Acta Obstetricia et Gynecologica Scandinavica最新文献

Introduction: Women may need a surgical uterine evacuation for miscarriage, surgical termination, or retained products of conception. Previous research has indicated possible complications of uterine dilatation and curettage and potential benefits of an ultrasound-guided procedure. This study aimed to compare the rate of complications for uterine evacuation when performed blind or with ultrasound guidance, including whether the presence of patient risk factors determined the use of ultrasound guidance.

Material and methods: This retrospective cohort study included 733 cases in an Australian hospital between January 2019 and December 2023. Medical records, imaging, and surgical reports were searched for patient demographics, risk factors, and the presence of surgical complications. Primary outcomes were complications of uterine perforation, false passage, incomplete curettage, heavy blood loss, or laparoscopy. Secondary outcomes were patient demographics and potential presurgical complication factors. The study created two cohorts: patients receiving evacuation performed blind or with ultrasound guidance.

Results: The uterine evacuation was performed blind for 421/733 (57%) women and ultrasound-guided for 312/733 (43%) women. The ultrasound-guided group included higher gestational ages 8 [7-11] weeks vs blind 8 [7-9] weeks, more patients with risk factors (OR 1.7, CI: 1.3 to 2.3), more patients for surgical termination (OR 15.3, CI: 5.4 to 43.3), or postpartum RPOC removal (OR 2.3, CI: 1.3 to 3.9). The ultrasound group had lower overall blood loss (20 mLs vs 30 mL) and clinically significantly lower volumes of continuing retained products of conception, 0.66 cm³ [0.53-1.23] vs 8.35 cm³ [1.49-18.94]. There was no difference in complications between groups after adjusting for gestational age (OR 1.0, CI: 0.5 to 2.0).

Conclusions: There were low complication rates for blind and ultrasound-guided uterine evacuations. However, ultrasound guidance was utilized for higher-risk cases and significantly reduced the volume of retained tissue in complicated cases. The use of ultrasound guidance by doctors and sonographers for uterine evacuation is a compelling choice where available.

Introduction: The aim of this study was to evaluate self-reported pelvic floor symptoms 12 months postpartum, in women after a first-time vaginal delivery complicated by an obstetric anal sphincter injury, according to body mass index. The hypothesis was that dyspareunia, urinary incontinence, and anal incontinence would be more common in overweight and obese women compared with normal weight women 12 months postpartum.

Material and methods: This is a population-based cohort study. Altogether, 6595 primiparous women with a first-time vaginal delivery complicated by an obstetric anal sphincter injury in Sweden between 2014 and 2019 were included in the Swedish Perineal Laceration Registry. Self-reported pre-pregnancy data and data from the 12-month follow-up questionnaire were retrieved from the Perineal Laceration Registry. Uni- and multivariate analyses were used to compare normal weight (BMI ≤ 24.9), overweight (25.0-29.9), and obese (≥30) women in regard to the self-reported prevalence of dyspareunia, urinary incontinence, and anal incontinence 12 months postpartum.

Results: Overweight and obese women had a decreased risk of dyspareunia compared with normal weight women, aOR 0.82 (CI = 0.68-0.98) and aOR 0.71 (CI = 0.54-0.93), respectively. The absolute rate of dyspareunia was 41% among normal weight women, 38% among overweight women, and 33% among the obese group. In the univariate analyses, episiotomy and the grade of anal sphincter injury did not affect the risk of dyspareunia. There was an increased risk of urinary incontinence among overweight (aOR = 1.51, CI = 1.11-2.04) and obese women (aOR = 2.82, CI = 1.94-4.12) compared with normal weight women. The risk of anal incontinence did not differ between the BMI groups.

Conclusions: Dyspareunia 12 months after an obstetric anal sphincter injury was less common among overweight and obese women than in normal-weight women. Self-reported anal incontinence one year after an obstetric anal sphincter injury was equally distributed over the BMI groups 12 months after delivery, which is a new finding and clinically relevant.

Introduction: Consensus is lacking regarding the upper limit for a safe contraction frequency during labor. We aimed to assess the association between different contraction frequencies and acidemia at birth, and whether an association was affected by oxytocin augmentation, concomitant cardiotocography (CTG) classification, and stage of labor.

Material and methods: This is a case-control study based on CTG traces from births in southern Sweden during 2012-2017. Cases (N = 364) had umbilical artery pH <7.1 if born by first-stage cesarean section and pH <7.05 if born vaginally or by second-stage cesarean. Controls were included with a 1:2 ratio (N = 728) and had pH ≥7.15. CTG traces from the hour prior to birth were assessed blinded to the clinical outcome. Logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI).

