Placenta-on-a-chip paves the path forward for easy drug screening during pregnancy

Courtesy: Penn State News Letter

Going forward with the concept of ‘organs-on-chip’ that mimic the physiological conditions in-vivo, researchers at the University of Pennsylvania’s School of Engineering and Applied Science have developed ‘placenta-on-a-chip’ to look at the placental barrier and drug transport in pregnancy.  

This is a real breakthrough to study the maternal-fetal drug transport across the placenta, as the placental barrier can never be exactly replicated in the lab and in-vivo studies in humans are not ethical. Pregnant women are not included as research subjects because of the risk of teratogenicity. Animal models are not exactly able to mimic human physiology.

We are all aware of the famous ‘Thalidomide’ disaster, in which a drug for morning sickness, crossed the placental barrier in humans and caused multiple birth defects, collectively known as ‘fetal thalidomide syndrome’ and deaths.

To address these issues, a team of researchers led by Dan Huh, Wilf Family Term Assistant Professor in Bioengineering at Penn and Cassidy Blundell, a graduate student in the Huh lab have developed a placenta-on-a-chip, using microfluidic channels in silicone casing.

The study was also published in the journal Advanced Healthcare Materials.

The two channels house human trophoblast cells on one side and endothelial cells on the other separated by a porous membrane. The unit mimics placental barrier and hence the permeability of the barrier to different drugs can be tested.

A blood-like fluid flows through the maternal side of the channel and the researchers can experiment by adding different drugs to the fluid and see the rate, amount of drug transferred to the fetal side of the channel.

“Ex vivo placental perfusion is a great method,” Huh said, “but it has a pretty high failure rate, and the experimental set-up is complicated: it’s prone to leaks and needs a high level of expertise. Most pharmaceutical companies are not going to be able to test their drugs using this method.”

Currently, to validate their model, the team has tested 2 drugs that they have already studied via ex vivo placental perfusion: heparin, an anticoagulant, and glyburide, used in the treatment of diabetes.

The placenta on the chip was able to simulate the drug transfer of these two drugs as it happens in human placenta and fetal interface. Heparin did not pass through the chip model as it is too large a molecule to breach the placental barrier and glyburide transfer was also limited as in real placenta to protect the fetus.

Huh further added, “We’re getting close, this study has given us confidence that the placenta-on-a-chip has tremendous potential as a screening platform to assess and predict drug transport in the human placenta.”

Besides its use by the pharmaceutical company to test various drugs, the ‘placenta-on-a-chip’ has tremendous potential in testing the transfer of supplements other than drugs like vitamins and nutritional supplement.

Penn State News Release

Abstract in Advanced Healthcare Materials

Novel flu drug that kills the virus in 1 day get clearance in Japan

Japanese pharmaceutical company Shionogi claims that treatment with baloxavir marboxil, effectively kills influenza A and B virus in just 24 hours as opposed to the current user oseltamivir (sold under the brand name Tamiflu), which takes 72 hours to kill the virus.

Japan’s health ministry recently approved the drug and will be sold under the brand name Xofluza.

This is a welcome announcement in healthcare and pharma industry, in the midst of worst Flu season that the USA has experienced. Probably it could make the next flu season safer.  

Baloxavir marboxil prevents the replication of the virus by cap-dependent endonuclease activity of the viral polymerase unlike the existing drug oseltamivir (Tamiflu, Genentech), which acts by inhibiting the neuraminidase enzyme.

It’s prescription as single dose treatment irrespective of age greatly improves patients’ compliance as opposed to the twice-daily dose of oseltamivir for 5 days.

Baloxavir marboxil was tested in a randomized, double-blind, parallel-group, multicenter, placebo- and active-controlled study (CAPSTONE-1), which enrolled 1,436 otherwise healthy patients diagnosed with influenza. 

These patients with age between 20-64 years were randomized in a ratio of 2:1:2 to receive a single 1-time oral dose of 40 or 80 mg of baloxavir marboxil based on body weight or a placebo, or 75 mg BID of oseltamivir for 5 days.

