Acta Obstetricia et Gynecologica Scandinavica最新文献

Introduction: Uterine transplantation is currently intended for women with absolute uterine infertility. Since proof of the concept in 2014, many countries have started research programs and clinical activities. However, access to uterine transplantation remains limited given that only a few hundred transplants have been described worldwide compared with the 1.5 million women of childbearing age who suffer from absolute uterine infertility. The aim of this study was to investigate how limited access to uterine transplantation is perceived by women with Mayer-Rokitansky-Küster-Hauser syndrome and health professionals involved in uterus transplantation programs.

Material and methods: We conducted a qualitative study with semistructured interviews in France, Norway, and Sweden with women with Mayer-Rokitansky-Küster-Hauser syndrome and health professional involved in uterine transplantation programs. The interviews were analyzed manually using thematic content analysis. The research questions were: How do (a) women with Mayer-Rokitansky-Küster-Hauser syndrome and (b) healthcare professionals involved in uterus transplantation programs perceive uterus transplantation and its accessibility 10 years after proof of concept?

Results: The interviews enabled us to highlight a number of themes addressed by doctors and women with Mayer-Rokitansky-Küster-Hauser syndrome, the main ones being the hope raised by this technique and the disappointment for those who do not have access to it, the lack of perception of the risks associated with the technique, and finally, an inequity of access and the training difficulties this entails for the teams.

Conclusions: Access to uterine transplantation varies widely across Europe owing to legislative restrictions and limited access due to resources or competence. The result is a feeling of injustice/misunderstanding and despair for these women who had planned to become parents and cannot benefit from a transplant. They appear to be poorly supported. Women who are ultimately unable to access a transplant program should perhaps be given psychological support to deal with this disappointment, whereas the minority who finally have had access to transplant programs are supervised by well-trained multidisciplinary teams.

Introduction: Diagnostic work-up of older women with a positive cervical cancer screening test is often challenging due to incomplete visualization of the transformation zone. To reduce the risk of missing disease, a diagnostic cervical excision may be performed. However, little is known on treatment efficacy and post-treatment surveillance for older women. We aimed to investigate the proportion of women testing negative for human papillomavirus (HPV) following a diagnostic cervical excision due to an abnormal screening test.

Material and methods: We conducted a prospective cohort study on women aged ≥45 years who were referred for colposcopy due to an abnormal screening test between March 2019 and June 2021. All women had incomplete visualization of the transformation zone and underwent colposcopy and a diagnostic cervical excision at the first visit. Women were followed from date of excision until January 30, 2023. Follow-up data was retrieved from the Danish Pathology Databank, and baseline characteristics were obtained from medical records. Cox regression was used on interval-censored data to estimate crude and adjusted hazard ratios for a negative HPV test after cervical excision, stratified by histology and age.

Results: A total of 100 women underwent a diagnostic cervical excision and had at least one HPV test during follow-up. Median age was 67.4 years, and median follow-up time was 2.9 years. At the end of follow-up, 70% tested HPV negative. Women with cervical intraepithelial neoplasia grade two or worse in their excision specimen were more likely to test HPV negative at the first test after cervical excision compared to women with less than cervical intraepithelial neoplasia grade two, however, not statistically significant (adjusted hazard ratio 1.69, 95% CI 0.92-3.10). Women aged 65-84 years were less likely to test HPV negative compared to women <65 years (adjusted hazard ratio 0.49, 95% CI 0.28-0.87).

Conclusions: In older women undergoing a diagnostic cervical excision, 70% tested HPV negative after 2.9 years, leaving 30% with persistent HPV positivity. More studies are needed to determine the risks associated with continued HPV positivity in the absence of high-grade disease. Furthermore, given the absence of specific guidelines, the optimal surveillance frequency remains unknown.

Introduction: Evidence suggests that gestational diabetes mellitus (GDM) is associated with subsequent cardiovascular disease; however, it is unclear what impact changes in screening and diagnostic criteria have had on the association of GDM with long-term outcomes such as cardiovascular disease. The purpose of this study was to determine the association between GDM and subsequent cardiovascular disease during a period of rising gestational diabetes diagnosis in England. Specifically, associations were compared before and after 2008, when national guidelines supporting risk factor-based screening were introduced.

