Abstracts – 2008 - Obstetricia Crítica

Obstetricia CríticaEduardo Malvino - © 2008Abstracts – 2008Eur J Obstet Gynecol Reprod Biol. 2007 Sep;134(1):129-30. Epub 2006 Aug 28.Advanced cervical pregnancy: diagnostic and management challenges.Sanu O, Parisaei M, Dorman E, Akinfenwa O, Erskine K.Eur J Obstet Gynecol Reprod Biol. 2007 Sep;134(1):131-3. Epub 2006 Sep 7.Placenta increta: Use of dynamic MRI for diagnosis and evaluation ofplacental vascularity.Honnma H, Endo T, Hayashi T, Saito T.Eur J Obstet Gynecol Reprod Biol. 2007 Dec 18 [Epub ahead of print]Acute pancreatitis in pregnancy: Place of the different explorations(magnetic resonance cholangiopancreatography, endoscopicultrasonography) and their therapeutic consequences.Roumieu F, Ponchon T, Audra P, Gaucherand P.Department of Obstetrics, Edouard Herriot Hospital, Lyon, France.J Reprod Med. 2007 Nov;52(11):1011-5.Metformin and insulin in the management of gestational diabetes mellitus:preliminary results of a comparison.Moore LE, Briery CM, Clokey D, Martin RW, Williford NJ, Bofill JA, Morrison JC.Departments of Obstetrics and Gynecology, University of New Mexico,Albuquerque87131-0001, USA. lemoore@salud.unm.eduOBJECTIVE: To compare glycemic control and neonatal outcomes in womenwith gestational diabetes mellitus (GDM) treated with metformin vs. insulin.STUDY DESIGN: Women with GDM not controlled with diet and exercise wererandomized to metformin (n = 32) or insulin (n = 31). The levels of glycemiccontrol as well as maternal/neonatal complications were evaluated. RESULTS:The mean (+/- SD) fasting and 2-hour postprandial blood glucose did not differstatistically between the 2 treatment groups. No patient failed metformin andrequired insulin. The majority (27/32) were easily controlled on the initial dosage(500 mg twice a day). Gestational age at entry and delivery (p = 0.077, 0.412)were similar. The difference in the rate of cesarean delivery was not statisticallysignificant between the 2 groups (p = 0.102). Neonatal statistics were also notdifferent between the metformin and insulin groups: birth weight, Apgar score at5 minutes, respiratory distress syndrome, hyperbilirubinemia, neonatalhypoglycemia and neonatal intensive care unit admission (p = 0.144-0.373).CONCLUSION: Based on these preliminary data, metformin appears to be aneffective alternative to insulin in the treatment of GDM.

J Reprod Med. 2007 Nov;52(11):1046-51.Pregnancy outcomes in women with chronic hypertension: a populationbasedstudy.Gilbert WM, Young AL, Danielsen B.Department of Obstetrics and Gynecology, University of California, Davis, USA.gilberw@sutterhealth.orgOBJECTIVE: To determine the pregnancy outcomes associated with maternalchronic hypertension. STUDY DESIGN: Retrospective, population-based cohortstudy of maternal and infant discharge records linked to birth records in Californiafrom 1991 to 2001 were examined for demographics and pregnancy outcomes,and comparisons were made between those with and without chronichypertension. One randomly selected pregnancy per subject was included.RESULTS: The number of women who delivered with chronic hypertension(0.69% incidence) was 29,842. As compared to non-chronic hypertensivepatients, fetal and neonatal mortality and in-hospital maternal mortality wereincreased (ORs and 95% CIs 2.3, (2.1, 2.6); 2.3, (2.0, 2.7); and 4.8, (3.1, 7.6)respectively). Major maternal morbidity was increased: stroke, OR 5.3, (3.7, 7.5);renal failure, OR 6.0, (4.4, 8.1); pulmonary edema, OR 5.2, (3.9, 6.7); severepreeclampsia, OR 2.7, (2.5, 2.9); and placental abruption OR 2.1, (2.0, 2.3).Neonatal morbidity was increased as well: fetal growth restriction, OR 4.9, (4.7,5.2); prematurity, OR 3.2, (3.1, 3.3); low birth weight, OR 5.4, (5.2, 5.5); very lowbirth weight, OR 6.5, (6.2, 6.8); and respiratory distress syndrome, OR 4.0, (3.8,4.2). CONCLUSION: Pregnant women with chronic hypertension havesignificantly increased risks of maternal and perinatal morbidity and mortality.Women with this condition should be treated as high risk with appropriatematernal and fetal surveillance.Am J Obstet Gynecol. 2008 Jan;198(1):56.e1-4.Hyperemesis in pregnancy: an evaluation of treatment strategies withmaternal and neonatal outcomes.Holmgren C, Aagaard-Tillery KM, Silver RM, Porter TF, Varner M.Department of Obstetrics and Gynecology, University of Utah Health SciencesCenter, Salt Lake City, UT, USA. cholmgren73@yahoo.comOBJECTIVE: The objective of the study was to evaluate the use of interventionssuch as a peripherally inserted central catheters (PICC) line or nasogastric(NG)/nasoduodenal (ND) tube with the use of medications alone in themanagement of pregnancies with hyperemesis. STUDY DESIGN: Subjects wereidentified with confirmed intrauterine pregnancy, admitted with hyperemesisgravidarum (HEG) between 1998 and 2004. Medical records were thenabstracted for information with regard to therapy. Subjects were assigned on thebasis of the management plan: medication alone, PICC line, or NG/ND tube.Outcomes were compared between groups. RESULTS: Ninety-four patients metstudy criteria and had complete outcome data available. Of those, 33 had a PICCline placed (35.1%), 19 had a NG/ND placed (20.2%), and 42 were managedwith medication alone (44.7%). These groups were similar with respect to

gestational age at delivery, Apgar score, and mean birthweight. Maternalcomplications were significantly higher among those with PICC lines. Of patientsmanaged with PICC lines, 66.4% (P < .001) required treatment for infection,thromboembolism, or both. Adjusted odds ratio for a PICC line complication was34.5 (5.09, 233.73). CONCLUSION: Maternal complications associated withPICC line placement are substantial despite no difference in neonatal outcomes,suggesting that the use of PICC lines for treatment of HEG patients should notbe routinely used.Am J Obstet Gynecol. 2008 Jan;198(1):75.e1-7.Prenatal health care beyond the obstetrics service: utilization andpredictors of unscheduled care.Magriples U, Kershaw TS, Rising SS, Massey Z, Ickovics JR.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,Yale University School of Medicine, New Haven, CT 06520-8034, USA.urania.magriples@yale.eduOBJECTIVE: The objective of the study was to describe the patientcharacteristics of prenatal care utilization within and outside of routine obstetriccare, and the clinical and psychosocial factors that predict care utilization.STUDY DESIGN: Four hundred twenty pregnant women enrolled in arandomized controlled trial receiving prenatal care in a university-affiliated clinic.All hospital encounters were obtained by review of computerized databases. TheKotelchuck index (KI) was computed, and the characteristics of inadequate,adequate, or excessive prenatal care were described. Demographic andpsychosocial predictors of unscheduled visits were evaluated. RESULTS: A totalof 50.5% of women were adequate users by KI, with 19% being inadequate. Anaverage of 5 additional unscheduled encounters occurred (standard deviation4.2; range, 0-26). Almost 75% of participants made an unscheduled obstetricvisit, with 38% making 2 or more unscheduled visits. Overweight/obese, youngerwomen, high symptom distress, and excessive and inadequate prenatal userswere more likely to utilize the labor floor before delivery. CONCLUSION:Unscheduled care is common during pregnancy.Am J Obstet Gynecol. 2008 Jan 4 [Epub ahead of print]Maternal morbidity and infant death in twin vs triplet and quadrupletpregnancies.Luke B, Brown MB.University of Miami School of Nursing and Health Studies, Coral Gables, and theDepartments of Obstetrics & Gynecology and Pediatrics, Miller School ofMedicine, University of Miami, Miami, FL.OBJECTIVE: The purpose of this study was to calculate nationallyrepresentative, population-based estimates of maternal and neonatal risks intriplet and quadruplet pregnancies compared with twin pregnancies. STUDYDESIGN: The study population included 316,696 twin, 12,193 triplet, and 778quadruplet pregnancies from the 1995-2000 Matched Multiple Birth Data Set.Adjusted odds ratios (AORs) and 95% CIs estimated the risk of complications

and were controlled for maternal age, race, parity, and smoking status.RESULTS: Compared with mothers of twins, mothers of triplets and quadrupletswere more likely to be diagnosed with preterm premature rupture of membranes(AORs, 1.53, 1.74, respectively), pregnancy-associated hypertension (AORs,1.22, 1.27), and excessive bleeding (AORs, 1.50, 2.22), to require tocolysis(AORs, 2.85, 5.03), and to be delivered by cesarean (AORs, 6.55, 7.38) at /=1 infants die (AORs,3.02, 4.07). CONCLUSION: Triplet and quadruplet pregnancies have significantlyhigher risks than twin pregnancies for most maternal and neonatal complications.Maternal anthropometric, nutritional, and previous reproductive factors may beparticularly important in the reduction of these excess risks and improvement ofoutcomes in multiple births.Ultrasound Obstet Gynecol. 2007 Aug;30(2):227-8.Placenta previa percreta managed conservatively with methotrexate andmultiple bilateral uterine artery embolizations.Sherer DM, Gorelick C, Zigalo A, Sclafani S, Zinn HL, Abulafia O.Ultrasound Obstet Gynecol. 2007 Apr;29(4):363-7.Prenatal exposure to ultrasound waves: is there a risk?Abramowicz JS.Ultrasound Obstet Gynecol. 2007 Apr;29(4):475-6.Ectopic pregnancy within a Cesarean section scar.Hassan I, Lower A, Overton C.Am J Obstet Gynecol. 2008 Jan 15 [Epub ahead of print]Group B Streptococcus and pregnancy: a review.Larsen JW, Sever JL.The George Washington University, Washington, DC.In the 1960s, early onset neonatal sepsis caused by group B Streptococcus(GBS) had an attack rate of 2 per 1000 live births and a 50% fatality rate. Earlytreatment and then antibiotic prophylaxis were shown to reduce morbidity andmortality rates; however, GBS remains a leading cause of perinatal infection.This article will review our investigations and related studies, including ourstudies in monkeys, that have contributed to current diagnosis, treatment, andprevention of disease caused by GBS. Although it has not been possible toeradicate GBS colonization, intravenous antibiotic prophylaxis given duringparturition has been effective in the prevention of vertical transmission in animalsand humans. Recently, diagnostic tests with polymerase chain reaction haveoffered promise for rapid accurate detection. This could lead to a major shift inthe timing of diagnosis from the office setting to delivery suite. The potential forimmunization remains a challenge.Aust N Z J Obstet Gynaecol. 2007 Oct;47(5):383-8.

Maternal risk factors associated with fetal death during antenatal care inlow-resource tertiary hospitals.Oladapo OT, Adekanle DA, Durojaiye BO.Maternal and Fetal Health Research Unit, Department of Obstetrics andGynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, OgunState, Nigeria. tixon_y2k@hotmail.comBACKGROUND: Data on maternal characteristics that could predict antepartumfetal death in women receiving antenatal care in resource-constrained settingsare limited. Aims: To identify maternal sociodemographic and clinical risk factorsfor antepartum fetal death among women receiving antenatal care in adeveloping country setting. METHODS: Case-control analyses of risk factors inthe occurrence of singleton fetal death before labour at two university hospitals insouth-west Nigeria over 4-5 years. A total of 46 cases and 184 controls werecompared for 31 sociodemographic and clinical risk factors. Unconditionalmultivariate logistic regression analysis was applied to determine independentrisk factors. Level of significance was set at P < 0.05. RESULTS: The incidenceof antepartum fetal death among women receiving antenatal care was 10.8 per1000 total births during the period. Significant risk factors at univariate levelinclude proteinuria, pregnancy-induced hypertension, pre-existing hypertension,reduced weight gain per week, previous antepartum fetal death, antepartumhaemorrhage, previous miscarriage, symphysiofundal height-gestational agedisparity = 4 cm and perception of reduced fetal movements. The independentrisk factors were proteinuria (adjusted OR 4.23, CI: 1.57-11.42), pregnancyinducedhypertension (adjusted OR 8.24, CI: 3.01-22.51) and perceivedreduction in fetal movements (adjusted OR 7.17, CI: 1.57-45.76).CONCLUSIONS: The identified factors should serve as potential targets forantenatal interventions to prevent antepartum fetal death in these institutions.Awareness of these factors should stimulate appropriate risk assessment gearedtowards the prevention of antepartum fetal deaths by clinicians in these centresand centres in similar setting.Aust N Z J Obstet Gynaecol. 2007 Oct;47(5):368-77.Prophylactic antibiotics for the prevention of preterm birth in women atrisk: a meta-analysis.Simcox R, Sin WT, Seed PT, Briley A, Shennan AH.Maternal and Fetal Research Unit, Division of Reproduction and Endocrinology,King's College London School of Medicine at Guy's, King's College and St.Thomas' Hospitals, London, UK. rach.simcox@kcl.ac.ukBACKGROUND: Preterm birth (PTB) is the major determinant of perinatalmorbidity and mortality. Infection is implicated in a large proportion of pretermdeliveries, but there is no consensus regarding the efficacy of antibioticprophylaxis for women at risk. AIM: To determine whether antibiotic treatmentreduces the risk of preterm delivery in asymptomatic pregnant women at risk ofPTB. METHOD: Relevant publications were identified via electronic searches ofMEDLINE (1966 to August 2005), The Cochrane Pregnancy and ChildbirthGroup trials register, the Cochrane Central Register of Controlled Trials (the

Cochrane Library, Issue 3, 2005) and PubMed using multiple search termsrelated to PTB and antibiotics. Publications were limited to randomised controlledtrials comparing antibiotics with placebo given to asymptomatic non-labouringwomen. A random effect model was used, and combined risk ratios calculated forthe various risk groups. Associations between treatment effect and the rate ofPTB were analysed by meta-regression. RESULTS: Seventeen trials wereincluded, 12 identifying women at risk by abnormal vaginal flora, three on womenat high risk from a previous PTB and two recruiting women based on positivefetal fibronectin status. There was no significant association between antibiotictreatment and reduction in PTB irrespective of criteria used to assess risk, theantimicrobial agent administered, or gestational age at time of treatment (overallcombined random effect for delivery at less than 37 weeks RR 1.03 (95% CI0.86-1.24)). CONCLUSIONS: Treating women at risk of PTB with antibioticsdoes not reduce the risk of subsequent PTB.Gynecol Obstet Invest. 2008 Jan 14;65(4):258-261 [Epub ahead of print]Cranial Thromboembolism Secondary to Patent Foramen Ovale and DeepVenous Thrombosis after Cesarean Section.Bodur H, Caliskan E, Anik Y, Cakiroglu Y, Corakci A.Departments of Obstetrics and Gynecology, University of Kocaeli MedicalSchool, Kocaeli, Turkey.Background: Paradoxical embolism via a patent foramen ovale (PFO) is a rareevent in the puerperium as a cause of stroke. Case: We report a 21-year-old,G4P3A1 woman with the symptoms of convulsion, stroke and unconsciousness 1week after cesarean delivery. An infarction was detected in both frontal lobes,and echocardiography and MRI confirmed the PFO. Her follow-up course withlow-molecular-weight heparin and then warfarin for 6 months was uneventful.Conclusion: Patients with an unexplained arterial event should be screened forPFO and possible paradoxical embolism. Copyright (c) 2008 S. Karger AG,Basel.Obstet Gynecol. 2007 Dec;110(6):1270-8.Use of recombinant activated factor VII in primary postpartum hemorrhage:the Northern European registry 2000-2004.Alfirevic Z, Elbourne D, Pavord S, Bolte A, Van Geijn H, Mercier F, Ahonen J,Bremme K, Bødker B, Magnúsdóttir EM, Salvesen K, Prendiville W, Truesdale A,Clemens F, Piercy D, Gyte G.Division of Perinatal and Reproductive Medicine, University of Liverpool,Liverpool Women's Hospital, Liverpool, United Kingdom. zarko@liv.ac.ukOBJECTIVE: To collect data from nine European countries for cases of obstetrichemorrhage between 2000 and 2004 in which recombinant activated factor VII(rFVIIa) was used. METHODS: The cases were identified through nationalsurveys. Standardized case report forms included sociodemographic details, pastmedical and obstetric history, and details of the progress and management oflabor in which the postpartum hemorrhage occurred. Clinicians were asked todescribe subjectively the effect of rFVIIa administration using two mutually

exclusive categories: 1) bleeding reduced or 2) bleeding unchanged or worse.RESULTS: A total of 113 forms were returned (88%) with 97 (86%) classified astreatment, and 16 (14%) as "secondary prophylaxis." Clinicians notedimprovements after a single dose for 80% of women in the treatment group, andfor 75% in the secondary "prophylaxis" group. However, rFVIIa failed in 15 cases(13.8%). Few serious adverse events were noted related to rFVIIa administration;there were four cases of thromboembolism, one myocardial infarction, and oneskin rash. CONCLUSION: Clinical reports and hematologic data suggestimprovement for more than 80% of women after rFVIIa administration and fewadverse effects. LEVEL OF EVIDENCE: II.Acta Obstet Gynecol Scand. 2008;87(2):178-83.Obstetric outcome of teenage pregnancies compared with adultpregnancies.Usta IM, Zoorob D, Abu-Musa A, Naassan G, Nassar AH.Department of Obstetrics and Gynecology, American University of Beirut MedicalCenter, Beirut, Lebanon.BACKGROUND: To compare the obstetric outcome of teenage pregnancies withthat of older women. METHODS: Retrospective chart review of singleton births >or =24 weeks' gestational age at the American University of Beirut from 1994 to2003. Adolescents (

Department of Obstetrics and Gynecology, Washington University in St Louis, StLouis, MO, USA.OBJECTIVE: The purpose of this study was to examine the rate of and risks forabruption and adverse pregnancy outcome after minor trauma in pregnancy.STUDY DESIGN: This is a 3-year prospective cohort study of patients afternoncatastrophic trauma. Data collected included maternal demographics andhistory, trauma mechanism, and pregnancy outcome. Examination, lab testsincluding Kleihauer-Betke (KB), and a minimum of 4 hours of fetal monitoringwere performed. The primary outcomes were placental abruption and acomposite pregnancy morbidity outcome. Univariate and bivariate analysis wereperformed. RESULTS: Of the 317 patients evaluated for minor trauma, 9 had apositive KB test (2.8%). Delivery information was available on 256 (81%)patients, and there was 1 placental abruption. The 49 cases (19.4%) ofcomposite outcome could not be predicted. CONCLUSION: Perhaps it is time toreevaluate the extensive evaluations often done after minor trauma in pregnancy,particularly because none of the commonly used objective measures arepredictive of adverse outcomes.Am J Obstet Gynecol. 2008 Feb;198(2):178.e1-7.Acetaminophen use during pregnancy: effects on risk for congenitalabnormalities.Rebordosa C, Kogevinas M, Horváth-Puhó E, Nørgård B, Morales M, CzeizelAE, Vilstrup H, Sørensen HT, Olsen J.Autonomous University of Barcelona, Barcelona, Spain. crebordosa@imim.esOBJECTIVE: We evaluated if acetaminophen, one of the most frequently useddrugs among pregnant women is associated with an increased prevalence ofcongenital abnormalities. STUDY DESIGN: We selected 88,142 pregnant womenand their liveborn singletons from the Danish National Birth Cohort who hadinformation on acetaminophen use during the first trimester of pregnancy. Weused the National Hospital Registry to identify 3784 (4.3%) children from thecohort diagnosed with 5847 congenital abnormalities. RESULTS: Childrenexposed to acetaminophen during the first trimester of pregnancy (n = 26,424)did not have an increased prevalence of congenital abnormalities (hazard ratio =1.01, 0.93-1.08) compared with nonexposed children (n = 61,718). Noassociation was found between congenital abnormalities and duration of useduring the first trimester. Increased prevalence was not observed for specificabnormalities, except for "medial cysts, fistula, sinus" (congenital abnormalities ofthe ear, face, and neck, ICD-10 code Q18.8, n = 43) with an adjusted hazardratio of 2.15 (1.17-3.95). CONCLUSION: Acetaminophen is not associated withan increased prevalence of congenital abnormalities overall or with any specificgroup of major abnormalities.Am J Obstet Gynecol. 2008 Jan 24 [Epub ahead of print]Hyperemesis gravidarum that requires hospitalization and the use ofantiemetic drugs in relation to maternal body composition.Cedergren M, Brynhildsen J, Josefsson A, Sydsjö A, Sydsjö G.

Division of Obstetrics and Gynecology, Department of Clinical and ExperimentalMedicine, Faculty of Health Sciences, University of Linköping, Sweden.OBJECTIVE: The purpose of this study was to assess whether maternalprepregnancy body mass index was associated with the use of antiemetic drugsin early pregnancy and/or with the occurrence of hyperemesis gravidarum.STUDY DESIGN: A retrospective, population-based, cohort study. Women whodelivered singleton infants (n = 749,435) from 1995-2003 were evaluatedconcerning the use of antiemetic drugs in early pregnancy (data available from1995). Women who delivered singleton infants (n = 942,894) from 1992-2001were evaluated concerning hospitalization because of hyperemesis gravidarum(data available until 2001). Adjusted odds ratios were determined by Mantel-Haenszel technique and were used as estimates of relative risk (RR). RESULTS:Underweight pregnant women were more likely to use antiemetic drugs (RR,1.19; 95% CI, 1.14-1.24) and to become hospitalized for hyperemesisgravidarum (RR, 1.43; 95% CI, 1.33-1.54) compared with ideal weight women.Obese women were less likely to use antiemetic drugs (RR, 0.93; 95% CI, 0.89-0.97) and less likely to require hospitalization because of hyperemesis (RR, 0.90;95% CI, 0.85-0.95) compared with women with an ideal body mass index.CONCLUSION: The use of antiemetic drugs and the occurrence of hyperemesisgravidarum are related to maternal body composition.Clin Exp Obstet Gynecol. 2007;34(4):252-3.Spontaneous heterotopic pregnancy: a successful outcome.Seoud AA, Saleh MM, Yassin AH.Obstetrics and Gynaecology Department, Rochdale Infirmary, Whitehall Street,Rochdale, Lancashire, UK.Spontaneous heterotopic pregnancy is rare condition. We are reporting a casewhere the ectopic component was treated successfully laparoscopically and theintrauterine pregnancy continued to term uneventfully.Clin Exp Obstet Gynecol. 2007;34(4):250-1.Cholecystitis during pregnancy. A case report and brief review of theliterature.Chloptsios C, Karanasiou V, Ilias G, Kavouras N, Stamatiou K, Lebren F.Surgery Department, General Hospital of Thebes, Greece.Cholecystitis is an inflammation of the gallbladder caused by obstruction of thecystic duct. A gallstone usually causes the obstruction (calculus cholecystitis).However, in some cases the obstruction may be acalculous or caused by sludge.The clinical course of biliary sludge varies, from complete resolution togallbladder obstruction. This obstruction can result in gallbladder distension andacute cholecystitis. When inflammation occurs it could either be aseptic orbacterial. Biliary disease during pregnancy is relatively rare and occurs mainlyduring the last trimester. Whether women who are pregnant or have multiplepregnancies are more likely to develop stones or whether they are simply moresymptomatic with stones is unknown. We present a 33-year-old obese pregnantwoman with fever, moderately elevated bile acids, and leukocytosis in the 28th

week of pregnancy. Since need for surgery in these cases is controversial, thepatient has been treated conservatively. In our case cholecystitis responded verywell to treatment with amoxicillin, with no detrimental effects for mother and child.A healthy child was born at term. In the differential diagnosis of liver functionabnormalities during pregnancy, cholelithiasis should be included.J Perinatol. 2008 Feb;28(2):156-7.Pregnancy and active Huntington disease: a rare combination.Hoskins KE, Tita AT, Biggio JR, Ramsey PS.1Department of Obstetrics and Gynecology, Center for Women's ReproductiveHealth, University of Alabama at Birmingham, Birmingham, AL, USA.We describe the complicated course of a rare pregnant woman with symptomaticHuntington disease (HD) and discuss multidisciplinary care issues that may beencountered. A 31-year-old gravida 2, para 1 with advanced HD was admitted at30 weeks gestation for preterm labor. Her course was complicated byprogressive cognitive and physical impairment, dysphagia, malnutrition, diabetesinsipidus, aspiration pneumonia, chorioamnionitis, preterm delivery andpyelonephritis. Pregnant women with symptomatic HD may present multiplechallenges requiring extensive multidisciplinary input.Journal of Perinatology(2008) 28, 156-157; doi:10.1038/sj.jp.7211874.N Engl J Med. 2008 Jan 17;358(3):275-89.N Engl J Med. 2008 Jan 31;358(5):513-23.Case records of the Massachusetts General Hospital. Case 2-2008. A 38-year-old woman with postpartum visual loss, shortness of breath, and renalfailure.Magee CC, Coggins MP, Foster CS, Muse VV, Colvin RB.Renal Division, Brigham and Women's Hospital, Boston, MA, USA.Obstet Gynecol. 2008 Feb;111(2):555-8.Pulmonary synovial sarcoma presenting as a pneumothorax duringpregnancy.Esaka EJ, Celebrezze JU, Golde SH, Chiossi G, Thomas RL.Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,Allegheny General Hospital, Pittsburgh, Pennsylvania.BACKGROUND: Synovial sarcoma is a clinically rare, but morphologically welldefinedneoplasm, which accounts for approximately 10% of all malignant softtissuetumors. The diagnosis can be established with clinical and imagingevaluations together with immunohistochemical, electron microscopy, andmolecular genetic studies. CASE: We describe a case of primary pulmonarysynovial sarcoma presenting as a pneumothorax in a young woman at 34 weeksof gestation. Her persistent symptomatology ultimately led to a video-assistedthoracoscopy and thorascopic decortication. The diagnosis was established bypathology and immunohistochemistry of the cells, which were consistent withprimary pulmonary synovial sarcoma. CONCLUSION: Malignancies, even those

as uncommon as primary synovial sarcoma, should be considered in thedifferential diagnosis of pneumothorax during pregnancy.Obstet Gynecol. 2008 Feb;111(2):550-2.Extrapulmonary tuberculosis in pregnancy masquerading as adegenerating leiomyoma.Moore AR, Rogers FM, Dietrick D, Smith S.Department of Obstetrics and Gynecology, Franklin Square Hospital Center,Baltimore, Maryland.BACKGROUND: Tuberculosis (TB) is an increasingly common infectiouscomplication of pregnancy. The diagnosis of extrapulmonary TB in pregnancy ishampered by many factors and thus often delayed, and that has the potential ofincreasing morbidity and mortality. CASE: This case involves a gravida withextrapulmonary TB, which was originally diagnosed as a degeneratingleiomyoma. Diagnosis did not occur until lesions were discovered and biopsied atthe time of cesarean delivery. CONCLUSION: With proper identification,diagnosis, and treatment of pregnant women infected with all types oftuberculosis, the morbidity and mortality can be significantly decreased formother and infant, and a public health emergency can be prevented.Obstet Gynecol. 2008 Feb;111(2):528-9.Pregnancy-induced hemolytic anemia with a possible immune-relatedmechanism.Katsuragi S, Sameshima H, Omine M, Ikenoue T.Department of Obstetrics and Gynecology, Miyazaki Medical College, Universityof Miyazaki, Kiyotake-Cho, Miyazaki; and Division of Hematology, InternalMedicine, Showa University Fujigaoka Hospital, Yokohama, Japan.BACKGROUND: Pregnancy-induced hemolytic anemia is a rare maternalcomplication that occurs during pregnancy and resolves soon after delivery. Themechanism is unclear, and the disease is often referred to as unexplainedhemolytic anemia associated with pregnancy. CASE: We report a case of lifethreateninghemolytic anemia that occurred during pregnancy and resolvedspontaneously soon after delivery. Direct and indirect Coombs test results werenegative. Several possible causes were investigated, but all were ruled out.However, an increased immunoglobulin G level was observed in maternal redblood cells throughout pregnancy when the patient was severely anemic. Theimmunoglobulin G level decreased after delivery and was close to the controllevel on postpartum day 5. CONCLUSION: These observations suggest that thehemolytic anemia in this patient had an immune-related etiology.Obstet Gynecol. 2008 Feb;111(2):517-21.Transient severe fetal heart rate abnormalities in a pregnancy complicatedby thrombotic thrombocytopenic purpura.Strasser SM, Kwee A, Fijnheer R, Visser GH.Departments of Obstetrics and Gynecology, and Hematology, University MedicalCentre Utrecht, Utrecht, The Netherlands.

BACKGROUND: Thrombotic thrombocytopenic purpura is a rare disease.However, in pregnant women it occurs more frequently. Thromboticthrombocytopenic purpura may be a severe condition for both mother and fetus.CASE: This is a case of severe but temporary fetal heart rate abnormalities in apregnancy complicated by thrombotic thrombocytopenic purpura. There was aremarkably good outcome despite indications of an impaired fetal condition for aperiod of at least 48 hours. CONCLUSION: Based on the literature regardingtransient severe neurological symptoms in adults with thromboticthrombocytopenic purpura, we hypothesize that the transient fetal heart rateabnormalities were most likely due to reversible microthrombi in the placenta.Obstet Gynecol. 2008 Feb;111(2):505-7.Uterine artery embolization followed by dilation and curettage for cervicalpregnancy.Nakao Y, Yokoyama M, Iwasaka T.Department of Obstetrics and Gynecology Faculty of Medicine, Saga University,Saga City, Saga, Japan.BACKGROUND: Cervical pregnancy can be a life-threatening condition due tothe risk of severe hemorrhage. Progression of ultrasonographic diagnostictechnology has allowed the early detection of cervical pregnancy. However, astandard treatment protocol for fertility preservation has not yet been established.CASE: Two women with cervical pregnancy presented with cardiac activity at 6and 7 weeks of gestation. They were treated with transfemoral uterine arteryembolization followed by dilation and curettage with minimal bleeding. Onepatient gave birth to a healthy neonate 20 months after the procedure.CONCLUSION: Early cervical pregnancies were treated with dilation andcurettage after uterine artery embolization. This treatment can be considered asconservative management for patients who desire to preserve their fertility.Obstet Gynecol. 2008 Feb;111(2):502-4.Advanced abdominal pregnancy resulting from late uterine rupture.Naim NM, Ahmad S, Siraj HH, Ng P, Mahdy ZA, Razi ZR.Department of Obstetrics and Gynaecology, Faculty of Medicine, NationalUniversity of Malaysia, Hospital UKM, Kuala Lumpur, Malaysia.BACKGROUND: Advanced abdominal pregnancy is rare, and one that occursafter uterine rupture with delivery of a viable fetus is exceptional. CASE: Amultiparous patient was admitted at 29 weeks of gestation for conservativemanagement of placenta previa. She complained of intermittent abdominal pain,but repeated assessment suggested that both the patient and the fetus weredoing well. At 36 weeks, an abdominal pregnancy was diagnosed withradiological features suggestive of uterine rupture. Laparotomy was performedand a healthy infant was delivered. CONCLUSION: Fetal viability was achievedin this case of abdominal pregnancy secondary to uterine rupture after closematernal and fetal surveillance.Obstet Gynecol. 2008 Feb;111(2):487-489.

Cardiac Troponin I Elevation After Orogenital Sex During Pregnancy.Sánchez JM, Milam MR, Tomlinson TM, Beardslee MA.Washington University School of Medicine, Division of Cardiology, St. Louis,Missouri; Department of Gynecologic Oncology, M. D. Anderson Cancer Center,Houston, Texas; Department of Obstetrics and Gynecology, WashingtonUniversity School of Medicine, St. Louis, Missouri.BACKGROUND: Venous air embolism due to orogenital sex in pregnancy is anuncommon clinical event. CASE: A previously healthy, 29-week pregnant womanpresented to the emergency room unconscious 1 hour after engaging inorogenital sex with her partner. The cardiology service was consulted due totroponin elevation. Assessment was that the patient had likely suffered an airembolism with associated troponin leak. CONCLUSION: Although a rare clinicalevent, air embolism from air insufflation of the vagina can result in troponinelevation and should be considered in the differential diagnosis in pregnantpatients with a history of orogenital sex.Obstet Gynecol. 2008 Feb;111(2):481-2.Air embolism during pregnancy.Brown HL.Dr. Brown is Chair of the Department of Obstetrics and Gynecology, DukeUniversity Medical Center, Durham, North Carolina; e-mail:haywood.brown@duke.edu.Obstet Gynecol. 2008 Feb;111(2):457-64.ACOG Practice Bulletin No. 90: Asthma in Pregnancy.[No authors listed]Obstet Gynecol. 2008 Feb;111(2):341-7.Hospitalizations with amphetamine abuse among pregnant women.Cox S, Posner SF, Kourtis AP, Jamieson DJ.Division of Reproductive Health, Centers for Disease Control and Prevention,Atlanta, Georgia; and the Oak Ridge Institute for Science and Education, OakRidge, Tennessee.OBJECTIVE: To examine trends in pregnancy hospitalizations with a diagnosisof amphetamine or cocaine abuse and the prevalence of associated medicalcomplications. METHODS: Data were obtained from the Nationwide InpatientSample. Hospitalization ratios per 100 deliveries for amphetamine or cocaineabuse from 1998 to 2004 were tested for linear trends. Amphetamine-abusehospitalizations were compared with cocaine-abuse hospitalizations and nonsubstance-abusehospitalizations. A chi(2) analysis was used to comparehospitalization characteristics. Conditional probabilities estimated by logisticregression were used to calculate adjusted prevalence ratios for each medicaldiagnosis of interest. RESULTS: From 1998 to 2004, the hospitalization ratio forcocaine abuse decreased 44%, whereas the hospitalization ratio foramphetamine abuse doubled. Pregnancy hospitalizations with a diagnosis ofamphetamine abuse were geographically concentrated in the West (82%), and

were more likely to be among women younger than 24 years than the cocaineabuseor non-substance-abuse hospitalizations. Most medical conditions weremore prevalent in the amphetamine-abuse group than the non-substance-abusegroup. When the substance abuse groups were compared with each other,obstetric diagnoses associated with infant morbidity such as premature deliveryand poor fetal growth were more common in the cocaine-abuse group, whereasvasoconstrictive effects such as cardiovascular disorders and hypertensioncomplicating pregnancy were more common in the amphetamine-abuse group.CONCLUSION: As pregnancy hospitalizations with a diagnosis of amphetamineabuse continue to increase, clinicians should familiarize themselves with theadverse consequences of amphetamine abuse during pregnancy and evidencebasedguidelines to deal with this high-risk population. LEVEL OF EVIDENCE:III.Am J Obstet Gynecol. 2008 Jan 31 [Epub ahead of print]Preeclampsia as a risk factor for cardiovascular disease later in life:validation of a preeclampsia questionnaire.Diehl CL, Brost BC, Hogan MC, Elesber AA, Offord KP, Turner ST, Garovic VD.Division of Obstetrics and Gynecology.OBJECTIVE: This study was undertaken to validate a self-administeredquestionnaire in verifying the diagnosis of preeclampsia, eclampsia, or toxemia ina group of women with a greater than 20-year history of preeclampsia. STUDYDESIGN: Questionnaires were mailed to a random sample of 144 women whoreceived a diagnosis of any of these 3 conditions and 158 women who hadnormotensive pregnancies at Mayo Clinic, Rochester, Minnesota, from 1960-1979. RESULTS: A previous diagnosis of preeclampsia, eclampsia, or toxemiawas verified with 80% sensitivity and 96% specificity. CONCLUSION: Ourvalidated questionnaire may be a useful research tool in identifying women with aprevious history of preeclampsia. Women with a history of preeclampsia had ahigher prevalence of future hypertension than those with a history ofnormotensive pregnancy.Am J Obstet Gynecol. 2008 Jan 31 [Epub ahead of print]Pregnancies in glycogen storage disease type Ia.Martens DH, Rake JP, Schwarz M, Ullrich K, Weinstein DA, Merkel M, Sauer PJ,Smit GP.Department of Pediatrics, Beatrix Children's Hospital, University Medical CenterGroningen, the Netherlands.OBJECTIVE: Reports on pregnancies in women with glycogen storage diseasetype Ia (GSD-Ia) are scarce. Because of improved life expectancy, pregnancy isbecoming an important issue. We describe 15 pregnancies by focusing ondietary treatment, biochemical parameters, and GSD-Ia complications. STUDYDESIGN: Carbohydrate requirements (milligrams per kilogram per minute),triglyceride and uric acid levels, liver ultrasonography, and creatinine clearancewere investigated before, during, and after pregnancy. Data from the newborninfants were obtained from the records. RESULTS: In the first trimester, a

significant increase in carbohydrate requirements was observed (P = .007). Mostpatients had acceptable triglyceride and uric acid levels during pregnancy. Noincrease in size or number of adenomas was seen. In 3 of 4 patients, a decreasein glomerular filtration rate was observed after pregnancy. In 3 pregnancies,lactic acidosis developed during delivery with severe multiorgan failure in 1. Allbut 1 of the children are healthy and show good psychomotor development.CONCLUSION: Successful pregnancies are possible in patients with GSD-Ia,although specific GSD-Ia-related risks are present.BMJ. 2008 Feb 2;336(7638):239.Obstetric care must change if Netherlands is to regain reputation for safechildbirth.Sheldon T. Utrecht.Int J Gynaecol Obstet. 2007 Nov;99(2):142-3. Epub 2007 Jul 27.Recurrence following conservative management of placenta accreta.Kayem G, Clément D, Goffinet F.Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal deCréteil, University Paris XII, Créteil, France. gkayem@gmail.comInt J Gynaecol Obstet. 2007 Nov;99(2):105-9. Epub 2007 Jul 2.Intraumbilical injection of uterotonics for retained placenta.Habek D, Franicević D.Department of Obstetrics and Gynecology, School of Medicine, Sveti DuhGeneral Hospital, Zagreb, Croatia. dubravko.habek@os.t-com.hrOBJECTIVE: To assess the effect of injecting an uterotonic agent in the umbilicalvein during the third stage of labor in women with retained placentas.METHODS: In this prospective clinical study, 75 women with retained placentasreceived 20 mL of a 0.9% saline solution with either 20 IU of oxytocin (n=54), 0.5mg of carboprost tromethamine (n=7), or 0.2 mg of methylergometrine (n=14)injected in the umbilical vein after clamping. The treatment success wasdetermined by the clinical signs of placental ablation. RESULTS: There were nostatistically significant differences among the 3 therapeutic groups regarding age,parity, risk factors, pregnancy duration, type of delivery (spontaneous, induced,or augmented), or possible early postpartum complications caused by theintraumbilical injection. The rates of therapeutic success were 76.9% in theoxytocin group, 85.7% in the synthetic prostaglandin group, and 64.2% in themethylergometrine group. CONCLUSION: The intraumbilical injection ofuterotonics is a noninvasive, effective, and clinically safe method of shorteningthe third stage of labor in women with retained placentas.J Reprod Med. 2008 Jan;53(1):52-4.Acute colonic pseudoobstruction complicating twin pregnancy: a casereport.Tung CS, Zighelboim I, Gardner MO.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston,Texas, USA. ctung@mdanderson.orgBACKGROUND: Acute colonic pseudoobstruction, or Ogilvie's syndrome, is arare but serious medical and obstetric complication. When diagnosed early,treatment with expectant management or more invasive decompression is oftensuccessful. However, if not recognized promptly or managed appropriately, thiscondition can be fatal. CASE: We present an unusual case of acute colonicpseudoobstruction occurring after management of preterm labor in amonochorionic-diamniotic twin pregnancy at 29 weeks' gestation complicatedwith twin-twin transfusion syndrome. CONCLUSION: Acute colonicpseudoobstruction should be considered in the differential diagnosis in pregnantwomen who present with abdominal distention and vomiting.Aust N Z J Obstet Gynaecol. 2008 Feb;48(1):44-49.Venous thromboembolism during pregnancy and the post-partum period:Incidence and risk factors in a large Victorian health service.Sharma S, Monga D.Ballarat Health Services, Ballarat, Victoria, Australia.Background: There is a strong recommendation for post-partumthromboprophylaxis following emergency caesarean sections, particularly inoverweight women, and following prolonged labour. Aims: To analyse theincidence and epidemiological factors associated with antepartum and postpartumvenous thromboembolism in a large Victorian health service. Methods: Aretrospective study of all 6987 women delivering at Ballarat Health Servicesbetween March 1999 and June 2006. Case notes of women with confirmedvenous thromboembolism during this period were subjected to detailed analysis.The data were analysed for possible risk factors, the timing of thromboembolismin relation to the pregnancy and any correlation with thromboprophylaxis, ifadministered. Results: The rate of venous thromboembolism was 1.14 per 1000deliveries, with risk factors of age > 30 (100%), obesity (75%), previous history ofthromboembolism (62.5%) and caesarean section (37.5%). Majority of caseswere diagnosed in first trimester (62.5%), and in the right lower limb (75%). Noneof the patients had been given thromboprophylaxis. Conclusion: While theincidence and risk factors were similar to those generally quoted, a much higherincidence was found in early pregnancy, and in the right lower limb. Theimportance of meticulous screening for risk factors in early pregnancy cannot beoveremphasised.Aust N Z J Obstet Gynaecol. 2008 Feb;48(1):34-39.Symptomatic urinary stone disease in pregnancy.Cheriachan D, Arianayagam M, Rashid P.Department of Urology, Port Macquarie Base Hospital, New South Wales, andUNSW Rural Clinical School, Port Macquarie Campus, New South Wales,Australia.Background: Symptomatic urinary calculi are rare in pregnancy with an incidence

of one per 1500 pregnant women. Calculi may cause ureteric obstruction thatcan be further complicated by sepsis. This may have a significant morbidity formother and fetus. Objective: To provide an update on the current investigationsand management options for pregnant patients with symptomatic urinary calculi.Discussion: We discuss the different imaging modalities available to investigatethe renal tract in pregnant women and propose a management pathway. Thistopic is particularly pertinent to obstetricians in their roles as coordinators ofprenatal care.Aust N Z J Obstet Gynaecol. 2008 Feb;48(1):12-16.Guidelines for the use of recombinant activated factor VII in massiveobstetric haemorrhage.Welsh A, McLintock C, Gatt S, Somerset D, Popham P, Ogle R.Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick,New South Wales, Australia.Recombinant activated factor VII (rFVIIa) is emerging as a novel therapy for thetreatment of life or fertility-threatening post-partum haemorrhage (PPH)unresponsive to standard therapy that in some cases may prevent the need forperipartum hysterectomy. The level of evidence to date for use of rFVIIa in PPHis limited to case reports and case series with one nonrandomised study. Nohigh-quality randomised controlled trials have been published at this stage,precluding a quality systematic review. Guidelines have been published for theuse of rFVIIa in non-obstetric haemorrhage, though to date none are available forPPH. A multidisciplinary group of Australian and New Zealand clinicians from thefields of obstetrics, anaesthesia and haematology, who have both clinicalexperience in and/or knowledge of rFVIIa was convened by the manufacturer.This group produced an opinion and guideline based on their experience and thepublished international literature on the use of rFVIIa. This is intended to be usedas a guideline and algorithm for the use of rFVIIa, though any use should betailored to local practice and resources.Aust N Z J Obstet Gynaecol. 2008 Feb;48(1):2-4.Enough is enough! Time for a new model of care for women with earlypregnancy complications.Condous G.Acute Gynaecology and Early Pregnancy Unit, Nepean Centre for PerinatalCare, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith,Sydney, and Omni Gynaecological Care, Women's Ultrasound and EarlyPregnancy Centre, St Leonard's, Sydney, New South Wales, Australia.Australian women with early pregnancy complications, like their Englishcounterparts, should have access to ultrasound-based early pregnancy units(EPUs) nationwide. This modern approach to women with first trimester problemswould not only streamline individual care pathways but also reduce the impactthat early pregnancy problems have on already overburdened public emergencydepartments. Dedicated EPUs, with trained gynaecological sonologists

experienced in the management of first trimester complications, should becomethe benchmark standard of care for Australian women in early pregnancy.Eur J Obstet Gynecol Reprod Biol. 2008 Feb 7 [Epub ahead of print]Acute presentation of cauda equina syndrome in the third trimester ofpregnancy.Gupta P, Gurumurthy M, Gangineni K, Anarabasu A, Keay SD.University Hospitals of Coventry and Warwickshire, Clifford Bridge Road,Coventry CV2 2DX, UK.Eur J Obstet Gynecol Reprod Biol. 2008 Feb 7 [Epub ahead of print]Current guidelines on management of HIV-infected pregnant women:Impact on mode of delivery.Suy A, Hernandez S, Thorne C, Lonca M, Lopez M, Coll O.Institut Clinic de Ginecologia, Obstetrícia i Neonatologia, Hospital Clínic,IDIBAPS, Barcelona, Spain.OBJECTIVE: To evaluate acceptance, feasibility and difficulties in the applicationof a policy of vaginal delivery in selected cases in HIV-infected women. STUDYDESIGN: HIV-infected women delivering March 2002 to December 2004 andenrolled in a prospective observational study in a University hospital tertiary carecenter were included. A vaginal delivery was not considered if labor before 36weeks of pregnancy, preterm premature rupture of membranes, on non-highlyactive antiretroviral therapy (HAART) or viral load >1000copies/mL. Mainoutcome measures were mode of delivery, prematurity, acceptance of vaginaldelivery and mother-to-child transmission of HIV infection. RESULTS: The studyincluded 91 pregnancies, with a total of 95 fetuses. Eighty percent (n=73) ofwomen knew their HIV infection status before becoming pregnant and 57 (63%)were on HAART at conception. Median gestational age at delivery was 37 weeks(range 22-41). Twelve women delivered a live-born before 36 weeks, all with acaesarean section. Among 74 women who reached 36 weeks gestation, 47(64%) met the pre-established criteria for vaginal delivery, of whom 21 (45%)delivered vaginally. The most common reason for not having a vaginal deliverywas the woman's request for a caesarean section. No cases of HIV verticaltransmission occurred (0/90, 95% CI 0-4.02%). CONCLUSION: Recommendingvaginal delivery among HIV-infected women in selected cases was wellaccepted, particularly once the policy became established. Nevertheless, a highproportion of HIV-infected women will continue to require caesarean sectiondelivery.Gynecol Obstet Invest. 2008 Feb 11;66(1):44-46 [Epub ahead of print]Gastrointestinal Symptoms and Helicobacter pylori Infection in EarlyPregnancy. A Seroepidemiologic Study.Karaer A, Ozkan O, Ozer S, Bayir B, Kilic S, Babur C, Danişman N.Dr. Zekai Tahir Burak, Woman Health Education and Research Hospital,Department of Obstetrics and Gynecology, Ankara, Turkey.

