Akila Subramaniam

A cohort study evaluating robotic versus laparotomy surgical outcomes of obese women with endometrial carcinoma

OBJECTIVE Minimally invasive surgery offers advantages for management of obese patients, but technical difficulty often deters its utilization. Compared to laparotomy, robotic surgery should allow comparable staging and improved surgical outcomes. Therefore, we evaluated outcomes in robotic and laparotomy cohorts of obese women with endometrial cancer at our institution. METHODS Retrospective robotic and laparotomy cohorts of obese women (BMI ≥ 30 kg/m(2)) undergoing surgical management of primary endometrial cancer from March 2006 to March 2009 were formulated utilizing a computerized database. Patient demographics, operative statistics, peri-operative complications, and pathologic details were collected in an intent to treat analysis. Chi-square or Fishers exact test and t-test were used for statistical analysis. RESULTS 73 women underwent robotic surgical management, 11% converted to laparotomy. Mean BMI (39.8 vs. 41.9, p=0.152), number of co-morbidities (2.49 vs. 2.62, p=0.690), number of previous surgeries (0.97 vs. 0.94, p=0.841), and lymphadenectomies performed (65.8% vs. 56.7%, p=0.227) were similar between cohorts. Total lymph nodes obtained were not statistically different between cohorts (8.01 vs. 7.24, p=0.505). Total operative time and room time was significantly longer for robotic surgery; however, estimated blood loss, the percentage of patients receiving transfusion, hospital length of stay, wound complications (4.1% vs. 20.2%, p=0.002) and other complications (9.6% vs. 29.8%, p=0.001) were improved for the robotic cohort. CONCLUSIONS Robotic management of obese women with endometrial cancer yields acceptable staging results and improved surgical outcomes. Although operating time is longer, hospital time is shorter. Robotic surgery may be an ideal approach for these patients.

Antimicrobials for Preterm Birth Prevention: An Overview

Objective. Preterm birth (PTB) remains a major cause of neonatal morbidity and mortality. The association between PTB and infection is clear. The purpose of this report is to present a focused review of information on the use of antibiotics to prevent PTB. Methods. We performed a search of the PubMed database restricted to clinical trials or meta-analyses published in English from 1990 through May 2011 using keywords “antibiotics or antimicrobials” and “preterm.” Results. The search yielded 67 abstracts for review. We selected 31 clinical trials (n = 26) or meta-analysis (n = 5) for further full-text review. Discussion of each eligible clinical trial, its specific inclusion criteria, antibiotic regimen used, and study results are presented. Overall, trials evaluating antibiotic treatment to prevent preterm birth have yielded mixed results regarding any benefit. Conclusion. Routine antibiotic prophylaxis is not recommended for prevention of preterm birth.

Mode of delivery in women with class III obesity: planned cesarean compared with induction of labor

OBJECTIVE To compare maternal and neonatal outcomes between planned cesarean delivery and induction of labor in women with class III obesity (body mass index ≥40 kg/m(2)). STUDY DESIGN In this retrospective cohort study, we identified all women with a body mass index ≥40 kg/m(2) who delivered a singleton at our institution from January 2007 to February 2013 via planned cesarean or induction of labor (regardless of eventual delivery route) at 37-41 weeks. Patients in spontaneous labor were excluded. The primary outcome was a composite of maternal morbidity including death as well as operative, infection, and thromboembolic complications. The secondary outcome was a neonatal morbidity composite. Additional outcomes included individual components of the composites. Student t, χ(2), and Fisher exact tests were used for statistical analysis. To calculate adjusted odds ratios, covariates were analyzed via multivariable logistic regression. RESULTS There are 661 mother-infant pairs that met enrollment criteria-399 inductions and 262 cesareans. Groups were similar in terms of prepregnancy weight, pregnancy weight gain, and delivery body mass index. Of the 399 inductions, 258 had cervical ripening (64.7%) and 163 (40.9%) had a cesarean delivery. After multivariable adjustments, there was no significant difference in the maternal morbidity composite (adjusted odds ratio, 0.98; 95% confidence interval, 0.55-1.77) or in the neonatal morbidity composite (adjusted odds ratio, 0.81; 95% confidence interval, 0.37-1.77) between the induction and cesarean groups. CONCLUSION In term pregnant women with class III obesity, planned cesarean does not appear to reduce maternal and neonatal morbidity compared with induction of labor.

