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Clemons JL, Weinstein M, Guess MK, Alperin M, Moalli P, Gregory WT, Lukacz ES, Sung VW, Chen BH, Bradley CS; on behalf of the AUGS Research Committee
Female Pelvic Med Reconstr Surg. 2013 July/August;19(4):191-198.
To describe the frequency of use and recent change in use of synthetic mesh and biologic grafts in pelvic organ prolapse (POP) and stress urinary incontinence surgery by American Urogynecology Society (AUGS) members.
An electronic survey of AUGS members was conducted between December 2011 and January 2012. Frequency of graft use in POP (overall and by transvaginal and transabdominal approaches) and stress urinary incontinence surgery was queried relative to the timing of the 2011 Food and Drug Administration (FDA) safety update. Rates of materials' use before and after the statement were compared using Wilcoxon signed rank test.
Fifty-three percent (507/962) of AUGS members responded and were included in analysis; 79% were urogynecologists. Before the FDA warning, in POP surgery, most (90%) used synthetic mesh and fewer (34%) used biologic grafts; 99% used synthetic mesh slings. After the FDA statement, respondents reported an overall decrease in the percent of POP cases in which they used synthetic mesh (P < 0.001) but no change in biologic graft use for POP (P = 0.37) or synthetic mesh sling use (P = 0.10). Specifically, transvaginal mesh use decreased: 40% reported decreased use and 12% stopped use. However, transvaginal mesh was still used by 61% of respondents in at least some cases. No change (62%) or increased use (12%) of mesh was reported for transabdominal POP procedures.
Synthetic mesh use in transvaginal POP surgery decreased after the 2011 FDA safety update, but synthetic mesh use for transabdominal POP repair and sling procedures and overall biologic graft use in POP surgery did not decrease.
For a full text of the article, go here: S:\Applications\Departmental Publications, 2012, Impact of the 2011 FDA Transvaginal Mesh Safety Update on AUGS Members' Use of Synthetic Mesh and Biologic Grafts in Pelvic Reconstructive Surgery. Female Pelvic Med Reconstr Surg. 2013. 19 p. 191.pdf.
Hardy-Fairbanks AJ, Pan SJ, Decker MD, Johnson DR, Greenberg DP, Kirkland KB, Talbot EA, Bernstein HH.
Pediatr Infect Dis J. 2013 Jun 24. [Epub ahead of print]
The effect of maternal Tdap vaccination on infant immunologic responses to routine pediatric vaccines is unknown.
This was a cohort study of infants whose mothers received or did not receive Tdap vaccine during pregnancy. Maternal and cord blood samples were collected at delivery; infant blood samples collected before and after primary series and booster dose of DTaP and other vaccines. Geometric mean antibody concentrations or titers to pertussis, hepatitis B, tetanus, diphtheria, H. influenzae type b, and polio antigens were measured. Mean maternal-to-cord blood antibody ratios were calculated.
At delivery, maternal and cord antibody concentrations to pertussis antigens were higher in the Tdap group (n=16) than control group (n=54; maternal: 1.9 to 20.4-fold greater; cord: 2.7 to 35.5-fold greater). Increased antibody concentrations persisted for infants at first DTaP (3.2 to 22.8-fold greater). After primary series, antibody concentrations to pertussis antigens were lower in Tdap group (0.7 to 0.8-fold lower), except for FIM (1.5-fold greater). Antibody concentrations to pertussis antigens before and after booster dose were comparable (pre-booster: Tdap group 1.0 to 1.2-fold higher than controls; post-booster: 0.9 to 1.0-fold lower). Differences in FIM values at these time points are difficult to interpret, due to varying FIM content among DTaP vaccines administered to infants in both groups.
Maternal Tdap immunization resulted in higher pertussis antibody concentrations during the period between birth and the first vaccine dose. Although slightly decreased immune responses following the primary series were seen compared with controls, differences did not persist following the booster.
