Home OBGYN and Women's Health November 2016 Briefing – OBGYN & Women’s Health

November 2016 Briefing – OBGYN & Women’s Health

Here are what the editors at HealthDay consider to be the most important developments in OBGYN & Women’s Health for November 2016. This roundup includes the latest research news from journal articles, as well as the FDA approvals and regulatory changes that are the most likely to affect clinical practice.

Infant Diagnosed With First Case of Zika-Related Glaucoma

WEDNESDAY, Nov. 30, 2016 (HealthDay News) — The first case of an infant who developed glaucoma after being exposed to the Zika virus while in the womb has been reported by an international team of researchers. The case was reported online Nov. 30 in Ophthalmology.

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Levels of Total, LDL Cholesterol Continue to Fall in the U.S.

WEDNESDAY, Nov. 30, 2016 (HealthDay News) — Healthier diets may be a factor in the ongoing decline in cholesterol levels for Americans, according to a research letter published online Nov. 30 in JAMA Cardiology.

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Heart-Healthy Habits Should Also Be Promoted to Low-Risk Patients

WEDNESDAY, Nov. 30, 2016 (HealthDay News) — Primary care doctors should offer counseling about healthy lifestyle habits to prevent heart disease even to adults who have a low or average risk of developing cardiovascular disease, the U.S. Preventive Services Task Force advises.

Evidence Review
Draft Recommendation Statement
Comment on Recommendation

No Link for Maternal Flu Infection, Increased ASD Risk

WEDNESDAY, Nov. 30, 2016 (HealthDay News) — Maternal influenza infection during pregnancy is not associated with increased risk of autism spectrum disorder (ASD), according to a study published online Nov. 28 in JAMA Pediatrics.

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As Prices Soar, ADA Calls for Access to Affordable Insulin

TUESDAY, Nov. 29, 2016 (HealthDay News) — In early November, Sen. Bernie Sanders, the Vermont Democrat, pointed out that certain insulins had risen from $21 a vial in 1996 to $255 a vial in 2016.

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Methylation of Gene Panel May Help Predict Breast CA Survival

TUESDAY, Nov. 29, 2016 (HealthDay News) — Methylation of a gene panel is a strong predictor of survival outcomes in metastatic breast cancer (MBC), according to a study published online Nov. 21 in the Journal of Clinical Oncology.

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Link Found Between Surgery and Development of Guillain-Barré

MONDAY, Nov. 28, 2016 (HealthDay News) — Patients who’ve recently undergone surgery — especially those with cancer or autoimmune diseases — experience slightly higher risks of developing Guillain-Barré syndrome (GBS) soon afterward, according to a study published online Nov. 23 in Neurology: Clinical Practice.

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Mortality Rate From Infectious Diseases Holding Steady in U.S.

WEDNESDAY, Nov. 23, 2016 (HealthDay News) — The U.S. mortality rate from infectious diseases is about the same now as it was in 1980, but some of the specific disease threats have changed over the years, according to a research letter published in the Nov. 22/29 issue of the Journal of the American Medical Association.

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Only Two Doses of HPV Vaccine Necessary for Younger Teens

WEDNESDAY, Nov. 23, 2016 (HealthDay News) — Two doses of the human papillomavirus (HPV) vaccine, rather than three, can effectively protect younger teens against the virus, according to a study published online Nov. 21 in the Journal of the American Medical Association. The study was one of a number evaluated by the U.S. Centers for Disease Control and Prevention earlier this year, which led to the CDC’s revised guidelines in October.

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Review Suggests Yoga Beneficial in Irritable Bowel Syndrome

WEDNESDAY, Nov. 23, 2016 (HealthDay News) — Yoga is associated with decreased bowel symptoms, disease severity, and anxiety in patients with irritable bowel syndrome (IBS), according to a review published in the December issue of Clinical Gastroenterology and Hepatology.

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Mental Distress Common in Survivors of Teen, Young Adult CA

WEDNESDAY, Nov. 23, 2016 (HealthDay News) — Survivors of adolescent and young adult (AYA) cancer are more likely to have mental distress than individuals without cancer, but most do not talk to mental health professionals, according to a study published online Nov. 17 in Cancer.

