Randomised controlled multicentre open-label trial.

Seven Danish tertiary hospitals from March 2009 to June 2011.

Women with uncomplicated pregnancies, a single fetus, and a date of delivery estimated by ultrasound scheduled for delivery by elective caesarean section.

Perinatal outcomes after elective caesarean section scheduled at a gestational age of 38 weeks and 3 days versus 39 weeks and 3 days (in both groups ±2 days).

The primary outcome was neonatal intensive care unit (NICU) admission within 48 hours of birth. Secondary outcomes were neonatal depression, NICU admission within 7 days, NICU length of stay, neonatal treatment, and maternal surgical or postpartum adverse events.

Among women scheduled for elective caesarean section at 38⁺³ weeks 88/635 neonates (13.9%) were admitted to the NICU, whereas in the 39⁺³ weeks group 76/637 neonates (11.9%) were admitted (relative risk [RR] 0.86, 95% confidence interval [95% CI] 0.65–1.15). Neonatal treatment with continuous oxygen for more than 1 day (RR 0.31; 95% CI 0.10–0.94) and maternal bleeding of more than 500 ml (RR 0.79; 95% CI 0.63–0.99) were less frequent in the 39 weeks group, but these findings were insignificant after adjustment for multiple comparisons. The risk of adverse neonatal or maternal outcomes, or a maternal composite outcome (RR 1.1; 95% CI 0.79–1.53) was similar in the two intervention groups.

This study found no significant reduction in neonatal admission rate after ECS scheduled at 39 weeks compared with 38 weeks of gestation.

A multicentre interventional cohort study with before and after comparison.

Four Norwegian obstetric departments.

A total of 40 154 vaginal deliveries in 2003–09.

Pre-intervention and postintervention analyses. The associations of OASIS with possible risk factors were estimated using odds ratios obtained by logistic regression.

Risk factors of OASIS.

The risk of sustaining OASIS decreased by 59% (odds ratio [OR] 0.41; 95% confidence interval [95% CI] 0.36–0.46) after the intervention. Associations with obstetric risks for OASIS were largely unchanged after the intervention, including first vaginal delivery (OR 3.84; 95% CI 2.90–5.07), birthweight ≥4500 g (OR 4.42; 95% CI 2.68–7.27), forceps delivery (OR 3.54; 95% CI 1.99–6.29) and mediolateral episiotomy (OR 0.89; 95% CI 0.70–1.12). However, the highest reduction of OASIS, (65%), was observed in group 0 (low-risk) (OR 0.35; 95% CI 0.24–0.51), and a 57% (OR 0.43; 95% CI 0.35–0.52), 61% (OR 0.39; 95% CI 0.31–0.48), and 58% (OR 0.42; 95% CI 0.30–0.60) reduction in groups with one, two and three risk factors, respectively. No change was observed in the group with four risk factors.

After the intervention the most significant decrease of OASIS was observed in low-risk births, although the main risk factors for OASIS remained unchanged.

Case–control study.

Northeast of Scotland University Hospital, hosting the regional fertility centre and maternity unit.

A total of 18 846 mother–daughter record pairs from the Aberdeen Fertility Centre Data Set and the Aberdeen Maternity and Neonatal Databank (AMND). Cases were the daughters with ovulatory dysfunction attending the Aberdeen Fertility Centre between 1992 and 2007, Control group 1 included the daughters attending the fertility centre with confirmed ovulation, and Control group 2 included all women naturally fertile who gave birth in Aberdeen during the same period.

The electronic maternity records of the mothers of women in the three groups were retrieved from AMND and compared.

Daughters' birthweight and standardised birthweight, characteristics of mothers and daughters at delivery and current daughters' characteristics.

Cases, Control group 1 and Control group 2 included 466, 548 and 17 832 daughters, respectively. The mean birthweight (standard deviation) in grams was comparable between Cases 3203 (522), Control group 1, 3235 (482) P = 0.30, and Control group 2, 3226 (495) P = 0.31. The proportions of daughters born small for gestational age, large for gestational age, or preterm were comparable between the Cases group and each Control group, as was the mode of delivery and Apgar scores at 1 and 5 minutes. The age at delivery, body mass index, social class or pregnancy complications were comparable in the mothers of the Cases and each Control group.

Ovulatory dysfunction does not appear to be related to birthweight or perinatal events.

The development of prescriptive intrauterine and newborn growth standards derived from the INTERGROWTH-21^st Project provides the data that will allow us for the first time to establish what is ‘normal’ fetal growth.

The INTERGROWTH-21^st study centres provide the data set obtained under pre-established standardised criteria, and details of the methods used are also published.

Multicentre study with sites in all major geographical regions of the world using a standard evaluation protocol.

These standards will assess risk of abnormal size at birth and serve to evaluate potentially effective interventions to promote optimal growth beyond securing survival.

The new normative standards have the potential to impact perinatal and neonatal survival and beyond, particularly in developing countries where fetal growth restriction is most prevalent. They will help us identify intrauterine growth restriction at earlier stages of development, when preventive or corrective strategies might be more effective than at present.

These growth standards will take us one step closer to effective action in preventing and potentially reversing abnormal intrauterine growth. Achieving ‘optimal’ fetal growth requires that we act not only during pregnancy but that we optimize the maternal uterine environment from the time before conception, through embryonic development until fetal growth is complete. The remaining challenge is how ‘early’ will we be able to act, now that we can better monitor fetal growth.

A prospective cohort study.

The Swedish Patient Register (PAR) and the Swedish Medical Birth Registry (MBR).

Women who were delivered in Sweden between 1986 and 2004.

Women with the diagnosis of endometriosis, defined as codes 617 (International Classification of Diseases, ninth revision, ICD–9) or N80 (ICD–10), were retrieved from the PAR. Obstetric outcome was assessed through linkage with the MBR. Out of 709 090 women, 3110 were treated as inpatients with a first diagnosis of endometriosis after their first delivery. Women with a diagnosis of endometriosis before their first delivery were excluded. Cox analyses were performed to obtain hazard ratios for endometriosis and adjusted for maternal age at first delivery, body mass index, maternal smoking, and years of involuntary childlessness at study entry. Kaplan–Meier estimates were performed to calculate the risk according to time elapsed.

In-hospital diagnosis of endometriosis.

The Cox analyses yielded a hazard ratio of 1.8 (95% CI 1.7–1.9) for endometriosis in women who had had a previous caesarean section compared with women with vaginal deliveries only. The risk of endometriosis increased over time: one additional case of endometriosis was found for every 325 women undergoing caesarean section within 10 years. No increase in risk could be seen after two caesarean deliveries. The risk of caesarean scar endometrioma was 0.1%.

In addition to the recognised risk of scar endometrioma, we found an association between caesarean section and general pelvic endometriosis. Further studies are needed to confirm our findings.

Practical evaluation and prospective cost-effectiveness analysis.

A university hospital in France.

A cohort of 225 women in labour at the University-Hospital of Saint-Etienne.

Each woman had a conventional culture performed at 34–38 weeks of gestation. At the beginning of labour, two vaginal swabs were sampled for rapid PCR testing and culture. The decision to prescribe a prophylactic antimicrobial treatment or not was taken according to the result of the PCR test. A comparative cost-effectiveness analysis of the two diagnostic strategies was carried out.

Number of women receiving inadequate prophylactic antimicrobial drugs following each testing strategy, costs of PCR testing and culture, frequency of vaginal GBS, and diagnostic performance of the PCR test at delivery.

The percentage of unnecessarily treated women was significantly reduced using the rapid test versus conventional culture (4.5 and 13.6%, respectively; P < 0.001). The rate of vaginal GBS at delivery was 12.5%. The incremental cost-effectiveness ratio (ICER) for each inadequate management avoided was €36 and €173 from the point of view of the healthcare system and hospital, respectively.

The PCR assay reduced the number of inadequate antimicrobial treatments aimed to prevent the early onset of GBS disease. However, this strategy generates extra costs that must be put into balance with its clinical benefits.

Secondary analysis of data from a prospective pregnancy cohort.

The study was performed at the University of North Carolina prenatal care clinics.

Pregnant women enrolled for prenatal care at the University of North Carolina Hospital Center.

Participants were questioned about pregnancy intention at 15–19 weeks of gestation, and classified as having an intended, mistimed or unwanted pregnancy. They were evaluated for postpartum depression at 3 and 12 months postpartum. Log binomial regression was used to assess the relationship between unintended pregnancy and depression, controlling for confounding by demographic factors and reproductive history.

Depression at 3 and 12 months postpartum, defined as Edinburgh Postpartum Depression Scale score >13.

Data were analysed for 688 women at 3 months and 550 women at 12 months. Depression was more likely in women with unintended pregnancies at both 3 months (risk ratio [RR] 2.1, 95% confidence interval [95% CI] 1.2–3.6) and 12 months (RR 3.6, 95% CI 1.8–7.1). Using multivariable analysis adjusting for confounding by age, poverty and education level, women with unintended pregnancies were twice as likely to have postpartum depression at 12 months (RR 2.0, 95% CI 0.96–4.0).