For a full text of the article, go here: S:\Applications\Departmental Publications, 2012, Immune Responses in Infants Whose Mothers Received Tdap Vaccine During Pregnancy. Pediatr Infect Dis J. 2013 Jun 24. [Epub ahead of print].pdf
Hardy-Fairbanks AJ, Lauria MR, Mackenzie T, Mccarthy M Jr
Birth. 2013 June; 40(2):125–133
To date, most studies evaluating pain associated with cesarean birth have focused on delivery procedures or postoperative pain control methods rather than on the nature or severity of the pain experience of women, despite the increasing incidence and maternal requests for cesarean delivery. The objective in this study was to evaluate sensory, affective, and laterality aspects of pain after cesarean delivery and vaginal delivery.
A prospective cohort study using a seven-item visual analog scale assessed pain at rest and with activity, and the unpleasantness and location of pain on postpartum days 1 and 2. Chart review identified demographic and clinical factors influencing pain. Multivariable regression and propensity score analyses were used to evaluate patient-level outcomes.
Of 126 consenting women, 48 underwent cesarean delivery and 78 had vaginal delivery. No statistically significant differences in pain at rest and pain unpleasantness were found between groups on postpartum day 1, but women undergoing cesarean delivery reported more pain with activity than those who had a vaginal delivery (p < 0.0002). On postpartum day 2, cesarean delivery women reported significantly more pain when compared with those with a vaginal delivery (p < 0.04), and more cesarean delivery women reported lateralized pain (p < 0.0001). In multivariate regression analyses, cesarean delivery was the most significant predictor of activity-related pain on postpartum day 1 (p < 0.00001), followed by current substance abuse (p < 0.01). Women undergoing cesarean delivery required twice the dosage of analgesics on postpartum day 1 and four times greater amounts on postpartum day 2 relative to those with a vaginal delivery (p < 0.01 and p < 0.001).
Cesarean delivery was associated with higher levels of pain, more unpleasant pain, more lateralized pain, and greater narcotic use than vaginal delivery. Evaluation of factors associated with postpartum pain can help practitioners to counsel women better about their delivery alternatives and can promote improved management of women undergoing both types of delivery experiences
For a full text of the article, click here: http://onlinelibrary.wiley.com/doi/10.1111/birt.12039/pdf
Nelson EL, Stockdale CK.
Obstet Gynecol Clin North Am. 2013 Jun;40(2):359-76. doi: 10.1016/j.ogc.2013.03.003.
Human papilloma virus is associated with a multitude of lower genital tract diseases in women in addition to cervical cancer, including genital warts, vulvar intraepithelial neoplasia, vaginal intraepithelial neoplasia, and some vulvar, vaginal, and anal cancers that are associated with oncogenic subtypes. The degree to which HPV manifests pathology depends on viral type, host immune response, and local environmental factors. This article reviews the evaluation and management of the following vulvar and vaginal human papilloma virus diseases: condyloma, vulvar intraepithelial neoplasia, and vaginal intraepithelial neoplasia. Included is a brief discussion of the association with vulvar and vaginal cancer.
For a full text of the article, go here: S:\Applications\Departmental Publications, 2012, Vulvar and Vaginal HPV Disease. Obstet Gynecol Clin North Am. 2013. 40 p. 359.pdf
Cowman W, Hardy-Fairbanks AJ, Endres J, Stockdale CK. Proc Obstet Gynecol. 2013 ;3(2):Article 1 [15 p.]
One half of pregnancies in the United States are unintended and associated with adverse pregnancy outcomes. The postpartum period is an important, yet underutilized, time to initiate contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 provides evidence-based guidelines for choosing a contraceptive method and an update in 2011 specifically addresses contraceptive method use in the puerperium. The variety of contraceptive methods include hormonal contraception, lactational amenorrhea, barrier contraception, natural family planning, and sterilization. Ideally, counseling about contraceptive choice should begin early in pregnancy care and continue postpartum; it should also include a variety of teaching modalities. Specifically we recommend LARC options such as intrauterine devices and etonorgestrel implants, postpartum tubal sterilization, and progestin-only pills for those desiring an oral method.
