Dear Editor, We examined the recent review by Howe and colleagues with great interest, and we wish to commend the authors for producing an extremely useful framework for clinicians involved in the care of patients with the considerably challenging diagnosis of cervical cancer during pregnancy. It was with particular attention that we considered the guidance presented for the management of locally advanced disease, International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB3 and above. Locally advanced disease has been treated over the past 20 years with concomitant platinumbased chemotherapy and radiotherapy, with the potential for definitive surgery in some patients with stage IB3 and IIA. More recently, the use of neo-adjuvant chemotherapy (NACT) followed by radical surgery has been a subject of great interest to the gynaecological oncology community. While acknowledging that the evidence basis is limited, Howe and colleagues advise that NACT may provide some benefit to patients with locally advanced disease who wish to prolong their pregnancy prior to definitive treatment, citing a meta-analysis from 2012 examining NACT followed by surgery versus surgery alone. However, a recent randomised controlled trial examining NACT followed by surgery versus concomitant chemoradiotherapy found superior disease-free survival (DFS) among the chemoradiation group in their intention-to-treat analysis, with the main benefit being apparent among the FIGO stage IIB group. Furthermore, the post-hoc analysis showed worse DFS among patients who could not undergo surgery following NACT and crossed over to the chemoradiotherapy arm, as well as among those who underwent surgery following NACT but needed adjuvant treatment. Although by selection these patients will have had poor prognostic factors, the authors raise the possibility of a detrimental effect on disease control in delaying definitive chemoradiotherapy or inducing cross resistance between chemotherapy and radiotherapy. A further point, as alluded to by Howe and colleagues, is the controversial nature of surgical staging with lymphadenectomy prior to definitive treatment. When considering the challenging nature of accurate clinical staging in pregnancy, as discussed by the authors, one can envisage a scenario where a patient wishes to discuss this strategy to potentially guide her decision making regarding prolongation of her pregnancy. However, the very recent results of the UTERUS-11 trial (published after the work of Howe was submitted), examining clinical versus surgical staging in locally advanced cervical cancer, found no difference in DFS except among the FIGO stage IIB group. Furthermore, patients in this trial all underwent chemoradiotherapy following either clinical or surgical staging, with the goal of staging through identification of lymph node metastases being subsequent adjustment of the target volume definition of primary chemoradiation. We would be most interested to hear the
{"title":"Re: Cervical cancer in pregnancy: diagnosis, staging and treatment","authors":"J. Lowe‐Zinola, Oguljemal Redjepova, C. Griffin","doi":"10.1111/tog.12835","DOIUrl":"https://doi.org/10.1111/tog.12835","url":null,"abstract":"Dear Editor, We examined the recent review by Howe and colleagues with great interest, and we wish to commend the authors for producing an extremely useful framework for clinicians involved in the care of patients with the considerably challenging diagnosis of cervical cancer during pregnancy. It was with particular attention that we considered the guidance presented for the management of locally advanced disease, International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB3 and above. Locally advanced disease has been treated over the past 20 years with concomitant platinumbased chemotherapy and radiotherapy, with the potential for definitive surgery in some patients with stage IB3 and IIA. More recently, the use of neo-adjuvant chemotherapy (NACT) followed by radical surgery has been a subject of great interest to the gynaecological oncology community. While acknowledging that the evidence basis is limited, Howe and colleagues advise that NACT may provide some benefit to patients with locally advanced disease who wish to prolong their pregnancy prior to definitive treatment, citing a meta-analysis from 2012 examining NACT followed by surgery versus surgery alone. However, a recent randomised controlled trial examining NACT followed by surgery versus concomitant chemoradiotherapy found superior disease-free survival (DFS) among the chemoradiation group in their intention-to-treat analysis, with the main benefit being apparent among the FIGO stage IIB group. Furthermore, the post-hoc analysis showed worse DFS among patients who could not undergo surgery following NACT and crossed over to the chemoradiotherapy arm, as well as among those who underwent surgery following NACT but needed adjuvant treatment. Although by selection these patients will have had poor prognostic factors, the authors raise the possibility of a detrimental effect on disease control in delaying definitive chemoradiotherapy or inducing cross resistance between chemotherapy and radiotherapy. A further point, as alluded to by Howe and colleagues, is the controversial nature of surgical staging with lymphadenectomy prior to definitive treatment. When considering the challenging nature of accurate clinical staging in pregnancy, as discussed by the authors, one can envisage a scenario where a patient wishes to discuss this strategy to potentially guide her decision making regarding prolongation of her pregnancy. However, the very recent results of the UTERUS-11 trial (published after the work of Howe was submitted), examining clinical versus surgical staging in locally advanced cervical cancer, found no difference in DFS except among the FIGO stage IIB group. Furthermore, patients in this trial all underwent chemoradiotherapy following either clinical or surgical staging, with the goal of staging through identification of lymph node metastases being subsequent adjustment of the target volume definition of primary chemoradiation. We would be most interested to hear the","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47343821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Androgen therapy can improve sexual wellbeing, libido and sexual arousal in postmenopausal women through its effect on the central nervous system. Testosterone levels gradually decline throughout a woman’s lifespan and testosterone therapy may be useful for menopausal women with sexual dysfunction, in whom estrogen therapy alone has been ineffective.
{"title":"Androgens in postmenopausal women","authors":"K. Vigneswaran, H. Hamoda","doi":"10.1111/tog.12836","DOIUrl":"https://doi.org/10.1111/tog.12836","url":null,"abstract":"Androgen therapy can improve sexual wellbeing, libido and sexual arousal in postmenopausal women through its effect on the central nervous system. Testosterone levels gradually decline throughout a woman’s lifespan and testosterone therapy may be useful for menopausal women with sexual dysfunction, in whom estrogen therapy alone has been ineffective.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47117058","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Referral criteria to recurrent pregnancy loss (RPL) services vary, owing in part to a lack of consensus on the definition of RPL. Good quality evidence is limited, and controversies exist on recommendations for investigations and management of RPL. People with RPL will most likely achieve a live birth in their next pregnancy but should have an individualised approach that identifies and corrects any modifiable risk factors and offers appropriate psychological support.
{"title":"Current management of recurrent pregnancy loss","authors":"Mark R Chester, A. Tirlapur, K. Jayaprakasan","doi":"10.1111/tog.12832","DOIUrl":"https://doi.org/10.1111/tog.12832","url":null,"abstract":"Referral criteria to recurrent pregnancy loss (RPL) services vary, owing in part to a lack of consensus on the definition of RPL. Good quality evidence is limited, and controversies exist on recommendations for investigations and management of RPL. People with RPL will most likely achieve a live birth in their next pregnancy but should have an individualised approach that identifies and corrects any modifiable risk factors and offers appropriate psychological support.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48812004","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Rafi, P. Pathiraja, E. Gelson, Richard Brown, D. Alleemudder
Endometriosis in pregnancy is associated with an increased risk of spontaneous miscarriage, pre‐eclampsia, postpartum haemorrhage, caesarean section, placenta praevia, fetal growth restriction, prematurity and adverse neonatal outcomes. Women with mild disease are considered as having ‘low‐risk endometriosis’ (LRE) and can expect a normal pregnancy and labour. The ‘high‐risk endometriosis’ (HRE) group may require additional antenatal and intrapartum specialist care.
