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Selected AJOG Papers

Editor's comment: Prof. Jim Thornton: Second stage Caesarean section and subsequent preterm birth

This important planned secondary analysis of a large cohort study showed that women with a second-stage Caesarean had a 6-fold higher risk of spontaneous preterm birth in subsequent pregnancy compared with those undergoing a first-stage Caesarean. The association remained after adjustment for confounders (adjusted odds ratio, 5.8; 95% confidence interval, 1.08-30.8).

Editor’s comment: Prof. Yves Ville: To treat or not to treat. The Shakespearean dilemma in fetal medicine.
(Editor's comment relates to the AJOG article below)

The possibilities of treating the sick or malformed fetus have developed with the precocity and the increasing relevance of prenatal diagnosis. Although less spectacular, medical treatment of a sick fetus or more often a fetus at risk of developing a serious congenital disease involves the placental transfer of a drug administered to the pregnant woman.

  • Antenatal corticosteroids beyond 34 weeks gestation: What do we do now?

    Beena D. Kamath-Rayne MD, MPH, Paul J. Rozance MD, Robert L. Goldenberg MD, Alan H. Jobe MD, PhD

    American Journal of Obstetrics and Gynecology, Volume 215, Issue 4, October 2016, Pages 423 - 430

  • The role of antenatal corticosteroids in twin pregnancies complicated by preterm birth

    Nir Melamed MD, MSc, Jyotsna Shah MD, Eugene W. Yoon MSc, Ermelinda Pelausa MD, Shoo K. Lee MBBS, PhD, Prakesh S. Shah MD, MSc, Kellie E. Murphy MD, MSC, for the, Canadian Neonatal Network Investigators (Prakesh S. Shah MD, MSc, Adele Harrison MD, MBChB, Anne Synnes MDCM, MHSC, Joseph Ting MD, Zenon Cieslak MD, Rebecca Sherlock MD, Wendy Yee MD, Khalid Aziz MBBS, MA, MEd, Jennifer Toye MD, Carlos Fajardo MD, Zarin Kalapesi MD, Koravangattu Sankaran MD, MBBS, Sibasis Daspal MD, Mary Seshia MBChB, Ruben Alvaro MD, Sandesh Shivananda MBBS, MD, DM, Orlando Da Silva MD, MSc, Chuks Nwaesei MD, Kyong-Soon Lee MD, MSc, Michael Dunn MD, Brigitte Lemyre MD, Kimberly Dow MD, Ermelinda Pelausa MD, Keith Barrington MBChB, Christine Drolet MD, Bruno Piedboeuf MD, Martine Claveau, Daniel Faucher MD, Valerie Bertelle MD, Edith Masse MD, Roderick Canning MD, Hala Makary MD, Cecil Ojah MBBS, Luis Monterrosa MD, Akhil Deshpandey MBBS, MRCPI, Jehier Afifi MB BCh, MSc, Andrzej Kajetanowicz MD, Shoo K. Lee MBBS, PhD).

    American Journal of Obstetrics and Gynecology, Volume 215, Issue 4, October 2016, Pages 482.e1 - 482.e9

  • In utero treatment of congenital cytomegalovirus infection with valacyclovir in a multicenter, open-label, phase II study

    Marianne Leruez-Ville MD, PhD, Idir Ghout MSc, Laurence Bussières PhD, Julien Stirnemann MD, PhD, Jean-François Magny MD, Sophie Couderc MD, Laurent J. Salomon MD, PhD, Tiffany Guilleminot BA, Philippe Aegerter MD, PhD, Guillaume Benoist MD, PhD, Norbert Winer MD, Olivier Picone MD, PhD, François Jacquemard MD, Yves Ville MD, FRCOG

    American Journal of Obstetrics and Gynecology, Volume 215, Issue 4, October 2016, Pages 462.e1 - 462.e10

Editor’s comment: Prof. Dan Farine: Towards normal birth – but at what cost by Hans Peter Dietz and Stuart Campbell
(Editor's comment relates to the AJOG article below)

I read with interest the clinical opinion paper “Towards normal birth – but at what cost” by Hans Peter Dietz and Stuart Campbell that was published in the October edition of the American Journal of Ob/Gyn. The article is interesting for a variety of different reasons; the authors seem to be passionate about the topic. They provide well thought and well researched references to support their arguments; most practicing obstetricians can relate to the fact that often patients are biased towards CD (both ways) and that proper education and informed consent are very time consuming and in certain setting are very difficult to provide.

