Faculty Bibliography

BACKGROUND: The incidence of cesarean scar pregnancy (CSP) is rising due to the increasing numbers of cesarean deliveries in the United States. However, little is known with respect to epidemiology, best screening methodologies, and treatment options. CASES: Three patients in their first trimester of pregnancy presented with a history of cesarean delivery and were diagnosed by pelvic ultrasound as having CSP. Methods of treatment included definitive surgery with hysterectomy or conservative management with methotrexate and lidocaine injection into the gestational sac. CONCLUSION: In patients with prior cesarean delivery, careful attention to all possible ultrasound signs of CSP during routine first trimester ultrasound is important for an early diagnosis, which can allow for various treatment options.

OBJECTIVE: To compare composite maternal and neonatal morbidities (CMM, CNM) among nulliparous women with primary indications for caesarean section (CS) as acute clinical emergency (group I; ACE), non-reassuring fetal heart rate (group II) and arrest disorder (group III). DESIGN: A multicentre prospective study. SETTING: Nineteen academic centres in the USA, with deliveries in 1999-2002. POPULATION: Nulliparous women (n = 9829) that had CS. METHODS: Nulliparous women undergoing CS for three categories of indications were compared using logistic regression model, adjusted for five variables. MAIN OUTCOME MEASURES: CMM was defined as the presence of any of the following: intrapartum or postpartum transfusion, uterine rupture, hysterectomy, cystotomy, ureteral or bowel injury or death; CNM was defined as the presence of any of the following: umbilical arterial pH <7.00, neonatal seizure, cardiac, hepatic, renal dysfunction, hypoxic ischaemic encephalopathy or neonatal death. RESULTS: The primary reasons for CS were ACE in 1% (group I, n = 114) non-reassuring FHR in 29% (group II; n = 2822) and failed induction/dystocia in the remaining 70% (group III; n = 6893). The overall risks of CMM and CNM were 2.5% (95% confidence intervals, CI, 2.2-2.8%) and 1.9% (95% CI 1.7-2.2), respectively. The risk of CMM was higher in group I than in group II (RR 4.1, 95% CI 3.1, 5.3), and group III (RR 3.2, 95% CI 2.7, 3.7). The risk of CNM was also higher in group I than in group II (RR 2.8, 95% CI 2.3, 3.4) and group III (RR 14.1, 95% CI 10.7, 18.7). CONCLUSIONS: Nulliparous women who have acute clinically emergent caesarean sections are at the highest risks of both composite maternal and neonatal morbidity and mortality.

OBJECTIVE: To provide further sonographic, clinical and histological evidence that Cesarean scar pregnancy (CSP) is a precursor to and an early form of second- and third-trimester morbidly adherent placenta (MAP). METHODS: This is a report of 10 cases of CSP identified early, in which the patients decided to continue the pregnancy, following counseling that emphasized the possibility of both significant pregnancy complications and a need for hysterectomy. Pregnancies were followed at 2-4-week intervals with ultrasound scans and customary monitoring. The aim was for patients to reach near term or term and then undergo elective Cesarean delivery and, if necessary, hysterectomy. Charts, ultrasound images, operative reports and histopathological examinations of the placentae were reviewed. RESULTS: The ultrasound diagnosis of CSP was made before 10 weeks. By the second trimester, all patients exhibited sonographic signs of MAP. Nine of the 10 patients delivered liveborn neonates between 32 and 37 weeks. In the tenth pregnancy, progressive shortening of the cervix and intractable vaginal bleeding prompted termination, with hysterectomy, at 20 weeks. Two other patients in the cohort had antepartum complications (bleeding at 33 weeks in one case and contractions at 32 weeks in the other). All patients underwent hysterectomy at the time of Cesarean delivery, with total blood loss ranging from 300 to 6000 mL. Placenta percreta was the histopathological diagnosis in all 10 cases. CONCLUSION: The cases in this series validate the hypothesis that CSP is a precursor of MAP, both sharing the same histopathology. Our findings provide evidence that can be used to counsel patients with CSP, to enable them to make an informed choice between first-trimester termination and continuation of the pregnancy, with its risk of premature delivery and loss of uterus and fertility

OBJECTIVE:To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality. METHODS:We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use. RESULTS:Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures. CONCLUSIONS:The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations. LEVEL OF EVIDENCE/METHODS:II.

