C. Ovadia, Alice L Mitchell, C. Markus, W. Hague, C. Williamson
In this edition, Huri et al. (BJOG 2022) have added to the growing literature defining pregnancyspecific reference ranges for total serum bile acid (TSBA) concentrations. Reference intervals in clinical pathology are typically calculated using an ‘indirect resource’, such as stored laboratory samples. Results are partitioned into biologically relevant groups (typically age and sex), outliers are excluded to remove anomalous results due to disease, and the central 95% of the population is calculated for each group. Two large studies, that of Huri et al. and our own (Mitchell et al. BJOG 2021;128:1635– 44), have recently calculated reference intervals for nonfasting TSBA concentrations in the third trimester of pregnancy, finding strikingly similar results for the upper limit (20.2 and 18.3 μmol/l, respectively). Both studies excluded samples with cholestatic pathology before analysis, treating the cohorts as a ‘direct resource’ and obviating exclusion of outliers. However, the results demonstrate outliers within each dataset. In the study by Huri et al. this may have been the result of the selected participants having other gestational diseases (for example, gestational diabetes) and originating from samples taken during hospital admission; the reason for women being inpatients may have influenced serum bile acid concentrations and therefore confounded the findings. To assess the impact of excluding outliers, we used the block D/R (Zellner et al. arXiv preprint; 1907.09637.) procedure to identify outliers in our dataset (from outpatient samples routinely taken and limited to uncomplicated pregnancies), and reanalysis revealed a slight reduction in the upper limit of the reference interval and narrowing of the confidence interval (Table 1). Does this matter? When the disease outcomes and management relate closely to peak bile acid concentration (Ovadia et al. Lancet 2019;393:899– 909), what may be of more clinical relevance is a diagnostic threshold rather than a reference interval. Women previously diagnosed with intrahepatic cholestasis of pregnancy (ICP) using an upper limit of the nonfasting TSBA reference interval below 19 μmol/l had no higher rates of stillbirth and spontaneous preterm birth than the matched population, but a slightly higher rate of Accepted: 24 March 2022 | Published Online 10 May 2022
在这一版本中，Huri等人(BJOG 2022)增加了越来越多的文献，定义了血清总胆汁酸(TSBA)浓度的妊娠特异性参考范围。临床病理学中的参考区间通常使用“间接资源”计算，例如存储的实验室样本。将结果划分为生物学相关的组(通常是年龄和性别)，排除异常值以消除因疾病引起的异常结果，并为每个组计算人口的中心95%。两项大型研究，Huri et al.和我们自己的(Mitchell et al.)。BJOG 2021;128:1635 - 44)，最近计算了妊娠晚期非空腹TSBA浓度的参考区间，发现上限(分别为20.2和18.3 μmol/l)的结果非常相似。两项研究在分析前都排除了有胆汁淤积病理的样本，将队列视为“直接资源”，避免了异常值的排除。然而，结果显示了每个数据集中的异常值。在Huri等人的研究中，这可能是选定的参与者患有其他妊娠疾病(例如妊娠糖尿病)的结果，并且来自住院期间采集的样本;女性住院的原因可能影响了血清胆汁酸浓度，因此混淆了研究结果。为了评估排除异常值的影响，我们使用了块D/R (Zellner et al. ar14预印本;1907.09637.)程序来识别我们数据集中的异常值(来自常规门诊样本，仅限于无并发症的妊娠)，再分析显示参考区间上限略有降低，置信区间缩小(表1)。这重要吗?当疾病结局和管理与胆汁酸峰值浓度密切相关时(Ovadia等)。柳叶刀2019;393:899 - 909)，更具有临床相关性的可能是诊断阈值，而不是参考区间。使用低于19 μmol/l的非空腹TSBA参考区间上限诊断为妊娠肝内胆汁淤积症(ICP)的妇女，死胎和自发性早产的发生率不高于匹配人群，但发生率略高
{"title":"Bile acid reference intervals for evidence‐based practice","authors":"C. Ovadia, Alice L Mitchell, C. Markus, W. Hague, C. Williamson","doi":"10.1111/1471-0528.17171","DOIUrl":"https://doi.org/10.1111/1471-0528.17171","url":null,"abstract":"In this edition, Huri et al. (BJOG 2022) have added to the growing literature defining pregnancyspecific reference ranges for total serum bile acid (TSBA) concentrations. Reference intervals in clinical pathology are typically calculated using an ‘indirect resource’, such as stored laboratory samples. Results are partitioned into biologically relevant groups (typically age and sex), outliers are excluded to remove anomalous results due to disease, and the central 95% of the population is calculated for each group. Two large studies, that of Huri et al. and our own (Mitchell et al. BJOG 2021;128:1635– 44), have recently calculated reference intervals for nonfasting TSBA concentrations in the third trimester of pregnancy, finding strikingly similar results for the upper limit (20.2 and 18.3 μmol/l, respectively). Both studies excluded samples with cholestatic pathology before analysis, treating the cohorts as a ‘direct resource’ and obviating exclusion of outliers. However, the results demonstrate outliers within each dataset. In the study by Huri et al. this may