Residual risk associations between initial hyperglycemia and adverse pregnancy outcomes in a large cohort including 6709 women with gestational diabetes

AIMS

. - To estimate the residual risk associations between hyperglycemia and adverse pregnancy outcomes after glycemia-controlling intervention.

METHODS

. - Among 41,067 Chinese women, those with gestational diabetes mellitus (GDM), according to the IADPSG criteria, received standard interventions to control glycemia. Risk associations of plasma glucose (PG) levels with excess newborn birth weight, primary cesarean section, and preterm delivery were estimated and compared with those in the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, where hyperglycemia was left untreated.

RESULTS

. - A total of 6,709 (16.3%) women developed GDM and thus received predominantly lifestyle interventions. The incidence of excess newborn birth weight, primary cesarean section, and preterm delivery was 6.1%, 19.1%, and 4.0%, respectively. Higher fasting and higher post-load PG levels during 75-g oral glucose tolerance test (OGTT) were statistically significantly associated with increased risks of excess newborn birth weight and pre-term delivery. Compared with the HAPO study, the association of fasting PG level with excess newborn birth weight showed similar strength and dose-response pattern, contrasting with considerably weakened associations for post-load PG levels that involved glycemic control. Contrary risk associations were seen across GDM subtypes compared with non-GDM, isolated fasting GDM was associated with increased, whereas isolated post-load GDM was associated with decreased, risks of excess newborn birth weight and primary cesarean section. Limiting the analysis to non-GDM women and GDM women with low HbA1c (<6.0%) ≥30 days after interventions overall attenuated the risk associations.

CONCLUSIONS

. - Residual risk associations exist between hyperglycemia and adverse pregnancy outcomes despite seemingly appropriate glycemic control.

Historical Origins for the Overestimation of Mammographic Sensitivity

The sensitivity of screening mammography for the early detection of breast cancer has improved over the years due to advances in technology. However, guidelines for screening mammography are often based on the mortality reductions demonstrated in the historic trials, where sensitivity with the first-generation mammography was relatively low. With attempts to establish risk:benefit ratios for population screening, it is important to understand the wide range of sensitivities that have been reported for mammography. 

Original calculations for mammographic sensitivity were often based on studies that included palpable tumors, thus generating inflated numbers not fully applicable to non-palpable tumors. If restricted to asymptomatic screening, sensitivity calculations were often based on the inverse of interval cancers, a relatively inaccurate method since breast cancers missed on mammography can remain undetected clinically for several years. It was not until multi-modality imaging was developed, primarily ultrasound and MRI, where sensitivity determinations could be made in real time by cross-checking outcomes with each modality. From this, it became apparent that there was a strong correlation between breast density levels and sensitivity levels, such that a single number to denote mammographic sensitivity was disingenuous. The increasing awareness that mortality reductions in the historic trials were achieved with a low sensitivity tool has prompted great interest in additional technologic improvements in mammography, as well as multi-modality imaging approaches for women with high density and/or high risk. In order to appreciate the potential benefit of these new approaches, it is helpful to understand the historical basis behind overestimating the sensitivity of screening mammography.

Feasibility of Breast MRI as the Primary Imaging Modality in a Large Asian Cohort

Purpose

Contrast-enhanced MRI has repeatedly demonstrated significantly enhanced sensitivity compared to mammography and ultrasound in breast cancer detection. The purpose of this study was to evaluate the feasibility and outcomes of using breast MRI as the initial imaging study for screening and diagnosis. 

Materials and methods

In this retrospective review of a cohort of 10,374 breast MRI scans in 7967 patients in Taitung County, Taiwan, a total of 5619 participants met inclusion criteria and were included in our analysis. We reviewed all biopsies that were performed subsequent to MRI studies in women (screening vs. diagnostic). The primary outcomes were false-positive (FP) biopsy rates and positive predictive value (PPV) of MRI - parameters that have historically been associated with performance that restricts more widespread use of MRI. False-positive rate based on benign biopsies (FPR-3) and the positive predictive value (PPV-3) were calculated.

Results

Without complementary imaging or follow-up to identify false negatives, the study of performance characteristics was limited to false positives and PPV. There were 351 benign biopsies generated by MRI out of the cohort of 5555 participants (5619 minus the malignant biopsies), generating a false-positive rate of 6.3%. Sixty-four patients out of 415 biopsies were malignant, generating a PPV-3 of 15.4%.

