Pub Date : 2023-10-01DOI: 10.1097/ogx.0000000000001202
Jay Idler, Onur Turkoglu, Kara Patek, Sean Stuart, Birce Taskin, Lalitha Sivaswamy, Amy Whitten
Importance Neurocutaneous disorders have significant implications for care of the pregnant patient. As neurocutaneous disorders are uncommon, obstetricians may be unfamiliar with these disorders and with recommendations for appropriate care of this population. Objective This review aims to summarize existing literature on the interaction between neurocutaneous disorders and pregnancy and to provide a guide for physicians caring for an affected patient. Evidence Acquisition A PubMed, MEDLINE, and Google Scholar search was carried out with a broad range of combinations of the medical subject headings (MeSH) terms “pregnancy,” “Sturge -Weber,” “Neurofibromatosis Type 1,” “neurofibromatosis type 2,” “von Hippel Lindau,” “Tuberous Sclerosis,” “neurocutaneous disorder,” “treatment,” “congenital malformations,” “neurodevelopmental defects,” “miscarriage,” “breastfeeding,” “autoimmune,” “pathophysiology,” and “management.” References of included articles were searched to identify any articles that may have been missed after the above method was used. Results Neurocutaneous disorders are associated with increased pregnancy-associated maternal and fetal/neonatal morbidity, largely surrounding hypertensive disorders, epilepsy, and medication exposure. Some features of neurocutaneous disorders may be worsened or accelerated by pregnancy. Neurocutaneous disorders can often be diagnosed prenatally. Therefore, directed assessment should be offered to affected individuals with a personal or family history of a neurocutaneous disorder. Conclusion and Relevance Patients affected by neurocutaneous disorders who are pregnant or planning for future pregnancy should be carefully followed by a multidisciplinary team, which could include maternal-fetal medicine, neurology, and anesthesia, as well as other relevant subspecialists. Additional research is required regarding optimal counseling and management of these patients. Target Audience Obstetricians and gynecologists, family physician. Learning objectives After completing this activity, the learner will be better able to identify the most common neurocutaneous disorders seen in reproductive women and their implications in pregnancy; propose recommendations for genetic evaluation, diagnosis, management, and a differential diagnosis; describe treatment options including labor and delivery management, emphasizing multidisciplinary approach; and discuss potential maternal and fetal adverse outcomes related to neurocutaneous disorders.
{"title":"Neurocutaneous Disorders in Pregnancy","authors":"Jay Idler, Onur Turkoglu, Kara Patek, Sean Stuart, Birce Taskin, Lalitha Sivaswamy, Amy Whitten","doi":"10.1097/ogx.0000000000001202","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001202","url":null,"abstract":"Importance Neurocutaneous disorders have significant implications for care of the pregnant patient. As neurocutaneous disorders are uncommon, obstetricians may be unfamiliar with these disorders and with recommendations for appropriate care of this population. Objective This review aims to summarize existing literature on the interaction between neurocutaneous disorders and pregnancy and to provide a guide for physicians caring for an affected patient. Evidence Acquisition A PubMed, MEDLINE, and Google Scholar search was carried out with a broad range of combinations of the medical subject headings (MeSH) terms “pregnancy,” “Sturge -Weber,” “Neurofibromatosis Type 1,” “neurofibromatosis type 2,” “von Hippel Lindau,” “Tuberous Sclerosis,” “neurocutaneous disorder,” “treatment,” “congenital malformations,” “neurodevelopmental defects,” “miscarriage,” “breastfeeding,” “autoimmune,” “pathophysiology,” and “management.” References of included articles were searched to identify any articles that may have been missed after the above method was used. Results Neurocutaneous disorders are associated with increased pregnancy-associated maternal and fetal/neonatal morbidity, largely surrounding hypertensive disorders, epilepsy, and medication exposure. Some features of neurocutaneous disorders may be worsened or accelerated by pregnancy. Neurocutaneous disorders can often be diagnosed prenatally. Therefore, directed assessment should be offered to affected individuals with a personal or family history of a neurocutaneous disorder. Conclusion and Relevance Patients affected by neurocutaneous disorders who are pregnant or planning for future pregnancy should be carefully followed by a multidisciplinary team, which could include maternal-fetal medicine, neurology, and anesthesia, as well as other relevant subspecialists. Additional research is required regarding optimal counseling and management of these patients. Target Audience Obstetricians and gynecologists, family physician. Learning objectives After completing this activity, the learner will be better able to identify the most common neurocutaneous disorders seen in reproductive women and their implications in pregnancy; propose recommendations for genetic evaluation, diagnosis, management, and a differential diagnosis; describe treatment options including labor and delivery management, emphasizing multidisciplinary approach; and discuss potential maternal and fetal adverse outcomes related to neurocutaneous disorders.","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136009882","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/ogx.0000000000001207
Carrie E. Jung, Lie H. Chen, Linda T. Brubaker, Shawn A. Menefee
ABSTRACT Postoperative urinary tract infection (PO-UTI) is seen in 6.4%–32% of stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) surgeries despite perioperative antibiotic prophylaxis. Postoperative complications associated with PO-UTI include increased mortality and longer hospitalization. Increasing prevalence of resistance to antibiotics and antibiotic stewardship principles necessitate both the improvement of infection prevention strategies and judicious antibiotic prescriptions. Four factors are known to increase PO-UTI risk: (1) recurrent UTI (RUTI) history, (2) preoperative UTI, (3) day-of-surgery UTI, and (4) prolonged postoperative catheterization. This study intended to determine (1) risk factors of PO-UTI and PO-RUTI, (2) preoperative and postoperative UTI temporal distribution, and (3) detected uropathogens in a large database. The study used medical record data of all SUI/POP surgical procedures performed in the Kaiser Southern California Hospital system from January 1, 2008 to December 31, 2016 for women 18 years of age or older. Procedures used Current Procedural Terminology codes for identifying and subcategorizing surgical procedures and their route (SUI or POP; abdominal or vaginal, respectively). The study-wide definition of UTI was as follows: (1) positive standard urine culture of greater than 10 5 CFU/mL of ≤2 uropathogens, or (2) prescription of urinary antibiotics prescribed for the indication of UTI symptoms. The analysis consisted of 21,063 urogynecologic surgical procedures performed on 20,051 women (33,626 POP and/or SUI procedures), with 22,641 UTI events being diagnosed in 10,091 women. Mean age was 56.9 years, and mean BMI was 29.1. The cohort underwent surgery for only SUI (35.4%), only POP (32.7%), or POP/SUI combined (31.9%). In the 13.5 months postoperatively, 11,976 UTIs were diagnosed in 6733 women. The first month experienced a sharp increase compared with the preoperative year, the second month increased further, and the third month showed leveling of PO-UTI incidence. Prescribed antibiotics captured most UTI events (13,337 or 58.3%). Prescribed antibiotics, in order of most-prescribed to least-prescribed, were as follows: ciprofloxacin (33.7%), cephalexin (21.4%), nitrofurantoin (20.4%), and sulfamethoxazole-trimethoprim (17.6%). The study determined that most PO-UTIs occurred within the first 2 months, with many of these being diagnosed within 2 weeks of surgery. For those patients already having a history of RUTI, RUTI significantly increases in postoperative year 1 when compared with the preoperative year. All patients undergoing SUI procedures had increased PO-RUTI risks compared with their POP-only group peers. Escherichia coli was the most common pathogen found. Risk and event timing were affected by surgical indication: although surgery for only SUI had a lower 6-week PO-UTI risk, it was counterintuitively associated with a higher PO-RUTI risk. Multivariate regression revealed pred