have been the result of the selected participants having other gestational diseases (for example, gestational diabetes) and originating from samples taken during hospital admission; the reason for women being inpatients may have influenced serum bile acid concentrations and therefore confounded the findings. To assess the impact of excluding outliers, we used the block D/R (Zellner et al. arXiv preprint; 1907.09637.) procedure to identify outliers in our dataset (from outpatient samples routinely taken and limited to uncomplicated pregnancies), and reanalysis revealed a slight reduction in the upper limit of the reference interval and narrowing of the confidence interval (Table 1). Does this matter? When the disease outcomes and management relate closely to peak bile acid concentration (Ovadia et al. Lancet 2019;393:899– 909), what may be of more clinical relevance is a diagnostic threshold rather than a reference interval. Women previously diagnosed with intrahepatic cholestasis of pregnancy (ICP) using an upper limit of the nonfasting TSBA reference interval below 19 μmol/l had no higher rates of stillbirth and spontaneous preterm birth than the matched population, but a slightly higher rate of Accepted: 24 March 2022 | Published Online 10 May 2022","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76883093","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}
Dear Dr. Papageorghiou, De Vries et al. used data simulation to create two data sets, based on the Friedman and Zhang labour curve models, respectively, to assess whether the repeatedmeasures polynomial regression and intervalcensored regression used by Zhang et al. are appropriate statistical methods to describe the first stage of labour. It was concluded that these methods do not accurately reflect the underlying data. We respectfully disagree. The key issue regarding the appropriateness of polynomial repeatedmeasures regression hinges on whether the shape of the average labour curve matches the shape of the underlying individual curves. The authors demonstrated that when vaginal examinations are performed 1– 3 hourly or more, the average labour curve is close to the underlying labour pattern (figures 3B, S4 and S5). We suggest that the authors show a similar figure to figures 3B and S4 with an increasing frequency of vaginal examinations, to illustrate how similar the average curve becomes to the underlying labour pattern when the underlying labour pattern is assumed to be progressively accelerating. This evidence indicates that the polynomial regression is a reasonable method to model the labour curve when vaginal examinations are performed at least 1– 3 hourly. Labour patterns vary widely from woman to woman. Any single labour curve cannot truly represent the reality. The Friedman curve is an idealised individual curve. The rigid onecurveforall is too simplistic and has important clinical consequences. Whether the true active phase of labour follows a straight line or exponential curve still remains undetermined. Both trajectories, as well as other patterns, are likely to coexist. It may not be totally accurate to use the piecewise linear curve as the reference standard to judge the appropriateness of a statistical method. The estimate of labour duration, particularly the 95th centile, is influenced by the distribution of the transit time. While figure 1 demonstrated the approximate log normal distribution of the latent phase, active phase and total duration, it is also important to show such a distribution in each cmbycm segment with varying frequency of vaginal examinations. If the distribution is not log normal, the estimate may be biased. In addition, it is overly simplistic to assume that every parturient enters the active phase of labour at 4cm dilatation, which has been opposed by Cohen and Friedman. Such an assumption is likely to result in substantially reduced variations of the average labour duration. Subsequently, the 95th centiles based on the simulated data are much smaller than those based on the real data (table 1). Oladapo et al. used a multistate Markov model and produced very similar results to the interval censored regression, suggesting that the simulated data may be inappropriate to provide realistic results, which have much greater variations than the simulated data. Nonetheless, we agree that the admission time to lab