Conclusion

In this Asian cohort, utilizing breast MRI as the initial study for screening and/or diagnosis appears to be limited more by practical considerations such as cost and patient flow efficiency than by feasibility based on performance characteristics. With well-established superior sensitivity, coupled with improved interpretive skills and techniques that allow for low false-positive rates, MRI should be further studied for its role as the primary imaging modality in breast screening and diagnosis. 

Are there differences in pain intensity between two consecutive vaginal childbirths? A retrospective cohort study

BACKGROUND

Pain assessment is crucial for in-labour pain management. Even though women's self-rated pain intensity is the standard for pain relief or analgesic administration, multiparas appear to receive worse in-labour pain management than primiparas do. The discrepancy in pain perception between primiparas and multiparas remains unclear. Healthcare providers tend to think that multiparas endure the pain and report less pain because they have experienced childbirth.

OBJECTIVE

To retrospectively analyse the intensity of in-labour pain during first and second vaginal childbirth within the same group of women and explore whether parity may be an influential factor in labour pain intensity.

DESIGN

Retrospective cohort study.

SETTING

Labour and delivery in a large academic specialized hospital in Guangzhou, China.

PARTICIPANTS

Women were included if they had two consecutive vaginal childbirths with singleton cephalic presentations and cervical dilation ≤ 3 cm for the first childbirth and ≤ 2 cm for the second childbirth. The final study sample consisted of 417 women.

METHODS

All childbirth case records between January 2015 and August 2018 were scanned using a structured electronic medical system. Maternal and neonatal demographics as well as obstetric and neonatal outcomes were extracted. The in-labour pain for each childbirth was compared between first and second births. Paired t-tests, McNemar's chi-square tests and mixed-effects modelling were applied to compare the differences in labour pain intensity between the two vaginal childbirths and explore the factors that influenced maximum labour pain scores during the second childbirth.

RESULTS

Four hundred seventeen women were included, with an average birth interval of 1.7 years. The average maximum labour pain score during the latent phase was 6 (5,6) for the first childbirth and 5 (4,6) for the second childbirth (paired t =-6.13, P <0.001). Pain scores decreased in 28.1% (117/417) of women and increased in 13.7% (57/417) of women from the first to the second childbirth. More than half of the women in our study experienced the same maximum labour pain score during the first and second labour. Mixed-effects modelling revealed that parity, education and pregnancy complications were independently associated with maximum labour pain scores.

CONCLUSIONS

From a clinical point of view, in-labour pain is not clinically different for women when comparing their first and second labours. Health care professionals may underestimate in-labour pain in primiparas when comparing them with nulliparas. More studies are warranted to explore options for achieving better pain management for women with more childbirths.

Predicting poor outcomes and the need for surgical treatment in neonates with meconium peritonitis

OBJECTIVE

The objective of this study is to determine factors associated with poor outcomes and the need for surgical treatment in neonates with meconium peritonitis (MP).

METHODS

We evaluated the association between prenatal ultrasound features, maternal characteristics, and the likelihood of surgery, mortality, and serious morbidity in 49 neonates with a prenatal diagnosis of MP, who were born in Guangzhou Women and Children's Medical Center between January 2011 and December 2016.

RESULTS

Thirty of 49 neonates (61.2%) required surgical treatment, and 17 (34.7%) had a poor outcome. Independent predictors of need for surgical treatment were polyhydramnios, maternal intrahepatic cholestasis of pregnancy (associated with lower risk), and persistence of peritoneal fluid. The model correctly predicted 70.0% of the neonates who required surgery (at a 10% false-positive rate; area under the curve [AUC]: 0.86 [95% CI, 0.75-0.97]). For poor outcomes, independent predictors were low gestational age at birth, persistence of peritoneal fluid, and polyhydramnios. For the latter, the model only achieved a detection rate of 52.9% (10% false-positive rate, AUC: 0.82 [95% CI, 0.70-0.94]).

CONCLUSIONS

A combination of prenatal ultrasound features and maternal characteristics correctly predicted 70.0% the need for neonatal surgery. Prediction of poor outcome-based prenatal ultrasound features and gestational age did not perform well.

Understanding and management of gestational trophoblastic disease

Gestational trophoblastic disease or neoplasia covers a spectrum of benign and malignant conditions arising from pregnancies with highly abnormal development of trophoblastic tissue. In this brief review, we discuss the different features of these different conditions and their origins and risk factors and introduce some of the more novel and controversial treatment options currently being explored.