Background: To investigate the relationship of Helicobacter pylori infection withgastrointestinal symptoms in early pregnancy. Methods:H. pylori seropositivitywas determined in 296 pregnant women at 7-12 weeks' gestation by ELISAbetween January 2004 and April 2007. Sociodemographic characteristics andgastrointestinal symptoms were recorded at this time. Results: The prevalence ofH. pylori infection in our population was 56.8% (168 of 296). 76% of the womenwith H. pylori and 68% of the women who tested negative for H. pylori infectionreported at least one of the evaluated gastrointestinal symptoms. Althoughmorning sickness and morning vomiting were not associated with H. pyloriinfection, sickness and vomiting during the whole day were more frequentlynoted with H. pylori infection (OR 2.5, 95% CI 1.2-4.9, p = 0.01). Conclusions: Ofthe evaluated gastrointestinal symptoms, H. pylori infection is significantlyassociated with sickness and vomiting during the whole day. Copyright (c) 2008S. Karger AG, Basel.Gynecol Obstet Invest. 2008 Feb 11;66(1):40-43 [Epub ahead of print]Nonattendance in Obstetrics and Gynecology Patients.Dreiher J, Froimovici M, Bibi Y, Vardy DA, Cicurel A, Cohen AD.Clalit Health Services, Southern District, Faculty of Health Sciences, Ben GurionUniversity, Beer-Sheva, Israel.Background: Nonattendance for obstetrics and gynecology (OB/GYN)appointments disrupts medical care and leads to misuse of valuable resources.We investigated factors associated with nonattendance in an outpatient OB/GYNclinic. Methods: Nonattendance was examined for a period of 1 year in first-timevisitors of an ambulatory OB/GYN clinic. The effects of age, population sector,the treating physician, waiting time, and timing of the appointment on theproportions of nonattendance were assessed. chi(2) tests and logistic regressionwere used for simple and multiple regression models. Results: A total of 8,883visits were included (median age 36 years). The proportion of nonattendancewas 30.1%: 19.9% among rural Jewish, 30.5% in urban Jewish, and 36% inBedouins (p < 0.001). Nonattendance increased from 26.6% among thosewaiting up to 1 week to 32.3% among those who waited more than 15 days (p

Department of Obstetrics & Gynecology, and Infection Control Unit, UABHospital, University of Alabama at Birmingham, Birmingham, Alabama, USA.alan.tita@obgyn.uab.eduOBJECTIVE: To describe the effect of an extended-spectrum prophylacticantibiotic regimen on postcesarean endometritis. METHODS: This is a cohortstudy of trends in postcesarean endometritis using data both from prospectivesurveillance by the infection control unit and from query of our obstetriccomputerized database to compare three periods of antibiotic prophylaxis:standard narrow-spectrum with intravenous first- or second-generationcephalosporin (1992-1996), clinical trial of extended-spectrum with addition ofintravenous doxycycline and oral azithromycin (1997-1999), and routine use ofextended-spectrum with addition of intravenous azithromycin (2001-2006) tostandard cephalosporin prophylaxis. RESULTS: A total of 48,913 deliveries at 24weeks or more of gestation occurred from 1992 to 2006, of which 10,966 (22.4%)were cesarean deliveries. Annual cesarean rates increased from 16% to 27.5%.Trends in the incidence of postcesarean endometritis revealed a biphasicdecrease consistent with the phased introduction of extended-spectrumprophylaxis. Incidence (95% confidence interval [CI]) of endometritis byprospective surveillance dropped from 19.9% (95% CI 18.6-21.3%) to 15.4%(95% CI 13.2-17.9%) during the clinical trial period: relative risk (RR) 0.77 (95%CI 0.66-0.91), P=.002; and then to 6.3% (95% CI 5.0-7.9%) during routine use ofextended-spectrum prophylaxis: RR 0.41 (95% CI 0.31-0.54), P

PowerLab hardware unit and Chart v3.6 software. Data were analyzed usingone-way analysis of variance (ANOVA) followed by post hoc analysis. RESULTS:Nifedipine exerted a potent and cumulative inhibitory effect on spontaneouscontractions and oxytocin-induced contractions in human myometrium in vitro, incomparison to control measurements (P < .05, n = 6). Incubation of strips withTEA or IbTX, prior to addition of nifedipine, significantly attenuated the relaxanteffect exerted by nifedipine (P < .05, n = 6). CONCLUSION: This studydemonstrates that the uterorelaxant effect of nifedipina is attenuated bypotassium channel (K+) blockade. This suggests that K+ channel conductance,and particularly the BK(Ca) channel, plays a role in the potent relaxant effect ofnifedipine, hitherto presumed to act solely through L-gated calcium channels.Am J Obstet Gynecol. 2008 Feb;198(2):191.e1-7.Antifungal drugs and the risk of selected birth defects.Carter TC, Druschel CM, Romitti PA, Bell EM, Werler MM, Mitchell AA; NationalBirth Defects Prevention Study.Department of Epidemiology, School of Public Health, State University of NewYork at Albany, Albany, USA. carterto@mail.nih.govOBJECTIVE: This study examined whether first-trimester antifungal drug usewas associated with the risk of selected birth defects. STUDY DESIGN: Subjectswere participants in a case-control study, the National Birth Defects PreventionStudy, with singleton deliveries from 1997 to 2003. Based on maternalinterviews, first-trimester antifungal drug use was compared between 7047 caseswith isolated defects and 4774 nonmalformed controls using unconditionallogistic regression. RESULTS: Risk was elevated for hypoplastic left heartsyndrome (odds ratio, 2.30; 95% confidence interval, 1.04, 5.06) but not for othercardiovascular defects. An increased risk of 1.88 was observed for diaphragmatichernia but was not statistically significant. Estimates approximated unity forneural tube defects, oral clefts, anorectal atresia, hypospadias, andcraniosynostosis. CONCLUSION: First-trimester antifungal drug exposure wasnot strongly associated with the risk of most birth defects, but further studiesshould examine the preliminary results of an association with hypoplastic leftheart syndrome.Am J Obstet Gynecol. 2008 Feb;198(2):183.e1-7.Rapid HIV testing and prevention of perinatal HIV transmission in high-riskmaternity hospitals in St. Petersburg, Russia.Kissin DM, Akatova N, Rakhmanova AG, Vinogradova EN, Voronin EE,Jamieson DJ, Glynn MK, Yakovlev A, Robinson J, Miller WC, Hillis S.Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.DKissin@cdc.govOBJECTIVE: The purpose of this study was to evaluate the effectiveness of ahuman immunodeficiency virus (HIV) rapid testing (RT) program. STUDYDESIGN: From April 13, 2004, to April 13, 2005, pregnant women at 2 high-riskmaternity hospitals with no or incomplete HIV testing results (negative tests at

prophylaxis for RT-positive women and their infants. RESULTS: Overall, 89.2%of eligible women (3671/4117) underwent RT, of whom 90.4% received resultsbefore delivery. HIV seroprevalence among all women who underwent RT was2.7% (100/3671 women); among previously untested women, seroprevalencewas 6.5% (90/1375 women); the incidence of HIV seroconversion among womenwith previous negative tests during pregnancy was 0.4% (10/2296 women). Afteradjustment, the main predictor of receiving RT results after delivery was lateadmission. Among HIV-exposed infants, 97.9% (92/94) received prophylaxis;61.7% (58/94) had available follow-up data, and 8.6% (5/58) met criteria fordefinitive or presumptive HIV infection. CONCLUSION: The RT programachieved timely detection of HIV-infected women in labor with unknown HIVstatus and effectively prevented perinatal HIV transmission.Am J Obstet Gynecol. 2008 Feb;198(2):173.e1-5.Maternal-Fetal Medicine Units Network cesarean registry: impact of shiftchange on cesarean complications.Bailit JL, Landon MB, Lai Y, Rouse DJ, Spong CY, Varner MW, Moawad AH,Simhan HN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, O'Sullivan MJ, SibaiBM, Langer O;National Institute of Child Health and Human Development Maternal-FetalMedicine Units Network. Department of Obstetrics and Gynecology, CaseWestern Reserve University, Cleveland, OH, USA.OBJECTIVE: This study was undertaken to evaluate the effect of change of shiftfor physicians and nurses on complications associated with cesarean delivery.STUDY DESIGN: 17,996 term women undergoing an unscheduled cesareandelivery in 13 centers from 1999-2000 were included. Maternal and neonatalmorbidities were evaluated by time of infant delivery vis-à-vis nursing change ofshift (6 AM-8 AM, 2 PM-4 PM, 10 PM-12 AM vs all other hours). The sample wasthen limited to weekdays only and physician shift changes were evaluated(physician shift change 6 AM-8 AM, 5 PM-7 PM vs all others). A composite of 30maternal morbidities was also evaluated by logistic regression, controlling forpotentially confounding factors. RESULTS: Physician change of shift had nomeasurable effect on maternal and neonatal outcomes. Neonatal facial nervepalsies were increased at nursing change of shift (5 vs 0) as werehysterectomies (33 [0.24%] vs 23 [0.53%]; P < .007). Nursing change of shift hadno impact on composite maternal morbidity after controlling for age, race,insurance, medical problems, prior incision type, weekend day, and prenatal care(odds ratio = 0.98; 95% confidence interval = 0.89-1.08). CONCLUSION:Physician change of shift does not appear to be associated with an increase inmorbidities. However, cesarean delivery during nursing change of shift isassociated with increased risk of neonatal facial nerve palsy and hysterectomy.Further investigation is needed to understand the cause of this association.Am J Obstet Gynecol. 2008 Feb;198(2):189.e1-6. Epub 2007 Nov 12.

Prophylactic antibiotics for the prevention of postpartum infectiousmorbidity in women infected with human immunodeficiency virus: arandomized controlled trial.Sebitloane HM, Moodley J, Esterhuizen TM.Department of Obstetrics and Gynecology and Women's Health and HIV Group,Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban,South Africa. sebitloanem@ukzn.ac.zaOBJECTIVE: The purpose of this study was to determine the effect ofintrapartum prophylactic antibiotics in the prevention of postpartum sepsis inlaboring women who were infected with HIV. STUDY DESIGN: In a double-blind,randomized trial that was conducted in Durban (South Africa), pregnant womenwho were infected with HIV in whom vaginal delivery was anticipated wererandomized to receive either a single dose of cefoxitin (2 g) or placebointrapartum. Signs of sepsis were evaluated within 72 hours and at 1 and 2weeks postpartum. RESULTS: Of the 424 women who were enrolled, 213women received cefoxitin, and 211 women received placebo. Both groups werecomparable in all baseline parameters. The overall sepsis rate was 19% (40/211women) in the placebo group and 16.9% (36/213 women) in the cefoxitin group(P = .581). There was a 53% reduction in risk of postpartum endometritis in thecefoxitin group (95% confidence interval, 0.24-0.9). CONCLUSION: The use ofprophylactic intrapartum cefoxitin in HIV-infected women reduces the risk ofpostpartum endometritis.Am J Obstet Gynecol. 2008 Feb 13 [Epub ahead of print]Increased risk of stroke in patients who undergo cesarean section delivery:a nationwide population-based study.Lin SY, Hu CJ, Lin HC.Department of Family Practice, Taipei Medical University, Taipei, Taiwan,Republic of China; Topnotch Stroke Research Center, Taipei Medical University,Taipei, Taiwan, Republic of China; School of Medicine, Taipei Medical University,Taipei, Taiwan, Republic of China.OBJECTIVE: This study used a population-based dataset to determine whether(compared with vaginal deliveries), cesarean section deliveries increase the riskof postpartum stroke during the 3-, 6-, or 12-month period after delivery. STUDYDESIGN: This study used 1998-2003 records from the Taiwan National HealthInsurance Research Database for 987,010 women with singleton deliveries from1998-2002. Cox proportional hazard regressions were carried out to computestroke-free survival rates between the 2 delivery modes. RESULTS: Theregression model indicated that, compared with patients who delivered vaginally,the hazard ratio for postpartum stroke among those who delivered by cesareansection was 1.67 times greater within 3 months of delivery (95% CI, 1.29-2.16),was 1.61 times greater within 6 months of delivery (95% CI, 1.31-1.98), and was1.49 times greater within 12 months of delivery (95% CI, 1.27-1.76).CONCLUSION: Our data indicates that cesarean section delivery is anindependent risk factor for stroke.

Am J Obstet Gynecol. 2008 Feb 13 [Epub ahead of print]Serial hemodynamic measurement in normal pregnancy, preeclampsia, andintrauterine growth restriction.Rang S, van Montfrans GA, Wolf H.Department of Obstetrics and Gynecology, the Academic Medical Center,Amsterdam, The Netherlands.OBJECTIVE: The study hypothesis was that hemodynamic measurements inconjunction with uterine artery Doppler could enable selection of women at riskfor the development of preeclampsia or fetal growth restriction. STUDY DESIGN:Systolic (SBP) and diastolic blood pressure, heart rate (RR), cardiac output (CO),total peripheral resistance (TPR), phase difference of SBP and RR interval weremeasured serially before, during, and after pregnancy. At 20 weeks, uterineartery Doppler measurement was performed. Outcome was classified aspreeclampsia (PE) or gestational hypertension (GH) with or without fetal growthrestriction (FGR), FGR without PE or GH, and normal pregnancy (NP).Differences between these groups were assessed by 1-way analysis of varianceand discriminant analysis. RESULTS: In early pregnancy, in comparison with NP(n = 28), PE/GH had a higher SBP and phase difference of SBP-RR interval. COwas higher in PE/GH without FGR (n = 5) but not PE/GH with FGR (n = 5). FGR,either with or without PE/GH (n = 4), was associated with higher TPR.Conjunction with uterine Doppler allowed selection of 93% of women with anabnormal outcome with a specificity of 100%. CONCLUSION: The studysupports our hypothesis that in early pregnancy, hemodynamic parameters differfrom normal in women predisposed to develop preeclampsia or fetal growthrestriction.Aust N Z J Obstet Gynaecol. 2007 Dec;47(6):514-6.Splenic rupture following elective caesarean delivery at term, complicatedby low-molecular-weight heparin use.Kenny B, Volobuev V.Department of Obstetrics and Gynaecology, Toowoomba Health Service,Toowoomba, Queensland, Australia. Bryan_Kenny@health.qld.gov.auEur J Obstet Gynecol Reprod Biol. 2007 Nov;135(1):41-6. Epub 2006 Nov 22.Comment in:Eur J Obstet Gynecol Reprod Biol. 2007 Nov;135(1):136; author reply 137.Pregnancy outcome in primiparae of advanced maternal age.Delbaere I, Verstraelen H, Goetgeluk S, Martens G, De Backer G, TemmermanM. Department of Obstetrics and Gynaecology, Faculty of Medicine and HealthSciences, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.Ilse.Delbaere@UGent.beOBJECTIVE: To investigate the impact of maternal age on singleton pregnancyoutcome, taking into account intermediate and confounding factors. STUDYDESIGN: In this population-based retrospective cohort study, perinatal data ofprimiparous women aged 35 years or more (n = 2970), giving birth to a singletonchild of at least 500 g, were compared to data of primiparous women aged 25-29

years old (n = 23,921). Univariate analysis was used to assess the effect ofmaternal age on pregnancy outcomes. The effects of intermediate (hypertension,diabetes and assisted conception) and confounding factors (level of education)were assessed through multivariable logistic regression analysis. RESULTS:Older maternal age correlated, independently of confounding and intermediatefactors, with very preterm birth (gestational age

J Perinatol. 2008 Feb 21 [Epub ahead of print]Urinalysis vs urine protein-creatinine ratio to predict significant proteinuriain pregnancy.Dwyer BK, Gorman M, Carroll IR, Druzin M.1Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics,Stanford University, Stanford, CA, USA.Objective: To compare the urine protein-creatinine ratio with urinalysis to predictsignificant proteinuria (>/=300 mg per day).Study Design: A total of 116 pairedspot urine samples and 24-h urine collections were obtained prospectively fromwomen at risk for preeclampsia. Urine protein-creatinine ratio and urinalysis werecompared to the 24-h urine collection.Result: The urine protein-creatinine ratiohad better discriminatory power than urinalysis: the receiver operatingcharacteristic curve had a greater area under the curve, 0.89 (95% confidenceinterval (CI) 0.83 to 0.95) vs 0.71 (95% CI 0.64 to 0.77, P/=0.28) ismore sensitive than urinalysis (cutoff >/=1+): 66 vs 41%, P=0.001 (with 95 and100% specificity, respectively). Furthermore, the urine protein-creatinine ratiopredicted the absence or presence of proteinuria in 64% of patients; urinalysispredicted this in only 19%.Conclusion: The urine protein-creatinine ratio is abetter screening test. It provides early information for more patients.Journal ofPerinatology advance online publication, 21 February 2008;doi:10.1038/jp.2008.4.J Perinatol. 2008 Feb 21 [Epub ahead of print]Patterns of pregnancy exposure to prescription FDA C, D and X drugs in aCanadian population.Wen SW, Yang T, Krewski D, Yang Q, Nimrod C, Garner P, Fraser W,Olatunbosun O, Walker MC.[1] 1OMNI Research Group, Department of Obstetrics and Gynecology,University of Ottawa, Ottawa, ON, Canada [2] 2Clinical Epidemiology Program,Ottawa Health Research Institute, Ottawa, ON, Canada [3] 3Department ofEpidemiology and Community Medicine, University of Ottawa, Ottawa, ON,Canada [4] 4School of Public Health, Central South University, Changsha,Hunan, China [5] 5McLaughlin Centre for Population Health Risk Assessment,Institute of Population Health, University of Ottawa, Ottawa, ON, Canada.Objective:To examine prescription Food and Drug Administration (FDA) C, D andX drugs in general obstetric population.Study Design:Historical cohortstudy.Result:A total of 18 575 women who gave a birth in Saskatchewanbetween January 1997 and December 2000 were included. Among them, 3604(19.4%) received FDA C, D or X drugs at least once during pregnancy. Thepregnancy exposure rates were 15.8, 5.2 and 3.9%, respectively, for category C,D and X drugs, and were 11.2, 7.3 and 8.2%, respectively, in the first, secondand third trimesters. Salbutamol (albuterol), trimethoprim/sulfamethoxazole (cotrimoxazole),ibuprofen, naproxen and oral contraceptives were the mostcommon C, D, X drugs used during pregnancy.Conclusion:About one in every

five women uses FDA C, D and X drugs at least once during pregnancy, and themost common prescription drugs in pregnancy are antiasthmatic, antibiotics,nonsteroid anti-inflammation drugs, antianxiety or antidepressants and oralcontraceptives.Journal of Perinatology advance online publication, 21 February2008; doi:10.1038/jp.2008.6.Clin Obstet Gynecol. 2008 Mar;51(1):106-18.Principles and practice of teratology for the obstetrician.Fisher B, Rose NC, Carey JC.Department of Obstetrics and Gynecology, University of Utah, Salt Lake City,Utah 84132, USA. barbra.fisher@hsc.utah.eduCommon clinical problems of counseling patients about potential teratogenicrisks in pregnancy are presented and principles of teratogenicity assessment.Clin Obstet Gynecol. 2008 Mar;51(1):84-95.Genetics of pregnancy loss.Warren JE, Silver RM.Departments of Obstetrics and Gynecology, Division of Maternal Fetal Medicine,University of Utah, Salt Lake City, Utah, USA.Pregnancy loss is a common problem in reproductive-aged women. Althoughmost cases of pregnancy loss are sporadic, some couples experience recurrentpregnancy loss, a challenging clinical dilemma. A variety of possible etiologieshave been described for both sporadic and recurrent pregnancy loss. This reviewfocuses on the genetic abnormalities that may contribute to this clinical problemand delineates strategies for genetic evaluation and clinical management insubsequent pregnancies.Clin Obstet Gynecol. 2008 Mar;51(1):74-83.Genetic factors in common obstetric disorders.Ward K.Department of Obstetrics, Gynecology and Women's Health and The PacificResearch Center for Early Human Development, University of Hawai'i, John A.Burns School of Medicine, Honolulu, Hawai'i, USA. ken.ward.hi@mac.comGenetic research of disease has recently turned from individual genes for rarebut highly penetrant diseases (like cystic fibrosis) to focus on common, multigenedisorders with polygenic inheritance patterns, such as preterm labor,preeclampsia, gestational diabetes, placental abruption, and thromboembolism.These conditions are characterized by multiple etiologies, chronicity, fetalinvolvement, adaptive clinical manifestations, and gene-environment interactions.As we understand genetic contributions to complex disease and build upon thegenetic data and technology available, more effective and specific managementand treatment options will become available for clinicians and their patients.Curr Opin Obstet Gynecol. 2007 Dec;19(6):561-7.Postpartum care--what's new?Shaw E, Kaczorowski J.

Department of Family Medicine, McMaster University, Hamilton, Ontario,Canada. shawea@mcmaster.caPURPOSE OF REVIEW: The postpartum period is a time of significantemotional, social, and physical change for most women. This review focuses onrecent evidence supported by systematic reviews and randomized, controlledtrials to guide the care of postpartum women who are otherwise healthy.RECENT FINDINGS: Mental health outcomes are improved with postpartumsupport in at-risk women. Postpartum depression can be treated eitherpharmacologically or with counseling; however, exercise and omega-3 fatty acidsare emerging as potentially effective alternatives. Intrauterine devices are safeand effective methods of contraception in the postpartum period. There has yetto be an effective, postpartum, smoking-cessation program developed, althoughintensive motivational counseling shows some promising early results. Bladderdysfunction continues to be a significant problem for women even at 10 yearspostpartum. Pelvic floor muscle exercises can help prevent and treatincontinence at 12 months, but longer-term follow-up studies are needed.Prevalence studies suggest that bowel dysfunction is common in the postpartumperiod, but randomized, controlled trials are limited to treatment in women withthird-degree perineal damage. SUMMARY: Although some recommendationscan be made for evidence-based postpartum care, many important questionsrelated to the postpartum period have not been examined by rigorousmethodologies.N Engl J Med. 2008 Feb 21;358(8):852; author reply 852-3.Comment on:N Engl J Med. 2007 Nov 29;357(22):2277-84.Computed tomography and radiation exposure.Varnholt H.Am J Obstet Gynecol. 2008 Mar;198(3):297.e1-7.Advanced extrauterine pregnancy: diagnostic and therapeutic challenges.Worley KC, Hnat MD, Cunningham FG.Department of Obstetrics and Gynecology, University of Texas SouthwesternMedical Center, Dallas, TX 75390-9032, USA. kworle@parknet.pmh.orgOBJECTIVE: The objective of the study was to identify women with advancedextrauterine pregnancy, specifically assessing the problems encountered withtheir diagnosis and management, preoperative evaluation, and surgical removal.STUDY DESIGN: This was a case series including women diagnosed with anextrauterine pregnancy of 18 weeks' gestation or greater at our institution from1980 to 2005. RESULTS: We identified 10 women with advanced extrauterinepregnancies during the study period. Diagnosis was not optimal, and only 6 werediscovered preoperatively. Despite the fact that only 3 of 10 women metdiagnostic criteria for an abdominal pregnancy, surgical dissection wasuniversally difficult, and hemorrhage was common with 9 of 10 patients requiringblood transfusions. In 2 women, the placenta was left in situ, and both developedserious complications. All 5 viable fetuses survived, but their courses were long

and complicated. CONCLUSION: Irrespective of placental implantation site, anadvanced extrauterine pregnancy is a serious condition. The currently accepteddefinition of abdominal pregnancy is too exclusive.Am J Obstet Gynecol. 2008 Mar;198(3):e9-e12.Acute myocardial infarction in early pregnancy: definition of myocardiumat risk with noncontrast T2-weighted cardiac magnetic resonance.Zaidi AN, Raman SV, Cook SC.Department of Internal Medicine, Division of Cardiovascular Medicine The RossHeart Hospital, The Ohio State University, Columbus, OH, USA.We report a case of a 34-year-old woman who had a left anterior wall myocardialinfarction develop in the first trimester of pregnancy. Despite urgent andsuccessful revascularization, she demonstrated persistent segmental wall motionabnormalities by transthoracic echocardiography. To manage this patient safelythrough pregnancy with a better definition of myocardium at risk, a cardiacmagnetic resonance examination was performed. This identified a large territoryof acutely edematous myocardium in addition to providing accurate volumetricmeasurements of left ventricular size and function. Because of her gravid state,gadolinium was not administered nor was it required to delineate the region ofmyocardium at risk.Hum Reprod. 2008 Mar 5 [Epub ahead of print]Fertility and pregnancy outcomes following uterine devascularization forsevere postpartum haemorrhage.Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L, Verspyck E.Department of Obstetrics and Gynaecology, Rouen University Hospital, CharlesNicolle, 1, rue de Germont, 76031 Rouen-Cedex, France.BACKGROUND To evaluate the fertility and pregnancy outcomes followinguterine devascularization for postpartum haemorrhage (PPH). METHODS Allpatients who required uterine devascularization, i.e. bilateral uterine arteryligation (Group A), and either bilateral utero-ovarian ligament (Group B) orsuspensory ligament of ovary ligation (Group C) in cases of persistenthaemorrhage, for PPH with no concomitant procedures from December 1997 toMarch 2004 were included. Data were retrieved from medical files and telephoneinterviews. RESULTS Data were available for 32 of the 40 (80%) patientsincluded in the study. All patients but 4 had a return to normal menses.Postpartum amenorrhea was secondary to ovarian failure in two cases, andsynechiae or necrotic uterus each in one case. These four patients belonged toGroup C, whereas no adverse events were observed in groups A and B. Thirteenpatients had 16 pregnancies with 13 term deliveries, 1 ectopic pregnancy and 2abortions. Clinical course of the 13 complete gestations were uneventful but PPHrecurred in 4 (31%) due to placenta accreta in three cases. CONCLUSIONSUterine artery ligation, whether or not associated with utero-ovarian ligamentligation, for PPH does not appear to compromise the patients' subsequent fertilityand obstetrical outcome.

Int J Gynaecol Obstet. 2007 Dec;99 Suppl 2:S160-7. Epub 2007 Oct 26.Misoprostol: pharmacokinetic profiles, effects on the uterus and sideeffects.Tang OS, Gemzell-Danielsson K, Ho PC.Department of Obstetrics and Gynaecology, University of Hong Kong, HongKong SAR, China. ostang@graduate.hku.hkMisoprostol, a synthetic prostaglandin E1 analogue, is commonly used formedical abortion, cervical priming, the management of miscarriage, induction oflabor and the management of postpartum hemorrhage. It can be given orally,vaginally, sublingually, buccally or rectally. Studies of misoprostol'spharmacokinetics and effects on uterine activity have demonstrated theproperties of the drug after various routes of administration. These studies canhelp to discover the optimal dose and route of administration of misoprostol forindividual clinical applications. Misoprostol is a safe drug but seriouscomplications and teratogenicity can occur with unsupervised use.Int J Gynaecol Obstet. 2007 Dec;99 Suppl 2:S198-201. Epub 2007 Oct 24.Prevention of postpartum hemorrhage with misoprostol.Alfirevic Z, Blum J, Walraven G, Weeks A, Winikoff B.School of Reproductive and Developmental Medicine, University of Liverpool,Liverpool, UK. zarko@liv.ac.ukAs a stable, orally active and cheap uterotonic, misoprostol would appear ideallysuited to the prevention of postpartum hemorrhage (PPH) in the developingworld. Following numerous clinical trials, it appears that misoprostol prophylaxisusing an oral or sublingual dose of 600 microg is more effective than placebo atpreventing PPH in community births (relative risk 0.59, 95% confidence intervals0.41-0.84), but not in hospital settings (RR 1.23, 95% CI 0.86-1.74). It is,however, not as effective as injectable oxytocin (RR 1.34, 95% CI 1.16 to 1.55).Misoprostol is therefore indicated for prevention of PPH in settings whereinjectable conventional uterotonics are not available. In the event of continuedhemorrhage, a minimum of 2 h should lapse after the original dose before asecond dose is given. If the initial dose was associated with pyrexia or markedshivering, at least 6 h should lapse before the second dose is given.Int J Gynaecol Obstet. 2007 Dec;99 Suppl 2:S190-3. Epub 2007 Oct 24.Misoprostol for intrauterine fetal death.Gómez Ponce de León R, Wing D, Fiala C.Ipas and School of Public Health, UNC at Chapel Hill, Chapel Hill, NC 27510,USA. gomezr@ipas.orgThe frequency of intrauterine fetal death (IUFD) with retained fetus varies, but isestimated to occur in 1% of all pregnancies. The vast majority of women willspontaneously labor and deliver within three weeks of the intrauterine death. Thecomplexity in medical management increases significantly when the cervix isunripe or unfavorable, or when the woman develops disseminated intravascularcoagulation. Misoprostol regimens for the induction of labor for second and thirdtrimester IUFDs, range from 50 to 400 microg every 3 to 12 h, and are all

clinically effective. Nevertheless, the current scientific evidence supports vaginalmisoprostol dosages, which are adjusted to gestational age: between 13-17weeks, 200 microg 6-hourly; between 18-26 weeks, 100 microg 6-hourly; andmore than 27 weeks, 25-50 microg 4-hourly. In women with a previous cesarean,lower doses should be used and doubling of doses should not occur. Clinicalmonitoring should continue after delivery or expulsion because of the risk ofpostpartum atony and/or placenta retention.Int J Gynaecol Obstet. 2007 Dec;99 Suppl 2:S182-5. Epub 2007 Oct 24.Misoprostol to treat missed abortion in the first trimester.Gemzell-Danielsson K, Ho PC, Gómez Ponce de León R, Weeks A, Winikoff B.Department of Woman and Child Health, Division of Obstetrics and Gynecology,Karolinska Institutet/Karolinska University Hospital, Stockholm, Sweden.Kristina.gemzell@kbh.ki.seMissed abortion in the first trimester is characterized by the arrest of embryonicor fetal development. The cervix is closed and there is no or only slight bleeding.Ultrasound examination shows an empty gestational sac or an embryo/fetuswithout cardiac activity. Based on a review of the published literature a singledose of 800 microg vaginal misoprostol may be offered as an effective, safe, andacceptable alternative to the traditional surgical treatment for this indication.Alternatively, 600 microg misoprostol can be administered sublingually. Afteradministration of misoprostol, hospitalization is not necessary and the time toexpulsion varies considerably. Bleeding may last for more than 14 days withadditional days of light bleeding or spotting. The woman should be advised tocontact a provider in case of heavy bleeding or signs of infection. A follow-up isrecommended after 1 to 2 weeks.Int J Gynaecol Obstet. 2007 Dec;99 Suppl 2:S202-5. Epub 2007 Oct 24.Treatment of postpartum hemorrhage with misoprostol.Blum J, Alfirevic Z, Walraven G, Weeks A, Winikoff B.Gynuity Health Projects, New York, NY 10010, USA. jblum@gynuity.orgA literature review was conducted to determine whether misoprostol is aneffective treatment for postpartum hemorrhage (PPH) and in what dose. AllEnglish language articles published before March 2007 reporting on misoprostolfor treatment of PPH were reviewed. Unpublished data previously presented atinternational scientific meetings were also included in the review. Little evidenceexists in support of misoprostol for treatment of postpartum hemorrhage (PPH).Nonetheless, PPH remains a major killer of women worldwide, and newtreatment options are widely sought. For this reason, we recommend a singledose of misoprostol 600 microg oral or sublingual for PPH treatment in instanceswhen other treatments have either failed to work or are not available.Int J Gynaecol Obstet. 2007 Dec;99(3):255-6. Epub 2007 Sep 24.Hematometra following uterine compression sutures.Dadhwal V, Sumana G, Mittal S.Department of Obstetrics and Gynecology, All India Institute of Medical Sciences,

New Delhi, India.Int J Gynaecol Obstet. 2007 Dec;99(3):248-9. Epub 2007 Sep 24.Clinicopathology of maternal scleroderma.Papakonstantinou K, Hasiakos D, Kondi-Paphiti A.2nd Department of Obstetrics and Gynecology, University of Athens, AretaieionHospital, Athens, Greece. k_papakon@yahoo.grInt J Gynaecol Obstet. 2007 Dec;99(3):229-32. Epub 2007 Jul 20.Postpartum urinary retention after cesarean delivery.Liang CC, Chang SD, Chang YL, Chen SH, Chueh HY, Cheng PJ.Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital,Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan.ccjoliang@cgmh.org.twOBJECTIVE: To investigate the incidence of postpartum urinary retention (PUR)after cesarean delivery and determine which obstetric factors contribute to thisproblem. METHOD: A prospective study recruited 605 pregnant women who hada cesarean delivery. Each patient's postvoid residual bladder volume (PVRBV)was estimated with an ultrasound scan after first micturition. The women weredivided into 2 groups: PUR (PVRBV > or =150 mL) and normal. Patients'characteristics, obstetric parameters, and prevalence of lower urinary tractsymptoms at 3 months postpartum were compared. RESULT: The overallincidence of PUR was 24.1%. The incidence of overt and covert PUR was 7.4%and 16.7%, respectively. Morphine-related postoperative analgesia, multiplepregnancy, and low body mass index were significantly associated with PUR. At3-month follow-up, 5.0% of patients had obstructive voiding symptoms and 9.1%had irritative voiding symptoms. CONCLUSION: Our results revealed PUR was acommon phenomenon in patients who had a cesarean delivery, and morphinerelatedpostoperative analgesia was the main contributing factor.Int J Gynaecol Obstet. 2008 Mar 4 [Epub ahead of print]The influence of medical abortion compared with surgical abortion onsubsequent pregnancy outcome.Gan C, Zou Y, Wu S, Li Y, Liu Q.West China Hospital, Sichuan University, Chengdu, Sichuan, China.Seven prospective cohort studies (12484 cases) were included in this review ofthe respective effects on the next pregnancy of medical and surgical abortion inearly pregnancy. The incidence of miscarriage and postpartum hemorrhage wassignificantly lower in the pregnancy following a medical abortion. No othersignificant differences were found. With respect to the outcome of the nextpregnancy, first-trimester medical abortions may thus be safer than the surgicaloption.Int J Gynaecol Obstet. 2008 Mar 3 [Epub ahead of print]Severe liver disease in pregnancy.Chen H, Yuan L, Tan J, Liu Y, Zhang J.

Obstetrics and Gynecology Department, The Second Affiliated Hospital of SunYat-Sen University, Guangdong, China.Objective: To determine the clinical characteristics of patients with fulminanthepatitis of pregnancy (FHP) and acute fatty liver of pregnancy (AFLP) andanalyze their correlation with pregnancy outcome. Methods: Of 55 pregnantwomen with severe liver disease, 41 had FHP and 14 had AFLP. Results:Jaundice was the primary manifestation for both FHP and AFLP and hepaticencephalopathy was the most significant complication for both. Disseminatedintravascular coagulation, albuminuria, and prothrombin activity were found to beindependent risk factors of maternal mortality for both. However, the rates ofpreterm labor, fetal demise, and neonatal asphyxia were lower in the FHP group.Conclusion: Women with FHP or AFLP are at risk for severe complications andadverse pregnancy outcome. Since the 2 conditions are managed differently,early diagnosis is essential.Int J Gynaecol Obstet. 2008 Feb 27 [Epub ahead of print]Congenital intestinal malrotation masquerading as hyperemesisgravidarum.Pelikan H, Stoot J, Meens-Koreman S, Teijink J.Department of Obstetrics and Gynecology, Atrium Medical Center, Heerlen, TheNetherlands.Obstet Gynecol. 2008 Mar;111(3):777.Getting to havarti: moving toward patient safety in obstetrics.Mirabello J.Rochester, New Hampshire, e-mail: J.Mirabello@FMHospital.com.Obstet Gynecol. 2008 Mar;111(3):704-709.Risk Factors for Recurrence of Group B Streptococcus Colonization in aSubsequent Pregnancy.Cheng PJ, Chueh HY, Liu CM, Hsu JJ, Hsieh TT, Soong YK.Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital andChang Gung University College of Medicine, Linkou Medical Center, Taoyuan,Taiwan; and Department of Obstetrics and Gynecology, Chang Gung MemorialHospital and Chang Gung University College of Medicine, Taipei, Taiwan.OBJECTIVE: To document rates of recurrent group B streptococci (GBS)colonization in women with previous GBS colonization in an initial pregnancy andto assess maternal risk factors associated with recurrence. METHODS: Aretrospective, longitudinal study was performed in a teaching hospital on womenwith GBS colonization who were pregnant between 2002 and 2006 and had atleast one subsequent pregnancy during the same time period. When only theindex and first subsequent pregnancy were analyzed, the cohort included 251women. The rate of recurrence was estimated for GBS colonization in thepregnancy after the index pregnancy for GBS colonization. Multivariableregression models were constructed to model recurrence of GBS colonization ina subsequent pregnancy as functions of potential predictors to estimate relative

isks and confidence intervals. RESULTS: The rate of recurrence of GBScolonization in the pregnancy subsequent to the index pregnancy was 38.2%(95% confidence interval 33.5-42.9%). Multivariable regression models showedthat the time interval between the two pregnancies and the intensity of GBScolonization from the index pregnancy were predictive of recurrent GBScolonization. CONCLUSION: More than one third of women had recurrent GBScolonization in a subsequent pregnancy. These findings should assist cliniciansin counseling women with GBS colonization about their risk for recurrence, theimportance of appropriate prenatal GBS screening in a subsequent pregnancy,and intrapartum antibiotic prophylaxis for unknown GBS status. LEVEL OFEVIDENCE: II.Lancet. 2008 Mar 1;371(9614):705-6.Reducing eclampsia-related deaths--a call to action.Langer A, Villar J, Tell K, Kim T, Kennedy S.EngenderHealth, New York, NY 10001, USA. alanger@engenderhealth.orgN Engl J Med. 2008 Mar 6;358(10):1037-52.Acute pulmonary embolism.Tapson VF.Division of Pulmonary and Critical Care Medicine, Duke University MedicalCenter, Durham, NC 27710, USA. tapso001@mc.duke.eduAm J Obstet Gynecol. 2008 Mar 19 [Epub ahead of print]Management of an obstetric health care provider with acute parvovirus B19infection.Kho KA, Eisinger K, Chen KT.Department of Obstetrics and Gynecology, Columbia University, New York, NY.We report a case of an obstetrician with acute parvovirus B19 infection and theseries of exposed pregnant women. Currently, there are no establishedguidelines regarding management of an obstetric health care provider with acuteparvovirus B19 infection. We propose a management scheme of this clinicalscenario.BMJ. 2008 Mar 22;336(7645):663-7.Hyperthyroidism and pregnancy.Marx H, Amin P, Lazarus JH.Department of Obstetrics, University Hospital of Wales, Cardiff CF14 4XN.Eur J Obstet Gynecol Reprod Biol. 2008 Jan;136(1):133-4. Epub 2006 Dec 1.Fertility after B-Lynch suture in a patient previously treated for acutemyeloid leukaemia.Vitthala S, Misra PK.Eur J Obstet Gynecol Reprod Biol. 2008 Jan;136(1):129-30. Epub 2006 Nov 13.

Pregnancy-induced severe gestational hyperlipidemia mimicking familialhyperlipidemia.Basaran A, Dağdelen S, Gürlek A, Bozdağ G, Beksaç S.Eur J Obstet Gynecol Reprod Biol. 2008 Jan;136(1):126-7. Epub 2006 Oct 12.Osteogenesis imperfecta and pregnancy.Litos M, Michala S, Brown R.Eur J Obstet Gynecol Reprod Biol. 2008 Jan;136(1):127-8. Epub 2006 Sep 29.Congenital chloride diarrhea in pregnancy: A case report.Iijima S, Ohzeki T, Sugimura M, Kanayama N.Eur J Obstet Gynecol Reprod Biol. 2008 Mar 18 [Epub ahead of print]An unusual evolution of a pregnancy-associated Sweet's Syndrome.Sanchez ML, Sanchez YG, Marin AP.Carlos Sarthou 1, 6, 24, 46800 Xativa (Valencia), Spain.Int J Gynaecol Obstet. 2008 Mar 17 [Epub ahead of print]Detection of obstetric risk in women attending prenatal clinics in KadutuUrban Health District, Democratic Republic of Congo.Kyamusugulwa PM.Department of Public Health, Bukavu Medical College, Democratic Republic ofCongo.Lancet. 2008 Mar 8;371(9615):811; author reply 811-2.Comment on:Lancet. 2007 Oct 13;370(9595):1311-9.Maternal mortality ratio for Bangladesh.Talukder K.Obstet Gynecol. 2008 Feb;111(2 Pt 1):431-5.Postpartum ovarian vein thrombosis.Klima DA, Snyder TE.Division of General Obstetrics and Gynecology, Department of Obstetrics andGynecology, University of Kansas Medical Center, Kansas City, Kansas, USA.Obstet Gynecol. 2008 Feb;111(2 Pt 1):356-64.Intrapartum group B streptococci prophylaxis in patients reporting apenicillin allergy.Matteson KA, Lievense SP, Catanzaro B, Phipps MG.Department of Obstetrics and Gynecology, Women and Infants Hospital, theWarren Alpert Medical School at Brown University, Providence, Rhode Island02905, USA. KMatteson@wihri.orgOBJECTIVE: To examine adherence to the 2002 Centers for Disease Controland Prevention (CDC) guidelines for group B streptococci (GBS) prophylaxis inpatients who reported a penicillin allergy. METHODS: This is a retrospective

cohort study of GBS-positive, penicillin-allergic obstetric patients who delivered atour institution from 2004 through 2005 (N=233). Medical records were analyzedfor type of delivery, gestational age at delivery, antimicrobial sensitivity testing,and antibiotics administered. Antimicrobial sensitivity testing and appropriateprophylactic antibiotic choice were analyzed. "Appropriate antibiotic choice" wasdefined using the 2002 CDC guidelines for GBS prophylaxis. Women with eithera scheduled cesarean delivery or a preterm delivery were excluded fromanalyses. Data were analyzed using Stata 9.0. RESULTS: Overall, 95% (95%confidence interval [CI] 91-97%) of GBS-positive, penicillin-allergic womenreceived antibiotic prophylaxis and only 16% (95% CI 11-21%) of patientsreceived an appropriate antibiotic. The majority of women who were givenantibiotics received clindamycin (83%, 95% CI 77-87%); however, antimicrobialsensitivity testing was performed in only 11% (95% CI 9-17%) of patients. Morewomen received an appropriate antibiotic in 2005 than in 2004 (20% comparedwith 11%, P=0.11). Although the study was underpowered to evaluate themagnitude of increase, the overall prevalence of appropriate antibioticadministration in 2005 was still only 20% (95% CI 13-28%). CONCLUSION:Adherence to the 2002 CDC guidelines for GBS prophylaxis in penicillin-allergicwomen is far from optimal. Improvements are necessary in obtainingantimicrobial sensitivity testing and choosing an appropriate antibiotic for GBSpositivewomen with a reported penicillin allergy. LEVEL OF EVIDENCE: II.Acta Obstet Gynecol Scand. 2008;87(3):260-71.Prevalence of maternal group B streptococcal colonisation in Europeancountries.Barcaite E, Bartusevicius A, Tameliene R, Kliucinskas M, Maleckiene L,Nadisauskiene R.Department of Obstetrics and Gynaecology, Kaunas University of Medicine,Lithuania. eglebarcaite@yahoo.comBACKGROUND: Group B streptococcus (GBS) is a leading cause of neonatalsepsis in many industrialised countries. However, the burden of perinatal GBSdisease varies between these countries. We undertook a systematic review todetermine the prevalence of maternal group B streptococcal colonisation, one ofthe most important risk factor for early onset neonatal infection, and to examinethe serotype distribution of the GBS strains isolated and their susceptibility toantibiotics in European countries. METHODS: We followed the standardmethodology for systematic reviews. We prepared a protocol and a form for dataextraction that identifies key characteristics on study and reporting quality. Thesearch was conducted for the years 1996-2006 including electronic, handsearching and screening of reference lists. RESULTS: Twenty-one studiespresented data on 24,093 women from 13 countries. Among all studies, GBSvaginal colonisation rates ranged from 6.5 to 36%, with one-third of studiesreporting rates of 20% or greater. The regional carriage rates were as follows:Eastern Europe 19.7-29.3%, Western Europe 11-21%, Scandinavia 24.3-36%,and Southern Europe 6.5-32%. GBS serotypes III, II and Ia were the mostfrequently identified serotypes. None of the GBS isolates were resistant to

penicillin or ampicillin, whereas 3.8-21.2% showed resistance to erythromycinand 2.7-20% showed resistance to clindamycin. CONCLUSION: Although thereis variation in the proportion of women colonised with GBS, the range ofcolonisation, the serotype distribution and antimicrobial susceptibility reportedfrom European countries appears to be similar to that identified in overseascountries.Am J Obstet Gynecol. 2008 Mar 21 [Epub ahead of print]Acute hyperlipidemic pancreatitis in pregnancy.Crisan LS, Steidl ET, Rivera-Alsina ME.Methodist Health System, Dallas, TX.BACKGROUND: Pancreatitis in pregnancy remains a rare event and is mostoften associated with gallstone disease. Hyperlipidemic gestational pancreatitisusually occurs in women with a preexisting abnormality of the lipid metabolismand poses particular problems in diagnosis and clinical management. CASES:We describe 5 patients with acute episodes of pancreatitis during pregnancycaused by hyperlipidemia. CONCLUSION: Acute pancreatitis in pregnancycauses significant morbidity. Even though it is often associated with gallstones,we describe 5 cases in which the etiology of the pancreatitis was maternalhyperlipidemia. Etiology, diagnosis, and management will be discussed.Aust N Z J Obstet Gynaecol. 2008 Apr;48(2):130-6.Making pregnancy safer in Australia: The importance of maternal deathreview.Kildea S, Pollock WE, Barclay L.Graduate School for Health Practice, Institute of Advanced Studies, CharlesDarwin University, Darwin, Northern Territory.Australia is one of the safest countries in the world to birth. Because maternaldeaths are rare, often the focus during pregnancy is on the well-being of thefetus. The relative safety of birth has fostered a shift in the focus of maternalhealth, from survival, to the model of care or the birth experience. Yet women stilldie in Australia as a result of child bearing and many of these deaths areassociated with avoidable factors. The purpose of this paper is to outline thematernal death monitoring and review process in Australia and to present toclinicians the salient features of the most recently published Australian maternaldeath report. The notion of preventability and the potential for practice to have aneffect on reducing maternal mortality are also discussed.J Reprod Med. 2008 Jan;53(1):67-9.Extensive cervical prolapse during labor: a case report.Lau S, Rijhsinghani A.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,University of Iowa Hospitals and Clinics and College of Medicine, 200 HawkinsDrive, Iowa City, IA 52242-1080, USA.BACKGROUND: An extensive, irreducible cervical prolapse during pregnancy isa rare condition and can lead to various complications, including severe cervical

edema and dystocia in labor. Treatment options are very limited. CASE: A 33-year-old woman with spina bifida and a history of multiple intraabdominaloperations and extensive intraperitoneal adhesions was admitted in labor at36(6/7) weeks' gestation with an irreducible cervical prolapse. The cervicalprolapse was reduced by topical application of concentrated magnesium sulfate.CONCLUSION: In active labor, a prolapsed cervix that is enlarged andedematous can be managed with a topical concentrated magnesium solution toprevent cervical dystocia and lacerations.J Reprod Med. 2008 Jan;53(1):65-6.Expectant management of uterine incarceration from an anterior uterinemyoma: a case report.Rose CH, Brost BC, Watson WJ, Davies NP, Knudsen JM.Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, 200First Street, SW, Rochester, MN 55905, USA. rose.carl@mayo.eduBACKGROUND: Uterine incarceration is an infrequent complication of pregnancyin the early second trimester. Although imaging can be confirmatory, thediagnosis is made primarily on clinical grounds, and definitive treatment involvesmanual reduction to restore the proper anatomic position. Except for preexistinguterine retroversion, often this event is idiopathic. CASE: A 30-year-oldprimigrávidas presented at 15 weeks' gestation with uterine incarceration.Manual replacement was unsuccessful. Spontaneous resolution occurred at 20weeks, followed by uneventful pregnancy. The patient underwent a classicalcesarean section at term due to fetal malpresentation. CONCLUSION: Uterineincarceration may be managed conservatively, with a favorable outcome.Obstet Gynecol. 2008 Feb;111(2 Pt 2):577-9.Preoperative magnetic resonance imaging and antepartum myomectomy ofa giant pedunculated leiomyoma.Alanis MC, Mitra A, Koklanaris N.Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte,North Carolina, USA. mca3@musc.eduBACKGROUND: Antepartum myomectomy is reserved for severe pain andprevention of fetal complications. Magnetic resonance imaging has been usefulin nonpregnant women for preoperative management and patient counseling.CASE: A primigrávidas was admitted at 12 weeks of gestation in severe acuteabdominal pain with a large abdominal mass, confirmed by magnetic resonanceimaging to be a pedunculated 30x27x19-cm uterine leiomyoma. Anuncomplicated abdominal myomectomy was performed, incorporating a flat cupvacuum device to mobilize the mass without disturbing the gravid uterus. Thepatient later had an uncomplicated term vaginal delivery and healthy newborn.CONCLUSION: Magnetic resonance imaging and a flat cup vacuum device werehelpful in preoperative planning and performing an uncomplicated abdominalmyomectomy during pregnancy, respectively.Obstet Gynecol. 2008 Feb;111(2 Pt 2):575-7.

