Obstetrics and Gynecology

Published by Lippincott, Williams & Wilkins
Print ISSN: 0029-7844
The objective of this study was to evaluate pregnancy outcomes by obesity classification using the 2009 Institute of Medicine weight gain guidelines. We conducted a retrospective cohort analysis of 1,886 obese women who delivered a singleton pregnancy at our institution from 2009 to 2012. Women were stratified based on prepregnancy body mass index (BMI) into subclasses of obesity: class I (BMI 30.0-34.9 kg/m), class II (BMI 35.0-39.9 kg/m), and class III (BMI 40.0 kg/m or greater). The primary outcome was cesarean delivery. Secondary outcomes included hypertensive disorders of, gestational diabetes, preterm delivery, small for gestational age, and large for gestational age. Odds ratios and 95% confidence intervals were calculated based on weight gain less than or greater than the recommended 11-20 pounds. Weight gain within guidelines was the referent for each class. Before pregnancy, 957 women were obese class I, 508 women were obese class II, and 421 women were obese class III. During pregnancy, 60.1% of women gained more than the recommended amount of weight; only 18.7% of women gained the recommended 11-20 pounds. Women with class I obesity increased their risk of hypertensive disorders and large for gestational age with excessive weight gain. Women with class II obesity increased their risk of cesarean delivery with excessive weight gain. Women with class III obesity increased their risk of cesarean delivery and hypertensive disorders with excessive weight gain. Less than recommended weight gain had no clear associations. Weight gain above the guideline was common and associated with adverse pregnancy outcomes among all subclasses of obesity.
Patient-applied formulations of 0.5% podofilox (podophyllotoxin) were evaluated for the treatment of external genital warts in a double-blind, placebo-controlled study. Seventy-two women were enrolled and, using a randomized, computer-generated list, assigned to receive either active drug or placebo in a 2:1 ratio. Patients were instructed to apply the medication to their external warts twice each day for 3 consecutive days, followed by 4 days without treatment. This cycle was repeated at weekly intervals for a maximum of 4 weeks (and a minimum of 2 weeks). Patients were evaluated weekly for the first month and then at weeks 6 and 10. The number of warts present was recorded and the overall improvement was assessed. The treated area was examined, the patients were questioned about any adverse effects, and standard hematologic/biochemical studies were conducted. The final results showed that podofilox cleared 74% of the total wart count, compared with an 18% regression in the placebo group (P less than .001). The investigators' assessments of improvement correctly distinguished active drug from placebo at every observation point. Local untoward effects were minor and transient. There was no evidence of systemic effects. It is concluded that patient-applied podofilox is a safe and effective therapy for genital condylomata in women. When available, this drug will simplify the treatment of genital warts by providing a patient-applied alternative therapy.
To assess the efficacy of 0.75% metronidazole vaginal gel, formulated at pH 4.0, for the treatment of bacterial vaginosis in a double-blind, placebo-controlled crossover trial. Fifty-three women with bacterial vaginosis (clue cells of at least 20% plus vaginal pH of at least 4.7, amine odor, or homogeneous discharge) were enrolled. Women with concomitant infection by Candida, Trichomonas, Chlamydia trachomatis, or Neisseria gonorrhoeae were excluded. Five grams of metronidazole gel or placebo was inserted intravaginally twice daily for 5 days. Response to therapy was evaluated at 4-16 days and 1 month after treatment. Twenty-six of the 30 women (87%) who received metronidazole were free of bacterial vaginosis 9-21 days after enrollment, compared with only four (17%) of 23 placebo-treated women (P < .001). Women who were cured were followed prospectively. Those who had persistent bacterial vaginosis were crossed over to metronidazole gel in an open trial; bacterial vaginosis was eradicated in 21 of 23 (91%) of these women at the 2-week follow-up. Recurrent bacterial vaginosis developed within 1 month in four (15%) of 26 women who were initially cured after receiving metronidazole gel. Response to therapy was accompanied by a decrease in vaginal Bacteroides, Gardnerella vaginalis, and Mycoplasma hominis. Treatment with intravaginal metronidazole gel resulted in a clinical cure in 87% (placebo-controlled trial) to 91% (crossover trial) of women with bacterial vaginosis. The recurrence rate of 15% at 1 month after treatment is similar to that reported with oral metronidazole.
Terconazole is the first topical triazole antifungal agent. The results of several European clinical trials have shown both terconazole cream and suppositories to be effective and safe in the treatment of vulvovaginal candidiasis. We conducted a comparative placebo-controlled, double-blind study of 0.8 and 1.6% terconazole creams in a group of patients with persistent vulvovaginal candidiasis. In short-term evaluations (1-3 days and 8-11 days after therapy), 75% of patients receiving 0.8% terconazole cream were asymptomatic and 83.3% were mycologically cured. By 30-35 days after therapy, 75% were still asymptomatic and 58.3% were mycologically negative. No significant difference was seen between the results obtained with 0.8 and 1.6% terconazole creams. Safety data collected on these patients demonstrated that the side effects were rare and mild. This study confirms the efficacy and safety of topical terconazole in patients with vulvovaginal candidiasis.
