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

Background: Around half of preterm births lack identifiable causes, indicating the need for further investigation to understand preterm birth risk factors. Existing studies on the intergenerational association of preterm birth showed inconsistency in effect size and direction.

Objective: This systematic review and meta-analysis aimed to review existing studies and provide comprehensive evidence on the intergenerational association of preterm births.

Search strategy: We searched MEDLINE, Embase and Maternity and Infant Care databases, from the inception of each database to 04 April 2024.

Selection criteria: Eligibility criteria included studies that reported on women who had given birth and had recorded information about a family history of preterm birth in one or both of the child's biological parents.

Data collection and analysis: Data were extracted by two independent reviewers. A random-effects model was used to compute pooled estimates using odds ratios.

Main results: Sixteen eligible studies with a total of 2 271 612 mothers were included. The findings indicated a 1.44 (OR = 1.44, 95% CI: 1.34, 1.54) fold increase in odds of giving preterm births among women who were born preterm. Additionally, having a sibling born preterm (OR = 1.53, 95% CI: 1.24, 1.87) and having a partner born preterm (OR = 1.12, 95% CI: 1.01, 1.25) were associated with increased likelihood of giving preterm births among women.

Conclusion: The study revealed that women with a family history of preterm birth face an increased risk of giving preterm births. Screening pregnant women for a family history of preterm birth is essential, with those having a positive family history requiring closer follow-up.

Objective: To analyse the global burden, trends and cross-country inequalities of female breast and gynaecologic cancers (FeBGCs).

Design: Population-Based Study.

Setting: Data sourced from the Global Burden of Disease Study 2019.

Population: Individuals diagnosed with FeBGCs.

Methods: Age-standardised mortality rates (ASMRs), age-standardised Disability-Adjusted Life Years (DALYs) rates (ASDRs) and their 95% uncertainty interval (UI) described the burden. Estimated annual percentage changes (EAPCs) and their confidence interval (CI) of age-standardised rates (ASRs) illustrated trends. Social inequalities were quantified using the Slope Index of Inequality (SII) and Concentration Index.

Main outcome measures: The main outcome measures were the burden of FeBGCs and the trends in its inequalities over time.

Results: In 2019, the ASDRs per 100 000 females were as follows: breast cancer: 473.83 (95% UI: 437.30-510.51), cervical cancer: 210.64 (95% UI: 177.67-234.85), ovarian cancer: 124.68 (95% UI: 109.13-138.67) and uterine cancer: 210.64 (95% UI: 177.67-234.85). The trends per year from 1990 to 2019 were expressed as EAPCs of ASDRs and these: for Breast cancer: -0.51 (95% CI: -0.57 to -0.45); Cervical cancer: -0.95 (95% CI: -0.99 to -0.89); Ovarian cancer: -0.08 (95% CI: -0.12 to -0.04); and Uterine cancer: -0.84 (95% CI: -0.93 to -0.75). In the Social Inequalities Analysis (1990-2019) the SII changed from 689.26 to 607.08 for Breast, from -226.66 to -239.92 for cervical, from 222.45 to 228.83 for ovarian and from 74.61 to 103.58 for uterine cancer. The concentration index values ranged from 0.2 to 0.4.

Conclusions: The burden of FeBGCs worldwide showed a downward trend from 1990 to 2019. Countries or regions with higher Socio-demographic Index (SDI) bear a higher DALYs burden of breast, ovarian and uterine cancers, while those with lower SDI bear a heavier burden of cervical cancer. These inequalities increased over time.

One of the most concerning papers in this issue of BJOG is a study from the Netherlands noting an increased percentage of maternal deaths (through one year postpartum) are due to suicide (Lommerse et al, BJOG 2024). The percentage of maternal deaths in the Netherlands due to suicide increased from 18% between 1996 to 2005, to 28% between 20006 to 2020. Indeed, suicide is now the leading cause of maternal death in the Netherlands. Sadly, this problem is not unique to Holland. Suicide is also the most common cause of maternal death in the U.K., France, and the U.S. (Diguisto et al, BMJ. 2022;379:e070621; Knight et al., Oxford: National

Perinatal Epidemiology Unit, University of Oxford; 2021; Khalifeh et al, Lancet Psychiatry. 2016; 3:233–42; Trost et al, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2024). Further, mortality is merely the tip of the iceberg, accounting for only a small fraction of cases of severe maternal mental health and substance use disorders. Accordingly, improved screening for and treatment of mental health conditions and substance use disorder has the potential to greatly impact maternal morbidity and mortality.

