A Search for Novel Risk Factors for Obstetric Anal Sphincter Injury.

OBJECTIVE: The objective of this study is to evaluate factors associated with obstetric anal sphincter injury and identify modifiable risks. METHODS: A retrospective case-control study was performed in women who gave birth at our institution between May 2008 and December 2012. Patients who had a third- or fourth-degree lacerations were compared with those who did not. Parity, stretch marks, age, body mass index, tobacco use, fetal weight, operative delivery, labor, and second stage duration were compared between groups. Multivariate direct logistic regression was conducted on all patients who had complete data to calculate the adjusted odds ratio. RESULTS: We identified 299 patients with third- or fourth-degree lacerations and 8,459 patients without third- or fourth-degree lacerations during the time frame. Duration of second stage between 1 hour and 2 hours (P < 0.0001), duration of second stage greater than 2 hours (P < 0.0001), midline or unknown type episiotomy (P < 0.0001), mediolateral episiotomy (P < 0.0001), vacuum delivery (P < 0.0001), forceps delivery (P < 0.0001), fetal weight greater than 4,000 g (P < 0.0001), and antepartum stress urinary incontinence (P < 0.006) were associated with a significant increase in high-risk lacerations. This study did not find a statistically significant association between parity and these lacerations. CONCLUSIONS: We, as others, found that episiotomy and operative delivery were modifiable risks of obstetrical care. Furthermore, even a short second stage of labor (1-2 hours) was associated with significant risk of injury.

The effect of amniotomy on urine protein creatinine ratio test accuracy.

Introduction: While the gold standard for evaluation of maternal urinary protein is a 24-hr urine collection, spot urine protein/creatinine ratio has been instituted as an alternative for quantification proteinuria. Though it seems intuitive to obtain a catheterized urine sample on patients with ruptured amniotic membranes, it is a common practice to forgo this step under the argument that there is no data to show its necessity. Data on the effect of amniotomy, spontaneous or artificial, on the accuracy of the protein/creatinine ratio are scant. The present study was designed to address this issue and objectively compare protein/creatinine ratio values on samples obtained from the same patient before and after amniotomy. Methods: We conducted a prospective non-interventional study. Women presenting in active labor or for labor induction with intact amnion were enrolled. Separate random catch urines for the protein/creatinine ratio were obtained prior to and immediately after spontaneous or assisted amniotomy. The urine samples were analyzed in the hospital chemistry department, and the results were compared. Results: Of the 137 patients consented, 63 had pre- and post-amniotomy protein/creatinine ratios collected. The mean age was 28.5±5.6 y, Gravidity 2.7±1.6, Gestational age 39.2±1.8 wks, and BMI 31.6±6.4 kg/m2. Comorbidities included gestational diabetes (5/63, 7.9%), chronic hypertension (3/63, 4.7%), and pre-eclampsia (5/63, 7.9%). Post-amniotomy protein/creatinine ratio was significantly higher than pre-amniotomy ratio (1.3±2.5 vs 0.34±0.83, p<0.001). In addition, the number of patients with protein/creatinine ratio greater than 0.3 was higher post-amniotomy than pre-amniotomy (41/63 vs 14/63, p<0.001). Conclusion: Amniotomy results in a false elevation of the protein/creatinine ratio in term patients. Urine samples should be obtained by catheterization in the setting of ruptured membranes to reduce falsely elevated results. Although the same can be assumed for other gestational ages, further studies including this population need to be conducted.

A Randomized Controlled Trial Comparing Laparoscopic Lens Defogging Techniques through Simulation Model.

