Ob-Gyn Society Recognizes Resident/Fellow Research Papers

The St. Louis Ob-Gyn Society on April 21 held its annual scientific meeting showcasing resident and fellow research papers from the area’s three ob-gyn training programs, Mercy, Saint Louis University and Washington University.  From these peer-reviewed papers, eight were chosen for presentation and the top three papers received awards. For more information, contact Ob-Gyn Society members Andrew Galakatos, MD, (SLMMS), galakatos@wudosis.wustl.edu, or Gilad Gross, MD, ggross@slu.edu.

Following are the abstracts:

First Place
Baseline Uterine Tone in Labor: Does it Matter?

Kristina A. Epplin, MD; Molly J. Stout, MD, MSCI; Methodius G. Tuuli, MD, MPH; George A. Macones, MD,
MSCE; and Alison G. Cahill, MD, MSCI, Obstetrics & Gynecology, Washington University; Heather A. Frey,
MD, MSCI, Obstetrics & Gynecology, Ohio State University College of Medicine.

Objectives
There is limited data regarding uterine tone and labor outcomes. We aimed to estimate the effect of
baseline uterine resting tone during labor on adverse neonatal outcomes.

Study Design
This study included the first 5,000 consecutive women with term, singleton gestations of an ongoing
prospective cohort of women in labor. Uterine resting tone was assessed in the final 120 minutes prior
to delivery either externally or internally with intrauterine pressure catheters (IUPCs). A sensitivity
analysis was performed for IUPC only. Women with an average baseline resting tone >20 mmHg were
compared with women ≤20 mmHg; this threshold was determined based on previous small published
studies. A second analysis was performed for resting tone >25 mmHg, the 75th percentile in our cohort.
Outcomes included 1 and 5 minute APGAR <7, NICU or higher order nursery admission, neonatal
acidemia, or cesarean delivery. Logistic regression was used to adjust for relevant confounders.

Results
Of 4,890 eligible laboring women, 2,640 women had IUPCs. Of these 2,640 women, 1,450 (55%) had an
elevated resting tone >20 mmHg, and 760 (29%) had a resting tone >25 mmHg. Women with a resting
tone >20 mmHg were more than twice as likely to have a 5 minute APGAR <7 (aOR 2.58, CI 1.44‐4.61);
but, the overall rate was low occurring in 58 (4%) infants. There was no difference in 1‐minute APGAR <7,
NICU or higher order nursery admission, acidemia, or rate of cesarean. The resting tone group >25 mmHg
had higher rates of 1‐ and 5‐minute APGARs <7 (aOR 1.48, CI 1.13‐1.94; aOR 3.20, CI 1.95‐5.27), but
otherwise resting tone >25 mmHg did not impact outcomes. An analysis comparing all women with
either external or internal monitors revealed similar results.

Conclusions
Elevated uterine tone above 20 mmHg and 25 mmHg is associated with abnormal APGAR scores, but not
with more clinically meaningful outcomes such as NICU or higher order nursery admission, neonatal
acidemia or cesarean delivery. Resting tone alone should not impact a clinician’s judgment on labor
management.

Second Place
The Effect of Pyrroloquinoline Quinone on Meiotic Progression in Aged Mouse Oocytes Fed a Control and High‐Fat Diet

Violet Klenov, MD; Kasey Reynolds, MD; Emily Jungheim, MD; and Kelle Moley, MD; Ob‐Gyn,
Washington University

Introduction
It is accepted that the primary cause of decreased fecundability in aging women is an increased
prevalence of aneuploidy in oocytes resulting from disordered regulatory mechanisms involving
meiotic spindle formation and function. It is possible that reactive oxygen species (ROS) are
responsible for these abnormalities. Previous work suggests that supplementing mouse diet with
pyrroloquinoline quinone (PQQ) improves reproductive outcomes. Ongoing work suggests that the
pathophysiology of the aging oocyte may be similar to the oocyte from an obese model. This study
evaluates whether adding PQQ to in vitro maturation (IVM) culture media can increase normal
meiotic progression in mice exposed to age alone or to age as well as a high fat diet (HFD). Given the
suboptimal rates of normal embryos and clinical pregnancy using in vitro maturated oocytes in
humans, and the continued epidemic of obesity, this study is particularly relevant.

Methods
C57 mice were fed HFD or a control diet (CD) until 11 months of age. Mice from both diet groups were
injected intraperitoneally with 10 IU pregnant mare serum gonadotropin (PMSG). After 46‐48hrs, mice
were sacrificed and germinal vesicle (GV) stage oocytes were obtained by mechanically mincing the
ovaries in warmed media. GV oocytes from HFD and CD mice were then matured in vitro in either
control media, cysteine media or media supplemented with 50uM PQQ. Oocytes were then stained for
spindle architecture and morphology at the MII stage. Oocytes were then evaluated qualitatively and
grouped into normal vs abnormal.

