Acta Obstetricia et Gynecologica Scandinavica最新文献

Introduction: Term full dilatation cesarean delivery (FDCD) is associated with an increased risk of subsequent spontaneous preterm birth (sPTB). The impact of preterm FDCD on recurrent sPTB is unknown. We investigated the relationship between recurrent sPTB and the mode of prior sPTB.

Material and methods: This is a retrospective cohort study of singleton pregnant women attending two high-risk preterm birth surveillance clinics (University College London Hospital and St Thomas' Hospital London, UK), with one previous sPTB (24-36 + 6 weeks). Women were categorized according to their mode of birth in the index sPTB pregnancy: (1) preterm FDCD, (2) preterm vaginal birth and (3) preterm cesarean delivery at <10 cm cervical dilatation (CD < 10 cm). The primary outcome was recurrent sPTB <37 weeks of gestation. Secondary outcomes included sPTB <34 weeks, <28 weeks, spontaneous late miscarriage and short cervical length (≤25 mm). In a subgroup of women with preterm FDCD, CD scar characteristics were assessed during the second trimester of pregnancy using transvaginal ultrasound.

Results: Median gestation of prior sPTB was similar across all groups (32 weeks; p = 0.454). Recurrent sPTB <37 weeks was significantly more common in women with previous preterm FDCD, 38.1% (8/21) compared to vaginal birth, 15.1% (16/106) or CD < 10 cm, 13.8% (15/109); aOR 4.4 (95% CI 1.3-14.9; p = 0.023) and 5.1 (95% CI 1.6-16.5; p = 0.022), respectively. Recurrent sPTB <34 weeks was even higher in the previous preterm FDCD group, 23.8% (5/21) compared to vaginal birth 4.7% (5/106) or CD < 10 cm 8.3% (9/109); aOR 16.6 (95% CI 2.8-97.2; p = 0.016) and 5.7 (95% CI 1.4-23.1; p = 0.022), respectively. CD scar location was assessed in 15 women with preterm FDCD in one centre. Scar visualization was 87%, with 77% (10/13) of scars being located within the cervix or <5 mm above the internal cervical os.

Conclusions: Women undergoing FDCD following preterm labor have a significantly higher risk of recurrent sPTB at <37 and <34 weeks of gestation compared to women with previous preterm vaginal birth or CD prior to the second stage of labor. These findings suggest that preterm FDCD may further compromise cervical function. It is important that clinicians are aware of this increased risk of recurrent sPTB to guide patient counseling and management accordingly.

Introduction: Somatization disorders belong to a category of psychiatric conditions in which psychological distress and impairment are manifested as physical symptoms. Affected patients tend to utilize specialist healthcare services more frequently and have more emergency visits than those without somatization. From a gynecological perspective, it is of relevance to investigate whether any specific somatic symptoms are linked to previous experience of physical, psychological, or sexual violence. The study aimed to explore whether any specific symptoms could be associated with level of somatization among women consulting a gynecologist; whether experience of physical, psychological, or sexual violence could be associated with level of somatization; and whether experience of violence is associated with self-rated state of health.

Material and methods: A cross-sectional survey was conducted at three gynecological clinics in western Sweden between February and May 2024. A project-specific questionnaire was distributed to women who consulted the clinic and completed in the waiting room. The survey consisted of 13 items, including sociodemographic variables, reasons for the current gynecological consultation, self-rated health, history of physical, psychological or sexual violence, discomfort during gynecological examination, and somatic symptom severity. Data were analyzed using descriptive statistics, chi-square tests, ANOVA, and multivariable linear regression analyses.

Results: Of 2000 questionnaires distributed, 1766 were completed (response rate 88.3%). Among participants, 21.8% reported experience of sexual violence, 16.8% psychological violence, and 13.6% physical violence. Among those reporting any form of violence (n = 653), overlap was common: 236/653 (36.1%) had experienced only sexual violence, while 191/653 (29.2%) had experienced all three types. Somatic symptom severity was significantly associated with both sexual and psychological violence, but not physical violence. Clinical predictors of somatization included abdominal pain, dysmenorrhea, and multiple symptoms including pain. High somatic symptom severity was strongly associated with worse self-rated health. Somatic symptoms and specific consultation reasons, but not violence experiences, were significantly associated with self-rated health.

Conclusions: Somatization is common among women seeking gynecological care and is associated with a history of sexual and psychological violence. The findings underscore the importance of assessing underlying symptom patterns and the value of trauma-informed assessment to optimize patient management.

Introduction: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a technique combining vaginal entrance to the abdomen with endoscopic overview. Previous studies have shown that vNOTES decreases operating time, hospitalization, postoperative complications, and pain. We aimed to present patient demographics, costs, and surgical outcomes following the implementation of vNOTES for benign hysterectomies in Sweden.

