Journal of School Health

Cover image for Vol. 83 Issue 7

July 2013

Volume 83, Issue 7

Pages 463–524

Wiley Online Library : BJOG: An International Journal of Obstetrics & Gynaecologyhttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F%28ISSN%291471-0528John Wiley & Sons, Incen© RCOG1470-03281471-05282017-08-01T00:00:00-05:00August 20171249e264e278http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14829Improving Postmortem Testing for Perinatal Death from the Parents’ PerspectiveLindsey J. Wimmer, Claire Storey, Robert Silver2017-07-22T02:55:27.763562-05:00doi:10.1111/1471-0528.14829John Wiley & Sons, Inc.10.1111/1471-0528.14829http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14829Mini-commentaryn/an/a

Abstract

Parents experiencing the death of a baby through stillbirth, neonatal death, or other perinatal losses are required to make several decisions while under a great deal of emotional distress. One such decision is whether or not to pursue testing that could provide more information about their baby's death.

Lewis and colleagues state that postmortem testing is the most valuable tool available to learn about cause of death and implications for future health and pregnancies.

This article is protected by copyright. All rights reserved.

Parents experiencing the death of a baby through stillbirth, neonatal death, or other perinatal losses are required to make several decisions while under a great deal of emotional distress. One such decision is whether or not to pursue testing that could provide more information about their baby's death. Lewis and colleagues state that postmortem testing is the most valuable tool available to learn about cause of death and implications for future health and pregnancies. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14828The inherited risk of retained placenta: a population based cohort studyMargit Endler, Sven Cnattingius, Michaela Granfors, Anna-Karin Wikström2017-07-21T09:11:22.610645-05:00doi:10.1111/1471-0528.14828John Wiley & Sons, Inc.10.1111/1471-0528.14828http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14828Main Research Articlen/an/a

Abstract

Objective

To investigate whether retained placenta in the first generation is associated with an increased risk of retained placenta in the second generation.

Design

Population-based cohort study.

Setting

Sweden.

Population

Using linked generational data from the Swedish Medical Birth Register 1973-2012, we identified 494,000 second generation births with information on the birth of the mother (first generation index birth). For 292,897 of these births there was information also on the birth of the father.

Methods

Risk of retained placenta in the second generation was calculated as adjusted odds ratios (AOR) by unconditional logistic regression with 95% confidence intervals (CI) according to whether retained placenta occurred in a first generation birth or not.

Main outcome

Retained placenta in the second generation.

Results

The risk of retained placenta in a second generation birth was increased if retained placenta had occurred at the mother′s own birth (AOR 1.66, 95% CI 1.52-1.82), at the birth of one of her siblings (AOR 1.58, 95% CI 1.43-1.76) or both (AOR 2.75, 95% CI 2.18-3.46). The risk was slightly increased if retained placenta had occurred at the birth of the father (AOR 1.23, 95% CI 1.07-1.41). For preterm births in both generations, the risk of retained placenta in the second generation was increased 6-fold if retained placenta had occurred at the mother′s birth (OR 6.55, 95% CI 2.68-16.02).

Conclusion

There is an intergenerational recurrence of retained placenta on the maternal and most likely also on the paternal side. The recurrence risk seems strongest in preterm pregnancies.

This article is protected by copyright. All rights reserved.

Objective To investigate whether retained placenta in the first generation is associated with an increased risk of retained placenta in the second generation. Design Population-based cohort study. Setting Sweden. Population Using linked generational data from the Swedish Medical Birth Register 1973-2012, we identified 494,000 second generation births with information on the birth of the mother (first generation index birth). For 292,897 of these births there was information also on the birth of the father. Methods Risk of retained placenta in the second generation was calculated as adjusted odds ratios (AOR) by unconditional logistic regression with 95% confidence intervals (CI) according to whether retained placenta occurred in a first generation birth or not. Main outcome Retained placenta in the second generation. Results The risk of retained placenta in a second generation birth was increased if retained placenta had occurred at the mother′s own birth (AOR 1.66, 95% CI 1.52-1.82), at the birth of one of her siblings (AOR 1.58, 95% CI 1.43-1.76) or both (AOR 2.75, 95% CI 2.18-3.46). The risk was slightly increased if retained placenta had occurred at the birth of the father (AOR 1.23, 95% CI 1.07-1.41). For preterm births in both generations, the risk of retained placenta in the second generation was increased 6-fold if retained placenta had occurred at the mother′s birth (OR 6.55, 95% CI 2.68-16.02). Conclusion There is an intergenerational recurrence of retained placenta on the maternal and most likely also on the paternal side. The recurrence risk seems strongest in preterm pregnancies. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14827Paving the way for improved management of severe ITP in pregnancyAndra H. James2017-07-19T11:00:30.709027-05:00doi:10.1111/1471-0528.14827John Wiley & Sons, Inc.10.1111/1471-0528.14827http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14827Mini-commentaryn/an/a

Abstract

Those of us who take care of women with blood disorders have few data on which to base our management of thrombocytopenia in pregnancy, particularly immune thrombocytopenia purpura (ITP). We extrapolate from the management of ITP in nonpregnant individuals and try to raise platelet counts in an attempt to meet the bleeding challenges of childbirth. Thirty years ago we believed that ITP conferred fetal risks similar to those conferred by alloimmune thrombocytopenia.

This article is protected by copyright. All rights reserved.

Those of us who take care of women with blood disorders have few data on which to base our management of thrombocytopenia in pregnancy, particularly immune thrombocytopenia purpura (ITP). We extrapolate from the management of ITP in nonpregnant individuals and try to raise platelet counts in an attempt to meet the bleeding challenges of childbirth. Thirty years ago we believed that ITP conferred fetal risks similar to those conferred by alloimmune thrombocytopenia. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14825Feasibility of using self-reported ethnicity in pregnancy according to the Gestation Related Optimal Weight (GROW) classification: a cross-sectional studyElizabeth Lockie, Elizabeth McCarthy, Lisa Hui, Leonid Churilov, Susan P Walker2017-07-14T09:10:27.714178-05:00doi:10.1111/1471-0528.14825John Wiley & Sons, Inc.10.1111/1471-0528.14825http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14825Main Research Articlen/an/a

Abstract

Objective

To evaluate the feasibility of self-reported ethnicity using the Gestation Related Optimal Growth (GROW) classification in a contemporary multicultural antenatal population.

Design

Cross-sectional study.

Setting

Tertiary obstetric hospital in Melbourne, Australia.

Population

Pregnant women attending antenatal clinic.

Methods

We surveyed pregnant women during April-June 2016 regarding their understanding of the term ‘ethnicity’, and how they would classify the ethnicity of themselves, their partner and family members according to the Australian GROW classification.

Results

Two hundred and thirty five women completed the survey. When describing ‘ethnicity’, most women 103 (44%) chose multiple descriptors, most frequently country of birth (54%) and region of ancestry (47%). Interpretation of ‘ethnicity’ varied significantly between ethnic groups; those choosing ‘country of birth’ were more likely to identify as Indian (OR 3.5, p=0.03), whereas those choosing ‘physical appearance’ were more likely to identify as Chinese (OR 3.0, p=0.047). Thirty participants (13%) were unable to describe their ethnicity from the available GROW options. Sixty-one (26%) respondents’ ethnicity was inconsistent with that of their parents’ heritage. A further 35% had a partner of different ethnicity. The agreement between country of birth and self-reported ethnicity was only fair (kappa 0.73 (95%CI 0.64-0.82)).

Conclusions

This study confirms the complexity of defining ethnicity in contemporary multicultural settings. Self-reported ethnicity is often inaccurate, concepts of ethnicity vary by ethnic group and country of birth is a poor descriptive surrogate. Adjustment for maternal ethnicity should be undertaken with caution in the customised assessment of fetal growth.

This article is protected by copyright. All rights reserved.

Objective To evaluate the feasibility of self-reported ethnicity using the Gestation Related Optimal Growth (GROW) classification in a contemporary multicultural antenatal population. Design Cross-sectional study. Setting Tertiary obstetric hospital in Melbourne, Australia. Population Pregnant women attending antenatal clinic. Methods We surveyed pregnant women during April-June 2016 regarding their understanding of the term ‘ethnicity’, and how they would classify the ethnicity of themselves, their partner and family members according to the Australian GROW classification. Results Two hundred and thirty five women completed the survey. When describing ‘ethnicity’, most women 103 (44%) chose multiple descriptors, most frequently country of birth (54%) and region of ancestry (47%). Interpretation of ‘ethnicity’ varied significantly between ethnic groups; those choosing ‘country of birth’ were more likely to identify as Indian (OR 3.5, p=0.03), whereas those choosing ‘physical appearance’ were more likely to identify as Chinese (OR 3.0, p=0.047). Thirty participants (13%) were unable to describe their ethnicity from the available GROW options. Sixty-one (26%) respondents’ ethnicity was inconsistent with that of their parents’ heritage. A further 35% had a partner of different ethnicity. The agreement between country of birth and self-reported ethnicity was only fair (kappa 0.73 (95%CI 0.64-0.82)). Conclusions This study confirms the complexity of defining ethnicity in contemporary multicultural settings. Self-reported ethnicity is often inaccurate, concepts of ethnicity vary by ethnic group and country of birth is a poor descriptive surrogate. Adjustment for maternal ethnicity should be undertaken with caution in the customised assessment of fetal growth. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14822The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort studyA. J. M. W. Vervoort, J. Vissers, W.J.K. Hehenkamp, H. A. M. Brölmann, J. A. F. Huirne2017-07-13T09:30:38.843493-05:00doi:10.1111/1471-0528.14822John Wiley & Sons, Inc.10.1111/1471-0528.14822http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14822Main Research Articlen/an/a

Abstract

Objective

To evaluate the effectiveness of a laparoscopic niche resection on niche related symptoms and/or fertility related problems, ultrasound findings and quality of life.

Design

Prospective cohort study.

Setting

University hospital.

Population

Women with a large niche (residual myometrium (RM) <3 mm) and complaints of either postmenstrual spotting, dysmenorrhea, intrauterine fluid accumulation and/or difficulties with embryo transfer due to distorted anatomy.

Methods

Women filled out questionnaires and a validated menstrual score chart at baseline and six months after the laparoscopic niche resection. At baseline and between three to six months follow-up niches were evaluated by transvaginal ultrasound

Main outcome measures

The primary outcome was reduction of the main problem six months after the intervention. Secondary outcomes were complications, menstrual characteristics, dysmenorrhea, niche measurements, intrauterine fluid, surgical outcomes, satisfaction and quality of life.

Results

101 women underwent a laparoscopic niche resection. In 80 women (79.2%) the main problem was improved or resolved. Postmenstrual spotting was reduced statistically significant with 7 days at six months follow-up compared to baseline. Dysmenorrhea and discomfort related to spotting reduced statistically significant as well. The RM increased statistically significant at follow-up. The intrauterine fluid was resolved in 86.9% of the women with intra-uterine fluid at baseline. 83.3% of women were (very) satisfied. The physical component of quality of life increased, the mental component did not change.

Conclusions

A laparoscopic niche resection reduced postmenstrual spotting, discomfort due to spotting, dysmenorrhea and the presence of intrauterine fluid in the majority of women and increased the RM.

This article is protected by copyright. All rights reserved.

Objective To evaluate the effectiveness of a laparoscopic niche resection on niche related symptoms and/or fertility related problems, ultrasound findings and quality of life. Design Prospective cohort study. Setting University hospital. Population Women with a large niche (residual myometrium (RM) <3 mm) and complaints of either postmenstrual spotting, dysmenorrhea, intrauterine fluid accumulation and/or difficulties with embryo transfer due to distorted anatomy. Methods Women filled out questionnaires and a validated menstrual score chart at baseline and six months after the laparoscopic niche resection. At baseline and between three to six months follow-up niches were evaluated by transvaginal ultrasound Main outcome measures The primary outcome was reduction of the main problem six months after the intervention. Secondary outcomes were complications, menstrual characteristics, dysmenorrhea, niche measurements, intrauterine fluid, surgical outcomes, satisfaction and quality of life. Results 101 women underwent a laparoscopic niche resection. In 80 women (79.2%) the main problem was improved or resolved. Postmenstrual spotting was reduced statistically significant with 7 days at six months follow-up compared to baseline. Dysmenorrhea and discomfort related to spotting reduced statistically significant as well. The RM increased statistically significant at follow-up. The intrauterine fluid was resolved in 86.9% of the women with intra-uterine fluid at baseline. 83.3% of women were (very) satisfied. The physical component of quality of life increased, the mental component did not change. Conclusions A laparoscopic niche resection reduced postmenstrual spotting, discomfort due to spotting, dysmenorrhea and the presence of intrauterine fluid in the majority of women and increased the RM. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14823Treatment of post-caesarean niche: the accumulation of evidenceTarek El-Toukhy2017-07-13T09:30:21.935651-05:00doi:10.1111/1471-0528.14823John Wiley & Sons, Inc.10.1111/1471-0528.14823http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14823Mini-commentaryn/an/a

Abstract

Caesarean section is one of the most commonly performed surgical procedures globally and so any related morbidity is potentially of great importance. A post-caesarean niche (also known as an isthmocoele) is a wedge-shaped anechoic myometrial indentation at the site of the caesarean scar due to defective healing. The niche can be described as small or large depending on the thickness of residual myometrium.

This article is protected by copyright. All rights reserved.

Caesarean section is one of the most commonly performed surgical procedures globally and so any related morbidity is potentially of great importance. A post-caesarean niche (also known as an isthmocoele) is a wedge-shaped anechoic myometrial indentation at the site of the caesarean scar due to defective healing. The niche can be described as small or large depending on the thickness of residual myometrium. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14820Perinatal and maternal morbidity and mortality among term singletons following midcavity operative vaginal delivery versus caesarean deliveryGiulia M. Muraca, Amanda Skoll, Sarka Lisonkova, Yasser Sabr, Rollin Brant, Geoffrey W. Cundiff, K.S. Joseph2017-07-10T10:15:43.977627-05:00doi:10.1111/1471-0528.14820John Wiley & Sons, Inc.10.1111/1471-0528.14820http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14820Main Research Articlen/an/a

Abstract

Objective

To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery.

Design

Population-based, retrospective cohort study.

Setting

British Columbia, Canada.

Population

Term, singleton deliveries (2004-2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery (n=10,901 deliveries; 5,057 indicated for dystocia, 5,844 for fetal distress).

Methods

Multinomial propensity scores and mulitvariable log-binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (CI).

Main outcome measures

Composite severe perinatal morbidity/mortality (e.g., convulsions, severe birth trauma, and perinatal death) and severe maternal morbidity (e.g., severe postpartum haemorrhage, shock, sepsis and cardiac complications).

Results

Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46-3.07; vacuum ARR 2.71, 95% CI 1.49-3.15; sequential ARR 4.68, 95% CI 3.33-6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05-2.36; vacuum ARR 2.29, 95% CI 1.57-3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04-1.61) and in severe maternal morbidity following attempted midcavity forceps delivery (ARR 2.34, 95% CI 1.54-3.56).

Conclusion

Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument.

This article is protected by copyright. All rights reserved.

Objective To quantify severe perinatal and maternal morbidity/mortality associated with midcavity operative vaginal delivery compared with caesarean delivery. Design Population-based, retrospective cohort study. Setting British Columbia, Canada. Population Term, singleton deliveries (2004-2014) by attempted midcavity operative vaginal delivery or caesarean delivery in the second stage of labour, stratified by indication for operative delivery (n=10,901 deliveries; 5,057 indicated for dystocia, 5,844 for fetal distress). Methods Multinomial propensity scores and mulitvariable log-binomial regression models were used to estimate adjusted rate ratios (ARR) and 95% confidence intervals (CI). Main outcome measures Composite severe perinatal morbidity/mortality (e.g., convulsions, severe birth trauma, and perinatal death) and severe maternal morbidity (e.g., severe postpartum haemorrhage, shock, sepsis and cardiac complications). Results Among deliveries with dystocia, attempted midcavity operative vaginal delivery was associated with higher rates of severe perinatal morbidity/mortality compared with caesarean delivery (forceps ARR 2.11, 95% CI 1.46-3.07; vacuum ARR 2.71, 95% CI 1.49-3.15; sequential ARR 4.68, 95% CI 3.33-6.58). Rates of severe maternal morbidity/mortality were also higher following midcavity operative vaginal delivery (forceps ARR 1.57, 95% CI 1.05-2.36; vacuum ARR 2.29, 95% CI 1.57-3.36). Among deliveries with fetal distress, there were significant increases in severe perinatal morbidity/mortality following attempted midcavity vacuum (ARR 1.28, 95% CI 1.04-1.61) and in severe maternal morbidity following attempted midcavity forceps delivery (ARR 2.34, 95% CI 1.54-3.56). Conclusion Attempted midcavity operative vaginal delivery is associated with higher rates of severe perinatal morbidity/mortality and severe maternal morbidity, though these effects differ by indication and instrument. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14813Expulsions and adverse events following immediate and later insertion of a levonorgestrel-releasing intrauterine system after medical termination of late first and second trimester pregnancy: A randomised controlled trialRiina Korjamo, Maarit Mentula, Oskari Heikinheimo2017-07-10T08:30:22.648275-05:00doi:10.1111/1471-0528.14813John Wiley & Sons, Inc.10.1111/1471-0528.14813http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14813Main Research Articlen/an/a

Abstract

Objective

To compare expulsions and adverse events (AEs) between immediate and delayed insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) following medical termination of pregnancy (MTOP).

Design

Randomised controlled trial.

Setting

Helsinki University Hospital, Finland, Jan 2013–Dec 2014.

Population

102 (gestational age 64–84 days, late first trimester) and 57 (gestational age 85–140 days, second trimester) women requesting MTOP and LNG-IUS contraception.

Methods

LNG-IUS insertion occurred immediately (same day) or 2–4-weeks following MTOP. Follow-up visits were at 2–4 weeks, three months and one year.

Main outcome measures

LNG-IUS expulsion by three months and one year. AEs and bleeding profiles within 3 months.

Results

Following late first-trimester MTOP the LNG-IUS expulsion rates by three months were 14(27.5%) in the immediate and 2(4.0%) in the delayed-insertion group (RR 6.86, 95%CI 1.64–28.66). By one year the expulsion rates were 17(33.3%) and 6(12.0%) (RR 2.78, 1.19–6.47). Following second-trimester MTOP LNG-IUS expulsion rates by three months and one year were 5(18.5%) in the immediate and 1(3.6%) in the delayed-insertion group (RR 5.19, 0.65–41.54). No differences in AEs and bleeding profiles emerged between the groups.

Conclusions

Immediate LNG-IUS insertion after late first or second trimester MTOP is feasible, does not increase the complication or alter the uterine bleeding patterns. However, immediate insertion increased the expulsion rate, which may limit the cost-effectiveness.

This article is protected by copyright. All rights reserved.

Objective To compare expulsions and adverse events (AEs) between immediate and delayed insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) following medical termination of pregnancy (MTOP). Design Randomised controlled trial. Setting Helsinki University Hospital, Finland, Jan 2013–Dec 2014. Population 102 (gestational age 64–84 days, late first trimester) and 57 (gestational age 85–140 days, second trimester) women requesting MTOP and LNG-IUS contraception. Methods LNG-IUS insertion occurred immediately (same day) or 2–4-weeks following MTOP. Follow-up visits were at 2–4 weeks, three months and one year. Main outcome measures LNG-IUS expulsion by three months and one year. AEs and bleeding profiles within 3 months. Results Following late first-trimester MTOP the LNG-IUS expulsion rates by three months were 14(27.5%) in the immediate and 2(4.0%) in the delayed-insertion group (RR 6.86, 95%CI 1.64–28.66). By one year the expulsion rates were 17(33.3%) and 6(12.0%) (RR 2.78, 1.19–6.47). Following second-trimester MTOP LNG-IUS expulsion rates by three months and one year were 5(18.5%) in the immediate and 1(3.6%) in the delayed-insertion group (RR 5.19, 0.65–41.54). No differences in AEs and bleeding profiles emerged between the groups. Conclusions Immediate LNG-IUS insertion after late first or second trimester MTOP is feasible, does not increase the complication or alter the uterine bleeding patterns. However, immediate insertion increased the expulsion rate, which may limit the cost-effectiveness. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14812Studying women who don't make best use of antenatal careE J Buchmann2017-07-10T08:25:18.730691-05:00doi:10.1111/1471-0528.14812John Wiley & Sons, Inc.10.1111/1471-0528.14812http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14812Mini-commentaryn/an/a

Abstract

While it seems self-evident that antenatal care is a good thing, it helps that randomised trials have shown many antenatal interventions to be effective in reducing pregnancy risks. Antenatal care provides the vehicle for these interventions, and more frequent antenatal visits give more opportunities for intervention.

This article is protected by copyright. All rights reserved.

While it seems self-evident that antenatal care is a good thing, it helps that randomised trials have shown many antenatal interventions to be effective in reducing pregnancy risks. Antenatal care provides the vehicle for these interventions, and more frequent antenatal visits give more opportunities for intervention. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14809Time to test tamponadeG J Hofmeyr2017-07-10T08:20:19.107756-05:00doi:10.1111/1471-0528.14809John Wiley & Sons, Inc.10.1111/1471-0528.14809http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14809Commentaryn/an/a

Abstract

The general surgical principle of applying direct pressure at the site of haemorrhage has been applied in the treatment of postpartum haemorrhage (PPH) by means of an assortment of inflatable devices introduced into the uterine cavity. Over the last 23 years several reports and reviews in the BJOG and elsewhere have documented the apparent effectiveness of uterine balloon tamponade (UBT) for treatment of PPH. A large study in 2016 reported a success rate after vaginal delivery of 89% (152/171) and concluded that intrauterine balloon tamponade is an effective method for treating severe PPH.

This article is protected by copyright. All rights reserved.

The general surgical principle of applying direct pressure at the site of haemorrhage has been applied in the treatment of postpartum haemorrhage (PPH) by means of an assortment of inflatable devices introduced into the uterine cavity. Over the last 23 years several reports and reviews in the BJOG and elsewhere have documented the apparent effectiveness of uterine balloon tamponade (UBT) for treatment of PPH. A large study in 2016 reported a success rate after vaginal delivery of 89% (152/171) and concluded that intrauterine balloon tamponade is an effective method for treating severe PPH. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14808Risk of persistent or recurrent cervical neoplasia in patients with ‘pure’ adenocarcinoma-in-situ (AIS) or mixed AIS and high-grade cervical squamous neoplasia (cervical intraepithelial neoplasia grades 2 and 3 [CIN 2/3]): a population based studyElizabeth Codde, Aime Munro, Colin J R. Stewart, Katrina Spilsbury, Shirley Bowen, Jim Codde, Nerida Steel, Yee Leung, Jason Tan, Stuart G. Salfinger, Ganendra R. Mohan, Paul A. Cohen2017-07-05T10:00:33.221133-05:00doi:10.1111/1471-0528.14808John Wiley & Sons, Inc.10.1111/1471-0528.14808http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14808Main Research Articlen/an/a

Abstract

Objective

To compare outcomes of patients with pure AIS and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to adenocarcinoma.

Design

Retrospective cohort study.

Setting

Statewide population in Western Australia.

Population

Women diagnosed with AIS between 2001 and 2012.

Methods

We conducted a retrospective, population-based cohort study.

Main Outcome Measures

De-identified linked data were utilized to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS <12 months from treatment), recurrent AIS (≥12 months post treatment), and adenocarcinoma.

Results

Six hundred thirty-six patients were eligible for analysis. The mean age was 32.3 years and median follow-up interval was 2.5 years. Within the study cohort, 266 (41.8%) patients had pure AIS and 370 (58.2%) had mixed AIS/CIN 2/3. Overall, 47 (7.4%) patients had AIS persistence/recurrence and 12 (1.9%) had adenocarcinoma. Factors associated with persistence/recurrence were pure AIS (HR 2.3; 95%CI 1.28 – 3.94; p = 0.005), age >30 years (HR 2.1; 95%CI 1.16 – 3.81; p = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05 – 10.92; p = <0.001) and AIS lesions >8mm (HR 2.5; 95%CI 1.00 – 6.20; p = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence.

Conclusion

In this study, pure AIS was associated with greater risk of persistence/recurrence compared to mixed AIS/CIN 2/3. AIS lesions >8mm and positive endocervical margins were significant predictors for persistent or recurrent disease.

This article is protected by copyright. All rights reserved.