CONTEXT: Current literature demonstrates a lack of comparative studies regarding effective techniques for reducing laparoscopic lens fogging. AIM: Our primary objective is to determine the efficacy of various laparoscopic defogging techniques (LDT) through a randomized controlled trial that employs a novel simulation model of the abdominopelvic cavity. SETTINGS AND DESIGN: This study was conducted at academic community hospital. This study design was a randomized controlled trial through simulation. SUBJECTS AND METHODS: A chamber was constructed that simulated the abdominopelvic cavity. We used 5 and 10 mm 0° laparoscopes. A 10 cm visual analog scale was developed to assign visual clarity (VC) scores. The 10 cm mark indicated perfect VC. We employed the following LDTs: (1) glove warming (GLOVE), (2) surfactant solution (Fog Reduction and Elimination Device [FRED]), (3) chlorhexidine solution (SOAP), (4) warm saline (SALINE), and (5) control. Three observers were blinded to the LDT used. Primary outcomes included VC scores at designated time intervals (5, 30, and 60 s) for each LDT. A minimum of 10 observations per time interval were required to achieve adequate power based on a 2.5 cm difference in VC scores. RESULTS: For the 10 mm laparoscope, FRED, SOAP, and SALINE had a VC score at 60 s (VC60) higher than control (4.8 ± 2.2, 7.8 ± 0.8, 7.9 ± 0.7 vs. 2.4 ± 0.72, P < 0.05). Both SOAP and SALINE VC60 scores were higher than FRED (7.8 ± 0.8, 7.9 ± 0.7 vs. 4.8 ± 2.2, P < 0.05). No differences were noted in VC60 scores between control and GLOVE (2.4 ± 0.72 vs. 3.1 ± 2.2, P > 0.05) and between SOAP and SALINE (7.8 ± 0.8 vs. 7.9 ± 0.7, P > 0.05). Similar results were noted with the 5 mm laparoscope. CONCLUSIONS: Common LDTs such as SALINE and SOAP were more effective than FRED, while GLOVE was no different than control. These results demonstrate that the use of effective LDTs can potentially translate into improved patient care and operative outcomes during surgery.

A randomized controlled trial of abdominal binders for the management of postoperative pain and distress after cesarean delivery.

OBJECTIVE: To determine whether abdominal binders effectively control pain and distress after cesarean delivery. METHODS: A prospective randomized controlled trial was conducted between April and November, 2014, among women undergoing cesarean delivery (low-transverse skin incision) at two US hospitals. Participants were randomly allocated to either the abdominal binder or control groups on entry to the operating suite. Masking was not possible. Patients in the abdominal binder group were fitted with a device before leaving the operating room and were encouraged to wear it constantly, although breaks were allowed. The primary outcomes were postoperative distress (measured by the Symptom Distress Scale [SDS]) and pain (measured by a visual analog scale [VAS]). Individuals who asked to be removed from the study within 6hours of surgery were excluded from analyses. RESULTS: Analyses included 87 patients in the abdominal binder group and 68 in the control group. The abdominal binder and control groups did not differ in postoperative day 1 VAS (3.1±2.1 vs 3.4±2.3; P=0.33), postoperative day 2 VAS (3.0±1.9 vs 3.8±2.2; P=0.16), postoperative day 1 SDS (21.5±5.4 vs 21.8±5.1; P=0.87), and postoperative day 2 SDS (19.4±4.8 vs 19.9±5.0; P=0.53). CONCLUSION: Postoperative pain and distress scores after cesarean delivery were not affected by abdominal binders. ClinicalTrials.gov:NCT02129894.

Amniotic fluid embolism: despite progress, challenges remain.

PURPOSE OF REVIEW: This article reviews the incidence, pathophysiology, risk factors, diagnosis, and management of amniotic fluid embolism (AFE). RECENT FINDINGS: AFE is a leading cause of maternal morbidity and mortality despite an incidence of approximately 7 to 8 per 100,000 births. Recent reevaluation of AFE suggests that the presence of fetal tissue in maternal circulation alone is not sufficient to cause the clinical syndrome, but rather an individual's response to this fetal tissue. The 'anaphylactoid reaction' associated with AFE shares many clinical and metabolic aspects of septic shock. Acute dyspnea followed by cardiovascular collapse, coagulopathy, and neurological symptoms, such as coma and seizures may all be associated with the clinical AFE syndrome. Specific biochemical markers have been described, but are of limited clinical value because of the rapid progression of the disease process. Treatment is based on an interdisciplinary approach that consists of a combination of prompt, aggressive hemodynamic resuscitation, provision of end-organ support, correction of hemostatic disorders, and delivery. SUMMARY: Although AFE cannot be prevented, early diagnosis and intervention may lead to better outcomes for both the mother and the fetus. Clinical suspicion, traditional laboratory data, or intravascular cellular debris (demonstrated only in 50% of patients) are insufficient to make a definitive diagnosis of AFE. An evolving array of novel biomarkers may help differentiate AFE from other conditions, but none of them currently provide sufficient 'early warning' ability to make real-time impact on diagnosis and/or treatment of AFE.

Diagnosis of gestational diabetes mellitus: can we avoid the glucose challenge test?