A theme linking several articles in this issue of BJOG, are the “non-scientific” aspects of medicine. These include implementation science, patient experience, and cost-effectiveness. Moffat and coworkers report on postpartum contraception uptake in the Northeast and North Cumbrian Integrated Care System in England (Moffat et al; BJOG 2024). Data were obtained via online survey, and thus, prone to bias. Nonetheless, only 38.7% of respondents accessed any contraception postpartum, and only 15.5% accessed long-acting reversable contraception. 18.8 % indicated that they could not obtain their preferred method of contraception. These data underscore the need for better implementation strategies. Although we know that contraception is effective, it only works if people can obtain it. Further work should identify barriers (educational, logistical, financial, cultural, etc.) and potential solutions to enhance utilization of contraception and other effective interventions.

The emotional impact of medical interventions is critically important, but often neglected in research studies. In work by Kwong et al, 2596 people evaluated for ovarian cancer were evaluated for anxiety using the State-trait anxiety inventory (STAI-6) and distress using the Impact of Event Scale – revised (Kwong et al, BJOG 2024). 52.1% of participants reported moderate-severe anxiety and 68.6% had moderate-severe distress. Category of anxiety or distress remained unchanged or worse after 12 months in 76%, despite finding out that they did not have cancer. This study underscores the need to provide mental health support for people being evaluated for cancer, and to consider the duress associated with false positive screening tests. In another study assessing emotional health, Cattani and cow

The aim of this document is to provide guidance for the management of women and birthing people with a permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD). Cardiac devices are becoming more common in obstetric practice and a reference document for contemporary evidence-based practice is required. Where evidence is limited, expert consensus has established recommendations. The purpose is to improve safety and reduce the risk of adverse events relating to implanted cardiac devices during pregnancy, birth and the postnatal period.

Objective: To investigate pelvic floor dysfunction (PFD; urinary incontinence (UI), faecal incontinence (FI) and prolapse) ≥20 years after childbirth and their association with delivery mode history and demographic characteristics.

Design: Cohort study with long-term follow-up.

Setting: Maternity units in Aberdeen and Birmingham (UK) and Dunedin (NZ).

Population: Women giving birth in 1993/1994.

Methods: Postal questionnaires at 20 (New Zealand) or 26 (United Kingdom) years after index birth (n = 6195). Regression analyses investigated associations between risk factors and UI, FI and prolapse symptoms.

Main outcome measures: Prevalence of self-reported UI, FI, 'something coming down' from or in the vagina (SCD), and the Pelvic Organ Prolapse-Symptom Score, and relationships with delivery method.

Results: Thirty-seven per cent (n = 2270) responded at 20/26 years, of whom 61% reported UI (59% of whom reported more severe UI), 22% FI and 17% prolapse symptoms. Having only caesarean section (CS) was associated with a significantly lower risk of UI (OR 0.63, 95% CI 0.46-0.85), FI (OR 0.63, 95% CI 0.42-0.96) and SCD (OR 0.44, 95% CI 0.27-0.74) compared to only spontaneous vaginal deliveries (SVDs). Having any forceps delivery was associated with reporting FI compared to only SVDs (OR 1.29, 95% CI 1.00-1.66), but there was no association for UI (OR 0.95, 95% CI 0.76-1.19) or SCD (OR 1.05, 95% CI 0.80-1.38). Higher current BMI was associated with all PFD outcomes.

Conclusions: Prevalence of PFD continues to increase up to 26 years following index birth, and differences were observed according to delivery mode history. Exclusive CS was associated with less risk of UI, FI and any prolapse symptoms.

Objective: Pregnancy complicated with type B aortic dissection is a rare but devastating condition. Guidelines for managing this condition are lacking. We present our observation and experiences in managing five pregnant women with complicated type B aortic dissection in the second or third trimesters, aiming to gain insights that can aid in proposing an appropriate management strategy.

Design: A retrospective study.

Setting: Zhongnan Hospital of Wuhan University.

Population: Pregnant women with complicated type B aortic dissection.

Methods: Clinical data of five pregnant women with complicated type B aortic dissection admitted to Zhongnan Hospital of Wuhan University from January 2022 to June 2023 were collected. The clinical characteristics, treatment strategies, and corresponding maternal and infant outcomes were retrospectively analysed.

