Adhesion prevention in patients with multiple cesarean deliveries.

Adhesion formation is a well-known complication of abdominal surgery. Although one third of all deliveries in the United States are by cesarean delivery (CD), little is known about adhesions in the obstetric setting. Various surgical techniques for reducing adhesion formation following CD have been investigated. The relative benefits of peritoneal closure and single-layer uterine closure are areas of continued research and debate. Adhesion prevention products are also becoming more commonplace in gynecologic surgery. Two membrane/adhesion barriers have been approved in the United States. A barrier consisting of oxidized regenerated cellulose (Interceed absorbable adhesion barrier) has been shown to reduce adhesions during microsurgery. Its use may be limited following CD because complete hemostasis is crucial to its efficacy. Seprafilm adhesion barrier, composed of hyaluronic acid and carboxymethylcellulose, is approved for use in abdominal or pelvic laparotomy. Preliminary data suggest that it may be effective for reducing adhesions following CD. This article discusses what is currently known about adhesion prevention in the obstetric population and highlights the paucity of level I evidence available to clinicians in this setting.

Hypoxia-inducible factors 1alpha and 2alpha exert both distinct and overlapping functions in long bone development.

The hypoxia-inducible factors have recently been identified as critical regulators of angiogenic-osteogenic coupling. Mice overexpressing HIFalpha subunits in osteoblasts produce abundant VEGF and develop extremely dense, highly vascularized long bones. In this study, we investigated the individual contributions of Hif-1alpha and Hif-2alpha in angiogenesis and osteogenesis by individually disrupting each Hifalpha gene in osteoblasts using the Cre-loxP method. Mice lacking Hif-1alpha demonstrated markedly decreased trabecular bone volume, reduced bone formation rate, and altered cortical bone architecture. By contrast, mice lacking Hif-2alpha had only a modest decrease in trabecular bone volume. Interestingly, long bone blood vessel development measured by angiography was decreased by a similar degree in both DeltaHif-1alpha and DeltaHif-2alpha mice suggesting a common role for these Hifalpha subunits in skeletal angiogenesis. In agreement with this idea, osteoblasts lacking either Hif-1alpha or Hif-2alpha had profound reductions in VEGF mRNA expression but only the loss of Hif-1alpha impaired osteoblast proliferation. These findings indicate that expression of both Hif-1alpha and Hif-2alpha by osteoblasts is required for long bone development. We propose that both Hif-1alpha and Hif-2alpha function through cell non-autonomous modes to promote vascularization of bone and that Hif-1alpha also promotes bone formation by exerting direct actions on the osteoblast.

Discussion: 'Novel clomiphene protocol in polycystic ovarian syndrome' by Hurst et al.

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Hurst BS, Hickman JM, Matthews ML, Usadi RS, Marshburn PB. Novel clomiphene "stair-step" protocol reduces time to ovulation in women with polycystic ovarian syndrome. Am J Obstet Gynecol 2009;200:510.e1-510.e4.