OBJECTIVE: To identify risk factors for gestational diabetes mellitus (GDM) in patients who had either a normal or abnormal glucose tolerance test (GTT) after failing the initial glucose challenge test (GCT). If identified, consideration can be given to circumvent the glucose challenge test for those at risk. DATA SOURCES: A chart review was performed on 557 patients with abnormal GCT, 278 had an abnormal GTT (cases), and 279 had normal GTT (controls). The following risk factors were extracted: patients' age, body mass index (BMI), ethnicity, selected personal history, and family history. A primary logistic regression and secondary exploratory logistic regression were used to analyze the data. CONCLUSIONS: Of the risk factors reviewed age, BMI, and prior history of GDM were predictive of GDM in the current pregnancy. Age 30-34 had an odds ratio (OR) of 1.95, 95% confidence interval (CI) [1.25,3.05] and over 35 had an OR 3.87 CI [2.12,7.05]. BMI over 30 had an OR 1.95, CI [1.25,3.05] and prior GDM had an OR 2.82 CI [1.55,5.13]. The combination of age and BMI had a significant OR, but not a significant increase over individual risk factors. IMPLICATIONS FOR PRACTICE: Screening by risk factors to circumvent glucose challenge testing may cause unnecessary testing and cost.

Crohn disease and the gynecologic patient.

Although Crohn disease (CD) is considered an inflammatory bowel disease, extraintestinal gynecologic manifestations are varied, frequent, and oftentimes difficult to manage. Its predilection for young and reproductive-age women makes it an important disease process for the gynecologist to understand, as its complications can have long-term repercussions on the developmental, sexual, reproductive, and psychological health of affected women. Patients may present with a variety of vulvovaginal, perineal, perianal, and urologic complaints. Perianal involvement from an intestinal fistula is the most common skin manifestation seen in CD. Other gynecologic manifestations include metastatic CD and rectovaginal and urovaginal fistulas. Recognition and accurate diagnosis of extraintestinal gynecologic manifestations, as well as a good understanding of the gynecologic effects of chronic disease, are necessary for optimal management. The article provides an overview of CD and highlights the gynecologic considerations in caring for women affected by this disease.

Cervical length screening in patients who have undergone loop electrosurgical excision procedure.

OBJECTIVE: To determine whether cervical length measurements in patients who have undergone a loop electrosurgical excision procedure (LEEP) is a predictor of spontaneous preterm delivery (PTD) at < 35 weeks. STUDY DESIGN: A retrospective chart review of 97 pregnant patients with a history of prior LEEP undergoing cervical length screening by transvaginal ultrasound (TVUS) was done. Of these, 87 were included in the study. All patients delivered at the St. Luke's Hospital and Health Network over a 5-year study period. Cervical length measurements in the LEEP group were included. Incidence of PTD in patients who have undergone prior LEEP was compared to patients delivered during the same period who had not undergone LEEP. RESULTS: Of 87 patients who had undergone LEEP, 3 (3.4%, 95% CI 1.1-9.6%) delivered at < 35 weeks. None of the 3 patients had cervical shortening on TVUS. The PTD rate was not statistically different in the LEEP and non-LEEP groups. A shortened cervix was noted in 4 of the 87 patients in the LEEP group (4.5%, 95% CI 1.8-11%) but none had a PTD. CONCLUSION: Cervical length screening in LEEP patients may not be a predictor of PTD.

Cervical lacerations: some surprising facts.

OBJECTIVE: Our aim was to calculate the incidence of cervical lacerations after vaginal delivery and to study its associated risk factors. STUDY DESIGN: A retrospective chart review of all patients with a cervical laceration after vaginal delivery during a 5 year period was performed. Their risk factors were studied. A chi2 test and Bonferroni's correction were applied. The relative risk, P values, and confidence intervals were calculated. RESULTS: Thirty-two patients of 16,931 vaginal deliveries had a cervical laceration for an incidence of 0.2%. Cervical cerclage was associated with an 11.5-fold increase (95% confidence interval 4.1 to 33.3) and induction of labor with a 3.1-fold increase (95% confidence interval 1.5 to 6.7) in the rate of cervical lacerations. Vacuum and forceps deliveries were not noted to be significant risk factors. CONCLUSION: We noted an association of cervical lacerations with cervical cerclage and induction of labor. We were unable to detect an association with cervical lacerations and operative vaginal delivery.

Transdermal progesterone cream as an alternative progestin in hormone therapy.

