Bjog-An International Journal of Obstetrics and Gynaecology最新文献

Objective: To determine risks for non-transfusion severe maternal morbidity and transfusion during a second delivery hospitalisation based on clinical risk factors and obstetric complications from an index, first delivery hospitalisation.

Design: Retrospective cohort.

Population: Delivery hospitalisations in the 2010-2017 New York State Inpatient Database.

Methods: Patients with a first index delivery hospitalisation followed by a second delivery hospitalisation during the study period were included. Clinical risk factors and obstetric complications were obtained from the first index delivery hospitalisation. Adjusted logistic regression models for non-transfusion severe maternal morbidity during the second delivery were performed with adjusted (aORs) odds ratios as measures of effect. These analyses were then repeated for the outcome of transfusion.

Results: Of 624 500 paired delivery hospitalisations to 312 250 women, severe maternal morbidity occurred among 0.85% of second deliveries (n = 2672). When adjusted analysis was performed, several clinical factors were associated with severe maternal morbidity in a subsequent pregnancy, including severe maternal morbidity during the index pregnancy (aOR 8.4, 95% CI 7.0, 9.9), transfusion (aOR 2.0, 95% CI 1.6, 2.4) and pregestational diabetes (aOR 2.2, 95% 1.6, 2.9). When analyses were repeated for transfusion, several factors were associated with increased risk, including severe maternal morbidity (aOR 1.5, 95% CI 1.2, 1.8), index transfusion (aOR 6.3, 95% CI 5.6, 7.0), chronic heart disease (aOR 1.6, 95% 1.4, 1.9) and pregestational diabetes (aOR 1.7, 95% 1.3, 2.2).

Conclusion: Many obstetric complications and chronic conditions identified during an index delivery hospitalisation are associated with severe morbidity during a second, subsequent delivery. Index severe maternal morbidity is associated with the highest odds. These findings may be of use in patient counselling and risk stratification.

Objective: Child marriage forces a girl into adult roles before physical and psychological maturity, which can take a toll on women's health over the life course. This article aims to assess whether child marriage and adolescent childbearing are associated with elevated risk of gynaecologic disorders leading to hysterectomy.

Design: Cross-sectional and time-to-event analysis.

Setting: India.

Population: 528 816 ever-married women, aged 20-49 years.

Methods: Women were grouped in four mutually exclusive categories: (i) married adult-not an adolescent mother (reference category), (ii) married adult-adolescent mother, (iii) married child-not an adolescent mother and (iv) married child-adolescent mother. Multivariable logistic regressions were fitted to assess the odds of hysterectomy for these groups. Nonparametric Kaplan-Meier survivor functions were estimated to evaluate survival rates across the groups.

Main outcome measures: Whether had a hysterectomy and age when hysterectomy was performed.

Results: Compared to women married as adults, not an adolescent mother, women married in childhood and gave birth in adolescence were 1.87 (95% CI: 1.78-1.96) times more likely to have a hysterectomy. The latter group also had the lowest survival probability for hysterectomy at all ages (e.g., 85.80% [95% CI: 85.41-86.18] at age 49 years as compared to 91.65% [95% CI: 91.37-91.89] for the former group). Women married as children but not adolescent mothers and married as an adult but gave birth in adolescence also had higher odds of hysterectomy-1.40 (95% CI: 1.31-1.50) and 1.53 (95% CI: 1.40-1.66) times of that of the reference group, respectively.

Conclusions: Our results, showing a strong relationship between child marriage and hysterectomy, contribute to the literature on later-life health consequences of child marriage.

Objective: Uncertainty surrounds the risk-benefit of low-molecular-weight heparin to prevent postpartum venous thromboembolism (VTE). Data from randomised clinical trials (RCT) are critically needed, but recent feasibility studies in North America yielded low participation rates, with <1 enrolment per month per centre. Our aim was to assess the feasibility of a trial of postpartum short-term enoxaparin in Europe.

Design: Pragmatic, open-label pilot randomised controlled trial (RCT).

Setting: Swiss tertiary hospital.

Population: Postpartum women, within 48 h of delivery, deemed at intermediate risk of VTE with at least one major risk factor (morbid obesity, thrombophilia, emergency caesarean section, pre-eclampsia, preterm delivery, intrauterine growth restriction or systemic peripartum infection) and/or at least two minor risk factors.

Methods: Participants were randomised to enoxaparin 40-60 mg once daily for 10 days or no treatment, with a 90-day follow-up.

Main outcome measures: Participation rate and study acceptance (randomised participants among women in whom informed consent was sought).

Results: Recruitment was open for 25 weeks in 2022. Among 1504 postpartum women, 480 were eligible and 77 were randomised. The recruitment rate was 3.1 per week (13.3 per month) and the study acceptance was 23.8%. At 3 months, there was no VTE event, but one major, one nonmajor obstetrical bleeding and one surgical site complication, all in the enoxaparin group.