Ultrasonograms of 45 patients with 51 surgically proved benign cystic teratomas (dermoid cysts) of the ovary were reviewed to evaluate the ultrasonographic appearance of this entity. Contrary to several recent reports stressing a "typical" appearance for ovarian dermoid cysts, ie, an echogenic focus with acoustic shadowing situated within a predominantly cystic mass, the authors observed a much broader spectrum of appearances. Thirty-three percent of the cases demonstrated "typical" findings, 23.5% were predominantly solid, 20% were almost entirely cystic, and 23.5% were not visible. Ultrasound and conventional radiography in patients with dermoid cysts were compared: Ultrasonography contributed significantly to the correct diagnosis in the majority of cases. Because ultrasonography lacks ionizing radiation, and its use may reveal unrelated pelvic pathology, it should be the initial diagnostic modality in the examination of patients with suspected dermoid cysts of the ovary.
To identify modifiable obstetric factors associated with the failure of zidovudine chemoprophylaxis to prevent perinatal human immunodeficiency virus type 1 (HIV-1) transmission. We analyzed data from Pediatric AIDS Clinical Trials Group protocol 076, a randomized, double-masked, placebo-controlled trial that demonstrated that a zidovudine regimen could prevent perinatal HIV-1 transmission. We estimated the zidovudine treatment effect using the relative reduction in transmission risk among women randomized to treatment with zidovudine compared with women randomized to receive placebo. Univariate and multivariate statistical analyses were used to assess whether the treatment effect differed in magnitude according to potential antepartum or intrapartum risk factors. In the univariate analysis, the zidovudine treatment effect was found to differ significantly in magnitude according to quartile of maternal weight at the time of study entry (interaction test, P = .03); among women in the heaviest-weight quartile (weight more than 82 kg), there was a 26% relative reduction in transmission risk, compared with a 79% relative reduction among the other three quartiles (interaction test, P = .05). In the zidovudine treatment group, women who transmitted HIV-1 were significantly more likely than nontransmitters to have had antepartum procedures or conditions associated with increased risk of fetal exposure to maternal blood or cervicovaginal secretions (43% compared with 19%, P = .04). In the multivariate analysis, adjustment for the plasma HIV-1 RNA level and CD4+ cell percentage did not eliminate the differential treatment effect according to these factors. High maternal weight and conditions associated with fetal exposure to maternal blood or cervicovaginal secretions may diminish the efficacy of zidovudine chemoprophylaxis.
The effect of maternal diet on serum 1,25-dihydroxyvitamin D has not been determined in human lactation. Serum 1,25-dihydroxyvitamin D, other calcitropic hormones, osteocalcin, and minerals were examined in lactating and nonlactating women consuming a vegetarian or nonvegetarian diet. The vegetarian diet was a macrobiotic diet consisting primarily of whole cereal grains and vegetables; dairy products, eggs, and meats were generally avoided. We tested the thesis that the effect of lactation on serum 1,25-dihydroxyvitamin D is more pronounced in women on vegetarian diets than in those on nonvegetarian diets. Serum 1,25-dihydroxyvitamin D concentrations were significantly higher in lactating women compared with nonlactating women and in vegetarian compared with nonvegetarian women. Among vegetarian women, mean serum 1,25-dihydroxyvitamin D concentrations were 37% higher in the lactating group. For all subjects, serum parathyroid hormone was elevated during lactation compared with nonlactation. Thus, a vegetarian diet appears to be associated with increased serum 1,25-dihydroxyvitamin D during lactation.
To evaluate whether mode of delivery is a predictor of poor short-term outcome at different birth weight categories in very low birth weight infants. This study examined a cohort of infants weighing less than 1,251 g born at 2 perinatal centers from January 1, 2000, to December 31, 2003. Outborn infants or those with major anomalies were excluded from the study. Outcome variables included death, severe intraventricular hemorrhage, periventricular leukomalacia (PVL), and combined poor short-term outcomes (death, severe intraventricular hemorrhage, and PVL). Of the 397 infants who met enrollment criteria, 44% were born vaginally and 56% by cesarean delivery. The proportion of multiparous, breech presentation and prolonged rupture of membranes was significantly different between groups. For infants weighing less than 751 g, the risks of severe intraventricular hemorrhage (41% versus 22%; odds ratio [OR] 2.79, 95% confidence interval [CI] 1.08-7.72) and combined poor short-term outcome (67% versus 41%; OR 2.95, 95% CI 1.25-6.95) were significantly higher if delivered vaginally. Among survivors weighing less than 751 g, the risk of severe intraventricular hemorrhage was higher among those delivered vaginally (24% versus 9%; OR 8.18, 95% CI 1.58-42.20). In infants less 1,251 g who survived, vaginal delivery had a strong association with PVL (5% versus 1%; OR 11.53, 95% CI 1.66-125). In infants less than 1,251 g who survived to discharge, vaginal delivery is associated with higher risk for PVL. Furthermore, in infants less than 751 g, vaginal delivery is a predictor for severe intraventricular hemorrhage and combined poor short-term outcome. The negative impact of vaginal delivery mode decreases as birth weight category increases.
