Showing papers in "Acta Obstetricia et Gynecologica Scandinavica in 2017"

Progesterone resistance in endometriosis: origins, consequences and interventions

Abstract: Endometriosis is a common cause of pelvic pain and affects up to 10% of women of reproductive age. Aberrant progesterone signaling in the endometrium plays a significant role in impaired decidualization and establishment of ectopic endometrial implants. Eutopic endometrial cells from women with endometriosis fail to downregulate genes needed for decidualization, such as those involved in cell cycle regulation, leading to unbridled proliferation. Several causes of progesterone resistance in the endometrium have been postulated, including congenital "preconditioning", whereby the in utero environment renders infants susceptible to neonatal uterine bleeding and endometriosis. Progesterone action is crucial to decreasing inflammation in the endometrium, and deviant progesterone signaling results in a proinflammatory phenotype. Conversely, chronic inflammation can induce a progesterone-resistant state. Repetitive retrograde endometrial shedding begets chronic peritoneal inflammation, which further exacerbates progesterone resistance. Genetic causes of progesterone resistance include progesterone receptor gene polymorphisms, altered microRNA expression, and epigenetic modifications to progesterone receptors and their targets. Environmental toxins such as dioxin play a possible role in the genesis of endometriosis by permitting an inflammatory milieu. A consequence of impaired progesterone action is that hormonal therapy is rendered ineffective for a subset of women with endometriosis. Synthetic progestins, such as dienogest, may overcome this phenomenon by increasing progesterone receptor expression and decreasing proinflammatory cytokines. Other modalities include high dose depot formulations of progestins, medicated intrauterine devices and the likely advent of oral GnRH antagonists. Unearthing root causes of progesterone inaction in endometriosis will aid in the development of novel therapeutics geared toward prevention and treatment.

Endometriosis-associated infertility: aspects of pathophysiological mechanisms and treatment options

Abstract: Endometriosis is a common condition in women of reproductive age. In addition to pain, endometriosis may also reduce fertility. The causes of infertility in women with endometriosis may range from anatomical distortions due to adhesions and fibrosis to endocrine abnormalities and immunological disturbances. In some cases, the various pathophysiological disturbances seem to interact through mechanisms so far not fully understood. Whether surgery should be offered as a treatment option in endometriosis-associated infertility has become controversial, partly due to its modest or undocumented effect. Medical or hormonal treatment alone has little or no effect and should only be used in conjunction with assisted reproductive technology (ART). Of the various methods of ART, intrauterine insemination, due to its simplicity, can be recommended in women with minimal or mild peritoneal endometriosis, even though insemination may yield a lower success rate than in women without endometriosis. In vitro fertilization (IVF) is an effective treatment option in less-advanced disease stages, and the success rates are similar to the results in other causes of infertility. However, women with more advanced stages of endometriosis have lower success rates with IVF.

Worldwide prevalence of tocophobia in pregnant women: systematic review and meta‐analysis

Abstract: Introduction Tocophobia is defined as a severe fear of pregnancy and childbirth. There is increasing evidence that tocophobia may have short‐term and long‐term adverse effects on mother and baby. We performed a systematic review and meta‐analysis to determine the global prevalence of tocophobia in pregnancy. Material and methods Relevant articles were identified through searching six relevant databases: MEDLINE, CINAHL, Pubmed, PsycINFO, Maternity & Infant Care and Scopus between 1946 and April 2016. We used search terms for tocophobia prevalence in pregnant women that we agreed on with a medical librarian. There were no language restrictions. Two review authors independently assessed data for inclusion, extracted data and assessed quality using a standardized appraisal tool. Meta‐analysis was performed to determine the overall pooled‐prevalence of tocophobia. Several subgroup and sensitivity analyses were conducted. Results Thirty‐three studies were included in the systematic review from 18 countries of which data from 29 studies were used in the meta‐analysis of 853 988 pregnant women. Definition of tocophobia varied, whereas prevalence rates ranged between 3.7 and 43%. The overall pooled prevalence of tocophobia, using a random‐effects model, was 14% (95% CI 0.12–0.16). Significant heterogeneity was observed (I2 = 99.25%, p = 0.00), which was not explained in subgroup analyses including tocophobia definition used, screening trimester and parity. Conclusion The prevalence of tocophobia is estimated at 14% and appears to have increased in recent years (2000 onwards). Considerable heterogeneity (99.25%) was noted that may be attributed to lack of consensus on the definition of tocophobia, so our results should be interpreted with caution.