{"title":"Urinary Tract Infections After Urogynecologic Surgery: Risk Factors, Timeline, and Uropathogens","authors":"Carrie E. Jung, Lie H. Chen, Linda T. Brubaker, Shawn A. Menefee","doi":"10.1097/ogx.0000000000001207","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001207","url":null,"abstract":"ABSTRACT Postoperative urinary tract infection (PO-UTI) is seen in 6.4%–32% of stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) surgeries despite perioperative antibiotic prophylaxis. Postoperative complications associated with PO-UTI include increased mortality and longer hospitalization. Increasing prevalence of resistance to antibiotics and antibiotic stewardship principles necessitate both the improvement of infection prevention strategies and judicious antibiotic prescriptions. Four factors are known to increase PO-UTI risk: (1) recurrent UTI (RUTI) history, (2) preoperative UTI, (3) day-of-surgery UTI, and (4) prolonged postoperative catheterization. This study intended to determine (1) risk factors of PO-UTI and PO-RUTI, (2) preoperative and postoperative UTI temporal distribution, and (3) detected uropathogens in a large database. The study used medical record data of all SUI/POP surgical procedures performed in the Kaiser Southern California Hospital system from January 1, 2008 to December 31, 2016 for women 18 years of age or older. Procedures used Current Procedural Terminology codes for identifying and subcategorizing surgical procedures and their route (SUI or POP; abdominal or vaginal, respectively). The study-wide definition of UTI was as follows: (1) positive standard urine culture of greater than 10 5 CFU/mL of ≤2 uropathogens, or (2) prescription of urinary antibiotics prescribed for the indication of UTI symptoms. The analysis consisted of 21,063 urogynecologic surgical procedures performed on 20,051 women (33,626 POP and/or SUI procedures), with 22,641 UTI events being diagnosed in 10,091 women. Mean age was 56.9 years, and mean BMI was 29.1. The cohort underwent surgery for only SUI (35.4%), only POP (32.7%), or POP/SUI combined (31.9%). In the 13.5 months postoperatively, 11,976 UTIs were diagnosed in 6733 women. The first month experienced a sharp increase compared with the preoperative year, the second month increased further, and the third month showed leveling of PO-UTI incidence. Prescribed antibiotics captured most UTI events (13,337 or 58.3%). Prescribed antibiotics, in order of most-prescribed to least-prescribed, were as follows: ciprofloxacin (33.7%), cephalexin (21.4%), nitrofurantoin (20.4%), and sulfamethoxazole-trimethoprim (17.6%). The study determined that most PO-UTIs occurred within the first 2 months, with many of these being diagnosed within 2 weeks of surgery. For those patients already having a history of RUTI, RUTI significantly increases in postoperative year 1 when compared with the preoperative year. All patients undergoing SUI procedures had increased PO-RUTI risks compared with their POP-only group peers. Escherichia coli was the most common pathogen found. Risk and event timing were affected by surgical indication: although surgery for only SUI had a lower 6-week PO-UTI risk, it was counterintuitively associated with a higher PO-RUTI risk. Multivariate regression revealed pred","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"86 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136009999","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/01.ogx.0000993700.13780.f9
Ana Domingo-Muelas, Robin M. Skory, Adam A. Moverley, Goli Ardestani, Oz Pomp, Carmen Rubio, Piotr Tetlak, Blake Hernandez, Eric A. Rhon-Calderon, Luis Navarro-Sanchez, Carmen M. García-Pascual, Stephanie Bissiere, Marisa S. Bartolomei, Denny Sakkas, Carlos Simon, Nicolas Plachta
ABSTRACT The proportion of babies born from in vitro fertilization (IVF) is rising at an exponential rate, highlighting the importance that we have a comprehensive understanding of human preimplantation development and determinants of embryo quality. The early divisions of the embryo after fertilization but before implantation and resulting mitotic errors have been studied primarily in the mouse embryo; however, thus far we have lacked the technology to characterize these critical steps in humans. Establishing an approach that can bypass genetic manipulation and microinjections of DNA or mRNA into human embryos would allow us to better uncover the processes patterning preimplantation human development. This study aimed to evaluate human blastocyst preimplantation development with noninvasive imaging using membrane permeable fluorescent dyes. First, the dyes SPY650-DNA, which labels genomic DNA, and SPY555-actin, which labels F-actin, were validated in the mouse embryo where they produced high contrast labelling with similar results to microinjection of fluorescent mRNAs and produced offspring at a similar rate to nondyed control embryos. Live imaging data using these dyes enabled 3-dimensional scans of the embryo at 5- to 10-minute intervals of the following central events during preimplantation development: the main phases of mitosis, visualizing the major changes in cell shape that characterize embryo compaction at the 8-cell stage, detecting cell polarization at the 8-cell stage, establishing apical F-actin rings at the 16-cell stage, tracking the expansion and zippering of F-actin rings, detecting the first internalized cells within the 16-cell embryo, and visualizing blastocyst expansion and hatching from the zona pellucida. Cleavage-stage human IVF embryos were then studied using the fluorescent dyes to track early cellular and morphogenetic processes. Early cell-cycle dynamics and mitotic stages revealed that the duration of human mitosis is similar to that of mice, but interphase is 27% ± 4% longer in humans (16.1 ± 0.9 vs 12.7 ± 0.4 hours; P < 0.01). Using live imaging, compaction dynamics such as increased cell-cell contact and angle between apical membranes with a decrease in cell sphericity were observed beginning at the 12-cell stage and differed significantly from development in mice. In comparison to mice, human compaction was found to be more asynchronous and did not have clear links to apical polarization or inner-outer segregation. Next, chromosomal segregation was analyzed to determine if this approach allowed detection of segregation errors in the human embryo leading to aneuploidy. Lagging chromosomes detected in human embryos using SPY-DNA appeared morphologically similar to those found in mouse embryos and had similar segregation dynamics. During blastocyst expansion, a subset of trophectoderm cell nuclei forms protruding bud-like that is shed into cytoplasm producing cytoplasmic DNA structures (cytDNA), suggesting an addit
通过体外受精(IVF)出生的婴儿比例正以指数速度上升，这凸显了我们对人类着床前发育和胚胎质量决定因素有全面了解的重要性。胚胎在受精后着床前的早期分裂以及由此产生的有丝分裂错误主要在小鼠胚胎中进行了研究;然而，到目前为止，我们还缺乏描述人类这些关键步骤的技术。建立一种可以绕过基因操作和向人类胚胎中微量注射DNA或mRNA的方法，将使我们能够更好地揭示胚胎植入前人类发育的过程。本研究旨在利用膜透性荧光染料无创成像技术评价人胚泡着床前发育。首先，标记基因组DNA的染料SPY650-DNA和标记f -肌动蛋白的染料SPY555-actin在小鼠胚胎中得到验证，它们产生的高对比度标记与显微注射荧光mrna的结果相似，并且产生后代的速度与未染色的对照胚胎相似。使用这些染料的实时成像数据可以在胚胎着床前发育期间每隔5到10分钟对以下中心事件进行三维扫描:有丝分裂的主要阶段，在8细胞阶段观察表征胚胎压实的细胞形状的主要变化，在8细胞阶段检测细胞极化，在16细胞阶段建立顶端的f -肌动蛋白环，跟踪f -肌动蛋白环的扩张和收缩，在16细胞胚胎中检测第一个内化细胞，并观察囊胚从透明带扩张和孵化。然后使用荧光染料跟踪早期细胞和形态发生过程研究卵裂期人类体外受精胚胎。早期细胞周期动力学和有丝分裂阶段显示，人类有丝分裂的持续时间与小鼠相似，但间期比小鼠长27%±4%(16.1±0.9 vs 12.7±0.4小时);P & lt;0.01)。通过实时成像，从12个细胞阶段开始观察到细胞接触增加、细胞顶膜之间角度增加、细胞球形度降低等压实动力学，这与小鼠的发育有很大不同。与小鼠相比，人类的压实更不同步，与根尖极化或内外分离没有明确的联系。接下来，对染色体分离进行分析，以确定这种方法是否允许检测人类胚胎中导致非整倍体的分离错误。利用SPY-DNA在人类胚胎中检测到的滞后染色体在形态上与在小鼠胚胎中发现的染色体相似，并且具有相似的分离动力学。在囊胚扩增过程中，滋养外胚层细胞核的一部分形成突出的芽状，并脱落到细胞质中，产生细胞质DNA结构(cytDNA)，这表明有丝分裂过程中存在不同于染色体分离错误的DNA丢失过程。在早期空化阶段形成的核周角蛋白网络似乎可以保护细胞DNA结构的形成，而囊胚膨胀的机械应力似乎会破坏某些细胞中的角蛋白网络，增加DNA脱落。接下来，在小鼠和人类胚胎中进行了滋养外胚层活检，以确定机械应力是否会增加DNA脱落。人囊胚活检导致核出芽显著增加(6.0% vs 0.70%;P = 0.0022)，这表明机械应力和DNA脱落之间存在联系。本研究展示了荧光染料和实时成像在人类胚胎着床前关键细胞和形态发生过程表征中的应用，并描述了机械应激反应中DNA脱落的过程，这值得未来的研究。