To assess the efficacy, safety, and tolerability of an extended-duration, combined hormonal oral contraceptive pill (OCP) that reduces the estrogen exposure by almost half compared with other OCPs. This open-label, uncontrolled, multicenter study used an ultra low-dose OCP (1.0 mg norethindrone acetate and 10 micrograms ethinyl E2). The OCP was administered in a regimen of 24 days of a 28-day cycle followed by 10 micrograms ethinyl E2 for 2 days and an inactive tablet for 2 days. The study included healthy, heterosexually active women aged 18-45 years who were at risk of pregnancy. The discontinuation rate was 41.7% (692/1,660 patients). Twenty-six pregnancies occurred in 1,555 participants during 15,596 at-risk cycles, resulting in a Pearl Index of 2.2 and a cumulative pregnancy rate of 2.1 for the overall population. Participants experienced an average of 2.6 days of intracyclic (unscheduled) bleeding or spotting per cycle over treatment cycles 213. Intracyclic bleeding was more common in users new to OCPs than in users switching from another OCP and in women aged 18-35 years compared with those aged 36 years or older. The frequency of bleeding episodes decreased after cycle 2 and throughout treatment in all subpopulations. The findings of this study demonstrate that this ultra low-dose OCP regimen is effective in preventing pregnancy with a safety and tolerability profile that is comparable with that reported for other low-dose OCPs. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00391807. LEVEL OF EVIDENCE:: III.
A recent over-the-counter simulation study (Raine TR, Ricciotti N, Sokoloff A, Brown BA, Hummel A, Harper CC. An over-the-counter simulation study of a single-tablet emergency contraceptive in young females. Obstet Gynecol 2012;119:772-9.) of a single-dose emergency contraceptive demonstrated young women's ability to appropriately select and correctly use the emergency contraceptive. This post hoc analysis examined the safety of the emergency contraceptive in various age subgroups. This was a noncomparative case-series study of a single-dose 1.5 mg levonorgestrel emergency contraceptive. Eligible women were 11-17 years of age and presented to study sites requesting emergency contraception. Safety information (side effects and any medical problems) was collected by telephone or return clinic visit at approximately 1, 4, and 8 weeks after the date the emergency contraceptive was dispensed. Safety data were retrospectively assessed in the following age subgroups: 13-14, 15-16, and 17 years. There were 299 women included in the safety analysis (11-12 year olds, n=0; 13 year olds, n=2; 14 year olds, n=30; 15 year olds, n=87; 16 year olds, n=123; 17 year olds, n=57). The incidence of treatment-emergent adverse events were 13% (4/32) in 13-14 year olds, 16% (34/210) in 15-16 year olds, and 12% (7/57) in 17 year olds. The emergency contraceptive was well tolerated in all age subgroups. The most commonly reported treatment-emergent adverse event(s) in each age subgroup was as follows: in 13-14 year olds, vaginal bleeding (6% [2/32]); in 15-16 year olds, nausea and headache (each 3% [6/210]); in 17 year olds, nausea and vulvovaginal mycotic infection (each 4% [2/57]). This post hoc analysis found a single-dose 1.5 mg levonorgestrel emergency contraceptive to be safe and well tolerated in young women of various ages, ranging from 13 to 17 year olds.
We evaluated the postoperative changes in serum electrolytes in relation to the amount of irrigating fluid absorption and the occurrence of nausea and vomiting after transcervical resection of endometrium and submucous fibroids. From May 1989 to October 1991, 101 consecutive patients were operated on for menometrorrhagia with transcervical resection of endometrium and submucous fibroids using glycine 1.5% for uterine irrigation. The deficit of glycine was assessed during and at the end of the operation. During the postoperative course, attention was paid to the occurrence of cerebral confusion, nausea (defined by at least one incident of vomiting), and dyspnea. The serum levels of sodium, potassium, and chloride were assessed before the operation, at the end of the procedure, and after 4, 8, and 12 hours. No marked water intoxication or signs of volume overload were seen, but 33% of the patients had nausea and vomiting in the postoperative period. These patients showed a more pronounced postoperative decrease in serum sodium (P = .0001) and a larger glycine deficit (P = .004) than did patients without nausea. The postoperative decrease in serum sodium correlated significantly to the glycine deficit (R2 = 0.83, P less than .001). Postoperative hyponatremia after transcervical resection of the endometrium correlated with the deficit of irrigant fluid but not with the operation time or the total amount of irrigant fluid used. We recommend that serum sodium be controlled and corrected if necessary postoperatively in patients with nausea and vomiting.
The safety and efficacy of the Silastic ring were examined for interval, postabortion, and postpartum sterilizations. The study includes an in-depth analysis of 10,086 cases generated by 51 collaborating institutions in 23 countries. Failure of the tubal ring is studied via the life-table method, although follow-up is limited to a relatively short period. Difficulties encountered when applying the ring, particularly those resulting in technical failure, are explored in detail. Surgical complications, infection, menstrual irregularity and abnormal bleeding, and pelvic surgery following sterilization are discussed. Comparisons are made among various approaches to the fallopian tubes. Such data are found to be similar to those for other occlusion techniques, demonstrating the comparable safety and efficacy of tubal ring sterilization.