Exercise during pregnancy and risk of gestational hypertensive disorders: a systematic review and meta-analysis

Abstract: Introduction Gestational hypertensive disorders, including gestational hypertension and preeclampsia, are one of the leading causes of maternal morbidity and mortality. The aim of our study was to evaluate the effect of exercise during pregnancy on the risk of gestational hypertensive disorders. Material and methods Electronic databases were searched from their inception to February 2017. Selection criteria included only randomized controlled trials of uncomplicated pregnant women assigned before 23 weeks to an aerobic exercise regimen or not. The summary measures were reported as relative risk with 95% confidence intervals. The primary outcome was the incidence of gestational hypertensive disorders, defined as either gestational hypertension or preeclampsia. Results Seventeen trials, including 5075 pregnant women, were analyzed. Of them, seven contributed data to quantitative meta-analysis for the primary outcome. Women who were randomized in early pregnancy to aerobic exercise for about 30–60 min two to seven times per week had a significant lower incidence of gestational hypertensive disorders (5.9% vs. 8.5%; relative risk 0.70, 95% confidence interval 0.53–0.83; seven studies, 2517 participants), specifically a lower incidence of gestational hypertension (2.5% vs. 4.6%; relative risk 0.54, 95% confidence interval 0.40–0.74; 16 studies, 4641 participants) compared with controls. The incidence of preeclampsia (2.3% vs. 2.8%; relative risk 0.79, 95% confidence interval 0.45–1.38; six studies, 2230 participants) was similar in both groups. The incidence of cesarean delivery was decreased by 16% in the exercise group. Conclusions Aerobic exercise for about 30–60 min two to seven times per week during pregnancy, as compared with being more sedentary, is associated with a significantly reduced risk of gestational hypertensive disorders overall, gestational hypertension, and cesarean delivery.

Prevalence of urinary incontinence among women and analysis of potential risk factors in Germany and Denmark

Abstract: Introduction Urinary incontinence (UI) is a prevalent condition that interferes with women's health-related quality of life. Prevalence rates from earlier studies are wide-ranging, due to heterogeneity in methodology, definition of UI and the populations included. We aimed to determine the prevalence of UI and associated risk factors in Germany and Denmark using the same methodology, definition and population. Material and methods A postal survey was conducted in two regions in Germany and Denmark, including 8000 women aged 18+ years. UI was defined as any complaint of involuntary loss of urine. The questionnaire contained socio-demographic questions and the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF). Results The response rate in Germany and Denmark was 46.2 and 66.6% (p < 0.001) and the prevalence rate of UI was 48.3 and 46.4% (p = 0.188), respectively. Stress urinary incontinence dominated among younger women, and urgency urinary incontinence and mixed urinary incontinence among women 80+ years in Germany and Denmark, respectively. The subgroup of women with body mass index (BMI) ≥35 had the highest prevalence of UI (67.3%). The subgroup of women with BMI <35 were more likely to have stress urinary incontinence, and the subgroup of women with BMI ≥35 were more likely to have mixed urinary incontinence. UI was significantly associated with age as with BMI, vaginal delivery, chronic obstructive pulmonary disease, and having at least one co-morbidity. Conclusions Prevalence rates in the two regions in Germany and Denmark were similar, despite significantly different response rates. This difference may reflect various attitudes towards answering a questionnaire, but the response rate on questions concerning UI seemed consistent.

Exercise during pregnancy and risk of preterm birth in overweight and obese women: a systematic review and meta-analysis of randomized controlled trials.

Abstract: Introduction The incidence of overweight and obesity in pregnancy has risen significantly in the last decades. Overweight and obesity have been shown to increase the risk for some adverse obstetric outcomes. Lifestyle interventions, such as diet, physical activity and behavior changes, may reduce these risks by promoting weight loss and/or preventing excessive weight gain. The possible impact of exercise on the risk of preterm birth (PTB) in overweight or obese women is controversial. Therefore, the aim of our study was to evaluate the effect of exercise on the risk of PTB in overweight or obese pregnant women. Material and methods MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library were searched from their inception to November 2016. This meta-analysis included only randomized controlled trials (RCTs) of pregnant women assigned or not assigned before 25 weeks to an aerobic exercise regimen. Types of participants included overweight or obese (mean body mass index ≥25 kg/m2) women with singleton pregnancies without any contraindication to physical activity. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI). The primary outcome was the incidence of PTB <37 weeks. Results Nine trials including 1502 overweight or obese singleton gestations were analyzed. Overweight and obese women who were randomized in early pregnancy to aerobic exercise for about 30–60 min three to seven times per week had a lower percentage of PTB <37 weeks (RR 0.62, 95% CI 0.41–0.95) compared with controls. The incidence of gestational age at delivery (MD 0.09 week, 95% CI −0.18 to 0.24) and cesarean delivery (RR 0.93, 95% CI 0.77–1.10) were similar in both groups. Women in the exercise group had a lower incidence of gestational diabetes mellitus (RR 0.61, 95% CI 0.41–0.90) compared with controls. No differences in birthweight (MD 16.91 g, 95% CI −89.33 to 123.19), low birthweight (RR 0.58, 95% CI 0.25–1.34), macrosomia (RR 0.92, 95% CI 0.72–1.18) and stillbirth (RR 2.13, 95% CI 0.22–20.4) between the exercise group and controls were found. Conclusions Overweight and obese women with singleton pregnancy can be counseled that, compared with being more sedentary, aerobic exercise for about 30–60 min three to seven times per week during pregnancy is associated with a reduction in the incidence of PTB. Aerobic exercise in overweight and obese pregnant women is also associated with a significant prevention of gestational diabetes mellitus, and should therefore be encouraged.

An Investment Framework for Nutrition: Reaching the Global Targets for Stunting Anemia Breastfeeding and Wasting.

