Complex Obstetrical Surgery: Building a Team and Defining Roles.

As the number of placenta accreta spectrum (PAS) cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetricians-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries (CD) and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process whereby key personnel within departments of obstetrics and gynecology are identified, and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the CD complexity level can be matched to specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is twofold: first, to return cases with higher levels of surgical complexity back to obstetricians, and second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.

Use of natural language processing to uncover racial bias in obstetrical documentation.

Natural Language Processing (NLP), a form of Artificial Intelligence, allows free-text based clinical documentation to be integrated in ways that facilitate data analysis, data interpretation and formation of individualized medical and obstetrical care. In this cross-sectional study, we identified all births during the study period carrying the radiology-confirmed diagnosis of fibroid uterus in pregnancy (defined as size of largest diameter of >5 cm) by using an NLP platform and compared it to non-NLP derived data using ICD10 codes of the same diagnosis. We then compared the two sets of data and stratified documentation gaps by race. Using fibroid uterus in pregnancy as a marker, we found that Black patients were more likely to have the diagnosis entered late into the patient's chart or had missing documentation of the diagnosis. With appropriate algorithm definitions, cross referencing and thorough validation steps, NLP can contribute to identifying areas of documentation gaps and improve quality of care.

Microbial Translocation and Gut Damage Are Associated With an Elevated Fast Score in Women Living With and Without HIV.

Background: Steatohepatitis is common in persons living with HIV and may be associated with gut microbial translocation (MT). However, few studies have evaluated the gut-liver axis in persons living with HIV. In the Women's Interagency HIV Study, we examined the associations of HIV and circulating biomarkers linked to MT and gut damage using the FibroScan-aspartate aminotransferase (FAST) score, a noninvasive surrogate for steatohepatitis with advanced fibrosis. Methods: Among 883 women with HIV and 354 without HIV, we used multivariable regression to examine the associations of HIV and serum biomarkers linked to MT and gut damage (kynurenine and tryptophan ratio, intestinal fatty acid-binding protein, soluble CD14, and soluble CD163) with a log-transformed FAST score after adjusting for key covariates. We used a path analysis and mediation models to determine the mediating effect of each biomarker on the association of HIV with FAST. Results: HIV infection was associated with a 49% higher FAST score. MT biomarker levels were higher in women with HIV than women without HIV (P < .001 for each). MT biomarkers mediated 13% to 32% of the association of HIV and FAST score. Conclusions: Biomarkers linked to MT and gut damage are associated with a higher FAST score and mediate the association of HIV with a higher FAST score. Our findings suggest that MT may be an important mechanism by which HIV increases the risk of steatohepatitis with advanced fibrosis.

Maternal Lutein Intake during Pregnancies with or without Gestational Diabetes Mellitus and Cognitive Development of Children at 2 Years of Age: A Prospective Observational Study.

Lutein and its isomer zeaxanthin serve as antioxidants and preserve cognitive function during aging. However, whether lutein/zeaxanthin (L + Z) exposure early in life improves cognitive development of children is rarely explored. It is also unknown whether gestational diabetes mellitus (GDM), characterized by heightened oxidative stress, affects lutein metabolism. This prospective longitudinal cohort study examined the differences in L + Z intake and metabolism, as well as the association between maternal L + Z intake and children's cognitive development in GDM versus non-GDM pregnancies. Seventy-six pregnant women (n = 40 with GDM) were recruited between 25 and 33 weeks of gestation and dietary intakes were recorded. At delivery, cord blood was collected, and 2 years later, the Bayley III developmental test was conducted on a subset of children (n = 38). The results suggest that GDM reduced cord blood lutein levels at birth; L + Z intake during pregnancy was associated with better cognitive (ß = 0.003, p = 0.001) and language (ß = 0.002, p = 0.038) scoring of children at 2 years regardless of GDM status. In conclusion, maternal L + Z intake was positively associated with children's developmental scores, regardless of GDM. More studies are needed to confirm such associations.

The case for making the first-trimester anatomical survey a standard of care post Dobbs.