Laparoscopy as an outpatient technique has brought sterilization within the reach of millions of women in the developing countries. A review of the literature indicates that it can be performed easily and safely with the patient under local anesthesia. This report presents the personal experience of the author in the performance of 10,100 laparoscopic sterilizations using the double-puncture technique and a Falope ring applicator on patients gathered in rural sterilization camps in India. Modifications of the standard procedures to suit the camp surroundings and to reduce the operating time are described. Results are described and discussed. There was 1 death (not related to the operation), 1 major complication, and a few minor complications. The method is urged as a valuable one for mass sterilization in Third World countries.
To evaluate maternal and neonatal factors that predict low Apgar scores in newborns weighing less than 1000 g. From a data set of all live-born infants who were delivered between 1979-1991 and who weighed 1000 g or less, we reviewed the records of 837 neonates born at 24-28 weeks' gestation. Potential risk factors were evaluated for associations with a 1-minute Apgar score of 3 or less and a 5-minute Apgar score of 6 or less. Analyses used chi 2 test and multiple logistic regression. The prevalence of 1-minute Apgar scores of 3 or less decreased from 65.9% at 24 weeks to 38.2% at 28 weeks, and the prevalence of 5-minute Apgar scores of 6 or less decreased from 83.3% at 24 weeks to 51.2% at 28 weeks. As the birth weight increased from 500-599 g to 900-1000 g, 1-minute Apgar scores of 3 or less decreased from 77.0% to 39.6%, and 5-minute Apgar scores of 6 or less decreased from 89.2% to 56.4%. Aside from gestational age and birth weight, corticosteroid use was the strongest predictor of Apgar scores above 3 at 1 minute and above 6 at 5 minutes. Male and nonvertex-presenting infants had an increased likelihood of low Apgar scores, as did infants with cord blood pH less than 7.05 or bicarbonate value less than 17 mEq/L. Neonates at very low gestational ages and birth weights are more likely than larger or more mature infants to have low Apgar scores. Males, nonvertex-presenting infants, and those who are acidotic at birth also have an increased prevalence of low scores. Infants born to mothers treated with antenatal corticosteroids are less likely to have low Apgar scores. This finding indicates that antenatal corticosteroids may benefit the newborn at birth, before respiratory distress syndrome becomes apparent.
The aim of this study was to assess the outcome up to 2 years of age for the fetus of birth weight 500-999 g, over time and in association with changes in obstetric care. Two consecutive cohorts of infants of birth weight 500-999 g were compared from two eras, 1977-1982 and 1985-1987, and their outcome up to 2 years of age was determined with particular emphasis on the effect of various obstetric interventions at the time of birth, such as cesarean delivery, electronic fetal monitoring, antenatal steroid therapy, and tocolytic therapy. The outcome to 2 years was analyzed by logistic function regression to adjust for imbalances in confounding perinatal variables. In the latter era, the survival rate to 2 years increased significantly by almost 50%, and only 7% of the survivors were severely disabled. The rates of delivery by cesarean and of electronic fetal monitoring both increased significantly in the latter era, but neither was associated with the improved outcome. The only variable associated with an improved outcome that was amenable to obstetric intervention at the time of birth was antenatal steroid therapy, which was used equally in both eras. The obstetrician may aid the fetus of birth weight 500-999 g by giving the mother steroids to accelerate fetal lung maturity, but cesarean cannot be recommended as the routine mode of delivery unless there are recognized maternal or fetal indications.
This retrospective analysis of 76 extremely low birth weight neonates (500-1000 g) compared the actual birth weight with the estimated fetal weight derived from 20 published formulas. In our population, Rose's formula (natural log of birth weight = 0.143 x (biparietal diameter + mean abdominal diameter + femur length) + 4.198] had the smallest standard deviation and the best r2 (69 g and 0.780, respectively). The maximum estimated fetal weight underestimate and overestimate were 95 and 159 g, respectively. Using this formula, 46 of 63 (73%) of the estimated fetal weights were within 10% of the birth weight and 56 of 63 (89%) were within (+/-) 100 g of the birth weight. No formula was found to be statistically different by pooled estimate of differences of slopes. When only the biparietal diameter and abdominal wall circumference were available, the Shepard revision of the Warsof equation gave standard deviation 81.7 g and r2 of 0.748; 53 of 67 estimated weights (79%) were within 100 g of the birth weight. When only femur length and mean abdominal diameter were available, the Rose 3 formula [natural log of birth weight = 0.2053 (femur length + mean abdominal diameter) + 4.3726] gave a standard deviation of 89.9 g and r2 of 0.658. Fifty-seven of 71 estimated weights (80%) were within 100 g of the actual birth weight. This study, the largest comparison of formulas to estimate the birth weight of 500-1000-g fetuses, found that no formula estimated fetal weight significantly more accurately than any other.