Patients between 12-19 years of age were given baloxavir marboxil based on body weight. Those who weighed less than 80 kg received 40 mg of the drug while patients weighing more than 80 kg were given 80 mg.

The trial results showed that:

•   Patients who received Baloxavir marboxil had significantly lower viral titer at 1, 2 and 4 days
• Viral shedding in Baloxavir marboxil group was significantly less at 24 hours as compared to 72 hours in patients on oseltamivir and 96 hours in patients on placebo.
• The patients in the study group were afebrile in 24 hours vs 42 hours in the placebo group.
• The time to alleviation of symptoms (TTAS) was significantly shortened in the study group (53.7 hours) vs (80.2 hours) in the placebo group (p<0.0001). 
• The new drug was also well tolerated with significantly fewer side effects (20.7%) as compared to placebo (24.6%) or oseltamivir (24.8%).  

Shionogi is currently conducting another phase 3 trials with the drug in patients who are at high risk for Influenza.

Following the approval by Japanese health ministry in February, the drug could be on sale in Japan as early as May.

The head of co-developer Roche's pharma unit, Daniel O'Day, told Bloomberg, "The advantage is that it's one pill once, versus a course of therapy, so particularly for pandemic planning, this could be an advantage, you don't have the potential resistance that comes with not completing your course of therapy."

Shionogi and the Tamiflu maker Roche share the rights to sell Baloxavir marboxil in international market, but it will be almost a year before the drug enters US market.

Shionogi News Release

Menopausal HT may help protect against development of age-related stooped posture

A new North American study found that women who are continuous or remote users menopausal hormone therapy have less evident kyphosis in their mid-eighties as compared to never users. The study is published ahead of print on February 16, 2018, in menopausal society journal Menopause.

Age-related hyperkyphosis is exaggerated anterior curvature of the spine is common in men and post-menopausal women and is associated with increased bone loss, degenerative disc diseases, and vertical compression fractures. It causes difficulty in performing activities of daily living and reduces the quality of life.

The Women’s Health Initiative study has also shown that hormone therapy (HT) reduces the odds of vertebral fractures. Based on the same hypothesis, this study also confirmed the protective effect of HT against the development of kyphosis or dowager’s hump.

The significant decline in estrogen levels after menopause results in accelerated bone loss resulting in the compression fracture of the vertebra. After a woman is put on HT, bone loss increases steadily in 3 years and is maintained by continuous use.

The authors of this study looked at data from nearly 10,000, community-dwelling women aged 65 and older from the landmark Study of Osteoporotic Fractures (SOF) and followed them for a period of 15 years. This study is a multicentric, observational study started in 1986 and closed after 31 years in September 2017.

Kyphosis was measured by mapping the Cobb angle in lateral radiograph spine and correlated with HT use.

The mean age of study participants was 83.7 ± 3.3 years and a mean Cobb angle of 51.3 ± 14.6°. 

Nearly half of the women reported having never used HRT, while 25% reported using it remotely in past, 17% reported that they used HT intermittently while only 12% reported continuous use.

After accounting for confounders, women who used HT in remote past and continuous users had nearly 3.0° less kyphosis compared with never users. Intermittent use did not confer any protection and the women had the same Cobb angle as never users.

The SOF findings also showed that women who lose more than two inches in height have an increased risk for fracture and early death.

NAMS executive director Dr. JoAnn Pinkerton concluded, “Women who reported the early use of HT were less likely to develop age-related kyphosis, and the protective benefits continued even after stopping HT. This supports a benefit of prescribing HT close to menopause.”

Abstract

NAMS press release

USPSTF updates its ovarian cancer screening guidelines

The US Preventive Services Task Force (USPSTF) recommends against screening for ovarian cancer in asymptomatic women who are not at high-risk for ovarian cancer. This update is in consensus with its previous 2012 recommendations. The updated guidelines were published in recent issue of Journal of American Medical Association (JAMA).

USPSTF advise against screening for ovarian cancer in women who are asymptomatic and not at high-risk of hereditary cancer syndrome (D recommendation).