While many elements may contribute to postpartum depression, unintended pregnancy could also be a contributing factor. Women with unintended pregnancy may have an increased risk of depression up to 1 year postpartum.

Prospective cohort study.

Rural northwest Bangladesh.

A cohort of 133 617 married women of reproductive age.

Verbal autopsies were conducted for women who died whilst under surveillance in the cohort trial. Physician-assigned causes of death based on verbal autopsies were used to categorise deaths.

The proportion of deaths due to non-communicable diseases, infectious diseases, injury or pregnancy.

Of the 1107 deaths occurring among women between 2001 and 2007, 48% were attributed to non-communicable diseases, 22% to pregnancy, 17% to infections, 9% to injury and 4% to other causes.

Although focus on pregnancy-related mortality remains important, more attention is warranted on non-communicable diseases among women of reproductive age.

Retrospective cost analysis of our prospective cohort study.

Boston, Massachusetts (USA).

Women (n = 176) presenting to the hospital at <34 weeks of gestation for evaluation of possible pre-eclampsia during 2009–10. Cases without complete cost or outcome data (n = 9) and re-enrolments (n = 18) were excluded.

Modelled comparisons between the standard approach (combination of blood pressure, urinary protein excretion, alanine aminotransferase and platelet counts) and a novel approach (ratio of plasma sFlt1 and PlGF) using actual hospital data converted to 2012 US dollars in accordance with the Centers for Medicare and Medicaid Services.

Direct 2-week costs and resource use by groups having true or false positive and negative test results for adverse outcomes according to approach.

The improved specificity of the novel approach decreased the proportion of women falsely labelled as test-positive from 42.3% (34.4–50.2%) to 4.0% (0.85–7.15%) and increased the proportion correctly labelled as test-negative from 23.5% (16.7–30.3%) to 61.7% (53.9–69.5%). This could potentially reduce average per-patient costs by $1215. Substantial quantities of resources [47.2% (35.7–58.7%) of antenatal admissions and 72.5% (68.0–77.0%) of tests for fetal wellbeing] were unnecessarily used for women who were truly negative. A proportion of iatrogenic preterm deliveries among women with negative results was potentially avoidable representing further cost and resource savings.

Clinical use of the plasma sFlt1 and PlGF ratio improves risk stratification among women presenting for pre-eclampsia evaluation and has the potential to reduce costs and resource use.

Prospective cohort study.

Women infected with HIV-1 undergoing LEEP for CIN2/3 in Kisumu, Kenya.

Participants underwent specimen collection for HIV-1 RNA prior to LEEP and at 1, 2, 4, 6, 10, and 14 weeks post-LEEP. HIV-1 viral load was measured in cervical and plasma specimens using commercial real-time polymerase chain reaction (PCR) assays, to a lower limit of detection of 40 copies per specimen.

Presence and magnitude of HIV-1 RNA (copies per specimen or cps) in post-LEEP specimens, compared with baseline.

Among women on highly active antiretroviral therapy (HAART), we found a statistically significant increase in cervical HIV-1 RNA concentration at week 2, with a mean increase of 0.43 log₁₀ cps (95% CI 0.03–0.82) from baseline. Similarly, among women not receiving HAART, we found a statistically significant increase in HIV-1 shedding at week 2 (1.26 log₁₀ cps, 95% CI 0.79–1.74). No other statistically significant increase in concentration or detection of cervical HIV-1 RNA at any of the remaining study visits were noted.

In women infected with HIV undergoing LEEP, an increase in genital HIV shedding was observed at 2 but not at 4 weeks post-procedure. The current recommendation for women to abstain from vaginal intercourse for 4 weeks seems adequate to reduce the theoretical increased risk of HIV transmission following LEEP.

Population-based study.

The Swedish Twin Register.

In 2005, a total of 14 094 female twins born between 1959 and 1985 in the Swedish Twin Registry participated in a comprehensive survey on common exposures and complex diseases. Structured questions provided information on GDM and OAB. The present study was designed as a cross-sectional analysis including all women in the cohort having given birth before 2005 (n = 7855).

A logistic regression model based on generalised estimating equations was used to derive odds ratios (ORs).

The association between a history of GDM and OAB was estimated using ORs with 95% confidence intervals (CIs).

The prevalence of OAB in women with a history of GDM was 19.1% compared with 10.7% in women without GDM. This corresponded to a two-fold increased odds of OAB in women with a history of gestational diabetes (OR 2.13, 95% CI 1.48–3.05). After adjusting the analysis for age, body mass index, parity, smoking, and diabetes mellitus, having had GDM was associated with doubled odds of OAB (OR 1.88, 95% CI 1.26–2.80).

A history of GDM was positively associated with OAB among women of premenopausal age. The association does not seem to be mediated by body mass index or type-I or type-II diabetes mellitus.

A population-based study.

Sweden.

All women with vaginal delivery and singleton pregnancy in Sweden in the years 2003–2008 (n = 210 678).

The Medical Birth Registry, the National Board of Health and Welfare, was used to identify cases of rupture and body mass index (BMI) classes. The population was categorised into four classes with BMI of <25, 25 to <30, 30 to <35 and >35 kg/m².

Odds ratios were estimated with 95% confidence intervals. In order to estimate the effect of BMI on obstetric anal sphincter lacerations, with possible confounders accounted for, uni- and multivariate logistic regressions were performed.

In total, 8958 (4.25%) cases of anal sphincter lacerations (grade III–IV) occurred; increasing BMI showed a significant near-dose–response type of protective effect against grade III–IV lacerations when compared with women with BMI <25 kg/m²: BMI 25 to <30 kg/m², 0.89; BMI 30 to <35 kg/m², 0.84; BMI > 35 kg/m², 0.70.

Overweight and obesity were associated with a decreased risk for obstetric anal sphincter lacerations.

Population-based study.

Western Australia.

All non-Aboriginal women giving birth to live singleton infants between 1984 and 2006.

Multinomial, multivariable regression models were used to assess antecedent profiles by preterm status and labour onset types (spontaneous, medically indicated, prelabour rupture of membranes [PROM]). Population attributable fraction (PAF) estimates characterized the contribution of individual antecedents as well as the overall contribution of two antecedent groups: pre-existing medical conditions (including previous obstetric history) and pregnancy complications.

Antecedent relationships with preterm birth, stratified by labour onset type.

Marked increases in maternal age and primiparous births were observed. A four-fold increase in the rates of pre-existing medical complications over time was observed. Rates of pregnancy complications remained stable. Multinomial regression showed differences in antecedent profiles across labour onset types. PAF estimates indicated that 50% of medically indicated preterm deliveries could be eliminated after removing six antecedents from the population; estimates for PROM and spontaneous preterm reduction were between 10 and 20%. Variables pertaining to previous and current obstetric complications (previous preterm birth, previous caesarean section, pre-eclampsia and antepartum haemorrhage) were the most influential predictors of preterm birth and adverse labour onset (PROM and medically indicated).

Preterm antecedent profiles have changed markedly over the 23 years studied. Some changes may be attributable to true change, others to advances in surveillance and detection. Still others may signify change in clinical practice.

All women of the Doetinchem Cohort Study (1987–91), a population-based cohort study, were included.

Women were examined (questionnaires and physical examination) four times at 5-year intervals. History of HPD was assessed from questionnaires. We compared 5-year changes in risk factors between women with and without HPD, by analysing longitudinal trends using generalised estimating equation analysis to estimate the effects of HPD and mean age, adjusting for treatment, body mass index (BMI), smoking and socio-economic status.

Change over time in traditional cardiovascular risk factors, including systolic blood pressure (SBP) and diastolic blood pressure (DBP), BMI, total and high-density lipoprotein (HDL) cholesterol for women with and without a history of HPD.

A total of 2703 women with normotensive pregnancies (mean age 40.5 years, SD 10.4) and 689 women with a history of HPD (mean age 38.4 years, SD 9.5) were included. Compared with normotensive women, in women with a history of HPD, SBP was 2.8 mmHg higher (95% CI 1.7–3.9), DBP was 2.3 mmHg higher (95% CI 1.6–3.0) and BMI was 0.7 kg/m² higher (95% CI 0.4–1.1). Total cholesterol (−0.05; 95% CI −0.1 to 0.0) and HDL cholesterol (0.02; 95% CI −0.0 to 0.1) were similar in both groups. No difference in annual change in blood pressure or in the other risk factors was observed between women with and without a history of HPD.

Women with a history of HPD have higher levels of SBP, DBP and BMI compared with normotensive women, but the increase with ageing is similar in both groups.

Case series.

Four level-three Japanese obstetric centres.