Abstract: The report estimates the costs impacts and financing scenarios to achieve the World Health Assembly global nutrition targets for stunting anemia in women exclusive breastfeeding and the scaling up of the treatment of severe wasting among young children. To reach these four targets the world needs $70 billion over 10 years to invest in high-impact nutrition-specific interventions. This investment would have enormous benefits: 65 million cases of stunting and 265 million cases of anemia in women would be prevented in 2025 as compared with the 2015 baseline. In addition at least 91 million more children would be treated for severe wasting and 105 million additional babies would be exclusively breastfed during the first six months of life over 10 years. Altogether achieving these targets would avert at least 3.7 million child deaths. Every dollar invested in this package of interventions would yield between $4 and $35 in economic returns making investing in early nutrition one of the best value-for-money development actions. Although some of the targets -- especially those for reducing stunting in children and anemia in women -- are ambitious and will require concerted efforts in financing scale-up and sustained commitment recent experience from several countries suggests that meeting these targets is feasible. These investments in the critical 1000 day window of early childhood are inalienable and portable and will pay lifelong dividends -- not only for children directly affected but also for us all in the form of more robust societies -- that will drive future economies.

Analysis of cell-free fetal DNA in maternal blood for detection of trisomy 21, 18 and 13 in a general pregnant population and in a high risk population - a systematic review and meta-analysis.

Abstract: IntroductionThe aim of this study was to review the performance of non-invasive prenatal testing (NIPT) for detection of trisomy 21, 18 and 13 (T21, T18 and T13) in a general pregnant population as ...

Contraceptive use in the Nordic countries.

Abstract: Introduction The aim was to compare contraceptive use in the Nordic countries and to assess compliance with recommendations from the European Medicines Agency regarding the use of combined oral contraception containing low-dose estrogen and levonorgestrel, norethisterone or norgestimate. Material and methods Data on hormonal contraceptive prescriptions and sales figures for copper intrauterine devices were obtained from national databases and manufacturers in Denmark, Finland, Iceland, Norway and Sweden in 2010–2013. Results Contraceptive use was highest in Denmark (42%) and Sweden (41%), followed by Finland (40%). Combined oral contraception was the most used method in all countries, with the highest use in Denmark (26%). The second most used method was the levonorgestrel-releasing intrauterine system, with the highest use in Finland (15%) and ≈10% in the other countries. Copper intrauterine devices (7%) and the progestin-only pill (7%) were most often used in Sweden. Combined oral contraception use decreased with increasing age and levonorgestrel-releasing intrauterine system and progestin-only pills use increased. The use of long-acting reversible methods of contraception (=levonorgestrel-releasing intrauterine system, copper intrauterine devices, and implants) increased with time and was highest in Sweden (20%) and Finland (18%). The highest use of European Medicines Agency recommended combined oral contraception was in Denmark, increasing from 13 to 50% between 2010 and 2013. In Finland, recommended combined oral contraception remained below 1%. Conclusions Contraceptive use was highest in Denmark and Sweden, levonorgestrel-releasing intrauterine system use was highest in Finland and all long-acting methods were most common in Sweden. The use of combined oral contraception recommended by the European Medicines Agency was highest in Denmark.

Endometriosis increases the risk of obstetrical and neonatal complications.

Abstract: Introduction The objective of this study was to assess obstetrical complications and neonatal outcomes in women with endometriosis as compared with women without endometriosis. Material and methods National cohort including all delivering women and their newborns in Denmark 1997-2014. Data were extracted from the Danish Health Register and the Medical Birth Register. Logistic regression analysis provided odds ratios (OR) with 95% confidence intervals (CI). Sub-analyses were made for primiparous women with a singleton pregnancy and for women with endometriosis who underwent gynecological surgery before pregnancy. Results In 19 331 deliveries, women with endometriosis had a higher risk of severe preeclampsia (OR 1.7, 95% CI 1.5-2.0), hemorrhage in pregnancy (OR 2.3, 95% CI 2.0-2.5), placental abruption (OR 2.0, 95% CI 1.7-2.3), placenta previa (OR 3.9, 95% CI 3.5-4.3), premature rupture of membranes (OR 1.7, 95% CI 1.5-1.8), and retained placenta (OR 3.1, 95% CI 1.4-6.6). The neonates had increased risks of preterm birth before 28 weeks (OR 3.1, 95% CI 2.7-3.6), being small for gestational age (OR 1.5, 95% CI 1.4-1.6), being diagnosed with congenital malformations (OR 1.3, 95% CI 1.3-1.4), and neonatal death (OR 1.8, 95% CI 1.4-2.1). Results were similar in primiparous women with a singleton pregnancy. Gynecological surgery for endometriosis before pregnancy carried a further increased risk. Conclusion Women with endometriosis had a significantly higher risk of several complications, such as preeclampsia and placental complications in pregnancy and at delivery. The newborns had increased risk of being delivered preterm, having congenital malformations, and having a higher neonatal death rate. Pregnant women with endometriosis require increased antenatal surveillance.