The presenting symptoms for ovarian cancer (bloating, constipation, abdominal pain or pressure, urinary symptoms, back pain, or fatigue) are nonspecific and may be present in both healthy women and women with late-stage ovarian cancer; therefore, these cannot be used to detect cancer at a very early stage.

This decision is based on benefits and harms of the screening test and cost was not considered in formulating the recommendations.

Ovarian cancer is the fifth in the list of cancer-specific mortality and tops the list of deaths due to gynecological malignancies, despite its low incidence of 11.4 cases per 100,000 women per year.

Many women who undergo screening for ovarian cancer receive false positive reports as the screening tests have low specificity.

courtesy: Thinkstock

USPSTF has sufficient evidence to recommend that screening with transvaginal ultrasound, testing for the serum tumor marker cancer antigen 125 (CA-125), or a combination of both does not reduce ovarian cancer mortality.

Routine pelvic examination and bimanual palpation also do not help in early detection of cancer; furthermore, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial discontinued it as a screening test because not a single case was detected based only on bimanual pelvic examination.

The number of false -positive cases may result in unnecessary surgery and further testing for women who are cancer-free.

Women with hereditary cancer syndromes such as women with BRCA1 or BRCA2 genetic mutations should follow the specific recommendations and talk to their healthcare providers for guidance and cancer screening.

The recommendations are in agreement with the 2012 recommendations because the result of large UKCTOCS trial was published which in consensus with the PLCO trial, did not find sufficient evidence that screening for ovarian cancer reduces ovarian cancer mortality in asymptomatic women.

These recommendations are also in consensus with other major organizations like American College of Obstetricians and Gynecologists, American Cancer Society American College of Radiology and the American Academy of Family Physicians. 

Full Text 

Novel cross-over sign in cesarean scar pregnancy helps predicts the risk of invasive placentation

power-point slide by ISUOG

First trimester ultrasound scan evaluating the relationship between the gestational sac and the endometrial line in women with cesarean scar pregnancy(CSP) helps predicts the development of abnormally invasive placenta (AIP) and consecutive intra and post-operative surgical morbidities reports the results of a retrospective case series published in Journal of International Society of Ultrasound in Obstetrics and Gynecology.

Recent advances in prenatal imaging and increase rate of cesarean sections have led to increased diagnosis of CSP. Although, most of the patients with CSP present with severe hemorrhage or rupture uterus, that requires emergency surgical management, few advance further, evolving into AIP.

There is no reliable marker that can predict whether a woman with CSP will end up in early abortion or further progress to develop placenta percreta or other less severe forms of AIP.

A novel ultrasound cross-over sign (COS) has recently been thought to predict the evolution of CSP into different forms of AIP so that the intraoperative and postoperative risk can be stratified.

A straight line is drawn from internal cervical os to the fundus of the uterus in sagittal view through the endometrium. The gestational sac is identified, and its superior-inferior diameter measured. The COS is classified according to the relationship of ectopic sac diameter with the endometrial straight line into COS-1 and COS-2.

This case series identified 102 women over a period of 8 years with AIP diagnosis confirmed by histopathological examination (HPE), of whom 68 patients had a first-trimester ultrasound with a diagnosis of CSP. The scans were read by sonographers who did not have any idea about the pregnancy outcome and pathology reports.  

COS sign was assessed as mentioned, and all patients received counseling regarding the prognosis, risk, and post-operative complications. Women with severe AIP were delivered early, as compared to less severe variants.

All women underwent cesarean hysterectomy with temporary occlusion of the internal iliac artery and ureteric stent in place. At HPE, 34 cases were diagnosed with placenta percreta, 13 with placenta increta and 21 with placenta accreta.

Pregnancies with COS-1 had early deliveries, longer operating time, more blood loss and required much more packed red blood cells during surgery mean as compared with those with COS-2+ or COS-2–.

Thus, predicting the likely course CSP diagnosed by COS sign in the first trimester can improve shared decision making between the patient and provider about the surgical difficulties endured, amount of blood loss and need for cesarean hysterectomy.