Thirty-four women with prior caesarean section and placenta praevia that widely covers the anterior uterine wall, in whom placenta accreta cannot be ruled out.

A transverse fundal incision was performed at the time of caesarean section and manual placental removal was attempted under direct observation.

Operative fluid loss.

The total volume of fluid lost during our operative procedure compares favourably with the volume lost during our routine transverse lower-segment caesarean sections performed in patients without placenta praevia or accreta. The average fluid loss was 1370 g. No patients required transfer to intensive care, and there were no cases of fetal anaemia.

This procedure has the potential to reduce the heavy bleeding that arises from caesarean deliveries in women with placenta praevia and placenta accreta.

Prospective cohort study.

Assisted reproduction clinic and general gynaecological unit in a university-affiliated, tertiary referral hospital.

A cohort of 150 women (75 after natural conception; 75 after assisted reproduction).

Completed semi-structured interviews using two standard questionnaires [the 12-item General Health Questionnaire (GHQ-12) and the 22–item Revised Impact of Events Scale (IES-R)], at 1, 4, and 12 weeks after a diagnosis of first-trimester miscarriage.

The GHQ–12 and IES–R scores for the two groups of women.

The GHQ-12 and IES-R scores were significantly higher in the assisted reproduction group than the scores in the natural conception group, at 4 weeks and 12 weeks after miscarriage. Further breakdown of the scores revealed significantly higher hyperarousal symptoms at 4 and 12 weeks in the assisted reproduction group, indicating the traumatic effect of miscarriage to these women.

Following first-trimester miscarriage, subfertile women who conceived after assisted reproduction had higher stress and anxiety-depression levels, and experienced more traumatic impact from the event, than those after natural conception. A timely support and psychological intervention would be beneficial in the management of this group of women.

Prospective population-based cohort.

UK.

Ten thousand five hundred and thirty-four 7-year-olds.

Quasi-experimental using propensity score matching (PSM) to compare children born to light (up to 2 units per week) and non-drinkers.

Behavioural difficulties rated by parents and teachers; cognitive test scores for reading, maths and spatial skills.

Ordinary least squares (OLS) regression and PSM analyses are presented. For behavioural difficulties, unadjusted estimates for percentage standard deviation (SD) score differences ranged from 2 to 14%. On adjustment for potential confounders, differences were attenuated, with a loss of statistical significance, except for teacher-rated boys' difficulties. For boys, parent-rated behavioural difficulties: unadjusted, −11.5; OLS, −4.3; PSM, −6.8; teacher-rated behavioural difficulties: unadjusted, −13.9; OLS, −9.6; PSM, −10.8. For girls, parent-rated behavioural difficulties: unadjusted, −9.6; OLS, −2.9; PSM, −4.5; teacher-rated behavioural difficulties: unadjusted, −2.4; OLS, 4.9; PSM, 3.9. For cognitive test scores, unadjusted estimates for differences ranged between 12 and 21% of an SD score for reading, maths and spatial skills. After adjustment for potential confounders, estimates were reduced, but remained statistically significantly different for reading and for spatial skills in boys. For boys, reading: unadjusted, 20.9; OLS, 8.3; PSM, 7.3; maths: unadjusted, 14.7; OLS, 5.0; PSM, 6.5; spatial skills: unadjusted, 16.2; OLS, 7.6; PSM, 8.1. For girls, reading: unadjusted, 11.6; OLS, −0.3; PSM, −0.5; maths: unadjusted, 12.9; OLS, 4.3; PSM, 3.9; spatial skills: unadjusted, 16.2; OLS, 7.7; PSM, 6.4.

The findings suggest that light drinking during pregnancy is not linked to developmental problems in mid-childhood. These findings support current UK Department of Health guidelines on drinking during pregnancy.

Cross-sectional study.

Four tertiary-care hospitals in urban and rural Nepal.

A total of 527 women presenting with complications from induced abortion in 2010.

Women completed questionnaires on their awareness of the legal status of abortion and their abortion-seeking experiences. The method of induction and whether the abortion was obtained from an uncertified source was documented. Multivariable logistic regression was used to identify associated factors.

Induction method; uncertified abortion source.

In all, 234 (44%) women were aware that abortion was legal in Nepal. Medically induced abortion was used by 359 (68%) women and, of these, 343 (89%) took unsafe, ineffective or unknown substances. Compared with women undergoing surgical abortion, women who had medical abortion were more likely to have obtained information from pharmacists (161/359, 45% versus 11/168, 7%, adjusted odds ratio [aOR] 8.1, 95% confidence interval 4.1–16.0) and to have informed no one about the abortion (28/359, 8% versus 3/168, 2%, aOR 5.5, 95% CI 1.1–26.9). Overall, 291 (81%) medical abortions and 50 (30%) surgical abortions were obtained from uncertified sources; these women were less likely to know that abortion was legal (122/341, 36% versus 112/186, 60%, aOR 0.4, 95% CI 0.2–0.7) and more likely to choose a method because it was available nearby (209/341, 61% versus 62/186, 33%, aOR 2.5, 95% CI 1.5–4.3), compared with women accessing certified sources.

Among women presenting to hospitals in Nepal with complications following induced abortion of pregnancy, the majority had undergone medically induced abortions using unknown substances acquired from uncertified sources. Women using medications and those accessing uncertified providers were less aware that abortion is now legal in Nepal. These findings highlight the need for continued improvements in the provision and awareness of abortion services in Nepal.

A population-based case–control study.

Seventeen EUROCAT (European Surveillance of Congenital Anomalies) registries, 1980–2008.

The study population consisted of 1417 cases with ARM, including 648 cases of isolated ARM, 601 cases of ARM with additional congenital anomalies, and 168 cases of ARM-VACTERL (vertebral, anal, cardiac, tracheo-esophageal, renal, and limb defects), along with 13 371 controls with recognised syndromes or chromosomal abnormalities.

Multiple logistic regression analyses were used to calculate adjusted odds ratios (ORs) for potential risk factors for ARM, such as fertility treatment, multiple pregnancy, primiparity, maternal illnesses during pregnancy, and pregnancy-related complications.

Adjusted ORs for pregnancy-related risk factors for ARM.

The ARM cases were more likely to be firstborn than the controls (OR 1.6, 95% CI 1.4–1.8). Fertility treatment and being one of twins or triplets seemed to increase the risk of ARM in cases with additional congenital anomalies or VACTERL (ORs ranging from 1.6 to 2.5). Maternal fever during pregnancy and pre-eclampsia were only associated with ARM when additional congenital anomalies were present (OR 3.9, 95% CI 1.3–11.6; OR 3.4, 95% CI 1.6–7.1, respectively), whereas maternal epilepsy during pregnancy resulted in a five-fold elevated risk of all manifestations of ARM (OR 5.1, 95% CI 1.7–15.6).

This large European study identified maternal epilepsy, fertility treatment, multiple pregnancy, primiparity, pre-eclampsia, and maternal fever during pregnancy as potential risk factors primarily for complex manifestations of ARM with additional congenital anomalies and VACTERL.

Prospective comparative study.

University hospital.

Umbilical cord blood from 124 newborns.

Arterial and venous cord blood was sampled immediately after birth (T₀), and at 45 seconds (T₄₅), from unclamped cords with intact pulsations taken from 66 neonates born vaginally and 58 neonates born via planned caesarean section at 36–42 weeks of gestation. Non-parametric tests were used for statistical comparisons, with P < 0.05 considered significant.

Temporal changes (T₀–T₄₅) in umbilical cord blood pH, the partial pressure of CO₂ () and O₂ (), and in the concentrations of lactate, haematocrit (Hct), and haemoglobin (Hb).

In both groups all arterial parameters, except for in the group delivered by caesarean section, changed significantly (pH decreased and the other variables increased). There were corresponding changes in venous acid–base parameters. When temporal arterial changes were compared between the two groups, the decrease in pH and increase in were more pronounced in the group delivered vaginally. Neonates born vaginally had significantly lower pH and higher lactate, Hct, and Hb concentrations at T₀ and T₄₅ in both the artery and the vein. At T₄₅, arterial and levels in the group delivered vaginally were also significantly higher.

Delayed umbilical cord sampling affected the acid–base balance and haematological parameters after both vaginal and caesarean deliveries, although the effect was more marked in the group delivered vaginally. The hidden acidosis phenomenon explains this change towards acidaemia and lactaemia. Arterial haemoconcentration was not the explanation of the acid–base drift.

A questionnaire development study.

Vulval Disorders Clinic serving a regional population.

Fifty-eight women with a histological diagnosis of VIN registered with the Vulval Disorders Clinic.

A 37-item questionnaire was developed through a comprehensive literature review, consultation with specialist clinicians and pretesting to assess the burden experienced by women. The questionnaire was assessed for validity and reliability against existing questionnaires used in related disease areas.