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USPSTF Continues to Recommend Against Thyroid Cancer Screening

TUESDAY, Nov. 22, 2016 (HealthDay News) — Clinicians should not screen for thyroid cancer in patients who have no symptoms of the disease, according to a U.S. Preventive Services Task Force (USPSTF) draft recommendation which reaffirms a recommendation issued 20 years ago.

Evidence Review
Draft Recommendation Statement
Comment on Recommendation

Rising Rx, ER Prices Pushing U.S. Health Care Spending Up

TUESDAY, Nov. 22, 2016 (HealthDay News) — Privately insured Americans spent nearly 5 percent more on health care last year than in 2014; this increase was significantly more than that seen in previous years and reflects higher costs for prescription drugs, emergency department visits, and hospitalizations, according to a report published Nov. 22 by the Health Care Cost Institute.

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Computer Order Entry System Ups Antimicrobial Policy Compliance

TUESDAY, Nov. 22, 2016 (HealthDay News) — Use of a computerized physician order entry (CPOE) system can improve compliance with antimicrobial restriction policies, according to a study published online Nov. 16 in the Journal of Pharmacy Practice and Research.

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Discussing Opioid Risks With Patients Reduces Misuse

TUESDAY, Nov. 22, 2016 (HealthDay News) — Discussing the risk of long-term opioid use disorder with patients is associated with reduced misuse of opioids, according to research published in the November/December issue of the Annals of Family Medicine.

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Thiazide-Type Diuretic Treatment Tied to Lower Fracture Risk

MONDAY, Nov. 21, 2016 (HealthDay News) — Thiazide-type diuretic therapy reduces hip and pelvic fracture risk compared with other antihypertensive medication therapy, according to a study published online Nov. 21 in JAMA Internal Medicine.

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Hemorrhage Risk Up in A-Fib Patients on Dabigatran, Statins

MONDAY, Nov. 21, 2016 (HealthDay News) — Combining dabigatran with certain statin medications could raise the odds for major hemorrhage in patients with atrial fibrillation, according to a study published online Nov. 21 in CMAJ, the journal of the Canadian Medical Association.

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Retail Clinics Don’t Reduce ER Visits for Minor Ailments

MONDAY, Nov. 21, 2016 (HealthDay News) — Having retail health clinics near hospitals does not reduce emergency department visits for minor health problems, according to a study published online Nov. 10 in the Annals of Emergency Medicine.

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Lean Sigma Six Methodology Can Cut Cesarean Rate

MONDAY, Nov. 21, 2016 (HealthDay News) — Use of the Lean Six Sigma (LSS) methodology is effective for reducing the cesarean section rate, according to a study published online Nov. 14 in the Journal of Evaluation in Clinical Practice.

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Calculator May Help Predict Individual Chances of IVF Success

FRIDAY, Nov. 18, 2016 (HealthDay News) — Free online calculators can predict how likely a woman is to have a baby after a series of in vitro fertilization (IVF) treatment cycles, according to a study published online Nov. 16 in The BMJ.

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CDC: Heart Disease Still Leading Cause of Death

THURSDAY, Nov. 17, 2016 (HealthDay News) — Heart disease continues to top the list of likely cause of death among Americans, according to research published in the Nov. 18 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

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Smart Skin Patch Can Monitor Body Function Acoustically

THURSDAY, Nov. 17, 2016 (HealthDay News) — A new type of acoustic sensor that resembles a small Band-Aid on the skin can monitor heartbeat and other health measures, according to a study published online Nov. 16 in Science Advances.

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FDA Approves Intrarosa for Postmenopausal Pain During Sex

THURSDAY, Nov. 17, 2016 (HealthDay News) — Intrarosa (prasterone) has been approved by the U.S. Food and Drug Administration to treat women who have moderate-to-severe pain during sexual intercourse caused by postmenopausal vulvar and vaginal atrophy (VVA).

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Palbociclib Efficacious in Metastatic Breast Cancer

THURSDAY, Nov. 17, 2016 (HealthDay News) — Palbociclib can help slow the progression of advanced breast cancer, according to a study published in the Nov. 17 issue of the New England Journal of Medicine.

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Maternal RA May Be Linked to Childhood Epilepsy in Offspring

THURSDAY, Nov. 17, 2016 (HealthDay News) — Some children born to mothers with rheumatoid arthritis (RA) may have higher-than-average odds of developing epilepsy, according to a study published online Nov. 16 in Neurology.

