Pelvic organ support, symptoms and quality of life during pregnancy: a prospective study.

INTRODUCTION AND HYPOTHESIS: Prevalence studies show an increase in lower urinary tract and pelvic floor symptoms during pregnancy. The aim of our prospective study was to evaluate changes in pelvic organ support, pelvic floor symptoms and their effect on quality of life (QOL) during the first pregnancy using validated measures. We hypothesised that pregnancy is associated with worsening of pelvic floor function. METHODS: Objective assessment of pelvic organ support using the Pelvic Organ Prolapse Quantification (POP-Q) system and subjective evaluation of symptoms of pelvic floor disorders and related QOL with the electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) were performed in the second trimester and then repeated at 36 weeks gestation. RESULTS: A total of 182 nulliparae attended the first visit at 20 weeks and 150 (82.4%) women returned for follow-up at 36 weeks gestation. There were no significant changes in POP-Q points or stage between the two visits except for a significant increase in genital hiatus (p = 0.0001) and perineal body length (p = 0.0001). The vaginal symptoms did not show any changes. Symptoms and bother with voiding difficulties and stress urinary incontinence increased during pregnancy. Constipation (p = 0.02) and evacuation subdomains improved significantly (p = 0.009). In the sexual domain, the only subdomain that worsened significantly (p = 0.03) was "sex and vaginal symptoms". None of the pelvic floor symptoms impacted the QOL. CONCLUSIONS: In our group of nulliparae, pelvic floor-related QOL and prolapse stage did not change significantly from the second to the third trimester of pregnancy.

Effect of childbirth on pelvic organ support and quality of life: a longitudinal cohort study.

INTRODUCTION AND HYPOTHESIS: Although childbirth is known to be a major risk factor for pelvic floor disorders, there is a paucity of prospective, long-term data addressing this issue. The aim of our study was to evaluate the changes of pelvic organ support, symptoms and quality of life (QOL) after childbirth. METHODS: Pelvic organ support was objectively assessed using the Pelvic Organ Prolapse Quantification method (POP-Q) and pelvic floor symptoms were subjectively evaluated using a validated questionnaire performed in the second trimester, 14 weeks, 1 and 5 years after delivery. RESULTS: We recruited 182 nulliparae and 97 (53.3 %) returned for follow-up at 5 years. POP-Q stage after vaginal delivery (VD) worsened at all time points. After caesarean the worsening in POP-Q stage was temporary at 14 weeks. Prolapse symptoms worsened at 14 weeks (p<0.001) and 1 year (p=0.006) after VD but not at 5 years. No changes in prolapse symptoms occurred after caesarean. Significant increase in faecal incontinence was observed in both delivery groups 5 years after delivery. For all pelvic floor disorder domains there were no significant changes in QOL irrespective of mode of delivery, except for worsening in general sexual QOL after VD. CONCLUSIONS: Five years after childbirth the stage of prolapse worsened after VD but not after caesarean. However, there was no impact on prolapse symptoms or QOL. After VD women were more likely to experience a worsening in general sex score, but no other difference in QOL measures.

A pilot study of Foley's catheter balloon for prevention of intrauterine adhesions following breach of uterine cavity in complex myoma surgery.

PURPOSE: During abdominal myomectomy for removal of multiple fibroids, the uterine cavity may be breached. Repair of the breach is associated with a risk of development of intrauterine adhesions. We conducted a pilot study to evaluate the effectiveness of temporary placement of a Foley's catheter balloon inflated with 30 ml normal saline into uterine cavity at the end of surgery to prevent this complication. METHODS: Retrospective cohort study. When the uterine cavity was breached during open myomectomy, it was repaired with a No. 2-0 vicryl suture. A Foley catheter balloon was inserted into the uterine cavity at the end of the procedure, and the balloon distended with 30 ml of normal saline. The balloon was removed on the fourth post-operative day. Follow-up hysteroscopy was performed after 6 months. RESULTS: At the time of follow-up hysteroscopy 6 months after the myomectomy, we found no intrauterine adhesions in 16 consecutive women treated with balloon, compared to 3 out of 10 (30 %) historical controls where the balloon was not used. CONCLUSION: A Foley catheter balloon inserted into the uterine cavity following breach and repair of the uterine cavity at open myomectomy appears to prevent the formation of intrauterine adhesions.

Could Perimenopausal Estrogen Prevent Breast Cancer? Exploring the Differential Effects of Estrogen-Only Versus Combined Hormone Replacement Therapy.

Breast cancer is the commonest cancer among women in the western world, accounting for up to 30% of all cancers in women. There is a long-standing controversy about the potential link to hormone replacement therapy (HRT), with large observational studies suggesting that HRT increases the risk, while the Women's Health Initiative (WHI), a prospective, randomized placebo-controlled trial, has reported several times over a period of 20 years that combined (estrogen and progestogen) HRT increases the risk, while estrogen-only HRT given to women who have had a prior hysterectomy, is associated with a significantly reduced risk of developing breast cancer. Evidence from the randomized trial shows a significant reduction in both incidence of and mortality from breast cancer in women who took estrogen replacement therapy; this message needs to be presented clearly and robustly so that it can help women with decision making when considering HRT for menopause.