Spearman correlations were calculated between items in the VIN questionnaire with the scores of the Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), Sabbatsberg Sexual Self-Rating Scale (SSRS) and the Process Outcome Specific Measure (POSM) to assess the new questionnaire's validity. Internal consistency was measured using Cronbach's alpha. Test–retest reliability was calculated using quadratic weighted kappa.

The VIN questionnaire had a high degree of internal consistency (Cronbach's alpha, 0.89). Test–retest reliability was assessed, with most questions showing a quadratic weighted kappa value of 0.5 or above. Most questions showed a stronger correlation with the corrected total VIN score than with HADS anxiety and depression subscales and the SSRS, indicating discriminant validity. Most questions correlated significantly with the DLQI and POSM scores, indicating convergent validity.

Initial assessment of the VIN questionnaire demonstrated that it is a valid and reliable measure of the burden of disease for women. The questionnaire could be used to compare new and existing treatments for VIN or to assess or monitor the impact of care.

Prospective study.

Departments of Obstetrics and Gynaecology and Biochemistry at UCMS & GTBH, Delhi, India.

Ninety pregnant women.

The progesterone concentration in saliva of asymptomatic pregnant women at high risk for preterm delivery was estimated by immunoassay, and cervical length was measured by TVS, at the first antenatal visit at 24–28 weeks of gestation, and then repeated 3–4 weeks later.

Early PTB, mean and critical cut-off values of salivary progesterone, and a diagnostic value comparison of salivary progesterone with TVS cervical length.

The mean value of salivary progesterone was significantly lower in all women who delivered at <37 weeks of gestation (n = 38), compared with the term group (n = 52; P < 0.001). Salivary progesterone decreased significantly from the first to the second visit, with the maximum decrease observed in women who delivered at <34 weeks of gestation (29.6%, 95% CI 17.8–41.4%, P < 0.002). The single predictive critical cut-off value for salivary progesterone was 2575 pg/ml, below which more than 80% of women delivered prematurely before 34 weeks of gestation, with sensitivity, specificity, and positive and negative predictive values of 83% (95% CI 58.6–96.4%), 86% (95% CI 75.9–93.1%), 60% (95% CI 38.6–78.8%) and 95% (95% CI 87.1–99.0%), respectively. The TVS cervical length decreased significantly (P < 0.001) in the women who delivered prematurely.

Low salivary progesterone concentration can be used for predicting early PTB in asymptomatic high-risk women.

Retrospective study.

A tertiary referral unit in Northern Ireland.

A total of 30 298 singleton pregnancies over an 8-year period, 2004–2011.

Women were categorised according to World Health Organization classification: underweight (BMI < 18.50 kg/m²); normal weight (BMI 18.50–24.99 kg/m²; reference group); overweight (BMI 25.00–29.99 kg/m²); obese class I (BMI 30.00–34.99 kg/m²); obese class II (BMI 35–39.99 kg/m²); and obese class III (BMI ≥ 40 kg/m²). Maternal and neonatal outcomes were examined using logistic regression, adjusted for confounding variables.

Maternal and neonatal outcomes.

Compared with women of normal weight, women who were overweight or obese class I were at significantly increased risk of hypertensive disorders of pregnancy (OR 1.9, 99% CI 1.7–2.3; OR 3.5, 99% CI 2.9–4.2); gestational diabetes mellitus (OR 1.7, 99% CI 1.3–2.3; OR 3.7, 99% CI 2.8–5.0); induction of labour (OR 1.2, 99% CI 1.1–1.3; OR 1.3, 99% CI 1.2–1.5); caesarean section (OR 1.4, 99% CI 1.3–1.5; OR 1.8, 99% CI 1.6–2.0); postpartum haemorrhage (OR 1.4, 99% CI 1.3–1.5; OR 1.8, 1.6–2.0); and macrosomia (OR 1.5, 99% CI 1.3–1.6; OR 1.9, 99% CI 1.6–2.2), with the risks increasing for obese classes II and III. Women in obese class III were at increased risk of preterm delivery (OR 1.6, 99% CI 1.1–2.5), stillbirth (OR 3.0, 99% CI 1.0–9.3), postnatal stay > 5 days (OR 2.1, 99% CI 1.5–3.1), and infant requiring admission to a neonatal unit (OR 1.6, 99% CI 1.0–2.6).

By categorising women into overweight and obesity subclassifications (classes I –III), this study clearly demonstrates an increasing risk of adverse outcomes across BMI categories, with women who are overweight also at significant risk.

Economic evaluation alongside a randomised controlled trial.

Obstetric departments of one university and 11 teaching hospitals in the Netherlands.

Women scheduled for labour induction with a singleton pregnancy in cephalic presentation at term, intact membranes and an unfavourable cervix; and without previous caesarean section.

Cost-effectiveness analysis from a hospital perspective.

We estimated direct medical costs associated with healthcare utilisation from randomisation to 6 weeks postpartum. For caesarean section rate, and maternal and neonatal morbidity we calculated the incremental cost-effectiveness ratios, which represent the costs to prevent one of these adverse outcomes.

Mean costs per woman in the Foley catheter group (n = 411) and in the prostaglandin E₂ gel group (n = 408), were €3297 versus €3075, respectively, with an average difference of €222 (95% confidence interval −€157 to €633). In the Foley catheter group we observed higher costs due to longer labour ward occupation and less cost related to induction material and neonatal admissions. Foley catheter induction showed a comparable caesarean section rate compared with prostaglandin induction, therefore the incremental cost-effectiveness ratio was not informative. Foley induction resulted in fewer neonatal admissions (incremental cost-effectiveness ratio €2708) and asphyxia/postpartum haemorrhage (incremental cost-effectiveness ratios €5257) compared with prostaglandin induction.

Foley catheter and prostaglandin E₂ labour induction generate comparable costs.

Two-year prospective cohort study with medical record review during the survey period, and for the subsequent 2 years.

Seven general practices with 67 100 registered patients.

All women aged 40–54 years on the practices age–sex registers.

Baseline postal questionnaire, with follow-up questionnaires sent to naturally menstruating respondents at 6, 12, 18 and 24 months. Medical record review using computerised searches from baseline to 48 months.

Prevalence and incidence of intermenstrual and postcoital bleeding, and rate of spontaneous resolution.

A total of 7121 baseline questionnaires were sent out, with an initial response rate of 66%. A total of 2104 naturally menstruating women were recruited for the prospective cohort study. The 2–year cumulative incidence of intermenstrual bleeding was 24% (95% CI 21–27%), and that of postcoital bleeding was 7.7% (95% CI 6.2–9.5%). The rates of spontaneous resolution without recurrence for 2 years were 37% (95% CI 29–45) and 51% (95% CI 40–62), respectively. Of the 785 women identified with intermenstrual and/or postcoital bleeding, only one developed uterine cancer.

There is a high prevalence, incidence, and spontaneous rate of resolution of intermenstrual and postcoital bleeding in naturally menstruating women during the perimenopausal years. The association of these symptoms with malignancy is weak. This is of importance to women in deciding when to consult and to those devising public health campaigns concerning symptoms of possible oncological significance.

Literature-based study.

N/A.

N/A.

Data for the calculations were taken from studies identified by PubMed searches. First, the differences in cardiovascular risk factors after pre-eclampsia compared with an uncomplicated pregnancy were estimated. Second, the effects of lifestyle interventions on cardiovascular risk were estimated. Validated risk prediction models were used to translate these results into cardiovascular risk.

After correction for known cardiovascular risk factors, the odds ratios of pre-eclampsia for ischaemic heart disease and for stroke are 1.89 (IQR 1.76–1.98) and 1.55 (IQR 1.40–1.71), respectively. After pre-eclampsia, lifestyle interventions on exercise, dietary habits, and smoking cessation decrease cardiovascular risk, with an odds ratio of 0.91 (IQR 0.87–0.96).

Cardiovascular risk factors do not fully explain the risk of cardiovascular disease after pre-eclampsia. The gap between estimated and observed odds ratios may be explained by an additive risk of cardiovascular disease by pre-eclampsia. Furthermore, lifestyle interventions after pre-eclampsia seem to be effective in decreasing cardiovascular risk. Future research is needed to overcome the numerous assumptions we had to make in our calculations.

Population-based cohort study.

Sweden.

A total of 941 841 Swedish women delivering their first child between 1987 and 2008.

Data from the Swedish Multigeneration Register were linked to the Swedish Hospital Discharge Register. The risk of PEC/EC was determined in primiparous women with a family history of VTE (in parents and/or siblings), compared with primiparous women without a family history of VTE. Odds ratios (ORs) were calculated by logistic regression.

PEC/EC in first pregnancy.

In total, 43 621 women had PEC/EC in association with their first pregnancy. The OR for PEC/EC in women with a family history of VTE was 1.06 (95% CI 1.01–1.11); however, a family history of VTE was associated with higher odds of PEC/EC among women with previous hypertension (OR 1.38, 95% CI 1.25–1.52).