Results: After excluding insufficient topography traces, 328 cases and 677 controls remained for analysis. Contraction frequencies 5, 5-6, and ≥6 per 10 min occurred in 15.2%, 19.5%, and 29.6% of cases and in 15.1%, 16.5%, and 11.1% of controls, respectively. The OR (95% CI) for acidemia were 1.6 (1.1-2.4), 1.9 (1.3-2.7), and 4.3 (3.0-6.2), respectively, compared with a reference group of <5. When comparing two separate binary cut-offs of >5 and ≥5 contractions, similar strengths of association with acidemia were demonstrated with OR 2.7 (2.1-3.6) and 2.5 (1.9-3.3), respectively. The effect of contraction frequency >5 was similar in spontaneous (n = 586) and oxytocin-augmented (n = 419) labor (OR 2.5, 1.7-3.8 vs. OR 2.4, 1.6-3.6), and whether the CTG was normal, suspicious, or pathological according to the Swedish CTG template (OR 2.1, 1.3-3.3; OR 3.5, 1.6-7.6; and OR 2.6, 1.4-4.7, respectively). The study lacked power to study any association during the first stage of labor.

Conclusions: Increasing contraction frequency is incrementally associated with fetal acidemia. Although an increased risk of acidosis is evident at contraction frequencies as low as five, such frequencies are common while acidemia is uncommon, implying a poor positive predictive value. A contraction frequency of more than five is associated with acidemia in both spontaneous and oxytocin-augmented labor, and even when the fetal heart trace is normal.

Introduction: Endometriomsis (EMs) is a complex and chronic gynecological disease characterized by distressing symptoms. Its pathogenesis remains unknown, and there is no effective treatment. Therefore, establishing patient-derived models is crucial for elucidating disease mechanisms and identifying potential therapeutic agents. We developed a coculture system combining epithelial organoids and stromal cells, enabling the study of their dynamic interactions. Using this model, we assessed the therapeutic efficacy of dienogest, a drug clinically used for treating endometriomas.

Material and methods: The epithelial gland-like organoids and stromal cells derived from patients with endometriomas were isolated and cultured, respectively. Both of them were cocultured in matrix for partially mimicking in vivo pathological features. Immunohistochemical (IHC) assay was used to identify their biomarkers. Cell viability was quantitatively assessed using the CellTiter-Glo^® assay following drug treatment.

Results: We successfully cultured patient-derived epithelial gland-like organoids and stromal cells derived from patients with endometriomas, a form of endometriosis characterized by ovarian cysts. Morphological and immunohistochemical analyses confirmed high consistency with native endometriotic lesions. These models exhibited comparable expression profiles for key biological markers, including estrogen receptors (ERs), progesterone receptors (PRs), E-cadherin, CD44, Intercellular Adhesion Molecule-1 (ICAM1), Integrin Beta 3 (ITGB3), Cytokeratin 7 (CK7), Matrix Metalloproteinase 2/9 (MMP2/9), Tissue Inhibitor of Metalloproteinases 1 (TIMP1), and TIMP2. Notably, drug responsiveness varied among the patient-derived models by coculturing two types of cells, indicating potential interpatient heterogeneity in treatment outcomes. We propose that this patient-specific endometriomas model serves as a valuable platform for investigating disease mechanisms and screening drug in endometriomas.

Conclusions: We established a novel coculture system integrating epithelial organoids and stromal cells to recapitulate the intricate cellular interactions within the endometriotic microenvironment, providing a more relevant in vitro representation of the disease. Upon evaluation with dienogest, a clinically used therapeutic agent for endometriomas, the patient-derived models exhibited heterogeneous drug responses.

Introduction: Tetralogy of Fallot (ToF) shows variability in neonatal outcomes, and identifying reliable prenatal predictors is essential for optimizing perinatal management. The aim of this study was to determine the prognostic value of feto-placental data and prenatal echocardiography in the third trimester in ToF and to compare these findings with a matched control population.

Material and methods: Multicenter prospective cohort study (2011-2023) at two referral centers (BCNatal and University Hospital of Gießen and Marburg). The cohort included 63 fetuses with isolated ToF and 66 healthy controls. All fetuses underwent a third trimester ultrasound and comprehensive echocardiography with 2D speckle tracking. Severe small-for-gestational age (SGA) was defined as estimated fetal weight (EFW) below the third percentile. Adverse composite outcomes were defined as the need for prostaglandin infusion, surgery or ductal stenting, corrective surgery before 3 months, and/or neonatal intensive care unit stay ≥7 days. The association of feto-placental and cardiac data with adverse composite outcome was evaluated.

Results: Compared with controls, ToF fetuses showed higher rates of severe SGA (19% vs. 0%, p < 0.001). Cardiac findings showed mild biventricular concentric hypertrophy (relative wall thickness ToF 0.7 [0.5-0.9] vs. controls 0.5 [0.5-0.6], p = 0.001), and reduced deformation (right and left ventricular global longitudinal strain: ToF -17.3% ± 3.8 vs. controls -19.3% ± 3.1, p = 0.001; ToF -18.0% ± 3.8 vs. controls -20.9% ± 3.45, p < 0.001), regardless of placental dysfunction. The adverse composite outcome occurred in 29.3% of ToF cases with pulmonary stenosis. Within this group, EFW <3rd centile (adjusted OR 9.17) and PV peak systolic velocity (aOR 1.03) showed the strongest association with adverse outcomes. Their combined performance yielded an AUC of 0.734, with a predictive value of 71.4% at a 20% false-positive rate. Assessed individually, the AUC was 0.650 for PV peak systolic velocity and 0.639 for estimated fetal weight. Optimal PV Doppler cutoff values were >70 cm/s when EFW was <3rd centile, and >144 cm/s when EFW was above the 3rd centile.

