Prepregnancy weight, gestational weight gain, and risk of growth affected neonates.

BACKGROUND: In 2009, the Institute of Medicine published revised gestational weight gain (GWG) guidelines with changes notable for altered body mass index (BMI) categorization as per World Health Organization criteria and a stated range of recommended gain (11-20 pounds) for obese women. The goal of this study was to evaluate associations between maternal BMI-specific GWG adherence in the context of these new guidelines and risk of small for gestational age (SGA) and large for gestational age (LGA) neonates. METHODS: Subjects were a retrospective cohort of 11,203 live birth singletons delivered at 22-44 weeks at a Massachusetts tertiary care center between April 2006 and March 2010. Primary exposure was GWG adherence (inadequate, appropriate, or excessive) based on BMI-specific recommendations. SGA and LGA were defined as <10th and ≥90th percentiles of U.S. population growth curves, respectively. The association between GWG adherence and SGA and LGA was examined in polytomous logistic regression models that estimated adjusted odds ratios (AOR) stratified by prepregnancy weight status, controlling for potential confounders. RESULTS: Before pregnancy, 3.8% of women were underweight, 50.9% were normal weight, 24.6% were overweight, and 20.6% were obese. Seventeen percent had inadequate GWG, and 57.2% had excessive GWG. Neonates were 9.6% SGA and 8.7% LGA. Inadequate GWG was associated with increased odds of SGA (AOR 2.51, 95% confidence interval [CI] 1.31-4.78 for underweight and AOR 1.78, 95% CI 1.42-2.24 for normal weight women) and decreased odds of LGA (AOR 0.5, 95% CI 0.47-0.73 for normal weight and AOR 0.56, 95% CI 0.34-0.90 for obese women). Excessive GWG was associated with decreased odds of SGA (AOR 0.59, 95% CI 0.47-0.73 for normal weight and AOR 0.64, 95% CI 0.47-0.89 for overweight women) and increased odds of LGA (AOR 1.76, 95% CI 1.38-2.24 for normal weight, AOR 2.99, 95% CI 1.92-4.65 for overweight, and AOR 1.55, 95% CI 1.10-2.19 for obese women). CONCLUSIONS: Efforts to optimize GWG are essential to reducing the proportion of SGA and LGA neonates, regardless of prepregnancy BMI.

Impact of updated Institute of Medicine guidelines on prepregnancy body mass index categorization, gestational weight gain recommendations, and needed counseling.

BACKGROUND: Our objective was to quantify how the 2009 revisions of the 1990 Institute of Medicine (IOM) gestational weight gain (GWG) guidelines change women's body mass index (BMI) categorization and BMI-specific GWG adherence categories. The goal was to identify how provider counseling practices need to change on a population level. METHODS: A retrospective review of automated labor and delivery records from a tertiary care hospital in Central Massachusetts was performed. The study cohort included women who delivered singleton, live birth gestations from from April 1, 2006, to September 30, 2009. Records missing weight, height, GWG, gestational age (GA), and/or GA <22 or >43 weeks were excluded. BMI groups and GWG adherence were categorized according to IOM 1990 and 2009 recommendations. Adherence analyses included full-term gestations only. RESULTS: The cohort consisted of 11,688 women, mean age 28.9 (±6.1) years and mean parity 1.0 (±1.1). By 1990 recommendations, 10.1%, 52.5%, 14.1%, and 23.3% gravidas were low weight, normal weight, high weight, and obese; and 19.8%, 33.3%, and 46.9% were undergainers, appropriate gainers, and overgainers, respectively. By 2009 recommendations, 3.9%, 51.3%, 24.5%, and 20.3% gravidas were underweight, normal weight, overweight, and obese, and 16.7%, 30.8%, and 52.6% were undergainers, appropriate gainers, and overgainers, respectively. Differences in categorization by guideline year was significant for BMI category (p<0.0001) and GWG adherence (p<0.0001). Compared to 1990 guidelines, 16.7% of women were classified differently using 2009 guidelines, with fewer classified as underweight, normal weight, or obese and more as overweight; 17.1% of 1990 appropriate gainers would be classified as overgainers, given new guidelines. CONCLUSIONS: Changes in IOM GWG recommendations alter gravidas' BMI categories and, thus, the recommended GWG. As the amount advised is associated with actual gain, accuracy is paramount. GWG is a modifiable parameter associated with immediate and long-term maternal/neonatal health outcomes, and counseling can have a significant public health impact and should involve BMI determination, followed by BMI-specific GWG recommendations in accordance with current guidelines.