Proteomics of Uterosacral Ligament Connective Tissue from Women with and without Pelvic Organ Prolapse

PURPOSE

Damage to the uterosacral ligaments is an important contributor to uterine and vaginal prolapse. The aim of this study is to identify differentially expressed proteins (DEPs) in the uterosacral ligaments of women with and without pelvic organ prolapse (POP) and analyze their relationships to cellular mechanisms involved in the pathogenesis of POP.

EXPERIMENTAL DESIGN

Uterosacral ligament connective tissue from four patients with POP and four control women undergo iTRAQ analysis followed by ingenuity pathway analysis (IPA) of DEPs. DEPs are validated using Western blot analysis.

RESULTS

A total of 1789 unique protein sequences are identified in the uterosacral ligament connective tissues. The expression levels of 88 proteins are significantly different between prolapse and control groups (≥1.2-fold, p < 0.05). IPA demonstrates the association of 14 DEPs with "Connective Tissue Function." Among them, fibromodulin, collagen alpha-1 (XIV) chain, calponin-1, tenascin, and galectin-1 appear most likely to play a role in the etiology of POP.

CONCLUSIONS AND CLINICAL RELEVANCE

At least six proteins not previously associated with the pathogenesis of POP with biologic functions that suggest a plausible relationship to the disorder are identified. These results may be helpful for furthering the understanding of the pathophysiological mechanisms of POP.

Association between serum progesterone concentration in early pregnancy and duration of pregnancy: a cohort study

Objective: To examine the association between progesterone concentration in early pregnancy and duration of pregnancy and risk of preterm delivery.Methods: Women enrolled in the Born in Guangzhou Cohort Study from 2013-2014, with a singleton pregnancy, who had serum progesterone measured at least one time between 4 and 10 weeks of gestation were included. The association between progesterone concentration both continuous and as categorical variable (quartile) and the risk of preterm delivery was assessed with Cox proportional hazards regression. Differences of length of gestation in four progesterone concentration quartiles were assessed using the Log-rank test.Results: We studied 1860 mother-newborn pairs. The mean overall progesterone concentration was 65.7 ± 21.3 nmol/L, with mean progesterone concentrations in the four quartiles of 42.4 ± 6.2 nmol/L (n = 463), 56.2 ± 3.3 nmol/L (n = 462), 68.9 ± 4.5 nmol/L (n = 470), and 95.1 ± 15.3 nmol/L (n = 465). There was no significantly difference in duration of gestation in four progesterone concentration groups (p=.511). There was no relation between progesterone level and preterm delivery (adjusted hazard ratio (HR) per 10 nmol/l progesterone level 1.00 (95% confidence interval (CI) 0.90, 1.11)). After adjusting for potential confounders, the HR of any preterm delivery for quartiles 1, 2 and 3 versus the highest quartile of progesterone level (> 77.3 nmol/L) was 1.04 (95% CI 0.52, 2.07), 1.17 (95% CI 0.60, 2.28), and 1.46 (95% CI 0.76, 2.78), respectively. When analysis was done for spontaneous preterm delivery only, also no association with first trimester progesterone was found.Conclusion: Lower first trimester serum progesterone concentration is not associated with reduction of length of gestation or increased risk of preterm delivery.

Neuroimaging findings in women who develop neurologic symptoms in severe preeclampsia with or without eclampsia

Eclampsia is a leading cause of maternal and fetal morbidity and mortality worldwide, and its pathogenesis remains elusive. Our objective was to investigate neuroimaging findings in women who developed neurologic symptoms in severe preeclampsia with or without eclampsia to further understand the relationship between neuroimaging findings and the pathogenesis of eclamptic seizures. This retrospective study included 79 women with severe preeclampsia/eclampsia who underwent brain MRI/CT examination between 2005 and 2017. We analyzed imaging findings, clinical data, and laboratory data in order to compare patients with severe preeclampsia to those with eclampsia and patients with abnormal imaging findings to those with normal CT or MRI. A total of 41 of 79 women were diagnosed with eclampsia, 36 (88.80%) of which had abnormal neuroimaging findings, including cerebral edema (19 cases), infarction (5 cases), cerebral venous thrombosis (5 cases), and cerebral hemorrhage (7 cases). Five patients died of cerebral hemorrhage. Of the 38 cases of severe preeclampsia, 21 (55.26%) cases had abnormal imaging findings, including cerebral edema (20 cases), and 1 case had cerebral hemorrhage. Serum uric acid was significantly higher in patients with abnormal imaging findings than in patients without them (P = 0.004). The imaging findings in women with neurologic symptoms were similar between the severe preeclampsia and eclampsia groups. Our results suggest that eclampsia may not be a diagnosis with a unique pathogenesis; rather, it may be best considered a severe symptom of the intracranial pathophysiology of preeclampsia. We suggest that cranial imaging should be performed early in the management of patients with severe preeclampsia who develop new neurologic symptoms.