Objective To compare outcomes of patients with pure AIS and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to adenocarcinoma. Design Retrospective cohort study. Setting Statewide population in Western Australia. Population Women diagnosed with AIS between 2001 and 2012. Methods We conducted a retrospective, population-based cohort study. Main Outcome Measures De-identified linked data were utilized to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS <12 months from treatment), recurrent AIS (≥12 months post treatment), and adenocarcinoma. Results Six hundred thirty-six patients were eligible for analysis. The mean age was 32.3 years and median follow-up interval was 2.5 years. Within the study cohort, 266 (41.8%) patients had pure AIS and 370 (58.2%) had mixed AIS/CIN 2/3. Overall, 47 (7.4%) patients had AIS persistence/recurrence and 12 (1.9%) had adenocarcinoma. Factors associated with persistence/recurrence were pure AIS (HR 2.3; 95%CI 1.28 – 3.94; p = 0.005), age >30 years (HR 2.1; 95%CI 1.16 – 3.81; p = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05 – 10.92; p = <0.001) and AIS lesions >8mm (HR 2.5; 95%CI 1.00 – 6.20; p = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence. Conclusion In this study, pure AIS was associated with greater risk of persistence/recurrence compared to mixed AIS/CIN 2/3. AIS lesions >8mm and positive endocervical margins were significant predictors for persistent or recurrent disease. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14807Caesarean Myomectomy: TE or not TE?Karl S.J. Oláh2017-07-05T09:55:18.477241-05:00doi:10.1111/1471-0528.14807John Wiley & Sons, Inc.10.1111/1471-0528.14807http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14807Mini-commentaryn/an/a

Abstract

Many years ago as a trainee I removed a subserosal fibroid during a caesarean section that was hanging by a thin stalk on the back of the uterus. The berating I received was severe and disproportionate to my crime. The rule was that myomectomy performed at caesarean section was not just frowned upon, but expressly forbidden.

This article is protected by copyright. All rights reserved.

Many years ago as a trainee I removed a subserosal fibroid during a caesarean section that was hanging by a thin stalk on the back of the uterus. The berating I received was severe and disproportionate to my crime. The rule was that myomectomy performed at caesarean section was not just frowned upon, but expressly forbidden. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14805Mental health near miss indicators in maternity care: a missed opportunity? A CommentaryA. Easter, L M Howard, J. Sandall2017-06-30T10:45:24.679807-05:00doi:10.1111/1471-0528.14805John Wiley & Sons, Inc.10.1111/1471-0528.14805http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14805Commentaryn/an/a

Abstract

Medical comorbidities are common among individuals with mental illness and during pregnancy physical and mental health problems are intrinsically interrelated and can result in serious complications or death. Pregnancy and childbirth represent an optimal opportunity for recognition and response to both physical and mental illness due to increased contact with healthcare professionals. However, in addition to the psychological morbidity associated with mental illness, women with mental illness continue to have an increased risk of obstetric complications and a higher mortality rate during the perinatal period.1 As such, perinatal mental health has been identified as a priority area for integrated health care.2

This article is protected by copyright. All rights reserved.

Medical comorbidities are common among individuals with mental illness and during pregnancy physical and mental health problems are intrinsically interrelated and can result in serious complications or death. Pregnancy and childbirth represent an optimal opportunity for recognition and response to both physical and mental illness due to increased contact with healthcare professionals. However, in addition to the psychological morbidity associated with mental illness, women with mental illness continue to have an increased risk of obstetric complications and a higher mortality rate during the perinatal period.1 As such, perinatal mental health has been identified as a priority area for integrated health care.2 This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14801Urinary Diversions in Low Resource SettingsJeffrey P. Wilkinson2017-06-26T09:52:53.747995-05:00doi:10.1111/1471-0528.14801John Wiley & Sons, Inc.10.1111/1471-0528.14801http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14801Mini-commentaryn/an/a

Abstract

Obstetric fistula is a devastating consequence of poorly attended childbirth which occurs almost exclusively in low resource settings. Most women with fistula can be cured or significantly improved by one or more vaginal surgeries. The last resort for women with otherwise incurable obstetric fistula is urinary diversion. The ileal conduit urinary diversion was the procedure considered by the authors of the accompanying article (Walker et al BJOG). Under optimal conditions, any urinary diversion is fraught with numerous potential risks. These include anastomotic leak, surgical site infection, sepsis, metabolic abnormalities, ureteral obstruction, uremia and death. In low resource settings, the magnitude of these complications is magnified exponentially by pervasive shortages of staff, supplies, training and high level care. Patients must be counseled on these risks when undergoing urinary diversion procedures: Risks which extend beyond the peri-operative period and involve more than just physical sequelae.

This article is protected by copyright. All rights reserved.

Obstetric fistula is a devastating consequence of poorly attended childbirth which occurs almost exclusively in low resource settings. Most women with fistula can be cured or significantly improved by one or more vaginal surgeries. The last resort for women with otherwise incurable obstetric fistula is urinary diversion. The ileal conduit urinary diversion was the procedure considered by the authors of the accompanying article (Walker et al BJOG). Under optimal conditions, any urinary diversion is fraught with numerous potential risks. These include anastomotic leak, surgical site infection, sepsis, metabolic abnormalities, ureteral obstruction, uremia and death. In low resource settings, the magnitude of these complications is magnified exponentially by pervasive shortages of staff, supplies, training and high level care. Patients must be counseled on these risks when undergoing urinary diversion procedures: Risks which extend beyond the peri-operative period and involve more than just physical sequelae. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14802Immediate vs. delayed initiation of the levonorgestrel-releasing intrauterine system following medical termination of pregnancy – one year continuation rates: A randomised controlled trialRiina Korjamo, Maarit Mentula, Oskari Heikinheimo2017-06-26T09:52:51.92228-05:00doi:10.1111/1471-0528.14802John Wiley & Sons, Inc.10.1111/1471-0528.14802http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14802Main Research Articlen/an/a

Abstract

Objective

To assess the 1-year continuation rates and new pregnancies following immediate vs. delayed insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) after medical termination of pregnancy (MTOP) of up to 20 weeks of gestation.

Design

A randomised controlled trial.

Setting

Helsinki University Hospital, Finland, Jan 2013–Dec 2014.

Population

267 women requesting MTOP and planning LNG-IUS for post-MTOP contraception.

Methods

LNG-IUS insertion occurred immediately (0-3 days) or after a delay (2–4-weeks) following MTOP. Follow-up visits were at three months and one year after MTOP.

Main outcome measures

LNG-IUS use at one year after MTOP.

Results

Women were randomised to immediate (n=134) or delayed (n=133) insertion of the LNG-IUS, and 133 and 131 were analysed. 127(95.5%) women received immediate and 111(84.7%) women delayed insertion of the LNG-IUS (risk ratio [RR] 1.13, 95% confidence interval 1.04–1.22). The verified number of women continuing the LNG-IUS use at one year were 83(62.4%) vs. 52(39.7%) (RR 1.57, 1.23–2.02). The number of new pregnancies was 6(4.5%) vs. 16(12.2%) (RR 0.37, 0.15–0.91), and subsequent TOPs 4(3.0%) vs. 5(3.8%) (RR 0.79, 0.22–2.87).

Conclusions

Immediate insertion of the LNG-IUS following MTOP resulted in higher 1-year continuation rates compared to delayed insertion. In addition, those receiving immediate insertion demonstrated a decreased new pregnancy rate, but no difference in the numbers of another TOP.

This article is protected by copyright. All rights reserved.

Objective To assess the 1-year continuation rates and new pregnancies following immediate vs. delayed insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) after medical termination of pregnancy (MTOP) of up to 20 weeks of gestation. Design A randomised controlled trial. Setting Helsinki University Hospital, Finland, Jan 2013–Dec 2014. Population 267 women requesting MTOP and planning LNG-IUS for post-MTOP contraception. Methods LNG-IUS insertion occurred immediately (0-3 days) or after a delay (2–4-weeks) following MTOP. Follow-up visits were at three months and one year after MTOP. Main outcome measures LNG-IUS use at one year after MTOP. Results Women were randomised to immediate (n=134) or delayed (n=133) insertion of the LNG-IUS, and 133 and 131 were analysed. 127(95.5%) women received immediate and 111(84.7%) women delayed insertion of the LNG-IUS (risk ratio [RR] 1.13, 95% confidence interval 1.04–1.22). The verified number of women continuing the LNG-IUS use at one year were 83(62.4%) vs. 52(39.7%) (RR 1.57, 1.23–2.02). The number of new pregnancies was 6(4.5%) vs. 16(12.2%) (RR 0.37, 0.15–0.91), and subsequent TOPs 4(3.0%) vs. 5(3.8%) (RR 0.79, 0.22–2.87). Conclusions Immediate insertion of the LNG-IUS following MTOP resulted in higher 1-year continuation rates compared to delayed insertion. In addition, those receiving immediate insertion demonstrated a decreased new pregnancy rate, but no difference in the numbers of another TOP. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14798The impact of a novel transendometrial approach for caesarean myomectomy on obstetric outcomes of subsequent pregnancy: A longitudinal panel studySY Huang, SW Shaw, SY Su, WF Li, HH Peng, PJ Cheng2017-06-24T04:48:40.858384-05:00doi:10.1111/1471-0528.14798John Wiley & Sons, Inc.10.1111/1471-0528.14798http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14798Main Research Articlen/an/a

Abstract

Objective

To evaluate the obstetric and surgical outcomes of a novel transendometrial approach for myomectomy during caesarean section in subsequent pregnancies.

Design

Longitudinal panel study.

Setting

Chang Gung Memorial Hospital, Taiwan, with approximately 5000 births per annum.

Population

Pregnant women complicated with uterine myoma.

Method

Sixty-three pregnant women who received transendometrial myomectomy during the first caesarean delivery reported a subsequent live pregnancy and planned an elective repeat caesarean delivery.

Main outcome measures

Obstetric outcomes consisted of gestational age at birth, newborn weight, Apgar score, birth weight adequacy, uterine rupture, placental abruption, placental previa, placental accreta, spontaneous preterm birth, and preterm premature rupture of membranes. Surgical outcomes consisted of surgical time, blood loss, blood transfusion, postoperative fever, length of hospital stay, and mean adhesion score.

Result

The mean gestational age at birth and newborn weight at the subsequent caesarean section were superior to those at the first caesarean delivery. Spontaneous preterm birth, small for gestational age, and preterm premature rupture of membranes occurred more often in the first pregnancy than in the subsequent pregnancy. The mean surgical time was shorter for the subsequent caesarean delivery than for the first caesarean delivery combined with myomectomy. The other surgical composite outcomes of blood loss, blood transfusion, postoperative fever, length of hospital stay, and mean adhesion score were similar across two stages of caesarean deliveries.

Conclusion

The novel transendometrial approach for caesarean myomectomy may improve the obstetric outcomes of subsequent pregnancy without causing any additional immediate and long-term adverse surgical outcomes.

This article is protected by copyright. All rights reserved.

Objective To evaluate the obstetric and surgical outcomes of a novel transendometrial approach for myomectomy during caesarean section in subsequent pregnancies. Design Longitudinal panel study. Setting Chang Gung Memorial Hospital, Taiwan, with approximately 5000 births per annum. Population Pregnant women complicated with uterine myoma. Method Sixty-three pregnant women who received transendometrial myomectomy during the first caesarean delivery reported a subsequent live pregnancy and planned an elective repeat caesarean delivery. Main outcome measures Obstetric outcomes consisted of gestational age at birth, newborn weight, Apgar score, birth weight adequacy, uterine rupture, placental abruption, placental previa, placental accreta, spontaneous preterm birth, and preterm premature rupture of membranes. Surgical outcomes consisted of surgical time, blood loss, blood transfusion, postoperative fever, length of hospital stay, and mean adhesion score. Result The mean gestational age at birth and newborn weight at the subsequent caesarean section were superior to those at the first caesarean delivery. Spontaneous preterm birth, small for gestational age, and preterm premature rupture of membranes occurred more often in the first pregnancy than in the subsequent pregnancy. The mean surgical time was shorter for the subsequent caesarean delivery than for the first caesarean delivery combined with myomectomy. The other surgical composite outcomes of blood loss, blood transfusion, postoperative fever, length of hospital stay, and mean adhesion score were similar across two stages of caesarean deliveries. Conclusion The novel transendometrial approach for caesarean myomectomy may improve the obstetric outcomes of subsequent pregnancy without causing any additional immediate and long-term adverse surgical outcomes. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14797Accuracy of visual cervical screening: Verification bias revisitedNicolas Wentzensen, Tamara Litwin2017-06-24T04:42:28.473633-05:00doi:10.1111/1471-0528.14797John Wiley & Sons, Inc.10.1111/1471-0528.14797http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14797Mini-commentaryn/an/a

Abstract

Cytology-based cervical cancer screening has led to substantial reductions in cancer incidence and mortality. Today, most cervical cancers arise in low-resource countries without screening. Since implementation of cytology is not feasible in most developing countries, visual screening and HPV testing are evaluated as alternative strategies.

This article is protected by copyright. All rights reserved.

Cytology-based cervical cancer screening has led to substantial reductions in cancer incidence and mortality. Today, most cervical cancers arise in low-resource countries without screening. Since implementation of cytology is not feasible in most developing countries, visual screening and HPV testing are evaluated as alternative strategies. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14796Is Transvaginal Contained Tissue Extraction for Everyone?Charles Miller2017-06-21T15:05:35.652505-05:00doi:10.1111/1471-0528.14796John Wiley & Sons, Inc.10.1111/1471-0528.14796http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14796Mini-commentaryn/an/a

Abstract

Professor Ghezzi, et al. should be congratulated for their excellent manuscript “Transvaginal Contained Tissue Extraction After Laparoscopic Myomectomy: A Cohort Study”. This is a well-conceived, well-written retrospective cohort study describing operative and peri-operative outcomes for patients who have undergone transvaginal morcellation via a posterior colpotomy. Given the continued controversy regarding electronic power morcellation leading to restriction of use in certain areas, this study is not only impactful, in that it describes an alternative technique with data accumulated over a decade of experience, but it describes a technique of contained morcellation that is neither based on the controversial power morcellation, nor the mini-laparotomy (https://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm424443.htm).

This article is protected by copyright. All rights reserved.

Professor Ghezzi, et al. should be congratulated for their excellent manuscript “Transvaginal Contained Tissue Extraction After Laparoscopic Myomectomy: A Cohort Study”. This is a well-conceived, well-written retrospective cohort study describing operative and peri-operative outcomes for patients who have undergone transvaginal morcellation via a posterior colpotomy. Given the continued controversy regarding electronic power morcellation leading to restriction of use in certain areas, this study is not only impactful, in that it describes an alternative technique with data accumulated over a decade of experience, but it describes a technique of contained morcellation that is neither based on the controversial power morcellation, nor the mini-laparotomy (https://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm424443.htm). This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14794Association between inadequate antenatal care utilisation and severe perinatal and maternal morbidity: an analysis in the PreCARE cohortM Linard, B Blondel, C Estellat, C Deneux-Tharaux, D Luton, J F Oury, T Schmitz, L Mandelbrot, E Azria, 2017-06-20T02:52:42.054364-05:00doi:10.1111/1471-0528.14794John Wiley & Sons, Inc.10.1111/1471-0528.14794http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14794Main Research Articlen/an/a

Abstract

Objective

Because the effectiveness of antenatal care in reducing pregnancy complications is still discussed despite widespread recommendations of its use, we sought to assess the association between utilisation of recommended antenatal care and severe maternal (SMM) and perinatal morbidity (SPM).

Design

Prospective cohort study.

Setting

Four maternity units around Paris in 2010-2012.

Sample

9117 women with singleton pregnancies.

Methods

Logistic regression models adjusted for maternal social, demographic and medical characteristics.

Main Outcome Measures

Antenatal care utilisation was assessed by: 1) initiation of care after 14 weeks, 2) less than 50% of recommended visits made, according to gestational age, 3) absence of the first, second or third trimester ultrasounds, 4) two modified Adequacy of Prenatal Care Utilization indexes, combining these components. The two main outcomes were composite variables of SMM and SPM.

Results

According to the modified Adequacy of Prenatal Care Utilization index, 34.6% of women had inadequate antenatal care utilization; the incidence of SMM was 2.9% and SPM 5.5%. A percentage of recommended visits below 50% (2.6% of women) was associated with SMM (aOR: 2.40 [1.38-4.17]) and SPM (aOR: 2.27 [1.43-3.59]). Late initiation of care (17.0% of women) was not associated with SMM or SPM. Failure to undergo the recommended ultrasounds (16%, 17% and 22% of women) was associated with SPM. Inadequate antenatal care utilization according to the index was associated with SPM (aOR: 1.37 [1.05-1.80]).

Conclusion

Inadequate antenatal care utilisation is associated with SMM and SPM, to degrees that vary with the component of care and the outcome considered.

This article is protected by copyright. All rights reserved.

Objective Because the effectiveness of antenatal care in reducing pregnancy complications is still discussed despite widespread recommendations of its use, we sought to assess the association between utilisation of recommended antenatal care and severe maternal (SMM) and perinatal morbidity (SPM). Design Prospective cohort study. Setting Four maternity units around Paris in 2010-2012. Sample 9117 women with singleton pregnancies. Methods Logistic regression models adjusted for maternal social, demographic and medical characteristics. Main Outcome Measures Antenatal care utilisation was assessed by: 1) initiation of care after 14 weeks, 2) less than 50% of recommended visits made, according to gestational age, 3) absence of the first, second or third trimester ultrasounds, 4) two modified Adequacy of Prenatal Care Utilization indexes, combining these components. The two main outcomes were composite variables of SMM and SPM. Results According to the modified Adequacy of Prenatal Care Utilization index, 34.6% of women had inadequate antenatal care utilization; the incidence of SMM was 2.9% and SPM 5.5%. A percentage of recommended visits below 50% (2.6% of women) was associated with SMM (aOR: 2.40 [1.38-4.17]) and SPM (aOR: 2.27 [1.43-3.59]). Late initiation of care (17.0% of women) was not associated with SMM or SPM. Failure to undergo the recommended ultrasounds (16%, 17% and 22% of women) was associated with SPM. Inadequate antenatal care utilization according to the index was associated with SPM (aOR: 1.37 [1.05-1.80]). Conclusion Inadequate antenatal care utilisation is associated with SMM and SPM, to degrees that vary with the component of care and the outcome considered. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14789The ominous association between severe endometriosis, in-vitro fertilisation, and placenta praevia: Raising awareness, limiting risks, informing womenPaolo Vercellini, Maria Pina Frattaruolo, Giussy Barbara, Laura Buggio, Edgardo Somigliana2017-06-15T15:15:24.149787-05:00doi:10.1111/1471-0528.14789John Wiley & Sons, Inc.10.1111/1471-0528.14789http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14789Commentaryn/an/a

Abstract

Endometriosis is associated with several adverse pregnancy outcomes.1 The most severe maternal complications are spontaneous haemoperitoneum in the second half of pregnancy and placenta praevia.1 Spontaneous haemoperitoneum, mostly associated with endometriosis infiltrating the broad and uterosacral ligaments and the Douglas pouch, is a potentially fatal but rare event. Placenta praevia is more common,1-3 and it is important to define its incidence, the association with different lesion types, the impact of additional risk factors, the potential obstetrical consequences, and the information that women should receive.

This article is protected by copyright. All rights reserved.

Endometriosis is associated with several adverse pregnancy outcomes.1 The most severe maternal complications are spontaneous haemoperitoneum in the second half of pregnancy and placenta praevia.1 Spontaneous haemoperitoneum, mostly associated with endometriosis infiltrating the broad and uterosacral ligaments and the Douglas pouch, is a potentially fatal but rare event. Placenta praevia is more common,1-3 and it is important to define its incidence, the association with different lesion types, the impact of additional risk factors, the potential obstetrical consequences, and the information that women should receive. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14786Medical therapy for preventing recurrent endometriosis after conservative surgery: a cost-effectiveness analysisBin Wu, Zhiyou Yang, Ruoyan Gai Tobe, Yu Wang2017-06-14T10:20:24.138314-05:00doi:10.1111/1471-0528.14786John Wiley & Sons, Inc.10.1111/1471-0528.14786http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14786Main Research Articlen/an/a

Abstract

Objective

To assess the cost-effectiveness of different strategies, including the gonadotropin-releasing hormone agonist (GnRH-a) and oral contraceptive therapy, for the prevention of endometriosis recurrence after conservative surgery.

Design

Cost-effectiveness analysis from a health care perspective.

Setting

Chinese setting represented as a health resource limited setting.

Population

patients who undergo laparoscopic or laparotomic conservative surgery for endometriosis.

Methods

A Markov model was developed for the disease course of endometriosis. Clinical data were obtained from published studies. Direct medical costs and resource utilization in the Chinese health care setting were taken into account. The health and economic outcomes were evaluated over a period from treatment initiation to menopause onset. Sensitivity analyses were carried out to test the impact of varied parameters and assumptions on the model output.

Main outcome measures

Quality-adjusted life years (QALYs) gained and costs from a health care perspective.

Results

The incremental cost effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with in peritoneal endometriosis The incremental cost effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with peritoneal endometriosis. A one-way sensitivity analysis showed considerably influential factors, such as remission rates and utility values. Probabilistic sensitivity analysis indicated that 6-month GnRH-a therapy is cost-effective in most cases at a threshold of $7,400/QALY, regardless of the type of endometriosis.

Conclusion

Six months of therapy with GnRH-a can be a highly cost-effective option for the prevention of endometriosis recurrence.

This article is protected by copyright. All rights reserved.

Objective To assess the cost-effectiveness of different strategies, including the gonadotropin-releasing hormone agonist (GnRH-a) and oral contraceptive therapy, for the prevention of endometriosis recurrence after conservative surgery. Design Cost-effectiveness analysis from a health care perspective. Setting Chinese setting represented as a health resource limited setting. Population patients who undergo laparoscopic or laparotomic conservative surgery for endometriosis. Methods A Markov model was developed for the disease course of endometriosis. Clinical data were obtained from published studies. Direct medical costs and resource utilization in the Chinese health care setting were taken into account. The health and economic outcomes were evaluated over a period from treatment initiation to menopause onset. Sensitivity analyses were carried out to test the impact of varied parameters and assumptions on the model output. Main outcome measures Quality-adjusted life years (QALYs) gained and costs from a health care perspective. Results The incremental cost effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with in peritoneal endometriosis The incremental cost effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with peritoneal endometriosis. A one-way sensitivity analysis showed considerably influential factors, such as remission rates and utility values. Probabilistic sensitivity analysis indicated that 6-month GnRH-a therapy is cost-effective in most cases at a threshold of $7,400/QALY, regardless of the type of endometriosis. Conclusion Six months of therapy with GnRH-a can be a highly cost-effective option for the prevention of endometriosis recurrence. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14783Accuracy of combinations of visual inspection using acetic acid or lugol iodine to detect cervical precancer: a Meta-analysisRosa Catarino, Sonja Schäfer, Pierre Vassilakos, Patrick Petignat, Marc Arbyn2017-06-12T03:20:20.56599-05:00doi:10.1111/1471-0528.14783John Wiley & Sons, Inc.10.1111/1471-0528.14783http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14783Systematic reviewn/an/a

Abstract

Background

Visual inspection of the cervix with acetic acid (VIA) or lugol's Iodine (VILI) have been evaluated for cervical cancer screening in developing countries.

Objectives

To assess the diagnostic accuracy and clinical utility of visual methods to detect CIN2+ using: 1) VIA alone, 2) VILI alone, 3) Cotesting, and 4) VILI as triage test of a positive VIA result.

Search Strategy

PubMed, EMBASE and the Cochrane Library up to May 2016 were searched.

Selection Criteria

All reports on accuracy of VIA and VILI, or combinations of VIA/VILI to detect CIN2+ were identified. Histology and colposcopy when no biopsy was taken were used as reference standard.

Data Collection and Analysis

Selected studies were scored on methodological quality, and sensitivity and specificity were computed. Clinical utility was assessed from the positive predictive value (PPV) and the complement of the negative predictive value (cNPV).

Main Results

We included 23 studies comprising 101,273 women. The pooled sensitivity and specificity of VILI was 88% and 86%, respectively. VILI was more sensitive, but not less specific, compared to VIA (relative sensitivity=1.11, 95%CI: 1.06-1.16; relative specificity=0.98, 95%CI: 0.95-1.01). Co-testing was hardly more sensitive, but significantly less specific, than VILI alone. VILI to triage VIA+ women was not less sensitive, but more specific, compared to VIA alone (relative sensitivity=0.98, 95%CI: 0.96-1.01; relative specificity=1.04, 95%CI: 1.02-1.05). The average PPVs were low (range 11-16%), whereas the cNPV varied between 0.3% (VILI, cotesting) and 0.6% (triage).

Conclusions

Although imperfect, VILI alone appeared to be the most useful visual screening strategy.

This article is protected by copyright. All rights reserved.