Conclusions: This pilot RCT of postpartum thromboprophylaxis set in Switzerland yielded greater participation rate and acceptance than previous attempts in North America. It calls for a large, international, collaborative trial to guide this important clinical decision.

Trial registration: ClinicalTrial.gov identifier: NCT05878899 and NCT04153760.

In the tapestry of global health challenges, few issues evoke as much urgency as the crisis of maternal and newborn health in low-resource settings. Nowhere is this challenge more pronounced than in Nigeria, where the struggle for accessible, quality healthcare resonates across its diverse landscape. Against the backdrop of staggering population statistics, the need for concerted action and innovative solutions becomes ever more pressing.

Nigeria with a population of over 200 million, grapples with an ongoing maternal mortality crisis that stretches logic and conscience, despite being endowed with vast human and natural resources. The risk of perinatal death in Nigeria is also unacceptably high, with no significant change recorded in the last 20 years.^1-4 Nigeria makes the second highest contribution of 12% of global maternal deaths, stillbirths and neonatal deaths, and is amongst the top 10 countries with the highest perinatal mortality globally.² These figures do not only pose a serious challenge to the attainment of the first target of the third sustainable development goal: behind these stark figures lie the untold stories of countless families, whose hopes and dreams are shattered by the cruel realities of inadequate healthcare access. Their struggles underscore the urgent need for increased political will, application of evidence-based interventions, and comprehensive healthcare reform to achieve universal health coverage.

To address the poor quality of care and high perinatal mortality in Nigeria, the Maternal and Perinatal Database for Quality, Equity, and Dignity Programme (MPD-4-QED) was established by the World Health Organization (WHO) and the Nigerian Federal Ministry of Health in 2019.⁵ The aim of the programme was to facilitate the largest, periodic analysis on the quality and outcomes of care provided to women and their newborns in Nigerian referral-level hospitals to inform policy and programmatic decisions at national, subnational and facility levels.⁶

In this Special Issue of BJOG we turn our attention to this critical issue of maternity care in Nigeria. In a series of articles, many of which represent analyses of the MPD-4-QED Programme, the authors examine the multifaceted complexities of maternal healthcare delivery in this African nation. The articles address diverse challenges from early pregnancy loss and preterm birth, hypertensive disorders, obstructed labour, postpartum haemorrhage, birth asphyxia and caesarean section, to neonatal jaundice and sepsis. The mission is clear: to shed light on the challenges, explore potential interventions, and pave the way for meaningful change.

Through rigorous epidemiological research and insightful analyses, the contributors undertake a detailed analysis of Nigeria's maternal and perinatal health crisis. From the underutilization of primary health centres,

Objective: To assess whether procedural-induced abortion or provider-initiated preterm delivery are associated with improved survival in pregnant people with cancer.

Design: Retrospective population-based cohort study.

Setting: Provinces of Alberta and Ontario, Canada, 2003-2016.

Population: Females aged 18-50 years diagnosed with cancer at <20 weeks' (for the assessment of procedural-induced abortion) or <37 weeks' gestation (for the assessment of provider-initiated delivery).

Methods: Cox proportional hazard models assessed all-cause mortality in relation to procedural-induced abortion and provider-initiated preterm delivery, adjusting for cancer site, stage at diagnosis and age. Meta-analysis pooled the results across both provinces.

Main outcome measures: All cause mortality.

Results: There were 512 pregnant people diagnosed with cancer at <20 weeks' gestation and 782 diagnosed with cancer at <37 weeks' gestation. Neither procedural-induced abortion (adjusted hazard ratio [aHR] = 1.39, 95% CI: 0.32-6.17) nor provider-initiated preterm delivery (aHR = 1.17, 95% CI: 0.76-1.81) were associated with improved survival following adjustment for age, stage at diagnosis and cancer site.

Conclusions: Neither procedural-induced abortion nor provider-initiated preterm birth was associated with improved survival in pregnant people diagnosed with cancer; however, these obstetric interventions are highly personal decisions best decided by the pregnant person in consultation with their care providers.

Objective: To examine if peritoneal conditioning with an altered insufflation gas mixture is associated with reduced postoperative pain intensity compared to the standard insufflation gas (i.e., 100% CO₂).

Design: A prospective, single-centre, randomized, double-blind, superiority trial was performed.

Setting: This study was conducted between 4 April 2019 and 10 February 2022 at the Jessa Hospital, Hasselt, Belgium.

Population: Patients scheduled for elective gynaecologic laparoscopic surgery.

Methods: Seventy-four patients scheduled for elective gynaecologic laparoscopic surgery were randomised to receive either the standard insufflation gas with 100 CO₂ (n = 37; control group) or the altered gas mixture of 86% CO₂, 10% N₂O and 4% O₂ (n = 37; experimental group).