A family history of VTE is weakly associated with PEC/EC risk, and is not clinically useful for the prediction of PEC/EC. The results of the present study suggest that it is unlikely that strong disease-causing mutations shared by VTE and PEC/EC are common in the Swedish population. The novel association between family history and PEC/EC among the subgroup with previous hypertension needs further confirmation in future studies.

Ten-year follow-up of a double-blind randomised controlled trial.

A teaching hospital in the Netherlands.

Premenopausal women suffering from heavy menstrual bleeding.

A follow-up questionnaire was sent to women 10 yearsafter randomisation for bipolar ablation and balloon ablation (2 : 1 ratio).

Amenorrhoea rates, re-intervention and patient satisfaction.

At 10 years of follow-up, the response rate was 69/83 (83%) in the bipolar group and 35/43 (81%) in the balloon group. Amenorrhoea rates were 50/69 (73%) in the bipolar group and 23/35 (66%) in the balloon group [relative risk, 1.1 (95% CI, 0.83–1.5)]. Further treatment following initial ablation was reported in 21 cases, 14 in the bipolar group and nine in the balloon group [relative risk, 0.9 (95% CI, 0.63–1.3)]. Eight of these women required further treatment after 5 years, including two hysterectomies. Patient satisfaction in the bipolar group was 81% (56/69) compared with 77% (27/35) in the balloon group [relative risk, 1.1 (95% CI, 0.82–1.2)].

Ten years after treatment, the superiority of bipolarablation over balloon ablation in the treatment of heavy menstrual bleeding was no longer evident.

Prospective cohort study.

Neuropsychological testing in four Danish cities, 2003–2008.

A total of 1628 women and their children sampled from the Danish National Birth Cohort.

Participants were sampled based on maternal alcohol drinking patterns during early pregnancy. When the children were 5 years of age the parent and teacher versions of the Strengths and Difficulties Questionnaire (SDQ) were completed by the mothers and a preschool teacher, respectively. The full statistical model included the following potential confounding factors: maternal binge drinking or low to moderate alcohol consumption, respectively; parental education; maternal IQ; prenatal maternal smoking; the child's age at testing; the child's gender; maternal age; parity; maternal marital status; family home environment; postnatal parental smoking; prepregnancy maternal body mass index (BMI); and the child's health status.

Behaviour among children assessed by the SDQ parent and teacher forms.

Adjusted for all potential confounding factors, no statistically significant associations were observed between maternal low to moderate average weekly alcohol consumption and SDQ behavioural scores (OR 1.1, 95% CI 0.5–2.3; OR 1.1, 95% CI 0.6–2.1 for the total difficulties scores) or between binge drinking and SDQ behavioural scores (OR 1.2, 95% CI 0.8–1.7; OR 0.8, 95% CI 0.6–1.2).

This study observed no consistent effects of low to moderate alcohol consumption or binge drinking in early pregnancy on offspring behaviour at the age of 5 years.

Data were collected as part of a randomised controlled trial to address intimate partner violence, depression, smoking, and environmental tobacco smoke exposure in African American women.

Prenatal care sites in the District of Columbia serving mainly women of minority background.

A cohort of 1044 African American pregnant women in the District of Columbia.

Mothers were classified by their initial response (acknowledgement of risks), and these data were updated during pregnancy. Risks were considered new if they were not previously reported. Standard hypothesis tests and logistic regression were used to predict the acknowledgment of any new risk(s) during pregnancy.

New risks: psychosocial variables to understand what factors might help identify the acknowledgement of additional risk(s).

Repeated screening identified more mothers acknowledging risk over time. Reported smoking increased by 11%, environmental tobacco smoke exposure increased by 19%, intimate partner violence increased by 9%, and depression increased by 20%. The psychosocial variables collected at the baseline that were entered into the logistic regression model included relationship status, education, Medicaid, illicit drug use, and alcohol use during pregnancy. Among these, only education less than high school was associated with the acknowledgement of new risk in the bivariate analyses, and significantly predicted the identification of new risks (OR 1.39, 95% CI 1.01–1.90).

It is difficult to predict early on who will acknowledge new risks over the course of pregnancy, and thus all women should be screened repeatedly to allow for the identification of risks and intervention during prenatal care.

Secondary analysis of data from a case–control study.

Thirty-nine general practices in Exeter, mid-Devon and east Devon.

Two hundred and twelve women with ovarian cancer and 1060 age-, sex- and practice-matched controls.

Conditional logistic regression was used to produce an additive scoring system and its receiver operator characteristic (ROC) curve. Several different cut-offs were then tested using a simple costs model.

The ROC curve value.

Each woman was assigned a score based on her symptoms in the year before diagnosis: we added a score for women aged ≥50 years, reflecting their increased incidence of ovarian cancer. The area under the ROC curve was 0.883 (95% confidence interval 0.853–0.912). The chosen cut-off had a sensitivity of 72.6% and a specificity of 91.3%.

This scoring system could potentially direct general practitioners to appropriate investigations for ovarian cancer on the basis of symptoms and save a substantial number of unnecessary ultrasound scans being requested.

Retrospective observational study.

Data were included from 1291 consecutive full-term, singleton cephalic births between 2 November 2006 and 30 November 2010 with malposition of the fetal head during the second stage of labour leading to an attempt to deliver by KF, RV or pEMCS.

Maternal and neonatal outcomes of all KF births were compared with other methods of operative birth for malposition in the second stage of labour (RV or pEMCS).

Achieving a vaginal birth was the primary outcome and fetal (admission to special care baby unit, low cord pH, low Apgar, shoulder dystocia, Erb's palsy) and maternal (massive obstetric haemorrhage—blood loss of >1500 ml, sphincter injury, length of stay in hospital) safety outcomes were also recorded.

Women were more likely to need caesarean section if RV (22.4%) was selected to assist the birth rather than KF (3.7%; adjusted odds ratio 8.20; 95% confidence interval 4.54–14.79). Births by KF had a rate of adverse maternal and neonatal outcomes comparable to those by RV and pEMCS in the second stage for malposition.

Our results suggest that, in experienced hands, assisted vaginal birth by KF is likely to be the most effective and safe method to prevent the ever rising rate of caesarean sections when malposition complicates the second stage of labour.

Single-centre cohort study.

Charing Cross Hospital, a UK national centre for the treatment of trophoblastic disease.

All women with a GTN FIGO score 5–6 treated with methotrexate (n = 92), between 1999 and 2011, at Charing Cross Hospital.

UAPI was measured before the start of chemotherapy, and women were monitored for the development of MTX-R.

Frequency of MTX-R in women with UAPI ≤1 compared with UAPI >1.

UAPI was measured before chemotherapy in 73 of 92 women with GTN FIGO score 5–6. UAPI ≤1 predicted MTX-R independent of the FIGO score (hazard ratio 2.9, P = 0.04), with an absolute risk of MTX-R in women with a UAPI ≤1 of 67% (95% CI 53–79%) compared with 42% (95% CI 24–61%) with a UAPI >1 (P = 0.036).

Our results suggest UAPI is an independent predictor of MTX-R in women with FIGO 5–6 GTN.

Predictive test accuracy study.

Prospective multicentre cohort study Screening for Pregnancy Endpoints (SCOPE).

Low-risk nulliparous women with a singleton pregnancy were recruited. Clinical risk factor data were obtained and plasma placental growth factor (PlGF), soluble endoglin and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured at 14–16 weeks of gestation. Prediction models were developed using multivariable stepwise logistic regression.

Preterm pre-eclampsia (delivered before 37⁺⁰ weeks of gestation).

Of the 3529 women recruited, 187 (5.3%) developed pre-eclampsia of whom 47 (1.3%) delivered preterm. Controls (n = 188) were randomly selected from women without preterm pre-eclampsia and included women who developed other pregnancy complications. An area under a receiver operating characteristic curve (AUC) of 0.76 (95% CI 0.67–0.84) was observed using previously reported clinical risk variables. The AUC improved following the addition of PlGF measured at 14–16 weeks (0.84; 95% CI 0.77–0.91), but no further improvement was observed with the addition of uterine artery Doppler or the other angiogenic markers. A sensitivity of 45% (95% CI 0.31–0.59) (5% false-positive rate) and post-test probability of 11% (95% CI 9–13) were observed using clinical risk variables and PlGF measurement.

Addition of plasma PlGF at 14–16 weeks of gestation to clinical risk assessment improved the identification of nulliparous women at increased risk of developing preterm pre-eclampsia, but the performance is not sufficient to warrant introduction as a clinical screening test. These findings are marker dependent, not assay dependent; additional markers are needed to achieve clinical utility.

Case–control study.

Iowa Health in Pregnancy Study (IHIPS), a population-based case–control study of preterm and small-for-gestational-age (SGA) live birth outcomes (from May 2002 through June 2005) in the USA.