Conclusions: Combining EFW with PV artery Doppler may allow identification of a high-risk subgroup of ToF-PS fetuses who may benefit from closer prenatal monitoring and prompt neonatal care.

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: Approximately 3%-4% of women experience childbirth-related posttraumatic stress disorder (CB-PTSD). The City Birth Trauma Scale (City BiTS) is a questionnaire developed to assess CB-PTSD, following the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders. The aim of the present study was to evaluate the psychometric properties of the Norwegian version of this questionnaire (City BiTS-Nor).

Material and methods: A community sample of 1079 mothers completed a cross-sectional online survey. The survey included questions on sociodemographic and obstetric characteristics, the City BiTS-Nor, the Impact of Event Scale-Revised, the Edinburgh Postnatal Depression Scale, the 10-item anxiety subscale of the Hopkins Symptom Checklist, and the Bergen Insomnia Scale.

Results: Confirmatory factor analysis supported a bifactor model comprising Birth-related Symptoms and General Symptoms in CB-PTSD, along with a General CB-PTSD factor that explained 58.4% of the variance. The study found high internal consistency (≥0.90), and good convergent and divergent validity were shown. Discriminant validity was evaluated by examining factors such as mode of birth, maternal complications, infant complications, parity, history of traumatic childbirth, and previous traumatic experiences. Higher General and Birth-related scores were observed in women who experienced emergency cesarean sections or instrumental vaginal births. This trend was observed in primiparous women, cases involving pregnancy and birth complications, and individuals with prior traumatic experiences.

Conclusions: The City BiTS-Nor presents appropriate psychometric properties for assessing CB-PTSD symptoms according to DSM-5 criteria. The findings suggest that using the total score, along with the individual subscale scores, is justified and enhances the comprehensive assessment of CB-PTSD symptoms. These findings support the clinical utility of the City BiTS-Nor as a screening tool for CB-PTSD, with potential to differentiate childbirth-related trauma from general psychopathology and to guide targeted interventions in perinatal care.

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.

Introduction: Maternal outcomes of pregnancy with subclinical hypothyroidism continue to be active areas of research interest. The objective of this study was to compare severe maternal morbidity at delivery between pregnant patients with subclinical hypothyroidism and those with overt hypothyroidism.

Material and methods: This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. Study population included 11 620 hospital deliveries with a diagnosis code of subclinical hypothyroidism and 697 320 hospital deliveries with a diagnosis code of overt hypothyroidism. Main outcome was severe maternal morbidity per the Centers for Disease Control and Prevention definition (20 indicators), assessed with multivariable generalized linear model.

Results: Pregnancy with subclinical hypothyroidism was associated with a 54% higher rate of severe maternal morbidity at delivery compared with those with overt hypothyroidism (18.1 and 11.1 per 1000 deliveries, adjusted-incidence rate ratio [aIR] 1.54, 95% confidence interval [CI] 1.34-1.76). Among the individual severe maternal morbidity indicators, the incidence rate of eclampsia (2.2 versus 0.7 per 1000 deliveries, aIR 2.73, 95% CI: 1.83-4.09) was particularly higher among pregnancies with subclinical hypothyroidism compared with pregnancies with overt hypothyroidism. In an exploratory evaluation according to patient demographics, maternal age younger than 25 years (31.9 vs. 9.4 per 1000 deliveries, aIR 3.62, 95% CI: 2.62-5.01), Black individuals (55.2 vs. 24.7 per 1000 deliveries, aIR 2.21, 95% CI: 1.60-3.06), pregestational hypertension (70.2 vs. 27.2 per 1000 deliveries, aIR 2.20, 95% CI: 1.60-3.03), and obesity disorder (35.2 vs. 16.7 per 1000 deliveries, aIR 1.87, 95% CI: 1.48-2.35) were associated with higher rates of severe maternal morbidity for subclinical hypothyroidism compared with overt hypothyroidism. Severe maternal morbidity rates were more than twice as high for subclinical hypothyroidism compared with overt hypothyroidism among pregnant patients younger than 25 years with obesity disorder (79.4 vs. 10.1 per 1000 deliveries, aIR 7.89, 95% CI: 4.78-13.02), Black individuals with pregestational hypertension (157.9 vs. 40.2 per 1000 deliveries, aIR 3.15, 95% CI: 1.77-5.61), and Black individuals with obesity disorder (102.0 vs. 33.9 per 1000 deliveries, aIR 2.81, 95% CI: 1.83-4.32).

Conclusions: The results of this cross-sectional study suggest that subclinical hypothyroidism may be associated with higher rates of severe maternal morbidity at delivery compared with overt hypothyroidism.