{"title":"Re: Impact of analysis technique on our understanding of the natural history of labour","authors":"Jun Zhang, J. Troendle, J. Souza, O. Oladapo","doi":"10.1111/1471-0528.17221","DOIUrl":"https://doi.org/10.1111/1471-0528.17221","url":null,"abstract":"Dear Dr. Papageorghiou, De Vries et al. used data simulation to create two data sets, based on the Friedman and Zhang labour curve models, respectively, to assess whether the repeatedmeasures polynomial regression and intervalcensored regression used by Zhang et al. are appropriate statistical methods to describe the first stage of labour. It was concluded that these methods do not accurately reflect the underlying data. We respectfully disagree. The key issue regarding the appropriateness of polynomial repeatedmeasures regression hinges on whether the shape of the average labour curve matches the shape of the underlying individual curves. The authors demonstrated that when vaginal examinations are performed 1– 3 hourly or more, the average labour curve is close to the underlying labour pattern (figures 3B, S4 and S5). We suggest that the authors show a similar figure to figures 3B and S4 with an increasing frequency of vaginal examinations, to illustrate how similar the average curve becomes to the underlying labour pattern when the underlying labour pattern is assumed to be progressively accelerating. This evidence indicates that the polynomial regression is a reasonable method to model the labour curve when vaginal examinations are performed at least 1– 3 hourly. Labour patterns vary widely from woman to woman. Any single labour curve cannot truly represent the reality. The Friedman curve is an idealised individual curve. The rigid onecurveforall is too simplistic and has important clinical consequences. Whether the true active phase of labour follows a straight line or exponential curve still remains undetermined. Both trajectories, as well as other patterns, are likely to coexist. It may not be totally accurate to use the piecewise linear curve as the reference standard to judge the appropriateness of a statistical method. The estimate of labour duration, particularly the 95th centile, is influenced by the distribution of the transit time. While figure 1 demonstrated the approximate log normal distribution of the latent phase, active phase and total duration, it is also important to show such a distribution in each cmbycm segment with varying frequency of vaginal examinations. If the distribution is not log normal, the estimate may be biased. In addition, it is overly simplistic to assume that every parturient enters the active phase of labour at 4cm dilatation, which has been opposed by Cohen and Friedman. Such an assumption is likely to result in substantially reduced variations of the average labour duration. Subsequently, the 95th centiles based on the simulated data are much smaller than those based on the real data (table 1). Oladapo et al. used a multistate Markov model and produced very similar results to the interval censored regression, suggesting that the simulated data may be inappropriate to provide realistic results, which have much greater variations than the simulated data. Nonetheless, we agree that the admission time to lab","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"164 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-02-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88055127","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}
Pub Date : 2022-01-12DOI: 10.22541/au.164200499.91345748/v1
A. Vashisht, Maria Masha Ben Zvi, N. Thanatsis
The surgical management of prolapse has followed a meandering path, with innovation, controversy and legislation all being encountered en route. Some of the dust is now settling with respect to the role of mesh implant surgery, and although it continues to have a role, albeit a contracted one, there is very much a new direction set on native tissue and nonmesh repairs with the advent of techniques such as laparoscopic suture hysteropexy, cervicopexy and colporrhaphy. The authors of this paper present the largest series of women undergoing autologous fascia sacrocolpopexy for the treatment of moderate– severe prolapse (Wang et al. BJOG 2022; https://doi.org/10.1111/1471-0528.17107). Learning from the past, two key questions that must always be answered when evaluating any new procedure are safety and efficacy. For both these measures, the authors show encouraging results comparable with the current gold