Obstetrics and Gynecology (OBSTET GYNECOL)

Publications in this journal

• Article: Factors associated with urgent cesarean delivery in women with type 1 diabetes mellitus.

  Grégoire Miailhe, Camille Le Ray, José Timsit, Jacques Lepercq
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  ABSTRACT: : Type 1 diabetes mellitus (DM) is associated with a threefold to fivefold increased risk for stillbirth during pregnancy. The objective of the present study was to identify factors associated with prelabor urgent cesarean delivery for fetal compromise in women with type 1 DM. : We performed a nested case-control study within a prospective cohort of single pregnancies in women with type 1 DM managed with standardized protocols regarding treatment of diabetes and prenatal care. Twice-weekly home antenatal surveillance including nonstress test was initiated at 32 weeks of gestation and continued until planned delivery at 38-39 weeks of gestation. We identified factors associated with urgent cesarean delivery for an abnormal nonstress test. The calculated total sample size was 416 pregnancies. Independent factors and adjusted odds ratio (OR) were identified by logistic regression. : Among 479 pregnancies, the rate of urgent cesarean delivery for an abnormal nonstress test was 4%. A hemoglobin A1C (Hb A1C) level at delivery of 6.4% or higher occurred in 34% of the pregnancies and was independently associated with urgent cesarean delivery (2% compared with 8%, P=.003, OR 4.16, 95% confidence interval 1.40-12.32). In the multivariable analysis, lack of preconception care and occurrence of gestational hypertension or preeclampsia were not associated with urgent cesarean delivery. The rate of stillbirth was 2 per 1,000. : In women with type 1 DM, an Hb A1C level at delivery of 6.4% or higher was associated with prelabor urgent cesarean delivery. This suggests that tight glycemic control throughout pregnancy might reduce the risk of late fetal compromise. : III.
  Obstetrics and Gynecology 05/2013; 121(5):983-9.
• Article: Maternal and Neonatal Outcomes of Successful Kielland's Rotational Forceps Delivery.

  Sarah J Stock, Katherine Josephs, Sarah Farquharson, Corinne Love, Sarah E Cooper, Chris Kissack, Ranjit Akolekar, Jane E Norman, Fiona C Denison
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  ABSTRACT: : To estimate the rates of early neonatal and maternal complications in a consecutive series of successful Kielland's rotational forceps deliveries. : This was a retrospective cohort study of consecutive cases of successful rotational forceps deliveries performed in singleton pregnancies at 36 weeks of gestation or more in a tertiary referral center in Scotland, UK, from 2001 to 2008 (n=873). We also compared outcomes associated with successful rotational forceps deliveries in 2008 (n=150) with those of nonrotational forceps delivery (n=873), ventouse delivery (n=159), spontaneous vertex delivery (n=3,494), and emergency cesarean delivery (n=947). : There was one stillbirth associated with a rotational forceps delivery. This was diagnosed before application of forceps. After rotational forceps deliveries, 58 of 872 (6.7%) of live-born neonates were admitted to the neonatal unit. Twenty-seven of 872 (3.1%) neonates had one or more complications that could be attributable to traumatic delivery and seven neonates (0.8%) had a diagnosis of neonatal encephalopathy. When compared with alternative methods of delivery over a single year, neonatal admission rates after delivery by rotational forceps deliveries (5 of 150 [3.3%]) were not significantly different from spontaneous vertex delivery (128 of 3,494 [3.7%; P=1.00]) or ventouse delivery (6 of 159 [3.8%; P=1.00]) and lower than emergency cesarean delivery (106 of 947 [11.2%; P=.002). Postpartum hemorrhage rates after rotational forceps deliveries (8 of 150 [5.3%; P=.008]) were lower than those associated with emergency cesarean delivery (142 of 947 [15.0%; P=.008]). : Rates of short-term neonatal and maternal complications after successful rotational forceps deliveries are low. : II.
  Obstetrics and Gynecology 05/2013; 121(5):1032-9.
• Article: Spontaneous reports of seizure in association with leuprolide (lupron depot), goserelin (zoladex implant), and naferelin (synarel nasal spray).

  Jasmine Gatti, Allen Brinker, Mark Avigan
  Obstetrics and Gynecology 05/2013; 121(5):1107.
• Article: Management of initial bleeding or spotting after levonorgestrel-releasing intrauterine system placement: a randomized controlled trial.

