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OBSTETRICS & GYNAECOLOGY

 

Gestational diabetes is on the increase

23 May 2017Paid-up subscribers

The prevalence of gestational diabetes mellitus (GDM) has been increasing over the past three decades, a large retrospective cohort study from the US has shown.

Uncomplicated menorrhagia can be effectively managed in primary care

24 Apr 2017Paid-up subscribers

A UK primary care study comparing the use of the levonorgestrel-IUS (LNG-IUS) with usual medical treatments for heavy menstrual bleeding (HMB) showed both to have very good outcomes.

Risk factors for antepartum stillbirth

22 Mar 2017Paid-up subscribers

Antepartum stillbirth is a complex syndrome associated with a range of risk factors, a prospective observational study has concluded.

Use of infant simulators does not reduce teenage pregnancies

15 Dec 2016Paid-up subscribers

Providing teenage girls with an infant simulator doll for a few days appeared to increase rather than decrease the risk of pregnancy, in a study from Western Australia.

Does alcohol consumption reduce fertility?

24 Oct 2016Registered users

Drinking in moderation does not appear to have an adverse effect on a woman’s ability to conceive, a prospective cohort study from Denmark has found.

Identifying risk factors for pre-eclampsia

23 Sep 2016Registered users

Previous pre-eclampsia, chronic hypertension, and pregestational diabetes, as well as BMI ≥ 30 kg/m2, and antiphospholipid antibody syndrome (APS), are all strongly associated with an increased risk of pre-eclampsia, a meta-analysis of large cohort studies has shown.

Atypical glandular cells on screening raise cervical cancer risk

23 Jun 2016Registered users

Atypical glandular cell change detected by cytological screening is associated with a high and persistent risk of cervical cancer, particularly adenocarcinoma, a Swedish longitudinal study has shown.

Mortality rates higher in women who have had a perinatal death

21 Mar 2016Paid-up subscribers

Women who experience a stillbirth or neonatal death have a higher mortality rate than those who do not, a large cohort study has found. Over a 29-year period 838,331 women who gave birth in Denmark were identified. Of these, 7,690 experienced either stillbirth or neonatal death (0.92%), 3,684 (52%) of which occurred at their first delivery. The mean follow-up period was 15 years (SD 8 years), and during this time 8,883 mothers died (1.06%).

High potato intake before pregnancy may be linked to GDM

22 Feb 2016Registered users

Research from the Nurses’ Health Study II (NHSII) suggests an association between pre-pregnancy potato consumption and subsequent gestational diabetes mellitus (GDM).

Do significant menopausal symptoms raise the risk of CHD?

22 Dec 2015Registered users

A large longitudinal study from Australia has found that women who often experience vasomotor menopausal symptoms such as hot flushes and night sweats appear to be at greater risk of coronary heart disease (CHD). Women in the Australian Longitudinal Study on Women’s Health (ALSWH), born between 1946 and 1951, were followed up at three-year intervals for 14 years. They were sent a series of six questionnaires between 1996 and 2010. In each survey they were asked whether they had had heart disease diagnosed.

PCOS mothers with twin pregnancies at high risk of preterm birth

25 Nov 2015Paid-up subscribers

In twin pregnancy women with a history of polycystic ovarian syndrome (PCOS) are a high-risk group for preterm birth. Using the comprehensive Swedish medical birth and national patient registers almost 1.5 million births over a 15-year period, between 1995 and 2009, were identified. Of these, 20,965 were twin births of which 223 (1.1%) were to women who had a diagnosis of PCOS.

Lifestyle intervention reduces gestational diabetes in high risk women

24 Sep 2015Paid-up subscribers

A small study from Finland has shown that a relatively simple dietary and exercise intervention during pregnancy can lower the risk of gestational diabetes mellitus (GDM) in high-risk groups.

Are statins safe to use during pregnancy?