Currently, 11- to 14-week-detailed anatomic surveys are generally reserved for at-risk populations because of the lower incidence of major fetal anomalies in low-risk populations. Until recently, such standard reflects, in part, the fact that pregnant persons retain the option of abortion even if the initial anatomy scan was in the second trimester of pregnancy. However, on June 24, 2022, the US Supreme Court overturned Roe, and many states subsequently lowered the gestational age at which abortions can legally be performed. Here, we argue for a reconsideration of limitations on first-trimester scans to preserve pregnant persons' reproductive options, particularly in those states that have imposed laws limiting access to abortion. Moreover, we acknowledge and discuss some of the challenges that will be associated with this approach.

Subclinical Atherosclerosis Across the Menopausal Transition in Women With and Without HIV.

The menopausal transition is a pivotal time of cardiovascular risk, but knowledge is limited in HIV. We studied longitudinal carotid artery intima-media thickness (CIMT) in the Women's Interagency HIV Study (2004-2019; 979 women/3247 person-visits; 72% with HIV). Among women with HIV only, those who transitioned had greater age-related CIMT progression compared to those remaining premenopausal (difference in slope = 1.64 µm/year, P = .002); and CIMT increased over time in the pretransition (3.47 µm/year, P = .002) and during the menopausal transition (9.41 µm/year, P < .0001), but not posttransition (2.9 µm/year, P = .19). In women with HIV, menopause may accelerate subclinical atherosclerosis as measured by CIMT.

The Two Front War on Reproductive Rights-When the Right to Abortion is Banned, Can the Right to Refuse Obstetrical Interventions Be Far behind?

The loss of the federally protected constitutional right to an abortion is a threat to the already tenuous autonomy of pregnant people, and may augur future challenges to their right to refuse unwanted obstetric interventions. Even before Roe's demise, pregnancy led to constraints on autonomy evidenced by clinician-led legal incursions against patients who refused obstetric interventions. In Dobbs v. Jackson Women's Health Organization, the Supreme Court found that the right to liberty espoused in the Constitution does not extend to a pregnant person's right to an abortion. With Roe's demise, the right to request specific types of care has been vitiated. The same argument underpinning that holding may now become ballast for attacks on the traditionally more robust right, the right to refuse. Here we discuss how the elevation of fetal and embryonic rights may lead to a cascade of medical intrusions and deprivations of liberty against pregnant persons, and offer an argument opposing these improprieties.

Are women residents of surgical specialties at a higher risk of developing imposter syndrome?

BACKGROUND: Imposter syndrome is a chronic feeling of doubt leading to a sense of incompetence, which is common among trainees. However, little is known about the effect of gender on imposter syndrome among surgical trainees. METHODS: An online national survey was distributed to the surgical subspecialty residents between March and September 2022, including demographics, validated Clance Imposter Scale and a short questionnaire evaluating depression and anxiety. RESULTS: Of the participants self identified as women (264, 69.1%) and men (118, 30.9%) (response rate 36.4%), the prevalence of imposterism was higher among women trainees (97% vs. 86%; p â€‹< â€‹0.0001). Risk factors were being a gynecologist (156, 59%, p â€‹< â€‹0.0001), single (157, 59.7% p â€‹= â€‹0.007), having no dependents (233, 88.3% p â€‹= â€‹0.001), being a foreign graduate (24, 9.1%, p â€‹= â€‹0.024) and having feelings of anxiety (82, 31.1% p â€‹= â€‹0.012). When using multivariate logistic regression to adjust for these factors, the prevalence of imposter syndrome remained significantly higher among women. CONCLUSION: Women trainees belonging to various surgical fields are affected by Imposter syndrome. Residency programs should develop wellness programs and provide mentorship to address this condition.

Grand Multiparity and Obstetric Outcomes in a Contemporary Cohort: The Role of Increasing Parity.

