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Am J Perinatol 2012; 29(10): 755-758
DOI: 10.1055/s-0032-1329220
Editorial
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reflections on 2011 from the Obstetrical Perspective

George R. Saade
1   Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
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Publication History

Publication Date:
18 October 2012 (online)

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The journal has had a very exciting year in 2011. The numbers are in and our impact factor jumped to 1.316, an 18% increase in 1 year and a 59% increase over the past 5 years. Of course, the impact of a journal should not be evaluated with numbers alone. It is reassuring to see that papers published in the journal are being cited in systematic reviews as well as in various clinical guidelines. It is also gratifying that the number of requested downloads from the Web site has markedly increased in the last few years ([Fig. 1]). These are a clear indication that the publications are informing knowledge and clinical practice. This is also a testament to the quality of the papers submitted and the review process. It is also noteworthy that the split between the 10 most commonly downloaded manuscripts in 2010 and 2011 is well balanced between obstetrical and neonatology topics.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] Being read and accessed by both obstetricians and neonatologists underscores the unique perspective of the American Journal of Perinatology. One of the many rewarding aspects of being an editor of the American Journal of Perinatology is the ability to cover both the prenatal and postnatal periods. To this end, I would like to profusely thank the authors, reviewers, and editorial board members. In particular, I would like to thank my co-editor in chief, Dr. Rosemary Higgins, and our associate editors, Dr. Catalin Buhimschi and Dr. Martin Keszler. The associate editors have taken a significant role in guiding the journal and managing the submissions. I am also deeply grateful to our publisher, Thieme Medical Publishers, Dr. Daniel Schiff, Thieme's Vice-President and Journals Publisher, and all the staff for their excellent support and for allowing us to manage the editorial side of the journal in full independence.

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Figure 1 Total number of requested downloads from the Web site per year.

Another important change was that all the case reports and case series are now published in the companion journal American Journal of Perinatology Reports. I encourage all of you to peruse the excellent published reports on the Web site http://www.thieme-connect.de/ejournals/toc/ajpr. Not only do the accepted manuscripts offer insight into rare conditions or rare presentations of common conditions, but they also include practical and useful clinical discussions. For those who are interested in submitting case reports or case series, the submission Web site is at http://mc.manuscriptcentral.com/ajpreports.

I would also like to take this opportunity to bring to your attention some of our most cited articles in the past year, as well as some noteworthy ones.

The debate regarding vitamin D deficiency in pregnancy is continuing. Published in the journal's first issue of 2011, a study evaluating the prevalence of vitamin D deficiency in pregnant women in the South United States found that 97% of African-Americans, 81% of Hispanics, and 67% of Caucasians were deficient or insufficient.[17] Another study also published in 2011 found that maternal serum levels of 25-hydroxyvitamin D in the first trimester were not associated with spontaneous preterm birth.[18] These two studies argue against a role of vitamin deficiency in adverse pregnancy outcomes.

Another debate in the perinatology field revolves around the association between maternal serotonin reuptake inhibitors (SSRI) use and persistent pulmonary hypertension in the newborn (PPHN). In a case control study, investigators from Madigan Army Medical Center found that PPHN was associated with cesarean delivery prior to the onset of labor but not with SSRI use in the second half of pregnancy.[19] Prior studies that found an association between maternal SSRI use and PPHN did not adequately control for the various confounders. Thousands of women enter pregnancy each year while on SSRIs. Given the discordant data regarding any association, as well as the rarity of PPHN, the decision to continue SSRIs should be based on the maternal needs, rather than the fear of PPHN.