standard— meshaugmented repairs. The use of autologous fascia has been well established for treatment of women with urinary incontinence, namely, pubovaginal/rectus fascial sling (Mcguire et al. J Urol 1978;119:824). There has been a resurgence of this method, following the widespread suspension of synthetic sling procedures. However, reports of autologous fascial support of the vaginal vault are limited to a few shortterm case series. This series involves 132 women, followed up for a median of 2.2 years; the authors present 5year data with comparable success rates to those reported in the landmark CARE study (Nygaard et al. JAMA 2013;309:201624) without the complication of mesh erosion. The mixed bag of patient types and concomitant surgery in this study underscores the myriad of pathologies and presenting symptoms to the pelvic floor surgeon; sadly, this reality hinders forensic evaluation of a single procedure. It is noted that around threequarters of the women in the study were having primary prolapse surgery, with a similar proportion undergoing some form of hysterectomy coupled with autologous fascial vault support. Other sacrocolpopexy series have involved women, the majority of whom have already had primary procedures, are without a uterus and represent an already failed and perhaps more difficult to treat group successfully (Maher et al. Cochrane Database Syst Rev 2016; CD012376). The addition of hysterectomy, as well as the harvesting of autologous fascia, inevitably means a lengthening of procedure times compared with those usually quoted for women undergoing laparoscopic vault suspension procedures of hysteropexy or sacrocolpopexy. The complexities of pelvic f loor patients and their symptoms mean that additionally nearly twothirds of the patients had Burch colposuspensions performed at the time of index surgery. The unpredictability of pelvic f loor surgery on bladder symptoms is amply demonstrated, as around onethird of women complain of stress incontinence and a third suffer overactive bladder symptoms following the procedure. It is
脱垂的外科治疗一直是一条曲折的道路，创新、争议和立法都是在这条道路上遇到的。现在，关于网状植入手术的作用，一些尘埃正在沉淀，尽管它继续发挥作用，尽管是收缩的作用，但随着腹腔镜缝合子宫切除术、宫颈切除术和阴道吻合术等技术的出现，在本地组织和非网状修复方面有了很大的新方向。本文作者介绍了接受自体筋膜骶colpop固定术治疗中重度脱垂的最大系列女性(Wang等)。问卷2022;https://doi.org/10.1111/1471 0528.17107)。从过去的经验中，在评估任何新手术时必须回答的两个关键问题是安全性和有效性。对于这两种方法，作者都展示了与目前的黄金标准——计量修复相媲美的令人鼓舞的结果。自体筋膜已被广泛用于治疗女性尿失禁，即耻骨阴道/直肌筋膜吊带(Mcguire等)。[J]中国生物医学工程学报(英文版);1997;19(1):1 - 4。有一个复苏的这种方法，继广泛暂停合成吊索程序。然而，自体筋膜支持阴道穹窿的报道仅限于几个短期的病例系列。该系列研究涉及132名女性，随访时间中位数为2.2年;作者提供的5年数据与具有里程碑意义的CARE研究报告的成功率相当(Nygaard等)。中国医学杂志2013;309:201624)，无网片糜烂并发症。在这项研究中，患者类型和伴随手术的混合袋强调了无数的病理和骨盆底外科医生提出的症状;可悲的是，这一现实阻碍了对单一程序的法医评估。值得注意的是，研究中约有四分之三的女性接受了原发性脱垂手术，同样比例的女性接受了某种形式的子宫切除术，并结合了自体筋膜穹窿支持。其他骶骶固定术系列涉及的女性，其中大多数已经进行了初级手术，没有子宫，代表了已经失败的，可能更难成功治疗的群体(Maher等)。Cochrane Database system Rev 2016;CD012376)。子宫切除术的增加，以及自体筋膜的收获，不可避免地意味着手术时间的延长，而那些通常引用的妇女接受腹腔镜拱顶悬吊手术的子宫切除术或骶髋固定术。骨盆底患者及其症状的复杂性意味着另外近三分之二的患者在指数手术时进行了Burch阴道悬吊术。骨盆底手术对膀胱症状的不可预测性得到了充分证明，因为大约三分之一的女性抱怨压力性尿失禁，三分之一的女性在手术后出现膀胱过度活跃症状。很明显，对于骨盆底患者，功能的改善并不总是与解剖的纠正同步进行。许多女性仍然对妇科补片隆胸手术的负面报道感到震惊(IzettKay等人)。问卷2021;128:1319)。当代最佳实践包括纳入无可辩驳的原则，如认识到适当的顶端支持的重要性，这通常是腹部最佳实现，以及对手术风险的认识，关于补片的仔细咨询，并能够提供基于证据的替代方案。本文为未来无网格手术技术提供了有价值的长期数据。
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BJOG relies heavily on its referees. They don’t just help us decide which papers we should publish, they also give freely of their time with comments to help the authors present their data more effectively, and thus improve the quality of the published article. To reflect the international nature of BJOG, the referees who contributed in 2020 are based in many different countries, including: Argentina, Australia, Austria, Bahrain, Bangladesh, Belgium, Botswana, Brazil, Canada, Chile, China, Colombia, Czech Republic, Denmark, Egypt, Estonia, Finland, France, Germany, Greece, Grenada, Hong Kong, India, Iran (the Islamic Republic of), Ireland, Israel, Italy, Japan, Kenya, Korea (the Republic of), Latvia, Lebanon, Malaysia, Mexico, Myanmar, Netherlands, New Zealand, Nigeria, Norway, Oman, Pakistan, Palestine (State of), Papua New Guinea, Poland, Portugal, Qatar, R eunion, Russia, Singapore, Slovenia, South Africa, Spain, Sri Lanka, Sweden, Switzerland, Taiwan, Thailand, Trinidad and Tobago, Tunisia, Turkey, United Arab Emirates, United Kingdom, USA, and Zambia. The referees who helped us in 2020 are listed below as a small token of our appreciation and thanks.