Background Visual inspection of the cervix with acetic acid (VIA) or lugol's Iodine (VILI) have been evaluated for cervical cancer screening in developing countries. Objectives To assess the diagnostic accuracy and clinical utility of visual methods to detect CIN2+ using: 1) VIA alone, 2) VILI alone, 3) Cotesting, and 4) VILI as triage test of a positive VIA result. Search Strategy PubMed, EMBASE and the Cochrane Library up to May 2016 were searched. Selection Criteria All reports on accuracy of VIA and VILI, or combinations of VIA/VILI to detect CIN2+ were identified. Histology and colposcopy when no biopsy was taken were used as reference standard. Data Collection and Analysis Selected studies were scored on methodological quality, and sensitivity and specificity were computed. Clinical utility was assessed from the positive predictive value (PPV) and the complement of the negative predictive value (cNPV). Main Results We included 23 studies comprising 101,273 women. The pooled sensitivity and specificity of VILI was 88% and 86%, respectively. VILI was more sensitive, but not less specific, compared to VIA (relative sensitivity=1.11, 95%CI: 1.06-1.16; relative specificity=0.98, 95%CI: 0.95-1.01). Co-testing was hardly more sensitive, but significantly less specific, than VILI alone. VILI to triage VIA+ women was not less sensitive, but more specific, compared to VIA alone (relative sensitivity=0.98, 95%CI: 0.96-1.01; relative specificity=1.04, 95%CI: 1.02-1.05). The average PPVs were low (range 11-16%), whereas the cNPV varied between 0.3% (VILI, cotesting) and 0.6% (triage). Conclusions Although imperfect, VILI alone appeared to be the most useful visual screening strategy. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14757GDM: Shades of grayRobert M. Silver2017-05-24T18:25:36.488615-05:00doi:10.1111/1471-0528.14757John Wiley & Sons, Inc.10.1111/1471-0528.14757http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14757Mini-commentaryn/an/a

Abstract

In this issue of BJOG, Kapur and colleagues call for all European women to undergo screening for gestational diabetes (GDM) as recommended by FIGO (Kapur et al., BJOG 2017 XX). They rightly note the adverse fetal, neonatal, and maternal effects of GDM as well as possible downstream implications for the mother and child. Their recommendations echo those of several leading organizations including FIGO. However, despite these recommendations, some European countries, communities, hospitals and clinicians do not screen all women for GDM.

This article is protected by copyright. All rights reserved.

In this issue of BJOG, Kapur and colleagues call for all European women to undergo screening for gestational diabetes (GDM) as recommended by FIGO (Kapur et al., BJOG 2017 XX). They rightly note the adverse fetal, neonatal, and maternal effects of GDM as well as possible downstream implications for the mother and child. Their recommendations echo those of several leading organizations including FIGO. However, despite these recommendations, some European countries, communities, hospitals and clinicians do not screen all women for GDM. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14724When East Meets WestQide Han2017-05-08T09:30:25.258477-05:00doi:10.1111/1471-0528.14724John Wiley & Sons, Inc.10.1111/1471-0528.14724http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14724Mini-commentaryn/an/a

In the current issue of BJOG, a report titled “Evaluation of HIFU Ablation for Uterine Fibroids: an IDEAL Prospective Exploration Study”, was led by Professor Jinghe Lang, a member of Chinese Academy of Technology. While Chinese researchers have been leading the R&D of High-intensity focused ultrasound surgery technology and its clinical applications for more than 20 years, worldwide clinical dissemination has been hindered by the lack of systematic and high quality clinical evaluation. The study by Lang et al. captures a snapshot of the arising upbeat of evidence-based clinical research in China and represents a leap forward that has overcome the inadequacy in research methods for producing high-quality evidence-based outcomes.

This article is protected by copyright. All rights reserved.

In the current issue of BJOG, a report titled “Evaluation of HIFU Ablation for Uterine Fibroids: an IDEAL Prospective Exploration Study”, was led by Professor Jinghe Lang, a member of Chinese Academy of Technology. While Chinese researchers have been leading the R&D of High-intensity focused ultrasound surgery technology and its clinical applications for more than 20 years, worldwide clinical dissemination has been hindered by the lack of systematic and high quality clinical evaluation. The study by Lang et al. captures a snapshot of the arising upbeat of evidence-based clinical research in China and represents a leap forward that has overcome the inadequacy in research methods for producing high-quality evidence-based outcomes. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14712Effectiveness, safety and acceptability of non-physician provision of first trimester medical termination of pregnancy: a systematic reviewS Sjöström, M Dragoman, S M Fønhus, B Ganatra, K Gemzell-Danielsson2017-04-26T11:30:28.644399-05:00doi:10.1111/1471-0528.14712John Wiley & Sons, Inc.10.1111/1471-0528.14712http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14712Systematic reviewn/an/a

Abstract

Background

Previous systematic reviews have concluded that medical termination of pregnancy (TOP) provided by non-physician providers may be as effective and safe as when provided by physicians. Medical treatment of incomplete miscarriage by non-physicians, and treated women's acceptability with non-physician providers of TOP has not previously been reviewed.

Objective

To review the effectiveness, safety and acceptability of non-physician provision of first trimester medical TOP including medical treatment for incomplete miscarriage.

Search strategy and selection criteria

A search strategy using appropriate medical subject headings was developed. Electronic databases (PubMed, Popline, Cochrane, CINAHL, Embase, and ClinicalTrials. gov) were searched from inception through April 2016. Randomized controlled trials and comparative observational studies were included.

Data collection and analysis

Meta-analyses were performed for included randomized controlled trials regarding the outcomes effectiveness and acceptability to women. Certainty of evidence was established using the GRADE approach assessing study limitations, consistency of effect, imprecision, indirectness and publication bias.

Main results

Six papers were included. Medical TOP and medical treatment of incomplete miscarriage is probably equally effective provided by non-physician providers as by physicians (RR 1.00; 95% CI 0.99 to 1.01). Women's acceptability reported as overall satisfaction with allocated provider is probably equally high between groups (RR 1.00; 95% CI 1.00 to 1.01).

Conclusions

Medical TOP and medical treatment of incomplete miscarrage provided by trained non-physician providers is probably equally as effective and acceptable to women as when provided by physicians.

This article is protected by copyright. All rights reserved.

Background Previous systematic reviews have concluded that medical termination of pregnancy (TOP) provided by non-physician providers may be as effective and safe as when provided by physicians. Medical treatment of incomplete miscarriage by non-physicians, and treated women's acceptability with non-physician providers of TOP has not previously been reviewed. Objective To review the effectiveness, safety and acceptability of non-physician provision of first trimester medical TOP including medical treatment for incomplete miscarriage. Search strategy and selection criteria A search strategy using appropriate medical subject headings was developed. Electronic databases (PubMed, Popline, Cochrane, CINAHL, Embase, and ClinicalTrials. gov) were searched from inception through April 2016. Randomized controlled trials and comparative observational studies were included. Data collection and analysis Meta-analyses were performed for included randomized controlled trials regarding the outcomes effectiveness and acceptability to women. Certainty of evidence was established using the GRADE approach assessing study limitations, consistency of effect, imprecision, indirectness and publication bias. Main results Six papers were included. Medical TOP and medical treatment of incomplete miscarriage is probably equally effective provided by non-physician providers as by physicians (RR 1.00; 95% CI 0.99 to 1.01). Women's acceptability reported as overall satisfaction with allocated provider is probably equally high between groups (RR 1.00; 95% CI 1.00 to 1.01). Conclusions Medical TOP and medical treatment of incomplete miscarrage provided by trained non-physician providers is probably equally as effective and acceptable to women as when provided by physicians. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14706Comparing induction of labour with oral misoprostol or Foley catheter at term: cost effectiveness analysis of a randomised controlled multi-centre non-inferiority trialMieke L.G. ten Eikelder, Gert-Jan van Baaren, Katrien Oude Rengerink, Marta Jozwiak, Jan Willem de Leeuw, Gunilla Kleiverda, Inge Evers, Karin de Boer, Josien Brons, Kitty W.M. Bloemenkamp, Ben W. Mol2017-04-25T10:45:37.022102-05:00doi:10.1111/1471-0528.14706John Wiley & Sons, Inc.10.1111/1471-0528.14706http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14706Main Research Articlen/an/a

Abstract

Objective

To assess the costs of labour induction with oral misoprostol compared to Foley catheter.

Design

Economic evaluation alongside a randomised controlled trial.

Setting

Obstetric departments of six tertiary and 23 secondary care hospitals in the Netherlands.

Population

Women with a viable term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix (Bishop score <6) without a previous caesarean section, had been randomised for labour induction with oral misoprostol (n = 924) or Foley catheter (n = 921).

Methods

We performed economic analysis from a hospital perspective. We estimated direct medical costs associated with healthcare utilisation from randomisation until discharge. The robustness of our findings was evaluated in sensitivity analyses.

Main Outcome Measures

Mean costs and differences were calculated per women induced with oral misoprostol or Foley catheter.

Results

Mean costs per woman in the oral misoprostol group and in the Foley catheter group were €4470 versus €4158, respectively (mean difference €312 (95% confidence interval (CI) -€508 to €1063)). Multiple sensitivity analyses did not change these conclusions. Only, when cervical ripening for low-risk pregnancies in the Foley catheter group would be carried out in an outpatient setting, with admittance to labour ward only at start of active labour, the difference would be €4470 versus €3489, respectively (mean difference €981 (95% CI €225 to €1817)).

Conclusions

Oral misoprostol and Foley catheter generate comparable costs. Cervical ripening outside labour ward with a Foley catheter could potentially save almost €1,000 per woman.

This article is protected by copyright. All rights reserved.

Objective To assess the costs of labour induction with oral misoprostol compared to Foley catheter. Design Economic evaluation alongside a randomised controlled trial. Setting Obstetric departments of six tertiary and 23 secondary care hospitals in the Netherlands. Population Women with a viable term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix (Bishop score <6) without a previous caesarean section, had been randomised for labour induction with oral misoprostol (n = 924) or Foley catheter (n = 921). Methods We performed economic analysis from a hospital perspective. We estimated direct medical costs associated with healthcare utilisation from randomisation until discharge. The robustness of our findings was evaluated in sensitivity analyses. Main Outcome Measures Mean costs and differences were calculated per women induced with oral misoprostol or Foley catheter. Results Mean costs per woman in the oral misoprostol group and in the Foley catheter group were €4470 versus €4158, respectively (mean difference €312 (95% confidence interval (CI) -€508 to €1063)). Multiple sensitivity analyses did not change these conclusions. Only, when cervical ripening for low-risk pregnancies in the Foley catheter group would be carried out in an outpatient setting, with admittance to labour ward only at start of active labour, the difference would be €4470 versus €3489, respectively (mean difference €981 (95% CI €225 to €1817)). Conclusions Oral misoprostol and Foley catheter generate comparable costs. Cervical ripening outside labour ward with a Foley catheter could potentially save almost €1,000 per woman. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14697Severe Primary Autoimmune Thrombocytopenia (ITP) in Pregnancy: a National Cohort StudyA Care, S Pavord, M Knight, Z Alfirevic2017-04-22T02:25:37.060051-05:00doi:10.1111/1471-0528.14697John Wiley & Sons, Inc.10.1111/1471-0528.14697http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14697Main Research Articlen/an/a

Abstract

Objective

To quantify UK incidence of severe ITP in pregnancy, determine current treatment strategies and establish maternal and neonatal morbidity and mortality associated with severe ITP in pregnancy.

Design

A prospective national cohort study

Setting

United Kingdom

Population

Women with severe ITP; defined as platelets <50 x 109/l in pregnancy or antenatal treatment of isolated low platelets.

Methods

Data collected via United Kingdom Obstetric Surveillance System (UKOSS) between 1st June 2013–31st January 2015 from all UK Consultant led obstetric units.

Main Outcome Measure

Incidence of Severe ITP in pregnancy.

Results

The estimated incidence of severe ITP in pregnancy is 0.83 per 10,000 maternities (95% CI 0.68-1.00). 22 pregnant women (21%) did not receive any antenatal therapy, 85 (79%) had therapy. There was no difference between asymptomatic treated and untreated cohorts in severity of disease or outcome. Postpartum haemorrhage (51%) and severe postpartum haemorrhage (21%) was reported more frequently than the reported rate in the general pregnant population (5-10%). No neonates required treatment for thrombocytopenia and there were no cases of neonatal intracranial bleeding.

Conclusions

Current UK management of severe ITP in pregnancy results in an exceptionally low morbidity and mortality for the neonate. Mothers with ITP remain at increased risk of severe post-partum haemorrhage and should be delivered at units that have the capacity to manage severe PPH effectively. Whilst balancing risks for pregnancy of prophylactic antenatal treatment in asymptomatic women against observed low disease morbidity, we may be over treating asymptomatic patients.

This article is protected by copyright. All rights reserved.

Objective To quantify UK incidence of severe ITP in pregnancy, determine current treatment strategies and establish maternal and neonatal morbidity and mortality associated with severe ITP in pregnancy. Design A prospective national cohort study Setting United Kingdom Population Women with severe ITP; defined as platelets <50 x 109/l in pregnancy or antenatal treatment of isolated low platelets. Methods Data collected via United Kingdom Obstetric Surveillance System (UKOSS) between 1st June 2013–31st January 2015 from all UK Consultant led obstetric units. Main Outcome Measure Incidence of Severe ITP in pregnancy. Results The estimated incidence of severe ITP in pregnancy is 0.83 per 10,000 maternities (95% CI 0.68-1.00). 22 pregnant women (21%) did not receive any antenatal therapy, 85 (79%) had therapy. There was no difference between asymptomatic treated and untreated cohorts in severity of disease or outcome. Postpartum haemorrhage (51%) and severe postpartum haemorrhage (21%) was reported more frequently than the reported rate in the general pregnant population (5-10%). No neonates required treatment for thrombocytopenia and there were no cases of neonatal intracranial bleeding. Conclusions Current UK management of severe ITP in pregnancy results in an exceptionally low morbidity and mortality for the neonate. Mothers with ITP remain at increased risk of severe post-partum haemorrhage and should be delivered at units that have the capacity to manage severe PPH effectively. Whilst balancing risks for pregnancy of prophylactic antenatal treatment in asymptomatic women against observed low disease morbidity, we may be over treating asymptomatic patients. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14694Core Outcome Sets in Women's and Newborn Health: A Systematic ReviewJames M. N. Duffy, Rachel Rolph, Chris Gale, Martin Hirsch, Khalid S. Khan, Sue Ziebland, Richard J. McManus, 2017-04-19T02:56:57.3482-05:00doi:10.1111/1471-0528.14694John Wiley & Sons, Inc.10.1111/1471-0528.14694http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14694Systematic reviewn/an/a

Abstract

Background

Variation in outcome collection and reporting is a serious hindrance to progress in our specialty, over eighty journals have come together to support the development, dissemination, and implementation of core outcome sets.

Objective

This study systematically reviewed and characterised registered, progressing, or completed core outcome sets relevant to women's and newborn health.

Search strategy

Systematic search using the Core Outcome Measures in Effectiveness Trial initiative and the Core Outcomes in Women's and Newborn Health initiative databases.

Selection criteria

Registry entries, protocols, systematic reviews, and core outcome sets.

Data collection and analysis

Descriptive statistics to describe characteristics and results.

Results

There were 46 core outcome sets in maternal and newborn health, with the majority registered in 2015 (22; 48%) or 2016 (16; 35%). Benign gynaecology (5; 11%) and newborn health (3; 9%) is currently under-represented. Twenty-four (52%) core outcome sets were funded by international (1; 2%), national (18; 39%), and regional (4; 9%) bodies. Seven protocols were published. Twenty systematic reviews characterised the inconsistency in outcome reporting across a broad range of relevant healthcare conditions. Four core outcome sets were completed: reconstructive breast surgery (11 outcomes), preterm birth (13 outcomes), epilepsy in pregnancy (29 outcomes), and maternity care (48 outcomes). The quantitative, qualitative, and consensus methods used to develop core outcome sets have varied considerably.

Conclusions

Core outcome sets are currently being developed across women's and newborn health, although coverage of topics is variable. Development of further infrastructure to develop, disseminate, and implement core outcome sets is urgently required.

This article is protected by copyright. All rights reserved.

Background Variation in outcome collection and reporting is a serious hindrance to progress in our specialty, over eighty journals have come together to support the development, dissemination, and implementation of core outcome sets. Objective This study systematically reviewed and characterised registered, progressing, or completed core outcome sets relevant to women's and newborn health. Search strategy Systematic search using the Core Outcome Measures in Effectiveness Trial initiative and the Core Outcomes in Women's and Newborn Health initiative databases. Selection criteria Registry entries, protocols, systematic reviews, and core outcome sets. Data collection and analysis Descriptive statistics to describe characteristics and results. Results There were 46 core outcome sets in maternal and newborn health, with the majority registered in 2015 (22; 48%) or 2016 (16; 35%). Benign gynaecology (5; 11%) and newborn health (3; 9%) is currently under-represented. Twenty-four (52%) core outcome sets were funded by international (1; 2%), national (18; 39%), and regional (4; 9%) bodies. Seven protocols were published. Twenty systematic reviews characterised the inconsistency in outcome reporting across a broad range of relevant healthcare conditions. Four core outcome sets were completed: reconstructive breast surgery (11 outcomes), preterm birth (13 outcomes), epilepsy in pregnancy (29 outcomes), and maternity care (48 outcomes). The quantitative, qualitative, and consensus methods used to develop core outcome sets have varied considerably. Conclusions Core outcome sets are currently being developed across women's and newborn health, although coverage of topics is variable. Development of further infrastructure to develop, disseminate, and implement core outcome sets is urgently required. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14678Cost-effectiveness analysis and Obstetrics: The time has comeRobert M. Silver, Brett D. Einerson2017-04-06T10:35:57.412346-05:00doi:10.1111/1471-0528.14678John Wiley & Sons, Inc.10.1111/1471-0528.14678http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14678Mini-commentaryn/an/a

Abstract

In this issue of BJOG, ten Eikelder and colleagues report that oral misoprostol and foley bulb catheters for cervical ripening have equal cost-effectiveness. If women receiving foley bulbs undergo ripening at home or on a less intensive unit than a labor and delivery suite, the foley bulb is considerably more cost-effective. They used data from a Dutch RCT, the PROBAAT2 trial, comparing the two methods, which had similar efficacy. The analysis has many strengths including using comparisons from within an RCT, careful assessment of measurable direct hospital costs, and the use of well-chosen sensitivity analyses to evaluate the assumptions under a wide variety of clinical scenarios.

This article is protected by copyright. All rights reserved.

In this issue of BJOG, ten Eikelder and colleagues report that oral misoprostol and foley bulb catheters for cervical ripening have equal cost-effectiveness. If women receiving foley bulbs undergo ripening at home or on a less intensive unit than a labor and delivery suite, the foley bulb is considerably more cost-effective. They used data from a Dutch RCT, the PROBAAT2 trial, comparing the two methods, which had similar efficacy. The analysis has many strengths including using comparisons from within an RCT, careful assessment of measurable direct hospital costs, and the use of well-chosen sensitivity analyses to evaluate the assumptions under a wide variety of clinical scenarios. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14670The HFEA should be regulating add-on treatments for IVF/ICSIWilliam L Ledger2017-04-04T06:40:39.790138-05:00doi:10.1111/1471-0528.14670John Wiley & Sons, Inc.10.1111/1471-0528.14670http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14670Mini-commentaryn/an/a

Abstract

The HFEA has come a long way since its inception in 1990. Public and professional concern was initially focused on the many ethical challenges presented by the new technologies used in ART, and in particular the need for consideration of the welfare of children that may be born after their use. Hence much of the time of the HFEA is spent on matters pertaining to medical ethics, such as reduction of the multiple embryo transfer rate (improving the health of ART children by avoiding multiple pregnancy), and identification of gamete donors to their offspring. The HFEA inspects all licensed clinics regularly, and has powers to withdraw a licence if there are serious breaches of the Code of Practice.

This article is protected by copyright. All rights reserved.

The HFEA has come a long way since its inception in 1990. Public and professional concern was initially focused on the many ethical challenges presented by the new technologies used in ART, and in particular the need for consideration of the welfare of children that may be born after their use. Hence much of the time of the HFEA is spent on matters pertaining to medical ethics, such as reduction of the multiple embryo transfer rate (improving the health of ART children by avoiding multiple pregnancy), and identification of gamete donors to their offspring. The HFEA inspects all licensed clinics regularly, and has powers to withdraw a licence if there are serious breaches of the Code of Practice. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14565Parental Orders and the Rights of Surrogate MothersNathan Hodson, Susan Bewley2017-01-19T13:55:22.802653-05:00doi:10.1111/1471-0528.14565John Wiley & Sons, Inc.10.1111/1471-0528.14565http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14565BJOG Perspectivesn/an/a

Abstract

Obstetricians need to be aware of potential legal changes which may impact the doctor-patient relationship in surrogacy cases. Presently, English law recognises the surrogate as the mother. After giving birth, she may hand over the baby. The commissioning couple then apply for Parental Orders and become legal parents if the conditions in the Surrogacy Arrangements Act 1985 are met.

This article is protected by copyright. All rights reserved.

Obstetricians need to be aware of potential legal changes which may impact the doctor-patient relationship in surrogacy cases. Presently, English law recognises the surrogate as the mother. After giving birth, she may hand over the baby. The commissioning couple then apply for Parental Orders and become legal parents if the conditions in the Surrogacy Arrangements Act 1985 are met. This article is protected by copyright. All rights reserved.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14772Continent versus incontinent diversion for obstetric fistulaMA Morgan2017-07-17T23:20:54.560286-05:00doi:10.1111/1471-0528.14772John Wiley & Sons, Inc.10.1111/1471-0528.14772http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14772Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14766Are minimally invasive approaches to ectopic pregnancy underutilized?AM Eskew2017-07-17T23:20:52.452881-05:00doi:10.1111/1471-0528.14766John Wiley & Sons, Inc.10.1111/1471-0528.14766http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14766Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14727Fibroid vascularisation as a predictor for uterine fibroid growthM Dueholm2017-07-17T23:20:35.897035-05:00doi:10.1111/1471-0528.14727John Wiley & Sons, Inc.10.1111/1471-0528.14727http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14727Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14781Pregnancy, Marfan syndrome, and type-B aortic dissectionMR Johnson, JW Roos Hesselink2017-07-17T23:16:59.776289-05:00doi:10.1111/1471-0528.14781John Wiley & Sons, Inc.10.1111/1471-0528.14781http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14781Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14767How do late terminations of pregnancy affect comparisons of stillbirth rates in Europe? Analyses of aggregated routine data from the Euro-Peristat ProjectB Blondel, M Cuttini, AD Hindori-Mohangoo, M Gissler, M Loghi, C Prunet, A Heino, L Smith, K Pal-de Bruin, A Macfarlane, J Zeitlin, 2017-07-17T23:16:00.721625-05:00doi:10.1111/1471-0528.14767John Wiley & Sons, Inc.10.1111/1471-0528.14767http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14767Original Articlen/an/a

Objective

To describe how terminations of pregnancy at gestational ages at or above the limit for stillbirth registration are recorded in routine statistics and to assess their impact on comparability of stillbirth rates in Europe.

Design

Analysis of aggregated data from the Euro-Peristat project.

Setting

Twenty-nine European countries.

Population

Births and late terminations in 2010.

Methods

Assessment of terminations as a proportion of stillbirths and derivation of stillbirth rates including and excluding terminations.

Main outcome measures

Stillbirth rates overall and excluding terminations.

Results

In 23 countries, it is possible to assess the contribution of terminations to stillbirth rates either because terminations are rare occurrences or because they can be distinguished from spontaneous stillbirths. Where terminations were reported, they accounted for less than 1.5% of stillbirths at 22+ weeks in Denmark, between 13 and 22% in Germany, Italy, Hungary, Finland and Switzerland, and 39% in France. Proportions were much lower at 24+ weeks, with the exception of Switzerland (7.4%) and France (39.2%).

Conclusions

Terminations represent a substantial proportion of stillbirths at 22+ weeks of gestation in some countries. Countries where terminations occur at 22+ weeks should publish rates with and without terminations in order to improve international comparisons and the policy relevance of stillbirth statistics.

Tweetable abstract

For valid comparisons of stillbirth rates, data about late terminations of pregnancy are needed.

Objective To describe how terminations of pregnancy at gestational ages at or above the limit for stillbirth registration are recorded in routine statistics and to assess their impact on comparability of stillbirth rates in Europe. Design Analysis of aggregated data from the Euro-Peristat project. Setting Twenty-nine European countries. Population Births and late terminations in 2010. Methods Assessment of terminations as a proportion of stillbirths and derivation of stillbirth rates including and excluding terminations. Main outcome measures Stillbirth rates overall and excluding terminations. Results In 23 countries, it is possible to assess the contribution of terminations to stillbirth rates either because terminations are rare occurrences or because they can be distinguished from spontaneous stillbirths. Where terminations were reported, they accounted for less than 1.5% of stillbirths at 22+ weeks in Denmark, between 13 and 22% in Germany, Italy, Hungary, Finland and Switzerland, and 39% in France. Proportions were much lower at 24+ weeks, with the exception of Switzerland (7.4%) and France (39.2%). Conclusions Terminations represent a substantial proportion of stillbirths at 22+ weeks of gestation in some countries. Countries where terminations occur at 22+ weeks should publish rates with and without terminations in order to improve international comparisons and the policy relevance of stillbirth statistics. Tweetable abstract For valid comparisons of stillbirth rates, data about late terminations of pregnancy are needed.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14729A call to action for data definition standardisation and core outcome setsGA Dildy2017-07-17T04:11:25.677623-05:00doi:10.1111/1471-0528.14729John Wiley & Sons, Inc.10.1111/1471-0528.14729http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14729Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14774Audit and feedback using the Robson classification to reduce caesarean section rates: a systematic reviewAA Boatin, F Cullinane, MR Torloni, AP Betrán2017-07-17T04:06:17.051377-05:00doi:10.1111/1471-0528.14774John Wiley & Sons, Inc.10.1111/1471-0528.14774http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14774Systematic Reviewn/an/a

Background

In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates.