Association between twin discordance at 6-9 weeks' of gestation and birthweight complications.

Twins achieved through in-vitro fertilisation often undergo a viability ultrasound at 6-9 weeks of gestation. The presence of inter-twin crown-rump length discordance at this stage is not an uncommon finding; however the clinical significance of this is unknown. We analyzed 218 dichorionic twin pregnancies, producing two live fetuses > 24 weeks gestation, to determine whether inter-twin discordance (> or = 85th centile) in the mid-first trimester was associated with birthweight discordance (> 20%), or small for gestational age (< 10th centile). The incidence of birthweight discordance and small for gestational age infants were determined, with no increased risk found for the discordant population. This may provide some reassurance to treating clinicians.

It is all in the name: The importance of correct terminology in hormone replacement therapy.

The global increase in life expectancy to 74 years for women, while the median age of the menopause remains at 51 years, means that an increasing number of women will live a significant portion of their adult lives in the menopause. The WHI publications in 2003/4 reported on the dangers of hormone replacement therapy, in particular with respect to breast cancer and dementia risk. This resulted in a dramatic reduction in hormone replacement therapy prescription and use. However, the findings from the WHI studies have been re-appraised, and the new perspective is reflected in the guidance published by NICE in 2015 in which they recommended that more women be offered hormone replacement therapy as the benefits are now perceived to outweigh the risks for most women. However, controversy continues to surround hormone replacement therapy, and there are probably few areas in medicine where the misuse of terminology causes quite as much confusion as in hormone replacement therapy. Commonly used terms such as 'menopausal hormone therapy' and 'hormone replacement therapy' lack specificity and there is an urgent need for correct terminology to accurately describe the hormones replaced.

Could Estrogen Protect Women From COVID-19?

The apparent gender differences in favor of women in the risk of contracting and dying from coronavirus disease 2019 (COVID-19), and the fact that such trends have also been observed in recent epidemics including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), have prompted the obvious question: Are the reasons life-style or biological? True, women generally make healthier lifestyle choices as compared to men. Women do not smoke or drink as much as men, and they have a lower burden of those diseases (heart disease, diabetes or chronic lung conditions) that are known to be significant factors in the higher death rates among men with COVID-19. But there is compelling evidence for a role for biological factors. Genes are likely to play an important role. The X chromosome, of which women possess two, contains the largest number of immune-related genes of the whole human genome, theoretically giving women double the advantage over men in mounting an efficient and rapid immune response. A fundamental difference between women and men is their hormonal milieu, and it is not unreasonable to suppose that the dominant female hormone estrogen could influence the response to infection. In this paper we evaluate the evidence and mechanisms by which estrogen could provide protection to women from a variety of viruses, perhaps including the coronavirus that causes COVID-19.

Thyroid function and autoantibody status among women who spontaneously deliver under 35 weeks of gestation.

OBJECTIVE: Recent studies report an association between maternal thyroid auto-antibodies and preterm birth. None have made the important distinction between spontaneous and iatrogenic preterm birth. We investigated the association between spontaneous preterm birth before 35-week gestation and both thyroid function and auto-antibody status. DESIGN: Retrospective nested case-control study, samples retrieved from a biobank of around 8000 samples. PATIENTS: Forty-six cases of spontaneous preterm birth <35-weeks gestation compared with 124 cases who delivered at 40 weeks gestation, matched for maternal age and duration of serum storage. All resulted in a singleton liveborn. MEASUREMENTS: First trimester serum levels of TSH, free T4, free T3, anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies. RESULTS: Women who had a preterm birth delivered at a median gestational age of 33 (+1 day) weeks gestation (controls 40 + 3 weeks) and had significantly lower birthweight infants [mean (range) weight 1965 (581-3117) grams compared with controls 3526 (2685-4760) grams]. Median levels of anti-thyroglobulin and anti-TPO antibodies were similar in the two groups (Anti-Tg: 3 IU/ml (Range 1-316) v 3 IU/ml (1-691); Anti-TPO 8 IU/ml (3-73) v 9 IU/ml (3-499); P >/= 0.18 for both comparisons, compared using three statistical models). In the preterm group, the median TSH level was 0.70 mIU/l (range 0.04-3.84), similar to controls (0.88 (0.01-2.87), P = 0.1). Free T3 and T4 levels were also similar in both groups. CONCLUSIONS: Thyroid function and thyroid autoantibody status among women who have a spontaneous preterm delivery before 35 weeks gestation are not different from women delivering at term.

Miscarriage risk for asymptomatic women after a normal first-trimester prenatal visit.