Large, multi-center studies to determine the role of COS sign in predicting the severity of AIP in CSP is needed in future.

Full text

This article has been selected for Journal Club. Click here to view slides and discussion points. 

North American Menopause Society (NAMS) video series about important midlife health topics: Clinical options for treating GSM

The North American Menopause Society (NAMS) is proud of its comprehensive video series for women on important midlife health topics. All the interviews in the series are hosted by NAM Board of Trustees Member and Immediate Past-President Dr. Marla Shapiro, a Canadian physician who led this exciting initiative. Dr. Shapiro is also the medical consultant for CTV News.

In this first video of 2018 series, Dr. Shapiro discusses clinical aspects of the genitourinary syndrome of menopause (GSM) with Dr.Nick Panay, an obstetrician-gynecologist from London and general secretary-elect of the international menopause society(IMS).

This is a very common problem worldwide, but it is severely underreported and undertreated because most of the women are reluctant to come forward and discuss it with the health care providers.

In this video, Dr. Panay discusses treatment options for women with GSM.

Vaccum -assisted deliveries are at highest odds for injury to anal sphincter

Women who undergo Ventouse, also known as vacuum-assisted vaginal delivery or vacuum  extraction (VE) to cut short the second stage of labor are at 4 times the odds of obstetric anal sphincter injuries (OASIS) as compared to spontaneous vaginal delivery reports the results of retrospective cohort study published in February issue of Obstetrics and Gynecology.

It is estimated that about 1 in 10 primiparas will develop some degree of anal incontinence after vaginal delivery, which improves as months' progress.  Despite it, the matter is rarely talked about because of shame and taboo associated with it.

OASIS results in considerable comorbidities later in life including urgency, fecal incontinence, sexual dysfunctions, rectovaginal fistula and chronic pain. Hence, an awareness regarding the risk factors is necessary among health care provider to avoid the primary event.

This single-center study carried out at Kaiser Permanente Northern California looked at delivery data of about 22,741 women over a period of 2 years. All these women had undergone term, singleton delivery with the fetus in cephalic presentation. The study mainly focused on the incidence of third and fourth degree perineal tear as per World Health Organization classification.

After statistical analysis, it was seen that about 5% of women suffered OASIS, with the rate being minimum with spontaneous delivery (3.6%) and highest (24%) in vacuum-assisted vaginal delivery (P<.001).

After accounting for confounders, the other risk factors identified for OASIS were nulliparity, Asian ethnicity, second stage more than 2 hours, vaginal birth after cesarean delivery (VBAC), episiotomy, and vacuum delivery.

Women with vacuum extraction had the highest odds (4 times) of OASIS, followed by women who had labored for more than 3 hours in the second stage of labor (3 times) vs 1 hour.

The authors concluded that vacuum extraction and prolonged second stage of labor were the two risk factors that put the women at highest odds of OASIS.

Abstract

Media courtesy: American Society of Colon and Rectal Surgeons

Innovative force sensing technology enables the surgeons to feel again from a distance

SensOR Medical Laboratories, a medical device start-up based out of Toronto, Canada has developed a novel force-sensing electronic skin called ForceFilm, that when paired with the existing laparoscopic tools enables the surgeons to get the ‘tactile sensation’ so easily felt during open surgeries.

Handling the tissues from a distance makes it difficult to get the idea of the amount of force applied, and increases the rate of surgical complications.

Minimal Invasive surgeries are on the rise in all specialties of surgery in hope of early recovery, shorter hospital stay and minimal pain and discomfort associated with the surgery. Transparency Market Research (TMR) recent study has projected a growth of 10.5% in the global minimally invasive surgery market by 2019.

CEO and co-founder Dr. Robert Brooks say “Our ultimate goal is to improve surgical safety. Medical error is the third largest cause of death. Up to 12% of medical error is caused by the inappropriate application of force in surgery.”