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Family History, Lifestyle Factors Impact Risk of Acne in Adulthood

THURSDAY, Nov. 17, 2016 (HealthDay News) — Factors that are associated with the appearance of acne in adult women include family history, personal history of acne, having no previous pregnancies, having hirsutism, and having a high level of psychological stress, according to a study published in the December issue of the Journal of the American Academy of Dermatology.

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Poor Sensitivity for HPV 16/18 in Minor Abnormal Cytology

THURSDAY, Nov. 17, 2016 (HealthDay News) — Testing for human papillomavirus (HPV) 16/18 has poor sensitivity for triaging women with minor abnormal cytology, according to a meta-analysis published online Nov. 15 in the Annals of Internal Medicine.

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Vaginal Immune Response May Up Zika Risk in Women

WEDNESDAY, Nov. 16, 2016 (HealthDay News) — Vaginal tissue is particularly vulnerable to infection by RNA viruses, such as Zika, according to a study published online Nov. 16 in the Journal of Experimental Medicine.

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Circulating Cell-Free DNA Can Predict RhD Status in Pregnancy

WEDNESDAY, Nov. 16, 2016 (HealthDay News) — Circulating cell-free DNA can predict fetal RHD status throughout pregnancy, according to a study published in the December issue of Obstetrics and Gynecology.

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Depression Rates Up Among Adolescents, Particularly Females

TUESDAY, Nov. 15, 2016 (HealthDay News) — Depression is on the rise among American teens and young adults, with adolescent girls showing the greatest vulnerability, according to research published online Nov. 14 in Pediatrics.

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Ablative Fractional Laser Beneficial for C-Section Scars

TUESDAY, Nov. 15, 2016 (HealthDay News) — Ablative fractional laser (AFXL) treatment is beneficial for patients with cesarean section (C-section) scars, according to a study published online Nov. 8 in Lasers in Surgery and Medicine.

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CHD Rates Down 20 Percent Since 1980s in the United States

MONDAY, Nov. 14, 2016 (HealthDay News) — Cases of coronary heart disease (CHD) have dropped 20 percent in the United States over the last four decades, according to a research letter published in the Nov. 15 issue of the Journal of the American Medical Association, a theme issue on statins.

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Oregon’s Hard-Stop Policy Tied to Drop in Elective Early Delivery

MONDAY, Nov. 14, 2016 (HealthDay News) — Introduction of the hard-stop policy in Oregon was associated with a reduction in elective early-term deliveries, according to a study published in the December issue of Obstetrics & Gynecology.

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USPSTF Advises Statins for Some Adults With No CVD History

MONDAY, Nov. 14, 2016 (HealthDay News) — The U.S. Preventive Services Task Force (USPSTF) recommends that certain adults aged 40 to 75 years without cardiovascular disease (CVD) history but with one or more cardiovascular risk factors initiate statins. These recommendations are included in the final recommendation statement published in the Nov. 15 issue of the Journal of the American Medical Association, a theme issue on statins.

Recommendation Statement
Evidence Report

Higher Iron Levels Linked to Increased Risk of Gestational DM

FRIDAY, Nov. 11, 2016 (HealthDay News) — High levels of iron are associated with an increased risk of gestational diabetes, according to research published online Nov. 10 in Diabetologia.

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CDC: Tobacco-Linked Cancers Make Up 40 Percent of All Cancers

FRIDAY, Nov. 11, 2016 (HealthDay News) — Although rates of smoking in the United States have declined to new lows, health officials still estimate that four out of every 10 cancers is linked to the habit.

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Women With GDM Have Elevated Risk of Future Cardiac Events

FRIDAY, Nov. 11, 2016 (HealthDay News) — The risk of cardiovascular outcomes is elevated for women with gestational diabetes mellitus (GDM), even in the absence of subsequent type 2 diabetes mellitus (T2DM), according to a study published online Nov. 7 in Diabetes Care.

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Intravaginal Testosterone Deemed Safe in Early Breast CA

FRIDAY, Nov. 11, 2016 (HealthDay News) — For postmenopausal (PM) women with early-stage breast cancer (BC) taking aromatase inhibitors (AIs), intravaginal testosterone cream (IVT) is safe for vaginal dryness or decreased libido, according to a study published online Nov. 10 in JAMA Oncology.