Infection and preterm birth

Preterm birth (PTB) remains a primary cause of neonatal morbidity and mortality. The purpose of this article is to outline the association between infection and PTB. We performed a search of the PubMed database for relevant scientific work published in English from 1995 to July 2015. Whereas there is substantial evidence regarding infection as a strong risk factor for preterm birth, the role of specific bacterial and viral infections is not totally conclusive. Newer high-dimensional biological technologies such as microbiomics and metabolomics offer hope to identify the causative pathogens. In addition, strategies have been developed to reduce PTB.

Incidence of mechanical malfunction in low-profile subcutaneous implantable venous access devices in patients receiving chemotherapy for gynecologic malignancies

OBJECTIVE The purpose of this study was to investigate the incidence of mechanical complications associated with low-profile subcutaneous implantable venous access devices in gynecologic oncology patients. METHODS Gynecologic oncology patients with low-profile Port-a-Caths implanted between March 2005 and July 2006 were identified into a computerized database. Patient demographics, operative complications, number of chemotherapy cycles, duration of implantation, and mechanical complications were collected. Primary outcomes included port leakage, catheter fracture, and catheter embolization. RESULTS 112 patients underwent 115 Port-a-Cath placements with low profile single-lumen plastic ports with Groshong-valved catheters. Mean Port-a-Cath indwelling duration was 197 days (range: 4-395) with a mean number of 12 chemotherapy cycles (range 0-64). The cumulative complication rate necessitating removal or replacement was 15%. Of the 14 Port-a-Caths removed, ten (8.7%) were secondary to mechanical malfunction: one for leakage at the port site, two for catheter fracture, and seven for fracture with catheter embolization to the heart or pulmonary vasculature-most commonly the right ventricle. Patients with embolization were asymptomatic and all embolized catheters were successfully retrieved by interventional radiology without complications. CONCLUSIONS The rates of catheter fracture and embolization have previously been reported to be low in patients with subcutaneous Port-a-Caths, and have not been studied in patients receiving low-profile subcutaneous Port-a-Caths. This study suggests that catheter fracture may be more common (8.7%) and must be considered in patients with malfunctioning low-profile Port-a-Caths. Embolized catheters can be removed by interventional radiology without significant adverse affects.

Trisomy 18: A single-center evaluation of management trends and experience with aggressive obstetric or neonatal intervention.

We conducted a retrospective cohort study including all prenatal and postnatal diagnoses of trisomy 18 (T18) from 2004 to 2014 at a single tertiary referral center in the southern United States to evaluate the natural history and perinatal outcomes associated with T18 over the past decade. We analyzed pregnancy outcome, mode of delivery, and for live‐births, the number and types of neonatal interventions, and characterized interventions as aggressive or non‐aggressive. Survival analyses were conducted based on mode of delivery and aggressive compared to non‐aggressive interventions. A total of 167 cases of T18 were identified, 150 with available records. There were 141 (94.0%) with full T18; the remainder had mosaicism (1.3%), a translocation (0.7%), or an isochromosome 18 (4.0%). Most diagnoses were prenatal (73.3%, n = 110). Of the 150 patients, there were 54 live births: 21 (38.9%) delivered vaginally, 32 (59.3%) delivered by cesarean, and mode of delivery could not be ascertained for one. Median duration of survival was 12 days (interquartile range 3–90 days). Over time, there were no changes toward increased intervention (obstetric or neonatal). For the 49 neonates who received some intervention, there was no significant difference in survival time between neonates receiving aggressive (n = 36, median survival 24 days, interquartile range 6–247) and non‐aggressive (n = 13, median survival 30 days, interquartile range 8–148) intervention (P = 0.90). There was similarly no difference in neonatal survival based on mode of delivery (P = 0.79). Survival of infants with T18 is not improved with aggressive obstetric or neonatal care.