The ForceFilm can be fitted and removed from any existing laparoscopic instrument without damaging its working. The ForceFilm measures the force exerted at the tip of the instrument by using 2 to 4 strain gauges and transmit it wirelessly through Bluetooth transceiver to be displayed on the endoscopic monitor. The display gives the surgeon a visual feedback about the amount of pressure exerted while cutting or handling the tissues; thereby, reducing the surgical complications.

ForceFilm is also very useful in effectively training surgical residents about the level of ‘safe force’ during simulated surgeries, so that the complication rate is reduced during live surgeries.

“Our technology is unique in that it is the only force-sensing technology that can be added to any make or model of the surgical instrument and doesn’t modify surgical or hospital workflow,” added Dr. Brooks.

In addition, the unique design of ForceFilm makes it fully sterilizable with no need to disassemble the instrument.

The company has future plans to expand SensOR to identify specific site and type of surgeries. This will enable the surgeons to get an idea about the force applied in the past, along with the ‘safe force’ limit while operating in real time.

They are also planning to get SensOR into surgical education to shorten the learning curve and designing it so that it can be applied on every force-applying instrument in the surgical tray.

SensOR was recently awarded the James Dyson Foundation Award for Canada for its unique ForceFilm technology.

SensOR Home

Media Courtesy: SensOR

Here is a video demonstrating SensOR’s award-winning (James Dyson Award for Canada) ForceFilm technology

Sutures are better than staples in third or high-order cesarean sections wound closures

Wound closure with suture is associated with 56% lower odds of wound complications as compared to using staple in third or high-order cesarean sections reports the results retrospective cohort study published ahead of print in February issue of Journal Obstetrics and Gynecology.

The researchers looked at wound closure techniques of all tertiary or higher-order cesarean deliveries over a period of 12 years at a large academic medical center. All the cases were performed by surgeons belonging to a single group practice.

Patients with three or more cesarean deliveries with pfannensteil incision were included in the study.

A total of 551 patients had third or higher order cesarean deliveries, in 192 patients staples were used while 359 received suture closure.

The patients were not randomized to receive either type of wound closure, but the group doctors used staples for most of the cases for the first 6 years and in the later 6 years subcuticular suture closure was preferred. If the subcutaneous fat was 2 cm or deeper, the space was obliterated in all the patients.

Prophylactic antibiotics were routinely used in all patients. The researchers looked at data on wound infection requiring antibiotics, resuturing or wound gaping that required packing 6 weeks post-operatively.

A total of 551 patients had third or higher order cesarean deliveries, in 192 patients staples were used while 359 received suture closure.

Wound complications were observed in about 5% of patients with suture closure as opposed to nearly 12% of patients with staple closure (P=.003).

Even after accounting for number of previous cesareans and operator surgical skills, suture closure has 56% lower odds of wound complications as opposed to staple closure (adjusted odds ratio 0.44, 95% CI 0.23–0.86).

Abstract

Media courtesy: Headley Family Medicine

Unusually high prevalence of Trichomonas vaginalis observed in pre-/perimenopausal women

Substantial population of older women harbor Trichomonas vaginalis without being aware of the infection reports the results of retrospective observational study to be published in the American Journal of Obstetrics & Gynecology.

As women progress into pre- and perimenopausal years, the prevalence of T. vaginalis increases, with the highest incidence found around 47 to 53 years of age, while the prevalence of Chlamydia trachomatis peaks around 10 years to 27 years and then slowly declined.

Quantitative real-time polymerase chain reactions were used in analyzing 1,554,966 and 1,999,077 cervicovaginal samples collected during gynecological examinations from women aged 10 to 79 years  for presence of T. vaginalis and C trachomatis, respectively. 

It was seen that T. vaginalis has a bimodal distribution with the first peak at age 22 years (4.1%) and another at age 48 (5.8%).  The prevalence of T. vaginalis also remained high at 4% in women aged 54 to 60 years.

A state-wide analysis showed that Mississippi (9.0%) has the highest prevalence for T. vaginalis while C.trachomatis was most common in Maine(6.4%).

This study is important because T. vaginalis is most common non-viral sexually transmitted disease but the physicians are not required to report the cases. Hence, not much is known about it distribution and prevalence.  