Main outcome measures: Postoperative pain was assessed at 4, 8 and 24 hours after surgery and on postoperative day (POD) 7 by an 11-point Numeric Rating Scale, with 0 indicating no pain and 10 indicating worst imaginable pain.

Results: No significant differences were found between the control and experimental groups regarding postoperative pain at 4, 8 and 24 h after surgery, as well as on POD7. In addition, the median (25% and 75%) total amount of IV piritramide consumption during the first 24 h after surgery was not significantly different between groups (control group: 18.0 [10.0, 27.0] mg vs. experimental group: 17.0 [10.0, 34.0] mg, p = 0.62).

Conclusion: The alternative insufflation gas mixture comprising 86% CO₂, 10% N₂O and 4% O₂ used for the pneumoperitoneum during gynaecologic laparoscopic surgery does not appear to reduce postoperative pain compared to the standard insufflation gas of 100% CO₂.

Objective: To identify factors associated with neonatal respiratory distress (NRD) in early Gestational diabetes mellitus (eGDM).

Design: Nested case-control analysis of the TOBOGM trial.

Setting: Seventeen hospitals: Australia, Sweden, Austria and India.

Population: Pregnant women, <20 weeks' gestation, singleton, GDM risk factors.

Methods: Women with GDM risk factors completed an oral glucose tolerance test (OGTT) before 20 weeks: those with eGDM (WHO-2013 criteria) were randomised to immediate or deferred GDM treatment. Logistic regression compared pregnancies with/without NRD, and in pregnancies with NRD, those with/without high-dependency nursery admission for ≤24 h with those admitted for >24 h. Comparisons were adjusted for age, pre-pregnancy body mass index, ethnicity, smoking, primigravity, education and site. Adjusted odds ratios (95% CI) are reported.

Main outcome measures: NRD definition: ≥4 h of respiratory support (supplemental oxygen or supported ventilation) postpartum. Respiratory distress syndrome (RDS): Supported ventilation and ≥24 h nursery stay.

Results: Ninety-nine (12.5%) of 793 infants had NRD; incidence halved (0.50, 0.31-0.79) if GDM treatment was started early. NRD was associated with Caesarean section (2.31, 1.42-3.76), large for gestational age (LGA) (1.83, 1.09-3.08) and shorter gestation (0.95, 0.93-0.97 per day longer). Among NRD infants, >24 h nursery-stay was associated with higher OGTT 1-h glucose (1.38, 1.08-1.76 per mmol/L). Fifteen (2.0%) infants had RDS.

Conclusions: Identifying and treating eGDM reduces NRD risk. NRD is more likely with Caesarean section, LGA and shorter gestation. Further studies are needed to understand the mechanisms behind this eGDM complication and any long-term effects.

All gynaecology departments should provide a dedicated outpatient hysteroscopy service to aid care of women and people with abnormal uterine bleeding, reproductive problems, and insertion/retrieval of intrauterine devices. [Grade A] Written information should be provided to the woman prior to their appointment. This should include details about the procedure, the benefits and risks, advice regarding pre-operative analgesia, as well as alternative options for care and contact details for the hysteroscopy unit. [Good Practice Point] Women should be made aware of other settings and modes of anaesthesia for hysteroscopy (e.g. under general or regional anaesthesia or intravenous sedation). [GPP] The woman should be advised that if they find the procedure too painful or distressing at any point, they must alert the clinical team who will stop the procedure immediately. The clinical team should alert the hysteroscopist if the woman appears to be in too much pain or is experiencing a vasovagal episode and therefore unable to voice the concerns so that the procedure can be stopped. [GPP] Women should be advised to take standard doses of oral non-steroidal anti-inflammatory agents (NSAIDs) one hour before their scheduled appointment. Vaginoscopy should be the standard technique for outpatient hysteroscopy unless the use of a vaginal speculum is required (e.g. for administering local cervical anaesthesia or dilating the cervix). [Grade A] When performing operative hysteroscopy, the smallest diameter hysteroscope should be used, with consideration given to the use of hysteroscopes with expandable outer working channels because they are associated with less pain. [Grade B] Mechanical hysteroscopic tissue removal systems should be preferred over miniature bipolar electrodes to remove endometrial polyps. [Grade A] Local anaesthesia should not be routinely administered prior to outpatient hysteroscopy where a vaginoscopic approach is used. It should be considered where use of a vaginal speculum is planned e.g. for cervical dilatation if anticipated, due to either cervical stenosis and/or the utilisation of larger-diameter hysteroscopes (≥5mm outer diameter). [Grade A] Saline should be instilled at the lowest possible pressure to achieve a satisfactory view. [Grade A] Conscious sedation should not be routinely used in outpatient hysteroscopic procedures. [Grade B].