Evaluation of Human Papillomavirus as a Risk Factor for Preterm Birth or Pregnancy-related Hypertension

OBJECTIVE: To compare rates of preterm birth and pregnancy-related hypertension in women with and without human papillomavirus (HPV) infection. METHODS: We performed a retrospective cohort study of all women delivered at our institution in 2013 who had cervical cancer screening test results within 3 years before delivery. Patients were excluded if they had prior procedure(s) for cervical dysplasia other than biopsy. There were two primary outcomes: preterm birth (less than 37 weeks of gestation) and pregnancy-related hypertension (gestational hypertension, preeclampsia, or eclampsia). Multivariable logistic regression was performed to adjust for confounders including demographic variables, diabetes, prior preterm birth, chronic hypertension, and other genital infections. Assuming a 10% prevalence of HPV, a rate of 12% in the HPV-negative group for both preterm birth and pregnancy-related hypertension, &agr; of 0.05, and &bgr; of 0.2, we needed 2,207 patients to detect a 60% increase in the rate of either outcome in the HPV-positive group. RESULTS: A total of 3,958 patients delivered in 2013, of whom 2,321 met eligibility criteria, 242 (10.4%) of whom were HPV-positive and 2,079 (89.2%) of whom were HPV-negative. In multivariate analyses, the rate of preterm birth was not significantly different between HPV-positive and HPV-negative women (16.5% compared with 12.2%, adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 0.9–1.9); rates of pregnancy-related hypertension also were not significantly different between HPV-positive and HPV-negative women (17.0% compared with 16.4%, adjusted OR 1.0, 95% CI 0.7–1.5). CONCLUSION: Maternal HPV infection is not an independent risk factor for preterm birth or pregnancy-related hypertension.

Vaginal Microbiota in Pregnancy: Evaluation Based on Vaginal Flora, Birth Outcome, and Race

OBJECTIVE This study aims to evaluate vaginal microbiota differences by bacterial vaginosis (BV), birth timing, and race, and to estimate parameters to power future vaginal microbiome studies. METHODS Previously, vaginal swabs were collected at 21 to 25 weeks (stored at -80°C), and vaginal smears evaluated for BV (Nugent criteria). In a blinded fashion, 40 samples were selected, creating 8 equal-sized groups stratified by race (black/white), BV (present/absent), and birth timing (preterm/term). Samples were thawed, DNA extracted, and prepared. Polymerase chain reaction (PCR) with primers targeting the 16S rDNA V4 region was used to prepare an amplicon library. PCR products were sequenced and analyzed using quantitative insight into microbial ecology; taxonomy was assigned using ribosomal database program classifier (threshold 0.8) against the modified Greengenes database. RESULTS After quality control, 97,720 sequences (mean) per sample, single-end 250 base-reads, were analyzed. BV samples had greater microbiota diversity (p < 0.05)-with BVAB1, Prevotella, and unclassified genus, Bifidobacteriaceae family (all p < 0.001) more abundant; there was minimal content of Gardnerella or Mobiluncus. Microbiota did not differ by race or birth timing, but there was an association between certain microbial clusters and preterm birth (p = 0.07). To evaluate this difference, 159 patients per group are needed. CONCLUSIONS There are differences in the vaginal microbiota between patients with and without BV. Larger studies should assess the relationship between microbiota composition and preterm birth.