Material and methods: We conducted a cohort study using routinely collected data from the Clinical Practice Research Datalink linked to the Hospital Episode Statistics and Office for National Statistics databases. The study consisted of persons aged 15-45 years with a livebirth or stillbirth between 1998 and 2017 and without a history of cardiovascular disease or pre-pregnancy diabetes mellitus. Cox proportional hazards models, with propensity score weighting using matching weights, were used to estimate adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the association of GDM diagnosis in the first recorded pregnancy with subsequent cardiovascular disease.

Results: Among 232 315 individuals, the incidence of cardiovascular disease was 6.6 per 1000 person-years among those with GDM and 2.2 per 1000 person-years among those without GDM over a mean follow-up duration of 5.8 years. The overall aHR, 95% CI was 1.91 (1.41, 2.60). Diagnosis of GDM increased over the study period, from 0.7% in 1998-99 to 5.3% in 2017. The effect size was not markedly different in the years before (1998-2007: adjusted HR 2.05, 95% CI 2.05 1.35, 3.12) and after 2008 (2008-2017: adjusted HR 1.79, 95% CI 1.15, 2.80).

Conclusions: There was a strong association of GDM with cardiovascular disease after accounting for social and demographic factors and multiple comorbidities, and this association was present both before and after 2008, when national gestational diabetes screening criteria were established.

Introduction: The pelvic floor is exposed to differing stresses and trauma depending on the mode of birth. At the same time, the pelvic floor plays a crucial role in female sexual functioning (FSF). Whereby FSF encompasses different dimensions, from subjective satisfaction to physiological aspects, such as lack of pain and orgasm ability. The aim of the study presented here is to assess FSF in relationship to postpartum pelvic floor disorder based on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), in a large convenience sample and to identify whether there is an association between mode of birth as well as perineal injuries and FSF of women up to 24 months postpartum.

Material and methods: We conducted a cross-sectional online survey and recruited via social media women up to 24 months after birth of their last child. FSF was surveyed using the PISQ-IR. Details were also collected on all previous births and birth-related perineal trauma, as well as current breastfeeding, obesity, and socio-demographics. Multivariate models were then calculated to determine a possible association between FSF and birth mode.

Results: The data basis is the responses of 2106 survey participants within the first 24 months postpartum. Even 12-24 months postpartum, 21% of respondents are not sexually active, which burdens almost 44% of these women. With regard to mode of delivery, differences in FSF are only evident in individual dimensions of the PISQ-IR. The dimensions "Condition Impact" and "Condition Specific" were significantly associated with more impairments in sexually active respondents up to 12 months postpartum whose last mode of delivery was forceps or vacuum extraction. If a perineal tear had occurred during last birth, this was significantly associated with a lower PISQ-IR subscore in the "Condition Impact," "Condition-Specific," "Global Quality," "Partner-Related," and "Arousal" models. The low variance explanation shows that further relevant factors on female sexuality may exist.

Conclusions: The issue of impairments in FSF following childbirth, persisting for an extended period of time, is a significant postpartum concern. Due to the very different dimensions of FSF, the influence of the mode of delivery must be considered in a differentiated way.

Introduction: In recent decades, centralization of health care has resulted in a number of obstetric unit closures. While studies support better infant outcomes in larger facilities, few have investigated maternal outcomes. We investigated obstetric unit closures over time and whether obstetric volume is associated with onset of labor, postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS).

Material and methods: All births registered in Sweden between 1992 and 2019 (Medical Birth Register, N = 2 931 140), linked with data on sociodemographic characteristics and maternal/infant diagnoses, were used to describe obstetric unit closures. After excluding congenital malformations, obstetric volume was categorized (low: 0-1999, medium: 2000-3999, high: ≥4000 births per year). Restricting to 2004 onwards (after most closures), the association between volume and onset of labor (spontaneous as reference) was estimated. Restricting to spontaneous, full-term (≥37 weeks gestation) cephalic births, we then investigated the association between volume and PPH and, after excluding planned cesarean sections, OASIS. Odds ratios from multilevel (logistic) models clustered by hospital were estimated.