21 May 2015Paid-up subscribers

A large epidemiological study from the United States on statin use in the first trimester of pregnancy has found no evidence of a teratogenic effect. However, the study authors concluded that further research is needed before statins can be considered safe in pregnancy. Although this study provides reassurance about the use of statins in pregnancy, as with any observational study, it was open to bias and its findings offer guidance rather than proof. It seems reasonable to continue advising women not to conceive while taking statins especially as more subtle neurodevelopmental and infant behaviour effects were not addressed.

Comorbidity a key factor in maternal deaths from pregnancy complications

23 Apr 2015Paid-up subscribers

An analysis from the National Perinatal Epidemiology Unit has estimated that almost 50% of the population attributable risk of maternal mortality is associated with the presence of a medical comorbidity. Using data from the Confidential Enquiry into Maternal Deaths, 135 cases of direct maternal death were identified between 2009 and 2012 from five major causes. Data from the UK Obstetric Surveillance System was used to identify 1,661 women who survived one of these five complications i.e. eclampsia, pulmonary embolism, severe sepsis, amniotic fluid embolism and peripartum haemorrhage. These survivors formed an unmatched control group.

Infant mortality risk raised in overweight mothers

23 Mar 2015Paid-up subscribers

Being overweight or obese in early pregnancy is associated with a significantly increased risk of infant death, with the greatest risk seen in severely obese women, a large cohort study from Sweden has shown.

IUI effective in couples with unexplained or mild male factor infertility

23 Feb 2015Paid-up subscribers

Intrauterine insemination (IUI) produced similar outcomes to in vitro fertilisation (IVF) with single embryo transfer and IVF in a modified natural cycle, in subfertile couples in a randomised controlled trial. A total of 602 couples, with mild male factor infertility or unexplained failure to conceive after 12 months’ unprotected intercourse, with an unfavourable prognosis for natural conception, were recruited from 17 centres across the Netherlands.

Pelvic floor exercises may be helpful for vaginal prolapse

22 Jan 2015Paid-up subscribers

Women with mild prolapse reported that pelvic floor muscle training (PFMT) helped to alleviate symptoms, in a study in primary care. Overall, 287 women, aged 55 or over, with symptomatic uterovaginal prolapse to, but not beyond, the hymenal remnants were recruited to the study from 15 general practices in Groningen, the Netherlands. Symptoms included vaginal bulging, a feeling of heaviness or urinary difficulties or incontinence.

Anatomy and histology of the G-spot revealed

15 Dec 2014Paid-up subscribers

A small study from Poland has identified an anatomically distinct discrete G-spot within the vagina. Anterior vaginal wall tissue was surgically removed, post-mortem, from eight women who had died suddenly from acts of violence, suicide or drug overdose. The demonstration of an anatomically discrete, neurovascular structure containing a nerve ganglion, located in the vicinity of the presumed G-spot is of interest not just in the discipline of sexual medicine but also to gynaecologists as well.

Lifestyle factors associated with risk of gestational diabetes

23 Oct 2014Paid-up subscribers

Maintaining a healthy lifestyle before pregnancy is associated with a substantially lower risk of developing gestational diabetes mellitus), a large prospective cohort study has found. The Nurses Health Study II recruited 116,671 female nurses aged 24-44 in 1989. After ten years’ follow-up, 20,136 singleton pregnancies had occurred in 14,437 women. There were 823 pregnancies affected by GDM.

Comparing treatments for infertility in women with PCOS

23 Sep 2014Registered users

Letrozole appears to be more effective, and associated with fewer maternal side effects, than clomiphene in the treatment of infertility in women with polycystic ovary syndrome (PCOS), a double blind trial of 750 women has found

Mortality risk highest on the day of birth — unless you live till your nineties

25 Jul 2014Registered users

The risk of a baby in the UK dying on the first day of life is higher than the average daily risk of death until the 92nd year, a study in the BJOG has shown. The study from Nottingham looked at the risk of death on the day of birth, measured in MicroMorts, and compared this with risks at other ages and for a variety of activities. A MicroMort is a figure expressed as the number of one in a million chances of death associated with an activity or event.