{"title":"Human Embryo Live Imaging Reveals Nuclear DNA Shedding During Blastocyst Expansion and Biopsy","authors":"Ana Domingo-Muelas, Robin M. Skory, Adam A. Moverley, Goli Ardestani, Oz Pomp, Carmen Rubio, Piotr Tetlak, Blake Hernandez, Eric A. Rhon-Calderon, Luis Navarro-Sanchez, Carmen M. García-Pascual, Stephanie Bissiere, Marisa S. Bartolomei, Denny Sakkas, Carlos Simon, Nicolas Plachta","doi":"10.1097/01.ogx.0000993700.13780.f9","DOIUrl":"https://doi.org/10.1097/01.ogx.0000993700.13780.f9","url":null,"abstract":"ABSTRACT The proportion of babies born from in vitro fertilization (IVF) is rising at an exponential rate, highlighting the importance that we have a comprehensive understanding of human preimplantation development and determinants of embryo quality. The early divisions of the embryo after fertilization but before implantation and resulting mitotic errors have been studied primarily in the mouse embryo; however, thus far we have lacked the technology to characterize these critical steps in humans. Establishing an approach that can bypass genetic manipulation and microinjections of DNA or mRNA into human embryos would allow us to better uncover the processes patterning preimplantation human development. This study aimed to evaluate human blastocyst preimplantation development with noninvasive imaging using membrane permeable fluorescent dyes. First, the dyes SPY650-DNA, which labels genomic DNA, and SPY555-actin, which labels F-actin, were validated in the mouse embryo where they produced high contrast labelling with similar results to microinjection of fluorescent mRNAs and produced offspring at a similar rate to nondyed control embryos. Live imaging data using these dyes enabled 3-dimensional scans of the embryo at 5- to 10-minute intervals of the following central events during preimplantation development: the main phases of mitosis, visualizing the major changes in cell shape that characterize embryo compaction at the 8-cell stage, detecting cell polarization at the 8-cell stage, establishing apical F-actin rings at the 16-cell stage, tracking the expansion and zippering of F-actin rings, detecting the first internalized cells within the 16-cell embryo, and visualizing blastocyst expansion and hatching from the zona pellucida. Cleavage-stage human IVF embryos were then studied using the fluorescent dyes to track early cellular and morphogenetic processes. Early cell-cycle dynamics and mitotic stages revealed that the duration of human mitosis is similar to that of mice, but interphase is 27% ± 4% longer in humans (16.1 ± 0.9 vs 12.7 ± 0.4 hours; P < 0.01). Using live imaging, compaction dynamics such as increased cell-cell contact and angle between apical membranes with a decrease in cell sphericity were observed beginning at the 12-cell stage and differed significantly from development in mice. In comparison to mice, human compaction was found to be more asynchronous and did not have clear links to apical polarization or inner-outer segregation. Next, chromosomal segregation was analyzed to determine if this approach allowed detection of segregation errors in the human embryo leading to aneuploidy. Lagging chromosomes detected in human embryos using SPY-DNA appeared morphologically similar to those found in mouse embryos and had similar segregation dynamics. During blastocyst expansion, a subset of trophectoderm cell nuclei forms protruding bud-like that is shed into cytoplasm producing cytoplasmic DNA structures (cytDNA), suggesting an addit","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"5 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135963382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/ogx.0000000000001208
Birgit M. M. Wever, Rianne van den Helder, Annina P. van Splunter, Mignon D. J. M. van Gent, Jenneke C. Kasius, Johannes W. Trum, Harold R. Verhoeve, Wilhelmina M. van Baal, Alicia Hulbert, Lisanne Verhoef, Daniëlle A. M. Heideman, Birgit I. Lissenberg-Witte, Nienke E. van Trommel, Renske D. M. Steenbergen, Maaike C. G. Bleeker
ABSTRACT Endometrial cancer is the sixth most common cancer in women globally and has a rising incidence, accounting for 417,000 new diagnoses and more than 97,000 deaths in 2020. Early detection is critical because of a poor advanced-stage prognosis and high relapse risk. Postmenopausal bleeding precedes endometrial cancer in 90% of cases, yet only 5% to 10% of patients with this symptom have an underlying malignancy. Recent cytology research has demonstrated endometrial cancer cells in vaginal samples, suggesting urine and cervicovaginal self-samples may allow convenient and minimally invasive screening. In addition, screening samples for DNA methylation in tumor suppressor genes can increase testing efficacy of triaging patients with postmenopausal bleeding as it does not require intact tumor cells. This study aimed to evaluate the diagnostic performance of endometrial cancer detection using DNA methylation analysis in paired urine, cervicovaginal self-samples, and clinician-taken cervical scrapes. Paired samples from participants of the SOLUTION1 study with endometrial cancer were collected between October 2016 and August 2020. A complete urine void and cervicovaginal self-sample was collected at home, whereas the cervical scrape was taken by a clinician in the operating room before surgery. Each patient had a paired urine, cervicovaginal self-sample, and clinician-taken cervical scrape available for methylation analysis. Controls were collected from the Urine Controls (URIC) biobank and Dutch national cervical cancer screening program. Promoter hypermethylation of the ADCYAP1 , BHLHE22 , CDH13 , CDO1 , GALR1 , GHSR , HAND2 , SST , and ZIC1 genes was tested using quantitative methylation-specific polymerase chain reaction. Optimal 3-marker combinations were determined for each sample type using multivariable logistic regression analysis, and diagnostic performances of each marker and 3-marker panels were assessed by leave-one-out cross validation. A total of 103 endometrial cancer patients were included in this study, with 317 unpaired samples of control women. Methylation levels of all markers were significantly higher in all 3 sample types of endometrial cancer patients compared with healthy control women. In urine, the non–cross-validated area under the curve of the DNA methylation markers ranged between 0.61 and 0.93, in cervicovaginal self-samples between 0.62 and 0.91, and in clinician-taken cervical scrapes between 0.61 and 0.95. Most markers (7/9) showed the highest performance in urine, with the remaining 2 showing best performance in clinician-taken cervical scrapes. The optimal 3-marker combination panels showed area under the curve values of 0.95 (05% confidence interval [CI], 0.92–0.98) for urine, 0.94 (95% CI, 0.90–0.97) for cervicovaginal self-samples, and 0.97 (95% CI, 0.96–0.99) for clinician-taken cervical scrapes. The sensitivity and specificity of the optimal urine testing panel were both 90%, were 89% sensitivity and 92%
{"title":"DNA Methylation Testing for Endometrial Cancer Detection in Urine, Cervicovaginal Self-Samples and Cervical Scrapes","authors":"Birgit M. M. Wever, Rianne van den Helder, Annina P. van Splunter, Mignon D. J. M. van Gent, Jenneke C. Kasius, Johannes W. Trum, Harold R. Verhoeve, Wilhelmina M. van Baal, Alicia Hulbert, Lisanne Verhoef, Daniëlle A. M. Heideman, Birgit I. Lissenberg-Witte, Nienke E. van Trommel, Renske D. M. Steenbergen, Maaike C. G. Bleeker","doi":"10.1097/ogx.0000000000001208","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001208","url":null,"abstract":"ABSTRACT Endometrial cancer is the sixth most common cancer in women globally and has a rising incidence, accounting for 417,000 new diagnoses and more than 97,000 deaths in 2020. Early detection is critical because of a poor advanced-stage prognosis and high relapse risk. Postmenopausal bleeding precedes endometrial cancer in 90% of cases, yet only 5% to 10% of patients with this symptom have an underlying malignancy. Recent cytology research has demonstrated endometrial cancer cells in vaginal samples, suggesting urine and cervicovaginal self-samples may allow convenient and minimally invasive screening. In addition, screening samples for DNA methylation in tumor suppressor genes can increase testing efficacy of triaging patients with postmenopausal bleeding as it does not require intact tumor cells. This study aimed to evaluate the diagnostic