  Terje Sørdal, Pirjo Inki, John Draeby, Mary O'Flynn, Thomas Schmelter
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  ABSTRACT: : To assess the efficacy of tranexamic acid or mefenamic acid in the management of the initial "nuisance" bleeding or spotting in the period immediately after placement of the levonorgestrel-releasing intrauterine system. : Women were randomized after levonorgestrel-releasing intrauterine system placement to oral tranexamic acid (500 mg), mefenamic acid (500 mg), or placebo three times daily during bleeding or spotting episodes over a 90-day treatment period. Treatment was initiated from onset of a bleeding or spotting episode and continued until the first day after bleeding or spotting stopped and restarted with a new bleeding or spotting episode. The primary efficacy variable was reduction in the number of bleeding or spotting days. Tranexamic acid and mefenamic acid were compared with placebo using a one-sided Wilcoxon rank-sum test. Bonferroni-Holm adjustment was used to account for multiple testing. : A total of 204 women were screened; 187 were randomized to tranexamic acid (n=63), mefenamic acid (n=63), or placebo (n=61). The median number of bleeding or spotting days experienced during treatment was 25, 29, and 33 days in the three groups, respectively. The median number of bleeding or spotting days was reduced by 6 days (95% confidence interval [CI] -14.0 to 1.0, P=.049) with tranexamic acid and by 3 days (95% CI -11.0 to 5.0, P=.229) with mefenamic acid compared with placebo. The relative risk of bleeding or spotting compared with placebo with tranexamic acid and mefenamic acid was 0.82 (95% CI 0.65-1.03) and 0.89 (95% CI 0.71-1.11), respectively. Most women (85% or more) were satisfied with the levonorgestrel-releasing intrauterine system across the groups. : Tranexamic acid and mefenamic acid during the first 90 days after levonorgestrel-releasing intrauterine system placement do not alleviate "nuisance" bleeding or spotting. : ClinicalTrials.gov, www.clinicaltrials.gov, NCT01295294. : I.
  Obstetrics and Gynecology 05/2013; 121(5):934-41.
• Article: In reply.

  Joshua L Woelk, John B Gebhart
  Obstetrics and Gynecology 05/2013; 121(5):1109-10.
• Article: In reply.

  Carmen M Tudela, James M Alexander
  Obstetrics and Gynecology 05/2013; 121(5):1110-1.
• Article: Expectant management compared with elective delivery at 37 weeks for gastroschisis.

  David Baud, Andrea Lausman, Malikah A Alfaraj, Gareth Seaward, John Kingdom, Rory Windrim, Jacob C Langer, Edmond N Kelly, Greg Ryan
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  ABSTRACT: : To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis. : The management of 296 pregnancies involving fetal gastroschisis (1980-2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation. : Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced. : In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation. : II.
  Obstetrics and Gynecology 05/2013; 121(5):990-8.
• Article: Electronic Fetal Monitoring in the United States: Temporal Trends and Adverse Perinatal Outcomes.

  Cande V Ananth, Suneet P Chauhan, Han-Yang Chen, Mary E D'Alton, Anthony M Vintzileos
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  ABSTRACT: OBJECTIVE:: To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality. METHODS:: We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use. RESULTS:: Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures. CONCLUSIONS:: The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations. LEVEL OF EVIDENCE:: II.
  Obstetrics and Gynecology 05/2013; 121(5):927-933.
• Article: Electronic fetal monitoring: the debate goes on...And on...And on.

  Robert Resnik
  Obstetrics and Gynecology 05/2013; 121(5):917-8.
• Article: Unintended pregnancy among active-duty women in the United States military, 2008 and "do ask, do provide" contraception for women in the u.s. Military.

  Kevin C Kiley
  Obstetrics and Gynecology 05/2013; 121(5):1111.
• Article: Severity of urinary incontinence and effect on quality of life in women by incontinence type.