To evaluate the influence of acid-base status at birth and Apgar scores on survival in very low birth weight infants. We evaluated 1073 infants born alive and weighing 500-1000 g during 1979-1991; 658 had umbilical artery gas values examined. Apgar scores were assigned at 1 and 5 minutes after birth. Umbilical artery blood samples were collected at delivery for pH, carbon dioxide pressure (PCO2), and bicarbonate. Infants were grouped at 23-24, 25-26, 27-28, and 29 weeks or more. Using survival as the dependent variable, multiple logistic regression analyses were performed controlling for gestational age, birth weight, plurality, antenatal glucocorticoid use, mode of delivery, and year of birth, as well as for Apgar scores and cord blood gases. In every gestational age grouping, compared with infants with a pH lower than 7.05, survival was higher in infants with an umbilical artery pH of 7.05 or higher, significantly so at 27-28 weeks. There was no consistent relationship between umbilical artery PCO2 or bicarbonate and survival. However, with the exception of the 1-minute Apgar score at 23-24 weeks, the relationship of Apgar scores to survival was significant in all gestational age periods. Using multiple logistic regression analyses, the only significant relationships between any of the cord blood gases, Apgar scores, and mortality involved low 1-minute (odds ratio [OR] 2.7 [95% confidence interval (CI) 2.0-3.6]) and low 5-minute Apgar scores (OR 2.8 [95% CI 2.0-3.8]) and a bicarbonate less than 21 mEq/L (OR 1.6 [95% CI 1.1-2.4]). One- and 5-minute Apgar scores are better predictors of survival than umbilical artery blood gases in neonates weighing 500-1000 g at birth.
To determine whether long-term intravenous (IV) tocolysis using combined terbutaline and magnesium sulfate is safe and effective. One thousand consecutive women in preterm labor were treated with combination IV tocolytic therapy. Terbutaline was initiated with an infusion rate of 1.75 micrograms/minute and increased to a maximum of 80 micrograms/minute. Magnesium sulfate was infused at 2 g/hour without any bolus and increased to maintain a serum level of 6.5-7.5 mg/dL. Tocolysis was continued until fetal lung maturity was achieved or delivery occurred. Combination tocolytic therapy prolonged pregnancy by a mean (+/- standard deviation) of 61 +/- 23.6 days in 751 women with intact membranes and by 20.5 +/- 17.4 days in 249 with ruptured membranes. The longest durations of continuous IV tocolysis were 123 days in a patient with intact membranes and 77 days in one with ruptured membranes. The most common side effects were nausea and vomiting, followed by chest tightness and shortness of breath. Long-term IV tocolysis appeared to be safe and to have acceptable side effects, allowing patients to receive combined terbutaline and magnesium sulfate until delivery.
During a 5-year period (1974 to 1978), 84 mothers with an average age of 26.3 +/- 4.5 years delivered 89 newborn infants who subsequently died. Each infant weighed less than 1000 g. These infants had a mean birth weight of 790 +/- 170 g and a mean gestational age of 26.3 +/- 1.9 weeks. Thirty-six (90%) of 40 mothers who subsequently became pregnant gave birth to a surviving newborn. The mean gestation age and birth weight were 37.6 +/- 3 weeks and 2754 +/- 754 g, respectively. Similar data were obtained from a control group of 565 mothers who delivered normal infants at term during a 2-month interval within the study period. In the control group 170 mothers subsequently became pregnant and 163 (96%) gave birth to normal infants at term. Mean gestational age was 39.09 +/- 2 weeks (P less than .001) and birth weight was 3304 +/- 566 g (p less than .001).
Thesis (M.S. (Med.) in Gynecology-Obstetrics)--Graduate School of Arts and Sciences, University of Pennsylvania, 1958. Bibliography: l. 34-35.
To examine the life expectancy and cost-effectiveness of hormone replacement therapy (HRT) and raloxifene therapy in healthy 50-year-old postmenopausal women. We performed a cost-effectiveness analysis using a Markov model, discounting the value of future costs and benefits to account for their time of occurrence. Both HRT and raloxifene therapy increase life expectancy and are cost-effective relative to no therapy for 50-year-old postmenopausal women. For women at average breast cancer and coronary heart disease risk, lifetime HRT increases quality-adjusted life expectancy more (1.75 versus 1.32 quality-adjusted life years) and costs less ($3802 versus $12,968) than lifetime raloxifene therapy. However, raloxifene is more cost-effective than HRT for women at average coronary risk who have a lifetime breast cancer risk of 15% or higher or who receive 10 years or less of postmenopausal therapy. Raloxifene is also the more cost-effective alternative if HRT reduces coronary heart disease risk by less than 20%. Assuming the benefit of HRT in coronary heart disease prevention from observational studies, long-term HRT is the most cost-effective alternative for women at average breast cancer and coronary heart disease risk seeking to extend their quality-adjusted life expectancy after menopause. However, raloxifene is the more cost-effective alternative for women at average coronary risk with one or more major breast cancer risk factors (first-degree relative, prior breast biopsy, atypical hyperplasia or BRCA1/2 mutation). These results can help inform decisions about postmenopausal therapy until the results of large scale randomized trials of these therapies become available.