{"title":"BJOG Referees 2020","authors":"Kathryn, Grieger","doi":"10.1111/1471-0528.16707","DOIUrl":"https://doi.org/10.1111/1471-0528.16707","url":null,"abstract":"BJOG relies heavily on its referees. They don’t just help us decide which papers we should publish, they also give freely of their time with comments to help the authors present their data more effectively, and thus improve the quality of the published article. To reflect the international nature of BJOG, the referees who contributed in 2020 are based in many different countries, including: Argentina, Australia, Austria, Bahrain, Bangladesh, Belgium, Botswana, Brazil, Canada, Chile, China, Colombia, Czech Republic, Denmark, Egypt, Estonia, Finland, France, Germany, Greece, Grenada, Hong Kong, India, Iran (the Islamic Republic of), Ireland, Israel, Italy, Japan, Kenya, Korea (the Republic of), Latvia, Lebanon, Malaysia, Mexico, Myanmar, Netherlands, New Zealand, Nigeria, Norway, Oman, Pakistan, Palestine (State of), Papua New Guinea, Poland, Portugal, Qatar, R eunion, Russia, Singapore, Slovenia, South Africa, Spain, Sri Lanka, Sweden, Switzerland, Taiwan, Thailand, Trinidad and Tobago, Tunisia, Turkey, United Arab Emirates, United Kingdom, USA, and Zambia. The referees who helped us in 2020 are listed below as a small token of our appreciation and thanks.","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"5 1","pages":"1395 - 1400"},"PeriodicalIF":0.0,"publicationDate":"2021-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72919141","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}
It is generally thought that coffee consumption should be limited in pregnancy because studies have linked high intake to fetal growth restriction. However, there are areas where reported ‘cups of coffee drunk’ may not accurately reflect caffeine effects because of recall, coffee types and choices, as well as questions about the precision of fetal anthropometric measurements. The National Institute of Child Health & Human Development study group sought to avoid such variables by recruiting 2000 non-smoking healthy women representative of the United States population and corroborating their declared coffee intake with caffeine levels and relating these to precise measures of fetal growth (Gleason et al. JAMA Netw Open 2021;4:e213238). Singleton neonates with a mean gestational age of 39.2 weeks formed the cohort whose measurements of weight, length, head, arm and thigh circumference were correlated with maternal plasma caffeine levels at the end of the first trimester. There were small but significant differences in growth between those infants whose mothers were on the first and fourth quantities of caffeine levels – for example, lower birth weight by a mean of 85 g, length 0.4 cm and head circumference 0.3 cm. The outcomes were consistent across all measurement domains. Most O&G Colleges recommend that pregnant women restrict their coffee consumption to less than 200 mg of caffeine per day – one cup. Data from the above study suggests a continuum of effects such that there may be no lower level that is safe. They even tested for known ‘fast versus slow’ genetic caffeine metabolisers and found no difference. Unlike in non-pregnant individuals where up to six cups of coffee per day has benefit, pregnancy may be a time to reduce intake to zero. Caesarean delivery and neurodevelopment
人们普遍认为，怀孕期间应该限制咖啡的摄入量，因为研究表明，过量摄入咖啡会限制胎儿的生长。然而，由于回忆、咖啡种类和选择，以及胎儿人体测量的准确性问题，在某些领域，报告的“喝咖啡杯数”可能无法准确反映咖啡因的影响。国家儿童健康与人类发展研究所的研究小组招募了2000名具有美国人口代表性的不吸烟的健康妇女，并将她们申报的咖啡摄入量与咖啡因水平相证实，并将这些与胎儿生长的精确测量相关联，试图避免这些变量(Gleason等人)。JAMA network Open 2021;4:e213238)。这些平均胎龄为39.2周的单胎新生儿的体重、身长、头部、手臂和大腿围围与妊娠早期母体血浆咖啡因水平相关。母亲摄入第一组和第四组咖啡因的婴儿在生长发育方面有微小但显著的差异——例如，出生时体重平均减少85克，身高平均减少0.4厘米，头围平均减少0.3厘米。所有测量领域的结果是一致的。大多数O&G学院建议孕妇将每天的咖啡摄入量限制在200毫克以内——一杯。上述研究的数据表明，影响是连续的，因此可能没有更低的安全水平。他们甚至测试了已知的“快与慢”咖啡因代谢基因，但没有发现差异。不像没有怀孕的人，每天喝六杯咖啡是有益的，怀孕可能是一个减少摄入量到零的时候。剖腹产和神经发育