  Vatche A Minassian, Elizabeth Devore, Kaitlin Hagan, Francine Grodstein
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  ABSTRACT: : To estimate how symptom severity, extent of bother, and quality of life differ across urinary incontinence (UI) subtypes. : We evaluated prevalent UI cases from the Nurses' Health Studies, including women aged 41-83 years. Women with UI (leaking more than once per month) were subclassified according to reported symptoms such as stress UI (SUI, leakage with activity), urge UI (UUI, leakage with urgency), or mixed UI (SUI and UI co-occurring equally). The UI severity was assessed in 102,418 women based on the Sandvik severity index. In a subset of older women with weekly UI, we asked about bother (n=1,697) and quality of life (Incontinence Impact Questionnaire; n=1,748). The UI severity, bother, and quality of life were compared across subtypes using polytomous logistic regression, adjusting for other characteristics. : The distributions of UI subtypes were 51% SUI, 27% UUI, and 22% mixed UI. Approximately half had slight UI, 26% had moderate UI, and 23% had severe UI. Severe UI was more common in women reporting mixed UI (37%) than UUI (27%) or SUI symptoms (15%) (P<.001). More women with severe mixed (21%; P=.02) and UUI symptoms (13%; P=.1) reported being "greatly" bothered by their UI compared with SUI (10%). Women with severe mixed (mean 18.0; P<.001) and UUI symptoms (mean 13.4; P=.004) had higher mean incontinence effect scores compared with SUI (mean 9.8). : Women reporting mixed UI symptoms describe more severe and bothersome incontinence, with higher effect on quality of life. : II.
  Obstetrics and Gynecology 05/2013; 121(5):1083-90.
• Article: Complications and continuation of intrauterine device use among commercially insured teenagers.

  Abbey B Berenson, Alai Tan, Jacqueline M Hirth, Gregg S Wilkinson
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  ABSTRACT: : Many U.S. health care providers remain reluctant to prescribe intrauterine devices (IUDs) to teenagers as a result of concerns about serious complications. This study examined whether 15-19-year-old IUD users were more likely to experience complications, failure, or early discontinuation than adult users aged 20-24 years and 25-44 years and whether there were differences in these outcomes between users of levonorgestrel-releasing intrauterine systems and copper IUDs. : A retrospective cohort study was conducted using health insurance claims obtained from a private insurance company of 90,489 women who had an IUD inserted between 2002 and 2009. Logistic regression models were used to estimate the odds of experiencing complications, method failure, or early discontinuation within 12 months of insertion by age group and type of IUD inserted. : Serious complications, including ectopic pregnancy and pelvic inflammatory disease, occurred in less than 1% of patients regardless of age or IUD type. Women aged 15-19 years were more likely than those aged 25-44 years to have a claim for dysmenorrhea (odds ratio [OR] 1.4, confidence interval [CI] 1.1-1.6), amenorrhea (OR 1.3, CI 1.1-1.5), or normal pregnancy (OR 1.4, CI 1.1-1.8). Overall, early discontinuation did not differ between teenagers and women aged 25-44 years (13% compared with 11%, P>.05). However, use of the levonorgestrel-releasing intrauterine system was associated with fewer complications and less early discontinuation than the copper IUD in all age groups. : The IUD is as appropriate for teenagers to use as it is for older women, with serious complications occurring infrequently in all groups. The levonorgestrel-releasing intrauterine system may be a better choice than the copper IUD as a result of lower odds of complications, discontinuation, and failure. : II.
  Obstetrics and Gynecology 05/2013; 121(5):951-8.
• Article: Breast effects of bazedoxifene-conjugated estrogens: a randomized controlled trial.