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HR Capabilities Positively Linked to Quality of Patient Care

FRIDAY, Nov. 11, 2016 (HealthDay News) — Human resource (HR) capabilities are positively associated with quality of patient care, with the relationship mediated by proactive work, according to a study published recently in Human Resource Management.

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Higher Serum Vitamin D Levels Up Survival in Breast Cancer

THURSDAY, Nov. 10, 2016 (HealthDay News) — Serum 25-hydroxyvitamin D levels may affect breast cancer patients’ chances of survival, according to a study published online Nov. 10 in JAMA Oncology.

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Clinical Features Can Be Used to Tailor Melanoma Screening

THURSDAY, Nov. 10, 2016 (HealthDay News) — Certain patients at high risk of melanoma may benefit from more tailored skin exams, according to a study published online Nov. 9 in JAMA Dermatology.

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Blood Test May Help ID Risk of Fetal Alcohol Spectrum Disorders

THURSDAY, Nov. 10, 2016 (HealthDay News) — A prenatal blood test may help identify infants at risk for fetal alcohol spectrum disorders, according to a study published online Nov. 9 in PLOS ONE.

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Protein Intake Tied to Modest Survival Advantage in Breast CA

THURSDAY, Nov. 10, 2016 (HealthDay News) — For women with breast cancer, higher intake of protein is associated with a modest survival advantage, according to a study published online Nov. 7 in the Journal of Clinical Oncology.

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Faster Delivery for Induction With Misoprostol Plus Cervical Foley

THURSDAY, Nov. 10, 2016 (HealthDay News) — For women undergoing induction, receipt of misoprostol-cervical Foley is associated with an increased likelihood of delivery before those receiving either method alone, according to a study published in the December issue of Obstetrics & Gynecology.

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RA Disease Activity Score Most Influential in Patient Reports

THURSDAY, Nov. 10, 2016 (HealthDay News) — Higher disease activity score (DAS) is one of the most influential factors for poor patient-reported outcomes (PROs) in rheumatoid arthritis (RA), according to a study published online Nov. 5 in the International Journal of Rheumatic Diseases.

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Dense-Dose Chemo of Little Benefit in Early Breast Cancer

WEDNESDAY, Nov. 9, 2016 (HealthDay News) — Tailored dose-dense chemotherapy offers little benefit over standard chemotherapy for women with high-risk early breast cancer, according to research published in the Nov. 8 issue of the Journal of the American Medical Association.

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Prediabetes Screening Guidelines Not Always Followed by PCPs

WEDNESDAY, Nov. 9, 2016 (HealthDay News) — Only about half of U.S. family doctors follow guidelines on screening patients for prediabetes, according to a study published in the November-December issue of the Journal of the American Board of Family Medicine.

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Self-Harm Now a Leading Cause of Pregnancy-Related Mortality

WEDNESDAY, Nov. 9, 2016 (HealthDay News) — In the past decade, self-harm has been the leading cause of pregnancy-related deaths in Colorado, according to research published in the December issue of Obstetrics & Gynecology.

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Naproxen Sodium Doesn’t Reduce Pain With IUD Insertion

WEDNESDAY, Nov. 9, 2016 (HealthDay News) — For patients undergoing intrauterine device (IUD) insertion, oral naproxen sodium does not reduce pain on insertion, but does reduce pain after insertion, according to a study published in the December issue of Obstetrics & Gynecology.

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Isolated Chorionic Bump Tied to Fetal Aneuploidy

TUESDAY, Nov. 8, 2016 (HealthDay News) — In high-risk fetuses, sonographically isolated chorionic bumps are associated with fetal aneuploidy, according to a study published online Nov. 3 in the Journal of Clinical Ultrasound.

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School-Required Tdap Vaccination Can Up HPV Immunization

TUESDAY, Nov. 8, 2016 (HealthDay News) — Schools that require routine vaccines as a condition of attendance have higher rates of vaccination, including higher rates of immunization for the human papillomavirus (HPV), and children at these schools are also more likely to get recommended tetanus, diphtheria, and pertussis (Tdap) and meningitis vaccines, according to research published online Nov. 8 in Pediatrics.