Infection of ectocervical tissue and universal targeting of T-cells mediated by primary non-macrophage-tropic and highly macrophage-tropic HIV-1 R5 envelopes

Background

HIV-1 variants carrying non-macrophage-tropic HIV-1 R5 envelopes (Envs) are predominantly transmitted and persist in immune tissue even in AIDS patients who have highly macrophage-tropic variants in the brain. Non-macrophage-tropic R5 Envs require high levels of CD4 for infection contrasting with macrophage-tropic Envs, which can efficiently mediate infection of cells via low CD4. Here, we investigated whether non-macrophage-tropic R5 Envs from the acute stage of infection (including transmitted/founder Env) mediated more efficient infection of ectocervical explant cultures compared to non-macrophage-tropic and highly macrophage-tropic R5 Envs from late disease.

Results

We used Env+ pseudovirions that carried a GFP reporter gene to measure infection of the first cells targeted in ectocervical explant cultures. In straight titrations of Env+ pseudovirus supernatants, mac-tropic R5 Envs from late disease mediated slightly higher infectivities for ectocervical explants although this was not significant. Surprisingly, explant infection by several T/F/acute Envs was lower than for Envs from late disease. However, when infectivity for explants was corrected to account for differences in the overall infectivity of each Env+ pseudovirus (measured on highly permissive HeLa TZM-bl cells), non-mac-tropic early and late disease Env+ pseudoviruses mediated significantly higher infection. This observation suggests that cervical tissue preferentially supports non-mac-tropic Env+ viruses compared to mac-tropic viruses. Finally, we show that T-cells were the main targets for infection regardless of whether explants were stimulated with T-cell or monocyte/macrophage cytokines. There was no evidence of macrophage infection even for pseudovirions carrying highly mac-tropic Envs from brain tissue or for the highly mac-tropic, laboratory strain, BaL, which targeted T-cells in the explant tissue.

Conclusions

Our data support ectocervical tissue as a favorable environment for non-mac-tropic HIV-1 R5 variants and emphasize the role of T-cells as initial targets for infection even for highly mac-tropic variants.

Electronic supplementary material

The online version of this article (doi:10.1186/s12977-015-0176-2) contains supplementary material, which is available to authorized users.

Effect of analgesics and their derivatives on antibiotic resistance of environmental microbes

This research is a preliminary study conducted to determine the effects of aspirin (acetyl-salicylic acid) and salicylic acid (analgesics and their derivatives) on the antibiotic resistance of ammonia oxidizing bacterium (AOB) (a non-pathogenic environmental microbe) cultured from the Texas Tech University-Water Recovery System that treats a space related wastewater for NASA. The effect of salicylic acid was investigated by obtaining the minimal inhibition concentration (MIC) of antibiotics (amoxicillin, ciprofloxacin, and nalidixic acid) in the presence of aspirin and salicylic acid. The possibility of transfer of resistance genes between unrelated species was investigated by analyzing the similarity of the AcrA protein (a multi-drug efflux protein) in Nitrosomonas europaea, Escherichia coli and Salmonella enterica. The protein alignment analysis was done using ExPASy, a proteomics tool. The results of this preliminary study indicated that the antibiotic resistance of AOBs increased in the presence of aspirin and salicylic acid and similarities in the AcrA protein of different species indicated the likelihood of possible resistance transfer between the species. This paper high lights the importance of research and further investigation on antibiotic resistance and resistance transfer, highlighting the number of parameters that should be considered while assessing antibiotic resistance in environmental samples.

'I'd rather just go on as I am'--pelvic floor care preferences of frail, elderly women in residential care

Little is known about how frail, elderly women in assisted living and long-term care facilities view pelvic floor dysfunctions and treatments. Twenty-five residents reflect on these issues, and quality of life.

