investigators analyzed whether variation in gestational age for deliveries at term also has associations with neurodevelopment. In total, they included 3,079 children in the study and evaluated them at 10 years of age.

The findings showed that the duration of gestation had a linear link with brain morphometry in childhood, even in the window term of delivery. The authors deem the results important because of the increasing rates of elective cesarean delivery.

Articles

Although previous research has shown preterm (PTB) and post-term births to result in adverse neuropsychiatric outcomes in children little research had been done on the outcomes of at-term deliveries. 

Neuropsychiatric impacts of pre- and post-term birth

The country is behind target, but does it mean the goal is unachievable? A recent report in 

According to the authors, the results of this study support the effectiveness of statewide policy for HPV vaccination education of families on vaccine coverage. Only 2 states—Virginia and Rhode Island—have adopted a law of HPV vaccination for school entry. Washington, District of Columbia, and Rhode Island had the highest rates of vaccine coverage in their data by 2017.

Investigators confirmed that the current HPV vaccination rates in children with commercial insurance were below the 80% target and that most states will not achieve the Healthy People 2020 goal of 80% coverage. Their findings correlated with vaccination policies and support the notion that clinician recommendations for HPV vaccination is critical to overcome vaccination barriers.

The Healthy People 2020 goal of HPV vaccine coverage was set at 80% by 15 years of age. 

HPV vaccination rates below Healthy People 2020 objective

This article was originally published on 

The following conversation has been edited for length and clarity.

Justice Ginsburg took part in a number of landmark cases, many of which dealing with healthcare. Did she have a guiding philosophy in terms of healthcare?

I don't know that, that she did have a big unifying view on it. I don't think she actually wrote that many opinions in healthcare cases. I mean, she would she was there for cases. 

She did, right. In the in the ACA case in 2012. Um, and she's written in in some others, but I think that her views about healthcare were kind of tied up with her broader views about the law. In general, so for example, in in the ACA case, which involve the constitutionality of the statute and have various provisions, she wrote her opinion in a way that try to fit her view of the of that statute into broader themes of constitutional doctrine. Chief Justice Roberts wrote the controlling opinion in that case, you'll recall and he said that the individual mandate was not a permissible exercise of Congress's power. 

She wrote a separate opinion, that strongly disagreed with Chief Justice Roberts in that regard, and said that, if you analyze the statute, according to the way, the Supreme Court had been analyzing commerce clause issues over the previous 75 years or so that this was a permissible exercise of the Congress power.

The other part of the case that was at issue was the Medicaid expansion and although the constitutionality of the of the mandate was upheld, five to four, the Medicaid expansion was actually struck down by a vote of seven to two and Justice Ginsburg, who dissented on that point, but she thought it Well, the reason it was struck down was because the majority concluded that that the arrangement was unduly coercive of the states on the mat, the expansion, provided that if the state did not expand Medicaid, not only would it fail to get the funds associated with expansion, it would lose all of the federal Medicaid funding even for what was already in place. 

And in the majority said that that that went too far. Justice Ginsburg thought that it was permissible, maybe debatable as a matter of policy, but but within federal power.

So, that didn't necessarily reflect a broad theme about health care as such. To the extent that she had a big, general view about health-related issues, I think we can say that you see that more in her views about access to contraception and abortion.

So, she was generally supportive of the efforts of the Obama administration to craft an exemption from the contraceptive mandate for religious employers. But her view was that the that the exception should be fairly narrow, because even if religious employers had scruples about any or some forms of contraception, the failure to pay for provide such coverage would have significant impact on third parties, right? 

Female workers or the partners of male workers. And so, but for her this was a, this was a question of, of autonomy for women, which was, of course one of her, one of her long standing concerns as a law professor and a lawyer before she went on the bench. 

Similarly, in the abortion context, she has been really, really she had been really supportive of providing women with access to abortion, to safe and legal abortion, as an aspect of autonomy in personhood, and things like that. So, to the extent that there was a general theme in these areas, it really was part of her her larger commitments to gender equality.

If you could completely remove politics from the equation, what kind of jurist would you like to see fill Ginsburg’s seat?

Well, I don't think anybody can. Well, somebody will sit in that chair, but nobody can fill her seat now. I'm biased, right? I knew her for 40 years, I worked with her. We were kind of family in a way. 

