem, Son Thach Tran, Beverly Winikoff
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  ABSTRACT: In high-resource settings, standard treatment of postpartum hemorrhage relies heavily on hospital-based interventions, and maternal death from hemorrhage is rare. Simpler methods are needed for intervention at all levels of care, especially in low-resource settings in rural areas. Misoprostol, a prostaglandin E1 analog, has been used for the management of postpartum hemorrhage although it is less effective than oxytocin. But because it has a number of advantages including ease of administration, thermostability, and relatively low cost, it can be of benefit in low resource settings. Three placebo-controlled randomized trials compared the use of misoprostol plus uterotonics and uterotonics alone in women with postpartum hemorrhage. Although a meta-analysis of these trials reported that addition of misoprostol was associated with 40% to 50% reduction in blood loss of 500 mL or more, the sample sizes were too small in these studies to make a meaningful conclusion. Moreover, a systematic review concluded that evidence for any benefit of addition of misoprostol to standard uterotonic treatment was insufficient. This multicenter, double-blinded, placebo-controlled, randomized trial investigated whether adjunctive use of misoprostol in women with postpartum hemorrhage could reduce blood loss more than standard uterotonic treatment alone. The participants were 1422 women delivering vaginally who had clinically diagnosed postpartum hemorrhage due to uterine atony. Between 2005 and 2008, all participants were enrolled from hospitals in Argentina, Egypt, South Africa, Thailand, and Vietnam. The women were randomly assigned to receive 600 μg misoprostol (n = 705) or matching placebo (n = 717) sublingually; both groups were also given routine injectable uterotonics. Special care was taken to conceal allocation. Both providers and participants were blinded as to treatment allocation. The primary study outcome measure was blood loss of 500 mL or more within 60 minutes after. There was no significant difference between the 2 groups in the proportion of women with measured blood loss of 500 mL or more (misoprostol group: 100 [14%] vs. the placebo group: 100 [14%]; the relative risk was 1.02, with a 95% confidence interval of 0.79–1.32). Within 60 and 90 minutes after randomization, compared with placebo, misoprostol was associated with an increased proportion of women with shivering, body temperature of 38°C or higher, and vomiting. These findings do not support the use of misoprostol as an adjunct to conventional uterotonics for the treatment of women with postpartum hemorrhage.
  Obstetrical and Gynecological Survey 09/2010; 65(10):609-610.
• Article: The Clinical Characteristics and Sonographic Findings of Maternal Ovarian Torsion in Pregnancy

  Noam Smorgick, Moty Pansky, Michal Feingold, Arie Herman, Reuvit Halperin, Ron Maymon
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  ABSTRACT: Maternal ovarian torsion is a very rare complication in pregnant women that may be misdiagnosed because signs and symptoms such as abdominal pain and nausea/vomiting are nonspecific and are present in a number of obstetric and surgical conditions. There is limited information in the medical literature on ovarian torsion in pregnancy. Most previous studies have been isolated case reports and small case series. This retrospective study investigated the incidence, risk factors, and sonographic findings of maternal ovarian torsion in pregnancy. The participants were 33 pregnant women with 38 episodes of surgically proven torsion who were examined and managed surgically at a tertiary referral center between the years 1993 and 2007. Ultrasound examination was performed upon admission in all cases. The primary outcome measures were clinical and sonographic findings of ovarian torsion in pregnancy. Seventeen (51.5%) of the pregnancies were spontaneously conceived and 16 (48.5%) were conceived by ovulation induction or in vitro fertilization. The majority of cases of torsion (55.3%, n = 21) occurred in the first trimester; 34.2% (n = 13) occurred in the second trimester and 10.5% (n = 4) in the third trimester. At presentation, all patients had abdominal pain and 57.9% (n = 22) reported nausea/vomiting. The preoperative ultrasound findings were ovaries with unilocular cysts in 15 (39.5%) cases, multicystic ovaries in 14 (36.8%) cases, and normally appearing ovaries without cystic components in 9 (23.7%) cases. Compared to the cystic and normal appearing ovaries, the multicystic ovary occurred more frequently in the first trimester than in second and third trimester torsion (47.6% vs. 23.5%), whereas the normal appearing ovary components occurred more frequently in second and third trimester torsion (35.3% vs. 14.3%). The median duration from admission to surgery, 6 hours (range: 1 hour to 3.7 days), was significantly shorter in the first trimester compared with the second and third trimester. The investigators recommend that patients with relevant clinical presentation and on ovarian mass or enlarged ovary should be followed throughout pregnancy to rule out the possibility of ovarian torsion. The correct diagnosis of maternal ovarian torsion may be delayed in the second half of pregnancy.
  Obstetrical and Gynecological Survey 04/2010; 65(5):291-292.
• Article: Trends in Postpartum Hemorrhage in High Resource Countries: A Review and Recommendations From the International Postpartum Hemorrhage Collaborative Group

  Marian Knight, William M. Callaghan, Cynthia Berg, Sophie Alexander, Marie-Helene Bouvier-Colle, Jane B. Ford, K. S. Joseph, Gwyneth Lewis, Robert M. Liston, Christine L. Roberts, Jeremy Oats, James Walker
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  ABSTRACT: There is considerable evidence for increasing trends in the incidence of postpartum hemorrhage (PPH) over time. The aim of the present study was to investigate trends in the frequency and the severity of PPH in developed countries, and to assess potential causes for any observed trends. There was an increasing trend in PPH in Australia, Canada, the United Kingdom, and the United States. The increased incidence of PPH was limited solely to immediate/atonic PPH in Australia, Canada, and the United States. Increasing rates of severe adverse outcomes due to PPH were found in Australia, Canada, the United Kingdom, and the United States. The key recommendations of the Collaborative Group are as follows: in future revisions of the International Classification of Diseases, there should be separate codes for atonic PPH and other forms of PPH that occur in the first 24 hours after delivery of the placenta. Separate codes are also required for morbidly adherent placenta including placenta accreta, increta, and percreta. A standardized definition of PPH should be used in all countries. Research is needed to determine how current definitions are applied in practice to the coding of data. Improved methods of data collection are required including assessment of severity. Additional studies are required to determine whether increases in rate of PPH have occurred in other countries, and to evaluate the role of potential risk factors of PPH including obesity, increased duration of labor, and changes in management of the second and third stage. A key to reducing the severity of PPH and preventing adverse outcomes is enhanced training of maternity care staff in the assessment of blood loss and the monitoring of women following childbirth. Physicians should be more aware of the likelihood that the frequency and severity of PPH has increased and be more vigilant. The reported increased incidence of PPH is especially a problem in small hospitals with few deliveries. Such hospitals have limited access to equipment or drugs and lack adequate management protocols to treat women with unexpected severe PPH.
  Obstetrical and Gynecological Survey 03/2010; 65(4):211-212.