Objectives

To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates.

Search strategy

Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016.

Selection criteria

Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates.

Data collection

Data on study design, interventions used, CS rates, and perinatal outcomes were extracted.

Results

Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias.

Conclusion

We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates.

Tweetable abstract

Use of the Robson classification in clinical audit cycles to reduce caesarean rates.

Background In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates. Objectives To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates. Search strategy Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016. Selection criteria Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates. Data collection Data on study design, interventions used, CS rates, and perinatal outcomes were extracted. Results Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias. Conclusion We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates. Tweetable abstract Use of the Robson classification in clinical audit cycles to reduce caesarean rates.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14773Current controversies with oral emergency contraceptionST Cameron, HWR Li, K Gemzell-Danielsson2017-07-17T04:00:26.662927-05:00doi:10.1111/1471-0528.14773John Wiley & Sons, Inc.10.1111/1471-0528.14773http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14773Review Articlen/an/a

Emergency contraception (EC) is a method to be used in the case of unprotected sexual intercourse, failure of a regular contraceptive method, or after rape to try to prevent an unintended pregnancy. Oral EC remains surrounded by controversy, much due to myths and misconceptions among the public, policy makers and healthcare providers. This has resulted in restrictions on its availability in many parts of the world and restrictions on women's access to it. The aim of this article is to provide an evidence-based view on some of these common controversial issues surrounding oral EC in clinical practice.

Tweetable abstract

Controversy about emergency contraception restricts access for women.

Emergency contraception (EC) is a method to be used in the case of unprotected sexual intercourse, failure of a regular contraceptive method, or after rape to try to prevent an unintended pregnancy. Oral EC remains surrounded by controversy, much due to myths and misconceptions among the public, policy makers and healthcare providers. This has resulted in restrictions on its availability in many parts of the world and restrictions on women's access to it. The aim of this article is to provide an evidence-based view on some of these common controversial issues surrounding oral EC in clinical practice. Tweetable abstract Controversy about emergency contraception restricts access for women.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14715Re: The fetal safety of clomiphene citrate: a population based retrospective cohort studySaumya Pandey2017-07-14T07:00:22.631945-05:00doi:10.1111/1471-0528.14715John Wiley & Sons, Inc.10.1111/1471-0528.14715http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14715BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14717Authors’ reply re: Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trial.Sarah L. Cohen, Sangeeta Senapati, Antonio R. Gargiulo, Serene S. Srouji, Frank Tu, Jonathon Solnik, Hye-Chun Hur, Allison Vitonis, Gudrun Maria Jonsdottir, Karen C. Wang, Jon Ivar Einarsson2017-07-14T07:00:20.172409-05:00doi:10.1111/1471-0528.14717John Wiley & Sons, Inc.10.1111/1471-0528.14717http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14717BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14714Re: Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trialChitra Rajeswari Thangaswamy2017-07-14T06:55:29.529981-05:00doi:10.1111/1471-0528.14714John Wiley & Sons, Inc.10.1111/1471-0528.14714http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14714BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14754Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trialsJ Pundir, D Psaroudakis, P Savnur, P Bhide, L Sabatini, H Teede, A Coomarasamy, S Thangaratinam2017-07-14T06:45:48.389086-05:00doi:10.1111/1471-0528.14754John Wiley & Sons, Inc.10.1111/1471-0528.14754http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14754Review Articlen/an/a

Polycystic ovary syndrome is a common cause of anovulation and infertility, and a risk factor for development of metabolic syndrome and endometrial cancer. Systematic review and meta-analysis of randomised controlled trials (RCT) that evaluated the effects of inositol as an ovulation induction agent. We searched MEDLINE, EMBASE, Cochrane and ISI conference proceedings, Register and Meta-register for RCT and WHO trials’ search portal. We included studies that compared inositol with placebo or other ovulation induction agents. Quality of studies was assessed for risk of bias. Results were pooled using random effects meta-analysis and findings were reported as relative risk or standardised mean differences. We included ten randomised trials. A total of 362 women were on inositol (257 on myo-inositol; 105 on di-chiro-inositol), 179 were on placebo and 60 were on metformin. Inositol was associated with significantly improved ovulation rate (RR 2.3; 95% CI 1.1–4.7; I2 = 75%) and increased frequency of menstrual cycles (RR 6.8; 95% CI 2.8–16.6; I2 = 0%) compared with placebo. One study reported on clinical pregnancy rate with inositol compared with placebo (RR 3.3; 95% CI 0.4–27.1), and one study compared with metformin (RR 1.5; 95% CI 0.7–3.1). No studies evaluated live birth and miscarriage rates. Inositol appears to regulate menstrual cycles, improve ovulation and induce metabolic changes in polycystic ovary syndrome; however, evidence is lacking for pregnancy, miscarriage or live birth. A further, well-designed multicentre trial to address this issue to provide robust evidence of benefit is warranted.

Tweetable abstract

Inositols improve menstrual cycles, ovulation and metabolic changes in polycystic ovary syndrome

Polycystic ovary syndrome is a common cause of anovulation and infertility, and a risk factor for development of metabolic syndrome and endometrial cancer. Systematic review and meta-analysis of randomised controlled trials (RCT) that evaluated the effects of inositol as an ovulation induction agent. We searched MEDLINE, EMBASE, Cochrane and ISI conference proceedings, Register and Meta-register for RCT and WHO trials’ search portal. We included studies that compared inositol with placebo or other ovulation induction agents. Quality of studies was assessed for risk of bias. Results were pooled using random effects meta-analysis and findings were reported as relative risk or standardised mean differences. We included ten randomised trials. A total of 362 women were on inositol (257 on myo-inositol; 105 on di-chiro-inositol), 179 were on placebo and 60 were on metformin. Inositol was associated with significantly improved ovulation rate (RR 2.3; 95% CI 1.1–4.7; I2 = 75%) and increased frequency of menstrual cycles (RR 6.8; 95% CI 2.8–16.6; I2 = 0%) compared with placebo. One study reported on clinical pregnancy rate with inositol compared with placebo (RR 3.3; 95% CI 0.4–27.1), and one study compared with metformin (RR 1.5; 95% CI 0.7–3.1). No studies evaluated live birth and miscarriage rates. Inositol appears to regulate menstrual cycles, improve ovulation and induce metabolic changes in polycystic ovary syndrome; however, evidence is lacking for pregnancy, miscarriage or live birth. A further, well-designed multicentre trial to address this issue to provide robust evidence of benefit is warranted. Tweetable abstract Inositols improve menstrual cycles, ovulation and metabolic changes in polycystic ovary syndrome
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14750Healthcare utilisation, induced labour and caesarean section in the pregnancy after stillbirth: a prospective studyIK Gravensteen, E-M Jacobsen, PM Sandset, LB Helgadottir, I Rådestad, L Sandvik, Ø Ekeberg2017-07-14T06:00:41.666167-05:00doi:10.1111/1471-0528.14750John Wiley & Sons, Inc.10.1111/1471-0528.14750http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14750Original Articlen/an/a

Objective

To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes.

Design

Population-based pregnancy cohort study.

Setting

The Norwegian Mother and Child Cohort Study.

Sample

A total of 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous.

Methods

Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway.

Main outcome measures

Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery.

Results

Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% CI 9.4–10.7) compared with women with a previous live birth (mean 6.0; 95% CI 5.8–6.2) and previously nulliparous women (mean 6.3; 95% CI 6.1–6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3–5.0) compared with women with previous live birth and 3.7 (1.8–7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, whereas dread of childbirth was not a significant mediator for elective CS.

Conclusions

Women pregnant after stillbirth were more ample users of healthcare services and more often had induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth.

Tweetable abstract

Women pregnant after stillbirth are ample users of healthcare services and interventions during childbirth.

Objective To investigate healthcare utilisation, induced labour and caesarean section (CS) in the pregnancy after stillbirth and assess anxiety and dread of childbirth as mediators for these outcomes. Design Population-based pregnancy cohort study. Setting The Norwegian Mother and Child Cohort Study. Sample A total of 901 pregnant women; 174 pregnant after stillbirth, 362 pregnant after live birth and 365 previously nulliparous. Methods Data from questionnaires answered in the second and third trimesters of pregnancy and information from the Medical Birth Registry of Norway. Main outcome measures Self-reported assessment of antenatal care, register-based assessment of onset and mode of delivery. Results Women with a previous stillbirth had more frequent antenatal visits (mean 10.0; 95% CI 9.4–10.7) compared with women with a previous live birth (mean 6.0; 95% CI 5.8–6.2) and previously nulliparous women (mean 6.3; 95% CI 6.1–6.6). Induced labour and CS, elective and emergency, were also more prevalent in the stillbirth group. The adjusted odds ratio for elective CS was 2.5 (95% CI 1.3–5.0) compared with women with previous live birth and 3.7 (1.8–7.6) compared with previously nulliparous women. Anxiety was a minor mediator for the association between stillbirth and frequency of antenatal visits, whereas dread of childbirth was not a significant mediator for elective CS. Conclusions Women pregnant after stillbirth were more ample users of healthcare services and more often had induced labour and CS. The higher frequency of antenatal visits and elective CS could not be accounted for by anxiety or dread of childbirth. Tweetable abstract Women pregnant after stillbirth are ample users of healthcare services and interventions during childbirth.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14782Should we implement universal screening with late pregnancy ultrasound to prevent stillbirth?GCS Smith2017-07-12T08:20:22.788898-05:00doi:10.1111/1471-0528.14782John Wiley & Sons, Inc.10.1111/1471-0528.14782http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14782Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14753A pill or a patch for a hot flush?2017-07-05T03:40:19.075501-05:00doi:10.1111/1471-0528.14753John Wiley & Sons, Inc.10.1111/1471-0528.14753http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14753Journal Clubn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14733Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a randomised controlled trialAJMW Vervoort, LF Voet, WJK Hehenkamp, AL Thurkow, PJM Kesteren, H Quartero, W Kuchenbecker, M Bongers, P Geomini, LHM Vleeschouwer, MHA Hooff, H Vliet, S Veersema, WB Renes, K Oude Rengerink, SE Zwolsman, HAM Brölmann, BWJ Mol, JAF Huirne2017-07-05T02:21:19.54348-05:00doi:10.1111/1471-0528.14733John Wiley & Sons, Inc.10.1111/1471-0528.14733http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14733Original Articlen/an/a

Objective

To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect.

Design

Multicentre randomised controlled trial.

Setting

Eleven hospitals collaborating in a consortium for women's health research in the Netherlands.

Population

Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography.

Methods

Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months.

Main outcome measures

The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation.

Results

We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2–7 days) in the intervention group and 7 days (IQR 3–10 days) in the control group (P = 0.04); on a scale of 0–10, discomfort as a result of spotting had a median score of 2 (IQR 0–7) in the intervention group, compared with 7 (IQR 0–8) in the control group (P = 0.02).

Conclusions

In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting-related discomfort.

Tweetable abstract

A hysteroscopic niche resection is an effective treatment to reduce niche-related spotting.

Objective To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect. Design Multicentre randomised controlled trial. Setting Eleven hospitals collaborating in a consortium for women's health research in the Netherlands. Population Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography. Methods Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months. Main outcome measures The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation. Results We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2–7 days) in the intervention group and 7 days (IQR 3–10 days) in the control group (P = 0.04); on a scale of 0–10, discomfort as a result of spotting had a median score of 2 (IQR 0–7) in the intervention group, compared with 7 (IQR 0–8) in the control group (P = 0.02). Conclusions In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting-related discomfort. Tweetable abstract A hysteroscopic niche resection is an effective treatment to reduce niche-related spotting.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14763Commentary on changing the risk threshold for surgical prevention of ovarian cancerR Manchanda, R Legood, AC Antoniou, L Pearce, U Menon2017-07-05T02:10:28.405338-05:00doi:10.1111/1471-0528.14763John Wiley & Sons, Inc.10.1111/1471-0528.14763http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14763Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14617Re: Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume; Severe maternal morbidity requires regionalisation of obstetric critical care; Guilt, blame and litigation: can an overenthusiastic ‘safety culture’ cause harm?Shigeki Matsubara, Daisuke Matsubara, Hironori Takahashi, Alan Kawarai Lefor2017-07-03T01:55:38.717431-05:00doi:10.1111/1471-0528.14617John Wiley & Sons, Inc.10.1111/1471-0528.14617http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14617BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14642Authors' reply re: Variations in very preterm birth rates in 30 high-income countries: are valid international comparisons possible using routine data?Marie Delnord, Jennifer Zeitlin2017-06-27T06:58:10.28942-05:00doi:10.1111/1471-0528.14642John Wiley & Sons, Inc.10.1111/1471-0528.14642http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14642BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14618Authors’ reply re: Guilt, blame and litigation: can an overenthusiastic ‘safety culture’ cause harm?Matthew Cauldwell, Philip Steer, Susan Bewley2017-06-27T02:17:56.385184-05:00doi:10.1111/1471-0528.14618John Wiley & Sons, Inc.10.1111/1471-0528.14618http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14618BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14652Re: Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort studyLauren Barnfield, Montasser Mahran, Thangamma Katimada-Annaiah, Mary Esmyot, Lynne Cooke, Krishna Vusirikala, Vivian Leung, Wafa Ahmed, Ruby Groome2017-06-26T01:52:33.2673-05:00doi:10.1111/1471-0528.14652John Wiley & Sons, Inc.10.1111/1471-0528.14652http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14652BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14703Bone mineral density and fractures after surgical menopause: systematic review and meta-analysisIE Fakkert, N Teixeira, EM Abma, RHJA Slart, MJE Mourits, GH Bock2017-06-26T01:47:51.03444-05:00doi:10.1111/1471-0528.14703John Wiley & Sons, Inc.10.1111/1471-0528.14703http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14703Systematic Reviewn/an/a

Background

Oophorectomy is recommended for women at increased risk for ovarian cancer. When performed at premenopausal age oophorectomy induces acute surgical menopause, with unwanted consequences.

Objective

To investigate bone mineral density (BMD) and fracture prevalence after surgical menopause.

Search strategy

A literature search of PubMed, EMBASE and Cochrane library was performed with no date restriction. Date of last search was March 1st, 2016.

Selection criteria

Primary studies reporting on BMD, T-scores or fracture prevalence in women with surgical menopause and age-matched control groups.

Data collection and analysis

Data were extracted on BMD (g/cm2), T-scores and fracture prevalence in women with surgical menopause and control groups. Quality was assessed by an adaptation of the Downs and Black checklist. Random effects models were used to meta-analyse results of studies reporting on BMD or fracture rates.

Main results

Seventeen studies were included, comprising 43 386 women with surgical menopause. Ten studies provided sufficient data for meta-analysis. BMD after surgical menopause was significantly lower than in premenopausal age-matched women [mean difference lumbar spine, −0.15 g/cm2 (95% CI, −0.19 to −0.11 g/cm2); femoral neck, −0.17 g/cm2 (95% CI, −0.23 to −0.11 g/cm2)] but not lower than in women with natural menopause [lumbar spine, −0.02 g/cm2 (95% CI, −0.04 to 0.00 g/cm2); femoral neck, 0.04 g/cm2 (95% CI, −0.09 to 0.16 g/cm2)]. Hip fracture rate was not higher after surgical menopause compared with natural menopause [hazard ratio: 0.85 (95% CI, 0.70 to 1.04)].

Author's conclusions

No evident effect of surgical menopause was observed on BMD and fracture prevalence compared with natural menopause. However, available studies are prone to bias and need to be interpreted with caution.

Tweetable abstract

Bone health after menopause: no evidence for additional effect of surgical menopause on BMD and fractures.

Background Oophorectomy is recommended for women at increased risk for ovarian cancer. When performed at premenopausal age oophorectomy induces acute surgical menopause, with unwanted consequences. Objective To investigate bone mineral density (BMD) and fracture prevalence after surgical menopause. Search strategy A literature search of PubMed, EMBASE and Cochrane library was performed with no date restriction. Date of last search was March 1st, 2016. Selection criteria Primary studies reporting on BMD, T-scores or fracture prevalence in women with surgical menopause and age-matched control groups. Data collection and analysis Data were extracted on BMD (g/cm2), T-scores and fracture prevalence in women with surgical menopause and control groups. Quality was assessed by an adaptation of the Downs and Black checklist. Random effects models were used to meta-analyse results of studies reporting on BMD or fracture rates. Main results Seventeen studies were included, comprising 43 386 women with surgical menopause. Ten studies provided sufficient data for meta-analysis. BMD after surgical menopause was significantly lower than in premenopausal age-matched women [mean difference lumbar spine, −0.15 g/cm2 (95% CI, −0.19 to −0.11 g/cm2); femoral neck, −0.17 g/cm2 (95% CI, −0.23 to −0.11 g/cm2)] but not lower than in women with natural menopause [lumbar spine, −0.02 g/cm2 (95% CI, −0.04 to 0.00 g/cm2); femoral neck, 0.04 g/cm2 (95% CI, −0.09 to 0.16 g/cm2)]. Hip fracture rate was not higher after surgical menopause compared with natural menopause [hazard ratio: 0.85 (95% CI, 0.70 to 1.04)]. Author's conclusions No evident effect of surgical menopause was observed on BMD and fracture prevalence compared with natural menopause. However, available studies are prone to bias and need to be interpreted with caution. Tweetable abstract Bone health after menopause: no evidence for additional effect of surgical menopause on BMD and fractures.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14645Does antenatal care timing influence stillbirth risk in the third trimester? A secondary analysis of perinatal death audit data in South AfricaT Lavin, RC Pattinson2017-06-26T01:47:35.017359-05:00doi:10.1111/1471-0528.14645John Wiley & Sons, Inc.10.1111/1471-0528.14645http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14645Original Articlen/an/a

Objective

To explore stillbirth risk across gestation in three provinces of South Africa with different antenatal care schedules.

Design

Retrospective audit of perinatal death data using South Africa's Perinatal Problem Identification Programme.

Setting

In 2008, the Basic Antenatal Care Programme was introduced in Limpopo and Mpumalanga provinces, reducing appointments to five visits at booking, 20, 26, 32, 38 weeks and 41 weeks if required. In the Western Cape province seven appointments remained at booking, 20, 26, 32, 34, 36, 38 and 41 weeks if required.

Population

All audited stillbirths (n = 4211) between October 2013 to August 2015 in Limpopo, Mpumalanga and Western Cape.

Methods

Stillbirth risk (26–42 weeks of gestation, >1000 g) across gestation was calculated using Yudkin's method. Stillbirth risk was compared between provinces and relative risks were calculated between Limpopo/ Mpumalanga and Western Cape.

Main outcome measures

Stillbirth risk across gestation.

Results

Stillbirth risk peaked at 38 weeks of gestation in Limpopo (relative risk [RR] 3.11, 95% CI 2.40–4.03, P < 0.001)and Mpumalanga (RR 3.09, 95% CI 2.37–4.02, P < 0.001) compared with Western Cape, where no peak was observed. Stillbirth risk at 38 weeks gestation in Limpopo and Mpumalanga were statistically greater than both the 37 and 39 weeks gestation within provinces (P < 0.001). As expected, a peak at 41 weeks of gestation was observed in all provinces.

Conclusions

The increased period of stillbirth risk occurs after a 6-week absence of antenatal care. This calls for a refocus on the impact of reduced antenatal care visits during the third trimester.

Tweetable abstract

Reduced antenatal care in the third trimester may increase stillbirth risk.

Objective To explore stillbirth risk across gestation in three provinces of South Africa with different antenatal care schedules. Design Retrospective audit of perinatal death data using South Africa's Perinatal Problem Identification Programme. Setting In 2008, the Basic Antenatal Care Programme was introduced in Limpopo and Mpumalanga provinces, reducing appointments to five visits at booking, 20, 26, 32, 38 weeks and 41 weeks if required. In the Western Cape province seven appointments remained at booking, 20, 26, 32, 34, 36, 38 and 41 weeks if required. Population All audited stillbirths (n = 4211) between October 2013 to August 2015 in Limpopo, Mpumalanga and Western Cape. Methods Stillbirth risk (26–42 weeks of gestation, >1000 g) across gestation was calculated using Yudkin's method. Stillbirth risk was compared between provinces and relative risks were calculated between Limpopo/ Mpumalanga and Western Cape. Main outcome measures Stillbirth risk across gestation. Results Stillbirth risk peaked at 38 weeks of gestation in Limpopo (relative risk [RR] 3.11, 95% CI 2.40–4.03, P < 0.001)and Mpumalanga (RR 3.09, 95% CI 2.37–4.02, P < 0.001) compared with Western Cape, where no peak was observed. Stillbirth risk at 38 weeks gestation in Limpopo and Mpumalanga were statistically greater than both the 37 and 39 weeks gestation within provinces (P < 0.001). As expected, a peak at 41 weeks of gestation was observed in all provinces. Conclusions The increased period of stillbirth risk occurs after a 6-week absence of antenatal care. This calls for a refocus on the impact of reduced antenatal care visits during the third trimester. Tweetable abstract Reduced antenatal care in the third trimester may increase stillbirth risk.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14641Re: Variations in very preterm birth rates in 30 high-income countries: are valid international comparisons possible using routine data?Boris Filipović-Grčić, Urelija Rodin2017-06-26T01:42:36.03075-05:00doi:10.1111/1471-0528.14641John Wiley & Sons, Inc.10.1111/1471-0528.14641http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14641BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14653Authors’ reply re: Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort studyDawn M. Kopp, Angela M. Bengtson, Jennifer H. Tang, Ennet Chipungu, Margaret Moyo, Jeffrey Wilkinson2017-06-26T01:42:32.509966-05:00doi:10.1111/1471-0528.14653John Wiley & Sons, Inc.10.1111/1471-0528.14653http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14653BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14499Authors' reply re: Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort studyPatrick Rozenberg, Mathilde Revert2017-06-26T01:37:38.899072-05:00doi:10.1111/1471-0528.14499John Wiley & Sons, Inc.10.1111/1471-0528.14499http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14499BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14498Re: Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort studyShigeki Matsubara, Hironori Takahashi, Yosuke Baba, Alan Kawarai Lefor2017-06-26T01:32:41.34054-05:00doi:10.1111/1471-0528.14498John Wiley & Sons, Inc.10.1111/1471-0528.14498http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14498BJOG Exchangen/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14692Reduction of preterm birth rates starts at preconceptionMA Oudijk2017-06-23T03:40:21.966253-05:00doi:10.1111/1471-0528.14692John Wiley & Sons, Inc.10.1111/1471-0528.14692http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14692Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14732Misoprostol for cervical priming prior to office hysteroscopy works in premenopausal nulliparous but not in postmenopausal womenS Bakour2017-06-22T06:05:25.341655-05:00doi:10.1111/1471-0528.14732John Wiley & Sons, Inc.10.1111/1471-0528.14732http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14732Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14730Uterine fibroids: from observational epidemiology to clinical managementP Vercellini, MP Frattaruolo2017-06-22T04:35:19.834665-05:00doi:10.1111/1471-0528.14730John Wiley & Sons, Inc.10.1111/1471-0528.14730http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14730Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14721Quality of life among women in Bangladesh following ileal conduit urinary diversion operations for irreparable vesicovaginal fistula and bladder exstrophy: observational studySH Walker, B Ambauen-Berger, SL Saha, S Akhter2017-06-22T04:26:53.234812-05:00doi:10.1111/1471-0528.14721John Wiley & Sons, Inc.10.1111/1471-0528.14721http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14721Original Articlen/an/a

Objective

To determine the quality of life (QOL) of fistula patients in Bangladesh who have undergone ileal conduit (IC) urinary diversion operations, and to assess whether the risks and ethical challenges involved, outweigh the reality of leaving a woman with urinary incontinence for the rest of her life.

Design

Observational study.

Setting

LAMB Hospital, Bangladesh.

Population

Seventeen women who had undergone IC between February 2012 and March 2016: 14 women previously had irreparable obstetric fistulas and three had bladder exstrophy.

Methods

Demographic, obstetric, IC-related, stigma and discrimination information were collected by questionnaire. Univariate analysis was done using the two-sided t-test for comparison of differences before and after IC surgery.

Main outcome methods

Change in stigma and discrimination scores. Health-related QOL assessed using the 36-item Short Form Health Survey.

Results

Of the 17 women, 14 (82.3%) felt they were cured of their fistula disease. Three complained of occasional leakage due to insufficient seal of the bag, mainly at night, and all but one experienced no limits to their daily activities. Stigma and discrimination scores were significantly lower after having the IC surgery. The mean difference from when the woman had a fistula to when she had an IC for stigma score was 3.17 (1.12–4.16, P < 0.001), and for discrimination score was 3 (1.9–4.1, P < 0.001).

Conclusion

Overall, there has been improved QOL following IC among the women in this study and all would recommend IC to women in the same situation. They remain chronic patients with some physical symptoms, but are well re-integrated back into their communities.

Tweetable abstract

Improved QOL following ileal conduit in women with persistent fistula related disorder in Bangladesh.