Perinatal outcomes poorer following bariatric surgery

20 Mar 2014Paid-up subscribers

Women who have had bariatric surgery appear to be at higher risk of preterm and small for gestational age (SGA) babies, a large study from the Karolinska Institute in Sweden has found. The Swedish birth registry captures data on 98% of all births nationwide. Between 1992 and 2009 more than 1.7 million births were identified, after relevant exclusions, of which 2,562 were to women who had undergone bariatric surgery for obesity, and had a singleton pregnancy.

Does planned CS improve outcomes in twin births?

05 Dec 2013Paid-up subscribers

In uncomplicated twin pregnancies where the first twin presentation was cephalic, perinatal and maternal outcomes were similar whether the birth plan was for vaginal or abdominal delivery, a large study has found. Between December 2003 and April 2011, 2,804 women with twin pregnancies were recruited in 25 countries, including the UK. All 106 participating centres were staffed by experienced obstetricians with rapid access to operative intervention during labour. All pregnancies were otherwise uncomplicated and with the first twin presenting head first. All were randomised between the 32nd and the 38th completed week of pregnancy to either planned CS or vaginal delivery.

Comparing effectiveness of treatments in women with menorrhagia

23 Sep 2013Paid-up subscribers

Women treated with the levonorgestrel- releasing intrauterine system (IUS) rated their treatment more effective than those who received medical therapy in reducing the effect of heavy menstrual bleeding (HMB) on quality of life, a primary care study has found. A cohort of 571 women with HMB from 63 UK practices was studied between February 2005 and July 2009. Initially, 285 were randomised to receive an IUS and 286 to medical treatment.

Identifying risk factors for cerebral palsy

23 May 2013Paid-up subscribers

A population-based case control study from Sweden has identified different potential risk factors for the subtypes of cerebral palsy. The authors were unable to identify a single risk factor that was pre-eminent. Rather they observed a mix of antenatal, intrapartum and postnatal factors which differed according to cerebral palsy subtype. The authors conclude that the risk factors identified may be useful indicators for identifying children at risk of developing cerebral palsy and help to target individuals for early intervention programmes.

Preterm births fall after smoking bans

25 Apr 2013Paid-up subscribers

The rate of preterm births in Belgium dropped significantly following stepwise introduction of anti-smoking legislation, a study in the BMJ has found. The legislation was introduced in three waves. On 1 January 2006 smoking was banned in public places and in most workplaces, on the same date in 2007 in restaurants and at the start of 2010 in bars serving food.

Fetal growth restriction key risk factor for stillbirth

21 Mar 2013Paid-up subscribers

The stillbirth rate in pregnancies with fetal growth restriction (FGR) was four times higher than in those with normal growth, and eight times higher in cases where FGR had not been detected antenatally, in a large UK study.

Identifying risk factors for endometrial cancer

21 Feb 2013Paid-up subscribers

Obesity, polyps and a history of non-familial colorectal cancer appear to increase the risk of endometrial cancer in women with previous normal endometrial biopsy findings, a case-control study from the US has found.

Vascular ultrasound can safely exclude pregnancy related DVT

31 Oct 2012Paid-up subscribers

Single complete compression ultrasonography could be used to rule out suspected deep vein thrombosis (DVT) during pregnancy or the postpartum period, the findings of a study in the BMJ suggest.

Endometriosis associated with certain types of ovarian cancer

26 Jul 2012Paid-up subscribers

There is a strong association between endometriosis and risk of invasive low-grade serous, clear-cell, and endometrioid ovarian cancers, an international collaborative study has found.

LARC more effective than other methods in all age groups

26 Jul 2012Registered users

Failure rates with long-acting reversible contraceptive (LARC) methods are lower than those of oral contraceptives, transdermal patches or vaginal rings in women of all ages, a prospective cohort study from the US has concluded. [With external links to the current evidence base]

Assessing VTE risk with non-oral hormonal contraception

20 Jun 2012Registered users

Women who use combined contraceptive transdermal patches or vaginal rings are at an increased risk of venous thromboembolism (VTE) compared with non-users of hormonal contraception but the absolute risk is low, a large cohort study has confirmed. [With external links to the current evidence base]

Risk of birth defects low following assisted conception

20 Jun 2012Paid-up subscribers

A large study on fetal anomalies in children conceived with reproductive assistance suggests that the slight increase in birth defects associated with assisted conception may be caused by parental factors rather than the fertility treatments.