Material and methods: We conducted a historical cohort study with the first vNOTES hysterectomies in Sweden 2021-2023 involving 8 hospitals. Data was extracted from the Swedish National Quality Register for Gynecological Surgery (GynOp). Our main outcomes were intraoperative and postoperative complications, costs, and patient satisfaction. As a secondary objective, the odds ratios (OR) for any intraoperative or postoperative complication, respectively, were computed for BMI ≥30 versus <30, and for uterus weight ≥500 g versus <500 g.

Results: A total of 545 patients were included in the study. The mean age of the patients was 49.9 ± 10.7 years. Of the included patients, 8.1% (n = 44) were nullipara, 19.3% (n = 105) had a BMI ≥30, 17.4% (n = 95) had a previous cesarean section, and 16.7% (n = 91) had other previous abdominal surgery. The median uterus weight was 148 g (interquartile range, IQR 86-299). The median surgical time was 65 minutes (IQR 48-91), and the median blood loss was 40 mL (IQR 25-90). Conversions to laparotomy occurred in 2% (n = 11), and reoperations occurred in 0.6% (n = 3) of the cases. The total intraoperative complication rate was 2.2% and the total postoperative complication rate was 8.4%. No significant differences in intraoperative and postoperative complications were found between BMI ≥30 and <30 and between uterus weight ≥500 and <500 g. Most of the patients (57.1%, n = 311) left the hospital the same day as the surgery. The 1-year follow-up after surgery showed that 90% of the patients were satisfied or very satisfied with the result.

Conclusions: The implementation of vNOTES hysterectomies in Sweden has been safe showing similar complication rates compared to studies of other minimally invasive hysterectomy techniques. Surgical time, intraoperative bleeding, and conversions were in analogy with previous observational vNOTES studies. The 1-year follow-up after surgery showed high patient satisfaction.

Introduction: Laparoscopic cervical cerclage is an intervention for the prevention of preterm birth, for example, in women with a weak cervix due to prior cervical surgery or prior failed vaginal cerclage. Little is known about pregnancy outcomes when a cerclage is left in situ across consecutive pregnancies; this study aims to investigate neonatal outcomes following laparoscopic cervical cerclage placement in first and subsequent pregnancies and to compare pre- and postconception placement of the laparoscopic cervical cerclage on neonatal survival.

Material and methods: We performed an observational study in women who had a laparoscopic cervical cerclage at Aarhus University Hospital, Denmark, between 2011 and 2021. Data on the timing of the procedure (pre- vs post-conception), surgical complications, obstetric, and neonatal outcomes were collected from electronic patient records and analyzed descriptively. The primary outcome was neonatal survival. Secondary outcomes were neonatal survival without major morbidity, preterm birth, and gestational age at birth.

Results: A total of 170 women had a laparoscopic cervical cerclage during the study period. Uterine wall perforation occurred in 10/170 procedures (6%), postoperative infection in 4/170 (2%), and 125/170 (74%) were discharged on the same day as the procedure. There were 145 women with at least one subsequent pregnancy and 229 registered pregnancies in total. In the 185 pregnancies that progressed beyond 20 weeks, 166/181 (92%) delivered ≥34 weeks of gestation. Neonatal survival was 183/186 (98%), and survival without major morbidity was 181/186 (97%). Neonatal outcomes were similar between women with a cerclage placed pre- or postconception. Fifty of 145 women (34%) with a cerclage left in situ had more than one pregnancy beyond 20 weeks of gestation. These repeated pregnancies showed consistently favorable outcomes, with neonatal survival rates of 100% in second pregnancies (44/44) and 100% in third pregnancies (4/4).

Conclusions: Laparoscopic cervical cerclage supports favorable neonatal outcomes in first and subsequent pregnancies. Neonatal outcomes did not appear to differ based on whether the cerclage was placed pre- or postconception. Pregnancies in which the cerclage was left in situ demonstrated high neonatal survival rates and favorable obstetric outcomes in both second and third pregnancies.

While existing literature has compared the methodological strengths and limitations of randomized controlled trials (RCTs) and real-world data (RWD) in general medical research, two critical gaps remain unaddressed: (1) no prior communication papers have specifically examined this comparison in the context of maternity care where unique ethical and practical considerations exist, and (2) no studies have systematically compared cost-effectiveness analyses derived from RCTs versus RWD approaches-a crucial dimension for value-based maternity care decisions. This article examines how both approaches can strengthen the evidence base and support the delivery of value-based maternity care. We argue that neither RCTs nor RWD should be regarded as inherently superior in guiding decision-making. Each study design offers valuable insights, and their findings must be critically appraised in light of methodological rigor, context, and relevance, particularly when their results diverge.

Introduction: A frequently cited benefit of the first-trimester anomaly scan (FTAS) is that it reduces psychological impact by enabling earlier termination of pregnancy (TOP). However, the impact of early versus late TOP due to fetal anomalies remains unclear. This study evaluates the psychological impact and perspectives associated with early versus late TOP.

