Perceived quality of sleep across the menopausal transition: A retrospective cohort study.

Background and Aims: To compare sleep quality among naturally and surgically post-menopausal women, and to identify lifestyle factors that predict sleep quality in pre, peri, and postmenopausal women. Methods: This is a retrospective cohort study of data collected from 429 women who participated in Fels Longitudinal Study data. Sleep quality, based on the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale, demographics, medical history, depression, quality of life, and physical activity levels were included in the analysis. Results: The four study groups did not differ on overall sleep quality with either scale (p = 0.61). Both Post-M groups were more likely to have a major sleep problem than the Peri-M and Pre-M groups (p < 0.001), and to have a history of restless leg syndrome (p = 0.016), but the two Post-M groups did not differ on these problems. Predictors of sleep quality included depression, bodily pain, vitality, and surgical menopause (p<0.001). Conclusion: Menopause is associated with sleep disrupting conditions. This study did not find any significant differences in sleep quality among the three reproductive stages or for natural versus surgical menopause. Women may benefit from addressing other lifestyle factors associated with poor sleep quality including mental health factors.

Fetal membranes exhibit similar nutrient transporter expression profiles to the placenta.

INTRODUCTION: During pregnancy, the growth of the fetus is supported by the exchange of nutrients, waste, and other molecules between maternal and fetal circulations in the utero-placental unit. Nutrient transfer, in particular, is mediated by solute transporters such as solute carrier (SLC) and adenosine triphosphate-binding cassette (ABC) proteins. While nutrient transport has been extensively studied in the placenta, the role of human fetal membranes (FM), which was recently reported to have a role in drug transport, in nutrient uptake remains unknown. OBJECTIVES: This study determined nutrient transport expression in human FM and FM cells and compared expression with placental tissues and BeWo cells. METHODS: RNA sequencing (RNA-Seq) of placental and FM tissues and cells was done. Genes of major solute transporter groups, such as SLC and ABC, were identified. Proteomic analysis of cell lysates was performed via nano-liquid chromatography-tandem mass spectrometry (nanoLC-MS/MS) to confirm expression at a protein level. RESULTS: We determined that FM tissues and cells derived from the fetal membrane tissues express nutrient transporter genes, and their expression is similar to that seen in the placenta or BeWo cells. In particular, transporters involved in macronutrient and micronutrient transfer were identified in both placental and FM cells. Consistent with RNA-Seq findings, carbohydrate transporters (3), vitamin transport-related proteins (8), amino acid transporters (21), fatty acid transport-related proteins (9), cholesterol transport-related proteins (6) and nucleoside transporters (3) were identified in BeWo and FM cells, with both groups sharing similar nutrient transporter expression. CONCLUSION: This study determined the expression of nutrient transporters in human FMs. This knowledge is the first step in improving our understanding of nutrient uptake kinetics during pregnancy. Functional studies are required to determine the properties of nutrient transporters in human FMs.

Expression of CYP450 enzymes in human fetal membranes and its implications in xenobiotic metabolism during pregnancy.