Abetalipoproteinemia complicating the puerperium.Palmer AB, Knudtson EJ.Department of Obstetrics and Gynecology, University of Oklahoma HealthSciences Center, Oklahoma City, Oklahoma 73190, USA. Andrea-Palmer@ouhsc.eduBACKGROUND: Abetalipoproteinemia is a rare, autosomal recessive disease, inwhich the absence of beta-lipoprotein results in the malabsorption of fat-solublevitamins. There are few reported complications from abetalipoproteinemia duringpregnancy. We present a case of untreated abetalipoproteinemia complicatingthe puerperium. CASE: A 23-year-old, gravida 3, para 0020 woman presented toan outside facility in labor, and her delivery was complicated by postpartumhemorrhage and a large vulvar hematoma. She was coagulopathic andtransferred for suspected disseminated intravascular coagulation. Her preexistingmedical history was not appreciated by the transferring facility. CONCLUSION:Abetalipoproteinemia in pregnancy is rare. Untreated disease conveys multisystemorgan dysfunction and has ramifications in labor and delivery. Cliniciansmust elicit a comprehensive medical history to properly manage complications inthe puerperium.Obstet Gynecol. 2008 Feb;111(2 Pt 2):573-5.Late postpartum hemorrhage due to von Willebrand disease managed withuterine artery embolization.Salman MC, Cil B, Esin S, Deren O.Department of Obstetrics and Gynecology, Hacettepe University Faculty ofMedicine, Ankara, Turkey. csalman@hacettepe.edu.trBACKGROUND: Von Willebrand disease is the most common inherited bleedingdisorder caused by quantitative or qualitative defects of von Willebrand factor,which may lead to postpartum bleeding problems. In such patients, resistantpostpartum hemorrhage may be treated effectively by using transcatheter arterialembolization. CASE: Life-threatening late postpartum bleeding of a patient withvon Willebrand disease type 3 unresponsive to traditional medical approacheswas successfully managed with selective uterine artery embolization.CONCLUSION: Selective transcatheter uterine artery embolization may be usedto control life-threatening pelvic hemorrhage unresponsive to traditional localmeasures. Such an intervention may also be used successfully in patients withbleeding disorders as the last chance of uterine preservation.Obstet Gynecol. 2008 Feb;111(2 Pt 2):565-9.May-Thurner Syndrome resulting in acute iliofemoral deep vein thrombosisin the postpartum period.Zander KD, Staat B, Galan H.Department of Obstetrics and Gynecology, University of Colorado HealthSciences Center, Denver, Colorado, USA.BACKGROUND: May-Thurner Syndrome is a congenital anomaly of the rightiliac artery, which causes an acquired narrowing defect in the left iliac vein. Theartery abnormally compresses the vein causing intraluminal collagen deposition

and sluggish venous flow. This syndrome places patients at increased risk ofproximal deep venous thrombosis. CASES: We describe three postpartumpatients with May-Thurner Syndrome complicated by iliofemoral deep veinthrombosis and their management. There was no evidence of underlyingthrombophilia, yet these women had large proximal thrombi. They were treatedwith anticoagulation followed by thrombolysis and, in one case, stent placement.CONCLUSION: May-Thurner syndrome can predispose postpartum patients tolarge, proximal thrombi and may be treated effectively with a combination ofthrombolysis and stent placement. May-Thurner Syndrome should be consideredin the differential diagnosis of pelvic thrombosis, especially when thrombophiliasare excluded.Obstet Gynecol. 2008 Feb;111(2 Pt 2):540-1.Acute esotropia after epidural anesthesia.Yatziv Y, Stolowitch C, Segev Y, Kesler A.Department of Ophthalmology, Tel Aviv Sourasky Medical Center,Tel AvivUniversity, Tel Aviv, Israel. yyatziv@gmail.comBACKGROUND: Cranial nerve palsy after dural puncture is an uncommoncomplication. The sixth cranial nerve is the most commonly affected because ofits long intracranial course. We report a case of acute comitant esotropia thatoccurred after unintentional dural puncture. CASE: A young woman presentedwith acute onset comitant esotropia 1 week after epidural anesthesia for a normalvaginal delivery during which the dura was unintentionally punctured. Magneticresonance imaging revealed diffuse pachymeningeal enhancement, typicallyseen after dural puncture. Resolution was spontaneous. CONCLUSION:Puncture of the dura should be considered when acute strabismus is diagnosedshortly after epidural anesthesia.Obstet Gynecol. 2008 Feb;111(2 Pt 2):535-7.Postpartum thrombosis of the superior mesenteric artery after vaginaldelivery.Ducarme G, Lidove O, Leduey A, Geffroy A, Panis Y, Castier Y, Luton D.Departments of Obstetrics, Hôpital Beaujon, Assistance Publique-Hôpitaux deParis, Université Paris, Clichy, France. g.ducarme@gmail.comBACKGROUND: Several causes of severe and acute postpartum abdominal pain(pelvic infection, complications of pelvic thromboembolism, arterial ischemia)require early diagnosis and prompt therapy. CASE: Eight days after a normalvaginal delivery, a 38-year-old woman presented with severe acute abdominalpain that had been going on for 3 days. Abdominal computed tomographyshowed a superior mesenteric artery thrombosis with suggested ileal wallischemia. An emergency thrombectomy associated with ileal resection andileostomy were performed. No identifiable source of embolism, hemostaticdisorder, systemic vasculitis, or systemic disease associated with thrombosiswas found. CONCLUSION: Even after a vaginal delivery, the postpartum periodis associated with an increased risk of complications of thromboembolism. In the

case of acute abdominal pain, abdominal contrast-enhanced computedtomography may be necessary to exclude mesenteric arterial ischemia.Obstet Gynecol. 2008 Feb;111(2 Pt 2):533-5.Necrotizing cervical and uterine infection in the postpartum period causedby group A streptococcus.Castagnola DE, Hoffman MK, Carlson J, Flynn C.Department of Obstetrics and Gynecology, Christiana Care Health System,Newark, Delaware 19713, USA. dcastagnola@christiancare.orgBACKGROUND: Group A Streptococcus, once the most common causes ofpuerperal sepsis, is now a rare cause of postpartum fever. CASE: A term 27-year-old woman presented after spontaneous membrane rupture. After anuncomplicated vaginal delivery, she became febrile without a source of infection.Despite two different antibiotic regimens, she remained febrile for 3 days. Acomputed tomography scan showed a wedge-shaped discontinuity in the anterioruterus suggesting uterine infection with early abscess formation. The patientunderwent exploratory laparotomy and hysterectomy, with an uneventfulpostoperative course. Uterine pathology revealed a necrotizing infection withinthe uterus and cervix from Group A Streptococcus. CONCLUSION: Puerperalsepsis from Group A Streptococcus can be a cause of necrotizing infectionfollowing delivery. Physicians should be aware of the resurgence of thispotentially fatal pathogen.Obstet Gynecol. 2008 Feb;111(2 Pt 2):530-2.Complete fetal transection after a motor vehicle collision.Weir LF, Pierce BT, Vazquez JO.Department of Obstetrics and Gynecology, San Antonio Uniformed ServicesHeath Education Consortium, San Antonio, Texas, USA.larissa.weir@sbcglobal.netBACKGROUND: Motor vehicle collisions are the leading cause of fetal deathrelated to maternal trauma, with rupture of the gravid uterus being one potentialgrave outcome. CASE: We present a case of a woman at 22 weeks of gestationwho presented to the emergency department after a "high-speed" motor vehiclecollision. On initial presentation, she was hemodynamically stable, and theexamination was significant for midabdominal transverse ecchymosis fromseatbelt trauma. A computed tomography scan identified a probable uterinerupture. Laparotomy revealed a 1,500-mL hemoperitoneum and a completelyruptured uterus requiring hysterectomy. The fetus was completely transected atthe level of the midabdomen. CONCLUSION: Uterine rupture is possible forgravid women involved in motor vehicle collisions.Obstet Gynecol. 2008 Feb;111(2 Pt 2):489-91.Comment in:Obstet Gynecol. 2008 Feb;111(2 Pt 2):481-2.Venous air embolism after using a birth-training device.Nicoll LM, Skupski DW.

New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NewYork 10021, USA. LMN4@Cornell.EduBACKGROUND: This case describes a birth-training device used by a pregnantwoman to stretch the perineum. CASE: A primigravida suffered nearcardiovascular collapse and subsequent acute respiratory distress syndromeafter using the device at home. Her symptoms and clinical course of diseaserevealed a high likelihood of venous air embolism. CONCLUSION: The patientlikely suffered a venous air embolism in association with the use of the birthtrainingdevice. The complications suffered by this patient should give cautionabout use of such devices.Acta Obstet Gynecol Scand. 2008;87(4):408-12.Impaired maternal cognitive functioning after pregnancies complicated bysevere pre-eclampsia: a pilot case-control study.Brussé I, Duvekot J, Jongerling J, Steegers E, De Koning I.Division of Obstetrics and Prenatal Medicine, Department of Obstetrics andGynecology, Erasmus Medical Center. Rotterdam, TheNetherlands.i.brusse@erasmusmc.nlBACKGROUND: Pre-eclampsia is the most significant cause of neurologicalsymptoms in pregnancy. Neurological symptoms may persist even afterpregnancy. Somatic symptoms of pre-eclampsia, such as hypertension andproteinuria, generally disappear after delivery. However, formerly pre-eclampticwomen more often complain of cognitive disturbances compared to women afteruncomplicated pregnancies. METHODS: Three to eight months postpartum, aneuropsychological test battery was performed in 10 former severely preeclampticwomen (according to the guidelines of the American CollegeObstetricians and Gynecologists) and 10 women after uncomplicatednormotensive pregnancies. The control group was matched for age, educationallevel and mode of anesthesia. All women delivered by cesarean section eitherunder general or regional anesthesia. Tests were performed for premorbidintelligence, short- and long-term memory, attention, concentration, executivefunctions, visual and spatial abilities. Anxiety and depression levels weremeasured. RESULTS: The formerly pre-eclamptic women had significantly lowerscores on most indices of the auditory-verbal memory test. Formerly preeclampticpatients learned considerably fewer words than controls and recalledless after interference. Both case and control group did not differ in age, parity orlevel of education. There were no differences in the level of intellectualfunctioning and language tests, such as naming and word fluency. No persistentdifferences were observed in tests for attention/concentration and executivefunctioning. There were no significant differences on depression and anxietyscales. CONCLUSIONS: Maternal memory seems to be impaired afterpregnancies complicated by severe pre-eclampsia. This effect cannot beattributed to depression and/or anxiety or method of anesthesia.Am J Obstet Gynecol. 2008 Mar 28 [Epub ahead of print]Hypertensive disorders of pregnancy and long-term prognosis.

Callaway LK, Lawlor DA, McIntyre HD.Royal Brisbane and Women's Hospital, E Floor, Clinical Sciences Building,Herston, Queensland 4029, Australia.Curr Opin Obstet Gynecol. 2008 Apr;20(2):110-5.What matters in preeclampsia are the associated adverse outcomes: theview from Canada.von Dadelszen P, Magee L.Department of Obstetrics and Gynaecology, Canada Department of Medicine,Canada Department of Healthcare and Epidemiology, Canada Department ofChild and Family Research Institute, University of British Columbia, Vancouver,British Columbia, Canada.Curr Opin Obstet Gynecol. 2008 Apr;20(2):107-9.Hypertensive disorders of pregnancy: future perspectives. A French pointof view.Berkane N, Hertig A, Rondeau E, Uzan S.aUPMC University of Paris, France bDepartment of Gynecology and Obstetricsand Reproductive Medicine, Tenon Hospital, France cDepartment of Nephrology,France dInserm U702, Paris, France.Curr Opin Obstet Gynecol. 2008 Apr;20(2):102-6.Hypertensive disorders of pregnancy: the United States perspective.Sibai BM.University of Cincinnati, Cincinnati, Ohio, USA.Curr Opin Obstet Gynecol. 2008 Apr;20(2):96-101.Hypertensive disorders of pregnancy: a UK-based perspective.Chandiramani M, Shennan A.Kings College London, Division of Reproduction and Endocrinology, London,UK.Curr Opin Obstet Gynecol. 2008 Apr;20(2):91.Editorial summary of symposium on hypertensive disorders of pregnancy.Druzin ML, Charles B, Johnson AL.Department of Obstetrics and Gynecology, Stanford University School ofMedicine, Palo Alto, California, USA.PURPOSE OF REVIEW: Hypertensive disorders of pregnancy, particularly thepreeclampsia/eclampsia syndrome, remain the leading causes of worldwidepregnancy-related maternal and neonatal mortality and morbidity. This group ofconditions are a 'riddle wrapped in a mystery inside an enigma' to quote WinstonChurchill. We are fortunate to have contributions from leading clinical expertswho have devoted many years of their professional careers attempting to solvethis conundrum. RECENT FINDINGS: Dr Jack Moodley has provided us with aperspective on clinical management in underresourced countries. Referral toexperts, aggressive treatment of hypertension and use of magnesium sulfate

improves care. Dr Shennan focuses on the assessment of risk, close antenatalsurveillance and timely delivery. Dr Uzan continues to champion the use ofaspirin for prevention of preeclampsia, even though the evidence is contradictory.Dr Sibai addresses the lack of evidence for calcium, vitamin C and E inprevention of preeclampsia. Dr Von Dadelszen is developing a new paradigm forthe classification of these disorders and emphasizes the importance of evidencebasedintervention. SUMMARY: Evidence suggests that treatment of severehypertension, seizure prophylaxis with magnesium sulfate, and management byexperienced healthcare professionals will improve maternal, fetal and neonataloutcomes. Well designed studies will lead to evidence-based improvement incaring for mothers and babies worldwide.Curr Opin Obstet Gynecol. 2008 Apr;20(2):91-95.Hypertensive emergencies in pregnancies in underresourced countries.Moodley J.Womens Health and HIV Research Group, Department of Obstetrics andGynaecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Congella, South Africa.Gynecol Obstet Invest. 2008;65(2):81-3. Epub 2007 Sep 13.Placenta percreta leading to spontaneous complete uterine rupture in thesecond trimester. Example of a fatal complication of abnormal placentationfollowing uterine scarring.Fleisch MC, Lux J, Schoppe M, Grieshaber K, Hampl M.Department of Obstetrics and Gynaecology, Heinrich Heine University,Dusseldorf, Germany. Fleisch@uni-duesseldorf.deA 30-year-old gravida 2 para 1 was admitted to hospital 2 years after cesareansection at 20 weeks' gestation with acute onset of abdominal pain andhypovolaemic shock. Emergency laparotomy revealed a uterine rupture locatedin the anterior uterine wall caused by a placenta percreta and supracervicalhysterectomy was performed. This site of invasion and finally rupture was inprojection of the previous lower-segment cesarean section. This report illustratesthe dramatic consequences of abnormal placentation after prior uterine surgery,which can already occur early during pregnancy and prior to the onset of labour.(c) 2008 S. Karger AG, Basel.J Perinatol. 2008 Apr;28(4):310-2.Normoglycemic diabetic ketoacidosis in pregnancy.Chico M, Levine SN, Lewis DF.1Section of Endocrinology and Metabolism, Department of Internal Medicine,Louisiana State University Health Sciences Center, Shreveport, LA, USA.The clinical presentation of diabetic ketoacidosis in pregnancy is usually thesame as in nonpregnant women, although the blood glucose may not be as highas in the nongravid state. We report a case of a pregnant woman who developeddiabetic ketoacidosis with a normal blood glucose and review the pertinentmedical literature. A 29-year-old woman with type I diabetes developed diabetic

ketoacidosis during induction of labor. She had a glucose level of 87 mg per 100ml with ketonuria, a metabolic acidosis, and an anion gap of 20 mmol l(-1).Normoglycemic diabetic ketoacidosis during pregnancy is truly unusual but canoccur with relatively low, or even normal, blood sugars and necessitates promptrecognition and treatment. In this case, the combination of an initial episode ofhypoglycemia and subsequent blood glucose levels below 95 mg per 100 ml ledto a prolonged delay in the initiation of a planned insulin infusion for insulincoverage during the induction of labor. A significant ketoacidosis consequentlydeveloped, despite the absence of even a single elevated blood glucosemeasurement. This case illustrated the importance of not withholding insulin in apatient with type I diabetes for more than a few hours even if the blood glucoseis normal.Journal of Perinatology (2008) 28, 310-312; doi:10.1038/sj.jp.7211921.Obstet Gynecol. 2008 Apr;111(4):1001-20.ACOG Practice Bulletin No. 92: Use of Psychiatric Medications DuringPregnancy and Lactation.[No authors listed]Obstet Gynecol. 2008 Apr;111(4):927-934.Pregnancy Outcomes in Systemic Sclerosis, Primary PulmonaryHypertension, and Sickle Cell Disease.Chakravarty EF, Khanna D, Chung L.Division of Immunology and Rheumatology, Department of Medicine, StanfordUniversity School of Medicine, Palo Alto, California; Division of Rheumatology,Department of Medicine, David Geffen School of Medicine at University ofCalifornia Los Angeles, Los Angeles, California; and Palo Alto Veterans AffaireHealth Care System, Palo Alto, California.OBJECTIVE: Systemic sclerosis, primary pulmonary hypertension, and sickle celldisease are uncommon vasculopathic diseases affecting women. We estimatedthe nationwide occurrence of pregnancies in women with these conditions andcompared pregnancy outcomes to the general obstetric population. METHODS:We studied the2002-2004 Nationwide Inpatient Sample, of the Healthcare Costand Utilization Project to estimate the number of obstetric hospitalizations anddeliveries amongwomen with systemic sclerosis, primary pulmonaryhypertension, sickle cell disease, and women in the general population.Pregnancy outcomes included length of hospital stay, hypertensive disordersincluding preeclampsia, intrauterine growth restriction (IUGR), and cesareandelivery. Multivariable regression analyses were performed using maternal age,race or ethnicity, antiphospholipid antibody syndrome, diabetes mellitus, andrenal failure as covariates. RESULTS: Of an estimated 11.2 million deliveries,504 occurred in women with systemic sclerosis, 182 with primary pulmonaryhypertension, and 4,352 with sickle cell disease. Systemic sclerosis, wasassociated with an increased risk of hypertensive disorders includingpreeclampsia (odds ratio [OR] 3.71, 95% confidence interval [CI] 2.25-6.15),IUGR (OR 3.74, 95% CI 1.51-9.28), and increased length of hospital stay.Primary pulmonary hypertension was associated with an increase in the odds of

antenatal hospitalization (OR 4.67, 95% CI 2.88-7.57), hypertensive disordersincluding preeclampsia (OR 5.62, 95% CI 2.60-12.15) and a substantial increasein length of hospital stay. Sickle cell disease was associated with an increasedodds of antenatal hospitalization (OR 5.56 95% CI 5.08-6.09), hypertensivedisorders including preeclampsia (OR 1.78, 95% CI 1.48-2.14), and IUGR (OR2.91, 95% CI 2.16-3.93), with a modest increase in length of hospital stay.CONCLUSION: Women with systemic sclerosis, primary pulmonaryhypertension, and sickle cell disease have significantly increased rates ofadverse pregnancy outcomes, requiring extensive preconceptional counselingabout the risks of pregnancy. LEVEL OF EVIDENCE: II.Acta Obstet Gynecol Scand. 2008;87(2):222-5.Sublingual nitroglycerin seems to be effective in the management ofretained placenta.Ekerhovd E, Bullarbo M.Department of Obstetrics and Gynecology, Sahlgrenska University Hospital,Gothenburg, Sweden. erling.ekerhovd@obgyn.gu.seBACKGROUND: A common approach in the management of retained placenta isadministration of oxytocin followed by controlled cord traction. Previously it hasalso been demonstrated that intravenously administered nitroglycerin facilitatesmanual extraction of retained placenta. The purpose of the present trial was toexamine the success rate and safety of sequential administration of intravenousoxytocin in combination with sublingual nitroglycerin for the delivery of retainedplacenta. METHODS: The report is a chart review of 24 women with retainedplacenta despite intravenously administered oxytocin. The women were givensublingual nitroglycerin (1 mg) to promote detachment of the placenta. Some 5min after resorption of the tablets, controlled cord traction was carried out for amaximum of 5 min. In addition, changes in blood pressure following treatmentwith nitroglycerin and total blood loss during delivery were registered. RESULTS:Twenty-one of the women delivered the placenta successfully followingsublingual administration of nitroglycerin. The procedure failed in 3 women andoperative manual removal under regional or general anesthesia was undertaken.No complications due to nitroglycerin were registered. CONCLUSIONS:Sequential administration of oxytocin and nitroglycerin seems to be an effectiveand safe procedure in the management of retained placenta. However, largerstudies are needed to confirm the encouraging results of the present trial.Am J Obstet Gynecol. 2008 Mar;198(3):283.e1-8. Epub 2008 Jan 14.Postpartum dexamethasone for women with hemolysis, elevated liverenzymes, and low platelets (HELLP) syndrome: a double-blind, placebocontrolled,randomized clinical trial.Katz L, de Amorim MM, Figueiroa JN, Pinto e Silva JL.Department of Obstetrics, Professor Fernando Figueira Institute for Maternal andChild Health Care, Recife, Pernambuco, Brazil. katzleila@yahoo.com.brOBJECTIVE: The purpose of this study was to determine the effectiveness ofpostpartum dexamethasone in patients with hemolysis, elevated liver enzymes,

and low platelets (HELLP) syndrome. STUDY DESIGN: A prospective,randomized, double-blind trial was conducted in which 105 women with HELLPsyndrome were enrolled and assigned randomly to treatment or placebo groupsfollowing delivery. Duration of hospital stay, maternal morbidity, and laboratoryand clinical parameters were evaluated. RESULTS: There was no difference inmaternal morbidity or mortality between the 2 groups. There was also nodifference in duration of hospitalization and the need for rescue scheme or theuse of blood products between groups. Linear model adjustments showed nosignificant difference between groups with respect to the pattern of platelet countrecovery, aspartate aminotransferase, lactate dehydrogenase, hemoglobin, ordiuresis. CONCLUSION: These findings do not support the use ofdexamethasone in the puerperium for recovery of patients with HELLPsyndrome.Am J Obstet Gynecol. 2008 Apr 5 [Epub ahead of print]Clostridium difficile-associated diarrhea: an emerging threat to pregnantwomen.Rouphael NG, O'Donnell JA, Bhatnagar J, Lewis F, Polgreen PM, Beekmann S,Guarner J, Killgore GE, Coffman B, Campbell J, Zaki SR, McDonald LC.Division of Bacterial Diseases, Centers for Disease Control and Prevention,Atlanta, GA.OBJECTIVE: To estimate if Clostridium difficile-associated disease (CDAD) isincreasing in peripartum women. STUDY DESIGN: Peripartum CDAD wasassessed through 1) passive surveillance collecting clinical and pathology dataon severe cases and 2) survey among infectious disease consultants (ICDs) inthe Emerging Infections Network. RESULTS: Ten severe cases were collected;most had associated antibiotic use. Seven women were either admitted to theICU or underwent colectomy. Three infants were stillborn, and 3 women died.The epidemic Clostridium difficile strain was found in 2 cases. Among 798 ICDs,419 (52%) participated in the survey. Thirty-seven respondents (9%) recalled 55cases, mostly in the postpartum period with 21 complications, mainly due torelapse. CONCLUSION: Severe CDAD may be increasing in peripartum women.Clinicians should have a low threshold for testing, be aware of the potential forsevere outcomes, and take steps to reduce both the risk of disease and resultantcomplications.BMJ. 2008 Apr 10 [Epub ahead of print]Diagnostic accuracy of urinary spot protein:creatinine ratio for proteinuriain hypertensive pregnant women: systematic review.Côté AM, Brown MA, Lam E, Dadelszen PV, Firoz T, Liston RM, Magee LA.BC Women’s Hospital and Health Centre, Vancouver, BC, Canada.OBJECTIVE: To review the spot protein:creatinine ratio and albumin:creatininaratio as diagnostic tests for significant proteinuria in hypertensive pregnantwomen. DESIGN: Systematic review. DATA SOURCES: Medline and Embase,the Cochrane Library, reference lists, and experts. Review methods Literaturesearch (1980-2007) for articles of the spot protein:creatinine ratio or

albumin:creatinine ratio in hypertensive pregnancy, with 24 hour proteinuria asthe comparator. RESULTS: 13 studies concerned the spot protein:creatinine ratio(1214 women with primarily gestational hypertension). Nine studies reportedsensitivity and specificity for eight cut-off points, median 24 mg/mmol (range 17-57 mg/mmol; 0.15-0.50 mg/mg). Laboratory assays were not well described.Diagnostic test characteristics were recalculated for a cut-off point of 30mg/mmol. No significant heterogeneity in cut-off points was found betweenstudies over a range of proteinuria. Pooled values gave a sensitivity of 83.6%(95% confidence interval 77.5% to 89.7%), specificity of 76.3% (72.6% to80.0%),positive likelihood ratio of 3.53 (2.83 to 4.49), and negative likelihood ratio of 0.21(0.13 to 0.31) (nine studies, 1003 women). Two studies of the spotalbumin:creatinine ratio (225 women) found optimal cut-off points of 2 mg/mmolfor proteinuria of 0.3 g/day or more and 27 mg/mmol for albuminuria.CONCLUSION: The spot protein:creatinine ratio is a reasonable "rule-out" testfor detecting proteinuria of 0.3 g/day or more in hypertensive pregnancy.Information on use of the albumin:creatinine ratio in these women is insufficient.BMJ. 2008 Apr 10 [Epub ahead of print]Assessment of proteinuria in pregnancy.Chappell LC, Shennan AH.Division of Reproduction and Endocrinology, King’s College, London SE1 7EH.JAMA. 2008 Apr 9;299(14):1665; author reply 1665-6.Comment on:JAMA. 2007 Dec 19;298(23):2788-9.Evaluation of suspected pulmonary embolism during pregnancy.Siegel MD.Ultrasound Obstet Gynecol. 2008 Apr 4 [Epub ahead of print]Carcinoid tumor of the appendix: ultrasound findings in early pregnancy.Gilboa Y, Fridman E, Ofir K, Achiron R.Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, RamatGan, Israel.Ultrasound examination of a woman in early pregnancy with right lower quadrantabdominal pain demonstrated an edematous appendix with amorphous fluidsurrounding the appendix. At laparotomy, these findings were confirmed. Onpathological evaluation following surgical removal of the appendix a rare case ofcarcinoid tumor of the appendix was diagnosed. This is the first description of thetransvaginal ultrasound features of a carcinoid tumor of the appendix. Copyright(c) 2008 ISUOG. Published by John Wiley & Sons, Ltd.BMJ. 2008 Mar 29;336(7646):717-8.Commentary: Controversies in management of diabetes frompreconception to the postnatal period.Chappell LC, Germain SJ.

Division of Reproduction and Endocrinology, King's College London, London SE17EH. lucy.chappell@kcl.ac.ukBMJ. 2008 Mar 29;336(7646):714-7.Management of diabetes from preconception to the postnatal period:summary of NICE guidance.Guideline Development Group.Eur J Obstet Gynecol Reprod Biol. 2008 Feb;136(2):151-4. Epub 2007 May 3.Current clinical management of anti-Kell alloimmunization in pregnancy.Santiago JC, Ramos-Corpas D, Oyonarte S, Montoya F.Unidad de Medicina Fetal, Servicio de Obstetricia y Ginecología del HospitalUniversitario V. De las Nieves, 180-Granada, Spain.OBJECTIVES: Few reports have been published of the current clinicalmanagement of anti-Kell alloimmunization in pregnancy; its low frequency ofoccurrence means that the few long series published have covered very ampletime periods in which different kinds of clinical management have overlapped.The objective of the present paper is to present our experience in the currentclinical management of pregnant women who are positive for the anti-Kellantibody. STUDY DESIGN: A retrospective analysis was carried out of the casehistories of pregnant women who were alloimmunized for the Kell antigen andwho were studied and/or treated at the Department of Fetal Medicine in theVirgen de las Nieves University Hospital in Granada (Spain), between 2000 and2004. The clinical management included the basal measurement of the titre ofantibodies, the identification of the paternal phenotype (and that of the fetus, ifnecessary), the ultrasonographic monitoring of the fetus to detect signs ofanaemia, sampling of fetal blood by cordocentesis when fetal anaemia wassuspected, and fetal intravascular transfusion when necessary. RESULTS: Ofthe 10 pregnancies with anti-Kell antibodies, The Kell antigen was confirmed inthe fetus in three cases, in all of which moderate to severe fetal anaemiadeveloped, requiring fetal intravascular transfusions. Although one of the fetusdeveloped antenatal hydrops, a good perinatal result was advised.CONCLUSIONS: The current approach to anti-Kell alloimmunization enablespregnant women who have Kell-positive fetuses to be treated successfully.Int J Gynaecol Obstet. 2008 Feb;100(2):185. Epub 2007 Oct 24.Uterine rupture presenting as a vaginal prolapse of gangrenous smallbowel.Umezurike CC, Adisa AC.Department of Obstetrics and Gynaecology, Nigerian Christian Hospital, Aba,Nigeria.Int J Gynaecol Obstet. 2008 Feb;100(2):186-7. Epub 2007 Sep 27.Manual removal of suspected placenta accreta at cesarean hysterectomy.Yap YY, Perrin LC, Pain SR, Wong SF, Chan FY.

Department of Obstetrics and Gynecology, Logan Health Service, Logan,Queensland, Australia. yyyap@optusnet.com.auObstet Gynecol. 2008 Mar;111(3):805-7.ACOG Committee Opinion No. 402: Antenatal corticosteroid therapy forfetal maturation.American College of Obstetricians and Gynecologists Committee on ObstetricPractice.Obstet Gynecol. 2008 Mar;111(3):732-8.Peripartum hysterectomy: 1999 to 2006.Glaze S, Ekwalanga P, Roberts G, Lange I, Birch C, Rosengarten A, Jarrell J,Ross S.Department of Obstetrics and Gynaecology, University of Calgary, Calgary,Alberta, Canada.OBJECTIVE: To estimate the rate of peripartum hysterectomy over the last 8years in Calgary, the primary indication for peripartum hysterectomy (defined asany hysterectomy performed within 24 hours of a delivery), and whether therewas an increase in the rate of peripartum hysterectomy during that time.METHOD: Detailed chart review of all cases of peripartum hysterectomy, 1999-2006, including previous obstetric history, details of the index pregnancy,indications for peripartum hysterectomy, outcome of the hysterectomy, and infantmorbidity. RESULTS: The overall rate of peripartum hysterectomy was 87 of108,154 or 0.8 per 1,000 deliveries. The primary indications for hysterectomywere uterine atony (32 of 87, 37%) and suspected placenta accreta (29 of 87,33%). After hysterectomy, 46 (53%) women were admitted to the intensive careunit. Women were discharged home after a mean 6-day length of stay. The rateof peripartum hysterectomy did not appear to increase over time. CONCLUSION:Our population-based study found that abnormal placentation is the mainindication for peripartum hysterectomy. The most important step in prevention ofmajor postpartum hemorrhage is recognizing and assessing women's risk,although even perfect management of hemorrhage cannot always preventsurgery.Obstet Gynecol. 2008 Mar;111(3):723-31.Hospital, simulation center, and teamwork training for eclampsiamanagement: a randomized controlled trial.Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M.Department of Obstetrics and Gynaecology, North Bristol NHS Trust, SouthmeadHospital, Bristol, United Kingdom.OBJECTIVE: To compare the effectiveness of training for eclampsia in localhospitals and a regional simulation center, with and without teamwork theory.METHODS: This study is a randomized controlled trial of training in localhospitals and in a simulation center in the United Kingdom. Midwives andobstetricians working at participating hospitals were randomly assigned to 24teams. Teams were randomly allocated to training in local hospitals or at a

simulation center, and to teamwork theory or not. Performance was evaluatedbefore and after training with a standardized eclampsia scenario captured onvideo. Outcome measures were completion of tasks, time to completion of tasks,administration of magnesium sulfate, and quality of teamwork. RESULTS:Training was associated with an increase in completion of basic tasks; 87%before training and 100% afterward. Basic tasks were completed more quickly;55 seconds compared with 27 seconds, P=.012. The magnesium sulfate loadingdose was administered by 61% of teams before training and by 92% afterward(P=.040). There was a shorter median time to administration (116 seconds less;P=.011). Training at the simulation center was not associated with additionalimprovement. Teamwork generally improved (median global score rose from 2.5to 4.0; P

and preterm delivery in the current pregnancy), patients with a previous pretermcesarean delivery remained at an increased risk of subsequent uterine rupture(P=.043, odds ratio 1.6, 95% confidence interval 1.01-2.50) compared withwomen with previous term cesarean delivery. CONCLUSION: Women who havehad a previous preterm cesarean delivery are at a minimally increased risk foruterine rupture in a subsequent pregnancy when compared with women whohave had previous term cesarean deliveries.Eur J Obstet Gynecol Reprod Biol. 2008 Apr 24 [Epub ahead of print]Successful obstetrical management of a woman with Parkes-Webersyndrome.Akhtar MA, Campbell DJ.St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, BeckettStreet, LS9 7TF Leeds, United Kingdom.J Reprod Med. 2008 Mar;53(3):220-2.Respiratory compromise after MgSO4 therapy for preterm labor in a womanwith myotonic dystrophy: a case report.Catanzarite V, Gambling D, Bird LM, Honold J, Perkins E.Department of Maternal Fetal Medicine, Sharp Mary Birch Hospital for Womenand San Diego Perinatal Center, 92123, USA. vcatanza@aol.comBACKGROUND: MgSO4 is widely used for tocolysis. Serious complications arerare as long as dosing is carefully monitored. Adverse effects in muotonicdustrophy have not been previously described. CASE: A 35-year-old woman,gravida 1, para 0, was hospitalized with suspected mild myotonic dystrophy,polyhydramnios and preterm labor at 33 weeks. MgSO4 infusion rapidly resultedin respiratory compromise. Muscular strength returned to baseline after theinfusion was stopped. Mother and infant proved to have myotonic dystrophy.CONCLUSION: The choice of tocolytic medication in maternal myotonicdystrophy is problematic. Beta-2 sympathomimetics have been reported toprecipitate myotonia. This case illustrates the potential for MgSO4 to causerespiratory embarrassment. Indomethacin may be the tocolytic of choice inmyotonic dystrophy.J Reprod Med. 2008 Mar;53(3):183-7.Pregnancy outcome in women with psoriasis.Ben-David G, Sheiner E, Hallak M, Levy A.Department of Obstetrics and Gynecology, Faculty of Health Sciences, SorokaUniversity Medical Center, Ben Gurion University of the Negev, Beer-Sheva,Israel.OBJECTIVE: To determine pregnancy outcome in women with psoriasis. STUDYDESIGN: A case-control study of 145 deliveries in women with psoriasis duringthe years 1988-2004 was performed. For every birth, 6 births to nonpsoriaticwomen (n=860) were randomly selected and adjusted for ethnicity and year ofdelivery. RESULTS: Recurrent abortions (OR = 2.1, 95% CI 1.1-4.9, p = 0.04)and chronic hypertension (OR = 2.9, 95% CI 1.01-8.3, p= 0.048) were

significantly associated with psoriasis in a multivariable analysis with backwardelimination. Psoriasis was also found as an independent risk factor for cesareandelivery (CD) in another multivariable analysis with CD as the outcome variable(OR = 4.1, 95% CI 2.3-7.5, p < 0.001). CONCLUSION: A significant associationexists between psoriasis and pregnancy complications. Moreover, psoriasis is anindependent risk factor for CD. Thus, physicians should keep in mind thatpsoriasis might have nondermatologic implications that may adversely affectpregnancy.J Reprod Med. 2008 Mar;53(3):151-4.Anorectal symptoms in pregnancy and the postpartum period.O'Boyle AL, O'Boyle JD, Magann EF, Rieg TS, Morrison JC, Davis GD.Department of Obstetrics, Naval Medical Center Portsmouth, Portsmouth,Virginia, USA.OBJECTIVE: To determine the frequency of anorectal complaints in nulliparous,pregnant women before and after delivery. STUDY DESIGN: This was aprospective, observational study. Nulliparous, pregnant women attending anactive-duty prenatal clinic completed a 6-item anorectal symptom questionnairethat assessed anal continence and defecatory symptoms. RESULTS: Seventyfiveactive-duty, nulliparous women completed 158 questionnaires. Anorectalsymptoms were reported both antepartum (AP) and postpartum (PP): straining todefecate (AP: 28-59%; PP: 30%), hard or lumpy stools (AP: 48-59%; PP: 66%),incomplete emptying (AP: 38-53%; PP: 38%), uncontrolled loss of gas or stoolfrom the rectum (AP: 18-29%; PP: 15%), unpreventable soilage of underwear(AP: 15-33%; PP: 13%) and splinting (AP: 3-9%; PP: 9%). Constipationsymptoms were reported most frequently in the first trimester (p = 0.031) andanal incontinence most often in the third trimester but loss of gas or stool "often"more in the postpartum period (p = 0.027). Anal incontinence was more frequentin women who delivered by forceps (p = 0.007). CONCLUSION: Anorectalsymptoms are common both during pregnancy and in the postpartum period.Anal incontinence is reported more frequently in women who delivered byforceps.N Engl J Med. 2008 May 1;358(18):1929-40.A behavioral intervention to improve obstetrical care.Althabe F, Buekens P, Bergel E, Belizán JM, Campbell MK, Moss N, Hartwell T,Wright LL; Guidelines Trial Group. Collaborators: Buekens P, Belizán JM,Althabe F, Bergel E, Delgado M, Ciganda A, Sotero G, Tomasso G, Codazzi A,Colomar M, Buekens P, Belizán JM, Althabe F, Campbell MK, Sotero G,Tomasso G, Cafferata ML, Dugan E, Cohen S, Thorp J, Bergel E, Delgado M,Ciganda A, Bergel E, Bandiwala S, Yao Q, Hartwell T, Chakraborty H, Bartz J,Blake A, Karolinski A, del Pino A, Bonotti AM, del Pino A, Sánchez A, Walker M,Sotero G, Ciganda A, Belizán M, Campbell MK, Meier A, Codazzi A, Colomar M,Wright LL, Moss N, Schwarze L, Goco N, Kropp N, Senauer K, Lipovetsky S,Colugnat R, Brusca J, Lazo M, Longo M, Pacucci P, Rodríguez M, Ruíz MR,Milano E, Ferrari J, Corbo Castillo G, Martínez S, Romero S, Villar A, Corbo

Castillo G, Martínez S, Becker C, Nassif JC, Pesaresi M, Buscaglia ME, AvalosMH, Omega MC, Maffia A, Ferraro S, Legorburu L, López N, Caro F, GonzálezME, Gambaro E, Antón J, Paulette P, Cebrian L, Dos Santos E, Montes VarelaD, Trasmonte M, Varela S, Dossena R, Ríbola L, Frers Campos C, Finkelstein G,Feliz D, Yunis G, Lopes MI, Rodriguez Caro F, Antonacci M, Greco G, NowackiD, Ferrari M, Ocampo C, Sternberg K, Fernández D, García P, Castelli N, RubioC, Daneri J, Luchetta D, De Cicco J, León M, Haag C, Del'Oste M, Mamani MF,Sicaro L, De Pasquale HM, Comparato C, Rattel KL, Nicolaci V, Minsk E, ManettiG, Capaldo A, San Martín A, Puches A, Barbero HJ, Petel M, Bianco M, BiancoM, Lastra A, Renedo L, Lofeudo S, Rodriguez M, Donatti C, Mussi M, PorticcelliM, Pesalacha N, Hernández A, Re M, Sgallini K, Cuevas A, D'Alessandro L,Miño MR, Giffuni D, Sayago P, Tuya M, D'Alessandro L, Miño MR, Celhay JC,Solari ML, Banfi P, Barci A, Aguirre C, Silka S, Torres N, Beliera S, Jimenez S,Hurtado E, Cavia L, Barila S, Martínez H, Oviedo G, Villagra I, Di Monáco R, DiMarco A, Torres M, Laurito G, López C, Iglesias D, Contreras S, Van LeeuwenR, Gnagnarello G, Mamprím Dándrea R, Schlaen P, Hails E, Paccioco MA,Arregui B, Llompart C, Torales C, Raffagnini M, Navarro N, Aragonés L, Arena J,Sotero G, de Dios A, Piera J, González MC, Pintos S, Gentile P, Thevenet G,Michell A, Tambucho C, de los Santos N, Rodriguez G, Amado T, Gallazo A,Focault C, Beneditto M. Institute of Clinical Effectiveness and Health Policy,Buenos Aires, Argentina. althabef@gmail.comBACKGROUND: Implementation of evidence-based obstetrical practices remainsa significant challenge. Effective strategies to disseminate and implement suchpractices are needed. METHODS: We randomly assigned 19 hospitals inArgentina and Uruguay to receive a multifaceted behavioral intervention(including selection of opinion leaders, interactive workshops, training of manualskills, one-on-one academic detailing visits with hospital birth attendants,reminders, and feedback) to develop and implement guidelines for the use ofepisiotomy and management of the third stage of labor or to receive nointervention. The primary outcomes were the rates of prophylactic use of oxytocinduring the third stage of labor and of episiotomy. The main secondary outcomeswere postpartum hemorrhage and birth attendants' readiness to change theirbehavior with regard to episiotomies and management of the third stage of labor.The outcomes were measured at baseline, at the end of the 18-monthintervention, and 12 months after the end of the intervention. RESULTS: The rateof use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% afterthe end of the intervention at hospitals that received the intervention and from2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). Therate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receivingthe intervention but remained stable at control hospitals, with preintervention andpostintervention values of 43.5% and 44.5%, respectively (P

episiotomy and prophylactic oxytocin were sustained 12 months after the end ofthe intervention. CONCLUSIONS: A multifaceted behavioral interventionincreased the prophylactic use of oxytocin during the third stage of labor andreduced the use of episiotomy. (ClinicalTrials.gov number, NCT00070720[ClinicalTrials.gov]; Current Controlled Trials number, ISRCTN82417627[controlled-trials.com].).Am J Obstet Gynecol. 2008 May 2 [Epub ahead of print]Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006.Martin JN Jr, Bailey AP, Rehberg JF, Owens MT, Keiser SD, May WL.Obstetrics and Gynecology (Divisions of Maternal-Fetal Medicine and Women'sHealth), University of Mississippi Medical Center, Jackson, MS.A review of pregnancy-associated thrombotic thrombocytopenic purpura (TTP) in166 pregnancies was undertaken using 92 English-language publications from1955 to 2006. Initial and recurrent TTP presents most often in the secondtrimester (55.5%) after 1-2 days of signs/symptoms; postpartum TTP usuallyoccurs following term delivery. TTP with preeclampsia (n = 28) exhibits 2-4 timeshigher aspartate aminotransferase (AST) values and lower total lactatedehydrogenase (LDH) to AST ratios (LDH to AST ratio = 13:1), compared withTTP without preeclampsia (LDH to AST ratio = 29:1). Maternal mortality is higherwith initial TTP (26% vs 10.7%), especially with concurrent preeclampsia (44.4%vs 21.8%, P < .02). Although maternal mortality with TTP has substantiallydeclined when plasma therapy is utilized, delay of diagnosis and therapy forinitial TTP confounded by preeclampsia/hemolysis, elevated liver enzymes, andlow platelets (HELLP) syndrome remains a significant maternal-perinatal threat.Rapid and readily available laboratory testing to quickly diagnose TTP andHELLP syndrome/preeclampsia is desperately needed to improve care.Am J Obstet Gynecol. 2008 May 2 [Epub ahead of print]A national study of the complications of lupus in pregnancy.Clowse ME, Jamison M, Myers E, James AH.Division of Rheumatology and Immunology, Department of Medicine, DukeUniversity School of Medicine, Durham, NC.OBJECTIVE: This study was undertaken to determine the risk of rarecomplications during pregnancy for women with systemic lupus erythematosus.STUDY DESIGN: By using the Nationwide Inpatient Sample from 2000-2003, wecompared maternal and pregnancy complications for all pregnancy-relatedadmissions for women with and without systemic lupus erythematosus.RESULTS: Of more than 16.7 million admissions for childbirth over the 4 years,13,555 were to women with systemic lupus erythematosus. Maternal mortalitywas 20-fold higher among women with systemic lupus erythematosus. The risksfor thrombosis, infection, thrombocytopenia, and transfusion were each 3- to 7-fold higher for women with systemic lupus erythematosus. Lupus patients alsohad a higher risk for cesarean sections (odds ratio: 1.7), preterm labor (oddsratio: 2.4), and preeclampsia (odds ratio: 3.0) than other women. Women withsystemic lupus erythematosus were more likely to have other medical conditions,

including diabetes, hypertension, and thrombophilia, that are associated withadverse pregnancy outcomes. CONCLUSION: Women with systemic lupuserythematosus are at increased risk for serious medical and pregnancycomplications during pregnancy.Clin Obstet Gynecol. 2008 Jun;51(2):445-55.Management of chemical dependence in pregnancy.Christensen C.Addiction Medicine Services, Detroit Medical Center, Wayne State University,Detroit, Michigan, USA. cchriste@med.wayne.eduAlthough the percentage of pregnant patients who use illicit drugs is relativelylow, the effects can be devastating on both mother and fetus-loss of custody,growth restriction, placental abruption, and death. The practicing obstetricianmay be unfamiliar with the various presentations of chemical dependency inpregnancy, including intoxication and withdrawal, and difficulty in making thediagnosis. The obstetrician is in the unique situation of being responsible for thesafety of both mother and fetus, which may involve engaging the unwilling patientin treatment.Clin Obstet Gynecol. 2008 Jun;51(2):436-44.Pregnancy and alcohol use: evidence and recommendations for prenatalcare.Bailey BA, Sokol RJ.Department of Family Medicine, East Tennessee State University, Johnson City,Tennessee, USA.Pregnancy alcohol consumption has been linked to poor birth outcomes andlong-term developmental problems. Despite this, a significant number of womendrink during pregnancy. Although most prenatal care providers are askingwomen about alcohol use, validated screening tools are infrequently employed.Research has demonstrated that currently available screening methods andintervention techniques are effective in identifying and reducing pregnancydrinking. Implementing universal screening and appropriate intervention forpregnancy alcohol use should be a priority for prenatal care providers, as theseefforts could substantially improve pregnancy, birth, and longer termdevelopmental outcomes for those affected.Clin Obstet Gynecol. 2008 Jun;51(2):409-18.Nutrition and pregnancy.Mehta SH.Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine,Wayne State University/Hutzel Women's Hospital, Detroit, Michigan, USA.smehta@med.wayne.eduThe importance of nutrition during pregnancy with regard to pregnancy outcomehas long been acknowledged. This importance has only been further emphasizedby the recent changes in food quality and availability, lifestyle changes, and anew understanding of fetal programming on adult outcomes. The impact of the

ecent obesity epidemic has had a profound effect on the field of medicine, andnowhere may that impact be more critical than the field of obstetrics. We are onlybeginning to understand how maternal obesity may impact not only immediatepregnancy outcomes, but also life and health course of the offspring. Thefinancial and societal costs will likely be enormous. Much research is needed tounderstand how these problems can be ameliorated.Clin Obstet Gynecol. 2008 Jun;51(2):398-408.Trauma during pregnancy: outcomes and clinical management.Chames MC, Pearlman MD.Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor,Michigan, USA.Trauma affects up to 6% to 7% of all pregnancies, and accounts for up to 46% ofmaternal death. Adverse consequences such as preterm labor and delivery,abruptio, fetomaternal hemorrhage, and fetal demise may be seen with evenapparently minor degrees of injury. Maternal physiologic considerations arereviewed and a protocol for evaluation and management of the injured gravida ispresented.Eur J Obstet Gynecol Reprod Biol. 2008 May 1 [Epub ahead of print]Author's response: Antidepressants and anxiolytics in pregnancy: The factsstand.Campagne DM.UNED University, Faculty of Psychology, Madrid Spain.Int J Gynaecol Obstet. 2008 May 2 [Epub ahead of print]Evaluation of thyrotoxicosis during pregnancy with color flow DopplerSonography.Kumar KV, Vamsikrishna P, Verma A, Muthukrishnan J, Meena U, Modi KD.Department of Endocrinology, Medwin Hospitals, Nampally, Hyderabad, India.Objective: To determine whether color flow Doppler sonography (CFDS) is usefulin differentiating Graves vs non-Graves thyrotoxicosis during pregnancy, whennuclear imaging is contraindicated. Methods: Ten pregnant women withthyrotoxicosis were divided into Graves, and non-Graves, disease groups andwere evaluated by CFDS for thyroid volume, vascularity, and inferior thyroidartery (ITA) flow velocity. Each patient was matched with a euthyroid woman ofthe same pregnancy duration. Results: Of the 10 patients, 3 were diagnosed withGraves disease, 4 with gestational toxicosis, and 3 with destructive thyroiditis.Those in the Graves disease group had a greater thyroid gland volume (18.9+/-1.5 cm(3) vs 12.1+/-2.4 cm(3); P