So, I'm not at all objective here, but I think she can't be replaced. Because she was one of those rare figures on the Supreme Court, who would have been a nationally important person, even if she had never been a judge.

Maybe the fact that she was a prominent law professor doesn't count for national stature, particularly there aren't that many such people. But because of what she did as an advocate, in helping, in playing a huge role in transforming the law, there isn't anybody like that out there.

There’s not very many other people who sat on Supreme Court who were like that, Thurgood Marshall comes to mind, because he was so important for so long in the civil rights movement.

These days, where the parties are polarized. Supreme Court appointments, in particular, are really fraught politically. And it takes only a simple majority in the Senate to get somebody confirmed. People are now looking for “reliable appointees.” 

And how do you know if somebody is reliable? Well, you'll look for somebody who's been a Court of Appeals judge who has some kind of track record and that way you can root out people who are going to stray from the party line. And that, to me, is a big problem for the court, regardless, so we are almost certainly going to see a virtually party line vote on the next justice, even if the appointment were delayed until after the election. We'd still have those same dynamics.

Whether President Trump or Vice President Biden make the appointment, we're not going to get that kind of person. We're in a different place and I think that's unfortunate.

The latest attempt to strike down the Affordable Care Act (ACA) will be heard by the court just after the election. Where do you think Justice Ginsburg would fall on this particular case?

I think that if Justice Ginsburg were there, I think she would regard this as a pretty weak claim. I mean, there are a number of ways that case could could get decided.

But, given her approach to interpreting statutes, I can't imagine that (Justice Ginsburg) would say that the entire statute would be unconstitutional, even if the mandate is unconstitutional. She might have been prepared to say, and I can't say on the basis of any thing in particular.

I could envision the possibility that she might agree that the mandate is now unconstitutional, because it's zero. I doubt that she would do that. But I think she would be willing to say, even if I accepted that for the sake of discussion, it doesn't follow that you take down the entire statute as a result. I just don't see how that follows. That's an enormous tail to be wagging the small dog.

Do you think Justice Ginsburg is leaving a legacy within the healthcare space?

My sense is that she didn't do a lot of writing on healthcare issues that as a distinctive body of law and given the given the way the court seems to be headed, it looks like we'll have had a majority republican appointed Supreme Court for a very, very long time for 50 years or more, and she was always in the minority on the court, in that sense, and she is, you know, if that's likely to remain the case, going forward.

But in some ways, if you play the long game, if you have a long enough historical perspective, yes, maybe some of what she was saying on the court in the healthcare area, might come back down the road. 

But, you know, it's hard to tell what, once we're gone, we have no control over anything. And I mean, I think her legacy here in the law is not likely to be mainly in the healthcare space. That was not really her area.

She did write some opinions in the health care area, you know, besides abortion, contraception and the ACA, but along with kind of technical questions like, you know, to what extent do federal health care rules relate to state laws and in which courts have jurisdiction to entertain, which sorts of cases and those are really important.

As a law professor, she focused a lot on procedure and jurisdiction and things like that. So, it's not surprising that she would be writing in those areas, but those aren't the kinds of issues that the medical or healthcare sector would necessarily see as his top priority matters that affect them on a day to day basis. 

They can be important, but they're really things that the lawyers will advise them on more than things that will structure the way a doctor or a researcher will necessarily operate on a day to day basis.

The nation continues to mourn the loss of U.S. Supreme Court Justice Ruth Bader Ginsburg. In this Q&A-style interview from Medical Economics, hear from a former law clerk of Justice Ginsberg, Jonathan Eltin, now Professor Emeritus at Case Western Reserve University School of Law. 

Remembering Ruth Bader Ginsburg: Q&A with a former law clerk

 know what you thought of this month’s feature stories by tagging us on 

 (@ContempOBGYN) or send us an email at info.contemporaryobgyn.net.

The September issue of Contemporary OB/GYN discussed sensitive subjects, such as racism, implicit bias, mental health, sexism, and representation. Below is a recap of those featured on the cover:

Any professional who is exposed to high levels of stress is at risk. Physicians are especially vulnerable. e characteristics that are emphasized and rewarded during medical training are the same ones that make a physician vulnerable to burnout.