performance of endometrial cancer detection using DNA methylation analysis in paired urine, cervicovaginal self-samples, and clinician-taken cervical scrapes. Paired samples from participants of the SOLUTION1 study with endometrial cancer were collected between October 2016 and August 2020. A complete urine void and cervicovaginal self-sample was collected at home, whereas the cervical scrape was taken by a clinician in the operating room before surgery. Each patient had a paired urine, cervicovaginal self-sample, and clinician-taken cervical scrape available for methylation analysis. Controls were collected from the Urine Controls (URIC) biobank and Dutch national cervical cancer screening program. Promoter hypermethylation of the ADCYAP1 , BHLHE22 , CDH13 , CDO1 , GALR1 , GHSR , HAND2 , SST , and ZIC1 genes was tested using quantitative methylation-specific polymerase chain reaction. Optimal 3-marker combinations were determined for each sample type using multivariable logistic regression analysis, and diagnostic performances of each marker and 3-marker panels were assessed by leave-one-out cross validation. A total of 103 endometrial cancer patients were included in this study, with 317 unpaired samples of control women. Methylation levels of all markers were significantly higher in all 3 sample types of endometrial cancer patients compared with healthy control women. In urine, the non–cross-validated area under the curve of the DNA methylation markers ranged between 0.61 and 0.93, in cervicovaginal self-samples between 0.62 and 0.91, and in clinician-taken cervical scrapes between 0.61 and 0.95. Most markers (7/9) showed the highest performance in urine, with the remaining 2 showing best performance in clinician-taken cervical scrapes. The optimal 3-marker combination panels showed area under the curve values of 0.95 (05% confidence interval [CI], 0.92–0.98) for urine, 0.94 (95% CI, 0.90–0.97) for cervicovaginal self-samples, and 0.97 (95% CI, 0.96–0.99) for clinician-taken cervical scrapes. The sensitivity and specificity of the optimal urine testing panel were both 90%, were 89% sensitivity and 92% ","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"77 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135963379","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/01.ogx.0000993688.03052.e5
Kassie J. Bollig, Alex Finlinson, Kurt T. Barnhart, Christos Coutifaris, Danny J. Schust
Abstract For early pregnancy management, quantitative serum human chorionic gonadotropin (hCG) measurements and transvaginal ultrasonography are the standard clinical guides. Current guidelines use the change in hCG levels to determine likely location of the pregnancy but represent a minimal rate to predict viability. When incorrectly used, these are inaccurate. This study examined the performance of a new hCG threshold model and compared it with 3 established models. The study is a retrospective cohort study. All individuals with at least 2 consecutive quantitative hCG serum levels seen at the University of Missouri–Columbia from January 1, 2015, until March 1, 2020, were screened for study eligibility. Eligibility requirements were 3-fold: first, patients who presented with pregnancy of unknown viability; second, they had an initial hCG level between 2 and 5000 mIU/mL, maintaining the first interval of no greater than 7 days between testing; and third, the final pregnancy outcome was confirmed. Exclusion occurred for patients who had germ cell tumors, had molar pregnancies, had an intrauterine device in place, utilized hCG monitoring for a molar pregnancy or elective abortion, utilized assisted reproductive technology to achieve pregnancy, or were lost to follow-up. Results of the study came from a pool of 688 patients who met all the inclusion criteria. They contributed an average of 2.3 measurements per patient for a total of 1554 hCG measurements. There was an average of 10.1 days for follow-up. Of those patients included, 167 had viable intrauterine pregnancy (IUP) (24.3%), 463 experienced early pregnancy loss (67.3%), and 58 had ectopic pregnancies (8.4%). The rates of rise in values up to 4 days and again between 4 and 6 days were added for a total rate or rise. Because this was a retrospective study, a calculation was used when hCG levels were not available on day 4 or 6. The values were calculated to be conservative and to avoid incorrectly classifying any viable pregnancy as nonviable. Strengths of the study include its large sample size, its inclusion of all 3 pregnancy outcomes, verified pregnancy outcomes, and subsequent misclassification assessments based off of the aforementioned strength. This study confirmed 122 of 168 viable IUPs (72.6%) had live births, and the simple nature of the study allows for easy integration into clinical practice. Finally, the new model allows for greater variation in days on which a patient must present for care. Study limitations included imputed values from hCG samples not specifically collected on day 4 or 6. Despite this, application of the proposed model utilizing merely known values resulted in better performance. In addition, minimal rise for hCG rates in this data set may be a result of internal validation that may differ in larger, multi-institutional data sets. Furthermore, it must be remembered that current methods using hCG thresholds to determine pregnancy viability rely predominantly on
血清人绒毛膜促性腺激素(hCG)定量测定和经阴道超声检查是早期妊娠管理的标准临床指导。目前的指导方针使用hCG水平的变化来确定可能的怀孕位置，但代表了预测生存能力的最低比率。如果使用不当，这些都是不准确的。本研究检验了一种新的hCG阈值模型的性能，并将其与3种已建立的模型进行了比较。本研究为回顾性队列研究。2015年1月1日至2020年3月1日期间在密苏里-哥伦比亚大学(University of Missouri-Columbia)至少连续两次出现hCG定量血清水平的所有个体均被筛选为研究资格。资格要求有3个方面:第一，出现生存能力未知的妊娠的患者;第二，他们的初始hCG水平在2 - 5000 mIU/mL之间，第一次测试间隔不超过7天;第三，最终妊娠结局得到确认。排除有生殖细胞肿瘤、有磨牙妊娠、有宫内节育器、使用hCG监测磨牙妊娠或选择性流产、使用辅助生殖技术实现妊娠或失去随访的患者。该研究的结果来自688名符合所有纳入标准的患者。在1554次hCG测量中，他们平均为每位患者贡献了2.3次测量。随访时间平均为10.1天。在这些患者中，167例有宫内妊娠(IUP)(24.3%)， 463例早期妊娠丢失(67.3%)，58例异位妊娠(8.4%)。4天内和4至6天内的价值增长率相加，得到总增长率或增长率。因为这是一项回顾性研究，所以当第4天或第6天hCG水平无法获得时，使用了计算方法。这些数值的计算是保守的，并避免将任何可存活的妊娠错误地归类为不可存活的妊娠。该研究的优势包括样本量大，包括所有三种妊娠结局，验证妊娠结局，以及基于上述优势的后续错误分类评估。本研究证实168例可行的IUPs中有122例(72.6%)有活产，并且该研究的简单性使其易于整合到临床实践中。最后，新模式允许病人必须来看病的天数有更大的变化。研究的局限性包括未在第4天或第6天特异性收集的hCG样本的估算值。尽管如此，应用仅利用已知值的所提出的模型可以获得更好的性能。此外，该数据集中hCG率的微小上升可能是内部验证的结果，这在更大的多机构数据集中可能有所不同。此外，必须记住，目前使用hCG阈值来确定妊娠存活率的方法主要依赖于数学数据分析，因此由于生物变异，无法达到100%的准确性阈值。基于这个原因，hCG上升低于临界值不应该强制要求一个反射性的无生存能力的诊断。该研究得出结论，尽管共同决策在确定管理步骤方面仍然至关重要，但提出的新模型同时减少了不必要的干预，并优化了所有妊娠亚组的正确分类率。在广泛应用妊娠分类模型之前，需要进一步的前瞻性研究和成本效益调查。
{"title":"Evaluation of a New Model for Human Chorionic Gonadotropin Rise in Pregnancies of Unknown Viability","authors":"Kassie J. Bollig, Alex Finlinson, Kurt T. Barnhart, Christos Coutifaris, Danny J. Schust","doi":"10.1097/01.ogx.0000993688.03052.e5","DOIUrl":"https://doi.org/10.1097/01.ogx.0000993688.03052.e5","url":null,"abstract":"Abstract For early pregnancy management, quantitative serum human chorionic gonadotropin (hCG) measurements and transvaginal ultrasonography are the standard clinical guides. Current guidelines use the change in hCG levels to determine likely location of the pregnancy but represent a minimal rate to predict viability. When incorrectly used, these are inaccurate. This study examined the performance of a new hCG threshold model and compared it with 3 established models. The study is a retrospective cohort study. All individuals with at least 2 consecutive quantitative hCG serum levels seen at the University of Missouri–Columbia from January 1, 2015, until March 1, 2020, were screened for study eligibility. Eligibility requirements were 3-fold: first, patients who presented with pregnancy of unknown viability; second, they had an initial hCG level between 2 and 5000 mIU/mL, maintaining the first interval of no greater than 7 days between testing; and third, the final pregnancy outcome was confirmed. Exclusion occurred for patients who had germ cell tumors, had molar pregnancies, had an intrauterine device in place, utilized hCG monitoring for a molar pregnancy or elective abortion, utilized assisted reproductive technology to achieve pregnancy, or were lost to follow-up. Results of the study came from a pool of 688 patients who met all the inclusion criteria. They contributed an average of 2.3 measurements per patient for a total of 1554 hCG measurements. There was an average of 