In about 1.5% T. vaginalis positive specimens were associated with ntr6_TV polymorphism, but it was not related to the age distribution pattern seen in the study.

The authors concluded that it may be good idea to test older women for T. vaginalis infection, who are least suspected of harboring a sexually transmitted infection.

Abstract

Media Courtesy: http://araratnews.am/medical-trichomonas/?lang=en

Novel emerging infectious diseases in pregnancy

Last two decades have seen epidemics of several infectious diseases which were previously not so prevalent worldwide. Pregnant mothers are especially prone to many infections because of anatomical and physiological changes that accompany pregnancy. The immune tolerance to semiallogenic fetus is because of down regulation of immunity, which puts the pregnant women at high risk of other infectious diseases reports a paper published in May 2017 issue of Journal Obstetrics and Gynecology.

The world has seen epidemics of four major and other minor emerging infectious diseases in the last two decades such as severe acute respiratory syndrome, the 2009 H1N1 pandemic influenza, Ebola virus, and, most recently, the Zika virus. Each of this infection has unique implications in pregnant women that are distinctly different from general population.

Each of this infectious disease has different clinical course, complications and future implications when occurring in pregnant women and requires special technique and skills and coordination at national and international levels to contain the outbreak, some basic principles are common to all for diagnosing and limiting the spread of these diseases.

A number of epidemiological factors have contributed towards emergence and widespread occurrence of these infection in pregnant women like global travel, development of microbial resistance and barriers towards vaccinations in pregnant women in-spite of increasing evidence of distinct benefits to mother and fetus.

Although the general principles of disease containment are common to all, some disease specific measures for treatment and prevention of individual infections in pregnancy are:

SARS: During the severe acute respiratory syndrome (SARS) outbreak by coronavirus in 2003, standard non-pharmaceutical measures were applied, and global containment was achieved in 5 months.

Influenza: All pregnant women should get influenza vaccine every year as soon as it is available and should not wait for the unpredictable influenza season to start. It is safe in all the trimester. The rapid influenza tests currently available has low sensitivity resulting in many false negative results. Hence, to err on the side of safety it is always recommended to prescribe oseltamivir as precaution and is recommended both by Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists.

Ebola virus: Women are always at high risk for contracting Ebola during an epidemic as they are the primary caregivers to other infectious family members. Women who are pregnant with the virus during acute Ebola epidemic usually transmit virus to the fetus, leading to intrauterine fetal death, stillbirth, or neonatal death. Ebola virus is also excreted in breast milk.

They also transmit the virus to healthcare providers and caregivers during labor or abortion. Standard precaution including the use of personal protective equipment (PPE) during labor and delivery for protection against blood and body fluids should be used along with rigorous hand hygiene, appropriate waste, sharps and laundry management and cleaning and decontamination.

WHO states that women who get pregnant after having being recovered from Ebola infection are not infectious but standard precautions and use of PPE should be implemented all the time during handling such patients. 

Zika virus: Zika virus is a flavivirus that has potential for sexual and vector born transmission by Aedes (Stegomyia) species of mosquitoes. It was declared as a public health emergency by the World Health Organization from 2016. A pregnant woman is susceptible to Zika virus in all three trimesters. Maternal Zika infection is associated with a range of adverse neonatal complications, most important of which is microcephaly. Peripartum transmission is also known to occur.

In absence of antiviral vaccine, CDC recommends that all pregnant women should postpone their travel to Zika infected areas and those who are in such areas should avoid mosquito bite especially during the day.

Pregnant women with laboratory-confirmed Zika virus infection can be offered amniocentesis to test for Zika virus RNA by RT-PCR after 15 weeks of gestation.

Deliveries of mothers with positive Zika infection should take place at specialized center.   

No specific antiviral treatment is available.

Abstract

Expert Discussion

WHO guide to Ebola disease in pregnancy

Media courtesy: InfectiousDiseaseAdvisor and Coherent news.