Editor’s comment: Prof. Yves Ville: The street light effect of Down syndrome screening in pregnancy. Time to broaden risk assessment in early pregnancy.
(Editor's comment relates to the AJOG articles below)

Our present prenatal screening and diagnostic approach remains directed predominantly at identifying Down syndrome. However there are far more prevalent and serious conditions that have become amenable to prenatal screening and diagnosis.

Editor’s comment: Prof. Dan Farine: Exercise in Pregnancy the Norwegian outlook
(Editor's comment relates to the AJOG article below)

The issue of exercise in pregnancy has been studied extensively in the last 30 years with some researchers such as James Clapp the 3rd and Raoul Artal devoting a large portion of their careers to this issue.  The data generated by them and others showed generally that exercise in pregnancy had a variety of positive effects on associated diseases (diabetes hypertension etc.) and specific pregnancy outcomes. Concerns that extensive physical activity would lead to poor outcomes were shown to be non-true in studies such as James Clapp’s who found that Olympians had better outcomes than sedentary pregnant women.

Editor’s comment: Prof. Dan Farine: CMV in pregnancy what is new?
(Editor's comment relates to the AJOG article below)

This study provides more details on the diagnosis and probably more importantly the prognosis of CMV.  The paper starts with a statement that the CMV infection occurs in 0.7% of all births. Although this is probably the best current estimate it is important to note that in North America there is no routine screening for CMV. This in turn alters the presentation of the disease as few patients are screened for CMV (and these are obviously at a higher risk) and even fewer are tested for CMV. Many series are therefore skewed by the entry point of severe ultrasound findings. The question of the need for routine screening for CMV was obviously not addressed in this French study and still remains open. 

Editor’s comment: Prof. Yves Ville: Non-invasive whole fetal genome sequencing : Putting the cart before the horse ?
(Editor's comment relates to the AJOG article below)

The development of next-generation sequencing (NGS) technologies (ie, new high-throughput and massively parallel DNA sequencing technologies) has substantially reduced both the cost and the time required to sequence an entire human genome.  Its application to the human fetus has become a reality that is close to clinical implementation. (Lefkowitz R. et al) It is therefore both critical and urgent to be prepared for a shift in paradigm in prenatal screening and diagnosis.

Editor’s comment: Prof. Dan Farine: Disclosure of possible conflicts and other pitfalls waiting those who publish
(Editor's comment relates to the AJOG article below)

In this interesting paper the major finding is that 68% of physicians submitting a paper to the Society of Gynecological Surgery (SGS) did not properly disclose their full relationship to industry. Interestingly, the way that the under-reporting was found was based on earlier disclosure of these physicians of such a relationship.

Publishing is a way to achieve recognition as an expert and academic promotion. Publications are the major way to disseminate new information and improve medical practice. Individuals may feel pressure to publish for these reasons. The editors and readers want to see the best information published and they want to be sure that biases are optimally eliminated or at least disclosed...

Editor’s comment: Prof. Dan Farine: Acidemia with Normal pH:
(Editor's comment relates to the AJOG article below)

This interesting study looks retrospectively at the rare occurrence of acidemia and/or low base access in babies with normal Apgar scores. The “common sense approach” has been to assume that the test is erroneous as the baby was doing well and ignore it. In Medico-Legal conferences the rationale for pushing for universal cord pH testing has been that it may identify the group of interest for asphyxia (low pH and Apgar scores). According to this approach it was even more interesting to identify the neonates with a normal pH and base excess. These babies may have been exposed to a hostile intra-uterine environment based on history and/or abnormal fetal heart rates and possibly to less than optimal care. However, since they were not acidotic they would not go on to develop cerebral palsy based on the McLennan dogma that was adopted by the major obstetrical societies (FIGO, ACOG, UK guidelines Australian-NZ ones etc.)...