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.

Vaginal revision of intravesical tension-free vaginal tape 44 h after initial placement: a case report

Unintentional cystotomy is a known complication of the tension-free vaginal tape procedure and is commonly diagnosed intraoperatively. Delayed diagnosis does occur and various reparative techniques have been described, some requiring laparotomy with intentional cystotomy and repair. We report a case where a 46-year-old woman underwent vaginal reconstructive surgery including placement of a tension-free vaginal tape, which was complicated by unilateral cystotomy. A delayed diagnosis of intravesical tape placement was made requiring reoperation. The patient underwent a minimally invasive transvaginal procedure for removal and immediate replacement of the malpositioned arm of the tape. We conclude that a transvaginal approach may be an acceptable technique for revision and replacement of the tension-free vaginal tape where cystotomy is identified within 44 h after the initial procedure. With this technique, a more invasive surgery including laparotomy with cystotomy might successfully be avoided.

The risk of hydrosalpinx formation and adnexectomy following tubal ligation and subsequent hysterectomy: a historical cohort study

OBJECTIVE

The objective of the study was to further investigate a previous finding that tubal sterilization followed by hysterectomy was associated with hydrosalpinx formation.

STUDY DESIGN

The Rochester Epidemiology Project (Rochester, MN) was used to identify three cohorts: women who had undergone tubal sterilization and subsequent hysterectomy, women who had undergone tubal sterilization alone, and women who had undergone hysterectomy alone. Four hundred seventy-three charts were reviewed and 337 met inclusion criteria. Patient histories were analyzed prospectively, looking for subsequent adnexal surgery.

RESULTS

There was no increased risk of hydrosalpinx formation in patients who had undergone tubal sterilization and hysterectomy, compared with tubal sterilization alone. The proportion of subjects undergoing later adnexectomy for any reason was significantly higher in the hysterectomy groups, compared with the sterilization only group (relative risk 3.5, 95% confidence interval 1.3-9.4).

CONCLUSION

This prospective study does not support the previously reported case-control data suggesting that tubal sterilization followed by hysterectomy resulted in an increased risk of hydrosalpinx formation, compared with tubal sterilization alone.

Prediction of successful voiding immediately after outpatient mid-urethral sling

We set out to identify predictors of successful voiding immediately after outpatient mid-urethral sling. The charts of 126 patients who underwent an outpatient mid-urethral sling procedure were identified. Using discharge without a urinary catheter as the dependent variable, logistic regression analysis modeled the relationship of independent variables including demographic, preoperative urodynamic, and perioperative variables. Sixty-one percent of the patients passed their immediate postoperative voiding trial. Logistic regression analysis revealed that parity > or = 3, Valsalva leak point pressure > 60 cm H(2)O, and high preoperative anxiety remained independently associated with successful voiding. Identifying preoperative variables that are associated with successful voiding after mid-urethral sling may be useful in helping to accurately shape patient expectations and identify those most likely to benefit from preoperative teaching of self-catheterization.

Use of prescription medications with a potential for fetal harm among pregnant women

PURPOSE

To estimate the prevalence of use of prescription drugs with a potential for fetal harm among pregnant women in the United States.

METHODS

A retrospective study was conducted using the automated databases of eight health maintenance organizations involved in the HMO Research Network Center for Education and Research on Therapeutics (CERT). Women who delivered an infant from January 1996 to December 2000 were identified. The frequency of use of prescription drugs with a potential for fetal harm was based upon the expert review of a clinical teratologist and the U.S. Food and Drug Administration (FDA) risk classification system, assuming a gestational duration of 270 days.

RESULTS

Among the 114 165 women with no documentation of a diagnosis suggesting potential pre-term birth or dispensing of ovulation stimulants in the 270 days before delivery, 1305 (1.1%) received a teratogenic drug during the 270 days before delivery, based upon the expert review of a clinical teratologist. A larger proportion of women received U.S. FDA category D or X drugs (5.8%; N = 6600). However, the general patterns of use were similar, with higher use in early pregnancy compared to later trimesters. The proportion of women dispensed a teratogen during pregnancy was substantially higher among women who received a teratogen in the 90 days before pregnancy compared to women who did not (adjusted RR = 38.9, 95%CI, 33.5, 45.3).