Society of gynecologic surgeons' survey: mesh use in vaginal prolapse surgery.

OBJECTIVE: : To evaluate the practice patterns of the Society of Gynecologic Surgeons (SGS) members and guests regarding the use of synthetic mesh in vaginal prolapse repair. METHODS: : A 26-item questionnaire regarding synthetic mesh use in vaginal prolapse repair was placed on the desks of those SGS attendees present at the fourth scientific session of the 2008 annual scientific meeting. Voluntary participation was requested and the survey questionnaires were retrieved at the session's conclusion. Descriptive statistics and cross-tabulation using χ tests were performed with SPSS. RESULTS: : One hundred twenty-eight of the 180 scientific session attendees completed the surveys. Sixty-nine percent (88/128) of the respondents identified themselves as urogynecologists and 45% (83/128) were male. Forty-five percent (58/128) were SGS members. Sixty-six percent (84/128) described their practice setting as academic, 28% (36/128) as community-based, and 6% (8/128) as other. The majority of the urogynecologists, 65% (64/88), used mesh at the time of survey completion versus 40% (8/18) of the obstetrician/gynecologists (P < 0.001). Fifty-nine percent (74/125) respondents were currently using mesh and 11% (14/125) reported using mesh at one time. Fifty-six percent (48/86) used mesh in both primary and recurrent repairs. For anterior repair, 97% (82/86) used mesh; of these, 31% (26/86) used only mesh kits, 33% (28/86) used only free mesh and 33% (28/86) reported using both. For posterior repair, 70% (62/88) used mesh; of these 18% (16/88) used only mesh kits, 26% (23/88) used only free mesh and 26% (23/88) used both. For anterior repair, 84% (71/85) dissected full-thickness and 43% (35/85) plicated connective tissue prior to inserting the mesh. The respondents had excised mesh for indications including: persistent drainage (59%), persistent pain (21%), hispareunia (21%), dyspareunia (16%), and asymptomatic exposure (11%). Fifty percent (44/88) initially managed mesh erosion with estrogen cream whereas 29% (26/88) started with mesh excision. CONCLUSIONS: : This survey suggests that the majority of urogynecologists attending the 34th SGS annual scientific meeting have used vaginal mesh for prolapse repair, and they more commonly used it in the anterior as compared to the posterior compartment. This has occurred in the absence of prospective, controlled, high-quality studies supporting its efficacy and safety. Research is clearly needed in this area.

Long-term efficacy of the pubovaginal Mersilene mesh sling.

OBJECTIVE: The objective of the study was to determine the efficacy of the pubovaginal Mersilene mesh sling (PVMMS) for complicated urodynamic stress incontinence (USI). STUDY DESIGN: Between 1990 and 2008, patients with USI plus an at-risk diagnosis underwent a PVMMS by a single surgeon. They were followed up with urodynamics (UDE) and Pelvic Floor Distress Inventory-short form 20 (PFDI-20). Stratification was in an at-risk hierarchy: intrinsic sphincter deficiency (ISD) greater than recurrent USI (RUSI) greater than USI with chronically increased intraabdominal pressure (CI-IAP). A cough stress test determined objective cure. PFDI question 17 assessed subjective cure. RESULTS: Three hundred six patients with ISD (43.5%), RUSI (26.8%), and CI-IAP (29.7%) had objective cure rates of 89.2% in the short term, 86.7% in the intermediate term, and 91.2% in the long term. A group of 48 patients with both short- and long-term UDEs showed cures of 100% and 91.7%. Long-term objective cure rates were: ISD, 90.5% (n = 21); RUSI, 84.2%, (n = 19); CI-IAP, 100% (n = 17). The mean score of postoperative PFDI question 17 was 0.57 (n = 119). Mean symptom improvement was -2.98 (n = 52; P < .0001). CONCLUSION: We demonstrated PVMMS to be subjectively and objectively effective in long-term treatment of complicated forms of USI.

Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes.

Our aim was to study the anatomic recurrence rates and quality of life outcomes of patients who had undergone either anterior colporrhaphy (AC) or anterior colporrhaphy and vaginal paravaginal repair (AC + VPVR) as part of surgery for pelvic organ prolapse. Chart reviews were used to identify anatomic prolapse recurrence. Phone interviews assessed quality of life outcomes [Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ)] outcomes. There was a trend towards longer time to anatomic recurrence (any compartment > or =grade 2) in the AC group compared with the AC + VPVR group (median 24 vs 13 months, p=0.069). If only patients who had undergone previous surgery were compared, time to anatomic recurrence appeared significantly longer in the AC group (median 41 vs 12 months, p=0.022). There were 55% of women in the AC group and 46% of women in the AC + VPVR group who reported significant bladder or bulge symptoms based on responses to the phone-administered UDI and IIQ (p=0.89). Our retrospective study did not suggest that adding VPVR was superior in terms of anatomic or quality of life outcomes. Prospective assessment of the role of VPVR in the treatment of pelvic organ prolapse is needed.

Low risk of ureteral obstruction with "deep" (dorsal/posterior) uterosacral ligament suture placement for transvaginal apical suspension.

OBJECTIVE: Transvaginal uterosacral ligament fixation (USLF), often called "high" USLF, is associated with a 1.0% to 10.9% ureteral obstruction rate. Anatomic relations and pelvic rotation with positioning imply "high" (cephalad) suture placement may bring sutures closer to the ureter. We examined the ureteral obstruction rate with a "deep" (dorsal/posterior) uterosacral ligament suture placement modification of a standard USLF procedure. STUDY DESIGN: At the University of Massachusetts and Tufts, 411 consecutive patients underwent Mayo culdoplasty utilizing > or = 3 uterosacral sutures placed "deep" bilaterally. Intraoperative cystoscopy was performed. RESULTS: One patient (0.24% [.01%-1.35%]) had ureteral obstruction attributable to USLF. Two had obstruction secondary to concomitant procedures. Compared with previous published series, the odds of ureteral injury secondary to USLF was 4.6 times lower (95% CI 2.31-9.24; P < .0001). CONCLUSION: Placement of USLF sutures "deep" (dorsal/posterior) increases the margin of safety for the ureter and, in this study, decreased the ureteral injury rate nearly 5-fold.

Elucidating the Origin of Conformational Energy Differences in Substituted 1,3-Dioxanes: A Combined Theoretical and Experimental Study.

13C NMR spectroscopy, ab initio quantum mechanics, and molecular mechanics have been used to investigate the trans-4-(trifluoromethyl)-2,2,6-trimethyl-1,3-dioxane chair/twist-boat equilibrium. The molecular mechanics calculations were based upon the MM3 and AMBER force fields. A 6-31G basis set was used for the ab initio calculations, and MP2 correlation corrections were applied. Both the ab initio and AMBER molecular mechanics calculations are consistent with the (13)C NMR chemical shift differences for the trans-4-(trifluoromethyl)-2,2,6-trimethyl-1,3-dioxane conformers. The predicted chair to twist-boat equilibrium suggested by the MM3 calculations is not consistent with the experimental data. These results support the suggestion by Howard et al. (Howard, A. E.; Cieplak, P.; Kollman, P. A. J. Comput.Chem. 1995, 16, 243-261) on the critical role of electrostatic interactions in determining the chair/twist-boat equilibrium.