Editor’s comment: Prof. Yves Ville: To know the chance, a chance to know.
(Editor’s comment relates to the 3 AJOG articles below…)

Advanced screening for fetal aneuploidies using fetal DNA in maternal blood represents a major technical breakthrough that is still struggling to find a pragmatic place within the screening algorithms in most countries, after 4 years of clinical use. The wide and sometimes wild dissemination of the test stresses the critical need for the prescribers of the test to understand the difficulties of its interpretation.

Editor’s comment: Prof. Yves Ville: An unsuspected enemy is doubly dangerous (L. Frank Baum)
(Editor’s comment relates to the 3 AJOG articles below: Aubry et al, Khalifeh et al & Saade et al)
Over a third of infant deaths arise from complications related to preterm births, making prematurity the most frequent cause of infant mortality. Health complications are also a lifelong burden of survivors including mental retardation, cerebral palsy, learning and behavioral problems, respiratory problems, vision and hearing loss, but also diabetes, high blood pressure, and heart disease. This inventory has become a classic lament of perinatologists facing the implacable consequences of prematurity.

Trends in prematurity have been either on the rise (1990-2006) or flattening (2006-2013) with medically indicated « late » prematurity as the main adjustment variable. However around 1/25 pregnancies still face unexpected delivery before 33 weeks’ and roughly half of them are primigravidas without anticipated risk factors...

Editor’s comment: Prof. Yves Ville: Is the due date becoming overdue ?
(Editor’s comment relates to the 3 AJOG articles below: Gibson et al, Melamed et al & Masoudian et al)

In vitro fertilization using egg donation (ED) is being used increasingly for women requiring assisted reproduction techniques (ART) with a delivery rate per transfer of around 40%. Initially designed to overcome infertility in young women with hypergonadotropic hypogonadism, this technique is now also increasingly used to achieve pregnancy in older women.

Multiple studies have documented that ED pregnancies are associated with a higher incidence of pregnancy-induced hypertension and placental dysfunction, including small for gestational age, and preterm delivery. However, multiple gestations, advanced age, and underlying polycystic ovary syndrome are constant confounding factors for all studies examining the association between assisted reproductive techniques (ARTs) and hypertensive disorders in pregnancy...

  • A risk of waiting: the weekly incidence of hypertensive disorders and associated maternal and neonatal morbidity in low-risk term pregnancies

    Kelly S. Gibson MD, Thaddeus P. Waters MD, Jennifer L. Bailit MD, MPH

    American Journal of Obstetrics and Gynecology, Volume 214, Issue 3, March 2016, Pages 389.e1 - 389.e12

  • Induction of labor before 40 weeks is associated with lower rate of cesarean delivery in women with gestational diabetes mellitus

    Nir Melamed MD, Joel G. Ray MD, Michael Geary MD, Daniel Bedard MSc, Cathy Yang MSc, Ann Sprague PhD, Beth Murray-Davis PhD, Jon Barrett MD, Howard Berger MD

    American Journal of Obstetrics and Gynecology, Volume 214, Issue 3, March 2016, Pages 364.e1 - 364.e8

  • Oocyte donation pregnancies and the risk of preeclampsia or gestational hypertension: a systematic review and metaanalysis

    Pourya Masoudian BHSc, Ahmed Nasr MD, MSc, Joseph de Nanassy MD, Karen Fung-Kee-Fung MD, MHPE, Shannon A. Bainbridge PhD, Dina El Demellawy MD, PhD

    American Journal of Obstetrics and Gynecology, Volume 214, Issue 3, March 2016, Pages 328 - 339