OBJECTIVE: Evidence is inconsistent regarding grand multiparity and its association with adverse obstetric outcomes. Few large American cohorts of grand multiparas have been studied. We assessed if increasing parity among grand multiparas is associated with increased odds of adverse perinatal outcomes. STUDY DESIGN: Multicenter retrospective cohort of patients with parity ≥ 5 who delivered a singleton gestation in New York City from 2011 to 2019. Outcomes included postpartum hemorrhage, preterm delivery, hypertensive disorders of pregnancy, shoulder dystocia, birth weight > 4,000 and <2,500 g, and neonatal intensive care unit (NICU) admission. Parity was analyzed continuously, and multivariate analysis determined if increasing parity and other obstetric variables were associated with each adverse outcome. RESULTS: There were 2,496 patients who met inclusion criteria. Increasing parity among grand multiparas was not associated with any of the prespecified adverse outcomes. Odds of postpartum hemorrhage increased with history (adjusted odds ratio [aOR]: 2.65, 95% confidence interval [1.83, 3.84]) and current cesarean delivery (aOR: 4.59 [3.40, 6.18]). Preterm delivery was associated with history (aOR: 12.36 [8.70-17.58]) and non-White race (aOR: 1.90 [1.27, 2.84]). Odds of shoulder dystocia increased with history (aOR: 5.89 [3.22, 10.79]) and birth weight > 4,000 g (aOR: 9.94 [6.32, 15.65]). Birth weight > 4,000 g was associated with maternal obesity (aOR: 2.92 [2.22, 3.84]). Birth weight < 2,500 g was associated with advanced maternal age (aOR: 1.69 [1.15, 2.48]), chronic hypertension (aOR: 2.45 [1.32, 4.53]), and non-White race (aOR: 2.47 [1.66, 3.68]). Odds of hypertensive disorders of pregnancy increased with advanced maternal age (aOR: 1.79 [1.25, 2.56]), history (aOR: 10.09 [6.77-15.04]), and non-White race (aOR: 2.79 [1.95, 4.00]). NICU admission was associated with advanced maternal age (aOR: 1.47 [1.06, 2.02]) and non-White race (aOR: 2.57 [1.84, 3.58]). CONCLUSION: Among grand multiparous patients, the risk factor for adverse maternal, obstetric, and neonatal outcomes appears to be occurrence of those adverse events in a prior pregnancy and not increasing parity itself. KEY POINTS: · Increasing parity is not associated with adverse obstetric outcomes among grand multiparas.. · Prior adverse pregnancy outcome is a risk factor for the outcome among grand multiparas.. · Advanced maternal age is associated with adverse obstetric outcomes among grand multiparas..

Complete placenta previa and increta after radical trachelectomy: A case report.

Background: Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine surgeries other than cesarean section are important, yet less common, risk factors for PAS. Case: This is a case of a 43-year-old woman with a prior history of cervical cancer necessitating radical trachelectomy. She was subsequently diagnosed with a complete placenta previa with a high degree of suspicion for PAS. Multidisciplinary teams convened to plan for delivery. A cesarean hysterectomy was performed at 32 weeks. Final surgical pathology confirmed the presence of morbidly adherent placenta invading the vaginal cuff. Conclusion: Patients who are diagnosed with early-stage cervical cancers have the option of fertility-preserving surgical management. Serial ultrasound evaluations, specifically looking for PAS, might be warranted in post-trachelectomy pregnancies.

Associations between nutrients in one-carbon metabolism and fetal DNA methylation in pregnancies with or without gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM), characterized by hyperglycemia that develops during pregnancy, increases the risk of fetal macrosomia, childhood obesity and cardiometabolic disorders later in life. This process has been attributed partly to DNA methylation modifications in growth and stress-related pathways. Nutrients involved with one-carbon metabolism (OCM), such as folate, choline, betaine, and vitamin B12, provide methyl groups for DNA methylation of these pathways. Therefore, this study aimed to determine whether maternal OCM nutrient intakes and levels modified fetal DNA methylation and in turn altered fetal growth patterns in pregnancies with and without GDM. RESULTS: In this prospective study at a single academic institution from September 2016 to June 2019, we recruited 76 pregnant women with and without GDM at 25-33 weeks gestational age and assessed their OCM nutrient intake by diet recalls and measured maternal blood OCM nutrient levels. We also collected placenta and cord blood samples at delivery to examine fetal tissue DNA methylation of the genes that modify fetal growth and stress response such as insulin-like growth factor 2 (IGF2) and corticotropin-releasing hormone (CRH). We analyzed the association between maternal OCM nutrients and fetal DNA methylation using a generalized linear mixed model. Our results demonstrated that maternal choline intake was positively correlated with cord blood CRH methylation levels in both GDM and non-GDM pregnancies (r = 0.13, p = 0.007). Further, the downstream stress hormone cortisol regulated by CRH was inversely associated with maternal choline intake (r = - 0.36, p = 0.021). Higher maternal betaine intake and serum folate levels were associated with lower cord blood and placental IGF2 DNA methylation (r = - 0.13, p = 0.049 and r = - 0.065, p = 0.034, respectively) in both GDM and non-GDM pregnancies. Further, there was an inverse association between maternal betaine intake and birthweight of infants (r = - 0.28, p = 0.015). CONCLUSIONS: In conclusion, we observed a complex interrelationship between maternal OCM nutrients and fetal DNA methylation levels regardless of GDM status, which may, epigenetically, program molecular pathways related to fetal growth and stress response.