Uterine adenomyosis and infertility, review of reproductive outcome after in vitro fertilization and surgery

Abstract: This review includes an analysis of the clinical studies evaluating reproductive outcome and adenomyosis, and a review of studies on reproductive outcome and surgical treatment options for adenomyosis. Strict diagnostic criteria and classification of disease are needed for an image diagnosis of adenomyosis. Studies of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) populations and women with surgically treated deep endometriosis have suggested that adenomyosis has a negative impact on reproductive outcome, although there are substantial variations between studies. Few data are available on the relation between the extent of disease and impact on reproductive outcome, but a correlation appears to exist. Case series seem to confirm a positive effect of gonadotropin-releasing hormone analog treatment and surgery on reproductive outcome, but there are no controlled trials. Evidence is impaired by the poor quality of many studies, a lack of strict image diagnosis, and the absence of a classification of the extent of disease. Selection of the optimal evidence-based treatment options for adenomyosis in the fertility clinic is difficult because of a lack of evidence regarding the relation between fertility and the degree and composition of adenomyosis. Adenomyosis may reduce implantation so severely that surgical or other treatment options should be recommended, but the benefit of these treatment options needs to be verified. Referral of women with adenomyosis and recurrent miscarriage and repeated failure of assisted reproductive technology to centers with a special interest in adenomyosis research and treatment may be critical.

Cesarean section trends in the Nordic Countries – a comparative analysis with the Robson classification

Abstract: Introduction: The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates. Material and methods: Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate. Results: Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates. Conclusions: The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates. (Less)

Tonic immobility during sexual assault - a common reaction predicting post-traumatic stress disorder and severe depression.

Abstract: Introduction Active resistance is considered to be the ‘normal’ reaction during rape. However, studies have indicated that similar to animals, humans exposed to extreme threat may react with a state of involuntary, temporary motor inhibition known as tonic immobility. The aim of the present study was to assess the occurrence of tonic immobility during rape and subsequent post-traumatic stress disorder and severe depression. Material and methods Tonic immobility at the time of the assault was assessed using the Tonic Immobility Scale in 298 women who had visited the Emergency clinic for raped women within 1 month of a sexual assault. Information about the assault and the victim characteristics were taken from the structured clinical data files. After 6 months, 189 women were assessed regarding the development of post-traumatic stress disorder and depression. Results Of the 298 women, 70% reported significant tonic immobility and 48% reported extreme tonic immobility during the assault. Tonic immobility was associated with the development of post-traumatic stress disorder (OR 2.75; 95% CI 1.50–5.03, p = 0.001) and severe depression (OR 3.42; 95% CI 1.51–7.72, p = 0.003) at 6 months. Further, previous trauma history (OR 2.36; 95% CI 1.48–3.77, p < 0.001) and psychiatric treatment history (OR 2.00; 95% CI 1.26–3.19, p = 0.003) were associated with the tonic immobility response. Conclusions Tonic immobility during rape is a common reaction associated with subsequent post-traumatic stress disorder and severe depression. Knowledge of this reaction in sexual assault victims is important in legal matters and for healthcare follow up.

An update on the diagnosis, surgical management, and fertility outcomes for women with endometrioma

Abstract: Endometriosis is estimated to affect up to 50% of infertile women, and severity of endometriosis stage appears to correlate with reduced fertility. Ovarian endometriomas are found in up to 44% of women with endometriosis, and are significantly associated with the presence of pelvic deep infiltrating endometriosis, ovarian adhesions, and pouch of Douglas obliteration. Through the use of MEDLINE and PubMed databases, we conducted a literature review of all available research related to the diagnosis, surgical management and fertility outcomes for women with endometrioma. The evolving use of specialized transvaginal ultrasound for the diagnosis of endometrioma and related endometriotic pathologies can allow for preoperative mapping/staging of the disease, as well as appropriate surgical planning and fertility counseling. Surgical management of endometriomas appears to reduce markers of ovarian reserve, such as anti-Mullerian hormone, prompting concern of reduced fertility following surgery. Ovarian cystectomy appears to be superior to ablation in terms of endometrioma recurrence, pain symptoms and increased spontaneous conception rate among subfertile patients. Research is inconclusive as to which surgical method least damages ovarian reserve in the long term; however, bipolar hemostasis appears to be the most damaging technique and should be avoided. Surgical management should be individualized for women with endometrioma, and strong consideration should be given to the preoperative ovarian reserve status prior to performing ovarian cystectomy. Current evidence suggests that ovarian cystectomy does not improve reproductive outcomes for women with endometrioma undergoing assisted reproductive technology; however, the majority of studies have been performed retrospectively and more prospective studies are needed.

Sleep quality during pregnancy: associations with depressive and anxiety symptoms

Abstract: Introduction Sleep disturbances are common during pregnancy, yet underdiagnosed and under-investigated. We evaluated sleep quality during pregnancy and assessed associated factors, especially depressive and anxiety symptoms. Material and methods A total of 78 healthy pregnant women from the FinnBrain Birth Cohort Study were studied twice prospectively during pregnancy (in mid-pregnancy and late pregnancy). Sleep quality was evaluated by the Basic Nordic Sleep Questionnaire, depressive symptoms by the Edinburgh Postnatal Depression Scale, and anxiety symptoms by the State-Trait Anxiety Inventory. Results Poor general sleep quality, difficulty falling asleep, the number of nocturnal awakenings per night, and too-early morning awakenings increased in late pregnancy compared with mid-pregnancy (all p-values < 0.020). The total insomnia score (p < 0.001) and sleep latency increased (p = 0.005), but sleep duration and preferred sleep duration did not change. Women tended to snore more often in late pregnancy, but apneas remained rare. Almost one-fourth of the women reported both morning and daytime sleepiness, but the frequencies did not increase during the follow up. In late pregnancy, depressive and anxiety symptoms were cross-sectionally related to sleep disturbances, but depressive or anxiety symptoms in mid-pregnancy were not associated with sleep disturbances in late pregnancy. Conclusions We found deterioration in sleep quality across pregnancy. However, no increase in negative daytime consequences was found, presumably indicating a compensatory capacity against sleep impairment. Additionally, depressive and anxiety symptoms and sleep disturbances were only cross-sectionally associated. Our study calls for further research on the factors that influence sleep disturbances during pregnancy.