Perineal tears raise risk of pelvic floor disorders

22 May 2012Paid-up subscribers

A study from the United States has shown that perineal laceration occurring in two or more vaginal deliveries poses a significant risk of future pelvic floor problems.

Metabolic changes persist in older women with PCOS

25 Apr 2012Paid-up subscribers

In patients with polycystic ovary syndrome (PCOS) metabolic changes persisted and waist circumference increased over two decades of follow-up, although hormonal parameters improved, in a longitudinal study from Italy.

Annual IUD checks of little benefit

25 Feb 2012Registered users

Regular routine check ups on women fitted with intrauterine contraceptive devices (IUD) do not appear to confer any protection against adverse events, a UK general practice-based study has found. The medical records of women registered with one practice in Rugby, Warwickshire who had had an IUD fitted between 1976 and 2005 were examined. Only women who had a device in place for at least two years with a complete set of legible records covering the time between insertion and removal or study endpoint (March 2007) were included in this retrospective analysis. [With external links to the current evidence base]

Assessing risk of VTE with combined oral contraceptives

25 Feb 2012Registered users

Combined oral contraceptive pills (COCPs) containing desogestrel, gestodene or drospirenone appear to confer double the risk of venous thromboembolism (VTE) compared with those containing levonorgestrel, a large population-based study has found. Data on all women in Denmark aged 15-49 years were identified from four national registries during the period 2001-2009. [With external links to the current evidence base]

Comparing outcomes in different birth settings

24 Jan 2012Registered users

For healthy women with low-risk pregnancies the incidence of adverse perinatal outcomes is low in all birth settings. However, for those who are nulliparous the risk of an adverse outcome appears to be higher for births planned at home, a national cohort study has found. There was also a high intrapartum transfer rate. Over a two-year period nearly 65,000 women ‘attended by an NHS midwife during labour in the planned place of birth’ were enrolled in the Birthplace in England national prospective cohort study. Dr Chris Barclay, GP with an interest in O&G, Suffolk, reviews the study. He concludes: 'So, where is the best place to give birth? The answer appears to be that it depends on the presence of pre-existing risk factors and maternal preference. The outcomes in the midwifery units were very reassuring. However, the significantly higher figures for adverse perinatal outcomes and transfer during or just after labour from home to an obstetric unit in nulliparous cases opting for a home birth is food for thought.'

Laparoscopic sterilisation is more reliable than hysteroscopic procedures

16 Dec 2011Registered users

Failure rates are significantly higher following hysteroscopic sterilisation (HS), in a theatre or office setting, compared with laparoscopic sterilisation (LS), a study has found. A research group from Pittsburgh reviewed the literature and collated a number of studies from which data were extracted and analysed. All studies had to have a minimum of 50 subjects with follow-up for at least 12 months. No absolute figures were presented, only percentages. Figures for successful sterilisation at the first attempt were: 99%, 86% and 85% for LS, HS in theatre and HS in the office setting at three months and 99%, 88% and 87% respectively six months post-procedure. The respective figures at 12 months were 99%, 95% and 94%. However, the method by which some patients were eventually successfully sterilised was different from the method they chose initially. Although, some women elected to have a second HS attempt, 7.0% of patients who had had HS in theatre and 5.3% of those who had had HS in an office setting went on to have a laparoscopic procedure. Overall, 5% of patients declined any further sterilisation attempts. When best and worst case data were compared the difference in success rates at 12 months showed LS to outperform HS by 0.4-10%.