JAMA. 2008 May 7;299(17):2056-65.Epidemiology of invasive group B streptococcal disease in the UnitedStates, 1999-2005.Phares CR, Lynfield R, Farley MM, Mohle-Boetani J, Harrison LH, Petit S, CraigAS, Schaffner W, Zansky SM, Gershman K, Stefonek KR, Albanese BA, Zell ER,Schuchat A, Schrag SJ; Active Bacterial Core surveillance/Emerging InfectionsProgram Network.Collaborators: Daily P, Burnite S, Daniels A, Haubert N, Barrett N, Fraser Z,Hadler JL, Arnold KE, Martell-Cleary P, Sanza LT, Ferrieri P, Flores A, Besser J,Danila R, Glennen A, Jewell B, Johnson S, Juni B, Morin C, Rainbow J, Triden L,Spina N, Smith G, Dragoon M, Farland D, Zeigler A, Barnes BG, Bailiff T,Bashirian S, Carvalho G, Elliott J, Facklam R, Findley J, Franklin A, Gallagher G,Jackson D, Shewmaker P, Skoff T, Van Beneden C, Warren S, Weston E,Whitney C, Wright C.Epidemic Intelligence Service Program, Office of Workforce and CareerDevelopment, Division of Bacterial Diseases, Centers for Disease Control andPrevention, Atlanta, Georgia 30333, USA. cphares@cdc.govCONTEXT: Group B streptococcus is a leading infectious cause of morbidity innewborns and causes substantial disease in elderly individuals. Guidelines forprevention of perinatal disease through intrapartum chemoprophylaxis wererevised in 2002. Candidate vaccines are under development. OBJECTIVE: Todescribe disease trends among populations that might benefit from vaccinationand among newborns during a period of evolving prevention strategies. DESIGNAND SETTING: Analysis of active, population-based surveillance in 10 statesparticipating in the Active Bacterial Core surveillance/Emerging InfectionsProgram Network. MAIN OUTCOME MEASURES: Age- and race-specificincidence of invasive group B streptococcal disease. RESULTS: There were14,573 cases of invasive group B streptococcal disease during 1999-2005,including 1348 deaths. The incidence of invasive group B streptococcal diseaseamong infants from birth through 6 days decreased from 0.47 per 1000 live birthsin 1999-2001 to 0.34 per 1000 live births in 2003-2005 (P < .001), a relativereduction of 27% (95% confidence interval [CI], 16%-37%). Incidence remainedstable among infants aged 7 through 89 days (mean, 0.34 per 1000 live births)and pregnant women (mean, 0.12 per 1000 live births). Among persons aged 15through 64 years, disease incidence increased from 3.4 per 100,000 populationin 1999 to 5.0 per 100,000 in 2005 (chi2(1) for trend, 57; P < .001), a relativeincrease of 48% (95% CI, 32%-65%). Among adults 65 years or older, incidenceincreased from 21.5 per 100,000 to 26.0 per 100,000 (chi2(1) for trend, 15; P

guidelines in 2002. However, the disease burden in adults is substantial andincreased significantly during the study period.JAMA. 2008 May 6 [Epub ahead of print]A 40-Year-Old Woman With Diabetes Contemplating Pregnancy AfterGastric Bypass Surgery.Burns RB.Department of Medicine, Beth Israel Deaconess Medical Center, HarvardMedical School, Boston, Massachusetts.N Engl J Med. 2008 May 8;358(19):2061-3.Gestational diabetes--setting limits, exploring treatments.Ecker JL, Greene MF.N Engl J Med. 2008 May 8;358(19):2003-15.Metformin versus insulin for the treatment of gestational diabetes.Rowan JA, Hague WM, Gao W, Battin MR, Moore MP; MiG Trial Investigators.Collaborators: Rowan J, Cundy T, Elder R, Battin M, Hague B, Haslam R,Siegers A, Cropper M, Rafferty J, Coat S, Parker C, Barry A, Smith G, Clarke T,Cram M, Hendon S, Harding J, McCowan L, Cutfield R, Gao W, Skidmore P,Rowan J, Rowan J, Griffiths J, Hague W, Graham D, Walters B, Lust K, McIntyreHD, Moore P, Oats J, Wein P, Eagleton C, McLean M.National Women's Health, Auckland City Hospital, Grafton, Auckland, NewZealand. jrowan@internet.co.nzBACKGROUND: Metformin is a logical treatment for women with gestationaldiabetes mellitus, but randomized trials to assess the efficacy and safety of itsuse for this condition are lacking. METHODS: We randomly assigned 751women with gestational diabetes mellitus at 20 to 33 weeks of gestation to opentreatment with metformin (with supplemental insulin if required) or insulin. Theprimary outcome was a composite of neonatal hypoglycemia, respiratorydistress, need for phototherapy, birth trauma, 5-minute Apgar score less than 7,or prematurity. The trial was designed to rule out a 33% increase (from 30% to40%) in this composite outcome in infants of women treated with metformin ascompared with those treated with insulin. Secondary outcomes included neonatalanthropometric measurements, maternal glycemic control, maternal hypertensivecomplications, postpartum glucose tolerance, and acceptability of treatment.RESULTS: Of the 363 women assigned to metformin, 92.6% continued toreceive metformin until delivery and 46.3% received supplemental insulin. Therate of the primary composite outcome was 32.0% in the group assigned tometformin and 32.2% in the insulin group (relative risk, 1.00; 95% confidenceinterval, 0.90 to 1.10). More women in the metformin group than in the insulingroup stated that they would choose to receive their assigned treatment again(76.6% vs. 27.2%, P

not associated with increased perinatal complications as compared with insulin.The women preferred metformin to insulin treatment. (Australian New ZealandClinical Trials Registry number, 12605000311651.). Copyright 2008Massachusetts Medical Society.N Engl J Med. 2008 May 8;358(19):1991-2002.Hyperglycemia and adverse pregnancy outcomes.HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR,Trimble ER, Chaovarindr U, Coustan DR, Hadden DR, McCance DR, Hod M,McIntyre HD, Oats JJ, Persson B, Rogers MS, Sacks DA.Collaborators: Contreras M, Sacks DA, Watson W, Dooley SL, Foderaro M,Niznik C, Bjaloncik J, Catalano PM, Dierker L, Fox S, Gullion L, Johnson C,Lindsay CA, Makovos H, Saker F, Carpenter MW, Hunt J, Somers MH,Amankwah KS, Chan PC, Gherson B, Herer E, Kapur B, Kenshole A, LawrenceG, Matheson K, Mayes L, McLean K, Owen H, Cave C, Fenty G, Gibson E,Hennis A, McIntyre G, Rotchell YE, Spooner C, Thomas HA, Gluck J, HaddenDR, Halliday H, Irwin J, Kearney O, McAnee J, McCance DR, Mousavi M, TraubAI, Cruickshank JK, Derbyshire N, Dry J, Holt AC, Khan F, Lambert C, MareshM, Prichard F, Townson C, van Haeften TW, van de Hengel AM, Visser GH,Zwart A, Chaovarindr U, Chotigeat U, Deerochanawong C, Panyasiri I,Sanguanpong P, Amichay D, Golan A, Marks K, Mazor M, Ronen J, Wiznitzer A,Chen R, Harel D, Hoter N, Melamed N, Pardo J, Witshner M, Yogev Y, BowlingF, Cowley D, Devenish-Meares P, Liley HG, McArdle A, McIntyre HD, MorrisonB, Peacock A, Tremellen A, Tudehope D, Chan KY, Chan NY, Ip LW, Kong SL,Lee YL, Li CY, Ng KF, Ng PC, Rogers MS, Wong KW, Edgar M, Giles W, Gill A,Glover R, Lowe J, Mackenzie F, Siech K, Verma J, Wright A, Cao YH, Chee JJ,Koh A, Tan E, Rajadurai VJ, Wee HY, Yeo GS, Coustan D, Haydon B, AlexanderA, Hadden DR, Attias-Raved O, Hod M, Oats JJ, Parry AF, Collard A, Frank AS,Lowe LP, Metzger BE, Thomas A, Case T, Cholod P, Dyer AR, Engelman L,Xiao M, Yang L, Burgess CI, Lappin TR, Nesbitt GS, Sheridan B, Smye M,Trimble ER, Dyer AR, Hod M, Metzger BE, Lowe LP, Oats JJ, Persson B,Trimble ER, Cutter GR, Gabbe SG, Hare JW, Wagenknecht LE, Chen Y, ClamanJ, King J.Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.bem@northwestern.eduBACKGROUND: It is controversial whether maternal hyperglycemia less severethan that in diabetes mellitus is associated with increased risks of adversepregnancy outcomes. METHODS: A total of 25,505 pregnant women at 15centers in nine countries underwent 75-g oral glucose-tolerance testing at 24 to32 weeks of gestation. Data remained blinded if the fasting plasma glucose levelwas 105 mg per deciliter (5.8 mmol per liter) or less and the 2-hour plasmaglucose level was 200 mg per deciliter (11.1 mmol per liter) or less. Primaryoutcomes were birth weight above the 90th percentile for gestational age,primary cesarean delivery, clinically diagnosed neonatal hypoglycemia, and cordbloodserum C-peptide level above the 90th percentile. Secondary outcomeswere delivery before 37 weeks of gestation, shoulder dystocia or birth injury,

need for intensive neonatal care, hyperbilirubinemia, and preeclampsia.RESULTS: For the 23,316 participants with blinded data, we calculated adjustedodds ratios for adverse pregnancy outcomes associated with an increase in thefasting plasma glucose level of 1 SD (6.9 mg per deciliter [0.4 mmol per liter]), anincrease in the 1-hour plasma glucose level of 1 SD (30.9 mg per deciliter [1.7mmol per liter]), and an increase in the 2-hour plasma glucose level of 1 SD (23.5mg per deciliter [1.3 mmol per liter]). For birth weight above the 90th percentile,the odds ratios were 1.38 (95% confidence interval [CI], 1.32 to 1.44), 1.46 (1.39to 1.53), and 1.38 (1.32 to 1.44), respectively; for cord-blood serum C-peptidelevel above the 90th percentile, 1.55 (95% CI, 1.47 to 1.64), 1.46 (1.38 to 1.54),and 1.37 (1.30 to 1.44); for primary cesarean delivery, 1.11 (95% CI, 1.06 to1.15), 1.10 (1.06 to 1.15), and 1.08 (1.03 to 1.12); and for neonatalhypoglycemia, 1.08 (95% CI, 0.98 to 1.19), 1.13 (1.03 to 1.26), and 1.10 (1.00 to1.12). There were no obvious thresholds at which risks increased. Significantassociations were also observed for secondary outcomes, although these tendedto be weaker. CONCLUSIONS: Our results indicate strong, continuousassociations ofmaternal glucose levels below those diagnostic of diabetes with increased birtheight and increased cord-blood serum C-peptide levels. Copyright 2008Massachusetts Medical Society.Am J Obstet Gynecol. 2008 May 9. [Epub ahead of print]Is a previous unplanned pregnancy a risk factor for a subsequentunplanned pregnancy?Kuroki LM, Allsworth JE, Redding CA, Blume JD, Peipert JF.Warren Alpert Medical School, Brown University, Providence, RI.OBJECTIVE: The objective of the study was to determine whether a history ofunplanned pregnancy was a risk factor for a subsequent unplanned pregnancy.STUDY DESIGN: We analyzed 542 women aged 14-35 years, enrolled in ProjectPROTECT, a randomized clinical trial to promote dual-method contraception useto prevent sexually transmitted diseases and unplanned pregnancy. Predictors ofunplanned pregnancy were assessed by comparing women with and without ahistory of unplanned pregnancy. RESULTS: More than 1 in 5 women (22.5%)experienced an unintended pregnancy. History of an unintended pregnancy wasa predictor of unintended pregnancy (adjusted odds ratio 1.91, 95% confidenceinterval, 1.09 to 3.34). Other factors that were significantly associated withunplanned pregnancy included young age and low educational status.CONCLUSIONS: Future efforts should focus on bridging the gap betweenidentifying risk factors for unplanned pregnancy and interventions aimed atreducing the incidence in high-risk groups.BMJ. 2008 May 17;336(7653):1117-20. Epub 2008 May 14.Accuracy of mean arterial pressure and blood pressure measurements inpredicting pre-eclampsia: systematic review and meta-analysis.Cnossen JS, Vollebregt KC, Vrieze N, Riet GT, Mol BW, Franx A, Khan KS, PostJA.

Department of General Practice, Academic Medical Center, Meibergdreef 15,1100 DD, Amsterdam, Netherlands.OBJECTIVE: To determine the accuracy of using systolic and diastolic bloodpressure, mean arterial pressure, and increase of blood pressure to predict preeclampsia.DESIGN: Systematic review with meta-analysis of data on testaccuracy. DATA SOURCES: Medline, Embase, Cochrane Library, Medion,checking reference lists of included articles and reviews, contact with authors.Review methods Without language restrictions, two reviewers independentlyselected the articles in which the accuracy of blood pressure measurementduring pregnancy was evaluated to predict pre-eclampsia. Data were extractedon study characteristics, quality, and results to construct 2x2 tables. Summaryreceiver operating characteristic curves and likelihood ratios were generated forthe various levels and their thresholds. RESULTS: 34 studies, testing 60 599women (3341 cases of pre-eclampsia), were included. In women at low risk forpre-eclampsia, the areas under the summary receiver operating characteristiccurves for blood pressure measurement in the second trimester were 0.68 (95%confidence interval 0.64 to 0.72) for systolic blood pressure, 0.66 (0.59 to 0.72)for diastolic blood pressure, and 0.76 (0.70 to 0.82) for mean arterial pressure.Findings for the first trimester showed a similar pattern. Second trimester meanarterial pressure of 90 mm Hg or more showed a positive likelihood ratio of 3.5(95% confidence interval 2.0 to 5.0) and a negative likelihood ratio of 0.46 (0.16to 0.75). In women deemed to be at high risk, a diastolic blood pressure of 75mm Hg or more at 13 to 20 weeks' gestation best predicted pre-eclampsia:positive likelihood ratio 2.8 (1.8 to 3.6), negative likelihood ratio 0.39 (0.18 to0.71). Additional subgroup analyses did not show improved predictive accuracy.CONCLUSION: When blood pressure is measured in the first or second trimesterof pregnancy, the mean arterial pressure is a better predictor for pre-eclampsiathan systolic blood pressure, diastolic blood pressure, or an increase of bloodpressure.BMJ. 2008 May 17;336(7653):1079-80. Epub 2008 May 14.Mean arterial pressure and prediction of pre-eclampsia.Walsh CA, Baxi LV.Ipswich Hospital NHS Trust, Ipswich IP4 5PD.Gynecol Obstet Invest. 2008 May 16;66(2):138-141. [Epub ahead of print]Metformin-Associated Lactic Acidosis in a Pregnant Patient.Hong YC, O'Boyle CP, Chen IC, Hsiao CT, Kuan JT.Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi,Taiwan.Metformin-associated lactic acidosis is a rare but serious condition andpotentially even more hazardous during pregnancy. We reported a case of lacticacidosis in a 28-year-old pregnant woman (gravida 3, para 0, abortion 2, antepartum22 weeks) after ingestion of 39.50 g (approximately 80 tablets) metforminin a suicide attempt. She had no pre-existing systemic illness. Analysis of arterialblood gases revealed a high anion gap (28.1 mEq/l) and a normal osmol gap (8

mEq/l) metabolic acidosis. Other etiologies of high anion gap and normal osmolgap metabolic acidosis were excluded by laboratory investigation. The patientwas treated on an emergency basis and received aggressive fluid management,intravenous sodium bicarbonate (1 mEq/kg) and activated charcoal, orally. Thefetal condition was monitored intensively. The fetus was delivered smoothly viavaginal delivery in a healthy state at the 38th gestational week. Clinical follow-upover the next 2 years confirmed no congenital abnormality. We present a case ofsuccessful management of metformin-associated lactic acidosis duringpregnancy, treated simply, with intravenous sodium bicarbonate and intensivefetal monitoring. This relatively noninvasive method is an effective treatmentoption. However, hemodialysis still has a valuable role in the management ofacidosis which proves refractory to conservative treatment, such as thatdescribed. Copyright © 2008 S. Karger AG, Basel.J Reprod Med. 2008 Apr;53(4):279-82.Pregnancy and arterial compliance.Fox NS, Feit L, Skupski D.Department of Obstetrics and Gynecology, Weill Medical College of CornellUniversity, New York, New York, USA. naf9015@med.cornell.eduOBJECTIVE: To examine the hypothesis that pregnancy is associated withvascular remodeling, leading to an increased vascular compliance that can beobserved in subsequent pregnancies. STUDY DESIGN: Chart review of41multiparous deliveries at our institution from a 2-month period in 2004. Chartsexamined were from patients with uncomplicated, singleton pregnancies whowere nulliparous during their prior delivery. Patients with blood pressurerecordings in all 3 trimesters during both pregnancies were included. The meanarterial pressure (MAP) in the index and prior pregnancy was compared.RESULTS: There were no significant MAP differences noted, other than in thelate third trimester (MAP, 85.05 vs. 80.15, p < 0.001). When we plotted thedifference in >34 weeks MAP against the time between pregnancies, we did notsee any statistically significant correlation (Pearson Correlation -0.147, p = 0.35).We examined the mean pulse pressure at >34 weeks. We found no statisticallysignificant differences between the first and second pregnancies (mean pulsepressure, 42.27 vs. 43.55, p = 0.5). CONCLUSION: Our data does not supportthe hypothesis that pregnancy is associated with vascular remodeling, leading toan increased vascular compliance that can be observed in subsequentpregnancies. This could be due to demographic differences between ourpopulation and previously studied populations.Obstet Gynecol. 2008 Apr;111(4):921-6.Effect of antenatal corticosteroids on survival for neonates born at 23weeks of gestation.Hayes EJ, Paul DA, Stahl GE, Seibel-Seamon J, Dysart K, Leiby BE, MackleyAB, Berghella V.Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

edwardjhayes@comcast.netOBJECTIVE: To estimate if exposure to antenatal corticosteroids was associatedwith decreased rate of death in neonates born at 23 weeks of gestation.METHODS: This is a retrospective cohort study performed at three tertiarycenters of neonates born at 23 weeks of gestation between 1998 and 2007.Stillbirths, voluntary terminations, or parental elected nonresuscitations wereexcluded. Clinical and demographic variables were examined to determinepossible confounding variables. A multivariable logistic regression model wasused to assess the effect of steroids on the odds of death after adjustment forthese confounders. RESULTS: The sample included 181 neonates. Of themultiple variables examined (institution, race, diagnosis, illicit drug use,antibiotics, assisted reproduction, birth weight, gender, and route of delivery),only multiple gestations were significantly associated (P

Acta Obstet Gynecol Scand. 2008;87(5):577-8.Bowel and omentum prolapse into the vagina after third stage: an unusualpresentation of ruptured uterus.Singhal SR, Singhal SK, Gupta P.Am J Obstet Gynecol. 2008 May 15. [Epub ahead of print]Pregnancy complications associated with hepatitis C: data from a 2003-2005 Washington state birth cohort.Pergam SA, Wang CC, Gardella CM, Sandison TG, Phipps WT, Hawes SE.Department of Medicine, University of Washington School of Medicine, Seattle,WA.OBJECTIVE: The objective of the study was to determine the effect of hepatitis Cvirus (HCV) on selected maternal and infant birth outcomes. STUDY DESIGN:This population-based cohort study using Washington state birth records from2003 to 2005 compared a cohort of pregnant women identified as HCV positivefrom birth certificate data (n = 506) to randomly selected HCV-negative mothers(n = 2022) and drug-using HCV-negative mothers (n = 1439). RESULTS: Infantsof HCV-positive mothers were more likely to be low birthweight (odds ratio [OR],2.17; 95% confidence interval [CI] 1.24, 3.80), to be small for gestational age(OR, 1.46; 95% CI, 1.00, 2.13), to need assisted ventilation (OR, 2.37; 95% CI,1.46, 3.85), and to require neonatal intensive car unit (NICU) admission (OR,2.91; 95% CI, 1.86, 4.55). HCV-positive mothers with excess weight gain alsohad a greater risk of gestational diabetes (OR, 2.51; 95% CI, 1.04, 6.03).Compared with the drug-using cohort, NICU admission and the need for assistedventilation remained associated with HCV. CONCLUSION: HCV-positivepregnant women appear to be at risk for adverse neonatal and maternaloutcomes.Eur J Obstet Gynecol Reprod Biol. 2008 May 19. [Epub ahead of print]Red, orange and green Caesarean sections: A new communication tool foron-call obstetricians.Dupuis O, Sayegh I, Decullier E, Dupont C, Clément HJ, Berland M, Rudigoz RC.Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Gynécologie-Obstétrique, 69495 Pierre-Bénite, France.OBJECTIVE: To evaluate the effect of a novel communication tool, related to thedegree of urgency for Caesarean sections (CSs), on the decision-to-deliveryinterval for emergency CS. STUDY DESIGN: Red CS are very urgent casescorresponding to life-threatening maternal or foetal situations, orange CS areurgent cases and green CS are non-urgent intrapartum CS. We carried out thiscohort study in a French maternity hospital. The study included all emergencyCaesarean sections during two 6-month periods, before and after introduction ofthe code. We compared the decision-to-delivery interval of the two study periods.RESULTS: Our study included 174 emergency CS. The mean decision-todeliveryinterval after introduction of the code was 31.7min, significantly shorter(p=0.02) than the 39.6min interval before introduction of the colour code. Except

for the preparation time, each time interval decreased. This included transportingthe patient into the operating theatre, and the incision-to-delivery time interval.CONCLUSION: This study suggests that the use of the three-colour code couldsignificantly shorten the decision-to-delivery interval in emergency CS. Furtherprospective studies are needed to confirm this result.Eur J Obstet Gynecol Reprod Biol. 2008 May 15. [Epub ahead of print]Comment on: "Campagne DM, Fact: antidepressants and anxiolytics are notsafe during pregnancy" Eur J Obstet Gynecol Reprod Biol 2007Dec;135(2):145-8.Einarson A, Eberhard-Gran M.The Motherisk Program, The Hospital for Sick Children, Toronto, Ontario,Canada.J Reprod Med. 2008 Feb;53(2):129-31.Abruptio placentae in the setting of an atypical presentation of acuteappendicitis: a case report.Klatsky PC, Cronbach EJ, Shahine LK, Caughey AB.Department of Obstetrics, Gynecology, and Reproductive Sciences, University ofCalifornia, San Francisco, 513 Parnassus Avenue, Box 0132, 94143, USA.klatskyp@ucsf.obgyn.eduBACKGROUND: Causes of placental abruption include traumatic events,cocaine use, hypertension, cigarette smoking and advanced maternal age.Recent studies also implicate inflammatory precursors, such as pretermpremature rupture of membranes and chorioamnionitis. Clear precipitating eventsare often not identified, and precise etiologic determinants are still beingdetermined. CASE: A 25-year-old woman, grayida 4, para 2012, presented withacute onset of severe abdominal pain; frequent, low-amplitude contractions; anda nonreassuring fetal heart tracing. While performing an urgent cesarean sectionfor acute placental abruption, a ruptured appendicitis was identified.CONCLUSION: This case suggests that appendicitis in the third trimester may bea risk factor for placental abruption.Am J Obstet Gynecol. 2008 May;198(5):e54-6.A retrospective review of ampicillin-sulbactam and amoxicillin +clavulanate vs cefazolin/cephalexin and erythromycin in the setting ofpreterm premature rupture of membranes: maternal and neonataloutcomes.Ehsanipoor RM, Chung JH, Clock CA, McNulty JA, Wing DA.Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine,University of California, Irvine, Orange, CA, USA.OBJECTIVE: The purpose of this study was to compare the efficacy andoutcomes of 2 different antibiotic regimens that are used to prolong latency inpreterm premature rupture of membranes. The primary objective was todetermine whether the use of ampicillin-sulbactam/amoxicillin + clavulanate wasassociated with an increased risk of necrotizing enterocolitis. STUDY DESIGN: A

etrospective review of pregnancies that were complicated by preterm prematurerupture of membranes from 1999-2006 at 2 institutions was performed.Outcomes were compared between subjects who received parenteral ampicillinsulbactamfollowed by oral amoxicillin + clavulanate (protocol A) and subjectswho received parenteral cefazolin and erythromycin followed by oral cephalexinand erythromycin (protocol B). RESULTS: There were 147 women who wereevaluated; 88 women received protocol A, and 59 women received protocol B.There were no differences in latency period, gestational age at delivery, or routeof delivery. The incidence of necrotizing enterocolitis was 8.0% and 10.2% forprotocol A and protocol B, respectively (P = .64). CONCLUSION: Ampicillinsulbactam/amoxicillin+ clavulanate was not associated with an increase inneonatal necrotizing enterocolitis. Erythromycin in combination with cefazolin andcephalexin is an effective latency antibiotic regimen.Am J Obstet Gynecol. 2008 Apr;198(4):450.e1-9.Fetal outcome in motor-vehicle crashes: effects of crash characteristicsand maternal restraint.Klinich KD, Flannagan CA, Rupp JD, Sochor M, Schneider LW, Pearlman MD.University of Michigan Transportation Research Institute, Ann Arbor, MI, USA.OBJECTIVE: This project was undertaken to improve understanding of factorsassociated with adverse fetal outcomes of pregnant occupants involved in motorvehiclecrashes. STUDY DESIGN: In-depth investigations of crashes involving 57pregnant occupants were performed. Maternal and fetal injuries, restraintinformation, measures of external and internal vehicle damage, and details aboutthe crash circumstances were collected. Crash severity was calculated usingvehicle crush measurements. Chi-square analysis and logistic regression modelswere used to determine factors with a significant association with fetal outcome.RESULTS: Fetal outcome is most strongly associated with crash severity (P

hematoma and eventually diagnosed with HELLP syndrome with a sequela ofhepatic rupture.Am J Obstet Gynecol. 2008 May;198(5):e30-2. Epub 2008 Feb 14.Universal screening for substance abuse at the time of parturition.Azadi A, Dildy GA 3rd.Department of Obstetrics & Gynecology, LSU Health Sciences Center, NewOrleans, LA, USA. aazadi@utmem.eduOBJECTIVE: The purpose of this study was to determine the prevalence ofsubstance abuse in an inner city population at delivery admission by universalurine toxicology screening. STUDY DESIGN: This was a retrospective analysis ofuniversal urine toxicology screening at admission for delivery on the LSUobstetric service at University Hospital in New Orleans. RESULTS: Four hundredsixty-two women delivered during the first 4 months of 2005. Four hundred andsixteen (90%) had a urine screen performed and 79 (19%) screened positive for1 or more substances. Rates of a positive test by substance were: cocaine(3.1%), amphetamines (2.4%), barbiturates (2.1%), opiates (2.6%), THC(17.2%),benzodiazepine (5.7%), and phencyclidine (0%). CONCLUSION: Nineteenpercent of the tested population screened positive for at least 1 of 7 substancesat admission for delivery. Women who used illicit substances were older and ofhigher parity. Low birthweight and HIV were particularly prevalent in those whoscreened positive for cocaine and/or amphetamines.Am J Obstet Gynecol. 2008 Jun 2. [Epub ahead of print]Morbidity associated with sickle cell disease in pregnancy.Villers MS, Jamison MG, De Castro LM, James AH.Division of Gynecology and General Obstetrics, Department of Obstetrics andGynecology, Medical University of South Carolina, Charleston, SC.OBJECTIVE: The purpose of this study was to identify morbidity that isassociated with sickle cell disease (SCD) in pregnancy. STUDY DESIGN: TheNationwide Inpatient Sample from the Healthcare Cost and Utilization Project ofthe Agency for Healthcare Research and Quality for the years 2000-2003 wasqueried for all pregnancy-related discharges with a diagnosis of SCD. RESULTS:There were 17,952 deliveries (0.1% of the total) to women with SCD. There were10 deaths (72.4 per 100,000 deliveries). Cerebral vein thrombosis, pneumonia,pyelonephritis, deep venous thrombosis, transfusion, postpartum infection,sepsis, and systemic inflammatory response syndrome were much morecommon among women with SCD. They were more likely to undergo cesareandelivery, to experience pregnancy-related complications (such as gestationalhypertension/preeclampsia, eclampsia, abruption, antepartum bleeding, pretermlabor, and fetal growth restriction), and to have cardiomyopathy or pulmonaryhypertension at the time of delivery. CONCLUSION: Women with sickle celldisease are at greater risk for morbidity in pregnancy than previously estimated.Aust N Z J Obstet Gynaecol. 2008 Jun;48(3):228-35.

Maternal obesity and pregnancy complications: a review.Ramachenderan J, Bradford J, McLean M.Tamworth Base Hospital, Tamworth, New South Wales, Australia.Obesity in women of reproductive age is increasing at an unprecedented rate inwestern societies. Maternal obesity is associated with an unequivocal increase inmaternal and fetal complications of pregnancy. Excessive maternal weight gainin pregnancy also appears to be an independent risk factor, regardless ofprepregnancy weight. Few guidelines exist regarding appropriate weight gain inpregnancy in obese women. We review the association of maternal obesity withpregnancy complications. We also suggest that appropriate diet and lifestyleintervention can enable women with severe prepregnancy obesity to safelyachieve quite strict targets for limited weight gain in pregnancy.BMJ. 2008 Jun 7;336(7656):1303-5.Pregnancy and injecting drug use.Bell J, Harvey-Dodds L.National Addiction Centre, Institute of Psychiatry, London SE5 8RS.james.bell@sesiahs.health.nsw.gov.auBMJ. 2008 Jun 7;336(7656):1263.Screen women with gestational diabetes for type 2 diabetes.Sillender M.Int J Gynaecol Obstet. 2008 Jun 3. [Epub ahead of print]Spinal tuberculosis in pregnancy.Luewan S, Bunmaprasert T, Chiengthong K, Tongsong T.Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang MaiUniversity, Thailand.JAMA. 2008 Jun 4;299(21):2590.JAMA patient page. Pregnancy and diabetes.Torpy JM, Lynm C, Glass RM.Obstet Gynecol. 2008 Jun;111(6):1479-85.ACOG Practice Bulletin No. 94: Medical Management of Ectopic Pregnancy.[No authors listed]Obstet Gynecol. 2008 Jun;111(6):1327-1334.Cesarean Delivery and Subsequent Pregnancies.Daltveit AK, Tollånes MC, Pihlstrøm H, Irgens LM.Department of Public Health and Primary Health Care, University of Bergen,Bergen, Norway; and the Medical Birth Registry of Norway, Locus of RegistryBased Epidemiology, University of Bergen, Bergen, Norway and the NorwegianInstitute of Public Health, Oslo, Norway.OBJECTIVE: To assess possible effects of a cesarean delivery on outcome insubsequent pregnancies. METHODS: Using an historical cohort design, we

analyzed 637,497 first and second births among women with two or more singlebirths and 242,812 first, second, and third births among women with three ormore single births registered in the population-based Medical Birth Registry ofNorway between 1967 and 2003. RESULTS: Compared with a vaginal delivery atfirst birth, a cesarean delivery at first birth was followed, in a second pregnancy,by increased risks of preeclampsia (odds ratio [OR] 2.9 and corresponding 95%confidence interval [CI] 2.8-3.1), small for gestational age (OR 1.5; CI 1.4-1.5),placenta previa (OR 1.5; CI 1.3-1.8, placenta accreta (OR 1.9; CI 1.3-2.8),placental abruption (OR 2.0; CI 1.8-2.2), and uterine rupture (OR 37.4; CI 24.9-56.2). After excluding women with the actual complication at first birth, thecorresponding ORs were, in general, lower: 1.7 (CI 1.6-1.8), 1.3 (CI 1.3-1.4), 1.4(CI 1.2-1.7), 1.9 (CI 1.3-2.8), 1.7 (CI 1.6-1.9), and 37.2 (CI 24.7-55.9),respectively. Corresponding reduction in numbers of cesarean deliveries neededto prevent one case were 114, 56, 1,140, 3,706, 300, and 461. In third births,ORs after repeat cesarean delivery were similar to or lower than the ORs afterone cesarean delivery; also here, the exclusion of women with the actualoutcome in any of their previous pregnancies tended to reduce the ORs.CONCLUSION: Cesarean delivery was associated with an increased risk ofcomplications in a subsequent pregnancy, but excess risks were reduced afterexcluding women with the actual complication in any of their previous births. Toobtain less biased effects of cesarean delivery on subsequent pregnancies, it isimportant to account for obstetric history. LEVEL OF EVIDENCE: II.Obstet Gynecol. 2008 Jun;111(6):1274-1278.Episiotomy and Increase in the Risk of Obstetric Laceration in aSubsequent Vaginal Delivery.Alperin M, Krohn MA, Parviainen K.Division of Female Pelvic Medicine and Reconstructive Surgery, Division ofInfectious Diseases and Immunology, and Division of Maternal-Fetal Medicine,Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania.OBJECTIVE: To examine whether episiotomy at first vaginal delivery increasesthe risk of spontaneous obstetric laceration in the subsequent delivery.METHODS: A review was conducted of women with consecutive vaginaldeliveries at Magee-Womens Hospital between 1995 and 2005, using the MageeObstetrical Maternal and Infant database. The primary exposure of interest wasepisiotomy at first vaginal delivery. Multivariable polytomous logistic regressionmodeling of potential risk factors was used to estimate odds ratios (ORs) forobstetric laceration in the second vaginal delivery. RESULTS: A total of 6,052patients were included, of whom 47.8% had episiotomy at first delivery.Spontaneous second-degree lacerations at the time of second delivery occurredin 51.3% of women with history of episiotomy at first delivery compared with26.7% without history of episiotomy (P

interval 3.78-5.30) and severe obstetric lacerations (OR 5.25, 95% confidenceinterval 2.96-9.32) in the second vaginal delivery after controlling forconfounders. Based on these findings, for every four episiotomies not performedone second-degree laceration would be prevented. To prevent one severelaceration, performing 32 fewer episiotomies is required. CONCLUSION:Episiotomy at first vaginal delivery increases the risk of spontaneous obstetriclaceration in the subsequent delivery. This finding should encourage obstetricproviders to further restrict the use of episiotomy. LEVEL OF EVIDENCE: II.Ultrasound Obstet Gynecol. 2008 Jun 6. [Epub ahead of print]Effect of parity on maternal cardiac function during the first trimester ofpregnancy.Turan OM, De Paco C, Kametas N, Khaw A, Nicolaides KH.Harris Birthright Research Centre for Fetal Medicine, King's College Hospital,London, UK.OBJECTIVE: To investigate maternal cardiac adaptation in the first trimester ofpregnancy with increasing maternal parity. METHODS: This was a crosssectionalstudy carried out at the antenatal clinic of a teaching hospital. Weexamined 4689 pregnant women at 11 + 0 to 13 + 6 weeks of gestation,performing two-dimensional echocardiography of the maternal left ventricle.There were 2352 parous and 2337 nulliparous women. The relationshipsbetween parity, maternal cardiac function and neonatal birth weight wereanalyzed. RESULTS: Parous compared to nulliparous women had a significantlyhigher median cardiac output (5.6 vs. 5.2 L/min) and median cardiac index (2.3vs. 2.1 L/min/m(2)). This was owing to a significantly higher median strokevolume (73.5 vs. 70.5 mL), heart rate (76 vs. 75 bpm), left ventricular outflowdiameter (20.4 vs. 20.0 mm) and lower total vascular resistance (1190.8 vs.1253.7 dyne.s/cm(5)) and median uterine artery pulsatility index (1.6 vs. 1.7).Mean arterial blood pressure was not significantly different between the groups.There was a progressive increase in all maternal cardiac variables, apart fromtotal peripheral resistance, which decreased with increasing parity. Birth weightwas higher in parous compared to nulliparous women (3.39 vs. 3.23 kg) and itwas independently related to maternal hemodynamic variables and demographicand social characteristics (age, height, weight, ethnicity, smoking).CONCLUSION: Pregnancy in parous compared to nulliparous women ischaracterized by higher maternal cardiac output and birth weight. Copyright (c)2008 ISUOG. Published by John Wiley & Sons, Ltd.Obstet Gynecol. 2008 May;111(5):1089-95.Maternal morbidity rates in a managed care population.Bruce FC, Berg CJ, Hornbrook MC, Whitlock EP, Callaghan WM, Bachman DJ,Gold R, Dietz PM.Centers for Disease Control and Prevention, Division of Reproductive Health,Atlanta, Georgia, USA. cbruce@cdc.govOBJECTIVE: To identify and estimate prevalence rates of maternal morbiditiesby pregnancy outcome and selected covariates during the antepartum,

intrapartum, and postpartum periods in a defined population of pregnant women.METHODS: We used electronic data systems of a large, vertically integrated,group-model health maintenance organization (HMO) to develop an algorithmthat searched International Classification of Diseases, 9th Revision, ClinicalModification, codes for 38 predetermined groups of pregnancy-relatedcomplications among women enrollees of this HMO between January 1, 1998,and December 31, 2001. RESULTS: We identified 24,481 pregnancies among21,011 women. Although prevalence and type of morbidity varied by pregnancyoutcome, overall, 50% of women had at least one complication. The mostcommon complications were anemia (9.3%), urinary tract infections (9.0%),mental health conditions (9.0%), hypertensive disorders (8.5%), and pelvic andperineal trauma (7.0%). CONCLUSION: A range of mild-to-severe pregnancycomplications were identified using linked inpatient and outpatient databases.The most common complications we found usually do not require hospitalizationso would be missed in studies that use only hospitalization data. Our dataallowed examination of a broad scope of conditions and severity. These findingsincrease our understanding of the extent of maternal morbidity. LEVEL OFEVIDENCE: II.Eur J Obstet Gynecol Reprod Biol. 2008 Mar;137(1):125-6. Epub 2006 Dec 20.An uncomplicated pregnancy associated with Sturge-Weber angiomatosis.Zanconato G, Papadopoulos N, Lampugnani F, Caloi E, Franchi M.Eur J Obstet Gynecol Reprod Biol. 2008 Mar;137(1):118-9. Epub 2006 Nov 28.Plasma uric acid levels do not correlate to plasma-evoked changes inendothelial function in women with preeclampsia.Jewsbury S, Sheikh N, Crocker I, Baker PN, Myers JE.Eur J Obstet Gynecol Reprod Biol. 2008 Mar;137(1):115; author reply 116. Epub2006 Feb 3.Comment on:Eur J Obstet Gynecol Reprod Biol. 2005 Sep 1;122(1):122-5.Dangerous placement of sutures in a vesico-segmentary plane in anteriorplacenta percreta.Palacios Jaraquemada JM.Gynecol Obstet Invest. 2008 Jun 19;66(3):178-183. [Epub ahead of print]Gestational Diabetes: Using a Portable Glucometer to Simplify theApproach to Screening.Agarwal MM, Dhatt GS, Safraou MF.Department of Pathology, Faculty of Medicine, UAE University, Al Ain, UnitedArab Emirates.Background: In populations at a high-risk for gestational diabetes (GDM), therecommendation of screening every pregnant woman with the oral glucosetolerance test (OGTT) is very demanding. Aim: To assess the usefulness of theportable, plasma optimized glucometer in simplifying the approach to screening

of GDM. Methods: 1,662 pregnant women underwent the one-step 75 g OGTTfor routine screening of GDM, as defined by the criteria of the American DiabetesAssociation. The glucometer was used to measure the initial fasting venouswhole blood glucose (FBG) to assess its value as a screening test in predictingthe need to proceed with the OGTT. Results: 186 (11.2%) women had GDM. Thearea under the receiver operating characteristic curve (AUC) of the FBG was0.876 (95% CI 0.847-0.906). A FBG threshold (at an acceptable sensitivity of85%) independently could 'rule-out' GDM in 1,138 (68.5%) women; i.e. over twothirdsof the women would not need to continue with the cumbersome OGTT.Conclusions: Using the glucometer to initially measure the venous FBG as ascreen can help to significantly reduce the number of OGTTs needed for thediagnosis of GDM. This algorithm offers a simple, practical, cost-effective andpatient-friendly approach for the screening of GDM. Copyright © 2008 S. KargerAG, Basel.Gynecol Obstet Invest. 2008 Jun 19;66(3):162-168. [Epub ahead of print]Subfascial Hematomas and Hemoperitoneum after Cesarean Section:Prevalence according to Closure and Non-Closure of the ParietalPeritoneum.Malvasi A, Tinelli A, Tinelli R, Serio G, Pellegrino M, Mettler L.Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy.Aim: To compare early hemorrhagic complications and the surgical and clinicaloutcome in the closure and non-closure of the parietal peritoneum in cesareansection (CS) patients. Material and Methods: We retrospectively evaluated 2,576post-CS women subdivided and compared in two groups by open and closedparietal peritoneum (group I, n = 1,580, group II, n = 996). Results: Theultrasonographical detection of 23 blood collections (0.89%) was 14 in group Iand 9 in group II, and of these we surgically treated 11 patients in group I and 8patients in group II, with no statistical difference (p > 0.05); all group I patientsshowed hemoglobin point decreases and needed blood transfusions, withstatistical significance (p < 0.05) linked to more severe early complications thatmake the post-CS outcome worse; no difference was confirmed in terms ofantibiotic administration (p > 0.05). Conclusions: There was a significant increaseof blood loss and transfusions in the first group. As the posterior surface of theRetzius space is open and if post-CS pathological bleeding occurs, blood caninvade the peritoneal cavity causing a hemoperitoneum, with the possibility ofhemorrhagic shock and a worse clinical outcome. Copyright © 2008 S. KargerAG, Basel.Int J Gynaecol Obstet. 2008 Jun 13. [Epub ahead of print]Additional antibiotic use and preterm birth among bacteriuric andnonbacteriuric pregnant women.Anderson BL, Simhan HN, Simons K, Wiesenfeld HC.Department of Obstetrics and Gynecology, Brown University, Providence, RhodeIsland, USA.

Objective: To determine the risk of preterm birth related to use of additionalantibiotics. Methods: Women with Group B streptococcal (GBS) bacteriuria andwomen with negative urine cultures in a hospital-wide research registry wereincluded. The impact of prenatal antibiotics in addition to those used to treat GBSbacteriuria was assessed. Logistic regression was used to determine the risk ofpreterm birth among bacteriuric women who received "other antibiotics". Results:A total of 203 women with GBS bacteriuria and 220 women with negativecultures were included. The frequency of preterm birth was 16% (35/220) forwomen in the control group, 16% (19/120) for women with bacteriuria notreceiving additional antibiotics, and 28% (23/83) for women with bacteriuria whoreceived antibiotics for "other indications". Among women with GBS bacteriuria,the risk of preterm birth was increased with the use of "other antibiotics"(adjusted odds ratio, 2.7; 95% confidence interval, 1.2-6.1). Conclusion: Amongwomen with GBS bacteriuria, exposure to additional antibiotics is associated withan increased risk of preterm birth.Int J Gynaecol Obstet. 2008 Jun 14. [Epub ahead of print]Motorcycle ambulances for referral of obstetric emergencies in ruralMalawi: Do they reduce delay and what do they cost?Hofman JJ, Dzimadzi C, Lungu K, Ratsma EY, Hussein J.Liverpool School of Tropical Medicine, Liverpool, UK.OBJECTIVES: To assess whether motorcycle ambulances placed at rural healthcenters are a more effective method of reducing referral delay for obstetricemergencies than a car ambulance at the district hospital, and to compareinvestment and operating costs with those of a 4 wheel drive car ambulance atthe district hospital. METHODS: Motorcycle ambulances were placed at 3 remoterural health centers in Malawi. Data were collected over a 1-year period, fromOctober 2001 to September 2002, using logbooks, cashbooks, referral forms,and maternity registers. RESULTS: Depending on the site, median referral delaywas reduced by 2-4.5 hours (35%-76%). Purchase price of a motorcycleambulance was 19 times cheaper than for a car ambulance. Annual operatingcosts were US $508, which was almost 24 times cheaper than for a carambulance. CONCLUSIONS: In resource-poor countries motorcycle ambulancesat rural health centers are a useful means of referral for emergency obstetric careand a relatively cheap option for the health sector.Acta Obstet Gynecol Scand. 2008;87(6):617-27.Maternal use of thyroid hormones in pregnancy and neonatal outcome.Wikner BN, Sparre LS, Stiller CO, Källén B, Asker C.Department of Medicine, Karolinska Institutet, Clinical Pharmacology Unit,Karolinska University Hospital, Stockholm, Solna, Sweden. birgitta.norstedtwikner@karolinska.seOBJECTIVE: To describe neonatal outcome including the presence of congenitalmalformations in infants born to women substituted with thyroid hormones, andthe maternal characteristics of these women. DESIGN: Register study based onprospectively collected data in relation to delivery. SETTING: Swedish Health

Registers. POPULATION: All pregnant women (n=848,468) and all infants born(n=861,989) in Sweden from 1 July 1995 to 31 December 2004. METHODS:Women who reported the use of thyroid hormones in early pregnancy or obtaineda prescription for thyroid hormones later in pregnancy (n=9,866), as well as theirinfants (n=10,055) were identified from the Swedish Medical Birth Register. Thereference population consisted of all women giving birth and their offspring duringthe same time interval. MAIN OUTCOME MEASURES: Neonatal outcome,malformations and maternal characteristics. Data were analyzed withadjustments for identified confounders. RESULTS: Women using thyroxine hadan increased rate of pre-eclampsia, diabetes (pre-existing or gestational),cesarean sections and inductions of labour compared to women in the referencepopulation. The risk for preterm birth was marginally increased (OR 1.13, 95% CI1.03-1.25). Neonatal thyroid disease was found in eight infants (seven withthyreotoxicosis and one unspecified), the expected number was 0.2. No furtheranomalies in neonatal diagnoses were found. A small but statistically significantrisk for congenital malformations (OR =1.14, 95% CI 1.05-1.26) was found.CONCLUSION: Women on thyroid substitution during pregnancy had anincreased risk for some pregnancy complications, but their infants were onlyslightly affected.Am J Obstet Gynecol. 2008 Jun 21. [Epub ahead of print]The utility of thrombophilia testing in pregnant women with thrombosis:fact or fiction?Scifres CM, Macones GA.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,Washington University School of Medicine, St Louis, MO.Women who either present with an episode of acute venous thrombosis inpregnancy or who have a history of venous thrombosis who present for prenatalcare often undergo testing for inherited thrombophilia. The rationale for screeningmay include questions about whether screening for inherited thrombophilias canhelp to alter anticoagulation plans in a pregnancy complicated by venousthrombosis, whether patients with a history of venous thrombosis who present forcare in a subsequent pregnancy require anticoagulation and at what intensity,whether knowledge of thrombophilia changes the duration and intensity ofanticoagulation outside pregnancy, and whether screening of family members iswarranted. Data regarding these issues are reviewed, controversies surroundingthrombophilia testing in this setting are discussed, and clinical recommendationsare made.Eur J Obstet Gynecol Reprod Biol. 2008 Jun 19. [Epub ahead of print]Severe, very early onset preeclampsia: Subsequent pregnancies and futureparental cardiovascular health.Gaugler-Senden IP, Berends AL, de Groot CJ, Steegers EA.Department of Obstetrics and Gynaecology, Division of Obstetrics and PrenatalMedicine, Erasmus MC, University Medical Center Rotterdam, SKZ 4130, Dr.Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands.