Agreement and accuracy using the FIGO, ACOG and NICE cardiotocography interpretation guidelines.

Abstract: Introduction One of the limitations reported with cardiotocography is the modest interobserver agreement observed in tracing interpretation. This study compared agreement, reliability and accuracy of cardiotocography interpretation using the International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines. Material and methods A total of 151 tracings were evaluated by 27 clinicians from three centers where International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines were routinely used. Interobserver agreement was evaluated using the proportions of agreement and reliability with the κ statistic. The accuracy of tracings classified as “pathological/category III” was assessed for prediction of newborn acidemia. For all measures, 95% confidence interval were calculated. Results Cardiotocography classifications were more distributed with International Federation of Gynecology and Obstetrics (9, 52, 39%) and National Institute for Health and Care Excellence (30, 33, 37%) than with American College of Obstetrics and Gynecology (13, 81, 6%). The category with the highest agreement was American College of Obstetrics and Gynecology category II (proportions of agreement = 0.73, 95% confidence interval 0.70–76), and the ones with the lowest agreement were American College of Obstetrics and Gynecology categories I and III. Reliability was significantly higher with International Federation of Gynecology and Obstetrics (κ = 0.37, 95% confidence interval 0.31–0.43), and National Institute for Health and Care Excellence (κ = 0.33, 95% confidence interval 0.28–0.39) than with American College of Obstetrics and Gynecology (κ = 0.15, 95% confidence interval 0.10–0.21); however, all represent only slight/fair reliability. International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence showed a trend towards higher sensitivities in prediction of newborn acidemia (89 and 97%, respectively) than American College of Obstetrics and Gynecology (32%), but the latter achieved a significantly higher specificity (95%). Conclusions With American College of Obstetrics and Gynecology guidelines there is high agreement in category II, low reliability, low sensitivity and high specificity in prediction of acidemia. With International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence guidelines there is higher reliability, a trend towards higher sensitivity, and lower specificity in prediction of acidemia.

Maternal and neonatal outcomes following abnormally invasive placenta: a population-based record linkage study

Abstract: Introduction Abnormally invasive placenta involves abnormal adherence of the placenta to the myometrium and is associated with severe pregnancy complications such as blood transfusion and hysterectomy. Knowledge of outcomes has been limited by small sample sizes and a focus on maternal rather than neonatal outcomes. This study uses population-level data collected over 10 years to investigate maternal and neonatal outcomes and trends in incidence of abnormally invasive placenta (also known as placenta accreta, increta and percreta). Material and methods A population-based record linkage study was performed, including all women who gave birth in New South Wales, Australia, between 2003 and 2012. Data were obtained from birth records, hospital admissions and deaths registrations. Modified Poisson regression models, adjusted for confounding factors, were used to quantify the effect of abnormally invasive placenta on adverse maternal and neonatal outcomes. Results Abnormally invasive placenta was significantly associated with morbidity for mothers (adjusted relative risk 17.6, 99% confidence interval 14.5–21.2) and infants (adjusted relative risk 3.1, 99% confidence interval 2.7–3.5). Abnormally invasive placenta increased risk of stillbirth (relative risk 5.4, 99% confidence interval 4.0–7.3) and neonatal death (relative risk 8.0, 99% confidence interval 1.5–41.6). The overall rate of abnormally invasive placenta was 24.8 per 10 000 deliveries, and 22.7 per 10 000 among primiparae. Incidence increased by 30%, from 20.6 to 26.9 per 10 000, over the 10-year study period. Conclusions Abnormally invasive placenta substantially increases the risk of severe adverse outcomes for mothers and babies, and the incidence is increasing. Delivery should occur in tertiary hospitals equipped with neonatal intensive care units. Clinicians should be cognizant of the risks, particularly to infants, and maintain a high index of suspicion of abnormally invasive placenta, including in primiparae.