Women with an intended pregnancy and a history of either one prior cervical surgery (n = 152), colposcopy only (n = 151), or no prior cervical surgery or colposcopy (n = 1021).

Cervical treatment history, pregnancy intention, time to pregnancy, and other variables were self-reported by computer-assisted telephone interviews. Odds ratios were calculated using logistic regression to estimate the risk of prolonged time to pregnancy among women with a history of cervical surgery or colposcopy alone, compared with untreated women (control group).

Prolonged time to pregnancy (i.e. >1 year).

Prolonged time to pregnancy was most prevalent among treated women (16.4%), compared with untreated women (8.4%) and women with colposcopy only (8.6%) (P = 0.039). After adjusting for covariates, women with prior cervical surgery had a more than two-fold higher risk of prolonged time to pregnancy compared with untreated women (aOR 2.09, 95% CI 1.26–3.46). In contrast, women with a history of colposcopy only had a risk equivalent to that found among untreated women (aOR 1.02, 95% CI 0.56–1.89).

Women with a history of cervical treatment for CIN are at increased risk of subfertility, measured as a time to pregnancy of more than 12 months.

Cohort study.

Norwegian population.

A total of 90 417 women and singleton child pairs.

The Norwegian Mother and Child Cohort Study and Medical Birth Registry of Norway data sets were used.

Infant survival, congenitalmalformations, structural heart defects, neonatal complications, haemorrhage during pregnancy and postpartum, asthma at age of 18 months.

One or more of the four nonsteroidal anti-inflammatory drugs (NSAIDs) were used by 6511 pregnant women (7.2%). No effect on rates of infant survival, congenital malformation, or structural heart defects was found. The use of ibuprofen in the second trimester was significantly associated with low birthweight (adjusted OR 1.7, 95% CI 1.3–2.3), and ibuprofen use in the second and third trimesters was significantly associated with asthma in 18–month—old children (adjusted OR 1.5, 95% CI 1.2–1.9; adjusted OR 1.5, 95% CI 1.1–2.1). The use of diclofenac in the second trimester was significantly associated with low birthweight (adjusted OR 3.1, 95% CI 1.1–9.0), whereas diclofenac use in the third trimester was significantly associated with maternal vaginal bleeding (adjusted OR 1.8, 95% CI 1.1–3.0). No associations with other neonatal complications were found.

The lack of associations with congenital malformations is reassuring. The significant association between diclofenac and ibuprofen use late in pregnancy, and maternal bleeding and asthma in the child, respectively, is consistent with their pharmacological effects. The increased risk of low birthweight may partly have been caused by underlying inflammatory conditions, and was reassuringly similar to the expected baseline risk of low birthweight.

A prospective cohort study.

Rural Ethiopian highlands.

A total of 294 pregnant women at 32 weeks or more of gestation.

Before being provided with individualised risk advice, women were asked about their birth plans, and in particular, their planned delivery place. Those identified as being at risk of a complicated delivery were followed up to find out whether they altered their birth plans.

A change in birthplace.

Women identified as being at high risk of a complicated delivery significantly changed their plans (P < 0.01), with 34 (89%) women delivering in hospital. Women with a medium risk did not significantly change their birth plans (P = 0.082), with 35 (36%) delivering at home. Women with a high parity were less likely to change their birth plans compared with primigravid women (odds ratio 0.53; 95% confidence interval 0.34–0.83) and high-risk women were more likely to change their plans compared with medium-risk women (odds ratio 6.2; 95% confidence interval 1.8–21.6).

Providing simple, individualised advice about the risks of a complicated delivery leads to high-risk women delivering in hospital. Embedding this into the current antenatal care system in Ethiopia could significantly decrease maternal mortality.

Retrospective cohort study.

Three tertiary referral hospitals in the Netherlands.

Formerly pre-eclamptic women.

The presence or absence of metabolic syndrome was assessed in 480 women at least 6 months after their first pre-eclamptic pregnancy using World Health Organization criteria. We compared the prevalence of recurrent pre-eclampsia in the subsequent pregnancy, calculating odds ratios (OR), adjusted for confounders.

Recurrence of pre-eclampsia in the subsequent pregnancy.

Subsequent pregnancy outcome data were available for 197 women. Forty women had metabolic syndrome after previous pregnancy (20%). The prevalence of recurrent pre-eclampsia was 18/40 (45%) in women with metabolic syndrome versus 27/157 (17%) in women without metabolic syndrome; OR 3.94 (95% confidence interval [CI] 1.86–8.33, adjusted OR 3.77 (95% CI 1.61–8.81). The risk of recurrent pre-eclampsia increased with each extra component of the metabolic syndrome from 11.8% for absent components up to 43.9% for three or more (P for trend < 0.001).

Interpregnancy metabolic syndrome predisposes to recurrent pre-eclampsia.

Cross-sectional survey conducted from December 2011 to April 2012.

Muhimbili National Hospital antenatal clinic in Dar es Salaam, Tanzania.

1180 pregnant antenatal care patients.

Trained interviewers conducted face-to-face standardised interviews with the women in a private room prior to their antenatal care appointment. (PTSD), anxiety and depressive symptoms were assessed through the Conflict Tactics Scale, the John Hopkins Symptom Checklist (25) and the Posttraumatic Diagnostic Scale.

The Conflict Tactics Scale, the John Hopkins Symptom Checklist (25) and the Posttraumatic Diagnostic Scale.

Of the 1180 women who were interviewed, 27% reported experiencing both physical and sexual intimate partner violence in the index pregnancy, with 18% reporting physical violence and 20% reporting sexual violence. After adjusting for the sociodemographic characteristics of women, women who experienced physical and/or sexual intimate partner violence during pregnancy were significantly more likely to have moderate PTSD (AOR 2.94, 95% CI 1.71–5.06), anxiety (AOR 3.98, 95% CI 2.85–5.57) and depressive (AOR 3.31, 95% CI 2.39–4.593) symptoms than women who did not report physical and/or sexual intimate partner violence during pregnancy.

About three out of ten women experienced physical or sexual intimate partner violence during pregnancy by an intimate partner, which was significantly associated with poor mental health symptoms. These rates are alarming, and justify training and education of antenatal care providers to raise awareness.

Longitudinal prospective cohort study embedded within a two-centre randomised controlled trial (RCT).

Two UK tertiary-level maternity units.

Antenatally recruited participants of an RCT of restrictive versus routine use of episiotomy at OVD.

A self-completing questionnaire was administered antenatally, before hospital discharge, at 6 weeks and at 1 year postpartum.

Urinary and anal incontinence, dyspareunia, perineal pain and psychological morbidity.

Longitudinal data have revealed that morbidities historically associated with OVD were often as prevalent, if not more prevalent, in the third trimester of pregnancy than postpartum. Restrictive episiotomy use was associated with: a higher incidence of perineal pain in the immediate postpartum period (98.9% restrictive versus 87.8% routine, RR 1.10, 95% CI 1.01–1.21); greater psychological morbidity in the immediate postpartum period (mean scores on the Edinburgh Postnatal Depression Scale, Edinburgh Postnatal Depression Score (EPDS) 6.7 restrictive versus 5.1 routine; P = 0.01 ); and more stress urinary incontinence at 6 weeks postpartum (42.2% restrictive versus 27.2% routine, RR 1.55, 95% CI 1.00–2.40); however, this had resolved by 1 year. No other differences were found between the groups at 6 weeks and 1 year postpartum.

Morbidities previously attributed to OVD may in fact be present antenatally, to a greater or similar degree. A restrictive approach to the use of episiotomy at OVD may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.

A nested case–control study of change in maternal plasma soluble Flt-1 (sFlt-1), soluble endoglin (sEng) and placenta growth factor (PlGF). We studied 158 pregnancies complicated by pre-eclampsia and 468 normotensive nonproteinuric controls.

A multicentre study in 16 academic medical centres in the USA.

Low-risk nulliparous women.

Luminex assays for PlGF, sFlt-1 and sEng performed on maternal EDTA plasma collected at 9–12, 15–18 and 23–26 weeks of gestation. Rate of change of analyte between first and either early or late second trimester was calculated with and without adjustment for baseline clinical characteristics.

Change in PlGF, sFlt-1 and sEng.

Rates of change of PlGF, sEng and sFlt-1 between first and either early or late second trimesters were significantly different in women who developed pre-eclampsia, severe pre-eclampsia or early-onset pre-eclampsia compared with women who remained normotensive. Inclusion of clinical characteristics (race, body mass index and blood pressure at entry) increased sensitivity for detecting severe and particularly early-onset pre-eclampsia but not pre-eclampsia overall. Receiver operating characteristics curves for change from first to early second trimester in sEng, PlGF and sFlt-1 with clinical characteristics had areas under the curve of 0.88, 0.84 and 0.86, respectively, and for early-onset pre-eclampsia with sensitivities of 88% (95% CI 64–99), 77% (95% CI 50–93) and 77% (95% CI 50–93) for 80% specificity, respectively. Similar results were seen in the change from first to late second trimester.