The virtual well-woman visit is an ideal opportunity to promote healthy lifestyles, ensure appropriate screening for various conditions, and counsel patients on risk-reducing behavior. Successful adoption and uptake of telehealth may allow for interventions and care of patients at an unprecedented rate. 

The breathtaking physiology of reproduction may go astray in any facet and result in infertility. Evaluation for that aberration, followed by diagnosis-specific treatment, is perhaps the most cost-e effective way to help a couple conceive. is is an opportune time to add antenatal screening to the basic diagnostic evaluation of the infertile couple.

Driven by the cost-effective introduction of next-generation sequencing, prenatal screening for fetal genetic disease has dramatically expanded. Although noninvasive prenatal testing (NIPT) for the common aneuploidies (trisomy 21, 18, and 13) has had the greatest uptake and gained the most attention, fetal Mendelian disorders actually affect more pregnancies.

View the September Digital Edition for more peer-reviewed content. 

Highlights from articles featured in the September issue of Contemporary OB/GYN. 

September issue roundup: Vol 65 No 09

A 39-year-old G2P1102 presented to her gynecologist with a complaint of pelvic pressure. She had regular menses and no loss of urine. Her history was significant only for a postpartum bilateral tubal ligation 2 years earlier.

The woman’s examination revealed prolapse of the uterus, with the cervix visible at the introitus. An ultrasound performed by the physician 1 week after her initial presentation revealed a 4.8 4.5 6.8-cm left ovarian cyst. The physician recommended a laparoscopically assisted vaginal hysterectomy (LAVH) and left salpingo-oophorectomy (SP). 

The woman was presented with several options for management, including a total abdominal hysterectomy and left salpingo-oophorectomy. The gynecologist reviewed the risks of surgery and potential complications. All the patient’s questions were answered and operative permissions were signed. 

The surgery was scheduled for 1 week later. 

During surgery, insertion of the Veress needle was without incident. However, upon insertion of the umbilical trocar, profuse bleeding was noted and the patient became bradycardic and hypotensive and experienced cardiac arrest. 

She was resuscitated, following which, the gynecologist made a midline vertical incision and noted a laceration in the area of the aorta. A general surgeon was consulted, who could not fully control the bleeding. Thus, pressure was applied to the aorta and the patient was transferred to a tertiary hospital 40 minutes away that had a vascular surgeon.

Upon arrival at the tertiary hospital, the patient was taken immediately to surgery. The vascular surgeon noted transaction of the anterior wall of the common iliac artery encompassing almost half the diameter of the artery. Also noted was a duodenal serosal tear, presumably from the pressure held during transport. 

The vascular surgeon also noted thrombi of the common iliac artery, and the right and left iliac arteries. The surgeon repaired the vascular injury with an end-to-end anastomosis, and performed right and left iliofemoral thrombectomies, as well as from the common iliac artery, restoring flow to the right and left common iliac arteries. He then noted that both the patient’s feet had good capillary refill. 

The duodenal laceration was repaired without consequence. The patient had a relatively uncomplicated recovery, with the exception of residual neuropathy in her right leg and hip, with foot drop that persisted despite months of occupational and physical therapy.

Approximately 9 months after the attempted LAVH, the patient sought the care of another gynecologist, who noted that her uterus was protruding to the introitus with valsalva. 

An ultrasound was obtained, which was interpreted as normal, with no pelvic or ovarian masses or cysts. The physician recommended a total vaginal hysterectomy. Despite being “scared to death,” the patient elected to go forward with the procedure, which was performed without incident. Surgical findings stated that “both tubes and ovaries appeared normal.”

Ultimately, the patient filed suit against the original gynecologist, alleging inadequate and inappropriate preoperative evaluation, improperly performed surgery, with resultant complications, long-term physical deficits, pain and suffering, and loss of life’s enjoyment.

Deposition of the defendant gynecologist revealed several potential concerns. 

When questioned if it would be an option to wait and see if the cyst would go away on its own, the gynecologist stated, “I would not consider that to be an option in this case. I was trained that anything over 5 cm is a problem.”

During questioning about the performance of the surgery, the gynecologist described a closed-entry technique, using a Veress needle. A saline-drop test was used to confirm intraperitoneal placement of the Veress needle. 