Negative sliding sign by ultrasound in repeat cesarean section predicts presence of severe intrabdominal adhesions

Photo courtesy: YouTube video clip by Green Journal

A negative sliding sign by ultrasonography (USG) in patients with previous cesarean section helps alert the surgeon to expect massive intraabdominal adhesions, difficult repeat cesarean section and need of blood transfusion during surgery reports the results of a prospective observational study published ahead of print in the February issue of Journal Obstetrics and Gynecology.

Postoperative adhesion formation is quite prevalent after an abdominal or pelvic surgery and any method which can predict the existence of such adhesion could optimize the outcome of current surgery.

Real-time ultrasound-based technique of ‘slide test’ is the non-invasive way of detecting pelvic and intrabdominal adhesions preoperatively. The test measures the relative motion between abdominal and uterine wall.

The researchers recruited 370 women with previous cesarean section. The women underwent transabdominal sonography and a video-clip was recorded at deep inspiration in sagittal plane lateral to the midline.

The findings of preoperative ultrasonography were correlated with adhesions found during surgery by surgeons who were not aware about the preop USG findings.

Statistical analysis of these findings showed that when less or no movement was detected between the uterus and abdominal wall (negative ‘slide test’), it correctly identified patients with severe adhesion in 56% of cases (sensitivity 56%, 95% CI 35–76). It also predicted absence of severe adhesions correctly in 95% of patients (specificity 95%, 95% CI 93–97).

When the USG findings was combined with history of adhesions in previous surgery, severe adhesions were correctly predicted in 64% of patients and absence of adhesions was predicted in 94% of patients.

The surgeons noted a longer delivery time and significant blood loss in patients with negative sliding sign.

Thus, it was seen that ‘slide test’ is a simple, reliable and non-invasive screening test in repeat cesarean cases to predict technical difficulty during surgery.

Here is a short video of visceral slide test from video gallery of Journal Obstetrics and Gynecology.

This short video clip explains the equipment needed, how to perform, and how to interpret the visceral slide test. An example of a normal test and an abnormal ultrasound visceral slide test are illustrated, including a laparoscopic view of the patient with an abnormal test.

Video courtesy of Erica C. Dun, MD, MPH.

 Abstract 

Shocking revelation of FGM being widely practiced in Indian Dawoodi Bohra Community

Female Genital Mutilation (FGM) is widely prevalent in all forms in Indian Bohra Community and more than three-fourth study participants have undergone the procedure in some form according to a study published on February 5, 2018.

The study results reveal heart wrenching truth about the practice only weeks after Ministry for Women and Child Development submitted an affidavit to the Supreme Court of India on December 2017, denying the existence of any data on such practice in India.

The study was published on the eve of International Day of Zero Tolerance for FGM and supported by WeSpeakOut, the largest survivor led movement to end FGM in Bohra samaj in India and Nari Samata Manch (NSM) working for gender equality and end cruelty cross women in Maharastra.

International Day of Zero Tolerance for FGM is marked on February 6, 2018 to raise awareness of female genital mutilation (FGM) and to encourage abandonment of the procedure worldwide.

The study sampled 94 participants  from thirteen locations across five states in India: Gujarat, Madhya Pradesh, Maharashtra, Rajasthan and Kerala of which 83 were women and 11 were men. The samples also included Bohra expats from western world, traditional circumcisers, healthcare professionals, and teachers.

Data indicated that 81 (97%) women in the sample had been subjected to Khafd or Clitoridectomy. It was seen that both partial or total removal of clitoris and/or clitoral hood (Types 1a and 1b FGM) is widely practiced, as well as other forms (Type 4 FGM/C) like pricking, piercing or cauterization.

The average age at which the girls are cut is 7 years.  

Nearly all the women reported it as a painful experience with immediate and long term genitourinary complications and bleeding following the cut . One-third of women reported that the procedure has affected their sexual lives for ever while other reported many psychological and trust issues later in life.

Besides being a traditional ritual and religious beliefs, FGM also aims at curbing women’s sexual desire and promiscuity and limiting her sexual pleasure.