Objective To determine the quality of life (QOL) of fistula patients in Bangladesh who have undergone ileal conduit (IC) urinary diversion operations, and to assess whether the risks and ethical challenges involved, outweigh the reality of leaving a woman with urinary incontinence for the rest of her life. Design Observational study. Setting LAMB Hospital, Bangladesh. Population Seventeen women who had undergone IC between February 2012 and March 2016: 14 women previously had irreparable obstetric fistulas and three had bladder exstrophy. Methods Demographic, obstetric, IC-related, stigma and discrimination information were collected by questionnaire. Univariate analysis was done using the two-sided t-test for comparison of differences before and after IC surgery. Main outcome methods Change in stigma and discrimination scores. Health-related QOL assessed using the 36-item Short Form Health Survey. Results Of the 17 women, 14 (82.3%) felt they were cured of their fistula disease. Three complained of occasional leakage due to insufficient seal of the bag, mainly at night, and all but one experienced no limits to their daily activities. Stigma and discrimination scores were significantly lower after having the IC surgery. The mean difference from when the woman had a fistula to when she had an IC for stigma score was 3.17 (1.12–4.16, P < 0.001), and for discrimination score was 3 (1.9–4.1, P < 0.001). Conclusion Overall, there has been improved QOL following IC among the women in this study and all would recommend IC to women in the same situation. They remain chronic patients with some physical symptoms, but are well re-integrated back into their communities. Tweetable abstract Improved QOL following ileal conduit in women with persistent fistula related disorder in Bangladesh.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14725Optimising fertility outcomes for women with early-stage cervical cancer: when less is moreE Tingi, EJ Crosbie, G Owens2017-06-22T04:25:33.603302-05:00doi:10.1111/1471-0528.14725John Wiley & Sons, Inc.10.1111/1471-0528.14725http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14725Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14726Can we prevent preterm birth after radical trachelectomy?M Kyrgiou, P Bennett2017-06-22T04:25:22.22172-05:00doi:10.1111/1471-0528.14726John Wiley & Sons, Inc.10.1111/1471-0528.14726http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14726Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14696Importance of prenatal care in reducing stillbirthRL Goldenberg, EM McClure2017-06-22T02:20:32.673513-05:00doi:10.1111/1471-0528.14696John Wiley & Sons, Inc.10.1111/1471-0528.14696http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14696Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14728With smart strategies, immediate postpartum LARC is possibleARA Aiken2017-06-21T00:25:20.681756-05:00doi:10.1111/1471-0528.14728John Wiley & Sons, Inc.10.1111/1471-0528.14728http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14728Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14752Comparison of management regimens following ultrasound diagnosis of nontubal ectopic pregnancies: a retrospective cohort studyJ Ramkrishna, GR Kan, KL Reidy, WC Ang, R Palma-Dias2017-06-19T00:00:59.984065-05:00doi:10.1111/1471-0528.14752John Wiley & Sons, Inc.10.1111/1471-0528.14752http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14752Original Articlen/an/a

Objective

To review management options for nontubal ectopic pregnancies.

Design

Retrospective cohort study.

Setting

Tertiary hospital in Melbourne, Australia.

Population

A total of 100 nontubal pregnancies: 1 abdominal, 32 caesarean scar, 14 cervical, 41 cornual–interstitial, 12 ovarian.

Methods

Cases were classified according to ectopic site. Management categories were medical, surgical, combination or expectant. Use of minimally invasive approaches (ultrasound-guided intra-sac injections or selective surgical techniques) was identified. Primary management was considered to be successful if no further unplanned interventions were required.

Main outcome measures

Success of primary management and frequency of unplanned interventions.

Results

A high rate of success (82%) was demonstrated for all management regimens, with minimal morbidity and no deaths occurring. A high success rate was shown when the primary management regimen was systemic methotrexate or ultrasound-guided intra-sac injection (88%). The success rate for primary surgical management was 57%. High success rates were reported for both primary management with ultrasound-guided injections or in combination with systemic methotrexate (94%) and for primary management with systemic methotrexate alone (81%). Seventy-five per cent of women managed with minimally invasive surgical approaches avoided the need for more extensive surgery, but required longer follow up and additional interventions.

Conclusion

Minimally invasive approaches were found to be safe and effective treatment for women desiring to conserve fertility. Ultrasound-guided intra-sac injection and laparoscopic ectopic removal procedures aimed at preserving reproductive organs should be included as minimally invasive primary management tools in addition to the well-recognised option of systemic methotrexate.

Tweetable abstract

Nontubal ectopics: minimally invasive procedures a safe alternative to surgery in selected cases.

Objective To review management options for nontubal ectopic pregnancies. Design Retrospective cohort study. Setting Tertiary hospital in Melbourne, Australia. Population A total of 100 nontubal pregnancies: 1 abdominal, 32 caesarean scar, 14 cervical, 41 cornual–interstitial, 12 ovarian. Methods Cases were classified according to ectopic site. Management categories were medical, surgical, combination or expectant. Use of minimally invasive approaches (ultrasound-guided intra-sac injections or selective surgical techniques) was identified. Primary management was considered to be successful if no further unplanned interventions were required. Main outcome measures Success of primary management and frequency of unplanned interventions. Results A high rate of success (82%) was demonstrated for all management regimens, with minimal morbidity and no deaths occurring. A high success rate was shown when the primary management regimen was systemic methotrexate or ultrasound-guided intra-sac injection (88%). The success rate for primary surgical management was 57%. High success rates were reported for both primary management with ultrasound-guided injections or in combination with systemic methotrexate (94%) and for primary management with systemic methotrexate alone (81%). Seventy-five per cent of women managed with minimally invasive surgical approaches avoided the need for more extensive surgery, but required longer follow up and additional interventions. Conclusion Minimally invasive approaches were found to be safe and effective treatment for women desiring to conserve fertility. Ultrasound-guided intra-sac injection and laparoscopic ectopic removal procedures aimed at preserving reproductive organs should be included as minimally invasive primary management tools in addition to the well-recognised option of systemic methotrexate. Tweetable abstract Nontubal ectopics: minimally invasive procedures a safe alternative to surgery in selected cases.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14723Physical activity and preterm birth: risk factor or benefit?BA Armson2017-06-15T23:25:22.632719-05:00doi:10.1111/1471-0528.14723John Wiley & Sons, Inc.10.1111/1471-0528.14723http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14723Mini commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14719Safety and effectiveness of female tubal sterilisation by hysteroscopy, laparoscopy, or laparotomy: a register based studyE Jokinen, A Heino, T Karipohja, M Gissler, R Hurskainen2017-06-15T04:45:21.068794-05:00doi:10.1111/1471-0528.14719John Wiley & Sons, Inc.10.1111/1471-0528.14719http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14719Original articlen/an/a

Objective

To determine the safety and effectiveness of female sterilisation in the Finnish population.

Design

A national register-based study using record linkage.

Setting

National data from Finland.

Sample

A total of 16 272 female sterilisations performed in 2009–2014.

Methods

The Register of Sterilisations was linked with the Hospital Discharge Register, Termination of Pregnancy Register, and the Medical Birth Register in order to investigate the occurrence of re-sterilisations, other surgical operations, and unwanted pregnancies after sterilisation, per method.

Main outcome measures

Outcome measures included all pregnancies after sterilisation (births, miscarriages, terminations of pregnancy, and ectopic pregnancies) and operations (repeat sterilisations, other hysteroscopic and laparoscopic procedures, hysterectomies, and re-operations for a complication). The outcomes were presented by method as risk ratio (RR) with 95% confidence intervals (95% CIs).

Results

There was no significant difference in all spontaneous pregnancies between the groups. The risk ratio for any pregnancy was 1.27 (95% Cl 0.80–2.02) for Filshie® versus Essure® and 1.35 (95% Cl 0.92–1.96) for Pomeroy versus Essure®. In total, 1394 (8.6%) selected operations were identified after primary sterilisation. Re-sterilisations and hysteroscopies were most frequent among Essure® patients.

Conclusions

Patients undergoing hysteroscopic or laparoscopic sterilisation have a similar risk of unintended pregnancy. All sterilisations are safe, and the risk of re-operations because of complications is low. Women with Essure® have a higher risk of undergoing re-sterilisation compared with patients undergoing laparoscopic sterilisation.

Tweetable abstract

Essure®, Filshie®, and Pomeroy sterilisations are equally effective and safe.

Objective To determine the safety and effectiveness of female sterilisation in the Finnish population. Design A national register-based study using record linkage. Setting National data from Finland. Sample A total of 16 272 female sterilisations performed in 2009–2014. Methods The Register of Sterilisations was linked with the Hospital Discharge Register, Termination of Pregnancy Register, and the Medical Birth Register in order to investigate the occurrence of re-sterilisations, other surgical operations, and unwanted pregnancies after sterilisation, per method. Main outcome measures Outcome measures included all pregnancies after sterilisation (births, miscarriages, terminations of pregnancy, and ectopic pregnancies) and operations (repeat sterilisations, other hysteroscopic and laparoscopic procedures, hysterectomies, and re-operations for a complication). The outcomes were presented by method as risk ratio (RR) with 95% confidence intervals (95% CIs). Results There was no significant difference in all spontaneous pregnancies between the groups. The risk ratio for any pregnancy was 1.27 (95% Cl 0.80–2.02) for Filshie® versus Essure® and 1.35 (95% Cl 0.92–1.96) for Pomeroy versus Essure®. In total, 1394 (8.6%) selected operations were identified after primary sterilisation. Re-sterilisations and hysteroscopies were most frequent among Essure® patients. Conclusions Patients undergoing hysteroscopic or laparoscopic sterilisation have a similar risk of unintended pregnancy. All sterilisations are safe, and the risk of re-operations because of complications is low. Women with Essure® have a higher risk of undergoing re-sterilisation compared with patients undergoing laparoscopic sterilisation. Tweetable abstract Essure®, Filshie®, and Pomeroy sterilisations are equally effective and safe.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14702Outcome reporting across randomised controlled trials evaluating therapeutic interventions for pre-eclampsiaJMN Duffy, M Hirsch, A Kawsar, C Gale, L Pealing, MN Plana, M Showell, PR Williamson, KS Khan, S Ziebland, RJ McManus, 2017-06-14T07:20:44.37022-05:00doi:10.1111/1471-0528.14702John Wiley & Sons, Inc.10.1111/1471-0528.14702http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14702Original Articlen/an/a

Background

Standardising outcome collection and reporting in pre-eclampsia trials requires an appraisal of current outcome reporting.

Objectives

To map maternal and offspring outcome reporting across randomised trials evaluating therapeutic interventions for pre-eclampsia.

Search strategy

Randomised trials were identified by searching bibliographical databases from inception to January 2016.

Selection criteria

Randomised controlled trials.

Data collection and analysis

We systematically extracted and categorised outcome reporting.

Main results

Seventy-nine randomised trials, reporting data from 31 615 maternal participants and 28 172 of their offspring, were included. Fifty-five different interventions were evaluated. Included trials reported 119 different outcomes, including 72 maternal outcomes and 47 offspring outcomes. Maternal outcomes were inconsistently reported across included trials; for example, 11 trials (14%) reported maternal mortality, reporting data from 12 422 participants, and 16 trials (20%) reported cardiovascular morbidity, reporting data from 14 963 maternal participants. Forty-three trials (54%) reported fetal outcomes and 23 trials (29%) reported neonatal outcomes. Twenty-eight trials (35%) reported offspring mortality. There was poor reporting of childhood outcomes: six trials (8%) reported neurodevelopmental outcomes. Less than half of included trials reported any relevant information regarding harms for maternal participants and their offspring.

Conclusions

Most randomised trials evaluating interventions for pre-eclampsia are missing information on clinically important outcomes, and in particular have neglected to evaluate efficacy and safety in the offspring of participants. Developing and implementing a minimum data set, known as a core outcome set, in future pre-eclampsia trials could help to address these issues.

Tweetable abstract

Future #preeclampsia research requires a core outcome set to reduce #research waste. @coreoutcomes @jamesmnduffy

International Prospective Register of Systematic Reviews: CRD42015015529; www.crd.york.ac.uk/PROSPERO/display_record.aspID=CRD42015015529.

Background Standardising outcome collection and reporting in pre-eclampsia trials requires an appraisal of current outcome reporting. Objectives To map maternal and offspring outcome reporting across randomised trials evaluating therapeutic interventions for pre-eclampsia. Search strategy Randomised trials were identified by searching bibliographical databases from inception to January 2016. Selection criteria Randomised controlled trials. Data collection and analysis We systematically extracted and categorised outcome reporting. Main results Seventy-nine randomised trials, reporting data from 31 615 maternal participants and 28 172 of their offspring, were included. Fifty-five different interventions were evaluated. Included trials reported 119 different outcomes, including 72 maternal outcomes and 47 offspring outcomes. Maternal outcomes were inconsistently reported across included trials; for example, 11 trials (14%) reported maternal mortality, reporting data from 12 422 participants, and 16 trials (20%) reported cardiovascular morbidity, reporting data from 14 963 maternal participants. Forty-three trials (54%) reported fetal outcomes and 23 trials (29%) reported neonatal outcomes. Twenty-eight trials (35%) reported offspring mortality. There was poor reporting of childhood outcomes: six trials (8%) reported neurodevelopmental outcomes. Less than half of included trials reported any relevant information regarding harms for maternal participants and their offspring. Conclusions Most randomised trials evaluating interventions for pre-eclampsia are missing information on clinically important outcomes, and in particular have neglected to evaluate efficacy and safety in the offspring of participants. Developing and implementing a minimum data set, known as a core outcome set, in future pre-eclampsia trials could help to address these issues. Tweetable abstract Future #preeclampsia research requires a core outcome set to reduce #research waste. @coreoutcomes @jamesmnduffy International Prospective Register of Systematic Reviews: CRD42015015529; www.crd.york.ac.uk/PROSPERO/display_record.aspID=CRD42015015529.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14720Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort studyF Ghezzi, J Casarin, G De Francesco, P Puggina, S Uccella, M Serati, A Cromi2017-06-14T07:00:27.358731-05:00doi:10.1111/1471-0528.14720John Wiley & Sons, Inc.10.1111/1471-0528.14720http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14720Original Articlen/an/a

Objective

To describe the technique and report perioperative outcomes of transvaginal contained extraction of surgical specimens at laparoscopic myomectomy.

Design

Retrospective analysis of prospectively collected data.

Setting

Two Italian referral centres for gynaecological minimally invasive surgery.

Population

Consecutive patients who underwent laparoscopic myomectomy.

Methods

Tissue extraction was accomplished following laparoscopic myomectomy in a specimen retrieval bag via a posterior colpotomy incision. If morcellation was necessary, this was performed extracorporeally, using a scalpel within the specimen retrieval pouch, whose edges were exteriorised through the vaginal introitus.

Main outcome measures

Intra- and postoperative complications.

Results

A total of 316 women underwent transvaginal specimen retrieval with enclosed manual morcellation. The mean myomectomy specimen weight was 154 ± 128 g, and the mean operative time was 79 ± 26 minutes. No intraoperative complications occurred related to the specimen extraction or morcellation technique, or from rupture of the retrieval bag. Two (0.6%) women had a haemoperitoneum that spontaneously resolved and 16 (5.1%) had fever postoperatively. The final pathological diagnosis was benign in all cases. At the 30-day follow-up, no pelvic infection, vaginal dehiscence, or complaints of dyspareunia were recorded.

Conclusions

Contained transvaginal extraction of fibroid specimens can be performed safely and efficiently in most women undergoing laparoscopic myomectomy. This technique represents a valuable minimally invasive alternative to intracorporeal morcellation.

Tweetable abstract

Transvaginal contained morcellation at laparoscopic myomectomy is a valuable alternative to intracorporeal morcellation.

Objective To describe the technique and report perioperative outcomes of transvaginal contained extraction of surgical specimens at laparoscopic myomectomy. Design Retrospective analysis of prospectively collected data. Setting Two Italian referral centres for gynaecological minimally invasive surgery. Population Consecutive patients who underwent laparoscopic myomectomy. Methods Tissue extraction was accomplished following laparoscopic myomectomy in a specimen retrieval bag via a posterior colpotomy incision. If morcellation was necessary, this was performed extracorporeally, using a scalpel within the specimen retrieval pouch, whose edges were exteriorised through the vaginal introitus. Main outcome measures Intra- and postoperative complications. Results A total of 316 women underwent transvaginal specimen retrieval with enclosed manual morcellation. The mean myomectomy specimen weight was 154 ± 128 g, and the mean operative time was 79 ± 26 minutes. No intraoperative complications occurred related to the specimen extraction or morcellation technique, or from rupture of the retrieval bag. Two (0.6%) women had a haemoperitoneum that spontaneously resolved and 16 (5.1%) had fever postoperatively. The final pathological diagnosis was benign in all cases. At the 30-day follow-up, no pelvic infection, vaginal dehiscence, or complaints of dyspareunia were recorded. Conclusions Contained transvaginal extraction of fibroid specimens can be performed safely and efficiently in most women undergoing laparoscopic myomectomy. This technique represents a valuable minimally invasive alternative to intracorporeal morcellation. Tweetable abstract Transvaginal contained morcellation at laparoscopic myomectomy is a valuable alternative to intracorporeal morcellation.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14711Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million membersVH Eisenberg, C Weil, G Chodick, V Shalev2017-06-14T07:00:24.130579-05:00doi:10.1111/1471-0528.14711John Wiley & Sons, Inc.10.1111/1471-0528.14711http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14711Original Articlen/an/a

Objective

Endometriosis constitutes a significant burden on the quality of life of women, their families and healthcare systems. The objective of this study is to describe the real-world epidemiology of endometriosis in an unselected low-risk population in Israel.

Design

Retrospective population-based study.

Setting and sample

The computerised databases of Maccabi Healthcare Services (MHS), a 2-million-member healthcare provider representing a quarter of the Israeli population.

Methods

The crude point prevalence (31 December 2015; diagnosed since 1998) and annual incidence (2000–2015) rates of diagnosed endometriosis (ICD-9-CM 617.xx) were assessed among women aged 15–55 years. Prevalent patients were characterised in terms of sociodemographic and clinical characteristics, including validated MHS infertility and chronic disease registries.

Main outcome measures

Prevalence and incidence of diagnosed endometriosis in MHS.

Results

The point prevalence of endometriosis [n = 6146, mean age 40.4 ± 8.0 years (SD)] was 10.8 per 1000 (95% CI 10.5–11.0). Women aged 40–44 years had the highest prevalence rate of 18.6 per 1000 (95% CI 17.7–19.5). Infertility was documented in 37% of patients. A total of 6045 patients were included in the cohort of newly-diagnosed endometriosis (mean age 34.0 ± 8.1 years), corresponding to an average annual incidence rate of 7.2 per 10 000 (95% CI 6.5–8.0).

Conclusions

We observed a substantially lower prevalence of diagnosed endometriosis compared with previous reports in high-risk populations, in line with population-based estimates from European databases (range 0.8–1.8%). Further characterisation of this cohort may help to understand what affects the prevalence of endometriosis in Israel, and to promote earlier diagnosis and improve management in clinical practice.

Tweetable abstract

Endometriosis diagnosed in 1% of women, according to a large population-based study in a community setting.

Objective Endometriosis constitutes a significant burden on the quality of life of women, their families and healthcare systems. The objective of this study is to describe the real-world epidemiology of endometriosis in an unselected low-risk population in Israel. Design Retrospective population-based study. Setting and sample The computerised databases of Maccabi Healthcare Services (MHS), a 2-million-member healthcare provider representing a quarter of the Israeli population. Methods The crude point prevalence (31 December 2015; diagnosed since 1998) and annual incidence (2000–2015) rates of diagnosed endometriosis (ICD-9-CM 617.xx) were assessed among women aged 15–55 years. Prevalent patients were characterised in terms of sociodemographic and clinical characteristics, including validated MHS infertility and chronic disease registries. Main outcome measures Prevalence and incidence of diagnosed endometriosis in MHS. Results The point prevalence of endometriosis [n = 6146, mean age 40.4 ± 8.0 years (SD)] was 10.8 per 1000 (95% CI 10.5–11.0). Women aged 40–44 years had the highest prevalence rate of 18.6 per 1000 (95% CI 17.7–19.5). Infertility was documented in 37% of patients. A total of 6045 patients were included in the cohort of newly-diagnosed endometriosis (mean age 34.0 ± 8.1 years), corresponding to an average annual incidence rate of 7.2 per 10 000 (95% CI 6.5–8.0). Conclusions We observed a substantially lower prevalence of diagnosed endometriosis compared with previous reports in high-risk populations, in line with population-based estimates from European databases (range 0.8–1.8%). Further characterisation of this cohort may help to understand what affects the prevalence of endometriosis in Israel, and to promote earlier diagnosis and improve management in clinical practice. Tweetable abstract Endometriosis diagnosed in 1% of women, according to a large population-based study in a community setting.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14722Clomiphene citrate – a reassuringly safe drugM Afnan2017-06-14T00:31:42.049161-05:00doi:10.1111/1471-0528.14722John Wiley & Sons, Inc.10.1111/1471-0528.14722http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14722Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14709Quality of life of immigrant and non-immigrant infertile patients in a publicly funded in vitro fertilisation program: a cross-sectional studyJ Hasson, T Tulandi, T Shavit, T Shaulov, E Seccareccia, J Takefman2017-06-14T00:25:24.268454-05:00doi:10.1111/1471-0528.14709John Wiley & Sons, Inc.10.1111/1471-0528.14709http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14709Original articlen/an/a

Objective

To investigate whether there are differences in fertility quality of life (FertiQoL) and socio-demographic characteristics between immigrants and non-immigrant patients attending a government-funded fertility program.

Design

Cross-sectional study.

Setting

McGill University Reproductive Center in Montreal, Canada, at a time when governmental funding for in vitro fertilisation (IVF) was provided to all residents.

Population

All infertile patients, males and females, attending the center between March and July 2015.

Methods

Patients were invited to complete anonymous questionnaires which included socio-demographic items and the validated FertiQoL questionnaire.

Main outcome measures

Socio-demographic characteristics (age, gender, marital state, infertility type & duration, previous IVF attempts; education, employment, income, ethnicity, spoken languages) and FertiQoL scores.

Results

In all, 1020 patients completed the questionnaires; of these, 752 (77.7%) non-immigrant Canadian citizens and 215 (22.3%) resident immigrants were included in the analysis. Median duration in Canada for immigrants was 4 years. Immigrants were more likely to have university/graduate degrees (75% versus 64%), to be unemployed (37% versus 13.1%) and to have lower annual household incomes (72.8% versus 39.5%, all < 0.05). They also reported poorer QoL and achieved significantly lower scores in the emotional, mind/body, social, treatment and total FertiQoL domains. Multivariate analysis showed male gender, lower education level and Caucasian/European ethnicity to be significantly associated with higher QoL.

Conclusions

Despite governmental funding of IVF, immigrants experience reduced fertility QoL, implying cost is not the only barrier to IVF use. The reduced QoL may stem from cross-cultural differences in infertility perception. This population may be at greater risk for depression and anxiety and should be flagged accordingly.

Tweetable abstract

Immigrants’ fertility QoL is lower despite publicly funded IVF implying cost is not the only barrier to IVF use.

Objective To investigate whether there are differences in fertility quality of life (FertiQoL) and socio-demographic characteristics between immigrants and non-immigrant patients attending a government-funded fertility program. Design Cross-sectional study. Setting McGill University Reproductive Center in Montreal, Canada, at a time when governmental funding for in vitro fertilisation (IVF) was provided to all residents. Population All infertile patients, males and females, attending the center between March and July 2015. Methods Patients were invited to complete anonymous questionnaires which included socio-demographic items and the validated FertiQoL questionnaire. Main outcome measures Socio-demographic characteristics (age, gender, marital state, infertility type & duration, previous IVF attempts; education, employment, income, ethnicity, spoken languages) and FertiQoL scores. Results In all, 1020 patients completed the questionnaires; of these, 752 (77.7%) non-immigrant Canadian citizens and 215 (22.3%) resident immigrants were included in the analysis. Median duration in Canada for immigrants was 4 years. Immigrants were more likely to have university/graduate degrees (75% versus 64%), to be unemployed (37% versus 13.1%) and to have lower annual household incomes (72.8% versus 39.5%, all P < 0.05). They also reported poorer QoL and achieved significantly lower scores in the emotional, mind/body, social, treatment and total FertiQoL domains. Multivariate analysis showed male gender, lower education level and Caucasian/European ethnicity to be significantly associated with higher QoL. Conclusions Despite governmental funding of IVF, immigrants experience reduced fertility QoL, implying cost is not the only barrier to IVF use. The reduced QoL may stem from cross-cultural differences in infertility perception. This population may be at greater risk for depression and anxiety and should be flagged accordingly. Tweetable abstract Immigrants’ fertility QoL is lower despite publicly funded IVF implying cost is not the only barrier to IVF use.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14708Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population-based register studyS Hesselman, U Högberg, E-B Råssjö, E Schytt, M Löfgren, M Jonsson2017-06-14T00:20:20.888461-05:00doi:10.1111/1471-0528.14708John Wiley & Sons, Inc.10.1111/1471-0528.14708http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14708Original Articlen/an/a

Objective

The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS).

Design

Longitudinal population-based register study.

Setting

Sweden.

Population

Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000–2014, with a previous delivery during 1973–2013 (= 15 479).