For a full text of the article, click here: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1198&context=pog
Tikkanen S, Button A, Zamba G, Hardy-Fairbanks AJ.
Proc Obstet Gynecol. 2013;3(2):Article 2 [10 p.]
The obstetrical department at University of Iowa implemented several interventions at reducing post-operative infections and wound complication rates following a cesarean delivery. We implemented subcuticular closure of the skin following all cesarean sections in February of 2011 and switched from a povidone/iodine skin prep to a chlorhexidine-alcohol prep April 19th 2011. Based on prior studies, we hypothesized a 50% reduction in post cesarean wound complications
To determine if changes in skin prep type and closure method decreases post-operative infectious morbidity and wound complications.
The study reviewed charts of women who underwent a cesarean section between 7/1/2010 and 12/31/2010 compared to those that underwent a cesarean section between 4/19/2011 and 9/7/2011. A total of 568 charts were reviewed. Women were divided into two groups; the control group included those who had a povidone/iodine skin prep and staple closure, the intervention group included those women who had chlorhexidine skin prep and skin closure with subcuticular suture.
A total of 567 charts were reviewed and 190 control (iodine/staples) subjects and 139 intervention (chlorhexidine-alcohol/suture) subjects were identified. We found no statistical difference in the overall wound complication rates between the control and intervention groups, 22.1% vs 17.4% (p.22). We did however find a significant decrease in wound separation rates: 8.4% vs 3% (p.014) Analysis showed significant risk factors for infectious morbidity and wound separation to be labor prior to surgery
In our population the implementation of a chlorhexidine skin prep and closure of the skin with a subcuticular suture did not decrease overall infectious morbidity, it did however decrease our wound separation rate.
For a full text of the article, click here: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1201&context=pog
Abel J, Conklin J, Hunter S, Empey R, Tyler E, Christensen A, Talcott K, Ballas Z, Santillan M, Santillan D
Proc Obstet Gynecol. 2013 ;3(2):Article 8 [ 2 p.].
Immunoglobulin G (IgG) is the major serum immunoglobulin, accounting for roughly 75% of all immunoglobulin. IgG is the only class of immunoglobulin that crosses the placenta and it serves as the main immunologic barrier between the fetus and external environments. There has not been a clear consensus on what the normal values of IgG are throughout pregnancy. The aim of this study is to measure serum immunoglobulin G in each trimester of the pregnant female to determine a normal IgG profile throughout all trimesters in normal pregnancy.
For a full text of the article, click here: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1213&context=pog
Savage MW, Pottinger JM, Chiang HY, Yohnke KR, Bowdler NC, Herwaldt LA.
Am J Obstet Gynecol. 2013 May 24. pii: S0002-9378(13)00532-2. doi: 10.1016/j.ajog.2013.05.043. [Epub ahead of print]
To identify risk factors for and outcomes of surgical site infections (SSIs) and cellulitis after abdominal hysterectomies.
We used logistic regression analysis to analyze data from a case-control study of 1104 patients undergoing abdominal hysterectomies at a university hospital between 01/01/2007 and 12/30/2010.
Independent risk factors for SSIs and for cellulitis were: pulmonary disease, operations done in Main Operating Room East, and seroma. Body mass index > 35, no private insurance, and fluid and electrolyte disorders were risk factors for SSIs. The mean prophylactic dose of cefazolin was significantly higher for controls than for patients with SSIs. Pre-operative showers with Hibiclens® and cefazolin prophylaxis were associated with a significantly decreased cellulitis risk. SSIs and cellulitis were significantly associated with readmissions and return visits and SSIs were associated with reoperations.
Pre-operative showers, antimicrobial prophylaxis, surgical techniques preventing seromas, and the operating room environment may affect the risk of surgical site infections and cellulitis after abdominal hysterectomies.For a full text of the article, click here: http://www.sciencedirect.com/science/article/pii/S0002937813005322.