BACKGROUND: Environmental exposure to toxicants is a major risk factor for spontaneous preterm birth (PTB, <37 weeks). Toxicants and drugs administered to patients are metabolized primarily by the cytochrome P450 (CYP450) system. Along with the adult and fetal liver, the placenta, a critical feto-maternal interface organ, expresses CYP450 enzymes that metabolize these xenobiotics. However, the contribution of the fetal membranes, another tissue of the feto-maternal interface, to the expression of CYP450 enzymes and the detoxification of xenobiotics remains unknown. AIMS: This study characterized CYP450 expression and determined the functional activity of CYP450 enzymes in fetal membranes. MAIN METHODS: RNA sequencing (RNA-Seq) of placental and fetal membrane tissues and cells was done. Differential expressions of CYP450 genes were compared and validated via reverse transcription-quantitative polymerase chain reaction (RT-qPCR) between the two tissues. The functional activity of major CYP450 enzymes was determined using a fluorophore-based enzymatic assay in the presence and absence of their corresponding inhibitors. KEY FINDINGS: With the exception of genes that regulate cholesterol metabolism, the expression profile of CYP450 genes was similar between placental and fetal membranes tissues/cells. RT-qPCR analysis confirmed these findings with significant levels of mRNA for major CYP450 genes being detectable in amnion epithelial cells (AECs) and chorion trophoblasts cells (CTCs). Biochemical analyses revealed significant CYP450 enzymatic activities that were sensitive to specific inhibitors for both AECs and CTCs, suggesting that the genes were expressed as functional enzymes. SIGNIFICANCE: This is the first study to determine global expression of CYP450 enzymes in fetal membranes which may play a role in xenobiotic metabolism during pregnancy. Given that many women are exposed to environmental toxins or require medications during pregnancy, a better understanding of their role in metabolism is required to develop safer therapeutics and prevent adverse outcomes.

Quality improvement: patient education for management of hypertension in pregnancy.

Objective: To assess the effectiveness of interactive education tools for hypertension in pregnancy.Two interactive education tools were introduced.Methods: Pregnant women with hypertension completed questionnaires before (Pre-I) and after)Post-I) the intervention.Providers rated satisfaction and effectiveness of the education methods.Results: The Post-I group (N=45) showed slight improvement on both Perceived (4.5±0.7) and Actual knowledge (2.2 ± 1.0) compared to the Pre-I group (N=45; Perceived: 4.2±1.0; Actual: 1.7±1.3; p<.05) .Providers reported higher satisfaction after the intervention (2.6±1.1 vs 4.1±0.7; p <.001).iscussion: The intervention increased patients' knowledge and providers rating of patient knowledge, and decreased the time needed for patient education.

A Risk-Stratified Peri-Operative Protocol for Reducing Surgical Site Infection after Cesarean Delivery.

Background: Surgical site infections (SSI) are multifaceted. Pre-operative, intra-operative, and post-operative factors influence the risk of developing an infection. Our objective was to evaluate the effectiveness of an infection risk-stratification checklist, utilizing known SSI risk factors, and a tailored surgical protocol for SSI prevention in women undergoing cesarean delivery. Patients and Methods: A prospective project to reduce SSI was conducted for women undergoing cesarean delivery on the resident staff service at a midwestern, urban tertiary care hospital. Patients were categorized according to an SSI risk-stratification checklist as high risk or low risk. The low-risk group received the local standard of care (single prophylactic dose of pre-operative intravenous antibiotics and a standard pressure dressing). In the high-risk group, prophylactic antibiotic agents were given pre-operatively and continued for the first 24 hours post-operatively. Additionally, patients at high risk received an absorbent dressing (Mepilex Ag®; Mölnlycke Health Care AB, Gothenburg, Sweden) that was applied in the operating room and worn for one week. Results: The overall rate of SSIs decreased from 6.1% (pre-study rate) to 1.4% after initiation of the protocol, a 77% reduction (p < 0.001). The low- and high-risk groups did not differ in infection rate (0% and 1.4%, respectively; p < 0.59). Both deep incisional and organ/space SSIs decreased after initiation of the protocol (91% and 62% decrease, respectively). Conclusion: Stratifying patients into high- and low-risk groups with tailored peri-operative management strategies reduced overall SSIs. The protocol incorporates known risk factors for SSI in a surgical procedure with high rates of SSI. This approach offers a structured method that can be adopted by other hospital systems for SSI prevention in patients undergoing cesarean delivery.

Vaginal laceration during barium enema with extraperitoneal extravasation: Case report and literature review.