The use of maternal corticosteroids to accelerate fetal pulmonary maturity is one of the most important successes in perinatology. However, there is still some controversy regarding the benefit at the opposite ends of the therapeutic gestational age window. The role of corticosteroids after 34 weeks is currently being tested in randomized trials. The role at the other end of gestational age is harder to test in a randomized trial. To this end, a group from The Netherlands performed a systematic review.[20] Meta-analyses and meta-regression of trials including participants with a lower gestational age revealed no significant reduction of neonatal mortality and morbidity in the corticosteroid group as compared with nonintervention, in contrast to clear evidence of beneficial effects in trials including women given corticosteroids at a later gestational age. While this finding is unlikely to change practice in the neonates between 24 and 26 weeks, it may give some pause regarding corticosteroid administration before 24 weeks. At these periviable stages, the decision to use corticosteroid is actually the easiest. The harder decisions involve the use of tocolytics, fetal heart rate monitoring, and cesarean delivery. It is essential that obstetricians and neonatologists are on the same page regarding all the management issues surrounding periviable pregnancies, and not just corticosteroids.

Postpartum hemorrhage remains one of the leading causes of maternal mortality and severe morbidity, in both high and low resource countries. In a randomized, double-blind, placebo-controlled study, investigators from Turkey found that intravenous tranexamic acid, an antifibrinolytic agent, given prophylactically to women undergoing scheduled cesarean delivery significantly decreased the estimated blood loss as well as the proportion of women requiring additional uterotonics.[21] Tranexamic acid is currently not in use for prevention of postpartum bleeding in the United States. Tranexamix acid is simple to use and relatively inexpensive, which makes it an ideal choice in low resource countries.

Given that the vast majority of obstetricians in the United States no longer perform vaginal breech deliveries, the only approach to prevent cesareans in these cases is by external cephalic version. Unfortunately, the procedure is not always successful and women are counseled based on aggregate and average data. Using prospectively collected data from 310 women undergoing external cephalic version at 36 weeks or later, Kok and colleagues[22] developed a prediction model that could differentiate between women with less than 20% versus those with more than 60% chance of success. Once validated externally, this model can be used to counsel women regarding external cephalic version using individual patient characteristics, rather than using a uniform approach based on average population data.

Medical liability continues to be a concern. The effects of medico-legal factors on increasing health care costs cannot be ignored. At issue in perinatology is the effect these concerns have on the rates of cesarean delivery. Zwecker et al[23] compared the mode of delivery with the average state medical liability insurance premium paid by obstetricians in a cohort of more than 800,000 women who delivered across 37 states in 2006. They found that average state malpractice premium of over $100,000 was associated with more cesarean deliveries, less vaginal births after cesarean deliveries, and less instrumental deliveries (OR 0.72, 95% CI: 0.63, 0.83) compared with when the average state malpractice premium was less than $50,000, even after adjusting for confounders. These findings support an effect of fear of litigation on health care expenditures.

Preterm premature rupture of the membranes (PPROM) accounts for about half of spontaneous preterm births. PPROM is also associated with perinatal infectious morbidity. Prediction of these infectious complications remains elusive. The usual tests performed on amniotic fluid obtained by amniocentesis, such as glucose level, gram stain, and white blood cell count, have shown mixed results. Using real-time polymerase chain reaction that detects a highly conserved sequence of the bacterial 16S ribosomal DNA in the amniotic fluid, Debieve et al[24] were able to predict neonatal complications better than the usual tests.

Finally, I would like to bring our readers attention to a series of three manuscripts detailing the approach to autopsy and pathologic examination of the placenta in the Stillbirth Collaborative Network (the last one actually published in 2012).[25] [26] [27] The Network was formed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development to evaluate the scope and causes of stillbirth using a population-based approach. The protocols for pathologic evaluation of the placenta and stillborn infants are among the many contributions of the Network so far. The manuscripts are a must read for any researcher or clinician involved in the evaluation of stillbirth.

While the publications highlighted above are from the obstetrical perspective, they are also important for the neonatologist. In a future issue, Dr. Higgins will also be highlighting publications from the neonatology perspective. This reflects the uniqueness of our journal in that it bridges both disciplines to improve perinatal outcome. In closing, I would like to thank all of our readers for the continued interest in the American Journal of Perinatology, and hope that you will continue to read and disseminate the knowledge we publish. We remain motivated to publish the studies that will inform our readers and improve practice. I encourage you to reach out to me personally or to any of our editorial board members with your opinions.