CONCLUSIONS

Our results suggest that further efforts directed at physicians to counsel women or at the women themselves about the potential risks of particular medications appear warranted.

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.

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.

Exclusion of elderly women from published randomized trials of stress incontinence surgery

OBJECTIVE

More than 20,000 women, aged 70 years or older, undergo surgery for stress urinary incontinence each year. Our objective was to review the published randomized trials of the surgical treatment of stress urinary incontinence and estimate the proportion of women 70 years or older enrolled in those trials.

DATA SOURCES

MEDLINE and Cochrane Databases of Clinical Trials were searched from January 1966 through December 2003 with the terms "urinary incontinence," "stress incontinence," "urethropexy," "needle suspension," "pubovaginal sling," "tension-free vaginal tape," "urethral injection," "collagen injection," "anterior colporrhaphy," and "clinical trial," "controlled trial," or "randomized trial" as both subject headings and words contained in article titles. We supplemented this search with manual searches of meta-analyses and review articles from 2000 to 2003.

METHODS OF STUDY SELECTION

All studies that included at least one group undergoing an invasive treatment for stress incontinence (including urethral bulking injections) were reviewed. We excluded reports without sufficient data to estimate the number of women aged 70 and older who participated, those published only in abstract form, and those studies in languages other than English, French, German, Italian, or Spanish. Twenty studies met our inclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

The number of women aged 70 or older in each study was estimated using the demographic data provided. The median percentage of subjects aged 70 or older was 3.8% (interquartile range 0.37-15%). There was no significant difference in the proportion of subjects 70 years of age or older based on the year of publication.

CONCLUSION

Our review of the published literature suggests that elderly women are underrepresented in clinical trials of stress incontinence surgery. Efforts should be made to include more elderly women in clinical trials of stress incontinence surgery.

Prescription drug use in pregnancy

OBJECTIVE

The purpose of this study was to provide information on the prevalence of the use of prescription drugs among pregnant women in the United States.

STUDY DESIGN

A retrospective study was conducted with the use of the automated databases of 8 health maintenance organizations that are involved in the Health Maintenance Research Network Center for Education and Research on Therapeutics. Women who delivered of an infant in a hospital from January 1, 1996, through December 31, 2000, were identified. Prescription drug use according to therapeutic class and the United States Food and Drug Administration risk classification system was evaluated, with the assumption of a gestational duration of 270 days, with three 90-day trimesters of pregnancy, and with a 90-day period before pregnancy. Nonprescription drug use was not assessed.

RESULTS

During the period 1996 through 2000, 152,531 deliveries were identified that met the criteria for study. For 98,182 deliveries (64%), a drug other than a vitamin or mineral supplement was prescribed in the 270 days before delivery: 3595 women (2.4%) received a drug from category A; 76,292 women (50.0%) received a drug from category B; 57,604 women (37.8%) received a drug from category C; 7333 women (4.8%) received a drug from category D, and 6976 women (4.6%) received a drug from category X of the United States Food and Drug Administration risk classification system. Overall, 5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received a category X drug after the initial prenatal care visit.

CONCLUSION

Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman.

Changes in tensile strength of cadaveric human fascia lata after implantation in a rabbit vagina model

PURPOSE

We determined changes in tensile properties after vaginal implantation of human cadaveric fascia lata.

MATERIALS AND METHODS

Baseline tensile properties were determined for freeze-dried, gamma irradiated human cadaveric fascia lata from 3 separate lots. Fascial strips (2 x 0.5 cm.) from 2 lots were implanted between the rectovaginal membrane and vaginal mucosa in New Zealand white rabbits. The strips were excised en bloc 12 weeks after implantation. Tensile property measurements were repeated and compared with pre-implantation values.

RESULTS

Pre-implantation interlot and intralot variability in baseline tensile properties was significant. After implantation there was an approximate 90% decrease in tensile strength from baseline values. There was no gross evidence of graft autolysis.

CONCLUSIONS

The decrease in tensile strength of cadaveric fascial graft was significant after implantation in this model.

Does hysterectomy without adnexectomy in patients with prior tubal interruption increase the risk of subsequent hydrosalpinx?

OBJECTIVE

Our purpose was to examine the hypothesis that hysterectomy without adnexectomy after tubal interruption is associated with the development of hydrosalpinx.