OBJECTIVE: To study subsequent pregnancy outcome in women with severe,very early onset preeclampsia (onset before 24 weeks' gestation) and to analyzecardiovascular risk profiles of these women and their partners. STUDY DESIGN:Twenty women with preeclampsia with an onset before 24 weeks' gestation,admitted between 1 January 1993 and 31 December 2002 at a tertiary universityreferral center, were enrolled in the study. Data on subsequent pregnancies wereobtained from medical records. Their cardiovascular risk profiles and those oftheir partners (n=15) were compared with those of 20 control women afteruncomplicated pregnancies only, matched for age and parity, and those of theirpartners (n=13). Body weight, height, waist and hip circumference, bloodpressure and intima media thickness (IMT) of the common carotid artery weremeasured. Fasted blood samples were drawn for detection of metaboliccardiovascular risk factors. RESULTS: Of the 20 case women 17 women had 24subsequent pregnancies, of which 12 (50%) were complicated by preeclampsia.Severe preeclampsia developed in five (21%) pregnancies. No perinatal deathsoccurred. Case women had significantly more often chronic hypertension ascompared to controls (55% vs. 10%, P=0.002). IMT of the common carotid arterywas increased in a subset of case women using antihypertensive medication(P=0.03). Case women showed increased microalbuminuria (P

J Reprod Med. 2008 May;53(5):365-8.Transvaginal ligation of the cervical branches of the uterine artery andinjection of vasopressin in a cervical pregnancy as an initial step tocontrolling hemorrhage: a case report.Davis LB, Lathi RB, Milki AA, Dahan MH.Division of Reproductive Endocrinology and Infertility, Department of Obstetricsand Gynecology, Stanford University Medical Center, Palo Alto, California 94304,USA.BACKGROUND: Hemorrhage from a cervical pregnancy is a time-sensitivematter. Effective temporization measures for the initial management of thishemorrhage have not previously been reported in the literature. CASE: A 43-year-old woman, gravida 0, underwent in vitro fertilization and embryo transfer.She subsequently presented to the office with sudden onset of vaginalhemorrhage due to a cervical pregnancy. Cervical artery sutures were placed,and a cervical vasoconstricting agent was injected, at which point the patient'sbleeding stopped. She then underwent successful treatment with dilation andcurettage. CONCLUSION: Conservative measures to manage hemorrhage dueto cervical pregnancy can be initiated, with possible rapid establishment ofhemostasis until definitive treatment can be achieved.J Reprod Med. 2008 May;53(5):347-51.Clinical utility of esophagogastroduodenoscopy in the management ofrecurrent and intractable vomiting in pregnancy.Debby A, Golan A, Sadan O, Glezerman M, Shirin H.Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon,Israel. debby@nashim.netOBJECTIVE: To determine the impact of esophagogastroduodenoscopy (EGD)on the clinical management of pregnancy women with recurrent vomiting andtheir pregnancy outcome. STUDY DESIGN: Retrospective evaluation of 60pregnant women who underwent diagnostic EGD in the first trimester ofpregnancy. RESULTS: Pregnant women were divided into 2 groups according tothe indications for EGD: group 1, intractable vomiting with or without epigastricpain (n = 49) and group 2, vomiting and gastrointestinal bleeding (n = 11). Theendoscopic findings found in both groups were esophagitis (43%), gastritis(17%), diaphragmatic hernia (17%) and normal EGD (28%). The diagnostic yieldfor EGD was 69% for group 1 and 82% for group 2. EGD was helpful for clinicalmanagement when performed for suspected gastrointestinal bleeding rather thanfor other indications. Mean gestational age at delivery, fetal weight and meanApgar score did not differ by groups. No fetal malformations were observed.CONCLUSION: Recurrent intractable vomiting in pregnancy may beaccompanied by esophagitis or peptic disease in a significant proportion ofpatients. Based on the significant pathologies amenable to medical therapy, atherapeutic trial with a proton pump inhibitor during hyperemesis gravidarumseems warranted. EGD can be safely performed in pregnancy with no maternalor fetal complications.

N Engl J Med. 2008 Jun 19;358(25):2744-5; author reply 2745-6.Comment on:N Engl J Med. 2008 Mar 6;358(10):1037-52.Acute pulmonary embolism.Alijotas-Reig J.N Engl J Med. 2008 Jun 26;358(26):2848; author reply 2848-9.Case 4-2008: A pregnant woman with a swollen left breast and dyspnea.Tolar J, Neglia JP.Am J Obstet Gynecol. 2008 Jul;199(1):10-8.Cervical neoplasia in pregnancy. Part 2: current treatment of invasivedisease.Hunter MI, Tewari K, Monk BJ.Department of Obstetrics and Gynecology, Division of Gynecologic Oncology,University of California, Irvine, Irvine, CA, USA.Although the incidence of cervical cancer in the United States has declinedsharply, many young women are diagnosed with the disease every year.Naturally, coincident pregnancies will occur in this subset of reproductively activepatients. Although the treatment of cervical cancer has evolved under the drive ofmulticenter, randomized trials, the same level of evidence does not exist for thetreatment of this malignancy in pregnancy. Treatment algorithms are thereforeproposed as a series of modifications to the guidelines intended for thenonpregnant patient, taking into account the tremendous social, ethical, andemotional dilemmas specific to each trimester at presentation.Am J Obstet Gynecol. 2008 Jul;199(1):3-9.Cervical neoplasia in pregnancy. Part 1: screening and management ofpreinvasive disease.Hunter MI, Monk BJ, Tewari KS.Department of Obstetrics and Gynecology, Division of Gynecologic Oncology,University of California, Irvine, Irvine, CA 92868, USA.Cervical cancer screening is an essential component of prenatal care. Thediagnosis and management of cervical intraepithelial neoplasia (CIN) duringpregnancy are challenging, and sufficient information does not exist to allow for adefinitive evidence-based approach. The American Society for Colposcopy andCervical Pathology has recently published guidelines regarding the evaluation ofabnormal Papanicolaou tests and the treatment of CIN in this setting. Manytechniques traditionally recommended in the evaluation of abnormal cervicalcytology and the treatment of CIN in the nonpregnant woman, such ascolposcopy, cervical biopsy, and electrosurgical excision, can be applied to thepregnant patient with important exceptions. The vascular cervix associated withthe gravid condition and the risk of premature pregnancy loss mandatesdeviation from existing consensus guidelines in screening for cervical cancer inpregnancy and treating associated CIN. In the present review, current guidelines

egarding cervical cancer screening are reviewed, and data from studies ofpregnant populations are summarized.BMJ. 2008 Jul 3;337:a427. doi: 10.1136/bmj.39566.681458.BE.Inflammatory bowel disease in pregnancy.Ferguson CB, Mahsud-Dornan S, Patterson RN.The Royal Hospitals, Belfast BT12 6BA.BMJ. 2008 Jun 28;336(7659):1502-4.Migraine in pregnancy.Goadsby PJ, Goldberg J, Silberstein SD.Headache Group, Department of Neurology, University of California, SanFrancisco, CA 94143-0114, USA. peter.goadsby@ucsf.eduJ Perinatol. 2008 Jul;28(7):451-2.Predicting proteinuria in pregnancy: a potential algorithm.Caughey AB.1Department of Obstetrics, Gynecology and Reproductive Sciences, Universityof California, San Francisco, San Francisco, CA, USA. E-mail:abcmd@berkeley.edu.J Reprod Med. 2008 Mar;53(3):203-6.Efficacy of rectal misoprostol as second-line therapy for the treatment ofprimary postpartum hemorrhage.Baruah M, Cohn GM.Division of Clinical and Reproductive Genetics, Department of Obstetrics andGynecology, Baystate Medical Center, Springfield, Massachusetts 01199, USA.OBJECTIVE: To assess the efficacy of rectal misoprostol as second-line therapyin the management of primary postpartum hemorrhage (PPH) as compared tomethylergonovine maleate. STUDY DESIGN: This was a retrospective cohortstudy. Charts from July 2000 to February 2005 were reviewed. Inclusion criteriawere patients between 37 and 42 weeks' gestational age who received a clinicaldiagnosis of PPH following delivery of a singleton pregnancy and who required asecond uterotonic following initial oxytocin therapy. The control grouprepresented those receiving methylergonovine maleate (18 patients), and thestudy group consisted of those receiving misoprostol (40 patients). RESULTS:There was no significant difference in maternal age, gestational age, parity ortype of delivery between the 2 groups. There was no significant differencebetween the 2 groups in the need for blood transfusion (methylergonovinemaleate group, 0/18 [0%], misoprostol group, 5/40 [12.5%] [p = 0.11]), the needfor third-line medical therapy (methylergonovine maleate group, 10/18 [55.5%],misoprostol group, 22/40 [55%] [p = 0.961) or the need for any surgicalintervention (methylergonovine maleate, 4/18 [22.2%], misoprostol 5/40 [12.5%][p = 0.51]). CONCLUSION: This limited study suggests that rectal misoprostol iscomparable to methergine as second-line therapy for the treatment of 1 primarypostpartum hemorrhage.

Obstet Gynecol. 2008 Jul;112(1):201-7.ACOG Practice Bulletin No. 95: Anemia in Pregnancy.[No authors listed]Obstet Gynecol. 2008 Jul;112(1):135-44.Protein/Creatinine ratio in preeclampsia: a systematic review.Papanna R, Mann LK, Kouides RW, Glantz JC.Department of Obstetrics and Gynecology, Rochester General Hospital, Affiliatedto the University of Rochester; and Departments of Obstetrics and Gynecologyand Maternal Fetal Medicine, University of Rochester Medical Center, Rochester,New York.OBJECTIVE: To estimate the accuracy of the protein/creatinine ratio in predicting300 mg of protein in 24-hour urine collection in pregnant patients with suspectedpreeclampsia. DATA SOURCES: Articles were identified through electronicdatabases (MEDLINE, CINHAL, and Cochrane) using the terms "preeclampsia,""protein/creatinine ratio," and "diagnosis," during the period January 1966 toOctober 2007. The relevant citations were hand searched. METHODS OFSTUDY SELECTION: Included studies evaluated patients for suspectedpreeclampsia with a 24-hour urine sample and a protein/creatinine ratio. OnlyEnglish-language articles were included. Studies including patients with onlychronic illness such as chronic hypertension, diabetes mellitus, or renalimpairment were excluded. Using the Quality Assessment of DiagnosticAccuracy Studies questionnaire, we created group 1 satisfying all the requiredcriteria and group 2 not satisfying all of it. Two researchers independentlyextracted the accuracy data. A graph comparing six receiver operatingcharacteristic curves was plotted. TABULATION, INTEGRATION, ANDRESULTS: Twenty-one studies were identified, but only seven met our inclusioncriteria (1,717 total patients). Group 1, with three studies, had 510 patients. Thestudies evaluated different cut points for positivity of protein/creatinine ratio from130 mg/g to 700 mg/g. For protein/creatinine ratio 130-150 mg/g, sensitivityranged from 90-99%, and specificity ranged from 33-65%; for protein/creatinineratio 300 mg/g, sensitivity ranged from 81-98% and specificity ranged from 52-99%; for protein/creatinine ratio 600-700mg/g, sensitivity ranged from 85-87%,and specificity ranged from 96-97%. CONCLUSION: Random protein/creatinineratio determinations are helpful primarily when they are below 130-150 mg/g, inthat 300 mg or more proteinuria is unlikely below this threshold. Midrangeprotein/creatinine ratio (300 mg/g) has poor sensitivity and specificity, requiring afull 24-hour urine for accurate results. Higher thresholds have not beenadequately studied.Obstet Gynecol. 2008 Jul;112(1):85-92.Maternal Thyroid Hypofunction and Pregnancy Outcome.Cleary-Goldman J, Malone FD, Lambert-Messerlian G, Sullivan L, Canick J,Porter TF, Luthy D, Gross S, Bianchi DW, D'Alton ME; for the FASTERConsortium. Columbia University Medical Center, New York, New York; Royal

College of Surgeons in Ireland, Dublin, Ireland; Alpert Medical School at BrownUniversity, Providence, Rhode Island; DM-STAT, Medford, Massachusetts;University of Utah Health Sciences Center, Salt Lake City, Utah; SwedishMedical Center, Seattle, Washington; Montefiore Medical Center, Bronx, NewYork; and Tufts University School of Medicine, Boston, Massachusetts.OBJECTIVE: To estimate whether maternal thyroid hypofunction is associatedwith complications. METHODS: A total of 10,990 patients had first- and secondtrimesterserum assayed for thyroid-stimulating hormone (TSH), free thyroxine(freeT4), and antithyroglobulin and antithyroid peroxidase antibodies. Thyroidhypofunction was defined as 1) subclinical hypothyroidism: TSH levels above the97.5th percentile and free T4 between the 2.5th and 97.5th percentiles or 2)hypothyroxinemia: TSH between the 2.5th and 97.5th percentiles and free T4below the 2.5th percentile. Adverse outcomes were evaluated. Patients withthyroid hypofunction were compared with euthyroid patients (TSH and free T4between the 2.5th and 97.5th percentiles). Patients with and without antibodieswere compared. Multivariable logistic regression analysis adjusted forconfounders was used. RESULTS: Subclinical hypothyroidism was documentedin 2.2% (240 of 10,990) in the first and 2.2% (243 of 10,990) in the secondtrimester. Hypothyroxinemia was documented in 2.1% (232 of 10,990) in the firstand 2.3% (247 of 10,990) in the second trimester. Subclinical hypothyroidismwas not associated with adverse outcomes. In the first trimester,hypothyroxinemia was associated with preterm labor (adjusted odds ratio [aOR]1.62; 95% confidence interval [CI] 1.00-2.62) and macrosomia (aOR 1.97; 95%CI 1.37-2.83). In the second trimester, it was associated with gestational diabetes(aOR 1.7; 95% CI 1.02-2.84). Fifteen percent (1,585 of 10,990) in the first and14% (1,491 of 10,990) in the second trimester had antithyroid antibodies. Whenboth antibodies were positive in either trimester, there was an increased risk forpreterm premature rupture of membranes (P=.002 and P

type of treatment, and survival were reviewed and compared. Predictive factorsfor death from breast cancer were identified using proportional hazards modeling.RESULTS: Seven hundred ninety-seven pregnancy-associated breast cancercases were compared with 4,177 non-pregnancy-associated breast cancercontrols. Pregnancy-associated breast cancer cases were significantly morelikely to have more advanced stage, larger primary tumor, hormone receptornegative tumor, and mastectomy as a component of their treatment. In survivalanalysis, pregnancy-associated breast cancer had a higher death rate than nonpregnancy-associatedbreast cancer (39.2% compared with 33.4%, P=.002). In amultivariable analysis, advancing stage (2.22-10.76 times the risk of death forstages II-IV), race (African Americans had 68% increased risk of death over non-Hispanic whites), hormone receptor-negative tumors (20% increased risk ofdeath over receptor-positive tumors), and pregnancy (14% increased risk ofdeath over nonpregnant women) all were significant predictors of death.CONCLUSION: Pregnancy-associated breast cancer presented with moreadvanced disease, larger tumors, and increased percentage of hormonereceptor-negative tumors. When controlled for stage, race, and hormone receptorstatus, pregnancy-associated breast cancer cases had a slightly higher risk ofdeath, even when only localized-stage disease was considered. LEVEL OFEVIDENCE: II.Acta Obstet Gynecol Scand. 2008;87(6):662-8.Severe maternal morbidity and the mode of delivery.Pallasmaa N, Ekblad U, Gissler M.Department of Obstetrics and Gynecology, Turku University Central Hospital,Turku, Finland. nanneli.pallasmaa@tyks.fiOBJECTIVE: To define the rate of severe maternal morbidity in different modesof delivery and to find out if the rate of severe morbidity has changed over a 5-year time span. DESIGN: Retrospective register-based study. SETTING: FinnishMedical Birth Registry and Hospital Discharge Registry. POPULATION: Allsingleton deliveries in Finland in 1997 and 2002 (n=110,717). METHODS:Diagnoses and operative interventions recorded in the Hospital DischargeRegistry indicating a severe maternal complication were linked with BirthRegister data and compared by mode of delivery: spontaneous vaginal delivery(VD), instrumental VD, elective cesarean section and non-elective cesareansection. Main outcome measures were severe maternal morbidity: deep venousthromboembolism and amniotic fluid embolism, major puerperal infection, severehemorrhage, events requiring operative intervention after delivery, uterine ruptureand inversion, and intestinal obstruction. RESULTS: Severe maternal morbiditywas more frequent in cesarean than vaginal deliveries (p

maternal morbidity has increased both in cesarean and vaginal deliveries from1997 to 2002. Cesarean delivery, even an elective one, carries a significantlyhigher risk of life-threatening maternal complications than VD.Acta Obstet Gynecol Scand. 2008;87(6):652-61.Risk factors and interventions associated with major primary postpartumhemorrhage unresponsive to first-line conventional therapy.Mousa HA, Cording V, Alfirevic Z.Division of Perinatal and Reproductive Medicine, University of Liverpool,Liverpool, UK. mousa339@hotmail.comBACKGROUND: To examine risk factors and interventions associated with majorprimary postpartum hemorrhage (PPH) unresponsive to first-line conventionaltherapy. METHODS: From computerized maternity database, we identifiedwomen with major primary PPH defined as blood loss >or=1,000 ml and/or theneed for a blood transfusion within 24 h of delivery beyond 24 weeks' gestation.Cases were assigned according to the mode of delivery and response to the firstlinetherapy (responders and non-responders). RESULTS: Between 1998 and2002, 20,610 women delivered after 24 weeks' gestation. A total of 306 womendeveloped primary PPH (14.8/1,000 deliveries) including 103 vaginal and 203caesarean (CS) births. Out of 103 women with PPH following vaginal birth, 22(21%) failed to respond to first-line therapy. Following CS, 20 of 203 (10%) failedfirst line treatment and required examination under anesthesia (EUA) and otherinterventions to control bleeding. Irrespective of the mode of delivery, antepartumrisk factors did not differ between responders and non-responders to first-linetherapy. In the vaginal group, non-responders were treated with requiredbimanual compression and intra-myometrial PGF(2)alpha (49%), repair ofcervical tear (14%), vaginal packing (9%), and uterine packing (5%). In the CSgroup, hysterectomy was the most common surgical intervention (54%) afterother methods including uterine packing, B-Lynch procedure, uterine tamponade,and intra-myometrial prostaglandin were ineffective. CONCLUSIONS: Thecurrently known risk factors for primary PPH are not useful in the identification ofpatients who continue to bleed after first-line therapy. Emergency hysterectomywas the most common surgical intervention used to control major PPHunresponsive to conventional therapy following CS birth.Acta Obstet Gynecol Scand. 2008;87(6):635-42.Maternal factor V Leiden mutation is associated with HELLP syndrome inCaucasian women.Muetze S, Leeners B, Ortlepp JR, Kuse S, Tag CG, Weiskirchen R, GressnerAM, Rudnik-Schoeneborn S, Zerres K, Rath W.Department of Obstetrics and Gynecology, RWTH Aachen University Hospital,Aachen, Germany. smuetze@ukaachen.deOBJECTIVE: There is growing evidence that hypertensive pregnancycomplications and other adverse pregnancy outcomes are associated with thepresence of inherited or acquired thrombophilias. As hemolysis, elevated liverenzymes, low platelets (HELLP) syndrome is one of the most severe forms of

pre-eclampsia we aimed to assess the prevalence of the factor V Leiden, theprothrombin 20210G >A mutation and the methylenetetrahydrofolate reductase(MTHFR) 677C >T polymorphism in women with HELLP syndrome and in theirfetuses from the same index pregnancy. DESIGN: The study was performedretrospectively in a case-control design. SAMPLE: Seventy-one mother-childpairs with HELLP syndrome and 79 control mother-child pairs with uncomplicatedpregnancies were included in the study. METHODS: Genotyping of the threethrombophilic mutations was performed using the LightCycler technology. Thechi-squared test was used for statistical analysis. Main outcome measures werematernal and fetal genotypes and their correlation with clinical parameters.RESULTS: Maternal heterozygosity for factor V Leiden was significantly moreprevalent in the HELLP group than in controls (OR 4.45, 95% CI 1.31-15.31). Nosignificant association was observed for maternal prothrombin mutation orMTHFR polymorphism (p=0.894, p=0.189, respectively). The fetal genotype wasnot associated with HELLP syndrome for any of the three mutations investigated.Analysis of gene-gene interactions and genotype-phenotype correlation withrespect to clinical parameters and perinatal outcome revealed no furtherdifferences. CONCLUSIONS: Our study confirms that women heterozygous forfactor V Leiden have an increased risk of developing HELLP syndrome, while themost frequent mutations of the prothrombin and MTHFR gene do not play amajor role in the pathogenesis of HELLP syndrome.Acta Obstet Gynecol Scand. 2008 Jun 14:1-6. [Epub ahead of print]Acidemia at birth, related to obstetric characteristics and to oxytocin use,during the last two hours of labor.Maria J, Solveig NL, Ingrid O, Ulf H.Department of Women's and Children's Health, Uppsala University, Uppsala,Sweden.Objective. Evaluate obstetric characteristics during the last two hours of labor inneonates born with acidemia. Design. Case-control study. Setting. Delivery unitsat two university hospitals in Sweden. Study population. Out of 28,486 deliveriesduring 1994-2004, 305 neonates had an umbilical artery pH value /=7 at 5 minutes. Obstetriccharacteristics, cardiotocographic patterns and oxytocin treatment during the lasttwo hours of labor were recorded. Results. In the univariate analysis, >/=6contractions/10 minutes (odds ratio (OR) 4.94, 95% confidence interval (CI) 3.25-7.49), oxytocin use (OR 2.20, 95% CI 1.66-2.92), bearing down >/=45 minutes(OR 1.77, 95% CI 1.31-2.38) and occipito-posterior position (OR 2.18, 95% CI1.19-3.98) were associated with acidemia at birth. In the multivariate analysis,only >/=6 contractions/10 minutes (OR 5.36, 95% CI 3.32-8.65) and oxytocin use(OR 1.89, 95% CI 1.21-2.97) were associated with acidemia at birth. Amongcases with >/=6 contractions/10 minutes, 75% had been treated with oxytocin.Pathological cardiotocographic patterns occurred in 68.8% of cases and in 26.1%of controls (p

increased uterine activity was related to overstimulation in the majority of cases.The duration of bearing down is less important when uterine contractionfrequency has been considered.Am J Obstet Gynecol. 2008 Jun;198(6):700.e1-5.Length of rupture of membranes in the setting of premature rupture ofmembranes at term and infectious maternal morbidity.Tran SH, Cheng YW, Kaimal AJ, Caughey AB.Department of Obstetrics, Gynecology, and Reproductive Sciences, University ofCalifornia, San Francisco, School of Medicine, San Francisco, CA, USA.OBJECTIVE: This study was undertaken to define the time thresholds ofincreased risk for infectious maternal morbidities with relationship to length ofruptured membranes at term. STUDY DESIGN: We designed a retrospectivecohort study of all women with premature rupture of membranes beyond 37weeks' gestation at a single institution. Dichotomized time thresholds of length ofruptured membranes before delivery were examined in 2-hour increments usingbivariate and multivariable analyses to assess the rates of chorioamnionitis andendomyometritis. RESULTS: Among the 3841 women meeting inclusion criteria,increased rates of chorioamnionitis and endomyometritis were noted at timethresholds of 12 hours (adjusted odds ratio 2.3 [95% confidence interval, 1.2-4.4]) and 16 hours (adjusted odds ratio 2.5 [95% confidence interval, 1.1-5.6]),respectively. CONCLUSION: We found that when length of time of rupturedmembranes before delivery is examined via dichotomized time thresholds, therisks of chorioamnionitis and endomyometritis are significantly increased at 12hours and 16 hours, respectively. These time thresholds derived fromdichotomized time analyses should be considered during risk-based counselingand labor management in the setting of term premature rupture of membranes.Am J Obstet Gynecol. 2008 Jun;198(6):622.e1-7. Epub 2008 Mar 20.Improving patient safety and uniformity of care by a standardized regimenfor the use of oxytocin.Hayes EJ, Weinstein L.Department of Obstetrics and Gynecology, Thomas Jefferson University,Philadelphia, PA 19107, USA.Oxytocin is 1 of the most commonly used drugs in labor and has been associatedwith adverse maternal and fetal outcomes. In an attempt to improve patientsafety, we constructed a standardized protocol for labor induction with oxytocin.We reviewed the numerous publications regarding oxytocin use for eitherinduction or augmentation of labor in order to determine if there was a protocolavailable that would maximize success of delivery and minimize the adversematernal and fetal effects of the drug. Using the literature review and the specificpharmacokinetics of oxytocin, we developed a standardized approach for thedilution and administration of oxytocin in order to improve patient safety, developuniformity of the drug use, maximize its benefits, and minimize its side effects.We suggest that a standardized approach to oxytocin use be adopted that uses

an oxytocin dilution of 10 mU/mL, initial dose of 2 mU/min (12 mL/hr),incremental increase of 2 mU (12 mL) every 45 minutes until adequate labor withthe maximum dose being 16 mU/min (96 mL/hr).Int J Gynaecol Obstet. 2008 Jul 15. [Epub ahead of print]Pregnancy complicated by myocardial infarction.Brahim YB, Landoulsi H, Yassin A, Falfoul A.Obstetrics and Gynecology Department, Mohamed Tlatli Hospital, Nabeul,Tunisia.Int J Gynaecol Obstet. 2008 Jul 14. [Epub ahead of print]Duration of bladder catheterization after surgery for obstetric fistula.Nardos R, Browning A, Member B.Bahir Dar Hamlin Fistula Center, Bahir Dar, Ethiopia.OBJECTIVE: To compare the surgical outcome at discharge and at 6-monthsfollow up in patients who underwent repair of obstetric fistulae with postoperativebladder catheterization for 10, 12, or 14 days. METHODS: A retrospective studyof 212 obstetric fistula patients who underwent repair with postoperative bladdercatheterization for 10 days (group 1), 12 days (group 2), and 14 days (group 3) atthe Bahir Dar Hamlin Fistula Center in Ethiopia. Fistulas were classifiedaccording to Goh's system. RESULTS: There were 68 women (32%) in group 1,62 women (29%) in group 2, and 82 women (39%) in group 3. There was asignificant difference in the extent of urethral involvement, fistula size, anddegree of vaginal scarring among the 3 groups, with the more extensivelydamaged patients catheterized for longer. Breakdown of repair was seen in 1.5%of patients in group 1, none in group 2, and 2% in group 3 (P=0.47).CONCLUSION: Postoperative catheterization for 10 days may be sufficient formanagement of less complicated obstetric vesicovaginal fistulae.J Perinatol. 2008 Jul 17. [Epub ahead of print]Gestational diabetes: diagnosis and management.Cheng YW, Caughey AB.1Department of Obstetrics and Gynecology, University of California, SanFrancisco, CA, USA.Purpose:To review the diagnosis and management of gestationaldiabetes.Epidemiology:In the United States, approximately 2 to 5% of allpregnant women have gestational diabetes. Those women with a family historyof type 2 diabetes mellitus, Asian or native American race, Latina ethnicity orobesity are at higher risk for developing gestational diabetes.Conclusion:Womenwith gestational diabetes who are treated appropriately can achieve goodoutcomes in the majority of pregnancies. Frequent blood glucose monitoring,nutrition counseling and frequent physician contact allow for individualized careto achieve optimal outcomes. Such treatment includes diet, exercise and insulin.The use of oral hypoglycemic agents is controversial and there is some concernabout worse maternal and neonatal outcomes as compared to treatment withinsulin. Evolving technologies promise to provide more therapeutic

options.Journal of Perinatology advance online publication, 17 July 2008;doi:10.1038/jp.2008.62.Am J Obstet Gynecol. 2008 Jul;199(1):36.e1-5; discussion 91-2. e7-11. Epub2008 May 2.Maternal death in the 21st century: causes, prevention, and relationship tocesarean delivery.Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD.Hospital Corporation of America, Nashville, TN, USA.steven.clark@mountainstarhealth.comOBJECTIVE: We sought to examine etiology and preventability of maternal deathand the causal relationship of cesarean delivery to maternal death in a series ofapproximately 1.5 million deliveries between 2000 and 2006. STUDY DESIGN:This was a retrospective medical records extraction of data from all maternaldeaths in this time period, augmented when necessary by interviews withinvolved health care providers. Cause of death, preventability, and causalrelationship to mode of delivery were examined. RESULTS: Ninety-five maternaldeaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.)Leading causes of death were complications of preeclampsia, pulmonarythromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiacdisease. Only 1 death was seen from placenta accreta. Twenty-seven deaths(28%) were deemed preventable (17 by actions of health care personnel and 10by actions of non-health care personnel). The rate of maternal death causallyrelated to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per100,0000 for cesarean delivery, suggesting that the number of annual deathsresulting causally from cesarean delivery in the United States is about 20.CONCLUSION: Most maternal deaths are not preventable. Preventable deathsare equally likely to result from actions by nonmedical persons as from providererror. Given the diversity of causes of maternal death, no systematic reduction inmaternal death rate in the United States can be expected unless all womenundergoing cesarean delivery receive thromboembolism prophylaxis. Such apolicy would be expected to eliminate any statistical difference in death ratescaused by cesarean and vaginal delivery.Am J Obstet Gynecol. 2008 Jul;199(1):32.e1-5. Epub 2008 May 2.Higher maximum doses of oxytocin are associated with an unacceptablyhigh risk for uterine rupture in patients attempting vaginal birth aftercesarean delivery.Cahill AG, Waterman BM, Stamilio DM, Odibo AO, Allsworth JE, Evanoff B,Macones GA.Department of Obstetrics and Gynecology, Washington University School ofMedicine, St Louis, MO, USA.OBJECTIVE: The objective of the study was to more precisely estimate the effectof maximum oxytocin dose on uterine rupture risk in patients attempting vaginalbirth after cesarean (VBAC) by considering timing and duration of therapy.STUDY DESIGN: A nested case-control study was conducted within a

multicenter, retrospective cohort study of more than 25,000 women with at least1 prior cesarean delivery, comparing cases of uterine rupture with controls (norupture) while attempting VBAC. Time-to-event analyses were performed toexamine the effect of maximum oxytocin dose on the risk of uterine ruptureconsidering therapy duration, while adjusting for confounders. RESULTS: Withinthe nested case-control study of 804 patients, 272 were exposed to oxytocin: 62cases of uterine rupture and 210 controls. Maximum oxytocin ranges above 20mU/min increased the risk of uterine rupture 4-fold or greater (21-30 mU/min:hazard ratio [HR] 3.92, 95% confidence interval [CI], 1.06 to 14.52; 31-40mU/min: HR 4.57, 95% CI, 1.00 to 20.82). CONCLUSION: These findingssupport a maximum oxytocin dose of 20 mU/min in VBAC trials to avoid anunacceptably high risk of uterine rupture.Am J Obstet Gynecol. 2008 Jul;199(1):30.e1-5. Epub 2008 Apr 25.Prediction of uterine rupture associated with attempted vaginal birth aftercesarean delivery.Grobman WA, Lai Y, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW,Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M,Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, MercerBM; National Institute of Child Health and Human Development Maternal-FetalMedicine Units Network.Collaborators: Gilbert S, Johnson F, Gold J, Peaceman AM, Iams J, Johnson F,Meadows S, Walker H, Northen A, Tate S, Bloom S, Gold J, Bradford D, BelfortM, Porter F, Oshiro B, Anderson K, Guzman A, Hibbard J, Jones P, Ramos-Brinson M, Moran M, Scott D, Lain K, Cotroneo M, Fischer D, Luce M, Meis P,Swain M, Moorefield C, Lanier K, Steele L, Sciscione A, DiVito M, Talucci M,Pollock M, Norman G, Millinder A, Sudz C, Steffy B, Siddiqi T, How H, Elder N,Malone F, D'Alton M, Pemberton V, Carmona V, Husami H, Silver H, TillinghastJ, Catlow D, Allard D, Peaceman A, Socol M, Gradishar D, Mallett G, Burkett G,Gilles J, Potter J, Doyle F, Chandler S, Mabie W, Ramsey R, Conway D, BarkerS, Rodriguez M, Moise K, Dorman K, Brody S, Mitchell J, Gilstrap L, Day M, KerrM, Kerr M, Gildersleeve E, Catalano P, Milluzzi C, Slivers B, Santori C, Thom E,Gilbert S, Juliussen-Stevenson H, Fischer M, McNellis D, Howell K, Pagliaro S.Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL,USA. w-grobman@northwestern.eduOBJECTIVE: The purpose of this study was to develop a model that predictsindividual-specific risk of uterine rupture during an attempted vaginal birth aftercesarean delivery. STUDY DESIGN: Women with 1 previous low-transversecesarean delivery who underwent a trial of labor with a term singleton wereidentified in a concurrently collected database of deliveries that occurred at 19academic centers during a 4-year period. We analyzed different classificationtechniques in an effort to develop an accurate prediction model for uterinerupture. RESULTS: Of the 11,855 women who were available for analysis, 83women (0.7%) had had a uterine rupture. The optimal final prediction model,which was based on a logistic regression, included 2 variables: any previousvaginal delivery (odds ratio, 0.44; 95% CI, 0.27-0.71) and induction of labor (odds

atio, 1.73; 95% CI, 1.11-2.69). This model, with a c-statistic of 0.627, had poordiscriminating ability and did not allow the determination of a clinically usefulestimate of the probability of uterine rupture for an individual patient.CONCLUSION: Factors that were available before or at admission for deliverycannot be used to predict accurately the relatively small proportion of women atterm who will experience a uterine rupture during an attempted vaginal birth aftercesarean delivery.Am J Obstet Gynecol. 2008 Jul 16. [Epub ahead of print]Advanced extrauterine pregnancy: diagnostic and therapeutic challenges.Mahajan NN.Assistant Professor, Department of Obstetrics and Gynecology, B. Y. L. NairCharitable Hospital and T. N. Medical College, Dr. A. Nair road, Mumbai, Pin400008, Maharashtra, India.Hum Reprod. 2008 Jul;23(7):1553-9. Epub 2008 May 6.Serious primary post-partum hemorrhage, arterial embolization and futurefertility: a retrospective study of 46 cases.Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert P.Department of Gynecology-Obstetrics, University Hospital NORD, F-42055 Saint-Etienne Cedex 2, France. celine.chauleur@chu-st-etienne.frBACKGROUND: The guidelines advise arterial embolization in case of postpartumhemorrhage. We evaluated its feasibility and the subsequent fertility.METHODS: A retrospective study has been conducted in our center for the past10 years (1996-2005). Fifty-two patients experiencing a primary post-partumhemorrhage who were resistant to medical treatment underwent uterine arteryembolization and/or hysterectomy. In case of arterial embolization, a follow-up ofall the patients was realized, focusing on the preservation of fertility. RESULTS:Six (11.5%) patients underwent hysterectomy straightaway and 46 (88.5%)arterial embolization in the first instance including 35 arterial embolizations afterCesarean section. Embolization was successful among 41 patients (89.1%) andhysterectomy was performed on the 5 (10.9%) others. Overall, 11/24 398 womensuffered from a definitive loss of fertility after post-partum hemorrhage. Fertilitywas studied at least 1 year after the delivery. All patients had a return of normalmenses. Sixteen of 41 women (39%) wanted another child and 100%succeeded. Nineteen pregnancies, including two twin pregnancy and one earlyspontaneous abortion were observed. CONCLUSIONS: Embolization is a safeand effective non-surgical method to resolve post-partum hemorrhage andshould be regarded as gold standard in a hemodynamically stable patient.Furthermore, subsequent fertility is not impaired by the procedure.Int J Gynaecol Obstet. 2008 Jul 16. [Epub ahead of print]Gitelman syndrome in pregnancy.de Haan J, Geers T, Berghout A.Department of Internal Medicine, Medical Center Rijnmond-Zuid, Rotterdam, theNetherlands.

Obstet Gynecol. 2008 Jun;111(6):1335-41.Rapid group B streptococci screening using a real-time polymerase chainreaction assay.Edwards RK, Novak-Weekley SM, Koty PP, Davis T, Leeds LJ, Jordan JA.Phoenix Perinatal Associates, Obstetrix Medical Group of Phoenix, Phoenix,Arizona 85014, USA. rodney_edwards@pediatrix.comOBJECTIVE: To estimate the clinical performance characteristics of a real-timepolymerase chain reaction (PCR) assay using vaginal/rectal swabs fromantepartum (35-37 weeks of gestation) and intrapartum women. METHODS: Theassay evaluated is a qualitative, automated, real-time PCR test for the detectionof group B streptococci, with results available in approximately 75 minutes.Enrollment in this multicenter clinical study occurred between October 2005 andJanuary 2006. Vaginal/rectal swabs were analyzed by nursing personnel(intrapartum tests) or by laboratory technologists (all others). Polymerase chainreaction assay results were compared with culture using standard methods,including selective broth medium, and to a predicate nucleic acid amplificationtest. RESULTS: Of 1,028 enrolled women, 234 were deemed ineligible, and 10had unresolved test results. Of the 784 remaining women, valid PCR assayresults were obtained on the first test attempt for 93.0%. Performancecharacteristics relative to culture were sensitivity 91.1%, specificity 96.0%,positive predictive value 87.8%, negative predictive value 97.1%, and accuracy94.8%. These results exceeded those obtained using the predicate nucleic acidamplification test. CONCLUSION: Performance characteristics of the PCR assayexceed the threshold recommended by the Centers for Disease Control andPrevention when compared with culture. The test is sufficiently robust to beperformed for intrapartum patients in a point-of-care setting by medicalprofessionals. LEVEL OF EVIDENCE: II.Obstet Gynecol. 2008 Jun;111(6):1268-73.Comment in: Obstet Gynecol. 2008 Jun;111(6):1264-5.Antibiotic prophylaxis for prevention of postpartum perineal woundcomplications: a randomized controlled trial.Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY.Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center,San Jose, California 95128, USA. neene.duggal@hhs.sccgov.orgOBJECTIVE: To estimate whether prophylactic antibiotics at the time of repair ofthird- or fourth-degree perineal tears after vaginal delivery prevent woundinfection and breakdown. METHODS: This was a prospective, randomized,placebo-controlled study. Patients who sustained third- or fourth-degree perinealtears after a vaginal delivery were recruited for the study. Each patient was givena single intravenous dose of a second-generation cephalosporin (cefotetan orcefoxitin) or placebo before repair of third- or fourth-degree perineal tears.Obstetricians and patients were blinded to study drug. The perineum wasinspected for evidence of infection or breakdown at discharge from the hospitaland at 2 weeks postpartum. Primary end points were gross disruption or purulent

discharge at site of perineal repair by 2 weeks postpartum. RESULTS: Onehundred forty-seven patients were recruited for the study. Of these, 83 patientsreceived placebo and 64 patients received antibiotics. Forty patients (27.2%) didnot return for their 2-week appointment. Of the patients seen at 2 weekspostpartum, 4 of 49 (8.2%) patients who received antibiotics and 14 of 58(24.1%) patients who received placebo developed a perineal wound complication(P=.037). There were no differences between groups in parity, incidence ofdiabetes, operative delivery, or third-degree compared with fourth-degreelacerations. CONCLUSION: By 2 weeks postpartum, patients who receivedprophylactic antibiotics at the time of third- or fourth-degree laceration repair hada lower rate of perineal wound complications than patients who received placebo.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clincaltrials.gov,NCT00186082. LEVEL OF EVIDENCE: I.Am J Obstet Gynecol. 2008 Jul 28. [Epub ahead of print]The effect of newly diagnosed undifferentiated connective tissue diseaseon pregnancy outcome.Spinillo A, Beneventi F, Epis OM, Montanari L, Mammoliti D, Ramoni V, DiSilverio E, Alpini C, Caporali R, Montecucco C.Departments of Obstetrics and Gynecology, University of Pavia, Pavia, Italy.OBJECTIVE: The purpose of this study was to evaluate pregnancy outcome in acohort of patients with newly diagnosed undifferentiated connective tissuedisease (UCTD). STUDY DESIGN: We conducted a nested case-control studythat compared 41 patients who had early UCTD that was diagnosed at 11-14weeks of pregnancy with 82 healthy control subjects. RESULTS: Duringpregnancy, UCTD progressed to a definite connective tissue disease in 2 of 41patients (4.9%). Sixteen of the 41 patients (39%) with UCTD tested positive foranti-Ro (SSA) antibodies. Compared with the control subjects, the women withUCTD had higher rates of small for gestational age (SGA; 12/40 vs 11/80; P =.05). The rate of complications of pregnancy (preterm delivery at

Eur J Obstet Gynecol Reprod Biol. 2008 Apr;137(2):172-7. Epub 2007 Oct 24.Use of recombinant activated factor VII in massive postpartumhaemorrhage.Bouma LS, Bolte AC, van Geijn HP.Free University Medical Centre, Department of Obstetrics and Gynaecology,P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. ls.bouma@vumc.nlOBJECTIVE: Postpartum haemorrhage (PPH) remains an important cause ofmaternal morbidity and mortality. With regard to morbidity, preservation of theuterus is of paramount importance in fertile women. The objective of the studywas to describe the cumulative experience of a cohort of women that weretreated with recombinant factor VIIa. STUDY DESIGN: In this retrospective,descriptive study we approached all departments of obstetrics and gynaecologyin the Netherlands to find out if they had used rFVIIa for this indication. Twentysevencases were reported to us. To evaluate each case, we used astandardized case record form. RESULTS: The main cause of PPH was uterineatony (82%). In 21 cases rFVIIa was explicitly given to prevent a hysterectomy.This was successful in 16 cases (76%). Relevant reduction or completecessation of bleeding after rFVIIa was noted in 24/27 cases (89%). There was areduction in blood product requirements following rFVIIa administration. Thedose of rFVIIa was variable and ranged from 16 to 128mug/kg. CONCLUSION:There appears to be a role for the use of rFVIIa in PPH unresponsive toconventional therapy. Recombinant FVIIa can be helpful and avoid anemergency hysterectomy.Eur J Obstet Gynecol Reprod Biol. 2008 Apr;137(2):210-6. Epub 2007 Apr 24.Re-evaluation of the indication for and limitation of laparoscopicsalpingotomy for tubal pregnancy.Fujishita A, Khan KN, Kitajima M, Hiraki K, Miura S, Ishimaru T, Masuzaki H.Department of Obstetrics and Gynecology, Nagasaki University School ofMedicine, Nagasaki, Japan. sanka_fujishita@nmh.jp OBJECTIVE: We investigated the outcome of laparoscopic salpingotomy fortubal pregnancy by follow-up hysterosalpingography (HSG) or second-looklaparoscopy (SLL) and reexamined the indication for and limitation of thisconservative surgery. STUDY DESIGN: From April 1991 to December 2003, wetreated 181 cases of tubal pregnancy using laparoscopic salpingotomy. The tubalpatency was assessed by either HSG or SLL performed at 3 months postsurgery.The patients with a successful initial operation and confirmed ipsilateralpatent tubes at follow-up were classified as truly successful cases (group I). Evenafter successful operation, if the treated tubes were found to be occluded, theywere considered as unsuccessful cases. Therefore, those cases that wereunsuccessful at initial surgery as well as at follow-up were categorized as groupII. RESULTS: One hundred and thirty-four cases (74%) were successfully treatedby salpingotomy at initial laparoscopy and 85 of them (63.4%) were found to betruly successful at follow-up (group I). The remaining 47 cases (26.0%) wereunsuccessful at initial surgery and 18 (13.4%) cases at follow-up (group II).

Thirty-one other patients refused to accept a tubal patency test or were notexamined for personal reasons or were lost to follow-up. No difference in surgicaloutcome was observed between these two groups of patients with regard togestational age, intra-operative hemorrhage, size or anatomic location of thepregnancy mass, and pre-operative adhesions of the fallopian tube. However,pre-operative serum levels of hCG were significantly higher in group II than ingroup I. In addition, the unsuccessful cases were more frequently associated withpositive fetal heart beat (FHB), tubal rupture, and pre-operative serum levels ofhCG of more than 10,000 IU/l (p

Ault KA.Department of Gynecology and Obstetrics, Emory University School of Medicine,Atlanta, Georgia, USA. kevin.ault@emory.eduInt J Gynaecol Obstet. 2008 Apr;101(1):94-9. Epub 2008 Mar 4.Comment in:Int J Gynaecol Obstet. 2008 Apr;101(1):93.Factors associated with acute postpartum hemorrhage in low-risk womendelivering in rural India.Geller SE, Goudar SS, Adams MG, Naik VA, Patel A, Bellad MB, Patted SS,Edlavitch SA, Moss N, Kodkany BS, Derman RJ.University of Illinois, Chicago College of Medicine, Chicago, IL, USA.SGeller@uic.eduOBJECTIVE: Postpartum hemorrhage (PPH), a major cause of maternalmortality and morbidity in low-income countries, can occur unpredictably. Thisstudy examined the sociodemographic, clinical, and perinatal characteristics oflow-risk women who experienced PPH. METHODS: This analysis was conductedusing data on 1620 women from a randomized trial testing oral misoprostol forprevention of PPH in rural India. RESULTS: Of the women, 9.2% experiencedPPH. No maternal or sociodemographic factors and few perinatal factors differedbetween women with PPH and those without, other than treatment withmisoprostol. Having fewer than 4 prenatal visits and lack of iron supplementationincreased the risk for PPH (P&lt;0.001 and P=0.037, respectively). Severalfactors unknown until the second stage of labor (perineal tear and birth weight)were also associated (P=0.003). CONCLUSIONS: Among women at low risk forPPH, there were few factors associated with further risk. Given that PPH canoccur without warning, rural communities should consider ways to increase bothprimary prevention (iron supplementation, AMTSL) and secondary prevention ofPPH (availability of obstetric first aid, availability of transport, and availability ofemergency obstetric care).Int J Gynaecol Obstet. 2008 Apr;101(1):77-8. Epub 2007 Nov 26.Comparison of scarred and unscarred uterine ruptures.Sahu L, Rani R.Department of Obstetrics and Gynecology, Jawaharlal Institute of PostgraduateMedical Education and Research, Pondicherry, India. drksahoo@gmail.comN Engl J Med. 2008 Jul 31;359(5):509-15.Case records of the Massachusetts General Hospital. Case 24-2008. A 35-yearoldwoman with postpartum confusion, agitation, and delusions.Viguera AC, Emmerich AD, Cohen LS.Department of Psychiatry, Massachusetts General Hospital, USA.Obstet Gynecol. 2008 Aug;112(2):501-3.Resistance to thyroid hormone in pregnancy.Dhingra S, Owen PJ, Lazarus JH, Amin P.