Hess R, Huang AJ, Richter HE, Ghetti CC, Sung VW, Barrett-Connor E, Gregory WT, Pinkerton JV, Bradley CS, Kraus SR, Rogers RG, Subak LL, Johnson KC, Arya LA, Schembri M, Brown JS.Am J Obstet Gynecol. 2013 May 6. pii: S0002-9378(13)00480-8. doi: 10.1016/j.ajog.2013.05.008. [Epub ahead of print]
The objective of the study was to determine the longer-term efficacy and safety of initiating treatment for urgency-predominant urinary incontinence (UUI) in women diagnosed using a simple questionnaire rather than an extensive evaluation.
Women completing a 12 week randomized controlled trial of fesoterodine therapy for UUI diagnosed by questionnaire were invited to participate in a 9 month, open-label continuation study. UUI and voiding episodes were collected using voiding diaries. Participant satisfaction was measured by questionnaire. Safety was assessed by the measurement of postvoid residual volume and adverse event monitoring; if necessary, women underwent a specialist evaluation. The longitudinal changes in UUI and voiding episodes were evaluated using linear mixed models adjusting for baseline.
Of the 567 women completing the randomized trial, 498 (87.8%) took at least 1 dose of medication during this open-label study. Compared with the baseline visit in the randomized trial, fesoterodine was associated with a reduction in total incontinence episodes per day and urgency incontinence episodes per day at the end of the open-label study (adjusted mean [SE], 4.6 [0.12] to 1.2 [0.13] and 3.9 [0.11] to 0.9 [0.11], respectively, P < .0001 for both). Most women were satisfied with treatment (89%, 92%, and 93% at 3, 6, and 9 months, respectively). Twenty-six women experienced 28 serious adverse events, 1 of which was considered possibly treatment related. Twenty-two women had a specialist evaluation: 5 women's incontinence was misclassified by the 3 Incontinence Questions; none experienced harm because of misclassification.
Using a simple validated questionnaire to diagnose and initiate treatment for UUI in community-dwelling women is safe and effective, allowing timely treatment by primary care practitioners.
For a full text of the article, click here: http://www.sciencedirect.com/science/article/pii/S0002937813004808.
Shah DK, Correia KF, Vitonis AF, Missmer SA.Hum Reprod. 2013 May 14. [Epub ahead of print]
Is there a relationship between body mass index (BMI), body shape and endometriosis?
Endometriosis is inversely associated with early adult BMI and may correlate with a peripheral body fat distribution.
The literature suggests an inverse relation between endometriosis and BMI, although few studies have specifically explored this association in depth.
Prospective cohort study using data collected from 116 430 female nurses from September 1989 to June 2011 as part of the Nurses' Health Study II cohort.
Cases were restricted to laparoscopically confirmed endometriosis. Weight at age 18 and height were reported at baseline, and current weight was updated every 2 years. Waist and hip measurements were first taken in 1993 and updated in 2005. Rate ratios (RR) and 95% confidence intervals (CI) were calculated using Cox proportional hazards models with time-varying covariates.
A total of 5504 incident cases of endometriosis were reported during 1 299 349 woman-years (incidence rate = 385 per 100 000 woman-years). BMI at age 18 and current BMI were each significantly inversely associated with endometriosis (P-value, test for linear trend <0.0001). Both associations were stronger among infertile women. Obese infertile women with current BMIs of 35-39.9 kg/m2 and ≥40 kg/m2 had a 55% (95% CI 0.30-0.67) and a 62% (95% CI 0.23-0.62) lower risk of endometriosis, respectively, compared with the low-normal BMI referent (18.5-22.4 kg/m2). Rates of endometriosis were nearly 3-fold higher in women with waist-to-hip ratios <0.60 (RR = 2.78, 95% CI 1.38-5.60) compared with those with waist-to-hip ratios between 0.70 and 0.79, although the sample size for this category was very small.