{"title":"Insights from outside BJOG","authors":"A. Kent, S. Kirtley","doi":"10.1111/1471-0528.16746","DOIUrl":"https://doi.org/10.1111/1471-0528.16746","url":null,"abstract":"It is generally thought that coffee consumption should be limited in pregnancy because studies have linked high intake to fetal growth restriction. However, there are areas where reported ‘cups of coffee drunk’ may not accurately reflect caffeine effects because of recall, coffee types and choices, as well as questions about the precision of fetal anthropometric measurements. The National Institute of Child Health & Human Development study group sought to avoid such variables by recruiting 2000 non-smoking healthy women representative of the United States population and corroborating their declared coffee intake with caffeine levels and relating these to precise measures of fetal growth (Gleason et al. JAMA Netw Open 2021;4:e213238). Singleton neonates with a mean gestational age of 39.2 weeks formed the cohort whose measurements of weight, length, head, arm and thigh circumference were correlated with maternal plasma caffeine levels at the end of the first trimester. There were small but significant differences in growth between those infants whose mothers were on the first and fourth quantities of caffeine levels – for example, lower birth weight by a mean of 85 g, length 0.4 cm and head circumference 0.3 cm. The outcomes were consistent across all measurement domains. Most O&G Colleges recommend that pregnant women restrict their coffee consumption to less than 200 mg of caffeine per day – one cup. Data from the above study suggests a continuum of effects such that there may be no lower level that is safe. They even tested for known ‘fast versus slow’ genetic caffeine metabolisers and found no difference. Unlike in non-pregnant individuals where up to six cups of coffee per day has benefit, pregnancy may be a time to reduce intake to zero. Caesarean delivery and neurodevelopment","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"221 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-06-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89128702","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}
As estrogen levels fall through the menopause transition, women may experience physical changes to their genitalia and these can be accompanied by symptoms such as the genitourinary syndrome of menopause (GSM), vaginal laxity, urinary incontinence or dyspareunia. For these symptoms – specifically GSM – topical estrogen therapy is prescribed. Estradiol vaginal tablets (10 μg) are well tolerated and effective in terms of subjective and objective criteria giving symptomatic relief and improving cytological indicators but it is not clear whether early or late initiation of therapy is more effective. To explore the dilemma an analysis was carried out of a randomised trial in which some women were treated “early” – that is before the age of 60 years and some were treated “late” – starting after the age of 60 years, and their reactions evaluated (Derzko et al. Menopause 2021;28:113–8). It transpires that the earlier therapy starts, the more effective it is. In the words of the researchers “The stronger response observed in younger women supports current clinical recommendations to start treatment early. Continued treatment may be important to avoid recurrence of vaginal atrophy.” These findings of a more rapid and robust response to early treatment beg the question as to whether low-dose vaginal estrogen should not have wider application even in those with mild symptoms, reaching almost a preventative role? (Phillips & Bachmann. Menopause 2021;28:109–10). It is well-known that many women “put-up with” early bothersome vaginal symptoms for reasons of embarrassment or in the belief it is part of a natural process, and the outcomes of low-dose estrogen vaginal tablet therapy suggest this amounts to an opportunity lost in improving the woman’s chances of avoiding symptoms later that could be less amenable to simple treatment. Given the ubiquitous nature of the problem, is it not time for a placebo controlled trial assessing the quality of life (including sexual function/dysfunction) of healthy women through the menopause transition in terms of prophylactic topical estrogen therapy? Since sex is best as a dual pursuit, why not ask the women’s partners what they think? It would be refreshing to hear the men’s view (or the woman’s female partner). Or is that too avant-garde?