Methods

Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers.

Main outcome measures

Adhesions.

Results

In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70–5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (< 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05–1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49–2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05–2.30) increased the risk of adhesions.

Conclusions

Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence.

Tweetable abstract

Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.

Objective The aim of the study was to evaluate the association between abdominal adhesions at the time of gynaecologic surgery and a history of caesarean delivery, and to investigate obstetric factors contributing to adhesion formation after caesarean section (CS). Design Longitudinal population-based register study. Setting Sweden. Population Women undergoing benign hysterectomy and/or adnexal surgery in Sweden, 2000–2014, with a previous delivery during 1973–2013 (n = 15 479). Methods Information about abdominal adhesions during gynaecological surgery, prior medical history, pregnancies and deliveries were retrieved from Swedish National Health and Quality registers. Main outcome measures Adhesions. Results In women with previous CS, adhesions were present in 37%, compared with 10% of women with no previous CS [odds ratio (OR): 5.18, 95% confidence interval (CI): 4.70–5.71]. Adhesions increased with the number of caesarean sections: 32% after one CS; 42% after two CS and 59% after three or more CS (P < 0.001). Regardless of the number of CS, factors at CS such as age ≥35 years (aOR: 1.28, 95% CI: 1.05–1.55), body mass index (BMI) ≥30 [adjusted OR (aOR): 1.91, 95% CI: 1.49–2.45] and postpartum infection (aOR: 1.55, 95% CI: 1.05–2.30) increased the risk of adhesions. Conclusions Presence of adhesions in abdominal gynaecological surgery is associated with women's personal history of caesarean delivery. The number of caesarean sections was the important predictor of adhesions; advanced age, obesity and postpartum infection further increased the incidence. Tweetable abstract Repeat caesarean, age, obesity and infection increased the risk of pelvic adhesions after caesarean section.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14701Efforts to redefine endometriosis prevalence in low-risk patientsLR Goodman, JM Franasiak2017-06-14T00:15:21.14424-05:00doi:10.1111/1471-0528.14701John Wiley & Sons, Inc.10.1111/1471-0528.14701http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14701Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14690Self-management of first trimester medical termination of pregnancy: a qualitative study of women's experiencesC Purcell, S Cameron, J Lawton, A Glasier, J Harden2017-06-14T00:10:24.34335-05:00doi:10.1111/1471-0528.14690John Wiley & Sons, Inc.10.1111/1471-0528.14690http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14690Original articlen/an/a

Objective

To explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic.

Design

Qualitative interview study.

Setting

One National Health Service health board (administrative) area in Scotland.

Population or Sample

Women in Scotland who had undergone medical TOP ≤63 days, and self-managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014.

Methods

In-depth, semi-structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method.

Main outcome measures

Women's experiences of self-management of TOP ≤63 days of gestation.

Results

Key themes emerging from the analysis related to self-administration of misoprostol in clinic; reasons for choosing home self-management; facilitation of self-management and expectation-setting; experiences of getting home; self-managing and monitoring treatment progress; support for self-management (in person and remotely); and pregnancy self-testing to confirm completion.

Conclusions

Participants primarily found self-administration of misoprostol and home self-management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self-management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol.

Tweetable abstract

Women undergoing medical TOP 63 days found home self-management to be acceptable and/or preferable.

Objective To explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic. Design Qualitative interview study. Setting One National Health Service health board (administrative) area in Scotland. Population or Sample Women in Scotland who had undergone medical TOP ≤63 days, and self-managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014. Methods In-depth, semi-structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method. Main outcome measures Women's experiences of self-management of TOP ≤63 days of gestation. Results Key themes emerging from the analysis related to self-administration of misoprostol in clinic; reasons for choosing home self-management; facilitation of self-management and expectation-setting; experiences of getting home; self-managing and monitoring treatment progress; support for self-management (in person and remotely); and pregnancy self-testing to confirm completion. Conclusions Participants primarily found self-administration of misoprostol and home self-management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self-management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol. Tweetable abstract Women undergoing medical TOP 63 days found home self-management to be acceptable and/or preferable.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14691Should we be putting our scalpels down? Is HIFU the answer to fertility-sparing fibroid treatment?N Tempest, D Hapangama2017-06-08T07:30:34.372757-05:00doi:10.1111/1471-0528.14691John Wiley & Sons, Inc.10.1111/1471-0528.14691http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14691Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14693Do mHealth interventions prevent excessive gestational weight gain?SJ Herring2017-06-07T06:35:18.997406-05:00doi:10.1111/1471-0528.14693John Wiley & Sons, Inc.10.1111/1471-0528.14693http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14693Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14705The European Court of Human Rights on planned home birth: resolution of a paradoxical rulingFA Chervenak, A Grünebaum, B Arabin, LB McCullough2017-06-07T03:55:56.172262-05:00doi:10.1111/1471-0528.14705John Wiley & Sons, Inc.10.1111/1471-0528.14705http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14705Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14707Clinical follow-up of women after hypertensive disease in pregnancyHA Boyd2017-06-07T03:50:36.822557-05:00doi:10.1111/1471-0528.14707John Wiley & Sons, Inc.10.1111/1471-0528.14707http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14707Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14698Complications of pregnancy and labour in women with Klippel–Trénaunay syndrome: a nationwide cross-sectional studySER Horbach, MM Lokhorst, CEU Oduber, S Middeldorp, JAM Post, CMAM Horst2017-06-05T10:10:32.409666-05:00doi:10.1111/1471-0528.14698John Wiley & Sons, Inc.10.1111/1471-0528.14698http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14698Original Articlen/an/a

Objective

To evaluate complications of pregnancy, including thromboembolism, in women with extensive vascular malformations associated with Klippel–Trénaunay syndrome (KTS).

Design

Nationwide cross-sectional study.

Setting

Two tertiary expert centres and the Dutch Klippel–Trénaunay patient organisation.

Sample

Adult women with KTS.

Methods

Patients with KTS were invited to participate in a comprehensive online survey about their obstetric history. Reference data on pregnancy outcomes and complications of non-diseased women were collected from population-based cohorts from the literature.

Main outcome measures

Prevalence of complications, specifically venous thromboembolism and postpartum haemorrhage.

Results

Sixty women completed the survey. Seventeen patients did not conceive, of whom three refrained from pregnancy because of KTS. A total of 97 pregnancies and 86 deliveries were reported in 43 patients. KTS-related symptoms were aggravated during pregnancy in 43% of patients. Deep vein thrombosis was present in 5.8% and pulmonary embolism was present in 2.3% of pregnancies, which was extremely high compared with the reference population (P < 0.0001), with a relative risk of 108.9 (95% confidence interval, 95% CI 46.48–255.03) and 106.2 (95% CI 26.97–418.10), respectively. Severe postpartum haemorrhage (PPH) occurred in 11% of KTS pregnancies, compared with 5.8% of pregnancies in the reference population (relative risk, RR 1.81, 95% CI 0.97–3.37, P = 0.06).

Conclusions

Our data suggest that women with KTS have a significant risk of venous thromboembolic events, severe postpartum haemorrhage, and aggravation of KTS symptoms during pregnancy, and in early postpartum period. Obstetricians should counsel patients about these risks in the preconception phase. Antithrombotic prophylaxis should be considered in the obstetric management of patients with KTS.

Tweetable abstract

High risk of complications during pregnancy and labour in women with Klippel–Trénaunay syndrome.

Objective To evaluate complications of pregnancy, including thromboembolism, in women with extensive vascular malformations associated with Klippel–Trénaunay syndrome (KTS). Design Nationwide cross-sectional study. Setting Two tertiary expert centres and the Dutch Klippel–Trénaunay patient organisation. Sample Adult women with KTS. Methods Patients with KTS were invited to participate in a comprehensive online survey about their obstetric history. Reference data on pregnancy outcomes and complications of non-diseased women were collected from population-based cohorts from the literature. Main outcome measures Prevalence of complications, specifically venous thromboembolism and postpartum haemorrhage. Results Sixty women completed the survey. Seventeen patients did not conceive, of whom three refrained from pregnancy because of KTS. A total of 97 pregnancies and 86 deliveries were reported in 43 patients. KTS-related symptoms were aggravated during pregnancy in 43% of patients. Deep vein thrombosis was present in 5.8% and pulmonary embolism was present in 2.3% of pregnancies, which was extremely high compared with the reference population (P < 0.0001), with a relative risk of 108.9 (95% confidence interval, 95% CI 46.48–255.03) and 106.2 (95% CI 26.97–418.10), respectively. Severe postpartum haemorrhage (PPH) occurred in 11% of KTS pregnancies, compared with 5.8% of pregnancies in the reference population (relative risk, RR 1.81, 95% CI 0.97–3.37, P = 0.06). Conclusions Our data suggest that women with KTS have a significant risk of venous thromboembolic events, severe postpartum haemorrhage, and aggravation of KTS symptoms during pregnancy, and in early postpartum period. Obstetricians should counsel patients about these risks in the preconception phase. Antithrombotic prophylaxis should be considered in the obstetric management of patients with KTS. Tweetable abstract High risk of complications during pregnancy and labour in women with Klippel–Trénaunay syndrome.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14689Evaluation of high-intensity focused ultrasound ablation for uterine fibroids: an IDEAL prospective exploration studyJ Chen, Y Li, Z Wang, P McCulloch, L Hu, W Chen, G Liu, J Li, J Lang, 2017-06-05T05:46:07.661143-05:00doi:10.1111/1471-0528.14689John Wiley & Sons, Inc.10.1111/1471-0528.14689http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14689Original Articlen/an/a

Objective

To evaluate the clinical outcomes of high-intensity focused ultrasound (HIFU) and surgery in treating uterine fibroids, and prepare for a definitive randomised trial.

Design

Prospective multicentre patient choice cohort study (IDEAL Exploratory study) of HIFU, myomectomy or hysterectomy for treating symptomatic uterine fibroids.

Setting

20 Chinese hospitals.

Population or sample

2411 Chinese women with symptomatic fibroids.

Methods

Prospective non-randomised cohort study with learning curve analysis (IDEAL Stage 2b Prospective Exploration Study).

Main outcome measures

Complications, hospital stay, return to normal activities, and quality of life (measured with UFS-Qol and SF-36 at baseline, 6 and 12 months), and need for further treatment. Quality-of-life outcomes were adjusted using regression modelling. HIFU treatment quality was evaluated using LC-CUSUM to identify operator learning curves. A health economic analysis of costs was performed.

Results

1353 women received HIFU, 472 hysterectomy and 586 myomectomy. HIFU patients were significantly younger (P < 0.001), slimmer (P < 0.001), better educated (P < 0.001), and wealthier (P = 0.002) than surgery patients. Both UFS and QoL improved more rapidly after HIFU than after surgery (P = 0.002 and P = 0.001, respectively at 6 months), but absolute differences were small. Major adverse events occurred in 3 (0.2%) of HIFU and in 133 (12.6%) of surgical cases (P < 0.001). Median time for hospital stay was 4 days (interquartile range, 0–5 days), 10 days (interquartile range, 8–12.5 days) and 8 days (interquartile range, 7–10 days).

Conclusions

HIFU caused substantially less morbidity than surgery, with similar longer-term QoL. Despite group baseline differences and lack of blinding, these findings support the need for a randomised controlled trial (RCT) of HIFU treatment for fibroids. The IDEAL Exploratory design facilitated RCT protocol development.

Tweetable abstract

HIFU had much better short-term outcomes than surgery for fibroids in 2411-patient Chinese IDEAL format study.

Objective To evaluate the clinical outcomes of high-intensity focused ultrasound (HIFU) and surgery in treating uterine fibroids, and prepare for a definitive randomised trial. Design Prospective multicentre patient choice cohort study (IDEAL Exploratory study) of HIFU, myomectomy or hysterectomy for treating symptomatic uterine fibroids. Setting 20 Chinese hospitals. Population or sample 2411 Chinese women with symptomatic fibroids. Methods Prospective non-randomised cohort study with learning curve analysis (IDEAL Stage 2b Prospective Exploration Study). Main outcome measures Complications, hospital stay, return to normal activities, and quality of life (measured with UFS-Qol and SF-36 at baseline, 6 and 12 months), and need for further treatment. Quality-of-life outcomes were adjusted using regression modelling. HIFU treatment quality was evaluated using LC-CUSUM to identify operator learning curves. A health economic analysis of costs was performed. Results 1353 women received HIFU, 472 hysterectomy and 586 myomectomy. HIFU patients were significantly younger (P < 0.001), slimmer (P < 0.001), better educated (P < 0.001), and wealthier (P = 0.002) than surgery patients. Both UFS and QoL improved more rapidly after HIFU than after surgery (P = 0.002 and P = 0.001, respectively at 6 months), but absolute differences were small. Major adverse events occurred in 3 (0.2%) of HIFU and in 133 (12.6%) of surgical cases (P < 0.001). Median time for hospital stay was 4 days (interquartile range, 0–5 days), 10 days (interquartile range, 8–12.5 days) and 8 days (interquartile range, 7–10 days). Conclusions HIFU caused substantially less morbidity than surgery, with similar longer-term QoL. Despite group baseline differences and lack of blinding, these findings support the need for a randomised controlled trial (RCT) of HIFU treatment for fibroids. The IDEAL Exploratory design facilitated RCT protocol development. Tweetable abstract HIFU had much better short-term outcomes than surgery for fibroids in 2411-patient Chinese IDEAL format study.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14699Long-acting reversible contraception: conflicting perspectives of advocates and potential usersS Rowlands, R Ingham2017-06-05T04:35:21.997608-05:00doi:10.1111/1471-0528.14699John Wiley & Sons, Inc.10.1111/1471-0528.14699http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14699Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14704The vaginal microbiome and gynaecological cancer: exercise caution when considering causationNC Ramchander, EJ Crosbie2017-06-05T04:01:16.810647-05:00doi:10.1111/1471-0528.14704John Wiley & Sons, Inc.10.1111/1471-0528.14704http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14704Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14636Antenatal corticosteroids: it's all about timingC Gyamfi-Bannerman2017-06-02T08:45:27.748996-05:00doi:10.1111/1471-0528.14636John Wiley & Sons, Inc.10.1111/1471-0528.14636http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14636Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14673Hysteroscopic excision of symptomatic myometrial adenomyosis: feasibility and effectivenessW Xia, D Zhang, Q Zhu, H Zhang, S Yang, J Ma, H Pan, T Tong, J Sun, J Zhang2017-06-01T01:41:24.502031-05:00doi:10.1111/1471-0528.14673John Wiley & Sons, Inc.10.1111/1471-0528.14673http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14673Original Articlen/an/a

Objective

To explore the feasibility and efficacy of hysteroscopic excision of myometrial adenomyotic lesions.

Design

A case-series study.

Setting

A university medical centre.

Population

51 women with myometrial adenomyosis completed the study.

Methods

The patients underwent hysteroscopic excision of myometrial adenomyosis and were followed up for 24 months. The degree of symptoms, uterine volume, and serum CA125 concentrations were recorded. The degrees of menorrhagia and dysmenorrhea were evaluated.

Results

The mean MVJ and VAS score significantly decreased from the baseline. The uterine volume and the serum CA125 significantly reduced.

Conclusions

Hysteroscopic excision of myometrial adenomyotic lesions is feasible and may be effective in improving symptoms.

Tweetable abstract

Hysteroscopic excision is feasible for patients with symptomatic adenomyosisis.

Objective To explore the feasibility and efficacy of hysteroscopic excision of myometrial adenomyotic lesions. Design A case-series study. Setting A university medical centre. Population 51 women with myometrial adenomyosis completed the study. Methods The patients underwent hysteroscopic excision of myometrial adenomyosis and were followed up for 24 months. The degree of symptoms, uterine volume, and serum CA125 concentrations were recorded. The degrees of menorrhagia and dysmenorrhea were evaluated. Results The mean MVJ and VAS score significantly decreased from the baseline. The uterine volume and the serum CA125 significantly reduced. Conclusions Hysteroscopic excision of myometrial adenomyotic lesions is feasible and may be effective in improving symptoms. Tweetable abstract Hysteroscopic excision is feasible for patients with symptomatic adenomyosisis.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14679Changing outcomes, changing policies for periviable birthsMA Rysavy, JE Tyson, BJ Stoll2017-05-30T05:20:49.645352-05:00doi:10.1111/1471-0528.14679John Wiley & Sons, Inc.10.1111/1471-0528.14679http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14679Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14672Physical activity and the risk of preterm birth: a systematic review and meta-analysis of epidemiological studiesD Aune, S Schlesinger, T Henriksen, OD Saugstad, S Tonstad2017-05-30T00:00:27.769694-05:00doi:10.1111/1471-0528.14672John Wiley & Sons, Inc.10.1111/1471-0528.14672http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14672Systematic Reviewn/an/a

Background

Physical activity has been inconsistently associated with risk of preterm birth, and the strength of the association and the shape of the dose–response relationship needs clarification.

Objectives

To conduct a systematic review and dose–response meta-analysis to clarify the association between physical activity and risk of preterm birth.

Search strategy

PubMed, Embase and Ovid databases were searched for relevant studies up to 9 February 2017.

Selection criteria

Studies with a prospective cohort, case-cohort, nested case-control or randomized study design were included.

Data collection and analysis

Data were extracted by one reviewer and checked for accuracy by a second reviewer. Summary relative risks (RRs) were estimated using a random effects model.

Main results

Forty-one studies (43 publications) including 20 randomized trials and 21 cohort studies were included. The summary RR for high versus low activity was 0.87 [95% confidence interval (CI): 0.70–1.06, I2 = 17%, n = 5] for physical activity before pregnancy, and it was 0.86 (95% CI: 0.78–0.95, I2 = 0%, n = 30) for early pregnancy physical activity. The summary RR for a 3 hours per week increment in leisure-time activity was 0.90 (95% CI: 0.85–0.95, I2 = 0%, n = 5). There was evidence of a nonlinear association between physical activity and preterm birth, Pnonlinearity < 0.0001, with the lowest risk observed at 2–4 hours per week of activity.

Conclusion

This meta-analysis suggests that higher leisure-time activity is associated with reduced risk of preterm birth. Further randomized controlled trials with sufficient frequency and duration of activity to reduce the risk and with larger sample sizes are needed to conclusively demonstrate an association.

Tweetable abstract

Physically active compared with inactive women have an 10–14% reduction in the risk of preterm birth.

Background Physical activity has been inconsistently associated with risk of preterm birth, and the strength of the association and the shape of the dose–response relationship needs clarification. Objectives To conduct a systematic review and dose–response meta-analysis to clarify the association between physical activity and risk of preterm birth. Search strategy PubMed, Embase and Ovid databases were searched for relevant studies up to 9 February 2017. Selection criteria Studies with a prospective cohort, case-cohort, nested case-control or randomized study design were included. Data collection and analysis Data were extracted by one reviewer and checked for accuracy by a second reviewer. Summary relative risks (RRs) were estimated using a random effects model. Main results Forty-one studies (43 publications) including 20 randomized trials and 21 cohort studies were included. The summary RR for high versus low activity was 0.87 [95% confidence interval (CI): 0.70–1.06, I2 = 17%, n = 5] for physical activity before pregnancy, and it was 0.86 (95% CI: 0.78–0.95, I2 = 0%, n = 30) for early pregnancy physical activity. The summary RR for a 3 hours per week increment in leisure-time activity was 0.90 (95% CI: 0.85–0.95, I2 = 0%, n = 5). There was evidence of a nonlinear association between physical activity and preterm birth, Pnonlinearity < 0.0001, with the lowest risk observed at 2–4 hours per week of activity. Conclusion This meta-analysis suggests that higher leisure-time activity is associated with reduced risk of preterm birth. Further randomized controlled trials with sufficient frequency and duration of activity to reduce the risk and with larger sample sizes are needed to conclusively demonstrate an association. Tweetable abstract Physically active compared with inactive women have an 10–14% reduction in the risk of preterm birth.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14676Pitfalls in the use of register-based data for comparing adverse maternal and perinatal outcomes in different birth settingsA Jonge, MGAJ Wouters, J Klinkert, J Brandenbarg, JJ Zwart, J Van Dillen, HE Horst, FG Schellevis2017-05-29T06:10:42.39428-05:00doi:10.1111/1471-0528.14676John Wiley & Sons, Inc.10.1111/1471-0528.14676http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14676Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14663Venous thromboembolism and combined hormonal contraception: what are the implications for prescribing?S Cameron2017-05-23T04:45:23.194506-05:00doi:10.1111/1471-0528.14663John Wiley & Sons, Inc.10.1111/1471-0528.14663http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14663Mini Commentaryn/an/ahttp://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14340Issue Information - Editorial Board2017-07-20T06:02:28.827762-05:00doi:10.1111/1471-0528.14340John Wiley & Sons, Inc.10.1111/1471-0528.14340http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14340Issue Information12911292http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14339Issue Information - TOC2017-07-20T06:02:29.752209-05:00doi:10.1111/1471-0528.14339John Wiley & Sons, Inc.10.1111/1471-0528.14339http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14339Issue Information12951295http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14341Supervision, self care, rare events and rejectionJohn Thorp2017-07-20T06:02:34.777204-05:00doi:10.1111/1471-0528.14341John Wiley & Sons, Inc.10.1111/1471-0528.14341http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14341BJOG Editor's Choice13011301

imageDeputy Editor-in-Chief, Dr John Thorp, discusses his top articles from this issue in an audio podcast available at: https://soundcloud.com/bjog/august-editors-choice-2017.

Deputy Editor-in-Chief, Dr John Thorp, discusses his top articles from this issue in an audio podcast available at: https://soundcloud.com/bjog/august-editors-choice-2017.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14785Insights from outside BJOGAthol Kent, Shona Kirtley2017-07-20T06:02:33.05602-05:00doi:10.1111/1471-0528.14785John Wiley & Sons, Inc.10.1111/1471-0528.14785http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14785Insights from outside BJOG13021306http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14547The management of labour in women with cardiac disease: need for more evidence?M Cauldwell, M Cox, M Gatzoulis, C Nelson-Piercy, P O'Brien, JW Roos-Hesselink, S Thorne, F Walker, MR Johnson2017-02-20T07:30:40.817742-05:00doi:10.1111/1471-0528.14547John Wiley & Sons, Inc.10.1111/1471-0528.14547http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14547Commentary13071309http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14632The management of the cardiac patient in labour: primum non nocereR D'Souza, M Sermer, C Silversides2017-05-13T07:10:38.725356-05:00doi:10.1111/1471-0528.14632John Wiley & Sons, Inc.10.1111/1471-0528.14632http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14632Mini Commentary13101310http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14527Resident consultant obstetrician presence on the labour ward versus other models of consultant cover: a systematic review of intrapartum outcomesJ Henderson, JJ Kurinczuk, M Knight2017-02-28T06:11:06.734981-05:00doi:10.1111/1471-0528.14527John Wiley & Sons, Inc.10.1111/1471-0528.14527http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14527Systematic Review13111320

Background

Several key policy documents have advocated 24-hour consultant obstetrician presence on the labour ward as a means of improving the safety of birth. However, it is unclear what published evidence exists comparing the outcomes of intrapartum care with 24-hour consultant labour ward presence and other models of consultant cover.

Objectives

To collate and critically appraise evidence of the effect of continuous resident consultant obstetrician cover on the labour ward on outcomes of intrapartum care compared with other models of consultant cover.

Search strategy

Studies were included which quantitatively compared intrapartum outcomes for women and babies where continuous resident consultant obstetric cover was provided with other models of consultant cover.

Selection criteria

Quantitative studies within healthcare systems with mixed obstetric-midwifery models of care.

Data collection and analysis

Two researchers independently screened titles and full-text publications, extracted data and assessed the quality of included studies. Meta-analysis was performed using REVIEW MANAGER 5.3.

Main results

About 1508 publications were screened resulting in two papers, three conference abstracts and one letter being included. All were single-site time-period comparison studies. The quality of studies overall was poor with significant risk of bias. The only significant finding in meta-analysis related to instrumental deliveries, which occurred more frequently when there was on-call consultant cover (unadjusted risk ratio 1.14; 95% CI 1.04–1.24).

Conclusion

No reliable evidence of the effects of 24-hour resident consultant presence on the labour ward on intrapartum outcomes was identified.

Tweetable abstract

More robust research is needed to assess intrapartum outcomes with resident consultant labour ward presence.