STUDY DESIGN

In this case-control study, patients with a pathologic diagnosis of hydrosalpinx were compared with a group of patients undergoing adnexectomy without a hydrosalpinx. The incidence of prior tubal interruption followed by hysterectomy in the two groups was compared.

RESULTS

There was a statistically significant association between the development of hydrosalpinx and a history of hysterectomy after tubal interruption. Nine of 38 cases and 2 of 45 controls had a history of tubal interruption (odds ratio 6.67, P =.019).

CONCLUSIONS

Patients undergoing hysterectomy who have had a tubal interruption may be at risk for the development of hydrosalpinx because this combination of procedures results in a segment of tube that is blocked at both ends. If further study bears out this association, consideration should be given to performing salpingectomy at the time of hysterectomy even if the ovaries are being left behind.

Perioperative changes in serum creatinine after gynecologic surgery

OBJECTIVE

The purpose of this study was to prospectively determine the normal range of postoperative changes in serum creatinine levels when bilateral ureteral patency was confirmed by cystoscopy.

STUDY DESIGN

A total of 187 consecutive patients who had undergone major gynecologic surgery were evaluated prospectively. All patients had undergone perioperative cystoscopy to evaluate for ureteral patency, and creatinine levels had been determined before and 24 hours after surgery.

RESULTS

The mean change in serum creatinine level was 0.01 mg/dL, and the changes for the central 95% ranged from -0.2 to 0.3 mg/dL. With a previously defined cutoff value of an increase of >0.2 mg/dL after operation to indicate ureteral obstruction, specificity and negative predictive values (when compared with cystoscopic findings) were 98% and 100%, respectively.

CONCLUSION

Creatinine levels change minimally during the immediate postoperative period in the absence of ureteral compromise. If bilateral ureteral patency was demonstrated after operation in our population, creatinine level elevations were always <0.3 mg/dL.

Laparoscopic versus open Burch retropubic urethropexy: comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs

OBJECTIVE

The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs.

STUDY DESIGN

We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges.

RESULTS

The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups.

CONCLUSION

Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.

Successful pregnancy in a woman with lipoatrophic diabetes mellitus. A case report

BACKGROUND

Lipoatrophic diabetes mellitus is a rare insulin-resistance syndrome. A successful pregnancy occurred in a woman with lipoatrophic diabetes with no antepartum or intrapartum complications except hypertriglyceridemia, treated with gemfibrozil.

CASE

A 29-year-old primigravida had lipoatrophic diabetes most consistent with congenital partial lipodystrophy (Kobberling-Dunnigan syndrome). The antenatal course was remarkable only for a midtrimester rise in serum triglycerides. The patient underwent oxytocin induction and an uncomplicated vaginal delivery.

CONCLUSION

This case demonstrates that women with lipoatrophic diabetes who are otherwise healthy should not be discouraged from trying to conceive. Blood lipids should be checked periodically and hypertriglyceridemia treated to prevent pancreatitis. Gemfibrozil was used in this patient without apparent adverse effects.

Effects of fluoxetine or D-fenfluramine on serotonin release from, and levels in, rat frontal cortex

Using in vivo microdialysis of frontal cortex in anesthetized rats, as well as analysis of frontal cortex homogenates, we examined the effects of chronic administration of fluoxetine (30 mg/kg, i.p.) or D-fenfluramine (7.5 mg/kg, i.p.), administered daily for 3 days, on serotonin and 5-HIAA levels a day later. Measurements were also taken after 3-, 7- , and 21-day recovery periods. Neither chronic fluoxetine nor D-fenfluramine changed basal serotonin release. Both treatments, however, transiently decreased the release of serotonin evoked by an acute dose of D-fenfluramine (10 mg/kg, i.p.). Release initially was completely suppressed in fluoxetine-pretreated animals but returned to normal by the 21st day of washout; following D-fenfluramine pretreatment, normal release was attained by the 7th day of washout. Both fluoxetine and D-fenfluramine transiently decreased 5-HIAA levels in the dialysates and tissues. Both drugs also caused prolonged changes in frontal cortex serotonin levels, D-fenfluramine lowering them but fluoxetine elevating them. These results suggest that, at comparable dosage levels relative to their ED50s, fluoxetine and D-fenfluramine cause comparable reversible effects on brain serotonin release. The drugs also cause prolonged but opposite changes in brain serotonin levels, probably reflecting differences in the extents to which they or their principal metabolites release serotonin and block its reuptake.