OBJECTIVE: To evaluate the endometrial effects and determine patients' acceptance of transdermal progresterone cream compared to standard hormone therapy. METHODS: Healthy menopausal women were recruited and received a pretreatment endometrial biopsy (EMB). They were randomized to 0.625 mg conjugated equine estrogen (CEE) daily and 2.5 mg medroxyprogesterone acetate (MPA) (Prempro, Wyeth USA) or daily 0.625 mg CEE and twice daily 20 mg transdermal PC (Pro-gest, Transitions for Health USA). At the end of 6 months, a repeat EMB was obtained, and the women were crossed over to other treatment. A final EMB was performed after the final 6 months. RESULTS: Twenty-six women completed both arms of the study. Seventy-seven percent of women preferred the CEE/PC to the CEE/MPA (P<.001). Of the 52 post-treatment endometrial biopsies: 40 revealed atrophic endometrium and 12 proliferative endometrium (7 in the oral progestin group and 5 in the PC group). There was no evidence of endometrial hyperplasia in any of the specimens. The incidence of vaginal spotting was similar in both groups. CONCLUSION: Patients preferred transdermal PC over oral MPA. This preliminary data indicate that CEE/PC has a similar effect on the endometrium as standard oral HT over a 6-month period.

Autoimmune oophoritis as a mechanism of follicular dysfunction in women with 46,XX spontaneous premature ovarian failure.

OBJECTIVE: To assess the association between serum adrenal cortex autoantibodies and histologically confirmed autoimmune lymphocytic oophoritis. DESIGN: Controlled, prospective. SETTING: Tertiary research center. PATIENT(S): Two hundred sixty-six women with 46,XX spontaneous premature ovarian failure. INTERVENTION(S): Ovarian biopsy in 10 women. MAIN OUTCOME MEASURE(S): Serum adrenal cortex autoantibodies assessed by indirect immunofluorescence and autoimmune oophoritis assessed by immunohistochemical lymphocyte markers. RESULT(S): We obtained a histologic diagnosis of autoimmune oophoritis in four women who tested positive for adrenal cortex autoantibodies and excluded this diagnosis in ovarian biopsies from six women who tested negative for adrenal cortex autoantibodies (4/4 vs. 0/6). Women with histologically confirmed autoimmune oophoritis had a greater total ovarian volume as assessed by transvaginal sonography (11.4 +/- 5.6 mL vs. 1.5 +/- 0.4 mL) (mean +/- SEM). They were also more likely to have subclinical adrenal insufficiency and clinical signs of androgen deficiency (3/4 vs. 0/6). Overall, 10/266 women tested positive for adrenal cortex autoantibodies (3.8%, 95% confidence interval: 1.8%-6.5%). CONCLUSION(S): In women who present with 46,XX spontaneous premature ovarian failure as their primary concern there is a clear association between serum adrenal cortex autoantibodies and the presence of histologically confirmed autoimmune oophoritis.

Sharp-tipped dissecting scissors as an aid in performing endometrial biopsy.

OBJECTIVE: To investigate the effectiveness of employing sharp-tipped dissecting scissors as an aid in performing endometrial biopsy (EMB). STUDY DESIGN: Postmenopausal women undergoing routine EMB under approved protocols formed the study group. Three gentle yet firm attempts were made to pass a 3.0-mm Pipelle (Unimar, Wilton, Connecticut) into the uterine cavity. If they were unsuccessful, the closed tips of the dissecting scissors were inserted into the cervical canal and opened. A fourth attempt was then made to pass the Pipelle. RESULTS: A total of 147 postmenopausal women were studied. The average age was 55.7 years, with an average time since menopause of 6.9 years. We were unable to obtain an EMB initially in 11 women (7.5%). After using the scissors, EMB was obtained in 10 of the 11 (90.9%). Age, weight, years since menopause, hormone status and parity had no effect on the ability to perform EMB. Prior cervical surgery was associated with difficult EMB. CONCLUSION: In patients with a tight or closed cervical os, sharp-tipped dissecting scissors can aid in obtaining EMB.

Abdominopelvic inspection during nonemergent laparoscopic procedures: who looks?

OBJECTIVE: A study was performed to determine whether surgeons and gynecologists inspect the entire abdomen/pelvis at the time of nonemergent laparoscopic surgery. STUDY DESIGN: A retrospective chart audit was conducted of patients who underwent elective laparoscopic cholecystectomy or laparoscopic tubal ligation. Dictated and hand-written operative notes were reviewed. Any documentation of the pelvic structures from cholecystectomy operative notes or the upper abdomen from tubal ligation operative notes was determined to be positive for abdominopelvic surveillance. RESULTS: A total of 771 operative notes were reviewed, which included 358 tubal ligations and 413 laparoscopic cholecystectomies. Two hundred four of 358 (57%) tubal ligations performed by gynecologists had a survey of the upper abdomen versus 36 of 413 (8.7%) cholecystectomies performed by surgeons that had a survey of the pelvis. CONCLUSION: Gynecologists and general surgeons either do not document or do not perform total abdominopelvic inspection universally.