Background Several key policy documents have advocated 24-hour consultant obstetrician presence on the labour ward as a means of improving the safety of birth. However, it is unclear what published evidence exists comparing the outcomes of intrapartum care with 24-hour consultant labour ward presence and other models of consultant cover. Objectives To collate and critically appraise evidence of the effect of continuous resident consultant obstetrician cover on the labour ward on outcomes of intrapartum care compared with other models of consultant cover. Search strategy Studies were included which quantitatively compared intrapartum outcomes for women and babies where continuous resident consultant obstetric cover was provided with other models of consultant cover. Selection criteria Quantitative studies within healthcare systems with mixed obstetric-midwifery models of care. Data collection and analysis Two researchers independently screened titles and full-text publications, extracted data and assessed the quality of included studies. Meta-analysis was performed using REVIEW MANAGER 5.3. Main results About 1508 publications were screened resulting in two papers, three conference abstracts and one letter being included. All were single-site time-period comparison studies. The quality of studies overall was poor with significant risk of bias. The only significant finding in meta-analysis related to instrumental deliveries, which occurred more frequently when there was on-call consultant cover (unadjusted risk ratio 1.14; 95% CI 1.04–1.24). Conclusion No reliable evidence of the effects of 24-hour resident consultant presence on the labour ward on intrapartum outcomes was identified. Tweetable abstract More robust research is needed to assess intrapartum outcomes with resident consultant labour ward presence.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14649The effect of senior obstetric presence on maternal and neonatal outcomes in UK NHS maternity units: a systematic review and meta-analysisHE Reid, DJL Hayes, A Wittkowski, S Vause, J Whitcombe, AEP Heazell2017-05-05T07:36:45.444811-05:00doi:10.1111/1471-0528.14649John Wiley & Sons, Inc.10.1111/1471-0528.14649http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14649Systematic Review13211330

Background

There is little consensus regarding the hypothesised link between obstetric consultant presence and maternal and neonatal outcomes.

Objectives

To pool existing data on the impact of consultant presence on the outcomes of women who have given birth in UK National Health Service (NHS) maternity units.

Search strategy

Twelve databases, grey literature, and reference lists were searched.

Selection criteria

Studies conducted in UK NHS maternity units comparing outcomes during lesser consultant presence versus increased consultant presence that reported mode of delivery and adverse maternal or neonatal outcomes.

Data collection and analysis

Studies were divided into three groups by type of comparison: (1) hours of rostered consultant presence during the weekend versus hours of rostered consultant presence during the week; (2) hours per week of rostered consultant presence pre-increase versus hours per week of rostered consultant presence post-increase; and (3) no rostered consultant presence versus rostered consultant presence. A random-effects meta-analysis was performed.

Main results

Fifteen studies fulfilled the inclusion criteria, presenting data from 125 856 births. Overall, there was no significant difference between lesser and increased consultant presence for any outcome. When data were stratified by comparison type, the likelihood of emergency caesarean section was significantly lower (odds ratio, OR 0.91; 95% confidence interval, 95% CI 0.86–0.96) and the likelihood of non-instrumental vaginal delivery was significantly higher (OR 1.07; 95% CI 1.02–1.12) when the rostered hours of consultant presence per week were increased.

Conclusions

Increased consultant presence has some effect on mode of delivery, but no evidence for a benefit for adverse outcomes was found.

Tweetable abstract

Increasing hours of NHS obstetric consultant presence may increase chance of non-instrumental vaginal delivery.

Background There is little consensus regarding the hypothesised link between obstetric consultant presence and maternal and neonatal outcomes. Objectives To pool existing data on the impact of consultant presence on the outcomes of women who have given birth in UK National Health Service (NHS) maternity units. Search strategy Twelve databases, grey literature, and reference lists were searched. Selection criteria Studies conducted in UK NHS maternity units comparing outcomes during lesser consultant presence versus increased consultant presence that reported mode of delivery and adverse maternal or neonatal outcomes. Data collection and analysis Studies were divided into three groups by type of comparison: (1) hours of rostered consultant presence during the weekend versus hours of rostered consultant presence during the week; (2) hours per week of rostered consultant presence pre-increase versus hours per week of rostered consultant presence post-increase; and (3) no rostered consultant presence versus rostered consultant presence. A random-effects meta-analysis was performed. Main results Fifteen studies fulfilled the inclusion criteria, presenting data from 125 856 births. Overall, there was no significant difference between lesser and increased consultant presence for any outcome. When data were stratified by comparison type, the likelihood of emergency caesarean section was significantly lower (odds ratio, OR 0.91; 95% confidence interval, 95% CI 0.86–0.96) and the likelihood of non-instrumental vaginal delivery was significantly higher (OR 1.07; 95% CI 1.02–1.12) when the rostered hours of consultant presence per week were increased. Conclusions Increased consultant presence has some effect on mode of delivery, but no evidence for a benefit for adverse outcomes was found. Tweetable abstract Increasing hours of NHS obstetric consultant presence may increase chance of non-instrumental vaginal delivery.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14685The obstetric consultant on the labour ward: beyond infancy to early adolescenceWF Rayburn2017-05-22T06:25:23.848201-05:00doi:10.1111/1471-0528.14685John Wiley & Sons, Inc.10.1111/1471-0528.14685http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14685Mini Commentary13311331http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14686Resident consultant cover may become part of 21st century maternity care, but it is not a panaceaM Prior, T Draycott, C Burden2017-05-22T06:25:38.945826-05:00doi:10.1111/1471-0528.14686John Wiley & Sons, Inc.10.1111/1471-0528.14686http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14686Mini Commentary13321332http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14620UK Secretary of State for Health proposes new model for compensating the victims of adverse outcomes resulting from medical/midwifery errors during childbirthPhilip J Steer2017-07-20T06:02:28.387674-05:00doi:10.1111/1471-0528.14620John Wiley & Sons, Inc.10.1111/1471-0528.14620http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14620BJOG on the Case13331333http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14621Malpractice reduction and standardisation of care: two sides of the same coinSL Clark2017-07-20T06:02:36.190659-05:00doi:10.1111/1471-0528.14621John Wiley & Sons, Inc.10.1111/1471-0528.14621http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14621Mini Commentary13341334http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14477Assisted vaginal delivery in low and middle income countries: an overviewPE Bailey, J Roosmalen, G Mola, C Evans, L Bernis, B Dao2017-01-31T06:06:10.983436-05:00doi:10.1111/1471-0528.14477John Wiley & Sons, Inc.10.1111/1471-0528.14477http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14477Review Article13351344

Objective

To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use.

Design

Cross-sectional health facility assessments.

Setting

Up to 40 countries in Latin America, sub-Saharan Africa and Asia.

Population

Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors.

Methods

Descriptive secondary data analysis.

Main outcome measures

Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced.

Results

Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance.

Conclusions

The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe.

Tweetable abstract

Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.

Objective To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. Design Cross-sectional health facility assessments. Setting Up to 40 countries in Latin America, sub-Saharan Africa and Asia. Population Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. Methods Descriptive secondary data analysis. Main outcome measures Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. Results Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance. Conclusions The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe. Tweetable abstract Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14526Assisted vaginal delivery: an art worth preserving in all settingsW Bowes2017-01-31T06:06:22.235601-05:00doi:10.1111/1471-0528.14526John Wiley & Sons, Inc.10.1111/1471-0528.14526http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14526Mini Commentary13451345http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14548Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn HealthN Morisaki, T Ganchimeg, JP Vogel, J Zeitlin, JG Cecatti, JP Souza, C Pileggi Castro, MR Torloni, E Ota, R Mori, SM Dolan, S Tough, S Mittal, V Bataglia, B Yadamsuren, MS Kramer, 2017-02-20T23:45:58.294393-05:00doi:10.1111/1471-0528.14548John Wiley & Sons, Inc.10.1111/1471-0528.14548http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14548Fetal Medicine13461354

Objective

To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low- and middle-income countries.

Design

Secondary analysis of a multi-country cross-sectional study.

Setting

29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

258 215 singleton deliveries in 286 hospitals.

Methods

We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries.

Main outcome measures

Preterm delivery.

Results

In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high-HDI countries (4.8%, 4.4–5.5%).

Conclusion

Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low-HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary.

Tweetable abstract

Inclusion of stillbirths increases preterm birth rates estimates, especially in low-HDI countries.

Objective To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low- and middle-income countries. Design Secondary analysis of a multi-country cross-sectional study. Setting 29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health. Population 258 215 singleton deliveries in 286 hospitals. Methods We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries. Main outcome measures Preterm delivery. Results In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high-HDI countries (4.8%, 4.4–5.5%). Conclusion Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low-HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary. Tweetable abstract Inclusion of stillbirths increases preterm birth rates estimates, especially in low-HDI countries.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14591Importance of including stillbirth in measures of preterm birthRL Goldenberg, EM McClure2017-03-21T04:20:38.012553-05:00doi:10.1111/1471-0528.14591John Wiley & Sons, Inc.10.1111/1471-0528.14591http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14591Mini Commentary13551355http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14682HPV testing in first-void urine provides sensitivity for CIN2+ detection comparable with a smear taken by a clinician or a brush-based self-sample: cross-sectional data from a triage populationA Leeman, M Pino, A Molijn, A Rodriguez, A Torné, M Koning, J Ordi, F Kemenade, D Jenkins, W Quint2017-07-20T06:02:32.670946-05:00doi:10.1111/1471-0528.14682John Wiley & Sons, Inc.10.1111/1471-0528.14682http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14682General Gynaecology13561363

Objective

To compare the sensitivity of high-risk human papillomavirus (hrHPV) and genotype detection in self-collected urine samples in the morning (U1), and later on (U2), brush-based self-samples (SS), and clinician-taken smears (CTS) for detecting cervical intraepithelial neoplasia grade 2+ (CIN2+) in a colposcopic referral population.

Design

Cross-sectional single-centre study.

Setting

A colposcopy clinic in Spain.

Population

A cohort of 113 women referred for colposcopy after an abnormal Pap smear.

Methods

Women undergoing colposcopy with biopsy for abnormal Pap smears were sent a device (Colli-Pee™, Novosanis, Wijnegem, Belgium) to collect U1 on the morning of colposcopy. U2, CTS, and SS (Evalyn brush™, Rovers Medical Devices B.V., Oss, the Netherlands) were also analysed. All samples were tested for HPV DNA using the analytically sensitive SPF10-DEIA-LiPA25 assay and the clinically validated GP5+/6+-EIA-LMNX.

Main outcome measures

Histologically confirmed CIN2+ and hrHPV positivity for 14 high-risk HPV types.

Results

Samples from 91 patients were analysed. All CIN3 cases (n = 6) tested positive for hrHPV in CTS, SS, U1, and U2 with both HPV assays. Sensitivity for CIN2+ with the SPF10 system was 100, 100, 95, and 100%, respectively. With the GP5+/6+ assay, sensitivity was 95% in all sample types. The sensitivities and specificities for both tests on each of the sample types did not significantly differ. There was 10–14% discordance on hrHPV genotype.

Conclusions

CIN2+ detection using HPV testing of U1 shows a sensitivity similar to that of CTS or brush-based SS, and is convenient. There was substantial to almost excellent agreement between all samples on genotype with both hrHPV assays. There was no advantage in testing U1 compared with U2 samples.

Tweetable abstract

Similar CIN2+ sensitivity for HPV testing in first-void urine, physician-taken smear and brush-based self-sample.

Objective To compare the sensitivity of high-risk human papillomavirus (hrHPV) and genotype detection in self-collected urine samples in the morning (U1), and later on (U2), brush-based self-samples (SS), and clinician-taken smears (CTS) for detecting cervical intraepithelial neoplasia grade 2+ (CIN2+) in a colposcopic referral population. Design Cross-sectional single-centre study. Setting A colposcopy clinic in Spain. Population A cohort of 113 women referred for colposcopy after an abnormal Pap smear. Methods Women undergoing colposcopy with biopsy for abnormal Pap smears were sent a device (Colli-Pee™, Novosanis, Wijnegem, Belgium) to collect U1 on the morning of colposcopy. U2, CTS, and SS (Evalyn brush™, Rovers Medical Devices B.V., Oss, the Netherlands) were also analysed. All samples were tested for HPV DNA using the analytically sensitive SPF10-DEIA-LiPA25 assay and the clinically validated GP5+/6+-EIA-LMNX. Main outcome measures Histologically confirmed CIN2+ and hrHPV positivity for 14 high-risk HPV types. Results Samples from 91 patients were analysed. All CIN3 cases (n = 6) tested positive for hrHPV in CTS, SS, U1, and U2 with both HPV assays. Sensitivity for CIN2+ with the SPF10 system was 100, 100, 95, and 100%, respectively. With the GP5+/6+ assay, sensitivity was 95% in all sample types. The sensitivities and specificities for both tests on each of the sample types did not significantly differ. There was 10–14% discordance on hrHPV genotype. Conclusions CIN2+ detection using HPV testing of U1 shows a sensitivity similar to that of CTS or brush-based SS, and is convenient. There was substantial to almost excellent agreement between all samples on genotype with both hrHPV assays. There was no advantage in testing U1 compared with U2 samples. Tweetable abstract Similar CIN2+ sensitivity for HPV testing in first-void urine, physician-taken smear and brush-based self-sample.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14683Urinary HPV testing may offer hope for cervical screening non-attendersDA Blake, EJ Crosbie, S Kitson2017-07-20T06:02:34.872609-05:00doi:10.1111/1471-0528.14683John Wiley & Sons, Inc.10.1111/1471-0528.14683http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14683Mini Commentary13641364http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14553Trends in operative vaginal delivery, 2005–2013: a population-based studyAA Merriam, CV Ananth, JD Wright, Z Siddiq, ME D'Alton, AM Friedman2017-02-25T02:30:25.666133-05:00doi:10.1111/1471-0528.14553John Wiley & Sons, Inc.10.1111/1471-0528.14553http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14553General Obstetrics13651372

Objective

The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery.

Design

Retrospective cohort.

Setting

Population-based study of US birth records.

Population

US births from 2005 to 2013.

Methods

This study evaluated forceps and vacuum extraction during vaginal delivery in live-born, non-anomalous singleton gestations from ≥ 36 to < 42 weeks of gestation. The primary outcomes were vacuum, forceps and overall operative delivery. Obstetric, medical and demographic characteristics associated with operative vaginal delivery were analysed. Multivariable logistic regression models were developed to determine factors associated with forceps/vacuum use.

Results

A total of 22 598 971 vaginal deliveries between 2005 and 2013 were included in the analysis. In all, 1 083 318 (4.8%) were vacuum-assisted and 237 792 (1.1%) were by forceps. Both vacuum and forceps deliveries decreased over the study period; vacuum deliveries decreased from 5.8% in 2005 to 4.1% in 2013, and forceps deliveries decreased from 1.4% to 0.9% during the same period. The adjusted odds ratio for forceps delivery was 0.70 (95% CI 0.69–0.72) in 2013 with 2005 as a reference. For vacuum delivery the odds ratio was 0.68 (95% CI 0.67–0.69) comparing the same years.

Conclusion

Forceps and vacuum deliveries decreased during the study period. Low rates of operative delivery pose a challenge for resident education and may limit the degree to which women have access to alternatives to caesarean delivery. Initiatives that allow future generations of obstetricians to develop expertise in performing operative deliveries in the setting of decreased volume are an urgent resident education priority.

Tweetable abstract

Forceps and vacuum delivery decreased significantly in the USA from 2005 to 2013.

Objective The objectives of this study were to determine temporal trends in forceps and vacuum delivery and factors associated with operative vaginal delivery. Design Retrospective cohort. Setting Population-based study of US birth records. Population US births from 2005 to 2013. Methods This study evaluated forceps and vacuum extraction during vaginal delivery in live-born, non-anomalous singleton gestations from ≥ 36 to < 42 weeks of gestation. The primary outcomes were vacuum, forceps and overall operative delivery. Obstetric, medical and demographic characteristics associated with operative vaginal delivery were analysed. Multivariable logistic regression models were developed to determine factors associated with forceps/vacuum use. Results A total of 22 598 971 vaginal deliveries between 2005 and 2013 were included in the analysis. In all, 1 083 318 (4.8%) were vacuum-assisted and 237 792 (1.1%) were by forceps. Both vacuum and forceps deliveries decreased over the study period; vacuum deliveries decreased from 5.8% in 2005 to 4.1% in 2013, and forceps deliveries decreased from 1.4% to 0.9% during the same period. The adjusted odds ratio for forceps delivery was 0.70 (95% CI 0.69–0.72) in 2013 with 2005 as a reference. For vacuum delivery the odds ratio was 0.68 (95% CI 0.67–0.69) comparing the same years. Conclusion Forceps and vacuum deliveries decreased during the study period. Low rates of operative delivery pose a challenge for resident education and may limit the degree to which women have access to alternatives to caesarean delivery. Initiatives that allow future generations of obstetricians to develop expertise in performing operative deliveries in the setting of decreased volume are an urgent resident education priority. Tweetable abstract Forceps and vacuum delivery decreased significantly in the USA from 2005 to 2013.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14549Instrumental delivery: complex paternity and a fading artEric Jauniaux, John Thorp2017-07-20T06:02:30.61777-05:00doi:10.1111/1471-0528.14549John Wiley & Sons, Inc.10.1111/1471-0528.14549http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14549BJOG Since 190213731373http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14521The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive studyVA Beckett, M Knight, P Sharpe2017-02-24T00:01:02.114586-05:00doi:10.1111/1471-0528.14521John Wiley & Sons, Inc.10.1111/1471-0528.14521http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14521General Obstetrics13741381

Objective

To describe the incidence, risks, management and outcomes of cardiac arrest in pregnancy in the UK population, with specific focus on the use of perimortem caesarean section (PMCS).

Design

A prospective, descriptive study using the UK Obstetric Surveillance System (UKOSS).

Setting

All UK hospitals with maternity units.

Population

All women who received basic life support in pregnancy in the UK between 1 July 2011 and 30 June 2014 (n = 66).

Methods

Prospective case identification through UKOSS monthly mailing.

Main outcome measures

Cardiac arrest in pregnancy, PMCS, maternal death.

Results

There were 66 cardiac arrests in pregnancy, resulting in an incidence of 2.78 per 100 000 maternities (1:36 000; 95% CI 2.2–3.6). In all, 28 women died (case fatality rate 42%); 16 women arrested solely as a consequence of obstetric anaesthesia, 12 of whom were obese. Basic and advanced life support were rapidly delivered. Those who died were more likely to have collapsed at home. Perimortem caesarean section was performed in 49 women, 11 in the emergency department. The time from collapse to PMCS was significantly shorter in women who survived (median interval 3 versus 12 minutes, P = 0.001). Forty-six of 58 babies were born alive; 32 babies to surviving mothers and 14 to women who died.

Conclusion

Cardiac arrest is rare in the pregnant UK population, however, nearly a quarter of cases are precipitated by obstetric anaesthesia, suggesting an opportunity to reduce the incidence further. Maternal survival rates of 58% were achieved with timely resuscitation, including PMCS, delay in which was associated with maternal death. Inpatient arrests were associated with higher survival rates than arrests that occurred outside the hospital setting.

Tweetable abstract

25% of cardiac arrest in pregnancy is caused by anaesthesia. Rapid perimortem section improves survival.

Objective To describe the incidence, risks, management and outcomes of cardiac arrest in pregnancy in the UK population, with specific focus on the use of perimortem caesarean section (PMCS). Design A prospective, descriptive study using the UK Obstetric Surveillance System (UKOSS). Setting All UK hospitals with maternity units. Population All women who received basic life support in pregnancy in the UK between 1 July 2011 and 30 June 2014 (n = 66). Methods Prospective case identification through UKOSS monthly mailing. Main outcome measures Cardiac arrest in pregnancy, PMCS, maternal death. Results There were 66 cardiac arrests in pregnancy, resulting in an incidence of 2.78 per 100 000 maternities (1:36 000; 95% CI 2.2–3.6). In all, 28 women died (case fatality rate 42%); 16 women arrested solely as a consequence of obstetric anaesthesia, 12 of whom were obese. Basic and advanced life support were rapidly delivered. Those who died were more likely to have collapsed at home. Perimortem caesarean section was performed in 49 women, 11 in the emergency department. The time from collapse to PMCS was significantly shorter in women who survived (median interval 3 versus 12 minutes, P = 0.001). Forty-six of 58 babies were born alive; 32 babies to surviving mothers and 14 to women who died. Conclusion Cardiac arrest is rare in the pregnant UK population, however, nearly a quarter of cases are precipitated by obstetric anaesthesia, suggesting an opportunity to reduce the incidence further. Maternal survival rates of 58% were achieved with timely resuscitation, including PMCS, delay in which was associated with maternal death. Inpatient arrests were associated with higher survival rates than arrests that occurred outside the hospital setting. Tweetable abstract 25% of cardiac arrest in pregnancy is caused by anaesthesia. Rapid perimortem section improves survival.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14569Tipping our CAPS to the UKOSS cardiac arrest in pregnancy studyJM Mhyre, BT Bateman2017-03-15T22:55:48.459672-05:00doi:10.1111/1471-0528.14569John Wiley & Sons, Inc.10.1111/1471-0528.14569http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14569Mini Commentary13821382http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14662The Blue Journal Club2017-06-16T07:25:18.762757-05:00doi:10.1111/1471-0528.14662John Wiley & Sons, Inc.10.1111/1471-0528.14662http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14662Journal Club13831383http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14666Women and babies need protection from the dangers of normal birth ideologyHans Peter Dietz2017-07-20T06:02:28.660982-05:00doi:10.1111/1471-0528.14666John Wiley & Sons, Inc.10.1111/1471-0528.14666http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14666BJOG Debate13841384http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14668Women and babies need protection from the dangers of normal birth ideologyLesley Page2017-07-20T06:02:28.588007-05:00doi:10.1111/1471-0528.14668John Wiley & Sons, Inc.10.1111/1471-0528.14668http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14668BJOG Debate13851385http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14562Reduction in colposcopy workload and associated clinical activity following human papillomavirus (HPV) catch-up vaccination programme in Scotland: an ecological studyME Cruickshank, J Pan, SC Cotton, K Kavanagh, C Robertson, K Cuschieri, H Cubie, T Palmer, KG Pollock2017-03-09T04:25:29.615733-05:00doi:10.1111/1471-0528.14562John Wiley & Sons, Inc.10.1111/1471-0528.14562http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14562Gynaecological Oncology13861393

Objective

To measure patterns of clinical activity at colposcopy before and after vaccinated women entered the Scottish Cervical Screening Programme (SCSP).

Design

Population-based observational study using nationally collected data.

Setting

Scottish colposcopy clinics.

Sample

All women with a date of birth on or after 1 January 1985 who attended colposcopy in Scotland between 2008 and 2014.

Methods

Routinely collected data from the Scottish National Colposcopy Clinical Information Audit System (NCCIAS) were extracted, including: referral criteria, referral cervical cytology, colposcopic findings, clinical procedures, and histology results. Analysis was restricted to those referred to colposcopy at age 20 or 21 years.

Main outcome measures

Referral criteria, positive predictive value of colposcopy, default rates, and rates of cervical biopsies and treatments.

Results

A total of 7372 women referred for colposcopy at age 20 or 21 years were identified. There was a downward trend in the proportion of those referred with abnormal cytology (2008/9, 91.0%; 2013/14, 90.3%; linear trend P = 0.03). Women were less likely to have diagnostic or therapeutic interventions. The proportion with no biopsy (2008/9, 19.5%; 2013/14, 26.9%; linear trend P < 0.0001) and no treatment (2008/9, 74.9%; 2013/14, 91.8%; linear trend P < 0.0001) increased over the period of observation.

Conclusions

A reduction in clinical activity related to abnormal screening referrals is likely to be associated with the human papillomavirus (HPV) catch-up immunisation programme. Referral criteria and the service provision of colposcopy needs to be planned carefully, taking account of the increasing number of women who have been immunised against HPV that will be entering cervical screening programmes worldwide.

Tweetable abstract

Colposcopy referral criteria and service planning need attention following HPV immunisation programme.

Objective To measure patterns of clinical activity at colposcopy before and after vaccinated women entered the Scottish Cervical Screening Programme (SCSP). Design Population-based observational study using nationally collected data. Setting Scottish colposcopy clinics. Sample All women with a date of birth on or after 1 January 1985 who attended colposcopy in Scotland between 2008 and 2014. Methods Routinely collected data from the Scottish National Colposcopy Clinical Information Audit System (NCCIAS) were extracted, including: referral criteria, referral cervical cytology, colposcopic findings, clinical procedures, and histology results. Analysis was restricted to those referred to colposcopy at age 20 or 21 years. Main outcome measures Referral criteria, positive predictive value of colposcopy, default rates, and rates of cervical biopsies and treatments. Results A total of 7372 women referred for colposcopy at age 20 or 21 years were identified. There was a downward trend in the proportion of those referred with abnormal cytology (2008/9, 91.0%; 2013/14, 90.3%; linear trend P = 0.03). Women were less likely to have diagnostic or therapeutic interventions. The proportion with no biopsy (2008/9, 19.5%; 2013/14, 26.9%; linear trend P < 0.0001) and no treatment (2008/9, 74.9%; 2013/14, 91.8%; linear trend P < 0.0001) increased over the period of observation. Conclusions A reduction in clinical activity related to abnormal screening referrals is likely to be associated with the human papillomavirus (HPV) catch-up immunisation programme. Referral criteria and the service provision of colposcopy needs to be planned carefully, taking account of the increasing number of women who have been immunised against HPV that will be entering cervical screening programmes worldwide. Tweetable abstract Colposcopy referral criteria and service planning need attention following HPV immunisation programme.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14563The impact of human papillomavirus type on colposcopy performance in women offered HPV immunisation in a catch-up vaccine programme: a two-centre observational studyA Munro, C Gillespie, S Cotton, C Busby-Earle, K Kavanagh, K Cuschieri, H Cubie, C Robertson, L Smart, K Pollock, C Moore, T Palmer, ME Cruickshank2017-03-09T04:20:37.082946-05:00doi:10.1111/1471-0528.14563John Wiley & Sons, Inc.10.1111/1471-0528.14563http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14563Gynaecological Oncology13941401

Objective

To determine whether human papillomavirus (HPV) immunisation has affected the prevalence of HPV genotypes and colposcopic features of cervical intraepithelial neoplasia (CIN) in young women referred for colposcopy.