Women with PCOS have higher risks in pregnancy

16 Dec 2011Registered users

Women with polycystic ovary syndrome (PCOS) are more likely to suffer adverse pregnancy and birth outcomes, a population-based cohort study from Sweden suggests. The researchers identified women with singleton pregnancies who gave birth between 1995 and 2007, using the Swedish medical birth register. Using linkage to another national database, they established that, in this cohort, 3,787 births were to women with diagnosed PCOS and 1,191,336 were to women without the disease. Data on maternal and fetal pregnancy outcomes were collected. Comments Dr Chris Barclay: 'We know that women with PCOS are more likely to be overweight and are at greater future risk of diabetes and cardiovascular disease. The results of this study suggest that they are also more likely to have high-risk pregnancies. There are two observations I would like to make on this study. First, the numbers of women with diagnosed PCOS here were small, and this may have obscured the magnitude of its adverse effects on pregnancy. Second, nowhere in the paper were the significance of hyperinsulinism or the metabolic syndrome discussed which considering they are common and relevant characteristics of PCOS was baffling.'

Timing of IUD insertion after termination

22 Nov 2011Registered users

Uptake of IUD insertion is greater when it is offered immediately after termination than when insertion is delayed for four to six weeks. Expulsion and bleeding were no higher in the early insertion group a study has found. The authors conclude that immediate insertion of a copper IUD after medical termination should be offered routinely to women. [With external links to current evidence]

Sleeping position and risk of stillbirth

20 Oct 2011Registered users

A prospective population-based case control study from New Zealand suggests that maternal sleep practices may increase stillbirth rates, but the risk was still low. The absolute risk for late stillbirth among women who fell asleep in the left lateral position was 1.96/1,000 births compared with 3.93/1,000 for those who did not.

Does COCP formulation affect patients' thromboembolic risk?

22 Jun 2011Registered users

Combined oral contraceptives containing drospirenone appear to carry a three-fold higher risk of non-fatal idiopathic venous thromboembolism (VTE) than those containing levonorgestrel, although the overall risk is still low. The study used data from the UK General Practice Research Database (GPRD) that gathers information from a large number of general practices and more than three million people in the UK, including demographic data, information about prescribed drugs, diagnoses, hospital admissions and deaths. [With external links to the current evidence base]

Progesterone level predicts outcome in pregnancy of unknown location

25 May 2011Registered users

A single visit protocol based on serum progesterone measurements appears to be a safe and effective approach for triaging and managing women with pregnancy of unknown location (PUL). A total of 6,201 women with suspected early pregnancy complications attended King's College Hospital, London over the 15-month study period. There were 676 (10.9%) with PUL, defined as a positive pregnancy test but with no evidence of a gestation sac in utero or ectopic on ultrasound scanning. Of these 252 were found to have a progesterone level <10 nmol/L. All but one of these women were treated as outpatients and were not invited for further investigation.

Smaller loop excisions safe in younger women with high-grade CIN

25 May 2011Registered users

Loop excisions <10 mm for CIN do not raise the risk of recurrence in women aged 35 and under with high-grade disease, a study has found. A total of 1,558 women with high-grade CIN undergoing loop excision of the cervix, over a six-year period, were studied. 'The upshot is that smaller loop excisions in potentially fertile women appear safe.'

Should pill dosage be adjusted for larger women?

20 Apr 2011Registered users

The Clinical Effectiveness Unit of the Faculty of Sexual and Reproductive Healthcare currently advises that larger women need not take a higher dose of the progestogen-only contraceptive pill (POP) for effective contraceptive cover. However, a case report in the Faculty's journal casts doubt on this advice. Dr Chris Barclay reviews the paper and comments: 'I drew two conclusions from this interesting paper. First heavier women, >60-70 kg, using POP contraception, should be included in the decision about dosage. Second, that evidence-based medicine does not address every facet of day-to-day medical practice. Deploying clinical wisdom as the authors did here is, in my view, to be commended.' [With external links to current evidence]

Does diet affect outcomes in pregnant women who are overweight?