Results: The 20 dissolved obstetric units (1992-2019) had relatively stable volume until their closure. Compared to the average, women birthing in the highest volume hospitals were older (31.3 years vs. 30.4) and a higher proportion had >12 years of education (57 vs. 51%). Compared to high-volume hospitals, there was no significant difference in labor starting by elective cesarean section or induction, rather than spontaneously, among low (OR 0.88, 95% CI: 0.73-1.06) and medium (OR 0.84, 95% CI 0.71-1.01) volume hospitals. There were lower odds of PPH among low (OR 0.72, 95% CI 0.63-0.85) and medium (OR 0.83, 95% CI 0.72-0.97) volume hospitals. No significant association was found between obstetric volume and OASIS (low: OR 0.98, 95% CI 0.82-1.18; medium: OR 0.90, 95% CI 0.77-1.05).

Conclusions: There was not a strong relationship between obstetric volume and maternal outcomes. Reduced odds of PPH for women birthing in smaller units may be due to triaging high-risk pregnancies to larger hospitals. While there was no significant association between obstetric volume and onset of labor or OASIS, other important factors related to closures, such as workload and overcrowding, should be investigated.

Introduction: Being able to counsel patients with one prior cesarean birth on the risk of uterine rupture with a trial of labor after cesarean, (TOLAC) is an important aspect of prenatal care. Despite uterine rupture being a catastrophic event, there is currently no successful, validated prediction model to predict its occurrence.

Material and methods: This was a cross-sectional study using US national birth data between 2014 and 2021. The primary objective was to identify risk factors for uterine rupture during TOLAC and to generate a prediction model for uterine rupture among singleton gestations with one prior cesarean as their only prior birth. The secondary objective was to describe the maternal and neonatal morbidity associated with uterine rupture. The association of all candidate variables with uterine rupture was tested with uni- and multi-variable logistic regression analyses. We included term and preterm singleton pregnancies with one prior birth that was cesarean birth (CB) with cephalic presentation undergoing TOLAC. We excluded pregnancies with major structural anomalies and chromosomal abnormalities. The Receiver Operating Characteristics (ROC) Curve was generated. p value <0.001 was considered statistically significant.

Results: Of the 270 329 singleton pregnancies with one prior CB undergoing TOLAC during the study period, there were 957 cases of uterine rupture (3.54 cases per 1000). Factors associated with uterine rupture in multivariable models were an interpregnancy interval < 18 months vs the reference interval of 24-35 months (aOR 1.55; 95% CI, 1.19-2.02), induction of labor (aOR 2.31; 95% CI, 2.01-2.65), and augmentation of labor (aOR 1.94; 95% CI, 1.70-2.21). Factors associated with reduced rates of uterine rupture were maternal age < 20 years (aOR 0.33, 95% CI 0.15-0.74) and 20-24 years (aOR 0.79, 95% CI 0.64-0.97) vs the reference of 25-29 years and gestational age at delivery 32-36 weeks vs the reference of 37-41 weeks (aOR 0.55, 95% CI 0.38-0.79). Incorporating these factors into a predictive model for uterine rupture yielded an area under the receiver-operating curve of 0.66. Additionally, all analyzed maternal and neonatal morbidities were increased in the setting of uterine rupture compared to non-rupture.

Conclusions: Uterine rupture prediction models utilizing TOLAC characteristics have modest performance.

We evaluated the efficacy of large language models (LLMs), specifically, generative pre-trained transformer-4 (GPT-4), in predicting pregnancy following in vitro fertilization (IVF) treatment and compared its accuracy with results from an original published study. Our findings revealed that GPT-4 can autonomously develop and refine advanced machine learning models for pregnancy prediction with minimal human intervention. The prediction accuracy was 0.79, and the area under the receiver operating characteristic curve (AUROC) was 0.89, exceeding or being at least equivalent to the metrics reported in the original study, that is, 0.78 for accuracy and 0.87 for AUROC. The results suggest that LLMs can facilitate data processing, optimize machine learning models in predicting IVF success rates, and provide data interpretation methods. This capacity can help bridge the knowledge gap between data scientists and medical personnel to solve the most pressing clinical challenges. However, more experiments on diverse and larger datasets are needed to validate and promote broader applications of LLMs in assisted reproduction.