Results
Chi‐square analysis was used to compare proportions of normal versus abnormal oocytes obtained from
culture in MII media versus cysteine and MII versus PQQ. No differences were noted. The same
comparisons were made for oocytes obtained from mice on the HFD. No differences were noted in
oocytes cultured in MII media versus cysteine. There were however significantly fewer abnormal
oocytes noted after culture in PQQ supplemented media versus the MII media (p=0.04; OR 0.07, 95% CI
0.007‐0.75).

Conclusions
PQQ increases normal meiotic progression in mice exposed to age and HFD. Adding PQQ to IVM media
may improve the rate of normal oocytes and therefore improve clinical pregnancy rates in this growing
patient population. Further research is warranted.

Third Place
Effect of Salpingectomy on Ovarian Reserve: A Systematic Review and Meta‐Analysis

Christina E. Boots, MD; Emily A. Seidler, MD; Ali Ainsworth, MD; Angela Hardi, MLIS; Emily S. Jungheim,
MD, MSCI, Department of Obstetrics & Gynecology, Division of Reproductive Endocrinology & Infertility,
Washington University; Ali Ainsworth, MD, Department of Obstetrics & Gynecology, Mayo Clinic,
Rochester, Minn.

Objective
As a treatment for ectopic pregnancy or for excision of hydrosalpinx, salpingectomy is a relatively
common procedure performed on patients undergoing assisted reproductive technology (ART).
However, shared vasculature in the mesosalpinx raises the question of ovarian devitalization at time of
surgery. The effect of salpingectomy on ovarian reserve is not well understood and presents a unique
concern in women with already diminished reserve. The objective of this study is to ascertain the impact
of salpingectomy on the future fertility of women undergoing ART by evaluating ovarian reserve and
ovarian responsiveness in the ART cycle following unilateral or bilateral salpingectomy for the treatment
of ectopic pregnancy or hydrosalpinx.

Study Design
A systematic review was performed by searching PubMed, Embase, Scopus, and CENTRAL for studies
that compared markers of ovarian reserve and measures of ovarian responsiveness during ART before
and after salpingectomy for the treatment of ectopic pregnancy or hydrosalpinx. With IRB approval,
primary data from our institution was pooled in the final analysis. Meta‐analysis of the data was
performed using a DerSimonion‐Laird random effects model. Results are reported as weighted mean
difference and 95% confidence interval.

Results
Eight studies and our center’s primary data were included, totaling 274 women. No differences were
noted comparing pre‐salpingectomy IVF cycles to post‐salpingectomy cycles in regards to ovarian
reserve parameters or ovarian response as assessed by stimulation duration, total dose of
gonadotropins or peak estradiol levels. In addition, there were no differences in oocytes retrieved
(Figure 1). A post‐hoc power analysis determined that a study of this size would be able to detect an
8.3% difference in oocytes retrieved (1 oocyte) with 80% power.

Conclusions
Our findings support the continued use of salpingectomy in the management of ectopic pregnancy and
hydrosalpinges. Primary data is needed to stratify the analysis to determine if women of advanced age
or diminished ovarian reserve are at a higher risk of effects from salpingectomy.

Additional Presented Abstracts

Text Messages and Compliance in Diabetic Pregnant Patients

Dorothea Mostello, MD; Shannon Grabosch, MD; Scott Ballmann, MD; Jeffery Gavard, PhD; Saint Louis
University Department of Obstetrics, Gynecology, and Women’s Health

Objective: The purpose of this study is to determine if the use of text message reminders improves
patient compliance and clinical outcomes in pregnancies complicated by diabetes mellitus and
gestational diabetes mellitus.

Study Design: This is an interim analysis of a prospective, randomized controlled trial of pregnant
women that have been diagnosed with diabetes mellitus or gestational diabetes mellitus. This interim
analysis is based on data collected from 58 diabetic pregnant women that were randomized to one of
two texting groups. Of these women, 26 received generalized text messages from the online resource
Text4Baby. 26 received specific text message reminders about appointment times and treatment plans
using a Google Voice account created specifically for this study. 6 patients received no text messages

Results: Text message intervention, whether general or specific in nature, showed no statistical
significance in terms of patients keeping their appointments when compared to not receiving text
messages (P=0.86). However, text message intervention demonstrated improved glycemic control when
compared to receiving no texts at all (p<0.05). When comparing the general text group to the specific
text reminder group, the specific reminder group brought their glucose records with them more often
when they did keep their appointment, although the difference was not statistically significant (78.1%
vs. 86.3%, respectively; P=0.09). Also, comparisons were made from a designated “baseline” visit to
subsequent visits in regards to glucose record completeness among the two texting groups. The group
that received general text messages demonstrated less complete glucose records over the course of
time, while the specific reminder group demonstrated improved glucose record completeness. Analysis
showed, however, the difference was not statistically significant.