10.1 days for follow-up. Of those patients included, 167 had viable intrauterine pregnancy (IUP) (24.3%), 463 experienced early pregnancy loss (67.3%), and 58 had ectopic pregnancies (8.4%). The rates of rise in values up to 4 days and again between 4 and 6 days were added for a total rate or rise. Because this was a retrospective study, a calculation was used when hCG levels were not available on day 4 or 6. The values were calculated to be conservative and to avoid incorrectly classifying any viable pregnancy as nonviable. Strengths of the study include its large sample size, its inclusion of all 3 pregnancy outcomes, verified pregnancy outcomes, and subsequent misclassification assessments based off of the aforementioned strength. This study confirmed 122 of 168 viable IUPs (72.6%) had live births, and the simple nature of the study allows for easy integration into clinical practice. Finally, the new model allows for greater variation in days on which a patient must present for care. Study limitations included imputed values from hCG samples not specifically collected on day 4 or 6. Despite this, application of the proposed model utilizing merely known values resulted in better performance. In addition, minimal rise for hCG rates in this data set may be a result of internal validation that may differ in larger, multi-institutional data sets. Furthermore, it must be remembered that current methods using hCG thresholds to determine pregnancy viability rely predominantly on ","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"121 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136010146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/01.ogx.0000993660.40718.03
Alyssa R. Hersh, Kimberley A. Bullard, Bharti Garg, Megha Arora, Brooke F. Mischkot, Aaron B. Caughey
ABSTRACT Previous research has shown that non–medically indicated induction of labor contributes to some favorable outcomes compared with expectant management in low-risk pregnancies. Cesarean birth rates have risen in recent years and represent a significant impact on long-term health of both mother and child. Research has connected these 2 phenomena, showing that non–medically indicated induction may reduce the overall likelihood of cesarean delivery, but it is not yet known how these outcomes are affected by hospital facility variables. This study was designed to examine outcome differences in women undergoing non–medically indicated induction at 39 weeks' gestation based on hospital characteristics such as obstetric volume, location, and teaching status. This study was designed as a retrospective cohort study, analyzing births between January 1, 2007, and December 31, 2011. Inclusion criteria were singleton, nonanomalous births at 39 weeks 0 days' gestation to 41 weeks 6 days' gestation among nulliparous mothers. Births with missing data on induction or hospital type were excluded, as well as births to pregnant individuals with comorbid conditions, placenta previa, breech presentation, stillbirths, and elective or planned cesarean delivery. The primary outcome was cesarean birth, and secondary outcomes included perinatal outcomes of severe maternal morbidity, chorioamnionitis, postpartum hemorrhage, operative vaginal birth, and obstetric anal sphincter injury, as well as neonatal outcomes of neonatal intensive care unit admission for more than 24 hours, respiratory distress syndrome, and shoulder dystocia. Analysis included 455,044 births, with 24,272 (5.3%) experiencing non–medically indicated induction of labor. Significant differences were found between non–medically indicated induction and expectant management when the sample was stratified by urban versus rural settings. Cesarean birth was significantly less likely among those who underwent non–medically indicated induction, with lower odds for rural (adjusted odds ratio [aOR], 0.68; 99% confidence interval [CI], 0.53–0.86) versus urban hospitals (aOR, 0.78; 99% CI, 0.74–0.81). For other outcomes assessed based on location, urban hospitals showed significantly lower odds of severe maternal morbidity (aOR, 0.78; 95% CI, 0.61–0.98), chorioamnionitis (aOR, 0.26; 99% CI, 0.22–0.30), postpartum hemorrhage (aOR, 0.73; 99% CI, 0.65–0.83), operative vaginal birth (aOR, 0.85; 99% CI, 0.79–0.90), and obstetric anal sphincter injury (aOR, 0.90; 99% CI, 0.82–0.98). Odds were also decreased for the neonatal outcomes of neonatal intensive care unit admission for more than 24 hours (aOR, 0.71; 99% CI, 0.66–0.77) and respiratory distress syndrome (aOR, 0.64; 99% CI, 0.57–0.71). In an analysis stratified by obstetric volume, odds of cesarean delivery were lower for those with non–medically indicated induction in both medium- and high-volume hospitals (aORs, 0.86 [99% CI, 0.78–0.94] and 0.73 [99% CI, 0.69
{"title":"Analysis of Obstetric Outcomes by Hospital Location, Volume, and Teaching Status Associated With Non–Medically Indicated Induction of Labor at 39 Weeks","authors":"Alyssa R. Hersh, Kimberley A. Bullard, Bharti Garg, Megha Arora, Brooke F. Mischkot, Aaron B. Caughey","doi":"10.1097/01.ogx.0000993660.40718.03","DOIUrl":"https://doi.org/10.1097/01.ogx.0000993660.40718.03","url":null,"abstract":"ABSTRACT Previous research has shown that non–medically indicated induction of labor contributes to some favorable outcomes compared with expectant management in low-risk pregnancies. Cesarean birth rates have risen in recent years and represent a significant impact on long-term health of both mother and child. Research has connected these 2 phenomena, showing that non–medically indicated induction may reduce the overall likelihood of cesarean delivery, but it is not yet known how these outcomes are affected by hospital facility variables. This study was designed to examine outcome differences in women undergoing non–medically indicated induction at 39 weeks' gestation based on hospital characteristics such as obstetric volume, location, and teaching status. This study was designed as a retrospective cohort study, analyzing births between January 1, 2007, and December 31, 2011. Inclusion criteria were singleton, nonanomalous births at 39 weeks 0 days' gestation to 41 weeks 6 days' gestation among nulliparous mothers. Births with missing data on induction or hospital type were excluded, as well as births to pregnant individuals with comorbid conditions, placenta previa, breech presentation, stillbirths, and elective or planned cesarean delivery. The primary outcome was cesarean birth, and secondary outcomes included perinatal outcomes of severe maternal morbidity, chorioamnionitis, postpartum hemorrhage, operative vaginal birth, and obstetric anal sphincter injury, as well as neonatal outcomes of neonatal intensive care unit admission for more than 24 hours, respiratory distress syndrome, and shoulder dystocia. Analysis included 455,044 births, with 24,272 (5.3%) experiencing non–medically indicated induction of labor. Significant differences were found between non–medically indicated induction and expectant management when the sample was stratified by urban versus rural settings. Cesarean birth was significantly less likely among those who underwent non–medically indicated induction, with lower odds for rural (adjusted odds ratio [aOR], 0.68; 99% confidence interval [CI], 0.53–0.86) versus urban hospitals (aOR, 0.78; 99% CI, 0.74–0.81). For other outcomes assessed based on location, urban hospitals showed significantly lower odds of severe maternal morbidity (aOR, 0.78; 95% CI, 0.61–0.98), chorioamnionitis (aOR, 0.26; 99% CI, 0.22–0.30), postpartum hemorrhage (aOR, 0.73; 99% CI, 0.65–0.83), operative vaginal birth (aOR, 0.85; 99% CI, 0.79–0.90), and obstetric anal sphincter injury (aOR, 0.90; 99% CI, 0.82–0.98). Odds were also decreased for the neonatal outcomes of neonatal intensive care unit admission for more than 24 hours (aOR, 0.71; 99% CI, 0.66–0.77) and respiratory distress syndrome (aOR, 0.64; 99% CI, 0.57–0.71). In an analysis stratified by obstetric volume, odds of cesarean delivery were lower for those with non–medically indicated induction in both medium- and high-volume hospitals (aORs, 0.86 [99% CI, 0.78–0.94] and 0.73 [99% CI, 0.69","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"193 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135963376","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/01.ogx.0000993676.90007.9c