20 Apr 2011Registered users

A low-glycaemic load (GL) diet in overweight or obese women did not affect the birthweight or body fat of their babies when compared with a low-fat diet. However, women in the former group had smaller increases in triglycerides and total cholesterol and a greater decrease in C-reactive protein (CRP) than those in the latter. Infant head circumference and duration of pregnancy were also greater in this group. 'Rising rates of overweight and obesity within society in general are increasingly being mirrored in women during pregnancy. Current dietary advice does not seem to be achieving significant improvements and not surprisingly alternative dietary interventions are under scrutiny. Preterm and early-term births contribute significantly to perinatal morbidity and head circumference is directly related to brain volume and possibly later IQ. Drawing firm conclusions from pilot studies is difficult. Although a low-GL diet was associated with a more favourable maternal biochemistry profile and with better birth statistics, the number of subjects in the study was small. Larger studies are needed to evaluate whether a low-GL diet does improve maternal and infant outcomes.'

Weighing up the benefits and risks of HRT

21 Feb 2011Registered users

An observational study from Canada has shown that a decline in the use of HRT over the past decade was followed by a reduction in the incidence of breast cancer. Data on HRT prescriptions dispensed for women aged 50-69, during the years 2001-2006, was collated from a national registry. Information about current HRT use was obtained by telephone from a sample of 1,200 women in this age group already enrolled in the National Population Health Survey. However, the data are observations of association only, and are not controlled for other risk factors for breast cancer such as parity and alcohol intake. The absolute risk of breast cancer to an individual user of HRT is small (and smaller still in oestrogen-only formulation users). The potential benefits need to be weighed up against the risks for each individual patient. [With external links to current evidence and summaries]

Children with gynaecological problems benefit from a paediatric service

24 Jan 2011Registered users

The setting up of a paediatric and adolescent gynaecology (PAG) service in a DGH has enabled new pathways of care and the development of best practice, a study in the BJOG concludes. The report from this PAG service makes a case for special training for gynaecologists with an interest in paediatric gynaecology and that girls are seen in a paediatric rather than an adult clinic setting. A total of 800 girls were referred to the PAG service in Kettering General Hospital over a 15-year period between 1994 and 2009. The peak age for referral was bimodal at 4 and 15 years of age. 'Not surprisingly menorrhagia and dysmenorrhoea were common comprising 13% of all referrals with a peak age of 14 years. Only 17% had received any treatment from the GP before referral. Treatments given subsequently included the combined pill, depot provera, mefenamic and tranexamic acid as well as HRT and an IUS. And 5% required diagnostic laparoscopy for possible endometriosis. Other problems included amenorrhoea (primary and secondary), urinary symptoms and incontinence and suspected sexual abuse. This latter category comprised just 3% of the total with an age range of 3 months to 15 years. Sub-specialisation is the order of the day in gynaecology and other hospital specialties. The authors make a strong case that each unit have a consultant with a particular interest in paediatric gynaecology and multidisciplinary links for example with urology, endocrinology and dermatology services.'

Does treating dental infections affect pregnancy outcomes?

24 Jan 2011Registered users

 Treating periodontal infections during pregnancy is unlikely to reduce the risk of preterm birth. A trial of dental hygiene treatment was conducted among pregnant women in Pennsylvania. The initial phase was the development of standard criteria to determine if periodontal disease was present. This involved measurement of gingival pocket depth and connective tissue attachment to teeth. In the second phase, 322 pregnant women with periodontal disease were given oral hygiene instruction and free supplies of floss, brushes and toothpaste. Half were randomised to have dental scaling and root planing as well. No significant difference in the incidence of preterm births was seen between the two groups; 52.4% in the control group and 45.6% in the intervention group. The third phase of the study looked at those women who had the scaling and root planing. All received treatment before 20 weeks gestation and an assessment of the success or otherwise of treatment 20 weeks later. Success equated to improvement in periodontal disease criteria or being no worse. A total of 49 successful and 111 unsuccessful cases were identified. The numbers of preterm deliveries were 4 and 69 respectively, indicating a strong association between periodontal disease progression in pregnancy and preterm delivery. There was a significant relationship between successful periodontal treatment and full-term birth.

 

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