Conclusion: Text message intervention, as a whole, significantly influenced glycemic control. The two
types of text message interventions showed no statistically significant difference in the patient
compliance measures between the two texting groups. This data does suggest trends that may be
clinically significant, however. The specific text reminder group was shown to bring their glucose records
in more often and demonstrated more complete records than the general text message group. Further
recruitment and investigation are required to see if specific text message reminders are superior to
general text messages in this patient population in terms of compliance measures.

Symptoms and Timing Associated with Mesh Revision After Sacrocolpopexy

Simon P. Patton, MD; Sara C. Wood, MD; Dionysios K. Veronikis, MD; Division of Female Pelvic Medicine
and Reconstructive Surgery, Department of Obstetrics and Gynecology, Mercy Hospital St. Louis

Objective: Sacrocolpopexy is considered the gold standard procedure for apical prolapse and is routinely
performed using mesh via an open abdominal, laparoscopic, or robotic‐assisted approach. Studies on
sacrocolpopexy mesh revision specifically reporting data regarding symptoms and the timing of
presentation are limited possibly due to the infrequent incidence. Such data would be useful to counsel
and care for patients undergoing sacrocolpopexy. The objective of this study was to describe the chief
complaint and the time elapsed since implantation surgery in patients presenting for revision of
sacrocolpopexy mesh.

Study Design: Following IRB approval, a retrospective chart review from 2007‐2014 was performed by
and electronic search of the CPT code 57296 (removal of abdominal mesh) of two urogynecologists’
referral practice. Only sacrocolpopexy mesh revision patients were included. The original
sacrocolpopexy operative reports were reviewed to confirm approach and date of implantation. The
chief complaint, associated symptoms, demographic data, and other patient history were abstracted
from the chart.

Results: Thirty‐one patients met inclusion criteria including fifteen with a history of open abdominal
sacrocolpopexy (ASC), and 16 performed with robotic assistance (RSC). The most common complaints at
presentation were exposure of the mesh (n=11) and pelvic pain/dyspareunia (n=11) followed by apical
recurrence (n=9). When comparing modalities, exposure of the mesh was found in almost twice as many
patients who had undergone RSC (n=7) vs ASC (n=4). The median time to presentation was significantly
shorter in the RSC group [1.7 vs 5.6 (U=35.5, p<.05)] with an overall timeframe of 3.0 years.

Conclusions: This study suggests that the timing and chief complaint for mesh revision may differ based
on the surgical route of sacrocolpopexy. Further prospective studies are needed to delineate
associations between presentation for mesh revision and the time since implantation with the modality
of sacrocolpopexy approach.

The Maternal Glucose Response to Steroids for Fetal Lung Maturity: The Effect of Gestational Age, Body Mass Index, Maternal Age and Race

Genie Pierson, MD; Jennifer Goldkamp, MD; Jeffrey Gavard, MD; Dorothea Mostello, MD. Saint Louis University.

Objective: To determine if the glycemic response in pregnant women who received steroids for fetal
lung maturity differed by gestational age, BMI, race, or maternal age.

Study Design: Retrospective study from a single tertiary care center among women who did not have
pre‐pregnancy diabetes and had documented blood glucose readings following administration of
steroids for fetal lung maturity. The peak fasting glucose value, peak postprandial glucose value, time to
peak fasting glucose value, and time to peak postprandial glucose values were collected. Gestational age
groupings utilized were >22‐<27, >27‐<29, >29‐<31, >31‐<33, and >33‐36 weeks. BMI was categorized
by WHO standards into underweight/normal weight, overweight, class I, II, and III obesity. Maternal age
groups were divided into <20, 20‐24, 25‐29, >30 years. Differences across groups were assessed using
analysis of variance or Kruskal‐Wallis test. Student’s t‐test, Spearman’s correlations, and Kolmogorov‐
Smirnov test were used for pairwise comparisons.

Results: Fasting blood glucose values were available for 186 patients and postprandial blood glucose
levels were available for 188 patients. The median peak fasting glucose level was 138 (interquartile
range 125.5‐152), and the median peak postprandial glucose level was 179.5 (interquartile range 163‐
203.5). Median time to peak fasting glucose was 30.3 hours (interquartile range 13.9‐38.4). The median
time to peak postprandial was 28.4 hours (interquartile range 15.6‐41.4). Significant differences in peak
postprandial values were found across all five BMI categories (underweight/normal weight 175.9+/‐
34.3, overweight 179.4 +/‐ 29.6, class I obesity 188.4 +/‐ 32.1, class II obesity 180.7 +/‐ 24.2, and class III
obesity 201.2+/‐ 37.9). Significant differences in time to peak postprandial values were also found across
all five BMI categories (underweight/normal weight 32.7 +/‐ 18.5, overweight 36.1 +/‐ 20.9, class I
obesity 24.5 +/‐ 16.9, class II obesity 35.2 +/‐ 26.7, and class III obesity 27.5 +/‐ 16.7). No significant
difference in peak fasting glucose or time to peak fasting glucoses across BMI, gestational age, maternal
age, or race was demonstrated. No significant difference in peak postprandial glucose or time to peak
postprandial glucose by gestational age, maternal age, or race was found.

