American journal of obstetrics and gynecology
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Am. J. Obstet. Gynecol. · Jun 2016
Vaginal progesterone combined with cervical pessary: A chance for pregnancies at risk for preterm birth?
Precocious cervical ripening, as defined by cervical shortening on transvaginal sonography, has prompted a broad evaluation of secondary strategies (such as cerclage, vaginal progesterone, or a cervical pessary) to prevent preterm delivery. However, there is still a lack of direct comparisons between individual treatments or their combinations. ⋯ In this cohort study, treatment of precocious cervical ripening with cervical pessary plus vaginal progesterone did not reduce the rates of preterm delivery at <28, <32, <34, or <37 weeks of gestation compared with pessary alone. The neonatal intensive care use was shorter in patients who received additional vaginal progesterone, although there was no difference in composite poor neonatal outcome. These preliminary results may serve as a pilot for future trials and provide a basis for treatment until larger trials are completed.
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Am. J. Obstet. Gynecol. · Jun 2016
Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period.
Stroke, which is a rare but devastating event during pregnancy, occurs in 34 of every 100,000 deliveries; obstetricians are often the first providers to be contacted by symptomatic patients. At least one-half of pregnancy-related strokes are likely to be of the ischemic stroke subtype. Most pregnant or newly postpartum women with ischemic stroke do not receive acute stroke reperfusion therapy, although this is the recommended treatment for adults. Little is known about these therapies in pregnant or postpartum women because pregnancy has been an exclusion criterion for all reperfusion trials. Until recently, pregnancy and obstetric delivery were specifically identified as warnings to intravenous alteplase tissue plasminogen activator in Federal Drug Administration labeling. ⋯ Using data from the Get With the Guidelines-Stroke Registry to assemble the largest cohort of pregnant or postpartum ischemic stroke patients who had been treated with reperfusion therapy, we observed that pregnant or postpartum women had similarly favorable short-term outcomes and equal rates of total reperfusion therapy to nonpregnant women, despite lower rates of intravenous tissue plasminogen activator use. Future studies should identify the characteristics of pregnant and postpartum ischemic stroke patients who are most likely to safely benefit from reperfusion therapy.
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Am. J. Obstet. Gynecol. · Jun 2016
Mode of delivery after obstetric anal sphincter injury and the risk of long-term anal incontinence.
Primiparous women have an increased risk of obstetric anal sphincter injury; because most of these patients deliver again, there are major concerns about mode of delivery: the risk of recurrent obstetric anal sphincter injury and the risk of long-term symptoms of anal incontinence. Although an elective cesarean delivery protects against recurrent obstetric anal sphincter injury, it is uncertain how the second delivery affects the risk of long-term anal incontinence. ⋯ Mode of second delivery did not significantly affect the risk of long-term anal or fecal incontinence in multivariable analyses of patients with previous obstetric anal sphincter injury in this population in which patients with anal incontinence before the second pregnancy were recommended to have an elective cesarean delivery in the subsequent delivery. Nonetheless, we found that patients with vaginal delivery had a higher risk of deterioration of anal incontinence symptoms compared with those with an elective cesarean delivery.
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Am. J. Obstet. Gynecol. · Jun 2016
Midurethral slings: evidence-based medicine vs the medicolegal system.
Midurethral sling procedures are minimally invasive surgeries for stress urinary incontinence that use a trocar system to place a narrow ribbon of polypropylene mesh under the midurethra. The peer-reviewed scientific literature on these procedures is abundant and midurethral slings are the most well-studied incontinence procedure ever. Systematic reviews of the literature demonstrate that midurethral slings are safer and more (or equally) effective as traditional procedures. ⋯ It is not inconceivable that midurethral slings could become absent from the US market. If that happens, then US women with stress urinary incontinence will be harmed because they will not have access in this country to the best and safest stress urinary incontinence surgical procedure ever developed. It may be time for the Institute of Medicine or another comparable national agency to provide evidence-based recommendations on the midurethral sling.
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Am. J. Obstet. Gynecol. · Jun 2016
Maternal fat, but not lean, mass is increased among overweight/obese women with excess gestational weight gain.
Weight gain in pregnancy is an essential physiologic adaptation that supports growth and development of a fetus and is distributed among lean mass that includes total body water and fat mass gains. Although gestational weight gain provides a source of energy for the mother and fetus, excess gestational weight gain may underlie reported associations between parity and future metabolic disorders and is linked to postpartum weight retention and insulin resistance. Although weight gain often is proposed as a modifiable variable to mitigate adverse maternal and offspring health outcomes, our knowledge of specific maternal body composition changes with weight gain and the potential metabolic consequences is limited. Furthermore, although gestational weight gain alters maternal body composition, the impact of excess weight gain on fat and lean mass is not well-studied. Understanding the accrual of fat and lean body mass may improve our understanding of the role of excessive gestational weight gain and metabolic dysfunction. ⋯ Excess gestational weight gain is associated primarily with maternal fat, but not with lean body mass accrual. Our results may help explain the reason that excess gestational weight gain or fat mass accrual is associated with long-term obesity, metabolic dysfunction, and cardiovascular disease risk.