Unrecognized vaginal intubation during the barium enema procedure with subsequent balloon inflation and contrast instillation is a potentially fatal complication of an otherwise common and routine procedure. We describe a patient who, while undergoing a routine barium enema, had misplacement of the enema catheter into the vagina, subsequent rupture of the superior/lateral vagina upon inflation of the catheter retention balloon, and injection of barium contrast into the retroperitoneum. The patient was admitted for surgical repair of the vaginal laceration and monitoring for chemical peritonitis; and was managed without exploratory laparotomy. We review the existing literature, summarize 18 reported cases from worldwide literature, detail potential complications and propose management and prevention strategies based on the mechanism of injury.

Cesarean Scar Ectopic Pregnancy: Current Management Strategies.

IMPORTANCE: Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate. OBJECTIVE: This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes. EVIDENCE ACQUISITION: A literature review was performed utilizing the term cesarean scar ectopic pregnancy and subsequently selecting only meta-analyses and systematic reviews. Only articles published in English were included. Relevant articles within the reviews were analyzed as necessary. RESULTS: Five basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation. CONCLUSIONS: Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach. RELEVANCE: As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

Vaginal Urinary Calculi Formation Secondary to Vaginal Mesh Exposure with Urinary Incontinence.

BACKGROUND: Vaginal stones may form in the setting of mesh exposure with urinary incontinence. This report serves to help understand the presentation, evaluation, and management of vaginal urinary stones. CASE: A 68-year-old female presented with a vaginal calculus. She had a history of anterior and posterior polypropylene mesh placement for prolapse 7 years earlier and urinary incontinence. The stone was identified on a portion of exposed mesh and removed in office. Pathology confirmed urinary etiology. The exposed mesh resolved with topical estrogen. Cystourethroscopy excluded urinary fistula and bladder mesh erosion. CONCLUSIONS: When identified, a vaginal calculus should be removed and evaluated for composition. Cystourethroscopy should be performed to assess potential urinary tract fistulas and mesh erosion. Additional imaging should be considered.

Vulvodynia: What We Know and Where We Should Be Going.

OBJECTIVE: The aim of the study was to review the current nomenclature and literature examining microbiome cytokine, genomic, proteomic, and glycomic molecular biomarkers in identifying markers related to the understanding of the pathophysiology and diagnosis of vulvodynia (VVD). MATERIALS AND METHODS: Computerized searches of MEDLINE and PubMed were conducted focused on terminology, classification, and "omics" variations of VVD. Specific MESH terms used were VVD, vestibulodynia, metagenomics, vaginal fungi, cytokines, gene, protein, inflammation, glycomic, proteomic, secretomic, and genomic from 2001 to 2016. Using combined VVD and vestibulodynia MESH terms, 7 references were identified related to vaginal fungi, 15 to cytokines, 18 to gene, 43 to protein, 38 to inflammation, and 2 to genomic. References from identified publications were manually searched and cross-referenced to identify additional relevant articles. A narrative synthesis of the articles was conducted; however, meta-analysis was not conducted because of substantial heterogeneity in the studies and limited numbers of control-matched studies. RESULTS: Varying definitions of VVD complicate a meta-analysis, and standard definitions will better allow for comparisons of studies and enhance the applicability of evidence to patient populations. Although data are still limited, genomic and molecular diagnostic testings continue to be investigated as potential tools for the diagnosis of VVD. CONCLUSIONS: Standardized nomenclature will allow for comparability of studies and progress in research related to the pathophysiology of VVD and to facilitate clinical decision making and treatment choices. Although the current understanding of the pathogenesis of VVD is limited, there are new opportunities to explore potential diagnostic markers differences in women with VVD, which may lead to targeted therapy.

Hysteroscopic morcellator to overcome cervical stenosis.

OBJECTIVE: To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN: Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING: Academic-based practice. PATIENT(S): A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S): A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S): Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S): The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S): Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

US term stillbirth rates and the 39-week rule: a cause for concern?

BACKGROUND: More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule-by increasing the gestational age of delivery for a substantial number of pregnancies-might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown. OBJECTIVE: To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States. STUDY DESIGN: Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole. RESULTS: A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007-2009 with 2011-2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038-1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002-0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater. CONCLUSIONS: Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies.