Change in angiogenic biomarkers between first and early second trimester combined with clinical characteristics has strong utility for predicting early-onset pre-eclampsia.

Prospective, blinded, non-interventional cohort.

Urban teaching hospital.

Morbidly obese women.

Endometrial biopsies were obtained at the time of Roux–en–Y gastric bypass and again 1 year later. Both the patient and the physician were blinded to the results of the initial biopsy until the conclusion of the study. Specimens were independently reviewed by two blinded pathologists.

Effect of bariatric surgery-induced weight loss on the prevalence of endometrial pathology at 1 year.

Fifty-nine women underwent an endometrial biopsy during bariatric surgery. The mean (range) age, weight, and body mass index (BMI) were 42 years (22–62 years), 127 kg (87–176 kg), and 46.8 kg/m² (36–64.3 kg/m²), respectively. Four women had hyperplasia (three simple and one complex), for an overall prevalence of 6.8%. The prevalence among women not receiving some anti-estrogen therapy was 9.5%. Forty-six women (78%) underwent follow-up biopsy after a mean (range) weight loss of 42 kg (19–67 kg). Simple hyperplasia was identified in 3/46 women at the 1–year follow-up (6.5%). Two women had resolution of hyperplasia, two women had persistent, simple hyperplasia, and one had had a normal initial biopsy. No woman showed progressive pathology or cancer. At the end of the follow-up all but one patient had a documented resolution of endometrial pathology.

Asymptomatic morbidly obese women are at relatively high risk of harbouring occult endometrial hyperplasia. Bariatric surgery-associated weight loss reduced but did not eliminate this risk for endometrial pathology.

To conduct a systematic review to assess the risk of venous thromboembolism (VTE), myocardial infarction (MI), and stroke in individuals taking drospirenone-containing OCPs.

We systematically searched CINAHL, the Cochrane Library, Dissertation & Abstracts, EMBASE, HealthStar, Medline, and the Science Citation Index from inception to November 2012.

We included all case reports, observational studies, and experimental studies assessing the risk of venous and arterial thrombosis of drospirenone-containing OCPs.

Data were collected independently by two reviewers.

A total of 22 studies [six case reports, three case series (including 26 cases), and 13 comparative studies] were included in our systematic review. The 32 identified cases suggest a possible link between drospirenone-containing OCPs and venous and arterial thrombosis. Incidence rates of VTE among drospirenone-containing OCP users ranged from 23.0 to 136.7 per 100 000 woman-years, whereas those among levonorgestrel-containing OCP users ranged from 6.64 to 92.1 per 100 000 woman-years. The rate ratio for VTE among drospirenone-containing OCP users ranged from 4.0 to 6.3 compared with non-users of OCPs, and from 1.0 to 3.3 compared with levonorgestrel-containing OCP users. The arterial effects of drospirenone-containing OCPs were inconclusive.

Our systematic review suggests that drospirenone-containing OCP use is associated with a higher risk for VTE than both no OCP use and levonorgestrel-containing OCP use.

This review and meta-analysis sought to determine if maternal asthma is associated with an increased risk of adverse neonatal outcomes.

We searched electronic databases for: (asthma or wheeze) and (pregnan* or perinat* or obstet*).

Cohort studies published between 1975 and March 2012 reporting at least one perinatal outcome of interest (congenital malformations, neonatal complications, perinatal mortality).

In all, 21 studies met inclusion criteria in pregnant women with and without asthma. Further analysis was conducted on 16 studies where asthmatic women were stratified by exacerbation history, corticosteroid use, bronchodilator use or asthma severity.

Maternal asthma was associated with a significantly increased risk of congenital malformations (relative risk [RR] 1.11, 95% confidence interval [95% CI] 1.02–1.21, I² = 59.5%), cleft lip with or without cleft palate (RR 1.30, 95% CI 1.01–1.68, I² = 65.6%), neonatal death (RR 1.49, 95% CI 1.11–2.00, I² = 0%), and neonatal hospitalisation (RR 1.50, 95% CI 1.03–2.20, I² = 64.5%). There was no significant effect of asthma on major malformations (RR 1.31, 95% CI 0.57–3.02, I² = 70.9%) or stillbirth (RR 1.06, 95% CI 0.9–1.25, I² = 35%). Exacerbations and use of bronchodilators and inhaled corticosteroids were not associated with congenital malformation risk.

Despite limitations related to the observational nature of the primary studies, this review demonstrates a small increased risk of neonatal complications among pregnant women with asthma. Further investigations into mechanisms and potential preventive interventions to improve infant outcomes are required.

Prospective pregnancy cohort study of nulliparous women.

Melbourne, Australia.

A total of 1507 nulliparous women recruited in early pregnancy (≤24 weeks).

Women were recruited from six public hospitals. Data from hospital records and self-administered questionnaires at recruitment and 3, 6 and 12 months postpartum were analysed using univariable and multivariable logistic regression.

Resumption of vaginal sex.

Sexual activity was resumed earlier than vaginal sex, with 53% resuming sexual activity by 6 weeks postpartum, and 41% attempting vaginal sex. By 8 weeks a majority of women had attempted vaginal sex (65%), increasing to 78% by 12 weeks, and 94% by 6 months. Compared with women who had a spontaneous vaginal birth with an intact perineum, women who had a spontaneous vaginal birth with an episiotomy (adjusted odds ratio 3.43, 95% confidence interval 1.9–6.2) or sutured perineal tear (adjusted odds ratio 3.18, 95% confidence interval 2.1–4.9) were more likely not to have resumed vaginal sex by 6 weeks postpartum. Similarly, women who had an assisted vaginal birth or caesarean section had raised odds of delaying resumption of sex.

Most women having a first birth do not resume vaginal sex until later than 6 weeks postpartum. Women who have an operative vaginal birth, caesarean section or perineal tear or episiotomy appear to delay longer.

Population-based cohort study.

The Medical Birth Registry of Norway from 1967 to 2008.

All singleton, vertex-presenting infants weighing 500 g or more. Through linkage by national identification numbers, 393 856 mother–daughter pairs, 264 675 mother–son pairs, 134 889 mothers whose sisters later became mothers, 132 742 fathers whose brothers later became fathers, 131 702 mothers whose brothers later became fathers and 88 557 fathers whose sisters later became mothers were provided.

Comparison of women with and without a history of OASIS in their relatives.

Relative risk of OASIS after a previous OASIS in the family.

The risk of OASIS was increased if the woman's mother or sister had OASIS in a delivery (aRR 1.9, 95% CI 1.6–2.3; aRR 1.7, 95% CI 1.6–1.7, respectively). If OASIS occurred in one brother's partner at delivery, the risk of OASIS in the next brother's partner was modestly increased (aRR 1.2, 95% CI 1.1–1.4). If OASIS occurred in one sister at delivery, the risk of OASIS in the brother's partner was also increased a little (aRR 1.2, 95% CI 1.1–1.4). However, there was no excess occurrence in sisters whose brothers' partners had previously had OASIS (aRR 1.1, 95% CI 0.9–1.3).

There appears to be increased familial aggregation of OASIS. These risks are stronger through the maternal rather than the paternal line of transmission, suggesting a strong genetic role that shapes aggregation of OASIS within families. These observations must be cautiously interpreted because of bias from unmeasured confounding factors may have impacted the findings.

Descriptive, a part of the prospective longitudinal ‘Swedish study on gamete donation’.

All university clinics in Sweden performing gamete donation.

A consecutive sample of 214 lesbian couples requesting assisted reproduction, 165 of whom participated.

Participants individually completed three study-specific questionnaires and the Hospital Anxiety and Depression Scale (HADS): time point 1 (T1), at commencement of ART; time point 2 (T2), approximately 2 months after treatment; and time point 3 (T3), 2–5 years after first treatment.

Anxiety and depression (HADS), pregnancy outcome and future reproductive plans.

The vast majority of lesbian women undergoing assisted reproduction reported no symptoms of anxiety and depression at the three assessment points. A higher percentage of the treated women, compared with the partners, reported symptoms of anxiety at T2 (14% versus 5%, P = 0.011) and T3 (10% versus 4%, P = 0.018), as well as symptoms of depression at T2 (4% versus 0%, P = 0.03) and T3 (3% versus 0%, P = 0.035). The overall pregnancy outcome was high; almost three-quarters of lesbian couples gave birth 2–5 years after sperm donation treatments. Open-ended comments illustrated joy and satisfaction about family building.

Lesbian women in Sweden reported good psychological health before and after treatment with donated sperm.

Retrospective analysis.

The Dutch referral centre for fetal therapy.

IUTs for fetal alloimmune anaemia.