{"title":"Insights from outside BJOG","authors":"A. Kent, S. Kirtley","doi":"10.1111/1471-0528.16713","DOIUrl":"https://doi.org/10.1111/1471-0528.16713","url":null,"abstract":"As estrogen levels fall through the menopause transition, women may experience physical changes to their genitalia and these can be accompanied by symptoms such as the genitourinary syndrome of menopause (GSM), vaginal laxity, urinary incontinence or dyspareunia. For these symptoms – specifically GSM – topical estrogen therapy is prescribed. Estradiol vaginal tablets (10 μg) are well tolerated and effective in terms of subjective and objective criteria giving symptomatic relief and improving cytological indicators but it is not clear whether early or late initiation of therapy is more effective. To explore the dilemma an analysis was carried out of a randomised trial in which some women were treated “early” – that is before the age of 60 years and some were treated “late” – starting after the age of 60 years, and their reactions evaluated (Derzko et al. Menopause 2021;28:113–8). It transpires that the earlier therapy starts, the more effective it is. In the words of the researchers “The stronger response observed in younger women supports current clinical recommendations to start treatment early. Continued treatment may be important to avoid recurrence of vaginal atrophy.” These findings of a more rapid and robust response to early treatment beg the question as to whether low-dose vaginal estrogen should not have wider application even in those with mild symptoms, reaching almost a preventative role? (Phillips & Bachmann. Menopause 2021;28:109–10). It is well-known that many women “put-up with” early bothersome vaginal symptoms for reasons of embarrassment or in the belief it is part of a natural process, and the outcomes of low-dose estrogen vaginal tablet therapy suggest this amounts to an opportunity lost in improving the woman’s chances of avoiding symptoms later that could be less amenable to simple treatment. Given the ubiquitous nature of the problem, is it not time for a placebo controlled trial assessing the quality of life (including sexual function/dysfunction) of healthy women through the menopause transition in terms of prophylactic topical estrogen therapy? Since sex is best as a dual pursuit, why not ask the women’s partners what they think? It would be refreshing to hear the men’s view (or the woman’s female partner). Or is that too avant-garde?","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"38 17","pages":"1107 - 1111"},"PeriodicalIF":0.0,"publicationDate":"2021-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91438962","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}
Pub Date : 2021-04-15DOI: 10.22541/au.161849043.37002937/v1
J. Brandt, C. Ananth
The obese parturient is at increased risk for numerous postoperative complications, including surgical site infections (SSI). Several promising strategies have emerged to reduce the risk of wound complications, including appropriately dosed antibiotics, antiseptic vaginal preparations, and prophylactic incisional negative pressure wound therapy (iNPWT). The latter approach is an innovation that applies negative pressure to a closed caesarean incision, redistributes lateral tension, reduces edema, and protects the surgical site from external infectious sources.
{"title":"New trial of negative pressure wound therapy for obese parturients after caesarean raises more questions","authors":"J. Brandt, C. Ananth","doi":"10.22541/au.161849043.37002937/v1","DOIUrl":"https://doi.org/10.22541/au.161849043.37002937/v1","url":null,"abstract":"The obese parturient is at increased risk for numerous postoperative complications, including surgical site infections (SSI). Several promising strategies have emerged to reduce the risk of wound complications, including appropriately dosed antibiotics, antiseptic vaginal preparations, and prophylactic incisional negative pressure wound therapy (iNPWT). The latter approach is an innovation that applies negative pressure to a closed caesarean incision, redistributes lateral tension, reduces edema, and protects the surgical site from external infectious sources.","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"91 1","pages":"2131 - 2131"},"PeriodicalIF":0.0,"publicationDate":"2021-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79039521","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}
{"title":"Insights from outside BJOG","authors":"A. Kent, S. Kirtley","doi":"10.1111/1471-0528.16570","DOIUrl":"https://doi.org/10.1111/1471-0528.16570","url":null,"abstract":"","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"213 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76520978","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}
Pub Date : 2020-11-02DOI: 10.22541/au.160432227.71704439/v1
P. Braude, E. Morris
No profession should be more involved in the debate about Germline Genome Editing than the members of the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, and the practitioners of new reproductive technologies, for the safety of future generations is in their hands. After all, it is our profession which has been the guardian of the health of the next generation and should continue to be so; this can only be achieved by embracing understanding of the new genomic technologies and by becoming involved in the discussions and decisions about their implementation.