Referral patterns and incidence of cervical intraepithelial neoplasia in adolescent and pregnant patients: The impact of the 2006 guidelines

Objective. The 2006 American Society for Colposcopy and Cervical Pathology consensus guidelines for management of abnormal cervical cytologic diagnosis made significant changes to referral recommendations for adolescent and pregnant populations. In this study, we sought to review the impact of these new guidelines on referral patterns, along with the incidence of cervical intraepithelial neoplasia 2/3 and cervical cancer in these 2 populations. Materials and Methods. After obtaining institutional review board approval, a retrospective chart review of 12,333 patients referred to a single colposcopy clinic between January 2004 and November 2009 was performed. This colposcopy clinic serves as a statewide referral center. All adolescent patients (<21 y) and pregnant patients were included for analysis. Patients were analyzed in 2 groups with respect to implementation of the 2006 guidelines. Statistical analysis was performed using &khgr;2 and Student t test. Results. Between 2004 and 2007, before implementation of the 2006 guidelines, 9,346 patients were referred to the colposcopy clinic. Overall, 1,398 adolescents and 958 pregnant patients were identified and included in the analysis. The mean age was 23.0 years (range = 10-60 y). Of the 1,398 adolescent patients, atypical squamous cells of undetermined significance (ASCUS) Pap smears accounted for 406 referrals (29.0%). Of the 958 pregnant patients, ASCUS cytologic diagnosis accounted for 284 referrals (29.6%). One case of squamous cell carcinoma (SCC) was identified in the pregnant population (0.1%), and no cases of SCC were diagnosed in the adolescent population. After implementation of the 2006 guidelines, between 2008 and 2009, a total of 2,987 patients were referred, including 113 adolescent patients and 168 pregnant patients. Mean age was 25.5 (range = 16-54 y), which was not significantly different from 2004 to 2007, p = .79. Atypical squamous cells of undetermined significance accounted for 6 referrals (5.3%) in the adolescent population and 15 referrals (8.9%) in the pregnant population. The decrease in the proportion of ASCUS cytologic diagnosis referrals in these populations was statistically significant at p < .001. No adolescent or pregnant patients were diagnosed with SCC during their colposcopic evaluation. Conclusions. The 2006 American Society for Colposcopy and Cervical Pathology consensus guidelines decreased the number of ASCUS cytologic diagnosis referrals to colposcopy in the adolescent and pregnant populations. The overall number of patients with SCC in these populations is quite small, therefore practitioners can be reassured that the new screening guidelines are unlikely to miss this diagnosis. These guidelines provide an efficient, evidence-based approach to the cytologic evaluation of these special populations.

Relationship between interpregnancy interval and cervical length in high-risk women

Abstract Objective: Our objective was to evaluate the relationship between the interpregnancy interval (IPI) and next-pregnancy mid-trimester cervical length (CL) in women at high risk for recurrent spontaneous preterm birth (SPTB). Methods: Retrospective review identified high-risk women, defined as a prior SPTB <36 weeks, who began scheduled serial transvaginal sonographic CL screening at 16–18 weeks gestation between December 2008 and November 2010. All CL assessment ended by 226/7 weeks, and weekly 17-α hydroxyprogesterone caproate, 250 mg IM, was recommended to all patients. Details of the prior and current pregnancy were collected, and regression models were used to evaluate the relationship between IPI and CL shortening. Results: One hundred and eight women with singleton gestations and a qualifying SPTB underwent CL screening. The mean (SD) birth gestational age (GA) of the last pregnancy was 25 (10) weeks, the median IPI was 613 (range 49–6038) days, and the mean (SD) delivery GA in the current pregnancy was 36 (5.3) weeks. Linear regression found no significant relationship between the IPI and the GA of the current birth (p = 0.98). There was a weak significant relationship between IPI and shortest CL (p = 0.04). However, after controlling for the GA of the prior pregnancy, this relationship was non-significant (p = 0.13). Conclusions: IPI does not predict next birth outcome or next-pregnancy mid-trimester CL in high-risk women managed with progesterone and ultrasound-indicated cerclage.