Although women with undiagnosed endometriosis certainly remain in the comparison population even in this prospective cohort study, the community prevalence of endometriosis in an asymptomatic population is very low. Moreover, the characteristics of this small proportion of undiagnosed cases are diluted among the >90 000 women accurately defined as being endometriosis-free and are, therefore, unlikely to impact on effect estimation. Although geographically diverse, the NHS II cohort is overwhelmingly Caucasian, which may limit generalizability to more ethnically diverse populations.
The results of this study suggest that endometriosis is inversely associated with early adult BMI and may correlate with a peripheral body fat distribution.
For a full text of the article, click here: http://humrep.oxfordjournals.org/content/early/2013/05/09/humrep.det120.long.
Shah DK.Obstet Gynecol. 2013 Apr;121(4):869-71. doi: 10.1097/AOG.0b013e3182878246.
Borello-France D, Burgio KL, Goode PS, Ye W, Weidner AC, Lukacz ES, Jelovsek JE, Bradley CS, Schaffer J, Hsu Y, Kenton K, Spino C; for the Pelvic Floor Disorders Network.Phys Ther. 2013 Mar 28. [Epub ahead of print]
First-line conservative treatment for stress urinary incontinence (SUI) in women is behavioral intervention, including pelvic-floor muscle (PFM) exercise and bladder control strategies.
The purposes of this study were: (1) to describe adherence and barriers to exercise and bladder control strategy adherence and (2) to identify predictors of exercise adherence.
This study was a planned secondary analysis of data from a multisite, randomized trial comparing intravaginal continence pessary, multicomponent behavioral therapy, and combined therapy in women with stress-predominant urinary incontinence (UI).
Data were analyzed from the groups who received behavioral intervention alone (n=146) or combined with continence pessary therapy (n=150). Adherence was measured during supervised treatment and at 3, 6, and 12 months post-randomization. Barriers to adherence were surveyed during treatment and at the 3-month time point. Regression analyses were performed to identify predictors of exercise adherence during supervised treatment and at the 3- and 12-month time points.
During supervised treatment, ≥86% of the women exercised ≥5 days a week, and ≥80% performed at least 30 contractions on days they exercised. At 3, 6, and 12 months post-randomization, 95%, 88%, and 80% of women, respectively, indicated they were still performing PFM exercises. During supervised treatment and at 3 months post-randomization, ≥87% of the women reported using learned bladder control strategies to prevent SUI. In addition, the majority endorsed at least one barrier to PFM exercise, most commonly "trouble remembering to do exercises." Predictors of exercise adherence changed over time. During supervised intervention, less frequent baseline UI and higher baseline 36-Item Short-Form Health Survey (SF-36) mental scores predicted exercise adherence. At 3 months post-randomization, women who dropped out of the study had weaker PFMs at baseline. At 12 months post-randomization, only "trouble remembering" was associated with exercise adherence.
Adherence and barrier questionnaires were not validated.
Adherence to PFM exercises and bladder control strategies for SUI can be high and sustained over time. However, behavioral interventions to help women link exercise to environmental and behavioral cues may only be beneficial over the short term.
For a full text of the article, click here: http://ptjournal.apta.org/content/early/2013/03/26/ptj.20120072.long
Berger A, Frelin C, Shah DK, Benveniste P, Herrington R, Gerard NP, Zúñiga-Pflücker JC, Iscove NN, Paige CJ.PLoS One. 2013;8(3):e58787. doi: 10.1371/journal.pone.0058787. Epub 2013 Mar 14.