The opening pressure was 7 mmHg. To establish the pneumoperitoneum, the abdomen was insufflated with 2 L of CO2. When questioned if the surgeon insufflates to a particular pressure, for example 15 or 20 mmHg, the gynecologist replied that he does not use a pressure cut off. His reasoning was that “nobody is ever totally relaxed.” 

is Professor of Obstetrics and Gynecology and former Chair at the University of Mississippi Medical Center. He is a graduate of the University of Denver College of Law and is a nationally and internationally recognized expert in gynecology ultrasound and minimally invasive surgery. 

He actively consults on legal matters in medicine, including liability in ultrasound and gynecologic surgery, as well as issues surrounding privileging and insurance fraud.

Following establishment of the pneumoperitoneum, the patient was placed in Trendelenburg, her abdomen was elevated with the surgeon’s hand, and the trocar was inserted at a 45º angle into the pelvis. The gynecologist suspected that the vascular injury occurred with insertion of the trocar.

In reviewing the gynecologist’s surgical experience, he stated that he had performed thousands of laparoscopies and had assisted on or performed LAVHs since 1990. It was noted that the physician had completed his residency in 1984. 

Unfortunately, he could not document any formal continuing education courses, nor additional training or education in ultrasound or more advanced laparoscopy since that time. The physician was board-certified and was current with his maintenance of certification.

The plaintiff’s ultrasound expert reviewed the original ultrasound images and noted a 6.80 4.86 4.49-cm simple, unilocular cyst, consistent with a persistent follicular cyst or a serous cyst. 

This expert opined that the current recommendation for follow-up of such a cyst in reproductive-aged women is a repeat ultrasound in 2 to 6 months. Thus, immediate intervention was not indicated. Subsequently, prior to the TVH, an ultrasound revealed that the cyst had completely resolved, confirming that surgical intervention for the ovarian cyst was not required. 

Thus, one could have avoided the risk of laparoscopy altogether, particularly with the primary surgical indication of uterine prolapse.

The plaintiff’s laparoscopy expert noted several breeches in the standard of care. Although a closed-entry technique, and even a direct-insertion technique without a pneumoperitoneum, is an acceptable alternative, the method the defendant described was not within the standard of care. Insufflating a specific amount of CO2, for example 2 L, is not adequate. 

Contrary to the defendant’s statement, patients are paralyzed for the procedure, and thus, they are totally relaxed. One cannot assume that 2 L of CO2 provides an adequate pneumoperitoneum in all patients. Thus, current practice is to infuse enough CO2 to establish an intraperitoneal pressure of 12 to 15 mmHg prior to insertion of the primary trocar. 

In fact, many surgeons insufflate to a pressure of 20 mmHg for initial trocar insertion, reducing this pressure to 12 to 15 mmHg for placement of the secondary trocars. Inadequate intraperitoneal distension subjects the patient to a greater risk of vascular injury, as occurred in this case. 

The placement of a patient in Trendelenburg for insertion of the umbilical trocar is not currently recommended. The Trendelenburg position places the aorta and the common iliac vessels in direct line with insertion of a trocar at a 45º angle. 

Although this was common practice in the past, current recommendations, literally for several decades, are to maintain the patient in a supine position, with the abdominal wall elevated, for insertion of the umbilical trocar, only changing to the Trendelenburg position for insertion of the secondary trocars. 

The plaintiff’s expert opined that placing the patient in the Trendelenburg position for insertion of the umbilical trocar was a breech of the standard of care. Doing so places the patient at risk for the exact vascular injury encountered in this case.

No criticisms were levied against the care of the general surgeon, the vascular surgeon, or the subsequent postoperative care and rehabilitative services. Thus, the defense focused on the criticisms levied against the preoperative evaluation and the surgical technique.

In evaluating the defensibility of the case, the identified lack of documented continuing education and additional surgical training placed the case defense at risk. Unfortunately, proceeding to trial posed a significant risk of losing the case, with subsequent exorbitant damages. It was elected to settle the case prior to trial for $900,000.

This case highlights the importance of remaining cognizant of current literature and surgical practices. All too often, physicians fail to remain current in the various areas of their practices. 