Georgina Goldring, Cindy Trotter, Jeffrey T. Meltzer, Vivienne Souter, Lynn Pais, Wendy DiNonno, Wenbo Xu, Jeffrey N. Weitzel, Neeta L. Vora
ABSTRACT Technological advances in prenatal testing are allowing for earlier screening to detect fetal aneuploidies, infection, or abnormalities. Noninvasive tests in particular have enabled clinicians to screen early in pregnancy for conditions that severely affect fetal and neonatal outcomes (trisomies 21, 18, and 13, among others). Some of these methods rely on cell-free DNA (cfDNA) circulating in the maternal blood stream; although cfDNA can be released by the placenta, malignancy can be another cause for the release of cfDNA. The detection of such malignancies on noninvasive prenatal tests is rare but occurs. This study was designed to assess the incidence of cfDNA results indicating maternal malignancy and compare these findings to the existing literature. This was a retrospective cohort study, including data obtained from a commercial laboratory that performed single-nucleotide polymorphism (SNP)–based noninvasive prenatal screening between January 2015 and October 2021. Screenings were considered suggestive of malignancy if retrospective bioinformatics and SNP plots suggested multiple maternal copy number variants for at least 2 chromosomes; the laboratory returned these tests as fetal uninterpretable results. Of 2,004,428 samples included in the analysis, 38 (0.002%, or 1 in 52,748) were considered suggestive of malignancy. For 30 patients where follow-up was completed, health outcomes were analyzed for mother and child with maternal malignancy observed in 20 of them (66.7%). Six individuals had a preexisting diagnosis of cancer, 2 of which had a personal history of cancer but were thought to be in remission. Malignancies included lymphoma (10 patients), breast cancer (5 patients), and colon cancer (3 patients). Fetal outcomes for 15 of these patients were normal, with a few abnormal outcomes in the others; negative outcomes included fetal abnormality, multiple soft markers on prenatal ultrasound, and fetal growth restriction. Of the 10 patients without reported malignancy, 2 had identified fetal triploidy, 1 had maternal glomerulonephritis, and 1 had uterine leiomyomas. Of the original 30 patients with results suggestive of malignancy, 6 had no issues reported on follow-up. The findings reported in this study are similar to previous findings of maternal malignancy detected by noninvasive prenatal screenings. The prevalence of maternal malignancy identified in this study was lower than in previous studies, which estimated the prevalence to range from 1/2000 to 1/21,000. The percentage of patients with a confirmed malignancy after suspicious results in this study was 67% and has ranged from 8% to 73% in other studies. Some patients who had an identified malignancy were diagnosed as long as 11 months after the noninvasive prenatal screening; this indicates that longitudinal follow-up may result in higher rates of identified malignancy among those who have screening results suggestive of malignancy. Clinically, these findings highlight the
{"title":"Maternal Malignancy After Atypical Findings on Single-Nucleotide Polymorphism-Based Prenatal Cell-Free DNA Screening","authors":"Georgina Goldring, Cindy Trotter, Jeffrey T. Meltzer, Vivienne Souter, Lynn Pais, Wendy DiNonno, Wenbo Xu, Jeffrey N. Weitzel, Neeta L. Vora","doi":"10.1097/01.ogx.0000993676.90007.9c","DOIUrl":"https://doi.org/10.1097/01.ogx.0000993676.90007.9c","url":null,"abstract":"ABSTRACT Technological advances in prenatal testing are allowing for earlier screening to detect fetal aneuploidies, infection, or abnormalities. Noninvasive tests in particular have enabled clinicians to screen early in pregnancy for conditions that severely affect fetal and neonatal outcomes (trisomies 21, 18, and 13, among others). Some of these methods rely on cell-free DNA (cfDNA) circulating in the maternal blood stream; although cfDNA can be released by the placenta, malignancy can be another cause for the release of cfDNA. The detection of such malignancies on noninvasive prenatal tests is rare but occurs. This study was designed to assess the incidence of cfDNA results indicating maternal malignancy and compare these findings to the existing literature. This was a retrospective cohort study, including data obtained from a commercial laboratory that performed single-nucleotide polymorphism (SNP)–based noninvasive prenatal screening between January 2015 and October 2021. Screenings were considered suggestive of malignancy if retrospective bioinformatics and SNP plots suggested multiple maternal copy number variants for at least 2 chromosomes; the laboratory returned these tests as fetal uninterpretable results. Of 2,004,428 samples included in the analysis, 38 (0.002%, or 1 in 52,748) were considered suggestive of malignancy. For 30 patients where follow-up was completed, health outcomes were analyzed for mother and child with maternal malignancy observed in 20 of them (66.7%). Six individuals had a preexisting diagnosis of cancer, 2 of which had a personal history of cancer but were thought to be in remission. Malignancies included lymphoma (10 patients), breast cancer (5 patients), and colon cancer (3 patients). Fetal outcomes for 15 of these patients were normal, with a few abnormal outcomes in the others; negative outcomes included fetal abnormality, multiple soft markers on prenatal ultrasound, and fetal growth restriction. Of the 10 patients without reported malignancy, 2 had identified fetal triploidy, 1 had maternal glomerulonephritis, and 1 had uterine leiomyomas. Of the original 30 patients with results suggestive of malignancy, 6 had no issues reported on follow-up. The findings reported in this study are similar to previous findings of maternal malignancy detected by noninvasive prenatal screenings. The prevalence of maternal malignancy identified in this study was lower than in previous studies, which estimated the prevalence to range from 1/2000 to 1/21,000. The percentage of patients with a confirmed malignancy after suspicious results in this study was 67% and has ranged from 8% to 73% in other studies. Some patients who had an identified malignancy were diagnosed as long as 11 months after the noninvasive prenatal screening; this indicates that longitudinal follow-up may result in higher rates of identified malignancy among those who have screening results suggestive of malignancy. Clinically, these findings highlight the ","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"50 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135963381","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/ogx.0000000000001213
Brian G. Danaher, John R. Seeley, Richard K. Silver, Milagra S. Tyler, J. Jo Kim, Laura M. La Porte, Emily Cleveland, David R. Smith, Jeannette Milgrom, Jeff M. Gau
ABSTRACT Perinatal depression and postpartum depression represent a significant burden for those who experience them and are associated with preterm birth, low birth weight, postpartum hospitalization, diminished mother-child relationships, offspring developmental delay, and other important markers of health and well-being. Perinatal depression, in particular, is underidentified and thus undertreated. This study was designed to assess the MMB eHealth program (MomMoodBooster2 [MMB2]), which is targeted toward perinatal depression, with an aim to assess the effectiveness of the smartphone version of this tool. Primary outcomes were targeted toward analyzing the extent to which MMB2 relieved the severity of anxiety and depression symptoms in general (using both perinatal and postpartum tools); secondary outcomes focused on usage trends along with ratings of usability and helpfulness. Participants were recruited from the Perinatal Depression Program (PDP) in the NorthShore University HealthSystem. Eligibility criteria included pregnant women and women less than a year postpartum, age older than 18 years, no active suicidal ideation, access to internet, and English language proficiency. REDCap (Vanderbilt University Nashville, Tenn) was used for onboarding and randomization. Final analyses included 191 patients randomized into 2 groups, one with MMB2 and the PDP