  • Editor’s comment: Prof. Dan Farine: The twin study
    This is a very important study as it complements the initial results of the Twins Birth Study. Both of these studies are likely to reflect a world-wide results of twins delivery as this a rigorously designed RCT looked at patients in a multitude of centers around the world. As opposed to a common belief before the study, that Caesarean delivery is the “easy way out” in twins’ birth (as in many other conditions), these were not the results of this study. Neither the short term results nor the long term ones showed benefit of an elective Caesarean delivery in term or late preterm twins where the first twin is in a vertex presentation. This may be important to the young mother who has to take care of two babies who do not need to be hampered by inconvenience and possible complications of a Caesarean delivery. There is a new keen and justified interest in the long term effect of Caesarean deliveries. There is an impressive set of data correlating Caesarean birth with increased risks of: diabetes, asthma and increased weight. It is important to mention that this association does not necessarily mean causation. In contrast, there is also an alarming data about the rising rates of adhesive placentas (accreta and percreta). These are definitely related to the scar in the uterus. Luckily, the study by Silver from the MFM network in the USA suggested that this risk is increased mainly after 3 Caesarean deliveries.

    It is interesting to see that the results of this study could be interpreted in exactly the opposite way. Women who prefer a Caesarean birth for whatever reason (worries about double vaginal births, apprehension of the small risk of having both vaginal and Caesarean deliveries, need to plan delivery time etc.) may be reassured that a caesarean approach does not increase mortality or major neurological deficits. The same may apply to the obstetricians who are very uncomfortable with the delivery of the second twin. In other words this study is good for both the vaginal and CS camps.

    Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy

    Elizabeth V. Asztalos MD, Mary E. Hannah MD, CM, Eileen K. Hutton PhD, Andrew R. Willan PhD, Alexander C. Allen MD, CM, B. Anthony Armson MD, Amiram Gafni DSc, K.S. Joseph MD, PhD, Arne Ohlsson MD, Susan Ross PhD, J. Johanna Sanchez MIPH, Kathryn Mangoff BSc, Jon F.R. Barrett MB BCh, MD

    American Journal of Obstetrics and Gynecology, In Press, Corrected Proof, Available online 29 January 2016, Available online 29 January 2016

  • Editor’s comment: Prof. Dan Farine: Reduced fetal movements
    This is another interesting development in the saga of reduced fetal movements. The Canadian (1) and Australian NZ (2) guidelines ask women to monitor for Reduced Fetal Movements (RFM) while the British (3) and the American (4) ones make it an option and not a recommendation. These divergent approaches are interesting and maybe concerning as there is a large study from Norway (5) that showed that in a large cohort that Monitoring and managing RFM may eliminate one 1/3 of stillbirths. The current study goes beyond assessing RFM as it looked at the women that had repeated RFM. There was very limited data on repeated RFM prior to this study and most of us managed the subsequent episode similarly to the first one. In this study a subset of the patient had more than 1 episode of RFM. These women had a high incidence of placental insufficiency as well as high incidence of SGA (close to 50%) that was often not there in the first episode of the RFM. AS the authors outline this suggests that placental insufficiency as associated and possibly the cause of both RFM and growth restriction.

    This study may have very important clinical implications. Women may need to be advised that repeated episodes of RFM may carry an increased risk to the baby and clinicians may consider a change in mat on the form of either increased fetal surveillance or delivery close to term.

    Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome

    Carolina Scala MD, Amar Bhide MD, FRCOG, Alessandra Familiari MD, Giorgio Pagani MD, Asma Khalil MD, MRCOG, Aris Papageorghiou MD, FRCOG, Basky Thilaganathan PhD, FRCOG

    Am J Obstet Gynecol. 2015 Nov;213(5):678.e1-6. doi: 10.1016/j.ajog.2015.07.015. Epub 2015 Jul 20.