High intensity focused ultrasound for the treatment of adenomyosis: selection criteria, efficacy, safety and fertility

Abstract: Adenomyosis is a disorder of uterus in which endometrial glands and stroma are present within the uterine musculature. The main clinical manifestations are dysmenorrhea and menorrhagia. Adenomyosis has a great impact on both the quality of life and fertility of women. The treatment of adenomyosis remains an immense challenge. Relevant articles were searched through MEDLINE and PubMed between 2000 and March 2017. The search terms of adenomyosis, magnetic resonance imaging (MRI) features of adenomyosis, high intensity focused ultrasound (HIFU), ultrasound-guided HIFU and MRgFUS were used. There were no language restrictions. HIFU is a non-invasive local thermal ablation technique which has been used in the treatment of both focal and diffuse adenomyosis. Several case studies have demonstrated that HIFU presents low rate of minor and/or major complications and, at the same time, a long symptom-relief period. Multiple factors such as the enhancement type of the adenomyotic lesion, volume of the adenomyotic lesions, number of hyperintense foci on T2WI, location of the uterus, location of adenomyotic lesions, thickness of the abdominal wall and distance from the skin to the adenomyotic lesions contribute to the efficacy of HIFU. Consequently, based on these contributing factors, specific and strict selection criteria have been used to achieve higher efficacy. Thus, patients with pelvic endometriosis, adhesions between the bowel and the uterus, or an abdominal surgical scar wider than 10 mm, are not suitable for HIFU treatment. Moreover, HIFU-treated patients with adenomyosis, who wished to conceive, showed high conception and live birth rates. HIFU is a new and promising treatment option for patients with adenomyosis, but its efficacy, safety, cost-effectiveness and fertility outcome must be evaluated by randomized controlled trials.

Thromboembolism and in vitro fertilization - a systematic review.

Abstract: Introduction There is no accepted consensus on thromboprophylaxis in relation to in vitro fertilization (IVF). We aimed to study the frequency of thromboembolism and to assess thromboprophylaxis in relation to IVF. Material and methods We performed a systematic review. All study designs were accepted except single case reports. Language of included articles was restricted to English. Results Of 338 articles, 21 relevant articles (nine cohort studies, six case–control studies, three case series, and three reviews of case series) were identified. The antepartum risk of venous thromboembolism (VTE) after IVF is doubled (odds ratio 2.18, 95% CI 1.63–2.92), compared with the background pregnant population. This is due to a 5- to 10-fold increased risk during the first trimester in IVF pregnancies, in turn related to a very high risk of VTE after ovarian hyperstimulation syndrome (OHSS), i.e. up to a 100-fold increase, or an absolute risk of 1.7%. The interval from embryo transfer to VTE was 3–112 days and the interval from embryo transfer to arterial thromboembolism was 3–28 days. No robust study on thromboprophylaxis was found. Conclusions The antepartum risk of VTE after IVF is doubled, compared with the background pregnant population, and is in turn related to a very high risk of VTE after OHSS in the first trimester. Our group of authors and clinical experts recommend that IVF patients with OHSS be prescribed low-molecular-weight heparin during the first trimester, whereas other IVF patients should be given thromboprophylaxis based on the same risk factors as other pregnant women.

Intrapartum predictors of maternal levator ani injury

Abstract: Introduction Damage to the pelvic floor during vaginal childbirth is common, and may take the form of levator avulsion or irreversible overdistension of the levator hiatus (microtrauma). Such trauma is a major risk factor for pelvic organ prolapse later in life. In this study we aimed to identify intrapartum risk factors for levator trauma. Material and methods This is a retrospective analysis of data obtained in two perinatal studies on primiparous women. Between 2005 and 2014, 1148 women carrying an uncomplicated singleton pregnancy in the late third trimester were seen for 4D pelvic floor ultrasound and an interview. They were invited for a repeat assessment at three months postpartum. Results Of 1148 women, 871 (76%) returned for assessment at a mean of five months postpartum. The datasets of 844 women were analyzed due to missing data or concurrent pregnancy in 27. In all, 452 (54%) had a normal vaginal delivery, 102 (12%) a vacuum, 55 (6%) a forceps, and 235 (28%) a cesarean section. On multivariate analysis forceps, length of second stage and obstetric anal sphincter tears were significantly associated with levator avulsion. There were no significant predictors identified for irreversible overdistension. Conclusions The use of forceps, a prolonged second stage, and obstetric anal sphincter tears were associated with levator avulsion. There were no associated intrapartum predictors for hiatal overdistension.

Does surgery for deep infiltrating bowel endometriosis improve fertility? A systematic review

Abstract: Introduction Reduced fertility is a major concern in women with endometriosis. The influence of surgery of deep infiltrating endometriosis (DIE) affecting the bowel wall on fertility is controversial and the literature on this field is heterogeneous. In this review we addressed whether surgery for bowel DIE improves the spontaneous pregnancy rate, and the results of in vitro fertilization (IVF), and the potential risk of such surgery. Material and methods We conducted a literature search including the terms “deep”, “deep infiltrating”, “bowel”, rectovaginal”, “endometriosis”, “fertility”, “infertility” and “IVF” in PubMed. Results No randomized controlled studies were found. Other publications of relevance included four retrospective and three prospective observational studies. Moreover, one retrospective study compared results of IVF treatment with or without previous surgery for bowel DIE. All studies reported detailed data on surgical complications. The poor data quality precluded firm conclusions. The results indicate, however, the possibility that surgery for bowel DIE may improve the spontaneous pregnancy rate, and positive effects on IVF outcome cannot be excluded. Such surgery will be associated with risk of major complications. Conclusion The lack of proper data precludes conclusions on the potential role for bowel DIE surgery to improve the spontaneous pregnancy rate and results of IVF treatment. Positive effects cannot be excluded, but the definite risk of major complications must be taken into account.