Design

A two-centre observational study including vaccinated and unvaccinated women.

Setting

Colposcopy clinics serving two health regions in Scotland, UK.

Population

A total of 361 women aged 20–25 years attending colposcopy following an abnormal cervical cytology result at routine cervical screening.

Methods

Cervical samples were obtained from women for HPV DNA genotyping and mRNA E6/E7 expression of HPV 16, 18, 31, 33, and 45. Demographic data, cytology, and histology results and colposcopic features were recorded. Chi-square analysis was conducted to identify associations between vaccine status, HPV genotypes, and colposcopic features.

Main outcome measures

Colposcopic features, HPV genotypes, mRNA expression, and cervical histology.

Results

The prevalence of HPV 16 was significantly lower in the vaccinated group (8.6%) compared with the unvaccinated group (46.7%) (P = 0.001). The number of cases of CIN2+ was significantly lower in women who had been vaccinated (P = 0.006). The HPV vaccine did not have a statistically significant effect on commonly recognised colposcopic features, but there was a slight reduction in the positive predictive value (PPV) of colposcopy for CIN2+, from 74% (unvaccinated) to 66.7% (vaccinated).

Conclusions

In this group of young women with abnormal cytology referred to colposcopy, HPV vaccination via a catch-up programme reduced the prevalence of CIN2+ and HPV 16 infection. The reduced PPV of colposcopy for the detection of CIN2+ in women who have been vaccinated is at the lower acceptable level of the UK national cervical screening programme guidelines.

Tweetable abstract

Reduction of hrHPV positivity and CIN in immunised women consistent with lower PPV of colposcopy for CIN2+.

Objective To determine whether human papillomavirus (HPV) immunisation has affected the prevalence of HPV genotypes and colposcopic features of cervical intraepithelial neoplasia (CIN) in young women referred for colposcopy. Design A two-centre observational study including vaccinated and unvaccinated women. Setting Colposcopy clinics serving two health regions in Scotland, UK. Population A total of 361 women aged 20–25 years attending colposcopy following an abnormal cervical cytology result at routine cervical screening. Methods Cervical samples were obtained from women for HPV DNA genotyping and mRNA E6/E7 expression of HPV 16, 18, 31, 33, and 45. Demographic data, cytology, and histology results and colposcopic features were recorded. Chi-square analysis was conducted to identify associations between vaccine status, HPV genotypes, and colposcopic features. Main outcome measures Colposcopic features, HPV genotypes, mRNA expression, and cervical histology. Results The prevalence of HPV 16 was significantly lower in the vaccinated group (8.6%) compared with the unvaccinated group (46.7%) (P = 0.001). The number of cases of CIN2+ was significantly lower in women who had been vaccinated (P = 0.006). The HPV vaccine did not have a statistically significant effect on commonly recognised colposcopic features, but there was a slight reduction in the positive predictive value (PPV) of colposcopy for CIN2+, from 74% (unvaccinated) to 66.7% (vaccinated). Conclusions In this group of young women with abnormal cytology referred to colposcopy, HPV vaccination via a catch-up programme reduced the prevalence of CIN2+ and HPV 16 infection. The reduced PPV of colposcopy for the detection of CIN2+ in women who have been vaccinated is at the lower acceptable level of the UK national cervical screening programme guidelines. Tweetable abstract Reduction of hrHPV positivity and CIN in immunised women consistent with lower PPV of colposcopy for CIN2+.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14671Physical after-effects of colposcopy and related procedures, and their inter-relationship with psychological distress: a longitudinal surveyM O'Connor, K O'Brien, J Waller, P Gallagher, T D'Arcy, G Flannelly, CM Martin, J McRae, W Prendiville, C Ruttle, C White, L Pilkington, JJ O'Leary, L Sharp, 2017-05-31T06:35:38.260547-05:00doi:10.1111/1471-0528.14671John Wiley & Sons, Inc.10.1111/1471-0528.14671http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14671Gynaecological Oncology14021410

Objective

To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress.

Design

Longitudinal survey.

Setting

Two hospital-based colposcopy clinics.

Population

Women with abnormal cytology who underwent colposcopy (±related procedures).

Methods

Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables.

Main outcome measures

Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress.

Results

Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10–8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up.

Conclusions

The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress.

Tweetable abstract

Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.

Objective To estimate prevalence of post-colposcopy physical after-effects and investigate associations between these and subsequent psychological distress. Design Longitudinal survey. Setting Two hospital-based colposcopy clinics. Population Women with abnormal cytology who underwent colposcopy (±related procedures). Methods Questionnaires were mailed to women 4, 8 and 12 months post-colposcopy. Details of physical after-effects (pain, bleeding and discharge) experienced post-colposcopy were collected at 4 months. Colposcopy-specific distress was measured using the Process Outcome-Specific Measure at all time-points. Linear mixed-effects regression was used to identify associations between physical after-effects and distress over 12 months, adjusting for socio-demographic and clinical variables. Main outcome measures Prevalence of post-colposcopy physical after-effects. Associations between the presence of any physical after-effects, awareness of after-effects, and number of after-effects and distress. Results Five-hundred and eighty-four women were recruited (response rate = 73, 59 and 52% at 4, 8 and 12 months, respectively). Eighty-two percent of women reported one or more physical after-effect(s). Multiple physical after-effects were common (two after-effects = 25%; three after-effects = 25%). Psychological distress scores declined significantly over time. In adjusted analyses, women who experienced all three physical after-effects had on average a 4.58 (95% CI: 1.10–8.05) higher distress scored than those who experienced no after-effects. Women who were unaware of the possibility of experiencing after-effects scored significantly higher for distress during follow-up. Conclusions The prevalence of physical after-effects of colposcopy and related procedures is high. The novel findings of inter-relationships between awareness of the possibility of after-effects and experiencing multiple after-effects, and post-colposcopy distress may be relevant to the development of interventions to alleviate post-colposcopy distress. Tweetable abstract Experiencing multiple physical after-effects of colposcopy is associated with psychological distress.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14478Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection systemS Vause, B Clarke, CL Tower, CRM Hay, M Knight, 2016-12-26T02:10:28.378515-05:00doi:10.1111/1471-0528.14478John Wiley & Sons, Inc.10.1111/1471-0528.14478http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14478Maternal Medicine14111419

Objective

To describe the incidence of mechanical prosthetic heart valves (MPHV) in pregnancy in the UK; rates of maternal and fetal complications in this group of women, and whether these vary with the anticoagulation used during pregnancy.

Design

Prospective descriptive population-based study.

Setting

All consultant-led maternity units in the UK.

Population

All women with an MPHV who were pregnant between 1 February 2013 and 31 January 2015.

Methods

Collection and analysis of anonymous data relating to pregnancy management and outcome, using the UKOSS notification and data collection system.

Main outcome measures

Maternal death, serious maternal morbidity, poor fetal outcome.

Results

Data were obtained for 58 women giving an estimated incidence of 3.7 (95% CI 2.7–4.7) per 100 000 maternities. There were five maternal deaths (9%); a further 24 (41%) suffered serious maternal morbidity. There was a poor fetal outcome from 26 (47%) pregnancies. Only 16 (28%) women had a good maternal and good fetal outcome. Low-molecular-weight heparin (LMWH) was used throughout pregnancy by 71% of women. Of these, 83% required rapid dose escalation in the first trimester. Monitoring regimens lacked consistency.

Conclusions

This study has estimated the incidence of MPHV in pregnant women in the UK. It includes the largest cohort managed with LMWH throughout pregnancy reported to date. It demonstrates a high rate of maternal death, and serious maternal and fetal morbidity. Women with MPHVs, and their clinicians need to appreciate the significant maternal and fetal risks involved in pregnancy. Care should be concentrated in specialist centres.

Tweetable abstract

High rates of poor maternal and fetal outcomes in pregnant women with mechanical prosthetic heart valves

Objective To describe the incidence of mechanical prosthetic heart valves (MPHV) in pregnancy in the UK; rates of maternal and fetal complications in this group of women, and whether these vary with the anticoagulation used during pregnancy. Design Prospective descriptive population-based study. Setting All consultant-led maternity units in the UK. Population All women with an MPHV who were pregnant between 1 February 2013 and 31 January 2015. Methods Collection and analysis of anonymous data relating to pregnancy management and outcome, using the UKOSS notification and data collection system. Main outcome measures Maternal death, serious maternal morbidity, poor fetal outcome. Results Data were obtained for 58 women giving an estimated incidence of 3.7 (95% CI 2.7–4.7) per 100 000 maternities. There were five maternal deaths (9%); a further 24 (41%) suffered serious maternal morbidity. There was a poor fetal outcome from 26 (47%) pregnancies. Only 16 (28%) women had a good maternal and good fetal outcome. Low-molecular-weight heparin (LMWH) was used throughout pregnancy by 71% of women. Of these, 83% required rapid dose escalation in the first trimester. Monitoring regimens lacked consistency. Conclusions This study has estimated the incidence of MPHV in pregnant women in the UK. It includes the largest cohort managed with LMWH throughout pregnancy reported to date. It demonstrates a high rate of maternal death, and serious maternal and fetal morbidity. Women with MPHVs, and their clinicians need to appreciate the significant maternal and fetal risks involved in pregnancy. Care should be concentrated in specialist centres. Tweetable abstract High rates of poor maternal and fetal outcomes in pregnant women with mechanical prosthetic heart valves
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14502Care in the UK for pregnant women with mechanical prosthetic valves needs urgent improvementM Cauldwell, PJ Steer2017-02-01T05:56:48.735852-05:00doi:10.1111/1471-0528.14502John Wiley & Sons, Inc.10.1111/1471-0528.14502http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14502Mini Commentary14201420http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14517Anticoagulant options in pregnancy for women with mechanical valvesC McLintock2017-02-14T02:30:24.240192-05:00doi:10.1111/1471-0528.14517John Wiley & Sons, Inc.10.1111/1471-0528.14517http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14517Mini Commentary14211421http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14503Ultrasound bladder wall thickness and detrusor overactivity: a multicentre test accuracy studyP Latthe, L Middleton, S Rachaneni, S McCooty, J Daniels, A Coomarasamy, M Balogun, J Duckett, R Thakar, I Goranitis, T Roberts, J Deeks, 2017-02-07T23:21:36.878098-05:00doi:10.1111/1471-0528.14503John Wiley & Sons, Inc.10.1111/1471-0528.14503http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14503Urogynaecology14221429

Objective

Women with overactive bladder (OAB) often undergo urodynamics before invasive treatments are considered. Ultrasound measurement of bladder wall thickness (BWT) is a less invasive, less expensive and widely available test. It has the potential to diagnose the presence of detrusor overactivity (DO). We aimed to evaluate the accuracy of BWT in the diagnosis of DO.

Design

Prospective cohort study.

Setting

Twenty-two UK clinics (university and district general hospitals).

Methods

Consecutive eligible women with OAB symptoms had transvaginal ultrasound to estimate BWT (index test). The reference standard for the diagnosis of DO was urodynamic testing with multichannel subtracted cystometry.

Main outcome measures

The sensitivity, specificity and likelihood ratios using a BWT threshold of ≥5 mm were used to indicate the presence of DO, and the area under the receiver operating characteristics (ROC) curve to give an overall estimate of BWT accuracy.

Results

Between March 2011 and 2013, 644/687 (94%) women recruited had both tests. The mean age was 52.7 years (standard deviation 13.9) and DO was diagnosed in 399/666 (60%) women. BWT had a sensitivity of 43% [95% confidence interval (CI) 38–48%], specificity of 62% (95% CI 55–68%), and likelihood ratios of 1.11 (95% CI 0.92–1.35) and 0.93 (95% CI 0.82–1.06) for positive and negative tests, respectively. The area under the ROC curve was 0.53 (95% CI 0.48–0.57). Extensive sensitivity analyses and subgroup analyses were carried out, but did not alter the interpretation.

Conclusions

BWT is not a good replacement test for urodynamics in women with overactive bladder.

Tweetable abstract

Bladder wall thickness is not a good replacement test for urodynamics in women with overactive bladder.

Objective Women with overactive bladder (OAB) often undergo urodynamics before invasive treatments are considered. Ultrasound measurement of bladder wall thickness (BWT) is a less invasive, less expensive and widely available test. It has the potential to diagnose the presence of detrusor overactivity (DO). We aimed to evaluate the accuracy of BWT in the diagnosis of DO. Design Prospective cohort study. Setting Twenty-two UK clinics (university and district general hospitals). Methods Consecutive eligible women with OAB symptoms had transvaginal ultrasound to estimate BWT (index test). The reference standard for the diagnosis of DO was urodynamic testing with multichannel subtracted cystometry. Main outcome measures The sensitivity, specificity and likelihood ratios using a BWT threshold of ≥5 mm were used to indicate the presence of DO, and the area under the receiver operating characteristics (ROC) curve to give an overall estimate of BWT accuracy. Results Between March 2011 and 2013, 644/687 (94%) women recruited had both tests. The mean age was 52.7 years (standard deviation 13.9) and DO was diagnosed in 399/666 (60%) women. BWT had a sensitivity of 43% [95% confidence interval (CI) 38–48%], specificity of 62% (95% CI 55–68%), and likelihood ratios of 1.11 (95% CI 0.92–1.35) and 0.93 (95% CI 0.82–1.06) for positive and negative tests, respectively. The area under the ROC curve was 0.53 (95% CI 0.48–0.57). Extensive sensitivity analyses and subgroup analyses were carried out, but did not alter the interpretation. Conclusions BWT is not a good replacement test for urodynamics in women with overactive bladder. Tweetable abstract Bladder wall thickness is not a good replacement test for urodynamics in women with overactive bladder.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14516Bladder wall thickness has no role in the diagnosis of detrusor overactivityE Schuit2017-02-20T23:45:47.456431-05:00doi:10.1111/1471-0528.14516John Wiley & Sons, Inc.10.1111/1471-0528.14516http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14516Mini Commentary14301430http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14227Surgical treatment of stress urinary incontinence–trans-obturator tape compared with tension-free vaginal tape–5-year follow up: an economic evaluationD Lier, M Robert, S Tang, S Ross2016-08-10T03:56:59.229467-05:00doi:10.1111/1471-0528.14227John Wiley & Sons, Inc.10.1111/1471-0528.14227http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14227Urogynaecology14311439

Objective

To conduct an economic evaluation of the use of trans-obturator tape (TOT) compared with tension-free vaginal tape (TVT) in the surgical treatment of stress urinary incontinence in women.

Design

Cost–utility and cost-effectiveness analyses from a public-payer perspective, conducted alongside a randomised clinical trial.

Setting

Health services provided in Alberta, Canada.

Sample

A total of 195 women participated in the randomised clinical trial, followed to 5 years postsurgery.

Methods

Comparisons were undertaken between study groups for cost and two health-outcome measures. Multiple imputation was used to estimate the 14% of missing data. Bootstrapping was used to account for sampling uncertainty. Sensitivity analyses were based on complete case analyses and the removal of a TVT patient with extreme health service cost.

Main outcome measures

The 15D instrument was used to calculate quality-adjusted life-years (QALYs) for the primary analysis. Absence of serious adverse events was also analysed. Costs were based on inpatient and outpatient hospital use data and practitioner fee-for-service claims data.

Results

The TOT group had a nonsignificant average saving of $2368 (95% CI −$7166 to $2548) and incremental gain of 0.04 QALYs (95% CI −0.06 to 0.14) compared with TVT. TOT was dominant in over 71% of bootstrap replications and cost-effective over a wide range of willingness-to-pay. Cost-effectiveness analysis using the absence of an serious adverse events provided similar results.

Conclusion

The results suggest that TOT is cost-effective compared with TVT in the treatment of stress urinary incontinence.

Tweetable abstract

The results of a 5-year cost-effectiveness analysis suggest that trans-obturator tape is cost-effective compared with tension-free vaginal tape in the treatment of stress urinary incontinence.

Objective To conduct an economic evaluation of the use of trans-obturator tape (TOT) compared with tension-free vaginal tape (TVT) in the surgical treatment of stress urinary incontinence in women. Design Cost–utility and cost-effectiveness analyses from a public-payer perspective, conducted alongside a randomised clinical trial. Setting Health services provided in Alberta, Canada. Sample A total of 195 women participated in the randomised clinical trial, followed to 5 years postsurgery. Methods Comparisons were undertaken between study groups for cost and two health-outcome measures. Multiple imputation was used to estimate the 14% of missing data. Bootstrapping was used to account for sampling uncertainty. Sensitivity analyses were based on complete case analyses and the removal of a TVT patient with extreme health service cost. Main outcome measures The 15D instrument was used to calculate quality-adjusted life-years (QALYs) for the primary analysis. Absence of serious adverse events was also analysed. Costs were based on inpatient and outpatient hospital use data and practitioner fee-for-service claims data. Results The TOT group had a nonsignificant average saving of $2368 (95% CI −$7166 to $2548) and incremental gain of 0.04 QALYs (95% CI −0.06 to 0.14) compared with TVT. TOT was dominant in over 71% of bootstrap replications and cost-effective over a wide range of willingness-to-pay. Cost-effectiveness analysis using the absence of an serious adverse events provided similar results. Conclusion The results suggest that TOT is cost-effective compared with TVT in the treatment of stress urinary incontinence. Tweetable abstract The results of a 5-year cost-effectiveness analysis suggest that trans-obturator tape is cost-effective compared with tension-free vaginal tape in the treatment of stress urinary incontinence.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14512Maternal and neonatal outcomes in women with severe early onset pre-eclampsia before 26 weeks of gestation, a case seriesMF Oostwaard, L Eerden, MW Laat, JJ Duvekot, JJHM Erwich, KWM Bloemenkamp, AC Bolte, JPF Bosma, SV Koenen, RF Kornelisse, B Rethans, P Runnard Heimel, HCJ Scheepers, W Ganzevoort, BWJ Mol, CJ Groot, IPM Gaugler-Senden2017-01-27T08:05:55.366746-05:00doi:10.1111/1471-0528.14512John Wiley & Sons, Inc.10.1111/1471-0528.14512http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14512Case Report14401447

Objective

To describe the maternal and neonatal outcomes and prolongation of pregnancies with severe early onset pre-eclampsia before 26 weeks of gestation.

Design

Nationwide case series.

Setting

All Dutch tertiary perinatal care centres.

Population

All women diagnosed with severe pre-eclampsia who delivered between 22 and 26 weeks of gestation in a tertiary perinatal care centre in the Netherlands, between 2008 and 2014.

Methods

Women were identified through computerised hospital databases. Data were collected from medical records.

Main outcome measures

Maternal complications [HELLP (haemolysis, elevated liver enzyme levels, and low platelet levels) syndrome, eclampsia, pulmonary oedema, cerebrovascular incidents, hepatic capsular rupture, placenta abruption, renal failure, and maternal death], neonatal survival and complications (intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis, bronchopulmonary dysplasia, and sepsis), and outcome of subsequent pregnancies (recurrent pre-eclampsia, premature delivery, and neonatal survival).

Results

We studied 133 women, delivering 140 children. Maternal complications occurred frequently (54%). Deterioration of HELLP syndrome during expectant care occurred in 48%, after 4 days. Median prolongation was 5 days (range: 0–25 days). Neonatal survival was poor (19%), and was worse (6.6%) if the mother was admitted before 24 weeks of gestation. Complications occurred frequently among survivors (84%). After active support, neonatal survival was comparable with the survival of spontaneous premature neonates (54%). Pre-eclampsia recurred in 31%, at a mean gestational age of 32 weeks and 6 days.

Conclusions

Considering the limits of prolongation, women need to be counselled carefully, weighing the high risk for maternal complications versus limited neonatal survival and/or extreme prematurity and its sequelae. The positive prospects regarding maternal and neonatal outcome in future pregnancies can supplement counselling.

Tweetable abstract

Severe early onset pre-eclampsia comes with high maternal complication rates and poor neonatal survival.

Objective To describe the maternal and neonatal outcomes and prolongation of pregnancies with severe early onset pre-eclampsia before 26 weeks of gestation. Design Nationwide case series. Setting All Dutch tertiary perinatal care centres. Population All women diagnosed with severe pre-eclampsia who delivered between 22 and 26 weeks of gestation in a tertiary perinatal care centre in the Netherlands, between 2008 and 2014. Methods Women were identified through computerised hospital databases. Data were collected from medical records. Main outcome measures Maternal complications [HELLP (haemolysis, elevated liver enzyme levels, and low platelet levels) syndrome, eclampsia, pulmonary oedema, cerebrovascular incidents, hepatic capsular rupture, placenta abruption, renal failure, and maternal death], neonatal survival and complications (intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis, bronchopulmonary dysplasia, and sepsis), and outcome of subsequent pregnancies (recurrent pre-eclampsia, premature delivery, and neonatal survival). Results We studied 133 women, delivering 140 children. Maternal complications occurred frequently (54%). Deterioration of HELLP syndrome during expectant care occurred in 48%, after 4 days. Median prolongation was 5 days (range: 0–25 days). Neonatal survival was poor (19%), and was worse (6.6%) if the mother was admitted before 24 weeks of gestation. Complications occurred frequently among survivors (84%). After active support, neonatal survival was comparable with the survival of spontaneous premature neonates (54%). Pre-eclampsia recurred in 31%, at a mean gestational age of 32 weeks and 6 days. Conclusions Considering the limits of prolongation, women need to be counselled carefully, weighing the high risk for maternal complications versus limited neonatal survival and/or extreme prematurity and its sequelae. The positive prospects regarding maternal and neonatal outcome in future pregnancies can supplement counselling. Tweetable abstract Severe early onset pre-eclampsia comes with high maternal complication rates and poor neonatal survival.
http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14612Severe pre-eclampsia before 26 weeks of gestation: how should we counsel women?OA Ashimi, SP Chauhan2017-04-01T03:00:42.990923-05:00doi:10.1111/1471-0528.14612John Wiley & Sons, Inc.10.1111/1471-0528.14612http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14612Mini Commentary14481448http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14675Re: An economic evaluation on outpatient versus inpatient polyp treatment for abnormal bleedingAntonio Santos-Paulo, Maria Helena Solheiro2017-07-20T06:02:33.377639-05:00doi:10.1111/1471-0528.14675John Wiley & Sons, Inc.10.1111/1471-0528.14675http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14675BJOG Exchange14491449http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14677Re: RCT evidence should not drive everything we do clinically: Trials and errorsShashikant L Sholapurkar2017-07-20T06:02:30.53972-05:00doi:10.1111/1471-0528.14677John Wiley & Sons, Inc.10.1111/1471-0528.14677http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14677BJOG Exchange14491450http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14633Re: China's new two-child policy: maternity care in the new multiparous eraMJ Quin2017-07-20T06:02:30.357503-05:00doi:10.1111/1471-0528.14633John Wiley & Sons, Inc.10.1111/1471-0528.14633http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14633BJOG Exchange14501451http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14634Author's reply re: China's new two-child policy: maternity care in the new multiparous eraTony Duan2017-07-20T06:02:34.152213-05:00doi:10.1111/1471-0528.14634John Wiley & Sons, Inc.10.1111/1471-0528.14634http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14634BJOG Exchange14511451http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14680Re: Obstetric and neonatal complications in pregnancies conceived after oocyte donation: a systematic review and meta-analysisJessica Garner, Maryam Parisaei, Amit Shah2017-07-20T06:02:34.590727-05:00doi:10.1111/1471-0528.14680John Wiley & Sons, Inc.10.1111/1471-0528.14680http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14680BJOG Exchange14511452http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14681Authors' reply re: Obstetric and neonatal complications in pregnancies conceived after oocyte donation: a systematic review and meta-analysisMarianne Storgaard, Anja Pinborg2017-07-20T06:02:28.524898-05:00doi:10.1111/1471-0528.14681John Wiley & Sons, Inc.10.1111/1471-0528.14681http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14681BJOG Exchange14521452http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14650Re: AGAINST: fetal scalp blood sampling in conjunction with electronic fetal monitoring reduces the risk of unnecessary operative deliveryFerha Saeed2017-07-20T06:02:28.742314-05:00doi:10.1111/1471-0528.14650John Wiley & Sons, Inc.10.1111/1471-0528.14650http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14650BJOG Exchange14521453http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14654Author's reply re: AGAINST: fetal scalp blood sampling in conjunction with electronic fetal monitoring reduces the risk of unnecessary operative deliveryJan Stener Jørgensen2017-07-20T06:02:35.264101-05:00doi:10.1111/1471-0528.14654John Wiley & Sons, Inc.10.1111/1471-0528.14654http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14654BJOG Exchange14531454http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14768Blair Bell Research Society: Annual Academic Meeting Abstracts2017-07-20T06:02:35.351582-05:00doi:10.1111/1471-0528.14768John Wiley & Sons, Inc.10.1111/1471-0528.14768http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111%2F1471-0528.14768Blair Bell Abstractse264e278

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