Department of Obstetrics and Centre for Endocrine and Diabetes Sciences,University Hospital of Wales, Cardiff, United Kingdom.BACKGROUND: Resistance to thyroid hormone manifests as high serum levelsof free thyroxine and free triiodothyronine, with nonsuppressed thyroidstimulating hormone (TSH) levels. We report a case series of three patients withthis condition, the changes in thyroid function tests during their pregnancies, andtheir obstetric outcome. CASES: Three pregnant women with asymptomaticresistance to thyroid hormone developed goiter, and the levels of TSH in onecase suppressed progressively, necessitating treatment. The neonates born to allthese reported cases were healthy, with normal growth scans and normal thyroidfunction tests at 1 week. CONCLUSION: The prenatal diagnosis of resistance tothyroid hormone is important for adequate management of both mother and fetusin pregnancy and avoiding unnecessary intervention.The only clinicalmanifestation of resistance to thyroid hormone may be the presence of a goiter,and treatment in asymptomatic patients solely to normalize thyroid hormonelevels is not required during pregnancy. Careful evaluation of the neonate isindicated after delivery.Obstet Gynecol. 2008 Aug;112(2):483-5.Fascioliasis in pregnancy.Alatoom A, Sheffield J, Gander RM, Shaw J, Cavuoti D.Departments of Pathology, Obstetrics and Gynecology, and Internal Medicine,University of Texas Southwestern Medical Center, Dallas, Texas.BACKGROUND: Fascioliasis is a common zoonotic infection worldwide, althoughcases in the United States are uncommon, sporadic, and predominantly found inthe immigrant population. The small number of cases identified in the UnitedStates may reflect the unfamiliarity of physicians with this infection. CASE: A 28-year-old Hispanic woman who frequently visited northern Central Mexicopresented at 36 weeks of gestation with nausea, vomiting, and right upperquadrant pain. She was diagnosed with cholelithiasis. Postpartum endoscopicretrograde cholangiopancreatography and sphincterotomy were performed, withdiscovery of the trematode Fasciola hepatica. The patient receivedtriclabendazole, which led to clinical improvement. CONCLUSION: Fascioliasisoften mimics another common problem in pregnancy, cholelithiasis; cliniciansneed to be aware of this disease in high-risk populations.Obstet Gynecol. 2008 Aug;112(2):455-457.Eczema Herpeticum in Pregnancy and Neonatal Herpes Infection.Dicarlo A, Amon E, Gardner M, Barr S, Ott K.St. Louis University School of Medicine; Department of Obstetrics andGynecology, Division of Maternal-Fetal Medicine, St. Louis University School ofMedicine; St. Mary's Health Center, St. Louis, Missouri; Department of InternalMedicine, Division of Infectious Disease, St. Mary's Health Center, St. Louis,Missouri; and Department of Obstetrics and Gynecology, St. Louis UniversitySchool of Medicine, St. Louis, Missouri.

BACKGROUND: Eczema herpeticum is caused by herpes simplex infection ofatopic dermatitis. The infection typically causes a vesiculopustular rash, but candisseminate and be life threatening. CASE: A primigravida with a history ofeczema and hypogammaglobulinemia presented at 28 weeks of gestation withpreterm labor, fever, and extensive rash. After failed tocolysis, she deliveredvaginally. Prompt treatment with parenteral acyclovir was initiated for bothpatients based on a clinical diagnosis of maternal eczema herpeticum. Culturesconfirmed the diagnosis of eczema herpeticum and rectal swab of the infant waspositive for herpes simplex virus. The mother and infant did well. CONCLUSION:Early diagnosis and treatment of eczema herpeticum is necessary to preventpoor outcomes in pregnancy. Prophylactic acyclovir may help prevent eczemaherpeticum in pregnancy.Obstet Gynecol. 2008 Aug;112(2):450-2.Takotsubo cardiomyopathy in pregnancy.Brezina P, Isler CM.Department of Obstetrics and Gynecology, Brody School of Medicine at EastCarolina University, Greenville, North Carolina.BACKGROUND: Takotsubo cardiomyopathy is a cardiac condition associatedwith the acute onset of chest pain, abnormalities in cardiac enzymes andelectrocardiogram, and a distinct pattern of left ventricular dysfunction onechocardiography. This case evaluates an obstetric patient diagnosed withTakotsubo cardiomyopathy during her 23rd week of pregnancy. CASE: A woman(G3P2002) at 23 weeks in an intrauterine pregnancy was admitted with chestpain. ST-segment elevation was noted on electrocardiogram with elevatedcardiac enzymes. Subsequent tracings showed resolution of ST elevation withconservative management. Echocardiography was consistent with Takotsubocardiomyopathy. She delivered through spontaneous vaginal delivery at termafter a complete resolution of her cardiomyopathy. CONCLUSION: Althoughuncommon, physicians who manage cardiac complications should be familiarwith the diagnosis and management of Takotsubo cardiomyopathy.Obstet Gynecol. 2008 Aug;112(2):432-3.Lepirudin for treatment of acute thrombosis during pregnancy.Chapman ML, Martinez-Borges AR, Mertz HL.Department of Obstetrics and Gynecology, Wake Forest University School ofMedicine, Winston-Salem, North Carolina.BACKGROUND: Thromboprophylaxis during pregnancy can be challengingwhen heparin is contraindicated. Limited data exist regarding alternativeanticoagulants in the setting of pregnancy. CASE: We present a patient withantiphospholipid syndrome who developed heparin-induced thrombosis in thethird trimester of pregnancy. She was treated with therapeutic doses ofintravenous lepirudin until delivery. Induction of labor, regional anesthesia, andforceps-assisted vaginal delivery were performed with no fetal, neonatal, ormaternal complications. Postpartum, the patient was transitioned to warfarintherapy, and at 6 weeks postdelivery neither the patient nor her infant had

developed any new problems. CONCLUSION: Intravenous lepirudin use attherapeutic doses in late gestation as an alternative to heparin was accomplishedwith minimal maternal and fetal morbidity.Obstet Gynecol. 2008 Aug;112(2):427-9.Super-selective arterial embolization for uncontrolled bleeding inabdominal pregnancy.Oki T, Baba Y, Yoshinaga M, Douchi T.Department of Obstetrics and Gynecology, Faculty of Medicine, and Departmentof Radiology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan.BACKGROUND: Abdominal pregnancy with massive bleeding is life-threatening.Thus, multimodal treatment approaches are necessary. CASE: A 36-year-oldwoman with abdominal pregnancy at 14 weeks of gestation presented withabdominal pain due to intraabdominal bleeding. Laparotomy demonstratedmassive bleeding from the placenta implanted in the right lower quadrantinvolving the posterior uterine wall, right adnexa, and small intestine. Becauseattempted removal of the placenta aggravated the bleeding, only the fetus wasremoved. To stop abdominal bleeding, embolization of the placental vasculaturewas successfully performed with a 2.0-F microcatheter after identification of thebleeding point with computed tomography arteriography. The patient was thetreated with methotrexate. CONCLUSION: Super-selective arterial embolizationwith a microcatheter is a useful treatment of abdominal bleeding due toabdominal pregnancy.Obstet Gynecol. 2008 Aug;112(2):419-20.New anticoagulants and pregnancy.Silver RM.Dr. Silver is from the Department of Obstetrics and Gynecology at the Universityof Utah School of Medicine, Salt Lake City, Utah; e-mail: bsilver@hsc.utah.edu.Obstet Gynecol. 2008 Aug;112(2):359-72.Prediction and prevention of recurrent preeclampsia.Barton JR, Sibai BM.Division of Maternal-Fetal Medicine, Central Baptist Hospital, Lexington,Kentucky; and the Divison of Maternal-Fetal Medicine, University of Cincinnati,Cincinnati, Ohio.Women with a history of previous preeclampsia are at increased risk ofpreeclampsia and other adverse pregnancy outcomes in subsequentpregnancies. The magnitude of this risk is dependent on gestational age at timeof disease onset, severity of disease, and presence or absence of preexistingmedical disorders. The objective in the management of these patients is toreduce risk factors by optimizing maternal health before conception and to detectobstetric complications as early as possible. This objective can be achieved byformulating a rational approach that includes preconception evaluation andcounseling, early antenatal care, frequent monitoring of maternal and fetal wellbeing,and timely delivery. First-trimester ultrasound examination is essential for

accurate dating and establishing fetal number. Laboratory studies are obtained toassess the function of different organ systems that are likely to be affected bypreeclampsia and to establish a baseline for future assessment. Recent studieshave confirmed that there is no single biomarker that can be clinically useful forthe prediction of recurrent preeclampsia. Combinations of biomarkers andbiophysical parameters appear promising, but more data are needed to confirmtheir use in clinical practice. Supplementation with fish oil, calcium, or vitamin Cand E and the use of antihypertensives have been shown to be ineffective in theprevention of recurrent preeclampsia and are not recommended.Supplementation with low-dose aspirin may be offered on an individualized basis.Because women with previous preeclampsia are at increased risk for adversepregnancy outcomes (preterm delivery, fetal growth restriction, abruptioplacentae, and fetal death) in subsequent pregnancies, we recommend morefrequent monitoring for signs and symptoms of severe hypertension orpreeclampsia than that recommended for normal pregnancy. This monitoringmay include more frequent prenatal visits, home blood pressure monitoring, ornursing contacts. For patients with a prior pregnancy complicated bypreeclampsia with fetal growth restriction, we recommend serial ultrasoundevaluation of fetal growth and amniotic fluid volume. The development of severegestational hypertension, fetal growth restriction, or recurrent preeclampsiarequires maternal hospitalization.Obstet Gynecol. 2008 Aug;112(2):333-40.Guidelines for computed tomography and magnetic resonance imaging useduring pregnancy and lactation.Chen MM, Coakley FV, Kaimal A, Laros RK Jr.Department of Radiology and the Department of Obstetrics, Gynecology andReproductive Sciences, University of California, San Francisco, School ofMedicine, San Francisco, California.There has been a substantial increase in the use of computed tomography (CT)and magnetic resonance imaging (MRI) in pregnancy and lactation. Among somephysicians and patients, however, there are misperceptions regarding risks,safety, and appropriate use of these modalities in pregnancy. We havedeveloped a set of evidence-based guidelines for the use of CT, MRI, andcontrast media during pregnancy for selected indications including suspectedacute appendicitis, pulmonary embolism, renal colic, trauma, and cephalopelvicdisproportion. Ultrasonography is the initial modality of choice for suspectedappendicitis, but if the ultrasound examination is negative, MRI or CT can beobtained. Computed tomography should be the initial diagnostic imaging modalityfor suspected pulmonary embolism. Ultrasonography should be the initial studyof choice for suspected renal colic. Ultrasonography can be the initial imagingevaluation for trauma, but CT should be performed if serious injury is suspected.Pelvimetry now is used rarely for suspected cephalopelvic disproportion, butwhen required, low-dose CT pelvimetry can be performed with minimal risk.Although iodinated contrast seems safe to use in pregnancy, intravenousgadolinium is contraindicated and should be used only when absolutely essential.

It seems to be safe to continue breast-feeding immediately after receivingiodinated contrast or gadolinium. Although teratogenesis is not a major concernafter exposure to prenatal diagnostic radiation, carcinogenesis is a potential risk.When used appropriately, CT and MRI can be valuable tools in imaging pregnantand lactating women; risks and benefits always should be considered anddiscussed with patients.Obstet Gynecol. 2008 Aug;112(2):320-324.Inherited Thrombophilia and Pregnancy Complications Revisited.Rodger MA, Paidas M, Claire M, Middeldorp S, Kahn S, Martinelli I, Hague W,Rosene Montella K, Greer I.Thrombosis Program, Division of Hematology, Department of Medicine,University of Ottawa, and Clinical Epidemiology Unit, Ottawa Health ResearchInstitute, the Ottawa Hospital, Ottawa, Ottawa, Ontario, Canada; Department ofObstetrics and Gynecology, Yale University, New Haven, Connecticut;Department of Obstetrics and Gynecology, University of Auckland, Auckland,New Zealand; Department of Clinical Epidemiology, Leiden University MedicalCenter, Leiden, the Netherlands; Department of Medicine, McGill University,Montreal, Quebec, Canada; Department of Medicine, IRCCS Maggiore HospitalFoundation, Milan, Italy; Department of Obstetrics and Gynecology, University ofAdelaide, Adelaide, Australia; Department of Medicine, Brown University,Providence, Rhode Island; and Hull York Medical School, York, United Kingdom.Inherited thrombophilias are not yet established as a cause of placenta-mediatedpregnancy complications, such as fetal growth restriction, preeclampsia,abruption, and pregnancy loss. An inherited thrombophilia is only one of manyfactors that lead to development of these diseases and is unlikely to be theunique factor that should drive management in subsequent pregnancies. Thepaucity of evidence for benefit, coupled with a small potential for harm, suggeststhat low molecular weight heparin should be considered an experimental drug forthese indications until data from controlled trials are published. At present,women with a history of placenta-mediated pregnancy complications, with orwithout a thrombophilia, should be followed closely without routine prophylacticlow molecular weight heparin other than for prevention of venousthromboembolism in limited circumstances.Obstet Gynecol. 2008 Aug;112(2):304-310.Chronic Hepatitis C in Pregnancy.Berkley EM, Leslie KK, Arora S, Qualls C, Dunkelberg JC.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,Division of Gastroenterology, Department of Internal Medicine, and Division ofBiostatistics, Department of Internal Medicine, the University of New MexicoHealth Sciences Center, Albuquerque, New Mexico.OBJECTIVE: To estimate outcomes, to determine whether appropriate follow-upwas performed for pregnant patients with hepatitis C virus (HCV), and to showthat maternal and neonatal complications would be higher in the HCV-positivegroup. METHODS: We compared pregnant women from a drug dependence and

treatment program who were HCV antibody-positive with those who were HCVantibody-negative using the University of New Mexico Perinatal Database.Maternal and neonatal outcomes were evaluated, including cholestasis ofpregnancy, preterm birth, low birth weight, neonatal intensive care unitadmissions, and neonatal methadone withdrawal. Variables were comparedusing Student t, Fisher exact, and chi(2) tests. RESULTS: Among 351pregnancies between January 2000 and 2006, 159 (53%) were HCV antibodyreactive, 141 (47%) tested nonreactive, and 51 (15%) were not screened.Hepatitis C reactivity was more common among Hispanics. Cholestasis ofpregnancy was increased in HCV antibody reactive (Ab+) pregnancies (10 of159, 6.3% compared with 0 of 141, P=.002). Among women taking methadone,there was a significantly higher incidence of neonatal withdrawal (P=.001). Thiswas significant in mothers on low (0-30 mg) and moderate (31-90 mg)methadone doses. Despite the high cure rate with intensive therapy, only 5.7% ofHCV Ab+ mothers and 1.9% of their neonates received Gastroenterologyreferrals. CONCLUSION: In pregnant women involved in this drug treatmentprogram, HCV reactivity was associated with Hispanic ethnicity, cholestasis ofpregnancy, and increased neonatal methadone withdrawal regardless ofmaternal methadone dose. Gastroenterology consultation was inadequate.LEVEL OF EVIDENCE: II.Obstet Gynecol. 2008 Aug;112(2):259-64.Recurrence of group B streptococci colonization in subsequent pregnancy.Turrentine MA, Ramirez MM.Department of Obstetrics and Gynecology, Kelsey Research Foundation, and theDepartment of Obstetrics, Gynecology, and Reproductive Sciences, University ofTexas Health Science Center at Houston, Houston, Texas.OBJECTIVE: To estimate the prevalence of group B streptococci (GBS)colonization in a subsequent pregnancy in women with and without GBScolonization in an index pregnancy. METHODS: A retrospective cohort study ofwomen who had two consecutive deliveries with the availability of GBS cultureresult at 35 to 37 weeks of gestation or the diagnosis of GBS colonization byurine culture for both pregnancies was undertaken. Women in the indexpregnancy with GBS genitourinary tract colonization were compared by culturedate with the next woman that screened negative for GBS colonization. To detecta doubling of GBS colonization from 20% to 40% would require 91 women ineach arm at P&lt;.05 with a power of 80%. Risk factors for GBS colonization wereascertained. Univariable and conditional logistic regression analyses wereperformed. P&lt;.05 was considered statistically significant. RESULTS: A total of102 women positive for GBS genitourinary colonization were compared withcontrols. The rate of recurrence for GBS colonization (53%) was significantlyhigher when judged against women GBS negative in their index pregnancy(15%) (adjusted odds ratio 11.7, 95% confidence interval 3.5-38.9, P&lt;.01).Women who were GBS positive in the index pregnancy were more often ofAfrican-American race and less likely to be nulliparous or smoke tobacco.CONCLUSION: Women with GBS colonization are at increased risk of GBS

colonization in a subsequent pregnancy. Prior GBS colonization should beconsidered in the algorithm to treat unknown GBS status during term labor.LEVEL OF EVIDENCE: II.Ultrasound Obstet Gynecol. 2008 Aug 1. [Epub ahead of print]Hemodynamics of the maternal venous compartment: a new area toexplore in obstetric ultrasound imaging.Gyselaers W.Department of Obstetrics and Gynecology, Ziekenhuis Oost Limburg, SchiepseBos 6, B-3600 Genk, Belgium.Am J Obstet Gynecol. 2008 Aug 7. [Epub ahead of print]A history of preeclampsia identifies women who have underlyingcardiovascular risk factors.Smith GN, Walker MC, Liu A, Wen SW, Swansburg M, Ramshaw H, White RR,Roddy M, Hladunewich M; Pre-Eclampsia New Emerging Team (PE-NET).Queen's Perinatal Research Unit, Department of Obstetrics and Gynecology,Kingston General Hospital, Queen's University, Kingston.OBJECTIVE: The objective of this study was to prospectively assess physicaland biochemical cardiovascular risk markers in women who had developedpreeclampsia (PE) at 1 year postpartum. STUDY DESIGN: Following anovernight fast, previously PE (n = 70) and normotensive women (n = 70) hadweight and blood pressure recorded and levels of morning blood for insulin,glucose, C-reactive protein, lipids, cholesterol, and urine for microalbumin andcreatinine measured. Body mass index, homeostatic model assessment index,and incidence of metabolic syndrome were determined. RESULTS: At 1 yearpostpartum, markers of cardiovascular disease were different between thegroups. There were also differences in the number of women with abnormalvalues. Mathematical modeling of cardiovascular event risk suggests that PEincreases the risk by 2- to 3-fold; the risk was greatest for women with severePE. CONCLUSION: The development of PE is 1 of the earliest clinicallyidentifiable markers of a woman's heightened risk of cardiovascular disease.Am J Obstet Gynecol. 2008 Aug 7. [Epub ahead of print]A rapid-growing uterine mass during pregnancy A fast-growing uterinemass complicated a first pregnancy.Matsuo K, Mighty HE, Im DD, Rosenshein NB.Department of Obstetrics, Gynecology, and Reproductive Sciences, University ofMaryland School of Medicine, Mercy Medical Center, Baltimore, MD.BMJ. 2008 Jul 31;337:a431. doi: 10.1136/bmj.39577.688229.47.The trouble with blood pressure cuffs.Bellamy JE, Pugh H, Sanders DJ.Royal Devon and Exeter Hospital, Exeter EX2 5DW. jebellamy2105@aol.comInt J Gynaecol Obstet. 2008 Aug 6. [Epub ahead of print]

Cryoglobulinemic vasculitis in pregnancy.Gupta A, Gupta G, Marouf R.Department of Hematology, Faculty of Pathology, Mubarak Al Kabeer Hospital,Kuwait University, Kuwait.Ultrasound Obstet Gynecol. 2008 Aug 13. [Epub ahead of print]Maternal cardiac function in normotensive and pre-eclamptic intrauterinegrowth restriction.Bamfo JE, Kametas NA, Chambers JB, Nicolaides KH.Harris Birthright Research Centre for Fetal Medicine, King's College Hospital,London, UK.OBJECTIVES: To compare maternal cardiac function between pregnanciescomplicated by normotensive and pre-eclamptic intrauterine growth restriction(IUGR). METHODS: Two-dimensional Doppler echocardiography and Dopplertissue imaging (DTI) were used to examine 19 pregnant women with IUGR and17 with pre-eclampsia complicated by IUGR at 20-38 weeks of gestation. Indiceswere converted into differences in SDs from the expected normal mean forgestation (Z-scores) and compared. RESULTS: With respect to normalpregnancy, in the normotensive IUGR compared with the pre-eclamptic IUGRgroup, there were similar reductions in maternal cardiac output (Z-score, - 1.71vs. - 1.37, P = 0.26) and heart rate (Z-score, - 3.67 vs. - 9.43, P = 0.1) and asimilar increase in total vascular resistance (Z-score, 2.91 vs. 3.93, P = 0.05).There was also a greater decrease in stroke volume (Z-score, - 1.72 vs. - 0.69, P= 0.01), a smaller increase in mean arterial pressure (Z-score, 0.73 vs. 2.94, P&lt; 0.01) and a smaller decrease in DTI systolic velocity at the lateral mitralmargin (Z-score, - 0.4 vs. - 1.42, P = 0.02). In terms of diastolic function, therewas a smaller transmitral late diastolic velocity (Z-score, 0.04 vs. 0.93, P = 0.03)and a greater DTI early diastolic velocity at the lateral mitral margin (Z-score, -0.17 vs. - 1.6, P &lt; 0.01). CONCLUSIONS: In normotensive IUGR and preeclampticIUGR there is a similar alteration in maternal left ventricular systolicfunction, but there is greater impairment in maternal diastolic function in preeclampticIUGR. Copyright (c) 2008 ISUOG. Published by John Wiley &amp;Sons, Ltd.Acta Obstet Gynecol Scand. 2008 Aug 11:1-7. [Epub ahead of print]Prepregnancy weight status and the risk of adverse pregnancy outcome.Hauger MS, Gibbons L, Vik T, Belizan JM.Department of Community Medicine and General Practice, Medical Faculty,Norwegian University of Science and Technology (NTNU), Trondheim, Norway.Objective. To examine the association between maternal pre-pregnancy weightstatus and the risk of stillbirth, pre-eclampsia and preterm delivery. Design.Hospital-based cohort study using prospectively recorded data. Setting. Tenpublic hospitals in Buenos Aires, Argentina. Population 46,964 pregnant womenwho had a delivery during 2003-2006. Methods. Prepregnancy body mass index(BMI) was used to categorize women in four weight categories from underweightto obese. The reference group were women with BMI between 18.5 and 24.9.

Crude and adjusted odds ratios were calculated using multiple logistic regressionanalysis. Main Outcome: Preterm birth, pre-eclampsia and stillbirth. Results. Therisk of preterm delivery decreased with increasing BMI, with the highest riskamong underweight women (OR: 1.45; 95% CI: 1.26-1.67), and the lowest riskamong the overweight. The risk of pre-eclampsia was highest among overweight(OR: 1.55; 95%CI: 1.30-1.86) and obese women (OR: 3.10; 95%CI: 2.54-3.78).Obese or overweight women did not have an increased risk of stillbirth in thisstudy. Conclusions. Overweight and obese women have an increased risk forpre-eclampsia, while underweight women have an increased risk for pretermdelivery. There is a high prevalence of overweight women in the obstetricpopulation in Buenos Aires.Acta Obstet Gynecol Scand. 2008 Aug 11:1-7. [Epub ahead of print]Maternal fatalities, fetal and neonatal deaths related to motor vehiclecrashes during pregnancy: A national population-based study.Kvarnstrand L, Milsom I, Lekander T, Druid H, Jacobsson B.The Department of Obstetrics & Gynecology, Sahlgrenska Academy at GoteborgUniversity, Goteborg, Sweden.Objectives. Firstly, determine the mortality rate for: pregnant women; fetuses andneonates, due to motor vehicle crashes (MVCs) during pregnancy; and secondly,the rate of major injuries among pregnant women and the rate of involvement ofpregnant women in crashes. Design. A national population-based, retrospectivedescriptive study. Setting. Sweden, 1991-2001. Population. All pregnant andnon-pregnant women age 15-44. Methods. Linkage of national traffic, medicaland autopsy registers. Main outcome measures. Maternal death or injury andcorresponding fetal death. Results. MVCs during pregnancy caused 1.4 maternalfatalities per 100,000 pregnancies and a fetus/neonate mortality rate of least 3.7per 100,000 pregnancies. The incidence of maternal major injury was 23/100,000pregnancies and crash involvement was 207/100,000 pregnancies. Conclusions.MVCs during pregnancy were a significant cause of maternal fatalities, fetal andneonatal deaths, responsible for almost 1/3 of all maternal deaths and fatalities,and caused nearly three times more fetal plus neonatal deaths than maternalfatalities.Aust N Z J Obstet Gynaecol. 2008 Apr;48(2):220-1.Intra-abdominal haemorrhage at 17 weeks gestation caused by placentapercreta: a case report.Judson E, Polyakov A, Lawrence A.Aust N Z J Obstet Gynaecol. 2008 Apr;48(2):218-20.Cauda equina syndrome post-caesarean section.Chow J, Chen K, Sen R, Stanford R, Lowe S.Cauda equina syndrome is rarely associated with pregnancy, with few casesreported in the literature. The majority of cases describe antenatal presentations,with only one case manifesting post-partum, three weeks after a normal vaginaldelivery. We outline a case of cauda equina syndrome following caesarean

section in a patient with known lumbar disc disease, and discuss the contributionof the mode of delivery and anaesthesia as precipitants of disc herniationcausing cauda equina compression. We conclude that vigilance, particularly inthe post-partum setting, be attributed towards the neurological surveillance ofwomen with known disc disease.Aust N Z J Obstet Gynaecol. 2008 Apr;48(2):179-84.Placental cultures in the era of peripartum antibiotic use.Bhola K, Al-Kindi H, Fadia M, Kent AL, Collignon P, Dahlstrom JE.Department of Neonatology, The Canberra Hospital, Woden, Australian CapitalTerritory, Australia.BACKGROUND: Histological examination of the placenta can provide valuableinformation that aids diagnosis and management for both the mother and thefetus. Positive placental cultures may also provide the clinician with valuableinformation on which to base therapy. AIMS: To determine the incidence ofpositive placental cultures, the association with chorioamnionitis and whether therate is affected by antibiotic administration in the peripartum period. METHODS:A retrospective study of placentas submitted for histopathology and microbiologyculture in higher risk deliveries over a 12-month period in a laboratory at a tertiaryfacility. Data collected included gestation age, duration of rupture of membranes,maternal fever, group B Streptococcus status, intrapartum antibiotics, placentalculture result and the histopathology result. RESULTS: Of the 412 placentassubmitted, 26% (106 of 412) had histological evidence of in utero inflammation.Sixty-three percent (259 of 412) of placentas were submitted for culture. Ofthese, only 4.6% (12 of 259) had a positive culture result, with 75% (nine of 12)having histological evidence of acute inflammation. Group B streptococcus andEscherichia coli were the most common isolates. Forty-two per cent (five of 12)of these women had received peripartum antibiotics. CONCLUSIONS: Positiveplacental cultures are found in only a small number of placentas with histologicalevidence of chorioamnionitis and funisitis. The current method of placentalswabbing and culture technique is highly specific but not sensitive. The value ofperforming current routine placental cultures appears limited.N Engl J Med. 2008 Aug 21;359(8):800-9.Comment in:N Engl J Med. 2008 Aug 21;359(8):858-60.Preeclampsia and the risk of end-stage renal disease.Vikse BE, Irgens LM, Leivestad T, Skjaerven R, Iversen BM.Renal Research Group, Institute of Medicine, Haukeland University Hospital,Bergen 5021, Norway. bjorn.vikse@med.uib.noBACKGROUND: It is unknown whether preeclampsia is a risk marker forsubsequent end-stage renal disease (ESRD). METHODS: We linked data fromthe Medical Birth Registry of Norway, which contains data on all births in Norwaysince 1967, with data from the Norwegian Renal Registry, which contains data onall patients receiving a diagnosis of end-stage renal disease (ESRD) since 1980,to assess the association between preeclampsia in one or more pregnancies and

the subsequent development of ESRD. The study population consisted of womenwho had had a first singleton birth between 1967 and 1991; we included datafrom up to three pregnancies. RESULTS: ESRD developed in 477 of 570,433women a mean (+/-SD) of 17+/-9 years after the first pregnancy (overall rate, 3.7per 100,000 women per year). Among women who had been pregnant one ormore times, preeclampsia during the first pregnancy was associated with arelative risk of ESRD of 4.7 (95% confidence interval [CI], 3.6 to 6.1). Amongwomen who had been pregnant two or more times, preeclampsia during the firstpregnancy was associated with a relative risk of ESRD of 3.2 (95% CI, 2.2 to4.9), preeclampsia during the second pregnancy with a relative risk of 6.7 (95%CI, 4.3 to 10.6), and preeclampsia during both pregnancies with a relative risk of6.4 (95% CI, 3.0 to 13.5). Among women who had been pregnant three or moretimes, preeclampsia during one pregnancy was associated with a relative risk ofESRD of 6.3 (95% CI, 4.1 to 9.9), and preeclampsia during two or threepregnancies was associated with a relative risk of 15.5 (95% CI, 7.8 to 30.8).Having a low-birth-weight or preterm infant increased the relative risk of ESRD.The results were similar after adjustment for possible confounders and afterexclusion of women who had kidney disease, rheumatic disease, essentialhypertension, or diabetes mellitus before pregnancy. CONCLUSIONS: Althoughthe absolute risk of ESRD in women who have had preeclampsia is low,preeclampsia is a marker for an increased risk of subsequent ESRD. 2008Massachusetts Medical SocietyAm J Obstet Gynecol. 2008 Aug;199(2):129.e1-6. Epub 2008 Apr 29.Sequential first- and second-trimester TSH, free thyroxine, and thyroidantibody measurements in women with known hypothyroidism: a FaSTERtrial study.McClain MR, Lambert-Messerlian G, Haddow JE, Palomaki GE, Canick JA,Cleary-Goldman J, Malone FD, Porter TF, Nyberg DA, Bernstein P, D'Alton ME;FaSTER Research Consortium. Collaborators: Welch K, Denchy R, Ball R,Belfort M, Oshiro B, Cannon L, Nelson K, Loucks C, Yoshimura A, Luthy D, CoeS, Comstock C, Esler J, Bukowski R, Hankins G, Saade G, Lee J, Berkowitz R,Eddleman K, Kharbutli Y, Merkatz I, Carter S, Dugoff L, Hobbins J, Schultz L,Timor-Tritsch I, Paidas M, Borsuk J, Craigo S, Bianchi D, Isquith B, Berlin B, CarrS, Duquette C, Wolfe H, Baughman R, Hanson J, de la Cruz F, Dukes K, Tripp T,Emig D, Sullivan L.Warren Alpert Medical School, Brown University, Providence, RI 02903, USA.OBJECTIVE: The purpose of this study was to examine how closelyhypothyroidism management in the general pregnancy population satisfiesrecently issued guidelines and to determine whether improvements are indicated.STUDY DESIGN: This was an observational study in which women at 5recruitment centers in the first- and second-trimester evaluation of risk foraneuploidy trial allowed the use of sequentially obtained first- and secondtrimestersera for additional research. Three hundred eighty-nine women hadhypothyroidism by self-report. Thyroid-related measurements were performed onall samples between July 2004 and May 2005. RESULTS: Forty-three percent of

the thyroid-stimulating hormone (TSH) values are at or above recentlyrecommended guidelines in the first trimester (2.5 mU/L), as opposed to 33% ofthe values in the second trimester (3.0 mU/L). Twenty percent of the TSH valuesare at or above a less restrictive 98 th percentile of normal in the first trimester, asopposed to 23% of the values in the second trimester. Mean TSH levels arehigher in women with antibodies. Free thyroxine values are unremarkable.CONCLUSION: Future strategies should focus on more effectively treatingwomen with hypothyroidism who have persistently elevated TSH values.Am J Obstet Gynecol. 2008 Aug;199(2):e12; author reply e13. Epub 2008 Apr 2.Comment on:Am J Obstet Gynecol. 2007 Nov;197(5):512.e1-7.Urinary incontinence after cesarean delivery or spontaneous vaginaldelivery.Mahajan NN.Am J Obstet Gynecol. 2008 Aug;199(2):133.e1-8. Epub 2008 Feb 15.Identification of severe maternal morbidity during delivery hospitalizations,United States, 1991-2003.Callaghan WM, Mackay AP, Berg CJ.Division of Reproductive Health, National Center for Chronic Disease Preventionand Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA,USA. WCallaghan@cdc.govOBJECTIVE: This investigation aimed to identify pregnancy complications andrisk factors for women who experienced severe maternal morbidity during thedelivery hospitalization and to estimate severe maternal morbidity rates. STUDYDESIGN: We used the National Hospital Discharge Survey for 1991-2003 toidentify delivery hospitalizations with maternal diagnoses and procedures thatindicated a potentially life-threatening diagnosis or life-saving procedure.RESULTS: For 1991-2003, the severe maternal morbidity rate in the UnitedStates was 5.1 per 1000 deliveries. Most women who were classified as havingsevere morbidity had an ICD-9-CM code for transfusion, hysterectomy, oreclampsia. Severe morbidity was more common at the extremes of reproductiveage and for black women, compared with white women. CONCLUSION: Severematernal morbidity is 50 times more common than maternal death.Understanding these experiences of these women potentially could modify thedelivery of care in healthcare institutions and influence maternal health policy atthe state and national level.Am J Obstet Gynecol. 2008 Aug 21. [Epub ahead of print]T2-weighted cardiovascular magnetic resonance to identify infarctassociatededema in early pregnancy.Abdel-Aty DH, Schulz-Menger J.Franz-Volhard-Klinik, Kardiologie, Charité Campus Buch, HELIOS-KlinikumBerlin, Universitätsmedizin Berlin, Schwanebecker Chaussee 50, D-13125 Berlin,Germany.

Acta Obstet Gynecol Scand. 2008 Sep 1:1-5. [Epub ahead of print]Pregnancy and women with spinal cord injuries.Ghidini A, Healey A, Andreani M, Simonson MR.Department of Obstetrics and Gynecology, Georgetown University, Washington,DC, USA.Objective. To investigate the impact of pregnancy and childbearing on womenwith spinal cord injuries and their attitude toward pregnancy. Design and setting.State-wide questionnaire survey from two databases, Florida, USA. Methods.Women with spinal cord injuries between 18 and 40 years were invited toparticipate. Main outcome measures. Knowledge about pregnancy after spinalcord injury and complications of pregnancy. Population. Hundred and fourteenwomen with spinal cord injuries. Results. Twenty-three women (20%) receivedinformation about pregnancy during rehabilitation, but only 12 (10%) found itadequate. Rates of response of 'adequate information' were similar betweenwomen who became pregnant after injury and those who did not (9.0% vs. 8.6%,p=1.0). Younger age at injury was the only predictor of pregnancy after spinalcord injuries. Preterm delivery occurred in 33% of women; 22% were unable tofeel preterm labor. Thrombosis (8%), urinary complications (59%), dysreflexia(27%), and worsened spasticity (22%) were the most common complications inpregnancy and post-partum depression (35%) was the most commoncomplication in the puerperium. Conclusions. Inadequate information aboutpregnancy is common among young women with spinal cord injury. Heightenedsurveillance for certain complications is warranted in women with spinal cordinjuries.Am J Obstet Gynecol. 2008 Sep;199(3):319.e1-4.Identifying the causes of stillbirth: a comparison of four classificationsystems.Vergani P, Cozzolino S, Pozzi E, Cuttin MS, Greco M, Ornaghi S, Lucchini V.Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza,Italy.OBJECTIVE: To identify the classification protocol for stillbirth that minimizes therate of unexplained causes. STUDY DESIGN: All stillbirths at > 22 weeks from1995-2007 underwent a workup inclusive of fetal ultrasonography, amniocentesisfor karyotype and cultures, placental histology, fetal autopsy, skin biopsy, totalbody X-ray, maternal testing for thrombophilias, TORCH, Parvovirus spp, thyroidfunction, indirect Coombs, Kleiheuer-Betke test, and genital cultures. To such acohort, we applied the 4 most commonly used classification protocols.RESULTS: The stillbirth rate during the study period was 0.4% (154/37,958). TheRoDeCo classification provided the lowest rate of unexplained stillbirth (14.3%)compared with Wigglesworth (47.4%), de Galan-Roosen (18.2%), and Tulip(16.2%) classifications. Mean gestational age at stillbirth in unexplained vsexplained stillbirth was similar in the 4 protocols. CONCLUSION: Adoption of aconsistent and appropriate workup protocol can reduce the rate of unexplainedstillbirth to 14%.

Am J Obstet Gynecol. 2008 Sep;199(3):247.e1-6.Expectant management of severe preeclampsia at less than 27 weeks'gestation: maternal and perinatal outcomes according to gestational ageby weeks at onset of expectant management.Bombrys AE, Barton JR, Nowacki EA, Habli M, Pinder L, How H, Sibai BM.Department of Obstetrics and Gynecology, University of Cincinnati College ofMedicine Division of Maternal-Fetal Medicine, Cincinnati, OH.OBJECTIVE: The objective of the study was to determine perinatal outcome andmaternal morbidities based on gestational age (GA) at the onset of expectantmanagement in severe preeclampsia at less than 27 weeks. STUDY DESIGN:This was a retrospective analysis of outcome in patients with severepreeclampsia. Forty-six patients (51 fetuses) with severe preeclampsia at lessthan 27 weeks were studied. Corticosteroids were administered beyond 23weeks. Perinatal and maternal complications (a composite maternal morbiditiesincluding HELLP (hemolysis, elevated liver enzymes, and low platelet count)syndrome, pulmonary edema, eclampsia, and renal insufficiency were analyzed.RESULTS: Four patients had multifetal gestations (1 triplet, 3 twins). Mediandays of prolongation was 6 (range 2-46). Overall perinatal survival was 29 of 51(57%). Birthweights of 27 (53%) were less than 10%, and 18 (35%) were lessthan 5%. There were no perinatal survivors in those with a GA less than 23weeks, at 23 to 23 6/7 weeks, 2 of 10 (20%) survived, and both reached 26weeks at delivery. For those at 24 to 24 6/7, 25 to 25 6/7, and 26 to26 6/7 weeks,the perinatal survival rates were 5 of 7 (71%), 13 of 17 (76%), and 9 of 10 (90%),respectively; but rates of respiratory complications were high. There were nomaternal deaths, but overall maternal morbidity was 21 of 46 (46%), but was 9 of14 (64%) in those at less than 24 weeks. CONCLUSION: Perinatal outcome insevere preeclampsia in the midtrimester is dependent on GA at onset ofexpectant management and GA at delivery. Given the high maternal morbidityand extremely low perinatal survival in expectant management at less than 24weeks, termination of pregnancies should be offered after extensive counseling.Am J Obstet Gynecol. 2008 Sep;199(3):209-12.Expectant management of severe preeclampsia remote from term: hope forthe best, but expect the worst.Norwitz ER, Funai EF.Department of Obstetrics, Gynecology & Reproductive Sciences, Yale UniversitySchool of Medicine, New Haven, CT.Eur J Obstet Gynecol Reprod Biol. 2008 Sep 2. [Epub ahead of print]Familial Mediterranean fever during pregnancy: An independent risk factorfor preterm delivery.Ofir D, Levy A, Wiznitzer A, Mazor M, Sheiner E.Departments of Obstetrics and Gynecology, Faculty of Health Sciences, SorokaUniversity Medical Center, Ben Gurion University of the Negev, Be'er-Sheva,Israel.

OBJECTIVE: To investigate pregnancy outcome of patients with FamilialMediterranean fever (FMF). STUDY DESIGN: A population-based studycomparing all pregnancies of women with and without FMF between the years1988 and 2006 was conducted. Stratified analyses, using the Mantel-Haenszelprocedure and multiple logistic regression models, were performed to control forconfounders. RESULTS: During the study period there were 175,572 deliveries,of which 239 occurred in patients with FMF. Using a multivariable analysis, thefollowing conditions were significantly associated with FMF: preterm delivery(PTD,

to the new macrolides (118 were exposed in the first trimester of pregnancy) and953 from a comparison groups were followed up. The rate of majormalformations in the study group was 4.1% compared to 2.1% in the otherantibiotics exposed group (OR=1.41, 95% CI 0.47-4.23) and 3.0% in the nonteratogensexposed group. The rate of elective terminations of pregnancy wassignificantly higher in the exposed group in compare to both comparison groups.CONCLUSION: Our study, although relatively small sized, suggests that the useof the new macrolides during the first trimester of pregnancy does not representan increased risk for congenital malformations strong enough for an inducedabortion after such an exposure. Elective terminations of pregnancy because ofearly exposure to these medications should be reconsidered.Eur J Obstet Gynecol Reprod Biol. 2008 Aug 28. [Epub ahead of print]Hypertension, fetal growth restriction and obstructive sleep apnoea inpregnancy.Yin TT, Williams N, Burton C, Ong SS, Loughna P, Britton JR, Thornton JG.Academic Division, Department of Obstetrics & Gynaecology, City Campus,Nottingham University Hospitals, Nottingham, United Kingdom.OBJECTIVE: To test the hypothesis that obstructive sleep apnoea (OSA) is morecommon in pregnancies complicated by hypertensive disease and fetal growthrestriction. STUDY DESIGN: An observational study comparing pregnant womenwith these two complications with normal pregnant women and non-pregnantwomen in two UK maternity hospitals. Each participant completed a sleepapnoea questionnaire and underwent nocturnal oxygen saturation monitoring.RESULTS: Using a strict definition of obstructive sleep apnoea confirmed byoxygen saturation monitoring only two mild cases were seen, 0/50 non-pregnantwomen, 1/69 of normal pregnant women, 0/48 women with various types ofhypertensive disease, and 1/33 women carrying fetuses affected with fetalgrowth restriction. Even using less strict definitions and self-reported sleepinessscores there was no relation between sleep apnoea and either fetal growthrestriction or hypertensive diseases. CONCLUSION: Obstructive sleep apnoea isat most a rare cause of either growth restriction or hypertensive disease inpregnancy.Eur J Obstet Gynecol Reprod Biol. 2008 Aug 29. [Epub ahead of print]A case of deep vein thrombosis complicating laparoscopic treatment ofectopic pregnancy.Olamijulo JA, Aderibigbe O.Department of Obstetrics and Gynaecology, Pilgrim Hospital, Boston PE21 9QS,United Kingdom.Int J Gynaecol Obstet. 2008 Sep 1. [Epub ahead of print]Effect of bariatric surgery on pregnancy outcome.Weintraub AY, Levy A, Levi I, Mazor M, Wiznitzer A, Sheiner E.Department of Obstetrics and Gynecology, Soroka University Medical Center,Ben-Gurion University of the Negev, Beer-Sheva, Israel.

OBJECTIVE: To compare the perinatal outcomes of women who deliveredbefore with women who delivered after bariatric surgery. METHODS: Aretrospective study was undertaken to compare perinatal outcomes of womenwho delivered before with women who delivered after bariatric surgery in atertiary medical center between 1988 and 2006. A multivariate logistic regressionmodel was constructed to control for confounders. RESULTS: During the studyperiod, 301 deliveries preceded bariatric surgery and 507 followed surgery. Asignificant reduction in rates of diabetes mellitus (17.3% vs 11.0; P=0.009),hypertensive disorders (23.6% vs 11.2%; P

Obstet Gynecol. 2008 Sep;112(3):606-10.Correlation of catheterized and clean catch urine protein/creatinine ratiosin preeclampsia evaluation.Chen BA, Parviainen K, Jeyabalan A.Department of Obstetrics, Gynecology, and Reproductive Sciences, University ofPittsburgh School of Medicine, Pittsburgh, PA.OBJECTIVE: To examine whether clean catch urine specimens correlate withcatheterized specimens for determination of protein/creatinine ratios in pregnantwomen being evaluated for preeclampsia. METHODS: Sixty pregnant womenwho were at least at 20 weeks of gestation were enrolled. Patients with rupturedmembranes, vaginal bleeding, or urinary tract infections were excluded.Midstream clean catch urine specimens were collected. Catheterized specimenswere then collected and used for clinical management. The specimens wereanalyzed for protein, creatinine, urinalysis, and culture. Based on sample sizecalculations, 60 participants were needed to detect a correlation of 0.90 with 80%power and alpha=0.05. RESULTS: Mean gestational age at enrollment was 35.9weeks (range 23.1-41.7 weeks). Median (range) clean catch and catheterizedprotein/creatinine ratios were 0.204 (0.089-3.465) and 0.181 (0.067-3.335),respectively, with a correlation coefficient of 0.897 (P

exceptionally rare. CASE: A 23-year-old woman delivered a male infant at 28weeks' gestational age after premature labor. The mother had an unremarkablehospital course. There was no prior IUD history. The infant had an extended stayin the fetal intensive care unit secondary to prematurity. Evaluation of theplacenta revealed necrotizing acute chorioamnionitis and organisms with afilamentous growth pattern. The morphology was consistent with Actinomycesspp. CONCLUSION: This case is important because of the rarity of the infection.Clinicians and pathologists alike must be aware of this possibility even in theabsence of IUD use.J Reprod Med. 2008 Apr;53(4):271-8.Gravid hysterectomy: a decade of experience at an academic referralcenter.Muench MV, Baschat AA, Oyelese Y, Kush ML, Mighty HE, Malinow AM.Department of Obstetrics, Gynecology and Reproductive Sciences, University ofMaryland, Baltimore, USA. mvmuench@comcast.netOBJECTIVE: To evaluate the incidence of gravid hysterectomy (GH) and toexamine the indications as well as risk factors and complications associated withthe procedure at an academic perinatal referral center. STUDY DESIGN:Retrospective chart review of all patients who underwent GH from 1991 to 2001.Demographics, obstetric history, delivery information, complications and outcomewere analyzed. RESULTS: There were 34 GHs out of 19,491 deliveries(1.74/1000). The preoperative indications were hemorrhage associated withatony (32.4%), placenta accreta (20.6%) and uncontrolled bleeding (17.6%). Ofthe patients, 87.5% were parous and 53.1% had previous cesarean section. GHwas performed prior to viability in 3. GH followed cesarean delivery in 24(68.6%). Uterine and/or hypogastric artery ligation were performed in 11 (32.4%).Postoperative complications included surgical re-exploration for recurrenthemorrhage in 5, transfusion of blood products in 30, disseminated intravascularcoagulopathy in 15, prolonged (> 24 hours) ventilation in 10 and admission to theSICU for prolonged intensive care in 12. There were 2 maternal deaths (5.9%). Asignificant rise in GH rate from 1/800 to 1/299 occurred over the past 5 yearsdespite constant cesarean rates (chi2, p < 0.05). CONCLUSION: Rates of GHincreased over the period examined. Placenta accreta associated with previouscesarean section is the predominant risk factor for GH.J Reprod Med. 2008 Aug;53(8):575-8.Pelvic imaging in gestational trophoblastic neoplasia.Lim AK, Patel D, Patel N, Hawtin K, Dayal L, Schmid P, Savage P, Seckl MJ.Department of Imaging and Charing Cross Gestational Trophoblastic DiseaseCentre, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London,UK. a.lim@imperial.ac.ukOBJECTIVE: To assess the accuracy of Doppler ultrasound (DU) compared withmagnetic resonance imaging (MRI) in high-risk patients with gestationaltrophoblastic neoplasia (GTN). STUDY DESIGN: From January 2005 to October2007, patients with proven high-risk GTN or suspicion of relapse who had both

DU and MRI of the pelvis were reviewed retrospectively for tumor detection andtumor extent and vascularity. RESULTS: There were a total of 54 patients whohad both DU and MRI performed; of these, 40 were first-time presentation and 14had either residual disease not responding to chemotherapy or suspicion ofrecurrent GTN based on rising human chorionic gonadotropin (hCG).Extrauterine extension and extent of endometrial encroachment were betterassessed on MRI than on DU in 10 of 46 patients with visible uterine lesion.CONCLUSION: MRI and DU are complementary investigations of the pelvis inpatients with GTN. Tumor vascularity is better assessed on DU, tumor extensionand detection are better with MRI.Obstet Gynecol. 2008 Aug;112(2 Pt 2):467-70.Contemporary diagnosis and management of a uterine arteriovenousmalformation.Brown JV 3rd, Asrat T, Epstein HD, Oglevie S, Goldstein BH.Gynecologic Oncology Associates, Hoag Memorial Hospital Cancer Center,Hoag Hospital, Department of Maternal Fetal Medicine, Newport Beach, CA92663, USA.BACKGROUND: Uterine arteriovenous malformations (AVMs) are extremely rareand can result in severe complications. Experience with diagnosis andmanagement of these vascular malformations is very limited. CASE: We reporton a patient with a history of nonmetastatic gestational trophoblastic disease.The patient developed a concomitant 4.4-cm intrauterine mass, suggestive of amolar pregnancy, during her second pregnancy. Despite suction and sharpcurettage, the mass and menorrhagia persisted. After complex diagnosticimaging, the diagnosis of a uterine AVM was made. Subsequently, the patientunderwent uterine arterial embolization and laparoscopic surgery to resect themass. CONCLUSION: Because uterine AVMs are infrequently encountered, theyinitially may not be included in the differential diagnosis. The use ofcontemporary imaging, interventional radiology, and surgery can optimize patientoutcome.Obstet Gynecol. 2008 Aug;112(2 Pt 2):429-31.Uterine necrosis: a complication of uterine compression sutures.Gottlieb AG, Pandipati S, Davis KM, Gibbs RS.Department of Obstetrics and Gynecology, University of Colorado at Denver andHealth Sciences Center and Northwest Perinatal Center, Women's HealthcareAssociates, Aurora, CO 80045, USA. amy.gottlieb@uchsc.eduBACKGROUND: In cases of uterine atony, uterine compression sutures work byapplying direct uterine compression. CASE: A 33-year-old gravida 2, para 0101with preterm premature rupture of the membranes at 31 and 4/7 weeks ofgestation underwent cesarean delivery. Because of significant uterine atony, twouterine compression sutures were placed. On postoperative day 8, the patientreturned to the operating room secondary to persistent fevers not responsive toantibiotic therapy. At the time of laparotomy, she was found to have fundaluterine necrosis at the location of the second compression suture.