  Joann V Pinkerton, Jennifer A Harvey, Kaijie Pan, John R Thompson, Kelly A Ryan, Arkadi A Chines, Sebastian Mirkin
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  ABSTRACT: : To evaluate the effects of bazedoxifene-conjugated estrogens on mammographic breast density and other breast parameters in nonhysterectomized postmenopausal women enrolled in a randomized, double-blind, placebo-controlled, and active-controlled phase 3 study. : The 1-year Selective estrogens, Menopause, And Response to Therapy-5 trial estimated the efficacy and safety of bazedoxifene-conjugated estrogens in 1,843 postmenopausal women seeking vasomotor symptom treatment. A substudy enrolled 940 women with technically acceptable digital mammograms at screening and at 1 year. Treatments included bazedoxifene 20 mg and conjugated estrogens 0.45 or 0.625 mg, placebo, bazedoxifene 20 mg, and conjugated estrogens (0.45 mg) and medroxyprogesterone acetate (1.5 mg). Mammograms were centrally read by a single radiologist blinded to treatment and time sequence; percent breast density was determined using validated software. Noninferiority was based on a predefined margin of 1.5% for comparison of adjusted mean differences in breast density at 12 months. : Bazedoxifene 20 mg and conjugated estrogens 0.45 and 0.625 mg demonstrated noninferiority to placebo in breast density. Mammographic breast density decreased from baseline with bazedoxifene 20 mg and conjugated estrogens 0.45 and 0.625 mg and placebo (mean -0.38% and standard error [SE] 0.22%, mean -0.44% and SE 0.22%, mean -0.32% and SE 0.23%, respectively). Conjugated estrogens-medroxyprogesterone acetate significantly increased breast density from baseline (mean 1.60%, SE 0.35%; P<.001) compared with placebo. Both bazedoxifene-conjugated estrogens doses showed rates of breast tenderness similar to placebo and significantly (P<.001) lower than conjugated estrogens-medroxyprogesterone acetate. No differences in incidence of breast-related adverse events were identified. : Bazedoxifene 20 mg and conjugated estrogens 0.45 and 0.625 mg did not increase mammographic breast density or breast tenderness over the course of 1 year with a favorable breast-related safety profile. : ClinicalTrials.gov, www.clinicaltrials.gov, NCT00808132. : I.
  Obstetrics and Gynecology 05/2013; 121(5):959-68.
• Article: The learning curve of robotic hysterectomy.

  James B Hall
  Obstetrics and Gynecology 05/2013; 121(5):1109.
• Article: Noor.

  Asima K Ahmad
  Obstetrics and Gynecology 05/2013; 121(5):1099-103.
• Article: Loop electrosurgical excision procedure and the risk for preterm delivery.

  Annu Heinonen, Mika Gissler, Annika Riska, Jorma Paavonen, Anna-Maija Tapper, Maija Jakobsson
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  ABSTRACT: : To estimate whether the severity of cervical intraepithelial neoplasia (CIN) and the loop electrosurgical excision procedure (LEEP) increase the risk for preterm delivery, and to evaluate the role of repeat LEEP and time interval since LEEP. : This was a retrospective register-based study from Finland from 1997 to 2009. We linked Hospital Discharge Register and Finnish Medical Birth Register data. Case group women consisted of 20,011 women who underwent LEEP during the study period and their subsequent singleton deliveries in 1998-2009. Control population included women from the Medical Birth Register with no LEEP (n=430,975). The main outcome measure was preterm delivery before 37 weeks of gestation. : The risk for preterm delivery increased after LEEP. Women with previous LEEP had 547 (7.2%) preterm deliveries, whereas the control population had 30,151 (4.6%) preterm deliveries (odds ratio [OR] 1.61, confidence interval [CI] 1.47-1.75, number needed to harm 38.5). The overall preterm delivery rate in the study period was 4.6% for singleton deliveries. Repeat LEEP was associated with an almost threefold risk for preterm delivery (OR 2.80, CI 2.28-3.44). The severity of CIN did not increase the risk for preterm delivery. However, with LEEP for carcinoma in situ or microinvasive cancer, the risk for preterm delivery was higher (OR 2.55, CI 1.68-3.87). The increased risk also was associated with non-CIN lesions (OR 2.04, CI 1.46-2.87). Similarly, the risk was increased after diagnostic LEEP (OR 1.39, 95% CI 1.16-1.67). Time interval since LEEP was not associated with preterm delivery. Adjusting for maternal age, parity, socioeconomic or marital status, urbanism, and previous preterm deliveries did not change the results. : The risk for preterm delivery was increased after LEEP regardless of the histopathologic diagnosis. The risk was highest after repeat LEEP, which should be avoided, especially among women of reproductive age. : II.
  Obstetrics and Gynecology 05/2013; 121(5):1063-8.
• Article: Association of atypical decelerations with acidemia.

  Michael G Ross, Kevin Amaya, Bryan Richardson, Martin G Frasch
  Obstetrics and Gynecology 05/2013; 121(5):1107-8.
• Article: In reply.

  Holly E Richter, Alison M Parden, Jonathan L Gleason
  Obstetrics and Gynecology 05/2013; 121(5):1108-9.
• Article: Prophylactic use of levonorgestrel-releasing intrauterine system in women with breast cancer treated with tamoxifen: a randomized controlled trial.