{"title":"Transgenerational genomics: the profession should enhance its role as advocate for the health of the next generation","authors":"P. Braude, E. Morris","doi":"10.22541/au.160432227.71704439/v1","DOIUrl":"https://doi.org/10.22541/au.160432227.71704439/v1","url":null,"abstract":"No profession should be more involved in the debate about Germline Genome Editing than the members of the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, and the practitioners of new reproductive technologies, for the safety of future generations is in their hands. After all, it is our profession which has been the guardian of the health of the next generation and should continue to be so; this can only be achieved by embracing understanding of the new genomic technologies and by becoming involved in the discussions and decisions about their implementation.","PeriodicalId":8984,"journal":{"name":"BJOG: An International Journal of Obstetrics & Gynaecology","volume":"54 1","pages":"1171 - 1173"},"PeriodicalIF":0.0,"publicationDate":"2020-11-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89316957","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}
Women generally have higher-pitched voices than men – by an octave on average. Women’s voices range from 165 to 255 Hz while men’s voices are deeper at 85–155 Hz and the difference is classically attributed to the testosterone surge around puberty experienced by boys when their voices “break” as their vocal cords elongate and thicken. Women’s voices tend to change through the menopause transition, with lower estrogen levels leading to fewer glandular cells in the sub-epithelial layer of the vocal cords with resultant reduced vibratory properties. This produces a lower pitch which can impact on social situations and perceived attractiveness. A recent systematic review reported that hormone replacement therapy (HRT) may be associated with a higher speaking fundamental frequency in postmenopausal women with a normal body mass index, and this has been measured at a mean 186 Hz in hormone users and 175 Hz in non-users (Lin & Wang JAMA Otol H N Surg 2020; https://doi.org/10. 1001/jamaoto.2020.2174). They conclude that HRT can be associated with a higher-pitched voice if used by women in their postmenopause. Another unexpected consequence of HRT is reported in a recent observational study as it demonstrated that menopausal hormone therapy was associated with a decreased prevalence of osteoarthritis of the knees (Jung et al. Menopause 2019;26:598–602). It is likely that further “indirect” effects – both positive and negative – will be uncovered. This does not necessarily make them indications for commencing therapy but they may be viewed as fringe benefits and certain women could find them cogent reasons for considering medication and clinicians should be informed of these unanticipated consequences (Figure 1). Cancer surveillance in older women
女性的嗓音通常比男性高——平均高一个八度。女性的声音在165 - 255赫兹之间，而男性的声音在85-155赫兹之间，这一差异通常归因于青春期男孩的睾丸激素激增，当他们的声带拉长和变厚时，他们的声音会“断裂”。女性的声音往往会在绝经期发生变化，雌激素水平降低导致声带亚上皮层的腺细胞减少，从而导致振动特性降低。这会产生一个较低的音调，影响社交场合和感知吸引力。最近的一项系统综述报道，激素替代疗法(HRT)可能与正常体重指数的绝经后妇女较高的说话基本频率有关，激素使用者的平均说话基本频率为186 Hz，非激素使用者的平均说话基本频率为175 Hz (Lin & Wang JAMA Otol H N Surg 2020;https://doi.org/10。1001 / jamaoto.2020.2174)。他们得出结论，如果绝经后的女性使用激素替代疗法，可能会导致更高的音调。最近的一项观察性研究报告了HRT的另一个意想不到的结果，该研究表明，绝经期激素治疗与膝关节骨关节炎患病率降低有关(Jung等)。更年期26:598 2019;602)。进一步的“间接”影响——包括积极的和消极的——很可能会被发现。这并不一定使它们成为开始治疗的指征，但它们可能被视为附带益处，某些妇女可能会发现它们是考虑药物治疗的有力理由，临床医生应该被告知这些意想不到的后果(图1)
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