protocol and one with only PDP. After program completion, 93% of patients completed an associated posttest. Primary screenings were not significantly different between groups, and baseline characteristics were likewise consistent. Controlling for perinatal status, posttests showed a significant decrease in depression severity, anxiety, stress, and automatic thoughts ( P ≤ 0.001), as well as an increase in behavioral activation and self-efficacy. Further analysis showed that the MMB2 group showed greater decreases from baseline to posttest in both stress ( P = 0.019) and depression severity ( P = 0.003). No other significant effects were found when comparing the 2 groups. Usage of MMB2 varied, but generally showed that patients visited the program shortly after receiving the first invitation and then periodically on multiple distinct days between their first and last visit to their health care provider (mean [SD] visits, 49.4 [30.2] distinct days). Perinatal tools were used by 41% of participants, and 43% used postpartum tools, with 10% using both tools because of being pregnant at initial recruitment but delivering over the course of the study. The program included text messages for the first 12 weeks, and impact of these was not directly assessed. Of ratings provided, 96% rated the program as “somewhat” to “extremely” easy to use, and 83% of participants rated it as “somewhat” to “extremely” helpful. Many participants in both groups reported using other management strategies such as medication, therapy sessions, and physician advice, but use of these interventions did not differ between group
{"title":"Trial of a Patient-Directed eHealth Program to Ameliorate Perinatal Depression: The MomMoodBooster2 Practical Effectiveness Study","authors":"Brian G. Danaher, John R. Seeley, Richard K. Silver, Milagra S. Tyler, J. Jo Kim, Laura M. La Porte, Emily Cleveland, David R. Smith, Jeannette Milgrom, Jeff M. Gau","doi":"10.1097/ogx.0000000000001213","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001213","url":null,"abstract":"ABSTRACT Perinatal depression and postpartum depression represent a significant burden for those who experience them and are associated with preterm birth, low birth weight, postpartum hospitalization, diminished mother-child relationships, offspring developmental delay, and other important markers of health and well-being. Perinatal depression, in particular, is underidentified and thus undertreated. This study was designed to assess the MMB eHealth program (MomMoodBooster2 [MMB2]), which is targeted toward perinatal depression, with an aim to assess the effectiveness of the smartphone version of this tool. Primary outcomes were targeted toward analyzing the extent to which MMB2 relieved the severity of anxiety and depression symptoms in general (using both perinatal and postpartum tools); secondary outcomes focused on usage trends along with ratings of usability and helpfulness. Participants were recruited from the Perinatal Depression Program (PDP) in the NorthShore University HealthSystem. Eligibility criteria included pregnant women and women less than a year postpartum, age older than 18 years, no active suicidal ideation, access to internet, and English language proficiency. REDCap (Vanderbilt University Nashville, Tenn) was used for onboarding and randomization. Final analyses included 191 patients randomized into 2 groups, one with MMB2 and the PDP protocol and one with only PDP. After program completion, 93% of patients completed an associated posttest. Primary screenings were not significantly different between groups, and baseline characteristics were likewise consistent. Controlling for perinatal status, posttests showed a significant decrease in depression severity, anxiety, stress, and automatic thoughts ( P ≤ 0.001), as well as an increase in behavioral activation and self-efficacy. Further analysis showed that the MMB2 group showed greater decreases from baseline to posttest in both stress ( P = 0.019) and depression severity ( P = 0.003). No other significant effects were found when comparing the 2 groups. Usage of MMB2 varied, but generally showed that patients visited the program shortly after receiving the first invitation and then periodically on multiple distinct days between their first and last visit to their health care provider (mean [SD] visits, 49.4 [30.2] distinct days). Perinatal tools were used by 41% of participants, and 43% used postpartum tools, with 10% using both tools because of being pregnant at initial recruitment but delivering over the course of the study. The program included text messages for the first 12 weeks, and impact of these was not directly assessed. Of ratings provided, 96% rated the program as “somewhat” to “extremely” easy to use, and 83% of participants rated it as “somewhat” to “extremely” helpful. Many participants in both groups reported using other management strategies such as medication, therapy sessions, and physician advice, but use of these interventions did not differ between group","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136009764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/ogx.0000000000001206
Tamara J. Oderkerk, Pleun Beelen, Ardy L. A. Bukkems, Sander M. J. van Kuijk, Hilde M. M. Sluijter, Mileen R. D. van de Kar, Malou C. Herman, Marlies Y. Bongers, Peggy M. A. J. Geomini
ABSTRACT A common gynecological problem for approximately 30% of women at reproductive age in European countries is heavy menstrual bleeding (HMB). Although hysterectomy is a highly successful treatment for this benign problem, it also risks serious complications due to its nature as a major operation. Less invasive HMB treatment options include insertion of a levonorgestrel-releasing intrauterine system, medical treatment (such as tranexamic acid and oral contraceptive pill), or endometrial ablation (which aims to destroy endometrial tissue and the superficial myometrium to reduce/stop menstrual bleeding). Endometrial ablation failure may result in the objective outcome of hysterectomy. This meta-analysis and review aimed to assess hysterectomy risk following nonresectoscopic endometrial ablation treatment to improve understanding and HMB patient counseling. Various nonresectoscopic ablation techniques versus their associated hysterectomy rates were investigated, and subgroup analyses were performed. Following a comprehensive and thorough search process of the MEDLINE, CENTRAL, and EMBASE databases, 53 articles ultimately met the inclusion criteria for inclusion in the systematic review. Between 1992 and 2017, in the included studies, 48,071 patients underwent endometrial ablation. A high risk of bias was found in 13 studies (mainly due to selection or reporting bias), whereas 12 studies maintained low risk of bias. However, exclusion of the 13 high-risk studies for a subgroup analysis yielded similar results to the original meta-analysis. Results of the analysis indicated a consistently increasing post–endometrial ablation hysterectomy, with 2% increments annually between 1 and 5 years following the procedure, rising to 4.3% after 1 year and 12.4% after 5 years. In 2 studies, a post–10-year follow-up found a mean hysterectomy rate of 21.3%. Between both various study designs and the different varieties of devices used, no major differences in hysterectomy rates were found, respectively. Limitations of the review include a high risk for heterogeneity found among studies in almost all analyses utilized by this analysis. Publication bias and methodological issues (variation of population size and study type) lent to the heterogeneity. Because of this variation, the authors performed analyses of subgroups with different study designs. In addition, of the 53 studies included, 15 of them included fewer than 50 participants, which was corrected in this analysis via an inverse variance. Overall, the study indicated that hysterectomy risk following endometrial ablation increases from 4.3% at the 1-year mark to 12.4% at the post–5-year mark. Neither differences in nonresectoscopic endometrial ablation techniques nor study design seemed to affect hysterectomy rates. This systematic review's data can be applied to clinical practice and used for counseling patients about hysterectomy risks within 5 years of endometrial ablation.