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Donor Milk Doesn’t Improve Neurodevelopment Outcomes

TUESDAY, Nov. 8, 2016 (HealthDay News) — For infants with very-low-birth weight (VLBW), use of supplemental donor milk does not improve neurodevelopment compared with placebo at 18 months’ corrected age, according to a study published in the Nov. 8 issue of the Journal of the American Medical Association.

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Age at Cancer Diagnosis Key in Determining Later Cardiac Risk

TUESDAY, Nov. 8, 2016 (HealthDay News) — The age at which cancer survivors are diagnosed with their disease may help predict their risk of death from cardiac disease, according to research published online Nov. 7 in Circulation.

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Long-Term Health Not Improved for Childhood Cancer Survivors

TUESDAY, Nov. 8, 2016 (HealthDay News) — Despite three decades of advancements in treating children with cancer, patients who survive into adulthood don’t report better physical or mental health than their counterparts who were treated years ago, according to research published online Nov. 8 in the Annals of Internal Medicine.

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Genetic Mortality Risk Can Be Attenuated by Lifestyle

TUESDAY, Nov. 8, 2016 (HealthDay News) — Genetic variations correlate with mortality in the elderly, although their effect can be influenced by lifestyle behaviors, according to a study published online Nov. 2 in the Journal of the American Geriatrics Society.

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Guideline Adapted for Surgical Antimicrobial Prophylaxis

TUESDAY, Nov. 8, 2016 (HealthDay News) — An adapted clinical practice guideline (CPG), published online Nov. 3 in the Journal of Evaluation in Clinical Practice, has been developed for surgical antimicrobial prophylaxis (SAP), using two validated tools.

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AMA Highlights Role of Patient Shame in Opioid Disorders

TUESDAY, Nov. 8, 2016 (HealthDay News) — Supported by the American Medical Association (AMA), the Providers’ Clinical Support System for Opioid Therapies (PCSS-O) has released a collection of resources from a national training and mentoring project developed by physicians to promote the role of self-education and help curb the opioid epidemic.

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Five Strategies Can Reduce Risk of Medical Lawsuits

MONDAY, Nov. 7, 2016 (HealthDay News) — Five strategies can be employed by physicians in order to help reduce the risk of lawsuits, according to an article published in Medical Economics.

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Recommendations Updated for Meningococcal Vaccine in HIV

MONDAY, Nov. 7, 2016 (HealthDay News) — In the Nov. 4 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, new recommendations are presented for meningococcal conjugate vaccination among HIV-infected individuals.

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Nonadherence in Nearly One-Third of Patients With HTN

MONDAY, Nov. 7, 2016 (HealthDay News) — More than 30 percent of patients with hypertension are not adherent to antihypertensive drug therapy, according to a study published online Nov. 3 in the Journal of Evaluation in Clinical Practice.

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Women Have Worse Outcomes During 36 Months After ACS

FRIDAY, Nov. 4, 2016 (HealthDay News) — In a study published in the Nov. 1 issue of The American Journal of Cardiology, among patients with acute coronary syndrome (ACS), women were found to have a higher mortality rate than men during 36 months of follow-up.

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Smoking Ups Cancer Risk by Causing Distinct Cell Mutations

FRIDAY, Nov. 4, 2016 (HealthDay News) — Tobacco smoking causes mutations that lead to cancer by multiple distinct mechanisms, according to a study published in the Nov. 4 issue of Science.

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Adjuvant Endocrine Tx Adherence Disparity Due to Varying Costs

FRIDAY, Nov. 4, 2016 (HealthDay News) — For women with hormone receptor-positive breast cancer, adherence to adjuvant endocrine therapy (AET) is mainly due to demographic variables and out-of-pocket medication costs, according to a study published online Oct. 28 in the Journal of Clinical Oncology.

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Standard of Care Underused for Locally Advanced Cervical Cancer

FRIDAY, Nov. 4, 2016 (HealthDay News) — For patients with locally advanced cervical cancer, standard of care (SOC), which includes pelvic external beam radiation (EBRT) with chemotherapy and interdigitated brachytherapy, is associated with significantly improved overall survival but is notably underused, according to a study published in the November issue of Gynecologic Oncology.

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Review Identifies Features of Congenital Zika Infection

THURSDAY, Nov. 3, 2016 (HealthDay News) — A distinctive phenotype of congenital Zika syndrome has been described in a review published online Nov. 3 in JAMA Pediatrics.