  • Editor’s comment: Prof. YvesVille: Cerebral Palsy: the changing face of an old enemy
    Cerebral palsy (CP) encompasses a heterogeneous group of early-onset, non-progressive, neuromotor disorders that affect the developing fetal or infant brain. CP has become our enemy but also our curse since Little linked this condition to birth asphyxia in the mid-19th century. Freud attributed the disorder to brain injury from various causes, including prenatal events, and emphasised that extended labour was not the exclusive or even principal cause, therefore increasing our responsibility not to say our feeling of guilt. Although our practice has been hugely influenced by this threat over the last 50 years, mainly through an increase in cesarean section rates. An update on the prevalence of cerebral palsy through a systematic review and meta-analysis gauging the prevalence of CP over time has shown that it has remained depressingly and frustratingly stable over the last 10 years at around 2 per 1,000 births. (Oskoui et al, 2013) The main illustration of this catch-22 situation in developed nations is largely explained by an increase in survival of very premature and low-birthweight babies together with higher numbers of multiple births, which often result in preterm births. This has therefore led to a new generation of people affected with CP, probably because of vulnerability of the immature brain, especially in babies with intraparenchymal or intraventricular bleeds or periventricular white-matter abnormalities. The increase in such high-risk situations may contribute to mask teh factors that may contribute to decrease the prevalence of CP, such as the use of antenatal corticosteroids, cooling for term-born asphyxiated infants, and the use of magnesium sulphate...

    Cerebral palsy: causes, pathways, and the role of genetic variants

    Alastair H. MacLennan MD, FRANZCOG, Suzanna C. Thompson MBBS, FRACP, Jozef Gecz PhD

    American Journal of Obstetrics and Gynecology, Volume 213, Issue 6, December 2015, Pages 779 - 788

  • Editor’s comment: Prof. Dan Farine: Another meta-analysis that changes dogmas in obstetrics
    This is another meta-analysis that changes dogmas in obstetrics.  The common wisdom has been that induction of labor increases the risk of cesarean delivery and the risk is higher if the cervix is unripe. This started changing with the post-term trial of Mary Hannah that showed that at 41 weeks there is better outcome with induction of labor. This is the third meta-analysis showing that induction of labor at term and post term does not increase the risk of CS and results in a better outcome for the baby. It has been known for long time that the rate of stillbirth starts increasing at 38 weeks on a weekly basis. This new sets of data allows for an earlier induction of labor without worrying  about poor outcome and increased cesareans. The meta-anlysis by Mishanina E et al. in the CMAJ may explain why the new data is different from the old dogma as they show that oxytocin only induction does not offer these benefits (and neither do preterm inductions).  This information is even more important as the number of pregnancies in older women is increasing. There is ample data now showing that risk of stillbirths at women that are 40 years and older at 39 weeks is similar to that of younger women at  41 weeks. These women can now be induced at 39 weeks without worrying about the induction per se increasing their CS rate.

    Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials

    Gabriele Saccone MD, Vincenzo Berghella MD

    AJOG Volume 213, Issue 5, November 2015, Pages 629–636

  • Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm birth: a systematic review and metaanalysis

    Agustin Conde-Agudelo MD, MPH, PhD, Roberto Romero MD, DMedSci

    American Journal of Obstetrics and Gynecology, Volume 213, Issue 6, December 2015, Pages 789 - 801

  • Prevention of preterm birth with vaginal progesterone or 17-alpha-hydroxyprogesterone caproate: a critical examination of efficacy and safety

    John M. O’Brien MD, David F. Lewis MD, MBA

    American Journal of Obstetrics and Gynecology, Volume 214, Issue 1, January 2016, Pages 45 - 56

  • Cervical pessary placement for prevention of preterm birth in unselected twin pregnancies: a randomized controlled trial

    Kypros H. Nicolaides MD, Argyro Syngelaki MS, RM, Liona C. Poon MD, Catalina de Paco Matallana MD, Walter Plasencia MD, Francisca S. Molina MD, Gemma Picciarelli MD, Natasa Tul MD, Ebru Celik MD, Tze Kin Lau MD, Roberto Conturso MD

    American Journal of Obstetrics and Gynecology, Volume 214, Issue 1, January 2016, Pages 3.e1 - 3.e9


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Commentaries by Editor Prof. Jim Thornton