{"title":"Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis","authors":"Tamara J. Oderkerk, Pleun Beelen, Ardy L. A. Bukkems, Sander M. J. van Kuijk, Hilde M. M. Sluijter, Mileen R. D. van de Kar, Malou C. Herman, Marlies Y. Bongers, Peggy M. A. J. Geomini","doi":"10.1097/ogx.0000000000001206","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001206","url":null,"abstract":"ABSTRACT A common gynecological problem for approximately 30% of women at reproductive age in European countries is heavy menstrual bleeding (HMB). Although hysterectomy is a highly successful treatment for this benign problem, it also risks serious complications due to its nature as a major operation. Less invasive HMB treatment options include insertion of a levonorgestrel-releasing intrauterine system, medical treatment (such as tranexamic acid and oral contraceptive pill), or endometrial ablation (which aims to destroy endometrial tissue and the superficial myometrium to reduce/stop menstrual bleeding). Endometrial ablation failure may result in the objective outcome of hysterectomy. This meta-analysis and review aimed to assess hysterectomy risk following nonresectoscopic endometrial ablation treatment to improve understanding and HMB patient counseling. Various nonresectoscopic ablation techniques versus their associated hysterectomy rates were investigated, and subgroup analyses were performed. Following a comprehensive and thorough search process of the MEDLINE, CENTRAL, and EMBASE databases, 53 articles ultimately met the inclusion criteria for inclusion in the systematic review. Between 1992 and 2017, in the included studies, 48,071 patients underwent endometrial ablation. A high risk of bias was found in 13 studies (mainly due to selection or reporting bias), whereas 12 studies maintained low risk of bias. However, exclusion of the 13 high-risk studies for a subgroup analysis yielded similar results to the original meta-analysis. Results of the analysis indicated a consistently increasing post–endometrial ablation hysterectomy, with 2% increments annually between 1 and 5 years following the procedure, rising to 4.3% after 1 year and 12.4% after 5 years. In 2 studies, a post–10-year follow-up found a mean hysterectomy rate of 21.3%. Between both various study designs and the different varieties of devices used, no major differences in hysterectomy rates were found, respectively. Limitations of the review include a high risk for heterogeneity found among studies in almost all analyses utilized by this analysis. Publication bias and methodological issues (variation of population size and study type) lent to the heterogeneity. Because of this variation, the authors performed analyses of subgroups with different study designs. In addition, of the 53 studies included, 15 of them included fewer than 50 participants, which was corrected in this analysis via an inverse variance. Overall, the study indicated that hysterectomy risk following endometrial ablation increases from 4.3% at the 1-year mark to 12.4% at the post–5-year mark. Neither differences in nonresectoscopic endometrial ablation techniques nor study design seemed to affect hysterectomy rates. This systematic review's data can be applied to clinical practice and used for counseling patients about hysterectomy risks within 5 years of endometrial ablation.","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135963561","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01DOI: 10.1097/ogx.0000000000001204
Julia R. Salinaro, Penny S. Jones, Amelia B. Beatty, Sarah K. Dotters-Katz, Jeffrey A. Kuller, Nicole P. Kerner
Importance Obstetrics and gynecology (OB/GYN) accounts for at least half of all open abdominal surgeries performed. Rates of surgical wound complications after open procedures in OB/GYN range from 5% to 35%. Therefore, optimizing management of surgical wound complications has the potential to significantly reduce cost and morbidity. However, guidelines addressing best practices for wound care in OB/GYN are limited. Objective The objectives of this review are to describe the fundamentals of wound healing and to evaluate available evidence addressing surgical wound care. Based on these data, we provide recommendations for management of extrafascial surgical wound dehiscence after OB/GYN procedures. Evidence Acquisition Literature search was performed in PubMed, Medline, OVID, and the Cochrane database. Relevant guidelines, systematic reviews, and original research articles investigating mechanisms of wound healing, types of wound closure, and management of surgical wound complications were reviewed. Results Surgical wound complications in OB/GYN are associated with significant cost and morbidity. One of the most common complications is extrafascial dehiscence, which may occur in the setting of hematomas, seromas, or infection. Management includes early debridement and treatment of any underlying infection until healthy granulation tissue is present. For wounds healing by secondary intention, advanced moisture retentive dressings reduce time to healing and are cost-effective when compared with conventional wet-to-dry gauze dressings. Negative pressure wound therapy can be applied to deeper wounds healing by secondary intention. Review of published evidence also supports the use of delayed reclosure to expedite wound healing for select patients. Conclusions Optimizing surgical wound care has the potential to reduce the cost and morbidity associated with surgical wound complications in OB/GYN. Advanced moisture retentive dressings should be considered for wounds healing by secondary intention. Data support delayed reclosure for select patients, although further studies are needed. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After reading this article, the provider will be better able to explain the clinical significance of surgical wound complications, particularly in OB/GYN; identify the stages of wound healing and types of wound closure; discuss the TIME framework for wound care; and describe a recommended approach for the management of extrafascial wound dehiscence.
{"title":"Optimizing Surgical Wound Care in Obstetrics and Gynecology","authors":"Julia R. Salinaro, Penny S. Jones, Amelia B. Beatty, Sarah K. Dotters-Katz, Jeffrey A. Kuller, Nicole P. Kerner","doi":"10.1097/ogx.0000000000001204","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001204","url":null,"abstract":"Importance Obstetrics and gynecology (OB/GYN) accounts for at least half of all open abdominal surgeries performed. Rates of surgical wound complications after open procedures in OB/GYN range from 5% to 35%. Therefore, optimizing management of surgical wound complications has the potential to significantly reduce cost and morbidity. However, guidelines addressing best practices for wound care in OB/GYN are limited. Objective The objectives of this review are to describe the fundamentals of wound healing and to evaluate available evidence addressing surgical wound care. Based on these data, we provide recommendations for management of extrafascial surgical wound dehiscence after OB/GYN procedures. Evidence Acquisition Literature search was performed in PubMed, Medline, OVID, and the Cochrane database. Relevant guidelines, systematic reviews, and original research articles investigating mechanisms of wound healing, types of wound closure, and management of surgical wound complications were reviewed. Results Surgical wound complications in OB/GYN are associated with significant cost and morbidity. One of the most common complications is extrafascial dehiscence, which may occur in the setting of hematomas, seromas, or infection. Management includes early debridement and treatment of any underlying infection until healthy granulation tissue is present. For wounds healing by secondary intention, advanced moisture retentive dressings reduce time to healing and are cost-effective when compared with conventional wet-to-dry gauze dressings. Negative pressure wound therapy can be applied to deeper wounds healing by secondary intention. Review of published evidence also supports the use of delayed reclosure to expedite wound healing for select patients. Conclusions Optimizing surgical wound care has the potential to reduce the cost and morbidity associated with surgical wound complications in OB/GYN. Advanced moisture retentive dressings should be considered for wounds healing by secondary intention. Data support delayed reclosure for select patients, although further studies are needed. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After reading this article, the provider will be better able to explain the clinical significance of surgical wound complications, particularly in OB/GYN; identify the stages of wound healing and types of wound closure; discuss the TIME framework for wound care; and describe a recommended approach for the management of extrafascial wound dehiscence.","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136009208","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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