When love hurts. A systematic review on the effects of surgical and pharmacological treatments for endometriosis on female sexual functioning.

Abstract: Introduction Endometriosis is associated with an increased risk of dyspareunia, therefore this chronic gynecologic disease should be considered as a major cause of sexual dysfunctions. The aims of this study were to review the literature on the effects of surgical and pharmacological treatments for endometriosis on female sexual functioning, and to provide suggestions for future treatment strategies. Material and methods We followed the PRISMA guidelines to conduct this systematic review, which involved an electronic database search of studies on the association between endometriosis and sexuality published between 2000 and 2016. Results As a result of the screening process, 22 studies were included in this systematic review. The 22 studies included were divided into two categories: (a) surgical intervention studies (n = 17), examining postoperative sexual outcomes of surgery for endometriosis; (b) pharmacological intervention studies (n = 5), evaluating the effects of pharmacological endometriosis treatments on sexual functioning. The studies considered showed that overall surgical and pharmacological interventions for endometriosis can lead to medium-/long-term improvement, but not necessarily to a definitive resolution of female sexual dysfunctions due to endometriosis. Conclusions Sexual functioning is a multidimensional phenomenon and the ideal treatment for endometriosis-related sexual dysfunctions should be conducted by a multidisciplinary team that involves not only gynecologists, but also sexologists and psychologists/psychotherapists. Improving global sexual functioning, and not just reducing pain at intercourse, should be considered as a major clinical goal of endometriosis treatment.

Self-management of stress urinary incontinence via a mobile app: two-year follow-up of a randomized controlled trial

Abstract: Introduction. We investigated the long-term effects of using a mobile app to treat stress urinary incontinence with a focus on pelvic floor muscle training. Material and methods. A previous randomi ...

Is the incidence of recurrent pregnancy loss increasing? A retrospective register-based study in Sweden

Abstract: Introduction The aim of this study was to estimate the incidence of recurrent pregnancy loss (RPL). The prevalence of RPL defined as three or more consecutive miscarriages before gestation week 22, is often stated to be 1%. To our knowledge no study has estimated the incidence of RPL, which might be more informative and clinically relevant than the prevalence. Material and methods This retrospective register-based study was conducted from 2003 until 2012 in Sweden with data provided by the Swedish National Board of Health and Welfare. In all, 6852 women were registered with the diagnoses of RPL in the National Patient Register. The incidence of RPL is the number of new women receiving the RPL diagnosis per year in the numerator and population at risk in the denominator. Results For each year, from 2003 to 2012, the incidence was calculated in two different risk populations: [1] all women aged 18–42 years, and [2] all women registered as being pregnant (deliveries or miscarriages). The average incidence in the study period was 53 per 100 000 (0.05%) in women aged 18–42 years and 650 per 100 000 (0.65%) in women who had achieved pregnancy in the period. The incidence of RPL in the two risk populations increased by 74 and 58%, respectively, during the study period. Conclusion This study suggests that the incidence of RPL increased during the 10-year period studied. Causes can only be speculated upon in this study design, but might be associated with environmental changes, as the increase was fairly rapid.

Risk factors of epithelial ovarian carcinomas among women with endometriosis: a systematic review

Abstract: Introduction The objective of this review was to evaluate the published literature on epidemiologic risk factors for epithelial ovarian cancer among women with a diagnosis of endometriosis. Material and methods A systematic literature search was conducted in PubMed and Scopus. Studies comparing epidemiologic risk factors of epithelial ovarian cancer among women with endometriosis were included. A quality assessment was conducted using the Newcastle-Ottawa Scale. Results Eight of 794 articles met the inclusion criteria. A lower risk of epithelial ovarian cancer was observed in women with documented complete surgical excision of endometriotic tissue and suggested among women with unilateral oophorectomy. The use of oral contraceptives (≥10 years) may be associated with a lower risk of epithelial ovarian cancer among women with endometriosis, whereas older age at endometriosis diagnosis (≥45 years, pre- or postmenopausal), nulliparity, hyperestrogenism (endogenous or exogenous), premenopausal status at endometriosis diagnosis, solid compartments as well as larger size of endometrioma (≥9 cm in diameter at endometriosis diagnosis) were all associated with an increased risk of ovarian cancer. Conclusions A subgroup of women with endometriosis characterized by endometriosis observed through surgery or imaging after the age of 45 years, nulliparity, postmenopausal status at endometriosis diagnosis, larger size of endometrioma (>9 cm) at endometriosis diagnosis, hyperestrogenism (endogenous or exogenous) and/or cysts with solid compartments may have an elevated risk of epithelial ovarian cancer. However, due to the limited number and size of studies in this area we cannot draw definitive conclusions. Further research into a risk factor profile among women with endometriosis is needed before clear recommendations can be made.

