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

Background: Endometriosis diagnosis reportedly faces delays of up to 10 years. Despite growing awareness and improved guidelines, information on the current status is limited.

Objectives: To systematically assess the published evidence on the status of time to diagnosis in individuals with endometriosis, with respect to the definition of time to diagnosis, geographical location and patient characteristics.

Search strategy: MEDLINE (via PubMed) and Embase were searched for publications reporting time to diagnosing endometriosis since 2018. No restrictions to population or comparators were applied. All publications were screened by two independent reviewers.

Selection criteria: Search results were limited to primary publications of randomised controlled trials, non-randomised trials and observational studies. Case reports, secondary publications and grey literature were excluded. No restrictions were made regarding language, provided that an English title and abstract were available.

Data collection and analysis: Publications were assessed with respect to time to diagnosis, diagnostic methods, study type, study country and potential bias.

Main results: The 17 publications eligible for inclusion in this literature review were all observational studies. The publications reported diagnosis times between 0.3 and 12 years, with variations depending on the definition of time to diagnosis (overall, primary, or clinical), geographical location and characteristics of the included study population. Evidence was of poor to good quality overall.

Conclusions: Diagnostic delay is still present, primarily driven by physicians, and this review underscores the need for standardised definitions, increased awareness and targeted diagnostic interventions.

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.

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.

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.

Objectives: This study aimed to evaluate the training and self-assessed proficiency of surgeons in the surgical management of pelvic organ prolapse (POP). We focused on the factors that influence decision-making, the surgical techniques employed, the training received, and the management of complications.

Design: A cross-sectional survey.

Setting: An electronic questionnaire.

Population: European Urogynaecological Association (EUGA) and International Urogynecological Association (IUGA) members.

Methods: A total of 33 questions evaluating surgeon preference regarding vaginal surgeries.

Main outcome measures: Demographics, surgical selection, proficiency and technique, and training methods.

Results: There were 471 respondents, of which 273 (58%) dedicated more than 50% of their week to urogynaecology. 250 (53%) had completed a fellowship, with 215 (86%) of those fellowships being in urogynaecology and pelvic floor reconstruction. A preference for hysterectomy in cases of uterine descent was noted by 297 (63%) respondents, influenced mainly by patient preference, age, and prolapse anatomical score. A total of 443 (94%) were proficient in vaginal hysterectomy, with two-thirds performing 30 or fewer procedures annually; 212 (45%) reporting a decrease in the number of procedures over the last decade. Additionally, 373 (79%) respondents believed that 10-30 cases were needed to achieve and maintain proficiency.

Conclusion: Vaginal hysterectomy remains a key component in uterine prolapse repair. However, with the rise of uterine-sparing prolapse repairs, the decision-making process may be influenced by multiple factors, including surgical training. Emphasis should be placed on training and maintaining proficiency in both traditional and novel techniques.

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.