CONCLUSION: This case demonstrates uterine necrosis confined to the uterinefundus after placement of a compression suture in this area. Although bracesutures are an invaluable technique for patients with uterine atony, uterinenecrosis is a rare complication.Obstet Gynecol. 2008 Aug;112(2 Pt 2):425-6.Conservative management of placenta percreta: experiences in two cases.Hays AM, Worley KC, Roberts SR.Department of Obstetrics and Gynecology, University of Texas SouthwesternMedical Center, Dallas, TX 75390-9032, USA.BACKGROUND: The management of an abnormally invaded placenta presentsa challenging obstetric problem. Recent reports have suggested that aconservative approach to the treatment of this condition is appropriate in selectedcases. We present the courses of two women with suspected placenta percretawho were managed conservatively and the complications that ensued. CASES:Two multiparous women underwent elective repeat cesarean deliveries and werefound to have clinical evidence of placenta percreta with bladder invasion. In bothcases, the placenta was left in situ and medical management was attempted withmethotrexate. Both women developed significant delayed complications requiringreoperation and hysterectomy, and both required multiple transfusions.CONCLUSION: Conservative management of the abnormally invaded placentashould be undertaken with caution, and complications should be anticipated.Obstet Gynecol. 2008 Aug;112(2 Pt 2):421-4.Medical and surgical treatment of placenta percreta to optimize bladderpreservation.Lee PS, Bakelaar R, Fitpatrick CB, Ellestad SC, Havrilesky LJ, Alvarez Secord A.Division of Gynecologic Oncology, Department of Obstetrics and Gynecology,and Division of Maternal and Fetal Medicine, Duke University Medical Center,Durham, NC 27710, USA. paula.s.lee@duke.eduBACKGROUND: Placenta percreta is associated with significant morbidity andmortality. Interventions are dictated by hemodynamic stability, desire to retainfuture fertility, and efforts to reduce surgical morbidity at time of delivery. CASES:Two cases of antenatally diagnosed placenta percreta with bladder invasion arepresented. Conservative management was used, including endovascularinterventions, leaving the placenta in situ, methotrexate, and delayedhysterectomy. Postoperative outcomes were acceptable, with no significanthemorrhagic complications or need for extensive bladder reconstruction.CONCLUSION: Antenatal diagnosis of placenta percreta with bladder invasion isessential in the multidisciplinary management of this potentially catastrophiccondition. A comprehensive approach including delayed hysterectomy aftermedical management resulted in an excellent clinical outcome.Obstet Gynecol. 2008 Aug;112(2 Pt 2):417-8.Peripartum bleeding at cesarean delivery: be prepared!Scott JR.

Acta Obstet Gynecol Scand. 2008 Sep 16:1-5. [Epub ahead of print]Reference values for alpha(1)-acid glycoprotein, alpha(1)-antitrypsin,albumin, haptoglobin, C-reactive protein, IgA, IgG and IgM duringpregnancy.Larsson A, Palm M, Hansson LO, Basu S, Axelsson O.Department of Medical Sciences, Clinical Chemistry, Uppsala University,Uppsala, Sweden.The objective of this study was to establish reference intervals and decision limitsfor the interpretation of the acute phase proteins alpha(1)-acid glycoprotein(orosomucoid), alpha(1)-antitrypsin, C-reactive protein (CRP), haptoglobin andalbumin, IgA, IgG and IgM during pregnancy by longitudinal sampling from 52healthy women with normal pregnancies. Each woman was sampled in weeks 7-17; weeks 17-24; weeks 24-28; weeks 28-31; weeks 31-34; weeks 34-38 andpredelivery (-14-0 days prior to delivery) and postpartum (>6 weeks afterdelivery). The 2.5th and 97.5th percentiles were calculated according to therecommendations of the International Federation of Clinical Chemistry on thestatistical treatment of reference values. Reference values for alpha(1)-acidglycoprotein, alpha(1)-antitrypsin, albumin, haptoglobin, CRP, IgA, IgG and IgMare reported. Most of these proteins changed during normal pregnancy, as areflection of the major physiological and biochemical changes that occur inpregnancy. A laboratory test result from a pregnant woman should be comparedwith pregnancy-specific reference intervals.Eur J Obstet Gynecol Reprod Biol. 2008 May;138(1):119-20. Epub 2007 Mar 27.Atrial fibrillation in pregnancy.Walsh CA, Manias T, Patient C.Int J Gynaecol Obstet. 2008 Jun;101(3):269-72. Epub 2008 Mar 4.Peripartum hysterectomy in Taiwan.Jou HJ, Hung HW, Ling PY, Chen SM, Wu SC.Department of Obstetrics and Gynecology, Taiwan Adventist Hospital, Taipei,Taiwan.OBJECTIVE: To investigate the incidence and associated risk factors forperipartum hysterectomy in singleton pregnancies. METHODS: A retrospectivecohort study of all women with singleton pregnancies admitted for delivery in2002 taken from the National Healthcare Insurance database. Adjusted oddsratios (ORs) and 95% confidence intervals (CIs) were calculated for maternal andhospital characteristics using logistic regression. RESULTS: There were 287peripartum hysterectomies in 214 237 singleton pregnancies (0.13%). Cesareandelivery, vaginal birth after cesarean (VBAC), and repeat cesarean delivery hadhigher hysterectomy rates than vaginal delivery, with adjusted ORs of 12.13(95% CI 8.30-17.74), 5.12 (95% CI 1.19-21.92), and 3.84 (95% CI 2.52-5.86),respectively. Pregnancies complicated with placenta previa, gestational diabetesmellitus (GDM), and premature labor were associated with significantly increasedrisks for peripartum hysterectomy (P

peripartum hysterectomy included cesarean delivery, VBAC, repeat cesarean,placenta previa, GDM, and premature labor. VBAC and repeat cesarean had asimilar risk.Acta Obstet Gynecol Scand. 2008;87(8):849-55.Management of postpartum hemorrhage by uterine balloon tamponade:prospective evaluation of effectiveness.Doumouchtsis SK, Papageorghiou AT, Vernier C, Arulkumaran S.Department of Obstetrics and Gynaecology, St George's University of London,London, UK. sdoum@yahoo.comOBJECTIVE: To evaluate uterine balloon tamponade in the management ofpostpartum hemorrhage (PPH). Method and study design. Prospective audit.Setting. St George's Hospital, London. POPULATION: Twenty-seven womenwith intractable PPH managed by uterine balloon tamponade using aSengstaken-Blakemore Oesophageal Catheter (SBOC) when medicalmanagement was not effective, and prior to surgical intervention. MAINOUTCOME MEASURES: Success rate of the SBOC in arresting hemorrhage.The need for additional measures, use of anesthesia and complication rates isreported. RESULTS: During the study period there were 27 women who hadplacement of the catheter. In 22 cases (81%) hemostasis was achieved, while infive cases (19%) the SBOC failed in arresting hemorrhage. Of the five failures,hysterectomy was required in four cases and in the remaining case the failurewas associated with expulsion of the balloon, but hemostasis was achieved withfurther conservative measures. Among the failed cases there was one maternaldeath due to amniotic fluid embolism with cardiac arrest and PPH secondary tocoagulopathy. In cases where the balloon was successful it was removed around24 hours later. In these cases no further bleeding was observed, and nocomplications occurred from the procedure. CONCLUSIONS: Placement of aSBOC successfully treats atonic PPH refractory to medical management inaround 80% of cases. It is simple, inexpensive and in those with successfulplacement no surgical morbidity was observed. The potential for it to be used byinexperienced operators in areas with limited resources makes it a useful adjunctin management of PPH.Acta Obstet Gynecol Scand. 2008;87(8):804-11.Heparin therapy for complications of placental dysfunction: a systematicreview of the literature.Dodd JM, Sahi K, McLeod A, Windrim RC, Kingdom JP.Division of Maternal Fetal Medicine, Mt Sinai Hospital, The University of Toronto,Toronto, Ontario, Canada. jodie.dodd@adelaide.edu.auOBJECTIVE: To assess the benefits and harms of antenatal antithrombotictherapy for women at risk of adverse pregnancy outcomes associated withplacental dysfunction. SEARCH STRATEGY: PUBMED and the CochraneControlled Trials Register (CENTRAL) were searched. Reference lists ofretrieved studies were searched by hand. No date or language restrictions wereplaced. Date of last search February 2008. Selection CRITERIA: Randomized

controlled trials comparing antenatal antithrombotic therapy (alone or combinedwith other agents) with placebo or no treatment were considered. Cohort studieswith an appropriate control group were also considered. Studies were evaluatedindependently for appropriateness for inclusion and methodological qualitywithout consideration of their results. Our search strategy identified five caseseries, two cohort studies with a control group, and one randomized controlledtrial. All of the case series and one of the cohort studies were excluded. DATACOLLECTION AND ANALYSIS: The methodological quality of the includedstudies was poor. There was considerable variation in methodology and theinterventions. It was not appropriate to combine results in meta-analysis. MAINRESULTS: From the randomized trial, heparin was not associated with areduction in preterm birth less than 37 weeks gestation (Heparin 5/68 versusControl 7/39; relative risk (RR) 0.41; 95% confidence intervals (CIs) 0.14-1.20),or birth weight below 10th centile (Heparin 4/68 versus Control 6/39; RR 0.38;95% CI 0.11-1.27). CONCLUSION: There is insufficient information torecommend the use of heparin during pregnancy for women at risk ofcomplications due to placental dysfunction. Further information from randomizedtrials is required.Acta Obstet Gynecol Scand. 2008;87(8):856-61.Direct maternal deaths in Norway 1976-1995.Beathe Andersgaard A, Langhoff-Roos J, Øian P.Department of Obstetrics and Gynecology, Innlandet Hospital Trust, Gjøvik,Norway. aba@sykehuset-innlandet.noAIMS: To report direct maternal mortality ratio (MMR) in Norway between 1976and 1995 including a description of the underlying complications in pregnancy,the causes of death and assessment of standard of care. METHODS: Thematernal deaths were identified through the Cause of Death Registry, StatisticsNorway, and Medical Birth Registry of Norway. We requested copies of thehospital case records and the maternal death autopsies. The direct maternaldeaths were classified on the basis underlying causes and assessed forsubstandard care according to the guidelines at the time of death andpreventability provided optimal conditions and up to date guidelines. RESULTS:In the period 1976-1995 we identified 61 direct maternal deaths in Norway. Thedirect MMR was 5.5/100,000 births. Sufficient information was available foranalysis in 51 of these cases. Six deaths occurred in early pregnancy. Amongthe 45 women who gave birth, 32 had a cesarean section, and the death wasjudged to be related to a complication of the operation in more than half of thesecases. The standard of care and the possibility of preventing death wereevaluated in 49 cases. Substandard care was observed in 21 of them and 27were considered avoidable or potentially avoidable. CONCLUSION: The directMMR in Norway was 5.5/100,000 births. The main causes were complications ofhypertensive disease of pregnancy and thromboembolism. The majority ofmaternal deaths were associated with cesarean delivery and consideredpotentially avoidable.

BMJ. 2008 Sep 8;337:a1397. doi: 10.1136/bmj.a1397.Management of sickle cell disease.de Montalembert M.Service de Pédiatrie Générale, Hôpital Necker, 75015 Paris.mariane.demontal@nck.aphp.frBMJ. 2008 Sep 25;337:a1680. doi: 10.1136/bmj.a1680.Effectiveness of continuous glucose monitoring in pregnant women withdiabetes: randomised clinical trial.Murphy HR, Rayman G, Lewis K, Kelly S, Johal B, Duffield K, Fowler D,Campbell PJ, Temple RC.Department of Diabetes and Endocrinology, Ipswich Hospital NHS Trust, IpswichIP4 5PD. Helen.Murphy@ipswichhospital.nhs.ukOBJECTIVE: To evaluate the effectiveness of continuous glucose monitoringduring pregnancy on maternal glycaemic control, infant birth weight, and risk ofmacrosomia in women with type 1 and type 2 diabetes. DESIGN: Prospective,open label randomised controlled trial. SETTING: Two secondary caremultidisciplinary obstetric clinics for diabetes in the United Kingdom.PARTICIPANTS: 71 women with type 1 diabetes (n=46) or type 2 diabetes(n=25) allocated to antenatal care plus continuous glucose monitoring (n=38) orto standard antenatal care (n=33). INTERVENTION: Continuous glucosemonitoring was used as an educational tool to inform shared decision makingand future therapeutic changes at intervals of 4-6 weeks during pregnancy. Allother aspects of antenatal care were equal between the groups. MAINOUTCOME MEASURES: The primary outcome was maternal glycaemic controlduring the second and third trimesters from measurements of HbA(1c) levelsevery four weeks. Secondary outcomes were birth weight and risk of macrosomiausing birthweight standard deviation scores and customised birthweight centiles.Statistical analyses were done on an intention to treat basis. RESULTS: Womenrandomised to continuous glucose monitoring had lower mean HbA(1c) levelsfrom 32 to 36 weeks' gestation compared with women randomised to standardantenatal care: 5.8% (SD 0.6) v 6.4% (SD 0.7). Compared with infants ofmothers in the control arm those of mothers in the intervention arm haddecreased mean birthweight standard deviation scores (0.9 v 1.6; effect size 0.7SD, 95% confidence interval 0.0 to 1.3), decreased median customisedbirthweight centiles (69% v 93%), and a reduced risk of macrosomia (odds ratio0.36, 95% confidence interval 0.13 to 0.98). CONCLUSION: Continuous glucosemonitoring during pregnancy is associated with improved glycaemic control in thethird trimester, lower birth weight, and reduced risk of macrosomia. TRIALREGISTRATION: Current Controlled Trials ISRCTN84461581.BMJ. 2008 Sep 25;337:a1472. doi: 10.1136/bmj.a1472.Continuous glucose monitoring in women with diabetes during pregnancy.Festin MR.Int J Gynaecol Obstet. 2008 Sep 22. [Epub ahead of print]

Use of healthcare services and risk factors among pregnant women inCrete.Papaioannou A, Patelarou E, Chatzi L, Koutis A, Kafatos A, Kogevinas M.Department of Social Medicine, Medical School, University of Crete, Heraklion,Greece.Lancet. 2008 Sep 17. [Epub ahead of print]Childhood outcomes after prescription of antibiotics to pregnant womenwith spontaneous preterm labour: 7-year follow-up of the ORACLE II trial.Kenyon S, Pike K, Jones D, Brocklehurst P, Marlow N, Salt A, Taylor D.Reproductive Sciences Section, Cancer Studies and Molecular Medicine,University of Leicester, Leicester, UK.BACKGROUND: The ORACLE II trial compared the use of erythromycin and/oramoxicillin-clavulanate (co-amoxiclav) with that of placebo for women inspontaneous preterm labour and intact membranes, without overt signs of clinicalinfection, by use of a factorial randomised design. The aim of the present studytheORACLE Children Study II-was to determine the long-term effects on childrenafter exposure to antibiotics in this clinical situation. METHODS: We assessedchildren at age 7 years born to the 4221 women who had completed theORACLE II study and who were eligible for follow-up with a structured parentalquestionnaire to assess the child's health status. Functional impairment wasdefined as the presence of any level of functional impairment (severe, moderate,or mild) derived from the mark III Multi-Attribute Health Status classificationsystem. Educational outcomes were assessed with national curriculum testresults for children resident in England. FINDINGS: Outcome was determined for3196 (71%) eligible children. Overall, a greater proportion of children whosemothers had been prescribed erythromycin, with or without co-amoxiclav, hadany functional impairment than did those whose mothers had received noerythromycin (658 [42.3%] of 1554 children vs 574 [38.3%] of 1498; odds ratio1.18, 95% CI 1.02-1.37). Co-amoxiclav (with or without erythromycin) had noeffect on the proportion of children with any functional impairment, compared withreceipt of no co-amoxiclav (624 [40.7%] of 1523 vs 608 [40.0%] of 1520; 1.03,0.89-1.19). No effects were seen with either antibiotic on the number of deaths,other medical conditions, behavioural patterns, or educational attainment.However, more children whose mothers had received erythromycin or coamoxiclavdeveloped cerebral palsy than did those born to mothers who receivedno erythromycin or no co-amoxiclav, respectively (erythromycin: 53 [3.3%] of1611 vs 27 [1.7%] of 1562, 1.93, 1.21-3.09; co-amoxiclav: 50 [3.2%] of 1587 vs30 [1.9%] of 1586, 1.69, 1.07-2.67). The number needed to harm witherythromycin was 64 (95% CI 37-209) and with co-amoxiclav 79 (42-591).INTERPRETATION: The prescription of erythromycin for women in spontaneouspreterm labour with intact membranes was associated with an increase infunctional impairment among their children at 7 years of age. The risk of cerebralpalsy was increased by either antibiotic, although the overall risk of this conditionwas low. FUNDING: UK Medical Research Council.

Lancet. 2008 Sep 17. [Epub ahead of print]Antibiotics in preterm labour-the ORACLE speaks.Russell AB, Steer P.Warwick Medical School, Warwick, UK; Neonatal Unit, Heart of England NHSTrust, Birmingham, UK.Lancet. 2008 Sep 17. [Epub ahead of print]Childhood outcomes after prescription of antibiotics to pregnant womenwith preterm rupture of the membranes: 7-year follow-up of the ORACLE Itrial.Kenyon S, Pike K, Jones D, Brocklehurst P, Marlow N, Salt A, Taylor D.Reproductive Sciences Section, Cancer Studies and Molecular Medicine,University of Leicester, Leicester, UK.BACKGROUND: The ORACLE I trial compared the use of erythromycin and/oramoxicillin-clavulanate (co-amoxiclav) with that of placebo for women withpreterm rupture of the membranes without overt signs of clinical infection, by useof a factorial randomised design. The aim of the present study-the ORACLEChildren Study I-was to determine the long-term effects on children of theseinterventions. METHODS: We assessed children at age 7 years born to the 4148women who had completed the ORACLE I trial and who were eligible for followupwith a structured parental questionnaire to assess the child's health status.Functional impairment was defined as the presence of any level of functionalimpairment (severe, moderate, or mild) derived from the mark III Multi-AttributeHealth Status classification system. Educational outcomes were assessed withnational curriculum test results for children resident in England. FINDINGS:Outcome was determined for 3298 (75%) eligible children. There was nodifference in the proportion of children with any functional impairment afterprescription of erythromycin, with or without co-amoxiclav, compared with thoseborn to mothers who received no erythromycin (594 [38.3%] of 1551 children vs655 [40.4%] of 1620; odds ratio 0.91, 95% CI 0.79-1.05) or after prescription ofco-amoxiclav, with or without erythromycin, compared with those born to motherswho received no co-amoxiclav (645 [40.6%] of 1587 vs 604 [38.1%] of 1584;1.11,0.96-1.28). Neither antibiotic had a significant effect on the overall level ofbehavioural difficulties experienced, on specific medical conditions, or on theproportions of children achieving each level in reading, writing, or mathematics atkey stage one. INTERPRETATION: The prescription of antibiotics for womenwith preterm rupture of the membranes seems to have little effect on the healthof children at 7 years of age. FUNDING: UK Medical Research Council.Acta Obstet Gynecol Scand. 2008;87(9):929-34.Improved accuracy of postpartum blood loss estimation as assessed bysimulation.Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A.Tel-Aviv Sourasky Medical Center, Lis Maternity Hospital, Tel-Aviv, Israel.maslovitz@gmail.comOBJECTIVE: Caregivers underestimate the amount of blood loss, but this almost

five decades-old assumption has not been validated. We aimed at assessing theaccuracy of estimated blood loss by obstetrical teams during a simulatedPostpartum hemorrhage (PPH) scenario. STUDY DESIGN: a prospective studyconducted as part of the simulation-based training course, using sophisticatedmannequin simulators adapted for obstetrical training by specially designeddevices. SETTING: Part of the simulation-based training course. POPULATION:Obstetrical teams consisted of physicians and obstetrical nurses. METHODS:Each of the participating obstetrical teams assessed blood loss during PPHscenarios. Their estimates were compared to the actual predefined 3.5-liter bloodloss. An intervention group underwent a similar course in which they recordedtheir estimations after 1, 2 and 3.5 liters were lost. OUTCOME MEASURES:Blood loss estimates after completion of the scenario in both groups. RESULTS:Fifty obstetrical teams took part in the study. Eight comprised the interventionalgroup. The average estimated blood loss was 1,780 ml (49% underestimation)for non-interventional teams. The interventional groups estimated blood loss tobe 2,400 ml (32% underestimation). The main method of estimating blood losswas 'gut feeling', followed by verbalized guesses of team members andassessments of the 'patient's' hemodynamic status. CONCLUSIONs: Accuracy ofblood loss estimations by a simulation-based PPH scenario was 50-60%.Measurements at predetermined intervals significantly improved accuracy ofthese estimations. Our study suggests that implementation of periodicestimations of blood loss in the management of PPH might improve clinicaljudgment.BMJ. 2008 Sep 22;337:a1800. doi: 10.1136/bmj.a1800.Unicef calls for more action to reduce maternal deaths in developing world.Zarocostas J.J Perinatol. 2008 Oct;28(10):712-4.Gestational diabetes insipidus and intrauterine fetal death ofmonochorionic twins.Wiser A, Hershko-Klement A, Fishman A, Nachasch N, Fejgin M.Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Sava,,Israel. wiserniv@netvision.net.ilGestational diabetes insipidus (GDI) is a rare disorder. The onset is usually inthe third trimester of pregnancy. We present a 24-year-old primigravida in her35th week of a monochorionic-diamniotic twin pregnancy. The patient presentedwith intrauterine death of both twins accompanied by HELLP syndrome,hypernatremia and hemoconcentration. Urine osmolality below that of the plasmasuggested GDI. 1-deamino-8D-arginine vasopressin (dDAVP) treatment wasstarted with a quick response. GDI is probably the result of excessive activity ofplacental vasopressinase. In cases of liver dysfunction, the clearance rate ofvasopressinase decreases, explaining the association of GDI with acute fattyliver and HELLP syndrome. Alert to this diagnosis, its evaluation and treatment isimportant.

Obstet Gynecol. 2008 Oct;112(4):951-62.ACOG Practice Bulletin No. 98: Ultrasonography in Pregnancy.[No authors listed]Obstet Gynecol. 2008 Oct;112(4):919-932.Pregnancy After Solid Organ Transplantation.Mastrobattista JM, Gomez-Lobo V; for the Society for Maternal–Fetal Medicine.Departments of Obstetrics, Gynecology, & Reproductive Sciences, University ofTexas Medical School at Houston, Houston, Texas; and Washington HospitalCenter, Washington, DC.For women with end-stage organ failure, transplantation is an establishedtherapeutic option. Pregnancy after solid organ transplantation is no longeruncommon, especially with the recent advances in transplantation surgery andthe availability of newer immunosuppressants. This article will reviewpreconceptional counseling, common pregnancy complications, prenatal andintrapartum considerations, outcome by organ, immunosuppressant therapies,and neonatal outcomes based on data available from case series and voluntaryregistries. Some recommendations are provided to assist in the management ofpregnancies after solid organ transplantation.Obstet Gynecol. 2008 Oct;112(4):884-889.Anti-factor Xa Plasma Levels in Pregnant Women Receiving Low MolecularWeight Heparin Thromboprophylaxis.Fox NS, Laughon SK, Bender SD, Saltzman DH, Rebarber A.Maternal Fetal Medicine Associates, PLLC, and the Department of Obstetrics,Gynecology and Reproductive Science, Mount Sinai School of Medicine, NewYork, New York; and the Department of Obstetrics, Gynecology andReproductive Services, University of Pittsburgh, Pittsburgh, Pennsylvania.OBJECTIVE: To report the incidence of prophylactic, subprophylactic, andsupraprophylactic anti-factor Xa activity in pregnant patients receiving lowmolecular weight heparin for venous thromboembolism prophylaxis, and toevaluate whether maternal weight, body mass index, age, gestational age, or thelow molecular weight heparin dose correlated with anti-factor Xa levels.METHODS: We reviewed 321 anti-factor Xa levels in 77 patients from oneMaternal-Fetal Medicine faculty practice. All patients were administered lowmolecular weight heparin that subsequently was adjusted based upon serialassessment of peak plasma (at 4 hours postinjection) anti-factor Xa levels at lessthan 36 weeks gestation. Targeted prophylactic range of peak plasma anti-factorXa level was 0.2-0.4 units/mL. RESULTS: Only 59% of anti-Xa concentrationswere in the prophylactic range, whereas 26% were subprophylactic, and 15%were supraprophylactic. Anti-Xa values were not significantly more likely to beprophylactic in early compared with late pregnancy, obese compared withnonobese patients, or in patients receiving a weight-based minimal dosecompared with patients receiving less than a weight-based minimal dose. AntifactorXa levels did not correlate with maternal age, weight, body mass index, orgestational age, but there was a positive correlation with the percent of the

minimal weight-based dose. CONCLUSION: Even with enhanced low molecularweight heparin dosing, 26% of patients have subprophylactic anti-factor Xalevels. Serial anti-factor Xa assessment for dose adjustment should beconsidered for all pregnant women receiving low molecular weight heparin.LEVEL OF EVIDENCE: III.Obstet Gynecol. 2008 Oct;112(4):828-833.Maternal Congenital Cardiac Disease: Outcomes of Pregnancy in a SingleTertiary Care Center.Ford AA, Wylie BJ, Waksmonski CA, Simpson LL.Department of Obstetrics and Gynecology, Columbia University Medical Center,New York, New York; Division of Maternal-Fetal Medicine, MassachusettsGeneral Hospital, Boston, Massachusetts; and Division of Cardiology, ColumbiaUniversity Medical Center, New York, New York.OBJECTIVE: To evaluate contemporary perinatal and cardiac outcomes ofpregnancies in women with major structural congenital heart disease.METHODS: Obstetric, neonatal, and cardiac outcomes were abstractedretrospectively from medical records of all women with congenital cardiacdisease delivering at our institution from 2000-2007 and compared by type ofstructural defect. Predictors of adverse cardiac or obstetric events wereidentified. RESULTS: Over the 7-year study period, 74 deliveries occurred in 69women with congenital heart disease, median age 28 years. There were threeright-obstructive defects, 14 left-obstructive defects, four right-regurgitant defects,19 conotruncal defects, 19 shunts, and four miscellaneous lesions. There were21 adverse cardiac events in 15 pregnancies (20.2%); these were defined asmaternal death, congestive heart failure, myocardial infarction, stroke, the needfor urgent cardiac intervention, or arrhythmia requiring treatment. There were 44adverse obstetric events in 34 pregnancies (45.9%), defined as preterm delivery,stillbirth, preeclampsia, small for gestational age, or neonatal intensive care unitadmission. Patients with shunt morphology were more likely to experienceadverse obstetric and cardiac outcomes. CONCLUSION: Pregnancy in womenwith underlying major congenital heart defects poses increased risks to bothmother and fetus. Nonetheless, favorable maternal and neonatal outcomes occurin the majority of patients. LEVEL OF EVIDENCE: III.Acta Obstet Gynecol Scand. 2008 Oct 10:1-5. [Epub ahead of print]Reduced adaptation of the pancreatic B cells during pregnancy is the majorcausal factor for gestational diabetes: Current knowledge and metaboliceffects on the offspring.Devlieger R, Casteels K, Van Assche FA.Department of Obstetrics and Gynecology, Division of Woman and Child,University Hospitals Leuven, Belgium.This commentary summarizes current knowledge on the pathophysiology ofgestational diabetes, focusing on the role of the endocrine pancreas and thebeta-cells, their adaptation in normal pregnancy, and recent insights in themolecular basis for deficient adaptation in diabetes occurring during pregnancy.

Additionally, the effects of disturbed maternal glucose metabolism duringpregnancy on the glucose metabolism of the offspring are discussed.Am J Obstet Gynecol. 2008 Oct 7. [Epub ahead of print]Can physiologic hyperlipidemia during pregnancy be the culprit foratherogenesis in utero?Basaran A.Kulu State Hospital, Department of Obstetrics and Gynecology, Dumlupinar cad.25/6, Cebeci/Altindag 06590, Ankara 06590, Turkey.Am J Obstet Gynecol. 2008 Oct 7. [Epub ahead of print]The frequency of pregnancy and exposure to cytomegalovirus infectionsamong women with a young child in day care.Marshall BC, Adler SP.Department of Pediatrics, Medical of College of Virginia Campus, VirginiaCommonwealth University School of Medicine, Richmond, VA.OBJECTIVE: The purpose of this study was to determine the frequency ofpregnancy and exposure to cytomegalovirus (CMV) among motherscontemplating a possible additional pregnancy and with a child less than 2 yearsof age in group day care. STUDY DESIGN: We performed a prospectiveobservational study that included a demographic questionnaire and serologic andvirologic monitoring of mothers and their children in day care. RESULTS: Of 60women, 62% were seronegative and 20% had a child shedding CMV. Of the 60women, 23 women or 38% (95% CI, 0.27-0.51) became pregnant on average 10months after enrollment. During pregnancy, 8 or 35% (95% CI, 0.19-0.55) ofthese pregnant women had a child in day care who shed CMV. CONCLUSIONS:These results illustrate the potential magnitude of the public problem associatedwith exposure to a silent viral infection during pregnancy. Our data, whenextrapolated to the US population, estimate that every 2 years between 31,000and 168,000 susceptible pregnant women will be exposed to CMV by an infectedchild.Am J Obstet Gynecol. 2008 Oct 7. [Epub ahead of print]Maternal thrombophilia and the risk of recurrence of preeclampsia.Facchinetti F, Marozio L, Frusca T, Grandone E, Venturini P, Tiscia GL, Zatti S,Benedetto C.Mother-Infant Department, Unit of Gynecology and Obstetrics, Faculty ofMedicine and Surgery, University of Modena and Reggio Emilia, Italy.OBJECTIVE: The aim of this prospective study was to determine the impact ofthrombophilia on the recurrence of preeclampsia. STUDY DESIGN: In amulticenter, observational, cohort design, 172 white patients with a previouspregnancy complicated by preeclampsia were observed in the next pregnancy.They were evaluated for heritable thrombophilia (factor V Leiden and factor IIG20210A mutations, protein S, protein C, and antithrombin deficiency),hyperhomocystinemia, lupus anticoagulant, and anticardiolipin antibodies.Development of preeclampsia and maternal complications and both gestational

age at delivery and birthweight were recorded. RESULTS: Sixty women (34.9%)showed the presence of a thrombophilic defect. They had a higher risk for therecurrence of preeclampsia (odds ratio [OR], 2.5; 95% confidence interval [CI],1.2-5.1), compared to patients without thrombophilia. Similar findings wereobserved considering only heritable thrombophilia. Thrombophilic patients wereat increased risk for the occurrence of very early preterm delivery (< 32 weeks;OR, 11.6; 95% CI, 3.4-43.2). CONCLUSION: When counseling white womenwith a history of preeclampsia, screening for thrombophilia can be useful forpreconceptional counseling and pregnancy management.Aust N Z J Obstet Gynaecol. 2008 Aug;48(4):447.Re: Guidelines for the use of recombinant activated factor VII in massiveobstetric haemorrhage.Nicklin J, Perrin L, Crandon A, Land R, Nascimento M, Obermair A.Aust N Z J Obstet Gynaecol. 2008 Aug;48(4):359.The hazards of pregnancy.Ellwood D.Gynecol Obstet Invest. 2008 Oct 9;67(1):67-69. [Epub ahead of print]Long-Term Survival after Postpartum Liver Rupture and Necrosis RequiringLiver Transplantation in a Twin Pregnancy.Saisto T, Stefanovic V, Vakkuri A.Department of Obstetrics and Gynecology, Helsinki University Central Hospital,Helsinki, Finland.A 32-year-old G6P5 (hepatitis B carrier, of African origin) with a spontaneoustwin pregnancy gave birth at the 37th gestational week. Four hours later shecollapsed. Upon an emergency laparotomy, right liver lobe rupture and latermassive liver necrosis were diagnosed. Four days later, a liver transplantationwas performed. She was discharged from the hospital 38 days after her delivery,four laparotomies, and having received 179 units of red blood cells, 221 units offresh frozen plasma, 144 units of platelets, and various separate clottingconcentrates. As a result of immune suppression medication, she laterdeveloped diabetes, sarcoma Kaposi, a Pneumocystis carinii pneumonia, andcoenurosis. Four years later, she is, however, in a relatively good condition.Copyright © 2008 S. Karger AG, Basel.Int J Gynaecol Obstet. 2008 May;101(2):137-40. Epub 2008 Feb 15.Predictors of prognosis in patients with peripartum cardiomyopathy.Duran N, Günes H, Duran I, Biteker M, Ozkan M.Cardiology Department, Kartal Kosuyolu Heart and Research Hospital, Istanbul,Turkey. eksduran@yahoo.comOBJECTIVES: To evaluate the long-term follow-up results of patients withperipartum cardiomyopathy and assess the echocardiographic findings relating toprognosis at time of diagnosis. METHODS: Thirty-three patients diagnosed withperipartum cardiomyopathy and hospitalized between 1995 and 2007 were

analyzed. Initial echocardiographic data were recorded and long-term clinicalstatus was evaluated. RESULTS: Eight (24%) patients recovered completely, 10(30%) died, 2 (6%) underwent heart transplants, and 13 (39%) were left withpersistent left ventricular dysfunction. Cut-off values for initial left ventricular endsystolicdiameter (< or =5.5 cm) and left ventricular ejection fraction (>27%) wereobtained from patients who had completely recovered. CONCLUSION: Cut-offvalues for initial left ventricular ejection fraction of >27% and left ventricular endsystolicdiameter of < or =5.5 cm may predict recovery of left ventricle function.Int J Gynaecol Obstet. 2008 May;101(2):129-32. Epub 2008 Mar 4.A randomized comparative study of prophylactic oxytocin versusergometrine in the third stage of labor.Orji E, Agwu F, Loto O, Olaleye O.Department of Obstetrics, Gynecology and Perinatology, Faculty of ClinicalSciences, Obafemi Awolowo University, Ile-Ife, Nigeria. eoorji11@yahoo.comOBJECTIVE: To compare the effect of prophylactic use of oxytocin andergometrine in management of the third stage of labor. METHODS: Aprospective randomized study of 600 women assigned to receive either oxytocinor ergometrine in the third stage of labor. Outcome measures were thepredelivery and 48-hour postdelivery hematocrit, duration of the third stage,specific side effects, and incidence of postpartum hemorrhage. Statisticalanalyses were done using the test for continuous variables and chi2 test forcategorical variables. The level of significance was set at P

antibiotics. METHODS: A double-blind randomized controlled trial evaluatingprenatal oral amoxicillin versus placebo with the primary outcome of GBScolonization at the time of labor. RESULTS: Of those patients receiving bothamoxicillin and a repeat culture at the time of labor, 6 of the 14 (43%) testedpositive for GBS colonization. Given persistent GBS colonization of 67% (10/15)in the placebo group, treatment with amoxicillin did not significantly impactcolonization at the time of delivery (P=0.20). CONCLUSION: A regimen ofoutpatient amoxicillin was associated with persistent GBS colonization in 43% ofwomen at the time of labor. Oral prenatal antibiotic prophylaxis against GBSdoes not sufficiently reduce colonization to preclude intrapartum intravenousantibiotics.J Reprod Med. 2008 Sep;53(9):714-6.Primary hyperparathyroidism in pregnancy presenting as intractablehyperemesis complicating psychogenic anorexia: a case report.Pachydakis A, Koutroumanis P, Geyushi B, Hanna L.Department of Obstetrics and Gynaecology, Queen Mary's Hospital, Sidcup,Kent, UK. pachydakis@hotmail.comBACKGROUND: Primary hyperparathyroidism is a rare complication ofpregnancy. Its peak incidence is in the perimenopausal period. CASE: A 31-yearoldwoman was admitted at 8 weeks of pregnancy with intractable hyperemesisand fatigue. After parathyroidectomy, at 18 weeks' gestation, she remainedasymptomatic. Biochemistry gradually normalized, and her body mass indexreturned to the levels found prior to her eating disorder manifestation. In ourreview there were no maternal complications in 32 of 43 (74%) cases. Therewere 10 cases (21%) of fetal complications identified. CONCLUSION:Postponing treatment increases the risk of preeclampsia, preterm labor and fetalparathyroid impairment, while early surgical treatment decreases the fetalcomplication rate 4-fold.J Reprod Med. 2008 Sep;53(9):703-7.Primary intussusception in pregnancy: a case report.Gould CH, Maybee GJ, Leininger B, Winter WE 3rd.Department of Obstetrics and Gynecology, Wilford Hall Medical Center, LacklandAir Force Base, USA.BACKGROUND: Intussusception is a rare cause of bowel obstruction in adults,typically associated with malignancy, granuloma formation, a foreign body or ananatomic defect. CASE: A 21-year-old, primiparous woman presented at 33 5/7weeks' gestation with vague abdominal symptoms consistent with acute viralgastroenteritis. She did not improve with conservative measures. A presumptivediagnosis of severe preeclampsia was made based on elevated blood pressure,abnormal liver function tests and epigastric pain. Labor was induced 34 5/7weeks' gestation. The patient did not improve after an uncomplicated vaginaldelivery. Abdominal radiographs and computed tomography were consistent withintussusception. Surgical findings were consistent with the radiologic findings.The patient underwent a right hemicolectomy with stapled anastomosis. No

pathologic or anatomically anomalous lead point was identified intraoperatively oron final pathology. CONCLUSION: Intussusception is a rare finding in theperipartum period, often presenting with vague abdominal symptoms andmistaken for benign obstetric and nonobstetric diseases. This case is only thesecond one of adult perinatal intussusception without an anatomic or pathologiclead point.J Reprod Med. 2008 Sep;53(9):657-66.Low-molecular-weight heparins for the prevention and treatment of venousthromboembolism in at-risk pregnant women: a review.Duhl AJ.Department of Obstetrics and Gynecology, Mercy Hospital of Pittsburgh,Pittsburgh, Pennsylvania, USA. adamduhl@yahoo.comCertain pregnant populations are at high risk of developing venousthromboembolism (VTE) during pregnancy. Patients at particularly high risk ofVTE are those with a history of VTE, thrombophilia or adverse pregnancyoutcomes or with mechanical heart valves. In these high-risk patients, evidencebasedguidelines recommend the use of thromboprophylaxis. Low-molecularweightheparin (LMWH) is a safe and effective thromboprophylaxis option inthese patients and has a number of administrative and pharmacokineticadvantages over unfractionated heparin. Furthermore, LMWH has also beenshown to be a safe and effective treatment for confirmed deep vein thrombosis inpregnant women.J Reprod Med. 2008 Sep;53(9):649-50.Parenteral therapy in today's obstetric practice.Devoe LD.Acta Obstet Gynecol Scand. 2008 Oct 10:1-4. [Epub ahead of print]Treatment of deep venous thrombosis in pregnant women.Lykke JA, Grønlykke T, Langhoff-Roos J.Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark.The recommended dosage of tinzaparin in the treatment of thromboembolismduring pregnancy is 175 IU/kg/day, as for non-pregnant subjects. In clinicalpractice, we have experienced a need for a higher dosage, especially in the initialphase of the treatment of deep vein thrombosis, based on four-hour post-dosemeasurements of anti-Xa activity. Twenty-two pregnant patients with a confirmeddeep venous thrombosis were treated with tinzaparin either in a once- or twicedailyregimen. Four-hour post-dosage plasma anti-Xa activity was measured in357 sequential blood samples during treatment. An higher dosage thanrecommended, was required to maintain anti-Xa activity in the target range. Wesuggest that the starting dosage should be 250 IU/kg/day in a twice-dailyregimen, and that the dose in the initial phase be adjusted by daily monitoring ofanti-Xa.BMJ. 2008 Oct 15;337:a1935. doi: 10.1136/bmj.a1935.

A pregnant Jehovah's witness.Sheehan SR, Murphy DJ.Coombe Women and Infants University Hospital and Trinity College Dublin.Clin Exp Obstet Gynecol. 2008;35(2):98-102.Placenta percreta presenting in the first trimester: review of the literature.Papadakis JC, Christodoulou N.Department of Obstetrics & Gynaecology, Venizelion General Hospital, LeoforosKnossou, Heraklion Crete, Greece. juanpapadakis@doctors.org.ukPlacenta percreta complicating pregnancy in the first trimester is extremely rare,and only a few cases have been reported in the literature. We recently reportedon a patient with risk factors for placenta percreta that presented as first trimesterfetal demise, unresponsive to medical management with prostaglandin. Thepatient required an emergency hysterectomy to control the bleeding after uterinecurettage, and was complicated by severe consumption coagulopathy. This rareentity can lead to significant mortality and morbidity, particularly in thebackground of increased prevalence of the disease and its associated riskfactors, and the large number of spontaneous and induced abortions performedworldwide. Therefore, we also reviewed all reported cases of first-trimesterplacenta percreta in the literature to increase the awareness of physicians and tohighlight the clinical features and essentials of the management.Curr Opin Obstet Gynecol. 2008 Jun;20(3):308-12.Reproduction and contraception after kidney transplantation.Watnick S, Rueda J.Department of Medicine, Oregon Health & Science University, Portland, Oregon,USA. watnicks@ohsu.eduPURPOSE OF REVIEW: In this manuscript we review the most recent dataregarding birth rates and complications in the kidney transplant population.Despite improved fertility, contraceptive counseling is infrequent andcontraceptive use engenders many problems not frequently seen in women ofchildbearing age. RECENT FINDINGS: Pregnancy outcomes in this populationare improving, but these patients are still considered 'high risk'. With improvedfertility after transplantation, contraception should be viewed as essential in thosewho wish to avoid pregnancy. Many forms of contraception are viable for womenwith a kidney transplant. SUMMARY: Given increased rates of preeclampsia,preterm delivery, low birth weight, and increased risk of cesarean section, amultidisciplinary team must be involved, which will tend to everything fromgeneral fetal and maternal monitoring, serial measurement of kidney function,and medication adjustment. For all these reasons, contraceptive counseling isnecessary for all women of childbearing age, both pre and posttransplantation.Specific methods of contraception can be individualized to a patient's needs andshould be discussed between patient and provider. Future study of bothreproduction and contraception use in kidney transplant recipients is sorelyneeded.

Eur J Obstet Gynecol Reprod Biol. 2008 Jun;138(2):244-6. Epub 2007 May 9.Hemostatic multiple square suturing is an effective treatment for thesurgical management of intractable obstetric hemorrhage.Desbriere R, Courbiere B, Mattei S, Haumonte JB, Shojaï R, Antonini F, d'ErcoleC, Boubli L.Int J Gynaecol Obstet. 2008 Oct 11. [Epub ahead of print]Embolization of a rectus sheath hematoma in pregnancy.Riera C, Deroover Y, Marechal M.Department of Obstetrics and Gynecology, Chu Civil de Charleroi, Charleroi,Belgium.Am J Obstet Gynecol. 2008 Oct;199(4):431.e1-5.Longitudinal trajectory of bacterial vaginosis during pregnancy.Waters TP, Denney JM, Mathew L, Goldenberg RL, Culhane JF.Department of Obstetrics and Gynecology, MetroHealth Medical Center,Cleveland, OH, USA.OBJECTIVE: This study was undertaken to characterize the course of bacterialvaginosis in pregnancy and to discern the bacterial morphotypes responsible forinfection. STUDY DESIGN: Vaginal secretions were obtained in each trimester ofpregnancy and were evaluated for bacterial vaginosis by Gram stain, categorizedas normal or any of the following: Lactobacillus deficient, Gardnerella,Bacteroides, or Mobiluncus positive and by Nugent score. Results wereevaluated for trends of bacterial vaginosis and Gram stain over pregnancy.RESULTS: One hundred forty-eight women were evaluated. Seventy-one women(48%) were bacterial vaginosis negative in all trimesters, compared with 14(9.4%) who were positive throughout pregnancy. Among the 14 women whoremained bacterial vaginosis positive, Gram stain findings wereGardnerella+Bacteroides+Lactobacillus, with approximately 50% harboringMobiluncus. Few women become bacterial vaginosis positive as pregnancyprogressed (6.1%). With each increasing week of pregnancy, the risk ofbecoming bacterial vaginosis positive decreased (0.93: 0.91-0.95; P < .001).CONCLUSION: In this population, the majority of pregnant women trend towardbacterial vaginosis negative status. Few women are bacterial vaginosis positiveacross their pregnancy.Am J Obstet Gynecol. 2008 Oct;199(4):380.e1-4.Maternal glucose levels after dexamethasone for fetal lung development intwin vs singleton pregnancies.Foglia LM, Deering SH, Lim E, Landy H.Department of Obstetrics and Gynecology, Madigan Army Medical Center,Tacoma, WA, USA.OBJECTIVE: Betamethasone administration in singleton pregnancies causesmaternal hyperglycemia. With the increased risk of glucose intolerance in twinpregnancies, we sought to determine whether maternal hyperglycemia afterdexamethasone administration is different in twin vs singleton pregnancies.