  Alice W Y Wong, Symphorosa S C Chan, Winnie Yeo, Mei-Yung Yu, Wing-Hung Tam
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  ABSTRACT: : To estimate the rate of endometrial pathology with the prophylactic use of levonorgestrel-releasing intrauterine system in women with breast cancer treated with tamoxifen. : This was a randomized contro-lled trial of 129 Chinese women who attended a university hospital in Hong Kong and required adjuvant tamoxifen for breast cancer after the completion of postoperative radiotherapy and chemotherapy. Women were randomized to treatment (prophylactic levonorgestrel-releasing intrauterine system insertion before the commencement of tamoxifen) or control group. The uterine cavity was examined by hysteroscopy and endometrial sampling before the commencement of tamoxifen and at 12, 24, 45, and 60 months afterward. Any endometrial polyps or submucosal fibroids were resected through hysteroscopy at each assessment and specimens were sent for histologic confirmation. : A total of 94 women completed 5-year follow-up. There was no significant difference in the occurrence of submucosal fibroids (1 [1.8%] compared with 2 [3.4%]) and endometrial hyperplasia (both 0) in the treatment and control groups, respectively. Levonorgestrel-releasing intrauterine system significantly reduced de novo endometrial polyps (hazard ratio 0.19, 95% confidence interval 0.07-0.48) over the course of 5 years on an intention-to-treat basis. There was no statistically significant increase in breast cancer recurrence rate (10 [17.2%] compared with 6 [10.0%]) or cancer-related deaths (6 [10.3%] compared with 5 [8.3%]) in the treatment group, but the study was underpowered in this regard. : Prophylactic levonorgestrel-releasing intrauterine system prevents de novo endometrial polyps in women using tamoxifen. However, its role in the prevention of endometrial hyperplasia and adenocarcinoma as well as its effect on risk of breast cancer recurrence remain uncertain. : Chinese Clinical Trial Registry, http://www.chictr.org/en/, ChiCTR-TRC-09000625. : I.
  Obstetrics and Gynecology 05/2013; 121(5):943-50.
• Article: A Multistate Quality Improvement Program to Decrease Elective Deliveries Before 39 Weeks of Gestation.

  Bryan T Oshiro, Leslie Kowalewski, William Sappenfield, Caroline C Alter, Vani R Bettegowda, Rebecca Russell, John Curran, Lori Reeves, Marilyn Kacica, Nelson Andino, Peyton Mason-Marti, Dennis Crouse, Susan Knight, Karen Littlejohn, Sharyn Malatok, Donald J Dudley, Scott D Berns
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  ABSTRACT: OBJECTIVE:: Nonmedically indicated (elective) deliveries before 39 weeks of gestation result in unnecessary neonatal morbidity. We sought to determine whether implementation of a process improvement program will decrease the rate of elective scheduled singleton early-term deliveries (37 0/7-38 6/7 weeks of gestation) in a group of diverse community and academic hospitals. METHODS:: Policies and procedures for scheduling inductions and cesarean deliveries were implemented and patient and health care provider education was provided. Outcomes for scheduled singleton deliveries at 34 weeks of gestation or higher were submitted through a web-based data entry system. The rate of scheduled singleton elective early-term deliveries as well as the rates of early-term medically indicated and unscheduled deliveries, neonatal intensive care unit admissions, and singleton term fetal mortality rate were evaluated. RESULTS:: A total of 29,030 scheduled singletons at 34 weeks of gestation or higher were delivered in 26 participating hospitals between January 2011 and December 2011. Elective scheduled early-term deliveries decreased from 27.8% in the first month to 4.8% in the 12th month (P<.001); rates of elective scheduled singleton early-term inductions (72%, P=.029) and cesarean deliveries (84%; P<.001) decreased significantly. There was no change in medically indicated or unscheduled early-term deliveries. Neonatal intensive care unit admissions among scheduled early-term singletons decreased nonsignificantly from 1.5% to 1.2% (P=.24). There was no increase in the term fetal mortality rate. CONCLUSION:: A rapid-cycle process improvement program substantially decreased elective scheduled early-term deliveries to less than 5% in a group of diverse hospitals across multiple states. LEVEL OF EVIDENCE:: III.
  Obstetrics and Gynecology 05/2013; 121(5):1025-1031.