{"title":"Obstetric and perinatal outcomes in women with endometriosis","authors":"J. Rafi, P. Pathiraja, E. Gelson, Richard Brown, D. Alleemudder","doi":"10.1111/tog.12831","DOIUrl":"https://doi.org/10.1111/tog.12831","url":null,"abstract":"Endometriosis in pregnancy is associated with an increased risk of spontaneous miscarriage, pre‐eclampsia, postpartum haemorrhage, caesarean section, placenta praevia, fetal growth restriction, prematurity and adverse neonatal outcomes. Women with mild disease are considered as having ‘low‐risk endometriosis’ (LRE) and can expect a normal pregnancy and labour. The ‘high‐risk endometriosis’ (HRE) group may require additional antenatal and intrapartum specialist care.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44880494","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Raperport, E. Chronopoulou, Anna McLaughlin, Sophie Cox, G. Srivastava, Amit Shah, R. Homburg
Fertility treatment using donated gametes and embryos is increasingly common. Indications for the use of donated sperm and oocytes include azoospermia, single women and women in same‐sex relationships, inherited conditions, poor quality embryos or failed fertilisation in previous cycles of assisted reproductive technology, and ovarian insufficiency. Causes of azoospermia and ovarian insufficiency include congenital and genetic disorders, infectious and traumatic conditions, iatrogenic causes and age‐related decline. These treatment cycles have ethical and legal implications and require appropriate pre‐conception counselling and completion of Human Fertilisation and Embryology Authority (HFEA)‐mandated forms to ensure the safety of donors, recipients and any children born as a result of treatment. All donors are screened for infectious diseases and can also be screened for genetic conditions. Sperm donation can be organised outside of recognised fertility clinic settings, which increases the possibility of infection transmission. Compared with cycles using autologous gametes and embryos, treatment outcomes can increase live birth rates and reduce incidence of low birthweight, but may increase hypertensive disorders of pregnancy.
{"title":"‘It takes a village’ – fertility treatment using donor gametes, embryos and/or surrogacy","authors":"C. Raperport, E. Chronopoulou, Anna McLaughlin, Sophie Cox, G. Srivastava, Amit Shah, R. Homburg","doi":"10.1111/tog.12830","DOIUrl":"https://doi.org/10.1111/tog.12830","url":null,"abstract":"Fertility treatment using donated gametes and embryos is increasingly common. Indications for the use of donated sperm and oocytes include azoospermia, single women and women in same‐sex relationships, inherited conditions, poor quality embryos or failed fertilisation in previous cycles of assisted reproductive technology, and ovarian insufficiency. Causes of azoospermia and ovarian insufficiency include congenital and genetic disorders, infectious and traumatic conditions, iatrogenic causes and age‐related decline. These treatment cycles have ethical and legal implications and require appropriate pre‐conception counselling and completion of Human Fertilisation and Embryology Authority (HFEA)‐mandated forms to ensure the safety of donors, recipients and any children born as a result of treatment. All donors are screened for infectious diseases and can also be screened for genetic conditions. Sperm donation can be organised outside of recognised fertility clinic settings, which increases the possibility of infection transmission. Compared with cycles using autologous gametes and embryos, treatment outcomes can increase live birth rates and reduce incidence of low birthweight, but may increase hypertensive disorders of pregnancy.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47431021","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
H. Sekar, Dhanuson Dharmasena, Ayanthi Gunasekara, M. Nauta, V. Sivashanmugarajan, W. Yoong
Up to one‐third of healthcare personnel still have concerns about speaking up when they notice potential errors. Cultivation of a shallow authority gradient encourages trainees to clarify instructions, challenge decisions and voice concerns, thereby reducing ambiguity and potential errors. Senior doctors should support junior team members who raise concerns by encouraging a working environment that is effective and safe. Aviation, rail and maritime industries recognise that steep authority gradients can lead to reluctance to escalate, resulting in near misses and fatalities.