OBJECTIVE:To estimate the degree of association between body mass index (BMI) and some of the most common adverse outcomes and conditions in obstetrics and gynecology, and to compare it with the traditional descriptors such as age, gravidity, parity, history of preterm births, history of abortions or miscarriages, and race and ethnic status. METHODS:Using a PubMed search, abstracts were identified that dealt with the associations between each of the descriptors (age, gravidity, parity, history of preterm births, history of abortions, racial and ethnic identification, and BMI) and a variety of adverse outcomes and conditions in both obstetrics and in gynecology. RESULTS:Body mass index had the highest association with the most common adverse outcomes and conditions in obstetrics and in gynecology (53 of 57 [93%]) as compared with the traditional descriptors (age, 39 of 57 [88%]; gravidity, 19 of 57 [33%]; parity, 24 of 57 [42%]; previous preterm births, 22 of 57 [39%]; abortions, 14 of 57 [25%]; and race and ethnic status, 26 of 57 [46%]). CONCLUSION/CONCLUSIONS:This study underscores the prominence BMI plays regarding its frequently cited associations with an array of obstetric and gynecologic conditions. Body mass index should be included in the opening statement of the history of present illness and in all communications of health care providers regarding obstetric and gynecologic patients.

OBJECTIVE:The objective of the study was to identify the external funding status of the most frequently cited obstetrical publications (citation classics) and to assess trends in funded vs nonfunded manuscripts as well as each publication's type of external funding. STUDY DESIGN/METHODS:For the first objective, the citation classics, which were reported in a previous publication, were reviewed to identify their funding status. For the second objective, all pregnancy-related and obstetrical publications from the 2 US-based leading journals, the American Journal of Obstetrics and Gynecology and Obstetrics and Gynecology, were reviewed to identify the funding status and trends between 1989 and 2012. RESULTS:Twenty-seven of 44 of the citation classics (61%) had external funding, whereas only 43% of the reviewed regular (non-citation classic) obstetrical publications had external funding. There was a decreasing trend in the number of obstetrical manuscripts associated with a decreasing trend in the number and proportion of nonfunded manuscripts and an increasing trend in the number and proportion of National Institutes of Health (NIH)-funded manuscripts. Relative to 1989, in 2012 there was a 34.8% decrease in the number of published obstetrical manuscripts, a 59.6% decrease in the number of nonfunded manuscripts, and a 6.8% increase in the number of funded manuscripts accompanied by an 8.2% increase in the number of NIH-funded publications. In the last 9 years (2004-2012), there was a 35.1% increase in the proportion of NIH-funded manuscripts accompanied by an 18.8% decrease in the proportion of non-NIH-funded manuscripts. CONCLUSION/CONCLUSIONS:Our findings provide useful data regarding the importance of securing NIH-based funding for physicians contemplating academic careers in obstetrics.

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.

OBJECTIVE:To assess the role of the referees in assisting the peer review process of systematic reviews and meta-analyses. METHODS:A one-page questionnaire was mailed to 1391 referees of two journals, the American Journal of Obstetrics and Gynecology and Obstetrics and Gynecology. The referees were asked how often they verified by their own independent analysis 11 key items related to the methodology and statistical analysis of systematic reviews and meta-analyses. Response categories included "always", "frequently" (>50% of the time), "infrequently" (≤ 50% of the time) and "never". A second and a third mailing was sent to the non-respondents. RESULTS:42 mailings were returned because of change of address. Of the remaining 1349 referees, 272 responded (response rate 20%). Of the 272 respondents, 159 (58%) had previously reviewed articles dealing with systematic reviews or meta-analyses. The responses varied according to the key items in the questions but the referees used their own independent analyses "always" in only 2%-17% of the time. The rates of "infrequently" or "never" responses combined together ranged from 51% to 86% for the various key items. CONCLUSION/CONCLUSIONS:The overwhelming majority of the referees do not verify, by their own independent analysis, key items related to methodology and statistical analysis of submitted systematic reviews and meta-analyses.