STUDY DESIGN: Patients with singleton or twin pregnancies admitted between24 and 34 weeks' gestation with diagnoses requiring steroid administration wereapproached. Exclusion criteria included diabetes, abnormal glucose tolerancetest, infection, or medications known to interfere with glucose metabolism.Patients were NPO for 24 hours and received dexamethasone per protocol.Maternal glucose levels were checked at baseline and then at specified intervalsafter the initial dose; appropriate statistical analysis was performed. RESULTS:Ten singleton and 9 twin gestations were enrolled. There were no differences inmean maternal or gestational ages. Mean glucose levels were significantly higherin the twin group at 4 hours (114 mg/dL vs 95.6 mg/dL), 8 hours (121.4 mg/dL vs90.9 mg/dL), and 24 hours (116 mg/dL vs 81 mg/dL) (P < .01 for all).CONCLUSION: Twin pregnancies had higher mean glucose values thansingleton pregnancies in the first 24 hours after dexamethasone administration.Am J Obstet Gynecol. 2008 Oct;199(4):375.e1-5.The frequency of microbial invasion of the amniotic cavity and histologicchorioamnionitis in women at term with intact membranes in the presenceor absence of labor.Seong HS, Lee SE, Kang JH, Romero R, Yoon BH.Department of Obstetrics and Gynecology, Seoul National University College ofMedicine, Seoul, Korea.OBJECTIVE: The amniotic cavity is normally sterile for bacteria. However,experimental evidence indicates that regular uterine contractions exert a suctionlikeeffect whereby vaginal fluid ascends into the uterine cavity with contractions(demonstrated by sonohysterography contrast media). Consequently, this studywas conducted to determine whether the presence and progress of labor areassociated with an increased risk of microbial invasion of the amniotic cavity(MIAC), intraamniotic inflammation, and histologic chorioamnionitis in womenwith term pregnancies with intact membranes. STUDY DESIGN: Amniotic fluid(AF) was obtained from term singleton pregnant women with intact membranesat the time of cesarean delivery. AF was cultured for aerobic and anaerobicbacteria and genital mycoplasmas, and white blood cell (WBC) count wasdetermined. Patients were divided into 3 groups according to the presence orabsence of labor and the progress of labor. Nonparametric statistics were usedfor analysis. RESULTS: Results included: (1) a total of 884 pregnant womenwere enrolled and divided into 3 groups: group 1, not in labor (n = 775); group 2,in early labor (cervical dilatation less than 4 cm) (n = 86); and group 3, in activelabor (cervical dilatation 4 cm or greater) (n = 23); (2) the frequency of MIAC was1% (6 of 775) in women not in labor, 3.5% (3 of 86) in patients with early labor,and 13% (3 of 23) in patients with active labor; and (3) the median AF WBCcount and the frequency of histologic chorioamnionitis were also higher in thepresence of labor than in the absence of labor. CONCLUSION: We came to thefollowing conclusions: (1) labor is associated with an increased risk of MIAC, ahigher median AF WBC count, and histologic chorioamnionitis in term pregnancywith intact membranes; (2) the more advanced the cervical dilatation, the greaterthe risk of MIAC, a higher median AF WBC count, and histologic

chorioamnionitis; and (3) in contrast, fetal inflammation (funisitis) did not increasewith the presence of labor or as a function of cervical dilatation. We propose thatlabor predisposes to MIAC, a higher median AF WBC count, and histologicchorioamnionitis.BMJ. 2008 Oct 22;337:a1940. doi: 10.1136/bmj.a1940.Acute intrapartum obstetric emergency.Sheehan SR, McMillan HM, Murphy DJ.Coombe Women and Infants University Hospital, Dublin 8, and Trinity CollegeDublin, Ireland.J Reprod Med. 2008 May;53(5):357-9.Can digoxin and sotalol therapy for fetal supraventricular tachycardia andhydrops be successful? A case report.Merriman JB, Gonzalez JM, Rychik J, Ural SH.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,University of Pennsylvania Medical Center, University of Pennsylvania School ofMedicine, Philadelphia, PA 19104, USA. jmerriman@obgyn.upenn.eduBACKGROUND: Neonatal survival and prognosis are closely linked withdevelopment of hydrops in cases of sustained fetal tachycardia. Severalantiarrhythmic medications are available for conversion to sinus rhythm. CASE:An 18-year-old woman had an audible fetal arrhythmia at 25 weeks' gestation.Fetal echocardiography revealed supraventricular tachycardia with worseningcardiac function at 28 weeks. Digoxin therapy was initiated and sotalol was lateradded for new-onset hydrops. The medications were then adjusted, and thefetus' heart rate converted to sinus rhythm with resolution of the hydrops. Thepatient was then managed as an outpatient with antenatal testing, seriallaboratory studies and electrocardiograms until 39 weeks. CONCLUSION:Digoxin and sotalol therapy can be successful in blocking likely nodal reentry insustained fetal supraventricular tachycardia, thus allowing resolution of hydropswith a favorable outcome.Lancet. 2008 Sep 27;372(9644):1142-3.Midwives and obstetric catastrophe: retrieving the past.Green MH.Department of History, Arizona State University, Tempe, AZ 85287-4302, USA.Monica.Green@asu.eduSemin Perinatol. 2008 Oct;32(5):323-4.Maternal depression is a common complication among pregnant womenoccurring approximately 2-3% of this population. Introduction.Oh W, Sedin G.Acta Obstet Gynecol Scand. 2008 Oct 29:1-5. [Epub ahead of print]Hepatocellular enzyme glutathione S-transferase alpha and intrahepaticcholestasis of pregnancy.

Joutsiniemi T, Leino R, Timonen S, Pulkki K, Ekblad U.Department of Obstetrics and Gynaecology, Turku University Central Hospital,Turku, Finland.Objective. To evaluate and compare plasma glutathione S-transferase alpha(GSTA) concentrations in the third trimester of pregnancy in patients withintrahepatic cholestasis of pregnancy (ICP) and in healthy pregnant women.Design. Non-randomized clinical study. Setting. Maternity unit and Department ofClinical Chemistry, Turku University Central Hospital, Turku, Finland. Population.Twenty-seven women with ICP and 49 healthy pregnant women. Methods. GSTAconcentrations were assessed in plasma samples in the third trimester ofpregnancy using an enzyme-linked immunoassay (HEPKITtrade mark Alpha,Biotrin, Sinsheim-Reihen, Germany). Main outcome measures. Plasma GSTA,serum alanine and bile acid concentrations were compared between study andcontrol group. Correlation between plasma GSTA levels and serum alanineaminotransferase and bile acid levels in the ICP patients were tested bySpearman correlation coefficients. Main perinatal outcome was comparedbetween the groups. Results. GSTA concentration in the control group was 1.62microg/l (range: 0.25-6.1). In the ICP patients, the mean plasma GSTAconcentration was 51.0 microg/l (range: 2.1-183.5), the mean serum alanineaminotransferase concentration was 145.70 U/l (range: 6-393) and the mean bileacid concentration was 19.2 micromol/l (range: 3-63). There was a statisticallysignificant correlation in ICP patients between plasma GSTA concentration andserum alanine aminotransferase concentration (r=0.694, p=0.0001), but not withserum bile acid concentration. Nor was there any statistically significantcorrelation between gestational weeks and plasma GSTA concentration in thestudy group. Conclusion. Plasma GSTA measurements may provide a moresensitive and specific diagnostic tool for diagnosis of ICP than the evaluation oftransaminases or bile acid concentrations alone. Further studies are needed toevaluate the role of GSTA in the follow-up of patients with ICP and its prognosticvalue for threatening fetal distress in patients with ICP.Acta Obstet Gynecol Scand. 2008 Oct 24:1-10. [Epub ahead of print]The Stockholm classification of stillbirth.Varli IH, Petersson K, Bottinga R, Bremme K, Hofsjo A, Holm M, Holste C,Kublickas M, Norman M, Pilo C, Roos N, Sundberg A, Wolff K, PapadogiannakisN.Department of Obstetrics and Gynaecology, Karolinska University Hospital,Solna, and Karolinska Institutet, Stockholm, Sweden.Objective. To design and validate a classification system for audit groups workingwith stillbirth. The classification includes well-defined primary and associatedconditions related to fetal death. Design. Descriptive. Setting. All delivery wardsin Stockholm. Population. Stillbirths from 22 completed weeks in Stockholm,Sweden. Methods. Parallel to audit work, the Stockholm stillbirth group hasdeveloped a classification of conditions related to stillbirth. The classification hasbeen validated. Main outcome measure. The classification and the results of thevalidation are presented. Result. The classification with 17 groups identifying

underlying conditions related to stillbirth (primary diagnoses) and associatedfactors which may have contributed to the death (associated diagnoses) isdescribed. The conditions are subdivided into definite, probable and possiblerelation to the death. An evaluation of 382 cases of stillbirth during 2002-2005resulted in 382 primary diagnoses and 132 associated diagnoses. The mostcommon conditions identified were intrauterine growth restriction/placentalinsufficiency (23%), infection (19%), malformations/chromosomal abnormalities(12%). The 'unexplained' group together with the 'unknown' group comprised18%. Validation was done by reclassification of 95 cases from 2005 by sixinvestigators. The overall agreement regarding primary diagnosis was substantial(kappa =0.70). Conclusions. The Stockholm classification of stillbirth consists of17 diagnostic groups allowing one primary diagnosis and if needed, associateddiagnoses. Diagnoses are subdivided according to definite, probable andpossible relation to stillbirth. Validation showed high degree of agreementregarding primary diagnosis. The classification can provide a useful tool forclinicians and audit groups when discussing cause and underlying conditions offetal death.Am J Obstet Gynecol. 2008 Sep;199(3):e11-2; author reply e12-3. Epub 2008Jun 4.Comment on:Am J Obstet Gynecol. 2007 Nov;197(5):470.e1-4.Prophylactic balloon occlusion of the internal iliac arteries to treatabnormal placentation.Le Ray C, Audibert F, Dubois J.Am J Obstet Gynecol. 2008 Sep;199(3):e12; author reply e12-3. Epub 2008 May5.Comment on:Am J Obstet Gynecol. 2007 Nov;197(5):470.e1-4.Pitfalls of balloon occlusion in the pelvis.McLucas B, Mitty HA.Am J Obstet Gynecol. 2008 Sep;199(3):e11; author reply e12-3. Epub 2008 May5.Comment on:Am J Obstet Gynecol. 2007 Nov;197(5):470.e1-4.The ligation of hypogastric arteries is a safe alternative to balloonocclusion to treat abnormal placentation.Judlin P, Thiebaugeorges O.Eur J Obstet Gynecol Reprod Biol. 2008 Oct 23. [Epub ahead of print]Spontaneous common bile duct rupture in a pregnant female-A rare causeof peritonitis.O'Neill A, O'Sullivan MJ, McDermott E.St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

Acta Obstet Gynecol Scand. 2008;87(10):1020-6.B-Lynch suture for massive persistent postpartum hemorrhage followingstepwise uterine devascularization.Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L.Department of Obstetrics and Gynecology, Rouen University Hospital, CharlesNicolle, Rouen, France. loicsentilhes@hotmail.comOBJECTIVE: To estimate the effectiveness and safety of the B-Lynch suture forsevere persistent postpartum hemorrhage (PPH) following vessel ligation beforeconsidering hysterectomy and its impact on menstruation and uterine cavity.DESIGN: Cohort study. SETTING: University-affiliated tertiary referral center.Population. Fifteen consecutive women who underwent B-Lynch suture forpersistent PPH despite vessel ligation. METHODS: Data were retrieved frommedical files and telephone interviews. MAIN OUTCOME MEASURE(S):Hysterectomy, infection, hysteroscopy, future menstruations. RESULTS: In 13 ofthe 15 cases (86.7%), PPH occurred after cesarean deliveries. B-Lynch suturescontrolled the hemorrhage and resulted in an avoidance of immediatehysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for14 of 15 women (93.3%). In one case hysterectomy was required due topyometra in an ischemic uterus. In the remaining 11 women where the uteruswas preserved, ambulatory hysteroscopy was normal. No women reported anydifferences in menses or pain compared to that they experienced beforepregnancy, or any clinical symptoms of early menopause. One woman reported asubsequent pregnancy with normal conception delay, whereas the ten remainingwomen had no desired pregnancy due to, in each case, the fear of PPHrecurrence. CONCLUSIONS: B-Lynch technique appears to be an effectiveprocedure with a relatively low morbidity to control persistent severe PPHfollowing a failure of vessel ligation before considering hysterectomy.Am J Obstet Gynecol. 2008 Nov;199(5):443-4.Preeclampsia: new approaches but the same old problems.Roberts JM.Am J Obstet Gynecol. 2008 Nov;199(5):e9-e12.Acute voluntary intoxication with selective serotonin reuptake inhibitorsduring the third trimester of pregnancy: therapeutic management of motherand fetus.Tixier H, Feyeux C, Girod S, Thouvenot S, Morisse M, Douvier S, Sagot P.Department of Gynecology and Obstetrics, University of Dijon School ofMedicine,Bocage Teaching Hospital, 2, bd Maréchal de Lattre Tassigny, BP 77908, FR-21079 Dijon Cedex, France. herve_tixier@yahoo.frSelective serotonin reuptake inhibitor (SSRI) antidepressants are preferred totricyclics, because, for the same efficacy, they are better tolerated. Themechanisms of action are well understood. These drugs may be used duringpregnancy. We present here the case of a voluntary intoxication with SSRI in the

third trimester of pregnancy.BMJ. 2008 Nov 3;337:a2316. doi: 10.1136/bmj.a2316.Caffeine intake during pregnancy.Olsen J, Bech BH.Clin Exp Obstet Gynecol. 2008;35(3):225-6.Placenta percreta presenting in the first trimester and resulting in severeconsumption coagulopathy and hysterectomy: a case report.Papadakis JC, Christodoulou N, Papageorgiou A, Rasidaki M.Department of Obstetrics and Gynecology, Leoforos Knossou, Heraklion, Crete,Greece. juanpapadakis@doctors.org.ukPlacenta percreta complicating pregnancy in the first trimester is extremely rare,and only a few cases have been reported in the literature. A patient with riskfactors for placenta percreta that presented as first trimester fetal demise,unresponsive to medical management with prostaglandin, is presented. Thepatient required an emergency hysterectomy to control the bleeding after uterinecurettage which was complicated by severe consumption coagulopathy. This rareentity can lead to significant mortality and morbidity, particularly in thebackground of an increased prevalence of the disease and its associated riskfactors, and the large number of spontaneous and induced abortions performedworldwide.Clin Exp Obstet Gynecol. 2008;35(3):221-4.Partial placenta increta and methotrexate therapy: three case reports.Pinho S, Sarzedas S, Pedroso S, Santos A, Rebordão M, Avillez T, Casal E,Hermida M.Department of Obstetrics, Gamrcia de Orta Hospital, Almada, Portugal.s.pinho@netcabo.ptThe term placenta accreta is used to describe any placental implantation in whichthere is abnormally firm adherence to the uterine wall. This condition complicates1/2,500 deliveries and is rising in incidence. Abnormal placentation is associatedwith increased maternal morbidity and mortality from severe hemorrhage, uterineperforation, infection and loss of fertility. The reported experience ofmethotrexate treatment in the conservative management of placenta accreta isscant. Three cases of partial placenta increta managed with methotrexate aredescribed. The patients were assessed with clinical surveillance, serum betahuman chorionic gonadotrophin (beta-hCG) and imaging (ultrasonography andmagnetic resonance in one case). In all cases conservative management withmethotrexate resulted in undetectable serum beta-hCG, a decrease in the size ofpartial placenta retained, and undetectable vascularization.Curr Opin Obstet Gynecol. 2008 Dec;20(6):557-62.Epileptic disorders in pregnancy: an overview.Harden CL, Sethi NK.Department ofNeurology, University of Miami Miller School of Medicine, Miami,

Florida, USA. charden@med.miami.eduPURPOSE OF REVIEW: Much new information has now become availableregarding outcomes of women with epilepsy (WWE) and pregnancy. RECENTFINDINGS: Valproate is associated with a risk of major congenital malformationswithin a range of 6.2-10.7%, though antiepileptic drugs (AEDs) other thanvalproate when used as monotherapy are associated with major congenitalmalformation rates ranging from 2.9 to 3.6%; the rate of major congenitalmalformations in WWE not treated with AEDs was similar to this at 3.1%. Seizurefreedom in 9-12 months before pregnancy is associated with seizure freedomduring pregnancy. A decline in AED levels can be expected during pregnancy,most dramatically for lamotrigine (but with marked variability between patients)and least with carbamazepine. Neonates born to WWE taking AEDs who receivevitamin K 1 mg intramuscularly at birth are not at additional risk of hemorrhagicdisease of the newborn. SUMMARY: The use of valproate and polytherapy withany AED combinations should be avoided, if clinically appropriate, duringpregnancy. Seizure freedom in 9-12 months before pregnancy should be a goal.AED levels should be maintained at or near the therapeutic level known for thatindividual patient, with frequent monitoring during pregnancy as appropriate forthe patient and the AED.Curr Opin Obstet Gynecol. 2008 Dec;20(6):550-6.Thromboembolism in pregnancy: recurrence risks, prevention andmanagement.James AH.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,Duke University Medical Center, Durham, North Carolina 27710, USA.andra.james@duke.eduPURPOSE OF REVIEW: The purpose of this review is to summarize theepidemiology of thromboembolism in pregnancy and describe strategies toprevent and treat it. RECENT FINDINGS: The main reason for the increased riskof thrombosis in pregnancy is hypercoagulability. Other risk factors include ahistory of thrombosis, inherited and acquired thrombophilia, certain medicalconditions, and complications of pregnancy and childbirth. SUMMARY: Thehypercoagulability of pregnancy is present as early as the first trimester and so isthe increased risk of thrombosis. Candidates for anticoagulation are women witha current thrombosis, a history of thrombosis, thrombophilia and a history of poorpregnancy outcome, or risk factors for postpartum thrombosis. For fetal reasons,the preferred agents for anticoagulation in pregnancy are heparins. There are nolarge trials of anticoagulants in pregnancy and recommendations are based oncase series and the opinion of experts. Nonetheless, anticoagulants are believedto improve the outcome of pregnancy for women and their fetuses.Curr Opin Obstet Gynecol. 2008 Dec;20(6):534-9.Management of the acute abdomen in pregnancy: a review.Kilpatrick CC, Orejuela FJ.Department of Obstetrics, Gynecology and Reproductive Sciences, University of

Texas Health Science Center, Houston, Texas, USA.Charles.C.Kilpatrick@uth.tmc.eduPURPOSE OF REVIEW: The acute abdomen remains a challenge for allphysicians who take part in the care of women in pregnancy. Obstetricians mustbe abreast of current topics, especially critical when having to consult otherspecialties for assistance in managing these conditions. RECENT FINDINGS:We will highlight recent observations in the literature concerning the ability toperform laparoscopy safely in pregnancy, the accuracy of diagnosingappendicitis, and new methods to accurately diagnose urolithiasis with lessionizing radiation effect on the fetus. Finally, with the proficiency of laparoscopyand choledochoscopy improving, we will review several articles underlining theirsafety. SUMMARY: Laparoscopy appears to be well tolerated in pregnancy, butlarger multicenter prospective studies are required to make betterrecommendations concerning its use, with a registry needed to facilitate thisendeavor. Conservative management of gallstone pancreatitis may fall out offavor, and choledochoscopy for symptomatic gallstones in the biliary tree maybecome the treatment of choice. Most cases of urolithiasis resolve withconservative management, but the possibility of preterm labor in these patientsmust be recognized and newer imaging techniques for diagnosis containing lessradiation be used. Adnexal torsion in pregnancy may be another condition that ismanaged through the laparoscope as the gynecologic community's laparoscopicskills improve.Eur J Obstet Gynecol Reprod Biol. 2008 Nov 4. [Epub ahead of print]Spontaneous haemoperitoneum after the second trimester of pregnancy.Diagnosis and management.Salama S, Nizard J, Camus E, Ville Y.Department of Obstetrics and Gynecology, CHI Poissy Saint Germain, Universitéde Versailles Saint-Quentin-en-Yvelines, France.N Engl J Med. 2008 Nov 6;359(19):2025-33.Venous thromboembolic disease and pregnancy.Marik PE, Plante LA.Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University,Philadelphia, PA 19107, USA. paul.marik@jefferson.eduObstet Gynecol. 2008 Oct;112(4):820-7.Eclampsia in the Netherlands.Zwart JJ, Richters A, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J.Department of Obstetrics, Leiden University Medical Centre, PO Box 9600, 2300RC Leiden, the Netherlands. j.j.zwart@lumc.nlOBJECTIVE: The incidence of maternal mortality due to hypertensive disordersof pregnancy in the Netherlands is greater than in other Western countries. Weaimed to confirm and explain this difference by assessing incidence, risk factors,and substandard care of eclampsia in the Netherlands. METHODS: In anationwide population-based cohort study, all cases of eclampsia were

prospectively collected during a 2-year period (2004-2006). All pregnant womenin the Netherlands in the same period acted as reference cohort (n=371,021).Substandard care was assessed in all cases. A selection of cases wasextensively audited by an expert panel. Main outcome measures were incidence,case fatality rate, possible risk factors, and substandard care. RESULTS: All 98Dutch maternity units participated (100%). There were 222 cases of eclampsia,for an incidence of 6.2 per 10,000 deliveries. Three maternal deaths occurred;the case fatality rate was 1 in 74. Risk factors in univariable analysis includedmultiple pregnancy, primiparity, young age, ethnicity, and overweight.Prophylactic magnesium sulfate was given in 10.4% of women, andantihypertensive medication was given in 39.6% of women with a blood pressureon admission at or above 170/110 mm Hg. Additionally, substandard care wasjudged to be present by an expert panel in 15 of 18 audited cases (83%).CONCLUSION: The incidence of eclampsia in the Netherlands is markedlyincreased as compared with other Western European countries. Substandardcare was identified in many cases, indicating the need for critical evaluation ofthe management of hypertensive disease in the Netherlands.Obstet Gynecol. 2008 Nov;112(5):1116-22.Activation of the fibrinolytic cascade early in pregnancy among womenwith spontaneous preterm birth.Catov JM, Bodnar LM, Hackney D, Roberts JM, Simhan HN.Department of Obstetrics, Gynecology and Reproductive Sciences, University ofPittsburgh, Magee Womens Research Institute, Pittsburgh, Pennsylvania 15213,USA. catovjm@upmc.eduOBJECTIVE: To evaluate the association of early pregnancy concentrations ofthrombin-antithrombin III complex with subsequent spontaneous preterm birth.METHODS: In a nested case-control study, thrombin-antithrombin III complexwas measured in plasma before 20 weeks of gestation (mean 9.9 weeks) amongwomen without chronic conditions, preeclampsia, or growth restriction. C-reactiveprotein and non-high-density lipoprotein cholesterol were also measured. Womenwith spontaneous preterm birth before 34 weeks of gestation (n=29) and 34weeks to 36 weeks of gestation (n=72) were compared with women with termbirths occurring at or after 37 weeks (n=219). Polychotomous logistic regressionwas used to relate elevated thrombin-antithrombin III complex (greater than 5.5ng/mL), dyslipidemia (non-high-density lipoprotein cholesterol greater than the90th percentile), and inflammation (C-reactive protein at or above 8micrograms/mL) to risk of spontaneous preterm birth subtypes. RESULTS:Women with spontaneous preterm birth compared with term births had elevatedthrombin-antithrombin III complex (P=.02), and they were more likely to have athrombin-antithrombin III complex greater than 5.5 ng/mL (P

preterm birth before 34 weeks (P

Peripartum cardiomyopathy: prognostic factors for long-term maternaloutcome.Habli M, O'Brien T, Nowack E, Khoury S, Barton JR, Sibai B.Department of Obstetrics and Gynecology, University of Cincinnati College ofMedicine, Cincinnati, OH 45219, USA.OBJECTIVE: The objective of the study was to assess the prognostic value ofejection fraction (EF) at index and subsequent pregnancy on long-term outcomein patients with peripartum cardiomyopathy (PPCM). STUDY DESIGN: SeventyPPCM patients met inclusion criteria. Patients had echocardiography evaluationsat the index pregnancy, at interval follow-up (F/U) or at the beginning of asubsequent pregnancy and the last F/U study available. Outcome data wereechocardiographic parameters and the subsequent need for cardiac transplant.RESULTS: Patients were categorized on the basis of their initial EF into EF of25% or less and EF greater than 25% and stratified on the basis of theirpregnancy into the following groups: group 1 (n = 33), no subsequent pregnancy;group 2 (n = 16), subsequent pregnancy with early termination; and group 3 (n =21), successful subsequent pregnancy. F/U from index pregnancy to final F/Uwas 3.4+/-1.9 (range, 1-6 years). Groups 1 and 2 had persistent left ventriculardysfunction at all echocardiographic evaluations. In group 3, despite a mean EFgreater than 40% at a subsequent pregnancy, 29% had worsening cardiacsymptoms. Among 28 patients with EF of 25% or less, 16 (57%) had end-stagecardiac disease. One had a transplant and 15 were on a transplant list. All 16had a baseline EF 25% or less at index pregnancy: 4 had improved (EF greaterthan 40%) at interval F/U and 3 at last F/U available. CONCLUSION: Womenwith a history of PPCM had a higher rate of progression of symptoms of heartfailure in a subsequent pregnancy. A baseline left ventricular EF 25% or less atindex pregnancy is associated with a higher rate of cardiac transplant.Am J Obstet Gynecol. 2008 Oct;199(4):e9; author reply e9. Epub 2008 Jul 29.Comment on:Am J Obstet Gynecol. 2008 Jul;199(1):49.e1-8.Amniotic fluid embolism: active surveillance versus retrospective databasereview.Knight M; UKOSS.Am J Obstet Gynecol. 2008 Oct;199(4):332-7. Epub 2008 Jul 17.Peripartum Clostridium difficile infection: case series and review of theliterature.Garey KW, Jiang ZD, Yadav Y, Mullins B, Wong K, Dupont HL.Texas Medical Center, University of Houston College of Pharmacy, Houston, TX77030, USA. kgarey@uh.eduClostridium difficile infection (CDI) in nonhospitalized patients has been reportedwith increased frequency. An association between CDI and pregnancy has notbeen stressed. This review will report 4 cases of peripartum CDI withcharacterization of the infecting strain and a literature review. A PubMed searchidentified 24 recorded cases of peripartum CDI; information was available for 14

cases. Most patients (91%) received prophylactic antibiotics during delivery or fortreatment of bacterial infections (50%). All patients reported diarrhea. Two of ourreported cases without known risk factors were found by polymerase chainreaction analysis to be infected with an epidemic and hypervirulent C difficilestrain. These cases demonstrate the need for clinicians to consider CDI inpatients with severe diarrhea, even if they do not have the traditional risk factorsfor CDI, such as antibiotic use or concurrent hospitalizations. Further researchinto the scope and risk factors for peripartum CDI is warranted.Am J Obstet Gynecol. 2008 Oct;199(4):e7-8. Epub 2008 Jul 3.Rupture of an aneurysm of the ovarian artery following delivery andendovascular treatment.Poilblanc M, Winer N, Bouvier A, Gillard P, Boussion F, Aubé C, Descamps P.Department of Obstetrics and Gynecology, Angers University Hospital, Angers,France.We report a case of spontaneous rupture of an ovarian artery aneurysm, 5 daysafter delivery. Severe abdominal pain justified a computed tomography scan,which revealed a massive retroperitoneal hematoma. Arteriography showed therupture of an ovarian artery aneurysm that was successfully embolized usingmicrocoils.Am J Obstet Gynecol. 2008 Nov 10. [Epub ahead of print]Cefazolin pharmacokinetics in maternal plasma and amniotic fluid duringpregnancy.Allegaert K, van Mieghem T, Verbesselt R, de Hoon J, Rayyan M, Devlieger R,Deprest J, Anderson BJ.Division of Woman and Child, University Hospitals Leuven, Leuven, Belgium.OBJECTIVE: To study cefazolin pharmacokinetics in maternal plasma andamniotic fluid during pregnancy. STUDY DESIGN: Newly collected timeconcentrationsprofiles and reported studies investigating cefazolin disposition(plasma, amniotic fluid) were pooled. Nonlinear mixed effect modeling wasapplied. A 2-compartment linear disposition model was used to fit cefazolinplasma observations. A third compartment was used to model amniotic fluidconcentration. RESULTS: One hundred eighty-seven plasma and 96 amnioticfluid samples were collected in 82 pregnancies (17-40 weeks gestational age).Cefazolin clearance and distribution estimates were 7.44 L/h and 12.04 L withoutgestational age-dependent trends in maternal plasma. The equilibration half-life(T(eq)) between plasma and amniotic fluid at term gestational age was 4.4 hours,increased with decreasing gestational age, and was 9.09 times longer in patientswith polyhydramnios. CONCLUSION: Cefazolin clearance and distributionvolume are increased during pregnancy. The cefazolin T(eq) depends ongestational age and polyhydramnios. On the basis of these observations, dosingregimes to attain higher amniotic fluid concentrations were formulated.Int J Gynaecol Obstet. 2008 Jul;102(1):71. Epub 2008 Apr 23.Maternal death due to postpartum hemorrhage after snakebite.

D'Ambruoso L, Byass P, Ouedraogo M.Immpact, University of Aberdeen, Aberdeen, United Kingdom.l.dambruoso@abdn.ac.ukA case of fatal postpartum hemorrhage demonstrates the need for the immediatereferral of all pregnant women who incur a snakebite.Obstet Gynecol. 2008 Sep;112(3):705; author reply 705-6.Comment on:Obstet Gynecol. 2008 Mar;111(3):732-8.Peripartum hysterectomy: 1999 to 2006.Corbett K.Obstet Gynecol. 2008 Sep;112(3):533-7.Community-acquired methicillin-resistant Staphylococcus aureus amongpatients with puerperal mastitis requiring hospitalization.Stafford I, Hernandez J, Laibl V, Sheffield J, Roberts S, Wendel G Jr.Department of Obstetrics and Gynecology, the University of Texas SouthwesternMedical Center, Dallas, Texas 75390-9032, USA. petrouia@yahoo.comOBJECTIVE: To estimate the incidence of puerperal mastitis requiring hospitaladmission and to describe demographic and obstetric risk factors for thiscondition. We also sought to identify trends in bacteriology among isolatesobtained from breast abscesses and breast-milk aspirates, with a focus ontreatment strategies used for community-acquired methicillin-resistantStaphylococcus aureus (MRSA). METHODS: Patients with puerperal mastitiswho were admitted to a county-based teaching hospital between January 1997and December 2005 were identified by International Classification of Diseases,9th Revision, codes (675.1, 675.2). Data collected included demographiccharacteristics, clinical presentation, treatment, duration of admission, premorbidantibiotic exposure, and bacteriology. Demographic variables and obstetricoutcomes were compared with all other pregnant women delivered at ourhospital. RESULTS: One hundred twenty-seven of 136,459 women delivered atour teaching hospital were admitted for puerperal mastitis (9.3 [95% confidenceinterval (CI) 7.8-11.1] per 10,000 deliveries). The incidence of mastitis onlyduring the study period was 6.7 (95% CI 5.4-8.3) per 10,000 deliveries, and theincidence of mastitis with breast abscess was 2.6 (95% CI 1.8-3.6) per 10,000deliveries. Puerperal mastitis was significantly associated with younger women(23.4 years compared with 25.1 years, P

Ultrasound Obstet Gynecol. 2008 Nov 7. [Epub ahead of print]Prediction of pre-eclampsia by a combination of maternal history, uterineartery Doppler and mean arterial pressure.Onwudiwe N, Yu CK, Poon LC, Spiliopoulos I, Nicolaides KH.Harris Birthright Research Centre for Fetal Medicine, King's College HospitalMedical School, London, UK.OBJECTIVES: To determine the value of combined screening for pre-eclampsiaby maternal history, and mid-trimester uterine artery (UtA) Doppler imaging andmaternal blood pressure. METHODS: In 3529 singleton pregnancies attendingfor routine care at 22-24 weeks' gestation we recorded maternal variables, andmade UtA Doppler and mean arterial pressure (MAP) measurements. Multipleregression analysis was used to determine the significant predictors of preeclampsia,gestational hypertension and small-for-gestational age (SGA) amongmaternal characteristics, UtA pulsatility index (PI) and MAP. RESULTS:Complete pregnancy outcomes were available in 3359/3529 (95.2%) cases. Preeclampsiadeveloped in 101 (3.0%) pregnancies, including 23 (0.7%) in whichdelivery was before 34 weeks (early pre-eclampsia) and 78 (2.3%) with deliveryat 34 weeks or more (late pre-eclampsia); 74 (2.2%) developed gestationalhypertension, 366 (10.9%) delivered SGA newborns with no hypertensivedisorders, and 2806 (83.8%) were unaffected by pre-eclampsia, gestationalhypertension or SGA. Multiple regression analysis demonstrated that maternalcharacteristics, UtA-PI and MAP provided a significant independent contributionin the prediction of pre-eclampsia, gestational hypertension and SGA. For afalse-positive rate of 10%, the estimated detection rates of early and late preeclampsiawere 100% and 56.4%, respectively. CONCLUSIONS: Thecombination of maternal demographic characteristics, and UtA Doppler andmaternal blood pressure measurements is an effective screening tool for theprediction of pre-eclampsia. Copyright (c) 2008 ISUOG. Published by John Wiley& Sons, Ltd.Am J Obstet Gynecol. 2008 Nov 17. [Epub ahead of print]The evidence that shows that stroke and cesarean section are associatedneeds to be critically reviewed.Eslava-Schmalbach J, Navarro-Vargas JR, Sabogal D.School of Medicine, National University of Colombia, Bogota, Colombia.Am J Obstet Gynecol. 2008 Nov 17. [Epub ahead of print]Diagnosis and management of atypical preeclampsia-eclampsia.Sibai BM, Stella CL.Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,University of Cincinnati College of Medicine, Cincinnati, OH.Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and lowplatelets syndrome are major obstetric disorders that are associated withsubstantial maternal and perinatal morbidities. As a result, it is important that

clinicians make timely and accurate diagnoses to prevent adverse maternal andperinatal outcomes associated with these syndromes. In general, most womenwill have a classic presentation of preeclampsia (hypertension and proteinuria) at> 20 weeks of gestation and/or < 48 hours after delivery. However, recent studieshave suggested that some women will experience preeclampsia without >/= 1 ofthese classic findings and/or outside of these time periods. Atypical cases arethose that develop at < 20 weeks of gestation and > 48 hours after delivery andthat have some of the signs and symptoms of preeclampsia without the usualhypertension or proteinuria. The purpose of this review was to increaseawareness of the nonclassic and atypical features of preeclampsia-eclampsia. Inaddition, a stepwise approach toward diagnosis and treatment of patients withthese atypical features is described.Eur J Obstet Gynecol Reprod Biol. 2008 Nov 17. [Epub ahead of print]Author's response: Fact: Antidepressants and anxiolytics are not safe duringpregnancy.Campagne DM.Department of Clinical Psychology, Clinica Bella Medica, Cap Negret 18, 03590Altea, Spain.Eur J Obstet Gynecol Reprod Biol. 2008 Nov 17. [Epub ahead of print]Fact: Antidepressants and anxiolytics are not safe during pregnancy.Einarson A.The Hospital for Sick Children, The Motherisk Program, 555 University Avenue,Toronto, Ontario M5G 1X8, Canada.Int J Gynaecol Obstet. 2008 Nov 18. [Epub ahead of print]Burn injuries during pregnancy in Iran.Karimi H, Momeni M, Momeni M, Rahbar H.Iran University of Medical Sciences, Tehran, Iran.OBJECTIVE: To report on maternal and fetal outcome in 53 pregnant womenseen at a referral burn center. METHODS: Possible links between outcome andmaternal age, level of education, marital status, percentage of total body surfacearea (TBSA) burned, inhalation injury, source and intentionality of the burn, andtrimester of pregnancy at the time of the burn were assessed. RESULTS: Of5497 women, 53 (1.3%) were pregnant at the time of admission. Maternal andfetal deaths occurred at significantly higher rates in cases of inhalation injury(P=0.001). The mean percentage of TBSA burned was significantly higher incases of maternal or fetal death (P

Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton L,Santry HP, Morton JM, Livingston EH, Shekelle PG.MSHS, Department of Surgery, David Geffen School of Medicine, University ofCalifornia, Los Angeles, CHS 72-215, 10833 Le Conte Ave, Los Angeles, CA90095. mmaggard@mednet.ucla.edu.CONTEXT: Use of bariatric surgery has increased dramatically during the past10 years, particularly among women of reproductive age. OBJECTIVES: Toestimate bariatric surgery rates among women aged 18 to 45 years and toassess the published literature on pregnancy outcomes and fertility after surgery.Evidence Acquisition Search of the Nationwide Inpatient Sample (1998-2005)and multiple electronic databases (Medline, EMBASE, Controlled Clinical TrialsRegister Database, and the Cochrane Database of Reviews of Effectiveness) toidentify articles published between 1985 and February 2008 on bariatric surgeryamong women of reproductive age. Search terms included bariatric procedures,fertility, contraception, pregnancy, and nutritional deficiencies. Information wasabstracted about study design, fertility, and nutritional, neonatal, and pregnancyoutcomes after surgery. Evidence Synthesis Of 260 screened articles, 75 wereincluded. Women aged 18 to 45 years accounted for 49% of all patientsundergoing bariatric surgery (>50 000 cases annually for the 3 most recentyears). Three matched cohort studies showed lower maternal complication ratesafter bariatric surgery than in obese women without bariatric surgery, or ratesapproaching those of nonobese controls. In 1 matched cohort study thatcompared maternal complication rates in women after laparoscopic adjustablegastric band surgery with obese women without surgery, rates of gestationaldiabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) werelower in the bariatric surgery group. Findings were supported by 13 otherbariatric cohort studies. Neonatal outcomes were similar or better after surgerycompared with obese women without laparoscopic adjustable gastric bandsurgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birthweight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). No differences inneonatal outcomes were found after gastric bypass compared with nonobesecontrols (26.3%-26.9% vs 22.4%-20.2% for premature delivery, P = not reported[1 study] and P = .43 [1 study]; 7.7% vs 9.0% for low birth weight, P = notreported [1 study]; and 0% vs 2.6%-4.3% for macrosomia, P = not reported [1study and P = .28 [1 study]). Findings were supported by 10 other studies.Studies regarding nutrition, fertility, cesarean delivery, and contraception werelimited. CONCLUSION: Rates of many adverse maternal and neonatal outcomesmay be lower in women who become pregnant after having had bariatric surgerycompared with rates in pregnant women who are obese; however, further dataare needed from rigorously designed studies.Am J Obstet Gynecol. 2008 Nov 20. [Epub ahead of print]Episodes of repeated sudden deafness following pregnancies.Pawlak-Osinska K, Burduk PK, Kopczynski A.Departament of Otolaryngology, Collegium Medicum UMK Torun, Bydgoszcz,Poland.

Sex hormones influence and provoke changes in hearing levels. Suddendeafness is rarely observed in pregnant women. The effective treatment ofsudden deafness in pregnant women is a challenging problem. We present acase of repeatable, completely regressed sudden deafness in a woman duringher first and second pregnancies.Aust N Z J Obstet Gynaecol. 2008 Oct;48(5):520.Spontaneous rupture of urinary bladder in second trimester of pregnancy:a case report.Faraj R, O'Donovan P, Jones A, Hill S.Aust N Z J Obstet Gynaecol. 2008 Oct;48(5):485-91.Obstetric management following traumatic tetraplegia: case series andliterature review.Skowronski E, Hartman K.Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia.emmasko@optusnet.com.auOBJECTIVE: Pregnancy in tetraplegia is a rare event, with only sporadic casesreported. This case series describes seven pregnancies in five tetraplegicwomen, all with spinal cord injuries in the region of C6. DESIGN: Retrospectivecase series. SETTING: Sydney, Australia. POPULATION: All tetraplegic womenpresenting to the obstetric service of a university teaching hospital, which alsoprovides a regional spinal injury service, between 1981 and 2006. METHODS:Hospital records of all patients were examined and information extractedregarding demographics, pregnancies and their complications, labour anddelivery and neonatal data. MAIN OUTCOME MEASURES: Course,complications, management and outcomes of pregnancy in tetraplegic women.RESULTS: Mean age at the time of injury was 22 years, and, at the time ofpregnancy, 33 years. All patients suffered recurrent, and sometimes severe,urinary tract infections and episodes of autonomic dysreflexia during pregnancy.Frequent and sometimes lengthy hospital admissions were required for theseand other reasons. Only two pregnancies required caesarean section and allentered labour spontaneously, at a mean of 37.9 weeks of gestation. Episodes ofautonomic dysreflexia were aggressively managed using pre-emptive epiduralanaesthesia and sublingual nifedipine. All pregnancies resulted in normal, neartermbabies with no serious perinatal problems. CONCLUSIONS: Pregnancy andchildbirth in tetraplegic women can be undertaken safely, usually withspontaneous onset of labour and vaginal delivery. However, hospitalisation forintercurrent problems is common. Management requires a multidisciplinaryapproach and is best undertaken in major centres with both obstetric and spinalcord injuries medical expertise.Aust N Z J Obstet Gynaecol. 2008 Oct;48(5):481-4.How accurate is the reporting of obstetric haemorrhage in hospitaldischarge data? A validation study.Lain SJ, Roberts CL, Hadfield RM, Bell JC, Morris JM.

Clinical and Population Health, Perinatal Research, Kolling Institute of MedicalResearch, University of Sydney, New South Wales, Australia.samlain@med.usyd.edu.auBACKGROUND: Routinely collected datasets are frequently used for populationbasedresearch but their accuracy needs to be assured. AIM: This study aims toassess the accuracy of hospital discharge data in identifying obstetrichaemorrhage diagnoses and procedures, and estimate their populationincidence. METHODS: The medical records of 1200 randomly selected womenwere reviewed and compared with obstetric haemorrhage diagnoses andprocedures in the hospital discharge data. Sensitivity, specificity, and positiveand negative predictive values were calculated using the medical records as the'gold standard'. Estimates of population incidence were calculated and weightedby the sampling probabilities. RESULTS: Estimated population incidence for anyantepartum haemorrhage was 1.8 per 100, and post partum haemorrhage was7.2 per 100 women. Obstetric haemorrhage diagnosis and procedure codestended to be underreported, with sensitivities ranging from 28.3% to 100%. Allcodes had specificities of 98.9% or greater. The identification of obstetrichaemorrhage differed between levels of severity. CONCLUSION: The resultsindicate that population health datasets can be a reliable information source;however, these datasets could be improved with more complete documentationin medical records.Int J Gynaecol Obstet. 2008 Nov 25. [Epub ahead of print]Iodine intake in pregnancy.Fumarola A, Calvanese A, D'Armiento M.Section of Endocrinology, Department of Experimental Medicine, SapienzaUniversity of Rome, Rome, Italy.Int J Gynaecol Obstet. 2008 Nov 21. [Epub ahead of print]Outcomes of pregnancies affected by hemoglobin H disease.Tongsong T, Srisupundit K, Luewan S.Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang MaiUniversity, Chiang Mai, Thailand.OBJECTIVE: To determine the outcomes of pregnancies affected by hemoglobinH (HbH) disease. METHODS: A retrospective cohort study was conducted with120 women with singleton pregnancies complicated by HbH disease only. Thecontrols-to-cases ratio was 2:1. RESULTS: Maternal outcomes were similar inthe 2 groups. The incidences of fetal growth restriction (relative risk [RR], 2.4;95% confidence interval [CI], 1.60-3.50), preterm birth (RR, 1.4; 95% CI, 1.03-1.96), and low birth weight (RR, 1.9; 95% CI, 1.46-2.56) were significantly higherin the study than in the control group. The perinatal mortality rate was slightlyhigher in the study group. CONCLUSION: In spite of attempts to keephemoglobin levels sufficiently high (>7.0 g/dL), pregnancies with HbH diseasewere significantly associated with increased risks of fetal growth restriction,preterm birth, and low birth weight.

Obstet Gynecol. 2008 Dec;112(6):1449-60.ACOG Committee Opinion No. 422: At-Risk Drinking and Illicit Drug Use:Ethical Issues in Obstetric and Gynecologic Practice.[No authors listed]Obstet Gynecol. 2008 Dec;112(6):1390-1.Maternal thyroid hypofunction and pregnancy outcome.Blumenfeld Z.Rambam Medical Center; Technion-Faculty of Medicine; Haifa, Israel.Obstet Gynecol. 2008 Dec;112(6):1294-1302.Long-Term Blood Pressure Changes Measured From Before to AfterPregnancy Relative to Nonparous Women.Gunderson EP, Chiang V, Lewis CE, Catov J, Quesenberry CP Jr, Sidney S, WeiGS, Ness R.Division of Research, Epidemiology and Prevention, Kaiser Permanente,Oakland, California; Division of Preventive Medicine, University of Alabama atBirmingham, Birmingham, Alabama; Department of Epidemiology, GraduateSchool of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania;Department of Obstetrics and Gynecology, Magee-Womens Hospital, Universityof Pittsburgh, Pittsburgh, Pennsylvania; and Division of Prevention andPopulation Sciences, National Heart, Lung, and Blood Institute, Bethesda,Maryland.OBJECTIVE: To prospectively examine whether blood pressure changes persistafter pregnancy among women of reproductive age. METHODS: This was aprospective, population-based, observational cohort of 2,304 (1,167 black, 1,137white) women (aged 18-30 years) who were free of hypertension at baseline(1985-1986) and reexamined up to six times at 2, 5, 7, 10, or 20 years later(2005-2006). We obtained standardized blood pressure measurements beforeand after pregnancies and categorized women into time-dependent groups bythe cumulative number of births since baseline within each time interval (zerobirths [referent]; one interim birth and two or more interim births; nonhypertensivepregnancies). The study assessed differences in systolic and diastolic bloodpressures among interim birth groups using multivariable, repeated measureslinear regression models stratified by baseline parity (nulliparous and parous),adjusted for time, age, race, baseline covariates (blood pressure, body massindex, education, and oral contraceptive use), and follow-up covariates (smoking,antihypertensive medications, oral contraceptive use, and weight gain).RESULTS: Among nulliparas at baseline, mean (95% confidence interval) fullyadjusted systolic and diastolic blood pressures (mm Hg), respectively, were lowerby -2.06 (-2.72 to -1.41) and -1.50 (-2.08 to -0.92) after one interim birth, andlower by -1.89 (-2.63 to -1.15) and -1.29 (-1.96 to -0.63) after two or more interimbirths compared with no births (all P

the biologic mechanism is unclear, pregnancy may create enduring alterations invascular endothelial function. LEVEL OF EVIDENCE: II.Obstet Gynecol. 2008 Dec;112(6):1391.Maternal Thyroid Hypofunction and Pregnancy Outcome.Cleary-Goldman J, Malone F.Royal College of Surgeons in Ireland; Dublin, Ireland.