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

Objective: To assess the added value of fetal fraction of cell-free DNA in the maternal circulation in the prediction of adverse pregnancy outcomes.

Design: Retrospective cohort study.

Setting: Nationwide implementation study on non-invasive prenatal testing (NIPT; TRIDENT-2 study).

Population: Pregnant women in the Netherlands opting for NIPT between June 2018 and June 2019.

Methods: Two logistic regression prediction models were constructed for each adverse pregnancy outcome. The first model (base model) included prognostic clinical parameters that were selected from existing first-trimester prediction models for adverse pregnancy outcomes. The second model (fetal fraction model) included fetal fraction as a predictor on top of the prognostic clinical parameters included in the base model. The added prognostic value of fetal fraction was assessed by comparing the base and fetal fraction models in terms of goodness of fit and predictive performance.

Main outcome measures: Likelihood ratio test (LRT), area under the curve (AUC) and Integrated Discrimination Improvement (IDI) index.

Results: The study cohort consisted of 56 110 pregnancies. The incidence of adverse pregnancy outcomes was 5.7% for hypertensive disorders of pregnancy (HDP; n = 3207), 10.2% for birthweight < p10 (n = 5726), 3.2% for birthweight < p2.3 (n = 1796), 3.4% for spontaneous preterm birth (sPTB; n = 1891), 3.4% for diabetes (n = 1902) and 1.3% for congenital anomalies (n = 741). Adding fetal fraction to the base model improved model fit for HDP, birthweight < p10, birthweight < p2.3, all sPTB, and diabetes, but not for congenital anomalies (LRT p < 0.05). For HDP, the AUC improved from 0.67 to 0.68 by adding fetal fraction to the base model (p = 0.14) with an IDI of 0.0018 (p < 0.0001). For birthweight < p10, the AUC improved from 0.65 to 0.66 (p < 0.0001) with an IDI of 0.0023 (p < 0.0001). For birthweight < p2.3, the AUC improved from 0.67 to 0.69 (p < 0.0001) with an IDI of 0.0011 (p < 0.0001). For all sPTB, the AUC was similar for both models (AUC 0.63, p = 0.021) with an IDI of 0.00028 (p = 0.0023). For diabetes, the AUC was similar (AUC 0.72, p = 0.35) with an IDI of 0.00055 (p = 0.00015).

Conclusions: Fetal fraction has statistically significant but limited prognostic value in the prediction of adverse pregnancy outcomes in addition to known prognostic clinical parameters.

Objective: To determine the association between unilateral oophorectomy (UO) and age at natural menopause.

Design: Secondary analysis of survey data from Alberta's Tomorrow Project (2000-2022).

Setting: Prospective cohort study in Alberta, Canada.

Population: 23 630 women; 548 experienced UO and 23 082 did not experience UO.

Methods: Flexible parametric survival analysis was used to analyse age at natural menopause, and logistic regression was used to analyse early menopause and premature ovarian insufficiency by UO status, controlling for birth year, parity, age at menarche, past infertility, hormonal contraceptive use and smoking.

Main outcome measures: Age at natural menopause occurred by a final menstrual period without medical cause and sub-classified as early menopause (< 45 years) and premature ovarian insufficiency (< 40 years).

Results: Compared to no UO, any UO was associated with elevated risk of earlier age at natural menopause, which was strongest in early midlife (adjusted HR at age 40 1.71, 95% CI 1.31-2.19) and diminished over time. Compared to age 55 years at UO, risks of earlier age at natural menopause were largest and uniform in magnitude when UO occurred between approximately ages 20-40 years (adjusted HR for UO at age 30 2.32, 1.46-3.54) and then diminished as age at UO approached the average age at natural menopause. Any UO was associated with higher odds of early menopause (adjusted OR 1.90, 1.30-2.79) and premature ovarian insufficiency (adjusted OR 3.75, 1.72-8.16).

Conclusions: Unilateral oophorectomy is associated with earlier age at natural menopause, particularly when performed before 40 years of age.

Objectives: The objectives of this study were to (i) quantify the contribution of maternal hypertensive disorders of pregnancy (HDP) to iatrogenic preterm birth (PTB) and neonatal unit (NNU) admissions < 34⁺⁰ weeks and (ii) describe short-term population-level outcomes for HDP infants, exploring ethnic disparities and comparing outcomes by HDP exposure.

Design: Retrospective population-based study using the National Neonatal Research Database.

Setting: England and Wales.

Population: Infants born < 34⁺⁰ weeks and admitted to NNU 2012-2020.

Methods: Descriptive statistics, linear and logistic regression models to compare outcomes between groups.

Main outcome measures: Survival to discharge with/without comorbidity.