Midlife body mass index, central adiposity and neuropsychological performance over 10 years in women living with and without HIV.

Background and objective: Observations of overweight and obesity in association with neuropsychological performance (NP) vary over the adult life course depending on baseline levels, biological sex, age, race, temporality of measurements, and other factors. Therefore, similar published analyses across cohorts are inconsistent. In our sample of women living with HIV (WLWH) and women without HIV (WWOH), we conducted comparable analyses as those published in men with and without HIV. We examined cross-sectional and longitudinal associations between body mass index (BMI) and waist circumference (WC) and NP. Methods: Four hundred thirty two 432 virologically-suppressed WLWH and 367 WWOH, ≥40 years in the Women's Interagency HIV Study (WIHS) with anthropometry and NP assessments every two years from 2009-2019 were included in the study. Demographically-adjusted T-scores were calculated for six NP domains: learning, memory, executive function, processing speed, attention and working memory, and motor function. Multivariable linear regression models stratified by HIV status were used to examine cross-sectional associations of BMI and WC by NP domain; repeated measures analyses assessed baseline BMI and WC in association with longitudinal change in NP. Covariates included sociodemographic, behavioral, and HIV-related characteristics. Results: At baseline among all women, the median age was 45 years, 65% were Non-Latinx Black women, and 45% were obese women. Obese WLWH (BMI≥30.0 kg/m2) had poorer executive function (ß=-2.27, 95%CI [-4.46, -0.07]) versus WLWH with healthy BMI (18.5-24.9 kg/m2). Longitudinally over ~8 years, obese versus overweight WWOH improved on memory (ß=2.19, 95%CI [0.13, 4.26]), however overweight versus healthy WWOH experienced declining memory (ß= -2.67, 95%CI [-5.40, -0.07]). Increasing WC was associated with declining executive, processing speed, and motor function (p's<0.05); an at-risk WC was associated with improved memory (ß=1.81, 95%CI [0.19, 3.44]) among WWOH. Among WLWH, increasing BMI was associated with improved learning (ß=0.07, 95%CI [0.00, 0.15]. Conclusion: Our cross-sectional and longitudinal analyses evaluating the associations of BMI and WC and NP were mixed compared to previous reports. This illustrates the importance of sociodemographic characteristics, baseline levels of exposures and outcomes, HIV status, temporality of measurements, and other factors when evaluating aging HIV epidemiology study results.

Changes in Rates of Hypertensive Disorders of Pregnancy Among Nulliparous Patients After the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial.

The ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial demonstrated lower rates of hypertensive disorders of pregnancy (HDP) among low-risk nulliparous patients undergoing labor induction at 39 weeks of gestation. We conducted a population-based cohort study in which we evaluated the association between the routinization of 39-week induction and the rate of HDP by comparing rates before and after the ARRIVE trial publication, using the National Vital Statistics System. Logistic regression models were used to project what the HDP rate would have been based on trends seen pre-ARRIVE. Despite an overall increase in the rate of HDP from pre-ARRIVE to post-ARRIVE (4.9% pre vs 6.3% post, adjusted odds ratio [aOR] 1.26, 95% CI 1.24-1.27), the HDP rate was significantly lower in the post-ARRIVE group among patients undergoing induction at 39 weeks of gestation (14.7% pre vs 14.1% post, aOR 0.91, 95% CI 0.90-0.93), decreasing by 12.0% per year (P<.001). The rate of HDP among all other delivering patients was higher in the post-ARRIVE group (4.1% pre vs 5.5% post, aOR1.32, 95% CI 1.30-1.34). Our findings may suggest that, as the overall HDP rate rises, the relative advantage of 39-week induction will rise similarly.