Conclusion: While hyperglycemia increases with increasing BMI, women in all BMI categories have the
potential for clinically significant elevations in glucoses after steroids.

Like Mother, Like Daughter? A Comparison of Anti‐Müllerian Hormone Levels in Sample Pairs of Maternal Serum and Female Neonatal Cord Blood

Emily A. Seidler, MD; Julie S. Rhee, MD; and Amber R. Cooper, MD, MSCI; Department of
Obstetrics & Gynecology, Washington University, Barnes Jewish Hospital; Elizabeth Eklund,
BS; Geralyn Lambert‐Messerlian, PhD; Brown University, Women and Infants Hospital
Providence, R.I.

Objective: Anti‐müllerian hormone (AMH) is gaining popularity as an ovarian reserve screen.
Nomograms for AMH have been created for healthy populations across the age spectrum. However, the
mother/daughter correlation of AMH at the time of birth is unknown. Our goal was to examine this
critical time just after fetal oocyte endowment.

Study Design: Prospective cohort pilot study. Materials and Methods: Maternal pre‐pregnancy and
paired neonatal cord blood was collected as part of the Women and Infant’s Health Specimen
Consortium at Washington University from 2009‐2013. Serum was frozen at ‐80 C until shipment to an
independent blinded lab (W&I) for batched AMH analysis. Samples were run in duplicate on a manual
ELISA (Ansh labs) with a lower limit of detection of 0.08.

Results: Twelve maternal/newborn pairs were included, three with female/female twin deliveries,
which were analyzed separately. Unlike in past female newborn studies, most cord blood samples had
detectable AMH levels on this more sensitive assay. Increased maternal age was highly associated
with decreased fetal cord blood AMH results (p=0.02) and increased fetal weight was associated with
increased AMH values (p=0.007). Mean cord blood AMH in singleton pregnancies (0.87+1.3 ng/mL) is
higher than those from twins (p=0.018), though zygosity was unknown. In a multivariate analysis
controlling for maternal age, BMI and fetal weight, increasing maternal pre‐pregnancy AMH was
associated with decreasing newborn cord blood AMH values (p=0.025).

Conclusions: Cord blood AMH values appear to be regulated by maternal characteristics. Our findings
suggest that pathologic processes related to higher maternal AMH values could lead to an untoward
effect on oocyte pool endowment and early antral follicle development in utero. Differences between
singleton and twin female neonates warrant further investigation.

Pharmacy Claims Data Versus Patient Self‐Report to Measure Contraceptive Method Continuation 

Jourdan E. Triebwasser, MD, MA; Stephanie Higgins, BA; Gina M. Secura, PhD, MPH; Qiuhong Zhao, MS;
Jeffrey F. Peipert, MD, PhD; Department of Obstetrics & Gynecology, Division of Clinical Research,
Washington University School of Medicine

Objective: To compare self‐reported 12‐month continuation of oral contraceptive pills (OCPs), patch and
ring versus continuation by pharmacy claims data.

Study Design: Women in the Contraceptive CHOICE project who chose OCPs, the patch, or ring as their
initial method were included. Continuation was assessed by periodic telephone survey and by obtaining
prescription claims data. Continuation was defined as no gap of more than 30 days. Kaplan‐Meier
survival functions were used to estimate continuation rates and cumulative unintended pregnancy
rates. Kappa statistic assessed the level of agreement between self‐report and claims data.

Results: We analyzed 1,510 women who initiated use by three months and provided information on
discontinuation. Of OCP users, 59% continued their method at 12 months by self‐report versus 38% by
pharmacy claims. Patch and ring users had self‐reported/pharmacy continuation of 45%/28% and
57%/37%, respectively. Kappa coefficients and their 95% confidence intervals between the two
measurements were 0.46 [0.40‐0.52], 0.54 [0.39‐0.68], and 0.54 [0.47‐0.61] for OCP, patch and ring,
respectively. Among women who self‐reported continuation, unintended pregnancy rates were 0.4% in
those who continued by pharmacy claims versus 4.9% in those who discontinued according to claims
data.

Conclusion: Contraceptive continuation rates differ by self‐report versus pharmacy claims with women
overestimating their continuation by self‐report.