Main outcome measures: Survival of mothers and foetuses.

Results: All five study participants were diagnosed with complicated type B aortic dissection by computed tomography angiography (CTA). The range of gestational weeks at admission was 27 weeks + 3 days to 36 weeks + 6 days. The first patient, planning a caesarean section (C-section) followed by thoracic endovascular aortic repair (TEVAR), died of aortic dissection rupture during C-section. Her neonate was successfully rescued. In contrast, the remaining four patients who underwent TEVAR first survived. Among them, three patients underwent single-stage aortic repair and delivery, while one patient received C-section 31 days after TEVAR. Three preterm live births were recorded among these surviving mothers. Neonatal death occurred in one case with a gestational age of 29 weeks + 5 days, who had foetal distress before surgery. During the follow-up period of up to 3 months, no maternal or infant death occurred. No device-related or systemic complications were observed in the surviving mothers after discharge. Routine physical examinations of the four live births showed no abnormalities.

Conclusions: For pregnant women with thoracic back pain and high suspicion of aortic dissection, CTA should be conducted promptly to prevent missed or delayed diagnosis. Maternal survival should be prioritised over foetal outcome once diagnosed. TEVAR was demonstrated to be safe and feasible for such patients. For women with complicated type B aortic dissection in late pregnancy, TEVAR followed by C-section may be a promising treatment strategy.

Objective: A Serous Tubal Intraepithelial Carcinoma (STIC) without concomitant invasive carcinoma is occasionally identified and associated with a high risk of subsequent peritoneal carcinomatosis. Management needs optimisation. This study explores professionals' opinions and clinical practices regarding the diagnosis, counselling, treatment and follow-up of isolated STIC to facilitate clinical decision making and optimise the direction of future research. A secondary aim is to assess international clinical guidelines.

Design: Focus group study.

Setting: Four online sessions.

Population: International panel (n = 12 countries) of gynaecologists, gynaecologic oncologists, pathologists and medical oncologists (n = 49).

Methods: A semi-structured interview guide was used. Two independent researchers analysed transcripts by open and axial coding. Results were organised in domains. Relevant (inter)national guidelines were screened for recommendations regarding isolated STIC.

Main outcome measures: Professionals' opinions and clinical practices regarding isolated STIC management.

Results: Regarding pathology, most professionals identified the SEE-FIM protocol as standard of care for high-risk patients, whereas variation exists in the histopathological examination of fallopian tubes in the general population. Confirmation of STIC diagnosis by a specialised pathologist was recommended. Regarding work-up and follow-up after STIC diagnosis, there was variety and discordance. Data on outcomes is limited. As for treatment, chemotherapy and PARP inhibitors were not recommended by most. Eleven guidelines provided limited recommendations.

Conclusions: We identified recommendations and highlighted knowledge gaps in the diagnosis and management of isolated STIC. Moreover, recommendations in clinical guidelines are limited. There is an agreed need for international collaboration for the prospective registration of isolated STIC.

Objective: To explore how women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome experience dilation or surgical vaginal lengthening treatment, and their current sexual well-being.

Design: A qualitative interview study.

Setting: Denmark.

Population: Women aged ≥25 years diagnosed with MRKH syndrome.

Methods: Semi-structured video interviews were conducted with 18 women. Interviews lasted a median of 92 min and were digitally recorded, transcribed and anonymised. Data were analysed using thematic analysis.

Main outcome measures: A qualitative analysis of women's experiences.

Results: The analysis identified three themes. Firstly, Experiences with dilation treatment revealed dilation as an awkward routine, especially for adolescents living with parents and yet to sexually debut. While some experienced successful vaginal lengthening, others faced treatment failure leading to frustration and self-blame. Secondly, Experiences with neovaginal surgery described the procedure as extremely painful but resulting in a 'normal size' vagina. Some women felt that the procedure had negatively impacted their self-confidence, and all underscored the importance of maturity before opting for surgery. Lastly, Current sex life and sexual well-being indicated a well-functioning sex life for many women, but with reported low sexual confidence and genital self-image due to the perceived 'deviance' of their genitalia.

Conclusions: For women with MRKH syndrome, vaginal lengthening treatment, whether through dilation or surgery, may result in a 'normal size' vagina. However, according to the women's experiences, vaginal lengthening treatment does not adequately foster positive sexual esteem and genital self-image.