Variations in Genes Encoding Human Papillomavirus Binding Receptors and Susceptibility to Cervical Precancer.

BACKGROUND: Cervical cancer oncogenesis starts with human papillomavirus (HPV) cell entry after binding to host cell surface receptors; however, the mechanism is not fully known. We examined polymorphisms in receptor genes hypothesized to be necessary for HPV cell entry and assessed their associations with clinical progression to precancer. METHODS: African American women (N = 1,728) from the MACS/WIHS Combined Cohort Study were included. Two case-control study designs were used-cases with histology-based precancer (CIN3+) and controls without; and cases with cytology-based precancer [high-grade squamous intraepithelial lesions (HSIL)] and controls without. SNPs in candidate genes (SDC1, SDC2, SDC3, SDC4, GPC1, GPC2, GPC3, GPC4, GPC5, GPC6, and ITGA6) were genotyped using an Illumina Omni2.5-quad beadchip. Logistic regression was used to assess the associations in all participants and by HPV genotypes, after adjusting for age, human immunodeficiency virus serostatus, CD4 T cells, and three principal components for ancestry. RESULTS: Minor alleles in SNPs rs77122854 (SDC3), rs73971695, rs79336862 (ITGA6), rs57528020, rs201337456, rs11987725 (SDC2), rs115880588, rs115738853, and rs9301825 (GPC5) were associated with increased odds of both CIN3+ and HSIL, whereas, rs35927186 (GPC5) was found to decrease the odds for both outcomes (P value ≤ 0.01). Among those infected with Alpha-9 HPV types, rs722377 (SDC3), rs16860468, rs2356798 (ITGA6), rs11987725 (SDC2), and rs3848051 (GPC5) were associated with increased odds of both precancer outcomes. CONCLUSIONS: Polymorphisms in genes that encode binding receptors for HPV cell entry may play a role in cervical precancer progression. IMPACT: Our findings are hypothesis generating and support further exploration of mechanisms of HPV entry genes that may help prevent progression to cervical precancer.

Lessons from Mortality Reviews: Nonbiologic Contributors to Maternal Deaths.

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly..

Changes in use of 17-OHPC after the PROLONG trial: a physician survey.

OBJECTIVES: To determine if 17α-hydroxyprogesterone caproate (17OHPC) or vaginal progesterone use for patients at risk for preterm birth has changed since the publication of the 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG) trial, and to assess which organizations' (Food and Drug Administration's [FDA], American College of Obstetrics and Gynecology's [ACOG] or Society of Maternal Fetal Medicine's [SMFM]) statements most influenced change. METHODS: Through a vignette-based physician survey, we sought to measure (by Likert scale) how counseling tendencies regarding 17OHPC and vaginal progesterone have changed since the PROLONG trial publication. Participants were also asked which organizations' statements most influenced change. RESULTS: With response rate of 97 % (141/145), a pre-to-post PROLONG trial comparison revealed significant changes in counseling for progesterone. Respondents were less likely to recommend 17OHPC (p<0.001) and more likely to recommend vaginal (p<0.001). The FDA statement most influenced the decision not to recommend 17OHPC for the prevention of preterm birth (r=-0.23, p=0.005). CONCLUSIONS: Providers have made significant changes in their counseling regarding progesterone use for patients at risk for preterm birth after the publication of the PRLONG trial.

Divisions of health equity in departments of obstetrics and gynecology.

Disparities in maternal morbidity and mortality remain vivid reminders of the role of racism in obstetrics and gynecology. If a serious attempt is to be made to purge medicine of its ongoing role in unequal care, then departments must commit the same intellectual and material resources as they would to the other health challenges in their remit. A division that understands the unique needs and complexities of the specialty, including translating theory into practice, is uniquely positioned to keep health equity as a focus of clinical care, education, research, and community engagement. To achieve reproductive justice, an approach addressing the intersectionality of race, ethnicity and gender identity is critical. In this article, we detailed the ways in which divisions of health equity within departments of obstetrics and gynecology can dismantle impediments to progress and can move our discipline closer to optimal and equitable care for all. We described the unique educational, clinical, research, and innovative community-based activities of these divisions.