Results: 122 228 infants met inclusion criteria. Where collected, 49 839/114 164 (43.7%, 95% CI 43.4%-43.9%) of infants had an iatrogenic PTB. HDP was recorded in 16 510/122 228 (13.5%) of all infants and 13 560/49 839 (27.2%) of iatrogenic PTBs. HDP and/or foetal growth restriction (FGR) were recorded in 24 124/49 839 (48.4%) of iatrogenic PTBs. Singleton HDP infants < 10th BWC had ≥ 90% survival to discharge from 28 weeks' gestation, versus from 26 weeks' gestation for those born ≥ 10th BWC. In extreme preterm HDP infants (< 27 weeks), 27.3% of infants < 10th BWC died compared to 15.2% of those ≥ 10th BWC. Survival without comorbidity was ≥ 90% from 32 weeks' gestation in HDP infants across BWC.

Conclusions: These contemporaneous population-level data show that almost one in two PTB < 34⁺⁰ weeks' gestation are iatrogenic, with HDP and/or FGR being the major contributors to iatrogenic prematurity. This has substantial implications for strategies to reduce preterm birth in the UK and internationally. The data further inform antenatal and at-birth counselling of HDP-exposed infants.

Objective: To quantify the association between a combination of modifiable prepregnancy lifestyle factors and the risk of adverse pregnancy outcomes (APOs).

Design: Prospective cohort study.

Setting: The Japan Environment and Children's Study.

Population: A total of 79 703 pregnant Japanese women without chronic disease.

Methods: Maternal lifestyle before pregnancy was assessed using a self-administered questionnaire. A healthy lifestyle score (HLS, 0-5 points) was calculated based on adherence to five prepregnancy healthy lifestyle factors: healthy weight, high-quality diet, regular physical activity, not smoking, and not drinking alcohol. Relative risks (RRs) and 95% credible intervals (CrIs) were estimated using a Bayesian log-binomial regression model.

Main outcome measures: Composite APOs, defined as the development of any APO, including gestational diabetes, hypertensive disorders of pregnancy, preterm birth, low birth weight, and small-for-gestational-age, transcribed from medical records.

Results: A total of 13 894 women (17.4%) experienced one or more APOs. HLS was inversely associated with the risk of APOs in a dose-response manner. Women with an HLS of 5 points had a 33% (RR 0.67; 95% CrI, 0.61-0.74) lower risk of APOs than those with the lowest HLS (0-1 points). The population attributable fraction of five healthy lifestyle factors was 10.3%. A 1-point increase of HLS could have reduced APO cases by 6.6%.

Conclusions: A higher HLS was associated with a lower risk of APOs, suggesting that adopting a healthy lifestyle before pregnancy may reduce the risk of APOs, which can increase the risk of future chronic diseases in both mother and child.

Background/objective: Current guidelines recommend biopsychosocial-informed treatment for chronic pelvic pain (CPP). The objective of this systematic review was to describe the available biopsychosocial approaches for the treatment of CPP, and the outcomes reported, to understand how guideline-recommended treatments can be applied.

Search strategy: MEDLINE, CINAHL, PsycINFO, EMBASE, Emcare, AMED and Cochrane trial registries were searched (inception to 17 November 2023).

Selection criteria: CPP Studies in women where the principal treatment modality was a biopsychosocial approach were included. Prospero registration: CRD42022374256.

Data collection/analysis: Data extraction included study setting, population, study design, intervention characteristics and outcome measures and is described via a narrative synthesis.

Results: The review included 14 RCTs (871 patients) and identified four broad intervention categories (Acceptance Commitment Therapy n = 2, Cognitive Behavioural Therapy n = 6, Mindfulness-based approaches n = 2, and Physiotherapy-based interventions n = 4). Pain science education (PSE) and, exposure/engagement with valued activity were recognised as important aspects of treatment regardless of intervention type. The most utilised outcomes were pain reduction and emotional functioning, with all studies reporting improvements in these domains. Heterogeneity in outcomes prevented efficacy comparison. High risk of bias was identified in six studies (1/4 physiotherapy-based approaches, 2/6 CBT, 1/2 ACT and 2/2 mindfulness-based interventions).

Conclusions: CBT and ACT-based biopsychosocial approaches were found effective in reducing pain and improving psychometric outcomes for CPP. Evaluation indicated PSE, and exposure/engagement in valued activity are important components of biopsychosocial management. Outcome heterogeneity needs to be addressed in future trials.

Background: Caesarean scar ectopic pregnancy (CSEP) is associated with significant maternal and foetal morbidity. However, the optimal treatment remains unknown.

Objectives: The aim of this study was to review outcomes reported in studies on CSEP treatment and outcome reporting quality.

Search strategy: We reviewed 1270 articles identified through searching PubMed, MEDLINE and Google Scholar from 2014 to 2024 using the search terms 'caesarean scar ectopic pregnancy and caesarean scar pregnancy'.

Selection criteria: We included all study types evaluating any form of CSEP treatment, with a sample size of ≥ 50, where diagnosis was described, and the article was in English.

Data collection and analysis: Two authors independently reviewed studies and assessed outcome reporting and methodological quality. The relationship between outcome reporting quality and publication year and journal type was assessed with univariate and bivariate models.