To investigate whether S-100beta, a brain-specific protein found in amniotic fluid and fetal circulation, is present in fetoplacental tissues throughout gestation. S-100beta protein localization and concentration were assessed in placentae, fetal membranes, and cord vessels. Tissues were obtained from 40 pregnant women at different gestational ages: first trimester (n = 10), second trimester (n = 10), early third trimester (n = 10), and late third trimester (n = 10). In the placenta, S-100beta was localized in villous and intermediate trophoblast cells. The intensity of immunostaining and protein concentration increased with advancing gestation. S-100beta protein was also present in amnion, trophoblast, and decidual cells of fetal membranes, and in endothelial cells of umbilical vessels at all gestational ages. This study demonstrated that fetoplacental tissues contain S-100beta protein, suggesting that these tissues may, at least in part, be responsible for the high level found in the fetal circulation. Although the significance of placental S-100beta is unknown, this origin should be taken into account when this protein is used as a marker of brain injury in the fetus or infant at birth.
To examine the hypothesis that alcohol consumption is associated with the risk of ovarian cancer by conducting a population-based, case-control study in Hawaii and Los Angeles, California. In-person interviews were obtained from 558 women with ovarian cancer and 607 population controls regarding lifetime alcohol consumption and other factors that may be related to the development of ovarian cancer. We found no overall association of alcohol drinking with the odds ratios (OR) for ovarian cancer. However, current alcohol drinkers, but not former drinkers, had a significantly lower OR for ovarian cancer compared with never drinkers (OR 0.69, 95% confidence interval [CI] 0.50, 0.96). Odds ratios for ovarian cancer associated with the current consumption of beer, wine, and spirits were also reduced, but were only significant for wine drinkers. Among current wine drinkers, women who drank red wine had a significantly reduced OR for ovarian cancer compared with never drinkers (OR 0.61, 95% CI 0.39, 0.94). The inverse association of current alcohol drinking with the OR for ovarian cancer was restricted to invasive tumors, especially the endometrioid cell type. The number of glasses of alcohol consumed on a weekly basis was inversely related to the OR for invasive ovarian cancer (P =.009): Current drinkers consuming 14 or more drinks per week had an OR of 0.36 (95% CI 0.19, 0.70) compared with never drinkers. A significantly increased risk of borderline serous tumors was associated with the use of spirits (OR 2.66, 95% CI 1.46, 4.85). The risk for borderline mucinous tumors was also significantly elevated for former wine drinkers. These findings suggest that the association of alcohol consumption with the OR for ovarian cancer may vary by alcohol type, tumor invasiveness, and histology.
Our goal was to evaluate the comfort, competence, and value of using the ARMS PelvicSim, a high-fidelity mobile training model for insertion of intrauterine contraception, to train clinicians in intrauterine contraception provision. Clinicians at ambulatory reproductive health care clinics participated in the PelvicSim training and completed a self-administered survey from January to July 2014. The survey assessed experience with levonorgestrel (LNG) and copper intrauterine contraception insertion, pretraining and posttraining competence and comfort inserting intrauterine contraception, and opinions regarding the value of the PelvicSim. The 140 respondents were primarily female (95.7%) and nurse practitioners (65.5%). Nearly half had inserted more than 50 LNG20 devices (46.4%) or copper t380A devices (48.3%), although 98.3% had never inserted the LNG14 device. For these devices, participants reported feeling more independently competent after training. We observed the largest influence on the LNG14; the proportion of participants who felt independently competent pretraining and posttraining increased significantly from 19.2% to 50.0% (P<.001). The majority of participants reported increased comfort with minimizing patient pain (76.7%) and inserting intrauterine contraception in a live patient (69.0%). Among respondents, 89.6% reported the PelvicSim intrauterine contraception insertion activities to be "valuable" or "very valuable." All participants would recommend the PelvicSim for intrauterine contraception training, and nearly all (95.6%) reported that the PelvicSim was a better method to teach intrauterine contraception insertion than the manufacturers' models. Clinicians reported increased competence and comfort regarding intrauterine contraception insertion after PelvicSim training. The PelvicSim was acceptable as an intrauterine contraception training tool, and nearly all participants found it superior to the manufacturers' models.
To investigate survivals from cervical cancer, with special reference to effects of glandular histology and its influence on prognostic characteristics and management decisions. Data on cervical cancers, diagnosed in 1984-2000, were obtained from the gynecologic oncology registry of hospitals of the University of Adelaide. Comparisons were made of disease-specific survival, age at diagnosis, diagnostic period, stage, grade, and primary course of treatment. The study included 544 squamous cell carcinomas, 43 adenosquamous carcinomas, five clear cell cancers, 136 other adenocarcinomas, and 19 cancers of "other" histological type. Overall survival was 72.2% at 5 years from diagnosis, decreasing to 67.5% at 15 years. Survival was lower for older ages, higher grades, and higher International Federation of Gynecology and Obstetrics stages, although equivalent for stages IIA and IIB. Unadjusted survivals varied by histological type (P =.001), with lower survivals suggested for adenosquamous and clear cell lesions and "other" histological types than for squamous cell carcinomas and other adenocarcinomas. After adjusting for age, stage, grade, and diagnostic period, adenocarcinomas had a higher case fatality than squamous cell lesions (relative risk 2.08, 95% confidence limit 1.35, 3.21), whereas the elevation in relative risk was lower and not statistically significant for a combined adenosquamous and clear cell category at 1.25 (0.69, 2.24). For stage II, both adenocarcinomas and the adenosquamous and clear cell group had lower survivals than squamous cell cancers. Relative to squamous cell carcinomas, adenocarcinomas and potentially adenosquamous cancers are becoming more common. This has implications for screening, treatment, and prognosis.