One would assume that maintenance of certification would allow physicians to stay current in their practice. However, ongoing education in specific practice areas may be required. Ultrasound, a valuable adjunct to our care of patients, is rapidly changing. 

The approach to adnexal masses is constantly evolving, with consensus guidance for management available. In this case, the physician’s lack of awareness of these newer guidelines impacted the preferred management option: observation. If there is any question about diagnosis or management, one can always seek a second opinion from a more experienced sonologist. 

As in this case, this functional cyst resolved, negating the need for an abdominal approach. Thus, the physician could have pursued a vaginal hysterectomy, the preferred route, which was ultimately performed, avoiding the risk of laparoscopy.

The need to adapt one’s surgical techniques is particularly true in the rapidly changing surgical environment of minimally invasive surgery. Changes in accepted techniques were not adopted in the current case. 

With the physician’s lack of documented continuing education and additional surgical training, this case was at greater risk. The cited breeches rendered the case one with a significant risk of losing at trial. Thus, the best perceived option was settlement.

An LVAH case underscores the importance of continuing education.

Major vascular injury incurred at laparoscopy

Johnson & Johnson announced the launch of its large-scale, global phase 3 trial for its COVID-19 vaccine candidate (JNJ-78436735) today in a 

. The vaccine, also known as Ad26.COV2.S, is being developed by its Janssen Pharmaceutical Companies.

The phase 3 trial will enroll up to 60,000 volunteers aged 18 years and older across 3 continents and will evaluate the safety and efficacy of a single vaccine dose compared with placebo in preventing COVID-19. The trial will include significant representation from those that are over the age of 60 years and will include individuals with and without comorbidities associated with an increased risk for progression in severe COVID-19. 

For further detail and additional trial coverage, 

The investigational vaccine produced positive interim results in the company’s 1/2a clinical study, which showed that the safety profile and immunogenicity after a single vaccination were supportive of further development.

Johnson & Johnson’s COVID-19 vaccine candidate enters phase 3 trial

Mistruths and misconceptions surrounding the COVID-19 pandemic continue to spread, including who’s at risk of contracting the virus, certain drugs to counteract its effects, and so on. To dispel the many mistruths and “un-facts” surrounding the virus, MJH Life Sciences COVID-19 Coalition will host a free, 1-hour webinar at 6 p.m. EST on Tuesday, Sept. 29.

Fact or Fiction? COVID-19 Myths and Controversies’

 will feature a panel of top-tier experts, including infection prevention epidemiologists, virologists, and research specialists.

Hosted by MJH Life Sciences COVID-19 Coalition, this free webinar will feature expert insight into the myths and controversies of the global pandemic. 

COVID-19 Fact or Fiction?

Researchers ultimately found that congenital cytomegalovirus infection significantly increased the prevalence of microcephaly at delivery 7-fold. These findings suggest that preventing cytomegalovirus in pregnancy may substantially reduce the number of babies with microcephaly at birth.

A new study in JAMA Pediatrics analyzed the number of microcephaly cases that resulted from congenital microcephaly and how it may be a larger cause than the 2016 Zika epidemic. 

Congenital cytomegalovirus may be leading cause of microcephaly

Dr. Einarsson, Deputy Editor, is Associate Professor of Obstetrics ad Gynecology, Harvard Medical School, and Director, Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

’s Deputy Editor Jon I. Einarsson, MD, MPH, was honored as Distinguished Surgeon by the society for his contributions to the field of gynecologic surgery — clinically and/or through research and innovation.

In his current role, Einarsson serves as the chief of the Division of Minimally Invasive Gynecology at Brigham and Women’s Hospital in Boston. His clinical interests include cervical insufficiency/incompetence, endometriosis, fibroids, laparoscopic surgery, LGBTQ health, and prolapse.

Senior Editor Angie DeRosa and Associate Editor Lindsey Carr sat down with Einarsson to discuss highlights from the scientific meeting. Einarsson gives his take in this video interview, including that surgeries are getting back to a normal schedule as the medical world works through COVID-19.

“All of our patients are getting tested and so on, but we’re back to a fairly normal schedule now,” he reports.

One of the presentations he highlighted was based on a multicenter randomized clinical trial of permanent versus delayed-absorbable monofilament suture for vaginal graft attachment during minimally invasive total hysterectomy and sacrocolpopexy.