{"title":"Understanding authority gradient: tips for speaking up for patient safety (and how to enhance the listening response)","authors":"H. Sekar, Dhanuson Dharmasena, Ayanthi Gunasekara, M. Nauta, V. Sivashanmugarajan, W. Yoong","doi":"10.1111/tog.12829","DOIUrl":"https://doi.org/10.1111/tog.12829","url":null,"abstract":"Up to one‐third of healthcare personnel still have concerns about speaking up when they notice potential errors. Cultivation of a shallow authority gradient encourages trainees to clarify instructions, challenge decisions and voice concerns, thereby reducing ambiguity and potential errors. Senior doctors should support junior team members who raise concerns by encouraging a working environment that is effective and safe. Aviation, rail and maritime industries recognise that steep authority gradients can lead to reluctance to escalate, resulting in near misses and fatalities.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46382826","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Healthcare professionals are often asked to collect data and contribute to national and international databases. It is important for us to understand the role data structure has in data performance, particularly focusing on data analysis. This article explores the principles of the role of data, the law and the ethics around its use and its interpretation. The importance of good data in health care underpins the principles of the International Consortium on Health Outcome Measures (ICHOM).
{"title":"Making the best use of clinical datasets: with examples from urogynaecology","authors":"Fiona Bach, P. Toozs-Hobson, Jeremy Purnell","doi":"10.1111/tog.12828","DOIUrl":"https://doi.org/10.1111/tog.12828","url":null,"abstract":"Healthcare professionals are often asked to collect data and contribute to national and international databases. It is important for us to understand the role data structure has in data performance, particularly focusing on data analysis. This article explores the principles of the role of data, the law and the ethics around its use and its interpretation. The importance of good data in health care underpins the principles of the International Consortium on Health Outcome Measures (ICHOM).","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":" ","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42917794","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The proportion of caesarean sections performed in the second stage of labour is rising. Complications of second stage caesarean births are known to be greater for both mother and baby, which may in part be due to deep engagement of the baby’s head in the pelvis, so-called ‘impacted fetal head’. Many different disimpaction techniques have been described. The objective of this study was to use the UK Obstetric Surveillance System (UKOSS) to determine the incidence of, and complication rates from, impacted fetal head at full dilatation caesarean birth in the UK and record what techniques were used. 3,518 second stage caesarean births were reported from 152 of 194 UK obstetric units (82%) between 1st March and 31st August 2019. The surgeon used a disimpaction technique or reported ‘difficulty’ in 564 (16%) of these. The most common disimpaction techniques used were manual elevation of the head by an assistant through the vagina (n = 235) and a fetal ‘pillow’ (n = 176). Fifteen babies (3%) died or sustained severe injury. Four babies died (two directly attributable to the impacted fetal head). Thirty-four women (6%) required level 2 or level 3 critical care. This study shows that impacted fetal head is common and can result in significant maternal and neonatal complications. Although difficulty with delivery of the fetal head and the use of disimpaction techniques during second stage caesarean sections are common there is no consensus as to the best method to achieve delivery and in what order.
{"title":"UKOSS update","authors":"Marian Knight","doi":"10.1111/tog.12821","DOIUrl":"https://doi.org/10.1111/tog.12821","url":null,"abstract":"The proportion of caesarean sections performed in the second stage of labour is rising. Complications of second stage caesarean births are known to be greater for both mother and baby, which may in part be due to deep engagement of the baby’s head in the pelvis, so-called ‘impacted fetal head’. Many different disimpaction techniques have been described. The objective of this study was to use the UK Obstetric Surveillance System (UKOSS) to determine the incidence of, and complication rates from, impacted fetal head at full dilatation caesarean birth in the UK and record what techniques were used. 3,518 second stage caesarean births were reported from 152 of 194 UK obstetric units (82%) between 1st March and 31st August 2019. The surgeon used a disimpaction technique or reported ‘difficulty’ in 564 (16%) of these. The most common disimpaction techniques used were manual elevation of the head by an assistant through the vagina (n = 235) and a fetal ‘pillow’ (n = 176). Fifteen babies (3%) died or sustained severe injury. Four babies died (two directly attributable to the impacted fetal head). Thirty-four women (6%) required level 2 or level 3 critical care. This study shows that impacted fetal head is common and can result in significant maternal and neonatal complications. Although difficulty with delivery of the fetal head and the use of disimpaction techniques during second stage caesarean sections are common there is no consensus as to the best method to achieve delivery and in what order.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":"24 1","pages":""},"PeriodicalIF":1.4,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41497974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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