Introduction: Intimate partner violence against women is a global health issue. Exposure to intimate partner violence during pregnancy leads to health-related problems for both the mother and the newborn. However, current knowledge on its occurrence varies widely and assessing the problem using standardized tools in different contexts is needed. This study aimed to estimate the prevalence and associated factors of IPV in pregnant women in Denmark and Spain through digital screening tools.

Material and methods: A cross-sectional design was used to systematically screen for intimate partner violence among pregnant women attending antenatal care by using standardized digital screening tools, Woman Abuse Screening Tool and Abuse Assessment Screen.

Results: A total of 17 220 pregnant women in Denmark and 2222 pregnant women in Spain were invited to participate. The response rate was high in both countries (77.3% and 92.5%, respectively). Overall, 6.9% (n = 913) and 13.7% (n = 282) screened positive in Denmark and Spain, respectively. Logistic regressions estimated crude and adjusted odds ratio with 95% confidence intervals of the relationship between sociodemographic variables and intimate partner violence. In both countries, being unmarried and lacking social support were risk factors of intimate partner violence. Additionally, in Denmark, pregnant women older than 40 years, unemployed or foreign, were at higher risk, while having higher educational levels was a protective factor. In Spain, not having a partner at the time of questionnaire completion and having at least one child prior to the current pregnancy were risk factors of intimate partner violence.

Conclusions: Prevalence results and found associated factors contribute to a more comprehensive understanding of the occurrence of intimate partner violence during pregnancy in Denmark and Spain, while highlighting the feasibility of digital systematic screening in antenatal settings.

Introduction: Occiput posterior (OP) position rates at birth are 5%-8% in studies mainly comprising white European women. The anthropoid pelvis is common in black African women. This pelvic shape has a narrow anterior segment and an ample room posteriorly. The fetal head is wider posteriorly, and the OP position may be favorable in women with an anthropoid pelvic shape. We aimed to examine the fetal rotation with ultrasound longitudinally during the active phase of labor in a sub-Saharan population. We also aimed to examine associations between fetal position, delivery mode, and duration of labor.

Material and methods: The study was conducted at Kilimanjaro Christian Medical Centre in Moshi, Tanzania from the 19th of November 2023 to 13th of April 2024. Women with a single fetus in cephalic presentation, gestational age >37 weeks, without previous or pre-labor cesarean section were eligible. Fetal position was classified as occiput anterior (OA) from 10 to 2 o'clock, occiput transverse (OT) at 3 or 9 o'clock, and OP position from 4 to 8 o'clock.

Results: The study participants comprised 215 women. Fetal positions at admission, in the first and second stage of labor and at birth are presented in the graphical figure. In all, 65/215 (30.2%) fetuses were in OP position at admission, 59/204 (28.9%) in the first stage, 38/210 (18.1%) in the second stage and 35/215 (16.3%) were delivered in OP position. The OP rates at birth were 25/92 (27.2%) in nulliparous and 10/123 (8.1%) in parous women. The operative delivery rate was 10/157 (6.4%) in women with ultrasound assessed fetal position as OA in the second stage (six cesarean section and four vacuum extractions), and 28/48 (58.3%) in the non-OA group (27 cesarean section and one vacuum extraction) (p < 0.01). The hazard ratio for delivery in the second stage was 0.26 (95% CI 0.13-0.52) for the non-OA vs the OA group in nulliparous women and 0.25 (95% CI 0.12-0.52) in parous women.

Conclusions: The persistent OP position rate at birth was higher than previously reported, and the operative intervention rate was nine time higher in women with the fetus in non-OA vs OA position in the second stage.