Material and methods: A prospective mixed methods study was conducted. The early group (TOP <18 weeks) included women with an abnormal FTAS; the late group (TOP 20-24 weeks) included women with an abnormal second-trimester scan (SAS), abnormal FTAS, or normal FTAS followed by abnormal SAS. Women completed questionnaires 2 (T1) and 6 months (T2) postpartum addressing psychological impact using validated scales (State-Trait Anxiety Inventory, Edinburgh Depression Scale, Impact of Event Scale, Perinatal Grief Scale) and study-specific questions. Semi-structured interviews were conducted with women and their partners 3-6 months after termination.

Results: 149 women with early TOP (15 + 2 weeks, range 14 + 4-16 + 1) and 129 with late TOP (22 + 0, 21 + 0-23 + 1) completed T1. In both groups, the majority had clinically relevant anxiety at T1 and T2 and moderate/severe distress at T1. The late TOP group had higher median depression and mean grief scores at T1 (5.0, range 3.0-8.0 vs. 4.0, range 2.0-7.0, p = 0.004) (85.9 ± 21.0 vs. 76.5 ± 22.4, p < 0.001) and at T2 (4.0, 1.0-7.0 vs. 3.0, 1.0-6.0, p = 0.043) (81.3 ± 22.9 vs. 70.8 ± 22.6, p < 0.001), respectively, and higher mean distress scores at T1 (33.8 ± 13.3 vs. 30.2 ± 14.7, p = 0.034). Of 51 interviews with women and partners (22 early, 29 late TOP), four themes were identified: fetal attachment, time pressure, grief, and reflections on gestational age. Most late TOP participants expressed strong fetal attachment; for early TOP participants, the experiences were more variable. Half of the late TOP participants reported time pressure due to the legal limit. Perceived grief and impact were substantial in both groups.

Conclusions: Our findings suggest that early TOP is associated with lower psychological impact compared to late TOP, mainly in the first months postpartum. This may reflect less intense fetal attachment and more time for reproductive decision-making for some parents, supporting the presumed benefit of earlier intervention. Nevertheless, TOP causes a significant emotional impact at any gestational age.

Mid-urethral slings (MUS) such as tension-free vaginal tape (TVT) are the established gold standard surgical approach for treating stress urinary incontinence (SUI). While generally effective, complications such as bladder injury, urinary retention, and bleeding can occur. This article focuses on a rare but significant complication: postoperative hemorrhage into the retropubic space (Cavum Retzii) following MUS/TVT placement. Key challenges, diagnostic options, and management strategies for this condition are assessed. Additionally, a structured clinical guideline to support a systematic approach to diagnosis and treatment of complications is provided.

Introduction: Anal incontinence can have a significant negative impact on quality of life. The leading cause of anal incontinence among women of child-bearing age is obstetric-related perineal injury. The objective of this study was to examine the impact of episiotomy on the incidence of anal incontinence among primiparous women with second-, third-, or fourth-degree perineal tears at 8 weeks and 1 year postpartum and to assess change in incidence over time across varying degrees of perineal tears.

Material and methods: This Swedish cohort study included 12 658 primiparous women who sustained a second- (n = 5309), third- (n = 6771), or fourth-degree tear (n = 578), either spontaneously or in association with an episiotomy, between 2014 and 2019. Data were collected from national health and quality registers. The primary outcomes assessed were fecal and gas incontinence at 1 year postpartum. Secondary outcomes included lifestyle alteration and Wexner score. Logistic regression analyses were performed, and results were presented as odds ratios (ORs) with 95% confidence intervals (CIs), using spontaneous tear as the reference group. Models were adjusted for age, body mass index, prepregnancy diabetes, gestational age, mode of delivery, length of the second stage, fetal presentation, birth weight, and head circumference.

Results: The incidence of gas incontinence 1 year after second-, third-, or fourth-degree tears was 11.0%, 23.6%, and 37.8%, respectively. The incidence of fecal incontinence was 1.8%, 5.2%, and 14.5% for loose stool, and 0.8%, 2.1%, and 6.6% for solid stool, respectively. Women with a second-degree tear and episiotomy had an adjusted OR of 1.26 (95% CI 1.02-1.55) for gas incontinence and 1.38 (95% CI 0.90-2.10) for fecal incontinence at 1 year postpartum. Episiotomy did not increase the risk of anal incontinence among women with third-degree and fourth-degree tears. Anal incontinence, lifestyle changes, and Wexner score decreased over time across all types of tears.

Conclusions: Anal incontinence increases with the severity of perineal tears; however, the risk of incontinence is primarily determined by the grade of injury rather than the presence or absence of an episiotomy. Symptoms decline over time across all degrees of tears.