To describe the efficacy of the Finnish mass screening program for cervical squamous carcinoma and adenocarcinoma, as reflected by changes of incidence and mortality rate. Cervical cancer incidence and mortality data were obtained from the Finnish Cancer Registry. Data were available from the year 1953, when the registry was established. The nationwide mass screening program in Finland was started in the mid-1960s. A centralized organization administers this program. Women age 30-60 years are notified for screening every 5 years. The mean incidence of cervical carcinoma in the early 1960s was 15.4 per 10(5) woman-years. In 1991, it was only 2.7 per 10(5) woman-years. The mortality rate has decreased in the same proportion since the mass screening program. In the early 1960s, the mortality was 6.6 and in 1991 1.4 per 10(5) woman-years. However, the decrease of the incidence is seen almost exclusively in squamous cell carcinomas. The mortality caused by adenocarcinoma has decreased in screened birth cohorts, but the incidence rate has remained the same. The Finnish mass screening program has been effective and its continuation is of utmost importance. In the future more attention should be given to glandular cell atypias in cervical smears. Thus, it might be possible to decrease the incidence of cervical adenocarcinoma.
To assess whether the G allele of the serotonin receptor 1A C(-1019)G polymorphism is associated with premenstrual dysphoric disorder. The study sample comprised 53 women with clinically diagnosed premenstrual dysphoric disorder (age range 27-46 years, mean 37.7 years) and 51 healthy control subjects (age range 22-48 years, mean 36.2 years). The serotonin receptor 1A C(-1019)G polymorphism was genotyped and compared between the two groups. In contrast to the postulated "high-risk" G/G genotype, there was a marked overrepresentation of the C/C genotype in the premenstrual dysphoric disorder group (P=.034; odds ratio 3.63, 95% confidence interval 1.22-10.78). The presence of at least one C allele was associated with a 2.5-fold increased risk of premenstrual dysphoric disorder (P=.053; odds ratio 2.46, 95% confidence interval 1.03-5.88). Our hypothesis that the high-risk G allele is associated with the occurrence of premenstrual dysphoria was not proved in this study. However, due to the increased prevalence of the C variant, we suggest that the C(-1019) allele may contribute to the risk of premenstrual dysphoria. II.
To examine short- and long-term mesh-related complications in women undergoing abdominal sacral colpopexy with concurrent hysterectomy, compared with women with a prior hysterectomy undergoing sacral colpopexy alone. Patient characteristics, hospital complications, postoperative clinical course, and long-term graft-related complications were reviewed for all women with genital prolapse who underwent abdominal sacral colopexy between 1996 and 1998. Women with concurrent hysterectomy were compared with women with vaginal prolapse after a prior hysterectomy. One hundred twenty-four patients, 60 with concurrent hysterectomy and 64 with prior hysterectomy, were observed postoperatively for a median of 35.5 (0-74) months. Demographics of the two groups were similar, with a mean age of 65.1 +/- 9.4 years and a mean body mass index of 25.8 +/- 4.2 kg/m(2). Eighty percent of colpopexies used prolene synthetic mesh and 20% allograft material. Initial operative and hospital complications were rare in both groups and included a blood transfusion of 2 U, a ureteral transection, a wound infection, heart block, and an arrhythmia. Delayed graft complications included one mesh erosion in a patient with a prior hysterectomy that was managed by office resection (0.8%). Concurrent hysterectomy with abdominal sacral colopopexy has a low incidence of mesh complications and can be used as a first-line treatment for genital prolapse.
The Liaison Committee on Medical Education Standard 6.2 requires that medical schools define the types of patients and clinical conditions that medical students encounter. The underlying message is a robust, diverse clinical experience may lead to better medical knowledge and preparation. However, little is known about how well clinical experience correlates to medical knowledge. Self-reported student log cards for the obstetrics and gynecology rotations at Loyola University Chicago Stritch School of Medicine were retrospectively reviewed between July 2009 and December 2012. Categories include specific clinical conditions as well as total number of patients seen in different areas. Performance on the National Board of Medical Examiners' subject examination was also recorded. A total of 345 records were reviewed. Per rotation, students performing in the top quintile on the subject examination (higher than 80) reported more total encounters (167 compared with 139, P=.04), ambulatory prenatal encounters (19 compared with 15, P=.02), and postoperative encounters (19 compared with 14, P=.04). There was no significant correlation between any encounters and participant examination performance. No differences were noted for students in the bottom quintile (less than 65). Over the 3-year period, the total number of encounters reported per rotation dropped significantly (153 compared with 148 compared with 122, P=.04). Students scoring in the top quintile on the subject examination reported more total cases encountered. A robust clinical experience may have positive effects on measures of objective medical knowledge. Because clinical work hours have changed, the number of reported clinical encounters has declined.