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Half of Americans Have at Least One Chronic Health Condition

THURSDAY, Nov. 3, 2016 (HealthDay News) — More than half of Americans have at least one chronic disease, mental illness, or problem with drugs or alcohol, according to a study published online recently in Psychology, Health & Medicine.

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Robotic Surgery Faster for Laparoscopy in Endometrial CA

THURSDAY, Nov. 3, 2016 (HealthDay News) — For patients with endometrial cancer, robotic-assisted laparoscopic surgery is faster than traditional surgery, according to a study published in the November issue of the American Journal of Obstetrics & Gynecology.

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Lower Anti-Müllerian Hormone Values for Endometriomas

THURSDAY, Nov. 3, 2016 (HealthDay News) — Women with endometriomas have significantly lower anti-Müllerian hormone values, and surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve, according to a study published in the November issue of the American Journal of Obstetrics & Gynecology.

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Scented Products, Environments Linked to Health Woes for Many

WEDNESDAY, Nov. 2, 2016 (HealthDay News) — Fragranced products such as soaps, candles, and air fresheners cause more than one-third of U.S. adults to suffer ill health effects, including headaches, dizziness and breathing difficulties, according to research published online Oct. 20 in Air Quality, Atmosphere & Health.

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Vague Food Labels Can Place Patients With Allergies at Risk

WEDNESDAY, Nov. 2, 2016 (HealthDay News) — Shoppers are often confused by food labels that warn of potential allergens, and the consequences can be serious, according to research published online Nov. 1 in the Journal of Allergy and Clinical Immunology: In Practice.

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Maternal, Neonatal Adverse Events Up With Antenatal ART

WEDNESDAY, Nov. 2, 2016 (HealthDay News) — For HIV-infected pregnant women, antiretroviral therapy (ART) is associated with significantly lower rates of early HIV transmission, but with a higher risk of adverse maternal and neonatal outcomes, according to a study published in the Nov. 3 issue of the New England Journal of Medicine.

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ASCO Updates Guidelines on Integration of Palliative Care

WEDNESDAY, Nov. 2, 2016 (HealthDay News) — The American Society of Clinical Oncology Clinical Practice Guideline on the integration of palliative care into standard oncology care has been updated. The update was published online Oct. 28 in the Journal of Clinical Oncology.

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Community Pharmacists Play Role in Providing Preventive Care

WEDNESDAY, Nov. 2, 2016 (HealthDay News) — Community pharmacists are well suited to provide clinical preventive services, including education, screenings, and making referrals, according to a report published in the Oct. 27 issue of the U.S. Centers for Disease Control and Prevention’s Preventing Chronic Disease.

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Outcomes Similar for Rx Dosing Protocols in Ectopic Pregnancy

WEDNESDAY, Nov. 2, 2016 (HealthDay News) — For ectopic pregnancy, outcomes are similar with a single- and double-dose methotrexate protocol, according to a study published in the November issue of the American Journal of Obstetrics & Gynecology.

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Tdap Vaccine During Pregnancy Seems Safe for Mother, Infant

TUESDAY, Nov. 1, 2016 (HealthDay News) — The tetanus, diphtheria, and pertussis (Tdap) vaccine does not appear to cause birth defects or any other major health problems for a developing fetus, according to a research letter published in the Nov. 1 issue of the Journal of the American Medical Association.

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Genetic Testing May Help ID VTE Risk in Breast Cancer Patients

TUESDAY, Nov. 1, 2016 (HealthDay News) — Genetic testing could help identify breast cancer patients at high risk for venous thromboembolism (VTE), according to a study published online Nov. 1 in Clinical Cancer Research.

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Weight Gain Impacts 25(OH)D Response in Pregnancy

TUESDAY, Nov. 1, 2016 (HealthDay News) — Among pregnant women taking cholecalciferol, factors have been identified that impact serum 25-hydroxyvitamin D (25[OH]D) response, including weight gain and season of delivery, according to research published online Oct. 27 in the Journal of Clinical Endocrinology & Metabolism.

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Oral Probiotics Have No Impact on Vaginal Health in Pregnancy

TUESDAY, Nov. 1, 2016 (HealthDay News) — For pregnant women, probiotics have no effect on vaginal health, according to a study published in the November issue of the American Journal of Obstetrics & Gynecology.

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