Fetuses were divided into two groups: fetuses requiring the first IUT before 20 weeks of gestation (Group 1) and those in which the IUTs started after 20 weeks (Group 2). The cause of perinatal loss was classified as procedure-related (PR) or not procedure-related (NPR). The cohort was divided into two periods to describe the change of perinatal loss over time.

Perinatal loss of fetuses requiring the first IUT before 20 weeks of gestation, compared with perinatal loss later in gestation.

A total of 1422 IUTs were performed in 491 fetuses. Perinatal loss rate in Group 1 was higher (7/29 24% versus 35/462 8%, P = 0.002). Especially NPR was higher for IUTs performed before 20 weeks (4/37 11% versus 19/1385 1%, P < 0.001). Kell alloimmunisation was overrepresented in Group 1 (7/29 24% versus 52/462 11%, P = 0.04). In a multivariate regression analysis, only hydrops was independently associated with perinatal loss (P = 0.001). In recent years, a decline in total perinatal loss was found (36/224 16% versus 6/267 2%, P < 0.001), but perinatal loss in Group 1 did not decline (4/224 1.8% versus 3/267 1.1%, P = 0.5).

Perinatal loss after IUT performed before 20 weeks of gestation is increased compared with loss after IUT performed later in gestation. In addition, we confirmed earlier observations that hydrops is a major contributor to adverse outcome. Early and timely detection and treatment may prevent hydrops and improve outcome.

Population-based retrospective cohort study.

British Columbia, Canada, 2001–2009.

All women with live births or stillbirths.

Detailed clinical information was obtained for 371 193 women from the British Columbia Perinatal Data Registry. Outcomes of interest were atonic PPH and severe atonic PPH (atonic PPH with blood transfusion ≥1 unit; atonic PPH with blood transfusion ≥3 units or procedures to control bleeding), whereas determinants studied included maternal characteristics (e.g. age, parity, and body mass index) and obstetrics practice factors (e.g. labour induction, augmentation, and caesarean delivery). Year-specific unadjusted and adjusted odds ratios for the outcomes were compared using logistic regression.

Atonic PPH and severe atonic PPH.

Atonic PPH increased from 4.8% in 2001 to 6.3% in 2009, atonic PPH with blood transfusion ≥1 unit increased from 16.6 in 2001 to 25.5 per 10 000 deliveries in 2009, and atonic PPH with blood transfusion ≥3 units or procedures to control bleeding increased from 11.9 to 17.6 per 10 000 deliveries. The crude 34% (95% CI 26–42%) increase in atonic PPH between 2001 and 2009 remained unchanged (42% increase, 95% CI 34–51%) after adjustment for determinants of PPH. Similarly, adjustment did not explain the increase in severe atonic PPH.

Changes in maternal characteristics and obstetric practice do not explain the recent increase in atonic and severe atonic PPH.

Historical cohort study.

Utah, USA.

Women who had their first three singleton live births in Utah between 1989 and 2007 and a preterm first or second birth were included.

Maternally linked birth records were used. Multivariable-adjusted risk ratios were calculated for recurrent PTB. Results were stratified by spontaneous and indicated PTB and by pattern of birth outcomes.

Risk ratios and 95% confidence intervals for risk factors for recurrent PTB.

Among women with PTB in their first or second live birth, recurrent PTB occurred in 21% of second live births (n = 1011/4805) and 22% of third live births (n = 1872/8468). Risk factors for recurrence included short inter-pregnancy interval, underweight prepregnancy body mass index, pre-existing maternal medical conditions, history of PTB at 28–32 weeks of gestation (versus 33–36 weeks), the presence of a fetal anomaly, and young maternal age. Risk factors for spontaneous, but not indicated PTB included young maternal age and less than appropriate gestational weight gain. Risk factors also varied in women experiencing a first versus second recurrence in their third birth.

Risk factors may vary by the clinical subtype of the most recent PTB and the pattern of term and preterm outcomes across births 1–3; some of the risk factors identified in this study may be modifiable through interventions targeted at women in the inter-conception period.

Retrospective review of cumulative reporting to the UK confidential haemovigilance scheme, Serious Hazards of Transfusion (SHOT), between 1996 and 2011.

Obstetric departments in the UK.

Mothers who require anti-D immunoglobulin to prevent RhD sensitisation during pregnancy or after birth.

Hospital transfusion teams reported adverse events to the SHOT database.

Reported number of events and their causes, and morbidity and mortality associated with errors.

In 15 years of reporting, SHOT haemovigilance has shown a total of 1211 errors related to the administration of anti-D immunoglobulin, particularly regarding omission or late administration (157/249 or 63% reported in 2011). Anti-D immunoglobulin errors comprised 13.7% (249/1815) of all SHOT reports in 2011. Failure to recognise women who already have RhD sensitisation occurred in 19 cases, and was followed by suboptimal monitoring of the pregnancy. Nine of the infants suffered haemolytic disease of the fetus and newborn (HDFN): one resulted in neonatal death and three required red cell transfusion.

Babies as well as their mothers remain at risk from avoidable errors. More active attention at national and local levels to further education and training, particularly for midwives, is an absolute necessity. We recommend the use of a SHOT-devised anti-D administration flowchart, adapted locally into a checklist, to help reduce errors.

Retrospective matched case–control study, employing variable matching.

Tertiary referral centre between 1993 and 2008.

Sixty-five cases and 102 controls were used for the analysis from a total of 82 667 births during the study period.

Relevant data were abstracted from clinical records. Matching of cases with controls was based on co-existing placenta praevia, number of previous caesarean sections, and age, with one or two controls per case. Results are presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).

Placenta accreta in a pregnancy complicated by placenta praevia following a primary elective or emergency caesarean section, and morbidity associated with pregnancies complicated by placenta accreta.

Significantly more cases than controls had an elective caesarean section for their primary caesarean delivery (46.2 versus 18.6%; P < 0.001). There were no differences between groups for previous pregnancy loss, uterine surgery, and vaginal delivery, before or after the primary caesarean section. Compared with primary emergency caesarean section, primary elective caesarean section significantly increased the risk of placenta accreta in a subsequent pregnancy in the presence of placenta praevia (OR 3.00; 95% CI 1.47–6.12; P = 0.025).

Our results suggest that women with a primary elective caesarean section without labour are more likely, compared with those undergoing primary emergency caesarean section with labour, to develop an accreta in a subsequent pregnancy with placenta praevia.

Retrospective observational study.

Northern Gynaecological Oncology Centre, Gateshead, UK.

A total of 100 women with histologically-proven HG VaIN.

Review of patient records from 1995 to 2011.

Rates of progression to cancer, treatment remission, and disease recurrence, particularly post-treatment when vaginoscopy is normal but cytology is abnormal.

Of 100 women referred, 69 underwent initial treatment of whom 47 (68%) went into remission: of these, seven developed a recurrence after a median follow-up of 29 months (range 15–214 months). Of the 31 women managed conservatively with cytological and vaginoscopic surveillance, no cancers developed after a median follow-up of 35 months (range 2–230 months). Rate of overall progression to cancer was 3% and all were detected among the initial treatment group after a median of 59 months (range 8–249 months). Post-treatment, when normal vaginoscopy was accompanied by abnormal cytology, two categories existed. Of 24 cases with low-grade cytological abnormality, recurrence of HG VaIN occurred in seven (29%) after a median follow-up of 12 months (range 2–110 months). Of 19 cases with HG cytological abnormality, 15 (79%) developed recurrence at a median follow-up of 7 months (range 2–21 months), giving a hazard ratio 5.6 (95% confidence interval 2.0–15.5, P = 0.001).

It is possible to select women with HG VaIN for conservative surveillance with excellent results. The majority of women undergoing initial treatment will enter remission. Post-treatment, if cytological abnormality develops in the presence of normal vaginoscopy, the majority of women will develop histological HG VaIN recurrence.

Low-resource obstetric hospitals in Nagpur and Vellore, India.

Pregnant women at risk for eclampsia due to hypertensive disease.

A pharmacokinetic study was performed as part of a randomised trial that enrolled 300 women comparing intramuscular and intravenous maintenance regimens of magnesium dosing. Data from 258 enrolled women were analysed in the pharmacokinetic study. A single sample was drawn per woman with the expectation of using samples in a pooled data analysis.

Pharmacokinetic parameters of magnesium distribution and clearance.

Magnesium clearance was estimated to be 48.1 dl/hour, volume of distribution to be 156 dl and intramuscular bioavailability to be 86.2%. The intramuscular regimen produced higher initial serum concentrations, consistent with a substantially larger loading dose. At steady state, magnesium concentrations in the intramuscular and intravenous groups were comparable. With either regimen, a substantial number of women would be expected to have serum concentrations lower than those generally held to be therapeutic.

Clinical implications were that a larger loading dose for the intravenous regimen should be considered; where feasible, individualised dosing of magnesium sulphate would reduce the variability in serum concentrations and might result in more women with clinically effective magnesium concentrations; and lower dose magnesium suphate regimens should be considered with caution.