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.

Contained morcellation using the GelPOINT advance access platforms and 3M Steri-Drape endobag.

OBJECTIVE: To report a technique that safely allows power and hand morcellation for laparoscopic hysterectomy and myomectomy specimens in a contained fashion in the event of unsuspected uterine sarcoma or leiomyosarcoma. DESIGN: Video article introducing a method for enclosed tissue morcellation for laparoscopic specimens. SETTING: Hospital of an academic-based practice. PATIENT(S): Two patients underwent laparoscopic hysterectomy: a 57-year-old G7 P5025 female for leiomyoma, anemia, and a history of CIN-3; and a 38-year-old G0P0 female with a 10-year history of pelvic pain and severe dysmenorrhea who failed medical therapy. INTERVENTION(S): A technique using the GelPOINT Platform incision extender system and GelSeal Cap (GSP) Advanced Access Platform and a 50 cm × 50 cm 3M Steri-Drape endobag for enclosed intracorporeal and extracorporeal tissue morcellation of laparoscopic specimens. MAIN OUTCOME MEASURE(S): For training purposes, we used a pelvic simulator and cadaver to describe the step-by-step process and troubleshoot issues to optimize intra- and extracorporeal morcellation. This allowed for easier implementation on the live patient. RESULT(S): Simulation training and the cadaver model provided a learning platform for contained internal power and external hand morcellation, accelerating the learning curve in its application to the live patient. CONCLUSION(S): The GSP and 3M Steri-Drape endobag is an alternative for laparoscopic power or hand morcellation. Using simulation training helped transition this technique to the live patient, allowing for easy and safe removal of tissue specimens and minimizing the potential for tissue seeding and dissemination.

Challenges and considerations in optimizing ovarian stimulation protocols in oncofertility patients.

The scope of cancer treatment in women of childbearing age has changed in the last decade. Fertility preservation is no longer an afterthought but central to multi-disciplinary cancer treatment planning and should be addressed due to the cytotoxic effects of cancer therapy. However, oncology patients present as a unique treatment challenge as the physician must balance the urgency of fertility preservation with the risks of delaying cancer therapy. Controlled ovarian stimulation (COS) is routinely applied in assisted reproductive technology but can be contraindicated in women with estrogen-receptor-positive tumors. This paper reviews some of the challenges to consider when using COS and newer stimulation protocols to minimize risks and optimize outcomes in oncofertility patients.

Obstetric vulvar lacerations and postpartum dyspareunia.

OBJECTIVE: To report the type and prevalence of obstetric lacerations in a primigravid patient population after term spontaneous vaginal delivery without episiotomy. We examined the characteristics of lacerations in patients with postpartum dyspareunia or vulvodynia. STUDY DESIGN: This was a retrospective cohort of primiparous patients who spontaneously delivered in the residents' service at a large urban hospital under the supervision of Ob/Gyn faculty. Data was extracted from medical records using discharge diagnosis codes. Postpartum medical records and diagnostic codes of all patients with lacerations and postpartum dyspareunia were reviewed. The study was IRB approved. RESULTS: A cohort of 1617 primiparous patients with spontaneous vaginal delivery met the inclusion criteria. No tears were recorded in 836 patients (51.7%), first-degree tears in 413 cases (25.5%), second-degree tears in 271 cases (16.8%), third-degree tears in 58 cases (3.6%), fourth-degree in 21 cases (1.3%), and 18 cases (1.1%) were not further classified. Only 51 patients (3.2%) with first- and second-degree lacerations had postpartum complications, and merely 6 (0.4%) had vulvar pain and 6 (0.4%) had dyspareunia. However, 4 of those patients (33.3%) required vulvoplasty for complete dyspareunia remission. CONCLUSION: Almost half of patients with spontaneous vaginal delivery without episiotomy experienced some type of vaginal laceration. A first degree was documented in >25% of cases; however, <10% of those subsequently had complaints of vulvar pain or dyspareunia.