Ectopic pregnancy represents an increasing proportion of direct maternal deaths which has reached 10%. Between 1950 and 1974 there were 102 deaths from early ectopic pregnancy reviewed by the Michigan Maternal Mortality Committee. These cases were analyzed by status on admission and compared to a control series treated at a medical center. Patients with ectopic pregnancy were older than women delivering live infants. There were no differences in age, gravidity, or parity between the study patients and controls. The study patients were slightly further advanced in pregnancy. Pain was the major presenting symptom. Marked delays occurred between first symptom, first consultation, and diagnosis. Seventy-five percent of the deaths were considered preventable. Hemorrhage was the leading cause of death. The estimated mortality of ectopic pregnancy is between 2 and 4/1000.
To examine alcohol consumption as a risk factor for epithelial ovarian cancer according to tumor histology. We examined total alcohol consumption and consumption of beer, wine, and spirits as risk factors for mucinous and nonmucinous tumors in a population-based, case-control study comparing 761 incident cases of epithelial ovarian cancer with 1352 community controls frequency-matched to cases by age and three-digit telephone exchange. Multivariable, unconditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for mucinous and nonmucinous tumors associated with alcohol consumption. Adjustments were made for age, parity, oral contraceptive use, education, tubal ligation, smoking, and family history of ovarian cancer. Overall, no association between total alcohol consumption and ovarian cancer was found. However, current heavy alcohol consumption (24 g or more per day) was associated with mucinous (OR 1.93; 95% CI 1.02, 3.65) but not nonmucinous tumors (OR 0.88; 95% CI 0.57, 1.37). The association between heavy current consumption and mucinous tumors was strongest for spirits (OR 8.83; 95% CI 2.89, 27.01) and apparent for beer (OR 2.53; 95% CI 0.86, 7.42). For nonmucinous tumors, no such associations were found for either spirits (OR 1.53; 95% CI 0.58, 4.00) or beer (OR 0.92; 95% CI 0.39, 2.14). Current heavy consumption of alcohol might be a risk factor for mucinous but not nonmucinous epithelial ovarian cancer. This supports the hypothesis of a distinct etiology for mucinous tumors.
OBJECTIVE; To compare the survival rates in younger (45 years or younger) and older women (over 45) diagnosed with advanced-stage invasive epithelial ovarian cancer. Clinical and pathologic factors responsible for survival differences between the two groups were also determined. All younger women with advanced-stage epithelial ovarian carcinoma diagnosed between 1984 and 2001 were identified from tumor registry databases at two hospitals. Patients with borderline tumors were excluded. An older group of comparable controls was selected for comparison. Kaplan-Meier and Cox proportional hazards analyses were used to determine the predictors for survival. Of 104 women with advanced-stage epithelial ovarian carcinoma, 52 were 45 or younger and the rest were over 45. The 5-year survival rate and median survival in younger patients were 48% and 54 months, compared with 22% and 34 months in the older women (P =.003). Younger women had significantly better performance status than older patients, and survival remained significantly better in younger women based on Kaplan-Meier analysis stratified by performance status (0 versus 1 to 2, P =.02). Furthermore, overall survival was significantly better in younger women after stratification by stage (III versus IV, P =.002) and by cytoreductive surgery (optimal versus suboptimal, P =.003). Multivariable analysis demonstrated that all these factors remained as significant independent prognostic factors for survival. Younger women with advanced-stage invasive epithelial ovarian cancer have significantly improved survival rates relative to older patients. Age, performance status, stage of disease, and extent of cytoreductive surgery are important independent prognostic factors for survival.
A total of 5447 contraction stress tests (CST) were performed on 3246 high-risk patients during pregnancy. Positive tests occurred in 102 patients (3.1%), 59 of whom had primary cesarean sections. Labor was induced in 40 patients (39.2%), and 17 developed cardiotocographic evidence of fetal distress. In 2 patients labor was terminated due to prolapse of the umblilical cord, and the remaining 21 patients did not develop fetal distress. Fetal distress was more common in patients with proved intrauterine growth retardation (IUGR) and where the acceleration patterns were not noted during the CST. Only 23% of the patients delivered vaginally. The fetal loss was 100% in those infants weighing less than 1000 g, but no infant weighing greater than or equal to 2500 g died. The overall perinatal mortality was 8.7%. The incidence of late decelerations during labor, low 5-minute Apgar scores, and small-for-date infants was significantly higher in patients with positive stress tests than in a control group of 257 patients with negative stress tests done over the same period of time.
Top-cited authors
Baha M Sibai
  • University of Texas Health Science Center at Houston
Donald D Mcintire
  • University of Texas Southwestern Medical Center
Ronald Wapner
  • Columbia University
Menachem Miodovnik
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development
John O. L. DeLancey
  • University of Michigan