Tachykinins are a large group of neuropeptides with both central and peripheral activity. Despite the increasing number of studies reporting a growth supportive effect of tachykinin peptides in various in vitro stem cell systems, it remains unclear whether these findings are applicable in vivo. To determine how neurokinin-1 receptor (NK-1R) deficient hematopoietic stem cells would behave in a normal in vivo environment, we tested their reconstitution efficiency using competitive bone marrow repopulation assays. We show here that bone marrow taken from NK-1R deficient mice (Tacr1(-/-)) showed lineage specific B and T cell engraftment deficits compared to wild-type competitor bone marrow cells, providing evidence for an involvement of NK-1R signalling in adult hematopoiesis. Tachykinin knockout mice lacking the peptides SP and/or HK-1 (Tac1 (-/-), Tac4 (-/-) and Tac1 (-/-)/Tac4 (-/-) mice) repopulated a lethally irradiated wild-type host with similar efficiency as competing wild-type bone marrow. The difference between peptide and receptor deficient mice indicates a paracrine and/or endocrine mechanism of action rather than autocrine signalling, as tachykinin peptides are supplied by the host environment.
For a full text of the article, click here:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3597582/
Bender RM, Ryan GLProceedings in Obstetrics and Gynecology, 2013;3(1):1
Preeclampsia is a complex multi-pathway disease process diagnosed by hypertension with two readings of systolic blood pressure ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, separated by a 4-6 hour period, and proteinuria with a urine dipstick of ≥ 1+ or ≥ 300 mg per 24 hours, after 20 weeks’ gestation in a previously normotensive patient. Ninety-nine percent of pregnancy related deaths occur in middle and low-income countries (LMIC). Of these deaths, the World Health Organization (WHO) ranks pre-eclampsia and eclampsia as the second leading direct cause of maternal morbidity and mortality, behind only postpartum hemorrhage. A woman born in a developing country has a seven times greater risk of developing pre-eclampsia and a three times greater risk of progressing to eclampsia. This paper seeks to review what we know about the basics of detection and management to encourage thoughtful applications in improving the global burden of pre-eclampsia and eclampsia in low resources settings.
For a full text of the article, click here: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1205&context=pog
Devor EJ, Santillan DA, Santillan MK. Proceedings in Obstetrics and Gynecology, 2013;3(1):2
Preeclampsia is a critical gestational condition that threatens the life of both mother and child. One of the most serious aspects of preeclampsia hampering both clinical management and scientific understanding is that there are, as yet, no early warning signs or risk markers. The discovery of microRNAs (miRNAs), tiny post-transcriptional regulators of gene expression, offers potentially fertile ground for developing such markers. The current state of knowledge about miRNAs in preeclampsia is presented along with information regarding miRNA detection in peripheral fluids that could lead to minimally invasive risk assessment.
For a full text of the article, click here: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1206&context=pog
Santillan DA, Hamilton W, Christenson A, Talcott K, Gravatt L, Santillan MK, Hunter SKProceedings in Obstetrics and Gynecology, 2013;3(1):3
The role of the microenvironment is important in cell differentiation. The effect of placental disease on the growth and differentiation and hematopoietic stem cells has not been well-studied.
Enzyme linked immunoassay was used to measure erythropoietin and osteopontin in plasma from umbilical cord blood of children born to normotensive and preeclamptic women. Additionally, CD34+ cells were isolated from umbilical cord blood and grown in complete methylcellulose media. Colony types were identified and enumerated.
Differences in the concentration of erythropoietin in the cord blood between the controls and the preeclamptics approached significance (P = 0.067) using a Mann-Whitney U test. In the plasma of cord blood from children born to normotensive women, the median erythropoietin was 0.186 mIU/mL compared to 1.986 mIU/mL in children of preeclamptic women. We did not find any significant differences in the number and types of colonies; however, there was a trend toward increased BFU-E in the preeclamptic samples. Furthermore, this trend for increased BFU-E colonies was also seen from CD34+ cells isolated from umbilical cord blood of severe preeclamptics compared to mild.
Our preliminary studies suggest that abnormalities in the placenta, such as those found when the mother experiences preeclampsia, may affect the ability of hematopoietic stem cells to grow and differentiate.
For a full text of the article, click here: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1207&context=pog