According to PubMed, the objective of the study was to compare mesh and permanent suture exposure rates in the first year after minimally invasive total hysterectomy and sacrocolpopexy with a light-weight polypropylene mesh using permanent or delayed absorbable sutures. 

Across five centers in the United States, women were randomized to permanent or delayed absorbable suture for vaginal attachment of a Y-mesh during hysterectomy and sacrocolpopexy for stage II prolapse and worse. The primary outcome was mesh or permanent suture exposure in the first year after surgery. 

The secondary outcome was to compare a composite measure for success defined as leading edge of prolapse not beyond the hymen and apex not descended more than one third vaginal length, and no subjective bulge and no prolapse retreatment. 

Patients completed a pelvic examination including the pelvic organ prolapse quantification system and questionnaires at baseline, 6 weeks, and 1-year post-surgery. A sample size of 80 per group was planned to compare the rate of mesh or permanent suture exposure in the permanent compared with delayed absorbable groups. From April 2015 to May 2019, 204 patients (n=102 permanent; n=102 delayed absorbable) were randomized. 

One hundred ninety-eight women had follow-up data, with 182 (93%) completing 1-year follow-up: 95 of 99 (96%) permanent, 87 of 101 (86%) delayed absorbable. The total rate of mesh or permanent suture exposure was 12 of 198 (6.1%): 5.1% for permanent compared with 7.0% for delayed absorbable (risk ratio 0.73, 95% CI 0.24-2.22). 

The majority (9/12) were asymptomatic. Composite success was 93% for permanent compared with 95% for delayed absorbable suture, P=.43). Six (3.0%) women had a serious adverse event.1

The trial essentially showed that there was no difference in outcomes between the two groups, which Einarsson found interesting because traditionally permanent sutures have been used for this procedure.

“It appears probably that the mesh just gets so incorporated into the tissues that using the permanent suture is not necessary, and that has some advantages because if those sutures get eroded through the vagina you can tell the patient, then, if it’s delayed absorbable, it’s just going to go away on its own, as opposed to a permanent suture you may have to go and remove it,” he explains. 

“In our practice, we converted to delayed absorbable sutures maybe 3 or 4 years ago and we haven’t noticed any difference in our clinical outcomes, so it was reassuring I guess for us to see that there wasn’t a difference in this randomized trial. There had been other studies, but they were cohort studies or retrospective studies, so I thought that was pretty interesting.”

Watch the full video interview to hear all that Einarsson has to say about this topic and other findings presented during this scientific meeting.

Matthews CA, Geller EJ, Henley BR, et al. Permanent Compared With Absorbable Suture for Vaginal Mesh Fixation During Total Hysterectomy and Sacrocolpopexy: A Randomized Controlled Trial. 

. 2020;136(2):355-364. doi:10.1097/AOG.000000000000388

Videos

The Society of Gynecologic Surgeons (SGS) held its 46th Annual Scientific Meeting virtually in July, in much the same way that all other associations are holding meetings or conferences these days.

SGS 46th Annual Scientific Meeting highlights

Researchers found that maternal perinatal depression and anxiety were significantly associated with poorer outcomes in cognitive, language, adaptive behavior, social-emotional, and motor skill functions: 

cognitive (antenatal period, r = −0.12 [95% CI, –0.19 to –0.05]; postnatal period, r = −0.25 [95% CI, –0.39 to –0.09])

language (antenatal period, r = −0.11 [95% CI, −0.20 to 0.02]; postnatal period, r = −0.22 [95% CI, −0.40 to 0.03])

adaptive behavior (antenatal period, r = −0.26 [95% CI, −0.39 to −0.12])

offspring social-emotional (antenatal period, r = 0.21 [95% CI, 0.16-0.27]; postnatal period, r = 0.24 [95% CI, 0.19-0.28])

motor (antenatal period, r = −0.07 [95% CI, −0.18 to 0.03]; postnatal period, r = −0.07 [95% CI, −0.16 to 0.03])

Findings also showed that these results went beyond the infant years into childhood and adolescents.

A new study published in JAMA Network Open investigated whether perinatal depression and/or anxiety impacted childhood development.

New content coming soon, please check back later.