Traditional circumcisers told the researchers that they have cut thousands of girls. With increasing urbanization FGH is increasingly being practiced by nurses and healthcare providers, with Bohra men being involved passively as well as actively.

The Bohra women are very vocal about the issue and have publicly demanded an end of this dehumanizing practice, but the government of India continues to turn a blind eye. A petition was filed in India’s Supreme court to ban FGM recently.

Meanwhile, the proponents of khafd say that it is just a ‘nick’ unlike the curse in African countries where the entire external genitalia is removed.

Internationally FGM is recognized as violation of human rights against girls and women.

FGM is widely practiced as a ritual in Africa, the Middle East and Asia but it is also rife in some communities from practicing countries across the western world. Often Bohra girls from diaspora communities are brought to India to be cut.

It is estimated that about 200 million women and girls alive have been subjected to some form of genital mutilation(GM) and 200 million more will undergo GM till the year 2030.

FGM study

Media courtesy: Sahiyo.com, Kolkata 24/7

Miscarriage rates tripled in women exposed to higher magnetic field (MF) non-ionizing radiation

Higher exposure to magnetic fields (MFs) non-ionizing radiations nearly triples the risk of miscarriage in pregnant women compared to those who get lower exposure reports the results of prospective cohort study published online in Nature’s Scientific Reports.

The electromagnetic spectrum 

This study reaffirms the findings from earlier studies that non-ionizing radiations are not totally harmless, and they have biological effects on human health.  

The lead author Dr. De-Kun Li, a senior research scientist at the Kaiser Permanente Division of Research in Oakland, California call it a serious public health challenge as humans are ubiquitously exposed to both low frequency MFs generated by home appliances, transformers, powerlines etc and higher frequency MFs from cell phones, wireless networks, smart meter networks, cell towers and wireless devices.

The authors identified 900 women with a positive pregnancy test through the electronic medical record (EMR) laboratory database from bay area counties in Northern California. The MFs exposure was measured in milligauss (mG) through EMDEX Lite meter (Enertech Consultants Inc.) that the women carried throughout 24 hours during pregnancy.

The exposure was further classified as typical or atypical based on the women following her daily schedule or doing something apart from her routine because it was seen that there was a significant difference between exposure on a typical day vs atypical day.  

As the women were followed progressively into pregnancy till 20 weeks since the positive urine pregnancy test, the study was able to detect early miscarriages that earlier studies might have missed.

Women’s personal risk factors and obstetric history was ascertained along with presence or absence of other confounders to rule out bias. They were followed into pregnancy till miscarriages, end of pregnancy due to other reasons like ectopic or till they reach 20 weeks.

Cox Proportional Hazards regression model was used to examine the association between MFs exposures and miscarriage rates.

After adjusting for the known confounders like maternal age, race, education, smoking during pregnancy, and prior miscarriage, overall, pregnant women who had higher MF exposure during pregnancy (higher 3 quartiles) had a 48% greater risk of miscarriage than women who had lower MF exposure (in the lowest quartile): adjusted HR = 1.48, 95% confidence interval (CI): 1.03–2.14 

The association was stronger and significant when the data was examined for typical days vs atypical days, on which no association was observed.

Similarly, no difference was observed between women with (≥2) miscarriages vs women with no prior bad obstetric history. Although, the association was stronger in women who were exposed to the higher quartiles as opposed to women exposed to lowest quartile, no significant dose response relationship was observed.

The association was also consistent across different sources of MFs exposure.

This is the only study that used an objective measuring device (EMDEX Lite meter) to measure the radiations and were able to measure the effects prospectively in months instead of years as in cancer and other chronic diseases.

Prior studies have found an association between long term exposure to non-ionizing radiations and increased risk of brain cancer and low sperm counts.

The lead author Dr. Li stresses the importance of further studies in this subject area. Meanwhile she advices children and young adults, especially pregnant women to stay away from cell phones and other equipments that emit non-ionizing radiations.

Couples who are trying to conceive should also minimize their exposure by maintaining a safe distance from cell phone and other house hold appliances.

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