Relevant human tissue resources and laboratory models for use in endometriosis research

Abstract: Endometriosis is characterized by the growth of endometrium-like tissue outside the uterus, most commonly on the pelvic peritoneum and ovaries. Although it may be asymptomatic in some women, in others it can cause debilitating pain, infertility or other symptoms including fatigue. Current research is directed both at understanding the complex etiology and pathophysiology of the disorder and at the development of new nonsurgical approaches to therapy that lack the unwanted side effects of current medical management. Tools for endometriosis research fall into two broad categories; patient-derived tissues, and fluids (and cells isolated from these sources) or models based on the use of cells or animals. In this review, we discuss the literature that has reported data from the use of these tools in endometriosis research and we highlight the strengths and weaknesses of each. Although many different models are reported in the literature, hypothesis-driven research will only be facilitated with careful experimental design and selection of the most appropriate human tissue from patients with and without endometriosis and combinations of physiologically relevant in vitro and in vivo laboratory models.

Detection of fetal abnormalities by second-trimester ultrasound screening in a non-selected population

Abstract: IntroductionThis study assessed the sensitivity of routine ultrasound examination for the detection of abnormal chromosomes and structural malformations in fetuses in the second trimester in a non- ...

A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low- and middle-income countries

Abstract: Cesarean section (CS) rates are increasing globally with an unclear effect on pregnancy outcomes. The study objective was to quantify maternal and perinatal morbidity and mortality in low- and middle-income countries associated with CS compared to vaginal delivery (VD) both within and across sites MATERIAL AND METHODS: A prospective population-based study including home and facility births in 337,153 women with a VD and 47,308 women with a CS from 2010 to 2015 was performed in Guatemala, India, Kenya, Pakistan, Zambia, and Democratic Republic of Congo. Women were enrolled during pregnancy; delivery and 6-week follow-up data were collected RESULTS: Across all sites, CS rates increased from 8.6 to 15.2%, but remained low in African sites. Younger, nulliparous women were more likely to have a CS, as were women with higher education and those delivering a 1500-2499g infant. Across all sites, maternal and neonatal mortality was higher, and stillbirths lower, in pregnancies delivered by CS. Antepartum and postpartum complications as well as obstetric interventions and treatments were more common among women who underwent CS. In stratified analyses, all outcomes were worse in women with a CS compared to VD in African compared to non-African sites CONCLUSIONS: CS rates increased across all sites during the study period, but at more pronounced rates in the non-African sites. CS was associated with reduced postpartum hemorrhage and lower rates of stillbirths in the non-African sites. In the African sites, CS was associated with an increase in all adverse outcomes. Further studies are necessary to better understand the increase in adverse outcomes with CS in the African sites. This article is protected by copyright. All rights reserved.

Maternal deaths in the Nordic countries

Abstract: Introduction Despite the seriousness of the event, maternal deaths are substantially underreported. There is often a missed opportunity to learn from such tragedies. The aim of the study was to identify maternal deaths in the five Nordic countries, to classify causes of death based on internationally acknowledged criteria, and to identify areas that would benefit from further teaching, training or research to possibly reduce the number of maternal deaths. Material and methods We present data for the years 2005–2013. National audit groups collected data by linkage of registers and direct reporting from hospitals. Each case was then assessed to determine the cause of death, and level of care provided. Potential improvements to care were evaluated. Results We registered 168 maternal deaths, 90 direct and 78 indirect cases. The maternal mortality ratio was 7.2/100 000 live births ranging from 6.8 to 8.1 between the countries. Cardiac disease (n = 29) was the most frequent cause of death, followed by preeclampsia (n = 24), thromboembolism (n = 20) and suicide (n = 20). Improvements to care which could potentially have made a difference to the outcome were identified in one-third of the deaths, i.e. in as many as 60% of preeclamptic, 45% of thromboembolic, and 32% of the deaths from cardiac disease. Conclusion Direct deaths exceeded indirect maternal deaths in the Nordic countries. To reduce maternal deaths, increased efforts to better implement existing clinical guidelines seem warranted, particularly for preeclampsia, thromboembolism and cardiac disease. More knowledge is also needed about what contributes to suicidal maternal deaths.

Introduction of robot‐assisted radical hysterectomy for early stage cervical cancer: impact on complications, costs and oncologic outcome

Abstract: Introduction The objective was to assess the impact of robot-assisted radical hysterectomy (RRH) on surgical and oncologic outcome and costs compared with open radical hysterectomy (ORH) at a tertiary referral center in Sweden. Material and methods In this retrospective analysis all patients treated with radical hysterectomy and pelvic lymphadenectomy for early stage uterine cervical cancer during 2006–2015 were included (n = 304). The patients were divided into two groups, ORH (n = 155) and RRH (n = 149). Patient characteristics, FIGO stage, histology, adjuvant therapy, operation time, length of stay (LOS), lymph node yield, recurrence rate and survival were retrieved from medical records. Complications were graded according to the Clavien–Dindo classification. In addition, costs related to the surgical treatments were calculated. Results Blood loss, LOS and intraoperative complications were significantly lower as well as lymph node yield after RRH. No differences in postoperative complications or costs were observed between the two groups. Recurrence of disease was detected in 13.4 and 10.3% after RRH and ORH, respectively. Regression analysis demonstrated that histology, tumor size, positive lymph nodes and type of operation (RRH) were significantly associated with recurrence. Conclusion The introduction of RRH was accompanied by similar postoperative complication rates and costs but lower LOS compared with ORH. An initial learning curve may account for the higher recurrence rate observed after RRH. These data reinforce the need for structured training and monitoring of outcomes when novel treatment modalities are introduced.