Main results: A total of 108 studies, including 17 941 women, were included. 83% of all studies originated from China. Studies reported on 326 outcomes; blood loss (86%), need for additional intervention (77%) and time for serum hCG to normalise post treatment (69%) were the most common outcomes. A primary outcome was clearly defined in 11 (10%) studies. The median quality of outcome reporting was 3 (IQR 3-4). No relationship was demonstrated between outcome reporting quality and publication year (p = 0.116) or journal type (p = 0.503).

Conclusions: This review demonstrates that there is a wide variation in outcomes reported in studies on CSEP treatment. Development and implementation of a core outcome set by international stakeholders which includes patients is urgently needed to enable high-quality research that is both useful and relevant to patients.

Objective: To explore factors affecting participation of pregnant women in randomised clinical trials in Belagavi, Karnataka, India.

Design: A qualitative study using semi-structured in-depth interviews and focus group discussions as data collection methods.

Setting: Primary, secondary and tertiary health facilities and their community catchment areas in Belagavi district.

Sample: Thirty-three in-depth interviews with health workers and previous participants of a pregnancy-focused trial, and 12 focus group discussions with currently pregnant women who had not previously participated in a clinical trial, family and community members, and accredited social health activists.

Methods: Inductive thematic analysis with a team-based approach to interpretation in the study context.

Results: Pregnant women were often unable to distinguish between maternal health programmes and trial interventions. Among previous trial participants, expectations of higher quality care were a key motivation for trial participation. Household gendered power relations and trust in the health workforce influenced decisional dynamics regarding participation. Health workers vouched for trial safety, once they assessed the intervention as acceptable. Trial Implementation by the health workforce required understanding and navigating pregnancy-related beliefs and practices in communities.

Conclusion: Anticipated health benefits, improved healthcare access, and trust in health workers are facilitators of trial participation. Engaging primary decision-makers is essential due to household gender dynamics. Trials must integrate strategies that clarify the distinct goals of research versus clinical care.

Objective: To examine whether a history of hysteroscopic adhesiolysis (HA)-treated intrauterine adhesions (IUAs) was associated with an increased risk of adverse obstetrical outcomes in subsequent pregnancies.

Design: Retrospective cohort study.

Setting: A tertiary-care hospital in Shanghai, China.

Population: A cohort of 114 142 pregnant women who were issued an antenatal card and received routine antenatal care in Shanghai First Maternity and Infant Hospital, between January 2016 and October 2021.

Methods: From the cohort of 114 142 pregnant women, each woman with a history of HA-treated IUA prior to the current pregnancy (n = 780) was matched with four women without a history of IUAs (n = 3010) using propensity score matching. The matching variables were maternal age and parity, mode of conception, pre-pregnancy body mass index and prior history of abortion.

Main outcome measures: Pregnancy complications, placental abnormalities, postpartum haemorrhage and adverse birth outcomes.

Results: Compared with women with no history of IUAs, women with a history of HA-treated IUAs were at higher risk of pre-eclampsia (RR 1.69, 95% CI 1.23-2.33), placenta accreta spectrum (RR 4.72, 95% CI 3.9-5.73), placenta praevia (RR 4.23, 95% CI 2.85-6.30), postpartum haemorrhage (RR 2.86, 95% CI 1.94-4.23), preterm premature rupture of membranes (RR 3.02, 95% CI 1.97-4.64) and iatrogenic preterm birth (RR 2.86, 95% CI 2.14-3.81). Those women were also more likely to receive cervical cerclage (RR 5.63, 95% CI 3.95-8.02) during pregnancy and haemostatic therapies after delivery (RR 2.17, 95% CI 1.75-2.69). Moreover, we observed that the RRs of those adverse obstetrical outcomes increased with the increasing number of hysteroscopic surgeries.

Conclusions: This study found that a history of HA-treated IUAs, especially a history of repeated HAs, was associated with an increased risk of adverse obstetrical outcomes.

Background: Patient-reported outcome measures (PROMs) are recommended to measure the impact of a health condition or intervention effectiveness as they aim to capture what is most meaningful to patients. Several PROMs are used to evaluate pelvic organ prolapse (POP)-related domains, yet the measurement properties of these instruments have not been fully explored with a rigorous analysis of the methodological quality and quality of evidence.

Objective: To conduct a systematic review reporting on the measurement properties of PROMs used for the assessment of POP-related domains in accordance with the COSMIN guidelines.

Search strategy: Five databases were searched from inception to December 2023.

Selection criteria: Studies were eligible if they involved (1) at least one group of female adults diagnosed with or presenting with symptoms of POP; (2) a self-reported outcome measure (PROMs, questionnaires) to evaluate POP-related domains; and (3) at least one measurement property.

Data collection and analysis: Methodological quality and measurement quality were assessed using the COSMIN risk of bias (ROB) checklist and the COSMIN criteria for good measurement properties.

Main results: A total of 13 PROMs were included. The BIPOP had the lowest ROB for Content Validity. The POP-SS was the only PROM with sufficient evidence of adequate construct validity and responsiveness to be used in both surgical and conservative management settings.

Conclusion: This original work identified a gap in evidence regarding the measurement qualities of identified PROMs used in the POP population.