OBJECTIVE: To estimate the risk of miscarriage among asymptomatic women after a prenatal visit between 6 and 11 weeks of gestation where proof of fetal viability of a singleton was obtained by office ultrasonography at the same visit. METHODS: This was a prospective cohort study performed over 2 years (March 2004-2006) at an antenatal clinic at a large tertiary hospital in Victoria, Australia. Those recruited were 697 asymptomatic women who attended their first antenatal visit between 6 (+2 days) and 11(+6 days) weeks of gestation, where evidence of fetal cardiac activity of a singleton was obtained by office ultrasonography. The main outcome measure was rates of miscarriage, stratified by gestation at presentation. RESULTS: One case was lost to follow-up. The risk of miscarriage among the entire cohort was 11 of 696 (1.6%). The risk fell rapidly with advancing gestation; 9.4% at 6 (completed) weeks of gestation, 4.2% at 7 weeks, 1.5% at 8 weeks, 0.5% at 9 weeks and 0.7% at 10 weeks (chi(2); test for trend P=.001). Most who miscarried received their ultrasound diagnoses many weeks after their visit; five (45%) were diagnosed in the second trimester, and all but one received their ultrasound diagnoses after 10 weeks of gestation. CONCLUSION: For women without symptoms, the risk of miscarriage after attending a first antenatal visit between 6 and 11 weeks is low (1.6% or less), especially if they present at 8 weeks of gestation and beyond. Our data could be used to reassure such women that the probability of progressing to later than 20 weeks of gestation is very good.

Randomized controlled trial of elevation of the fetal head with a fetal pillow during cesarean delivery at full cervical dilatation.

OBJECTIVE: To evaluate whether use of the Fetal Pillow (Safe Obstetric Systems, Shenfield, UK) affects maternal and fetal morbidity in cesarean delivery at full cervical dilatation. METHODS: A randomized controlled trial was conducted at two teaching hospitals in West Bengal, India, between April 1, 2013, and March 31, 2014. Women undergoing cesarean delivery at full dilatation were enrolled and randomly assigned with computer-generated random numbers (block size 10) to undergo delivery with or without the Fetal Pillow. Group assignment was not masked. The primary outcome was the incidence of major uterine wound extensions (grade 2-3). RESULTS: Overall, 120 women were assigned to each group. Major uterine wound extensions occurred in 6 (5.0%) women in the Fetal Pillow group and 39 (32.5%) in the control group (relative risk 0.23, 95% confidence interval 0.11-0.48). CONCLUSION: Use of the Fetal Pillow in second-stage cesarean delivery significantly reduces the risk of a major extension of the uterine incision. CTRI registration number: CTRI/2015/03/005651.

Premenstrual syndrome.

INTRODUCTION: A woman has premenstrual syndrome (PMS) if she complains of recurrent psychological and/or physical symptoms occurring during the luteal phase of the menstrual cycle, and often resolving by the end of menstruation. Symptom severity can vary between women. Premenstrual symptoms occur in 95% of women of reproductive age. Severe, debilitating symptoms occur in about 5% of those women. There is no consensus on how symptom severity should be assessed for PMS, which has led to the use of a wide variety of symptom scores and scales, thus making it difficult to synthesise data on treatment efficacy. The cyclical nature of the condition also makes it difficult to conduct RCTs. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of continuous hormonal treatments in women with premenstrual syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 132 studies. After deduplication and removal of conference abstracts, 132 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 102 studies and the further review of 30 full publications. Of the 30 full articles evaluated, one systematic review and three RCTs were added to this overview. We performed a GRADE evaluation for three PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for three interventions based on information relating to the effectiveness and safety of continuous combined oral contraceptives, continuous transdermal estradiol, and continuous subcutaneous estradiol implants.

Increased day 15-17 serum pro-alphaC inhibin levels specific to successful pregnancy.

In early pregnancy, serum levels of the luteal-derived hormone pro-alphaC inhibin peak by the second week after conception. Whether this early rise is biologically important and a consistent feature of only successful pregnancy is unknown. We undertook a prospective cross-sectional study to determine whether serum pro-alphaC inhibin levels at d 15-17 are predictive of a successful clinical in vitro fertilization pregnancy and compared levels between fresh embryo transfer (ET) and frozen-thawed ET. Median (95% confidence interval) pro-alphaC inhibin levels were 68 (57-76) pg/ml in 204 women who did not become clinically pregnant after ET, significantly lower than in either 90 women who became clinically pregnant after fresh ET and who had 3139 (1684-4220) pg/ml or in 39 women with a successful frozen ET who had 877 (678-1111) pg/ml. Pro-alphaC was highly sensitive and specific in predicting clinical pregnancy success but did not improve on the performance of human chorionic gonadotropin. Pro-alphaC inhibin levels were not correlated with progesterone or human chorionic gonadotropin. Levels were no higher in singleton compared with multiple pregnancies and did not increase across gestation, suggestive of a luteal source. The increase in circulating pro-alphaC inhibin in very early pregnancy is highly specific to clinical pregnancy, suggesting a possible biological role in early gestation.

A randomised trial of photographic reinforcement during postoperative counselling after diagnostic laparoscopy for pelvic pain.

OBJECTIVE: To measure the effect of seeing a photograph of the pelvic findings at laparoscopy. SETTING: Two university teaching hospitals. METHOD: A randomised-controlled trial. SUBJECTS: Two hundred thirty-three women undergoing diagnostic laparoscopy for the investigation of chronic pelvic pain. INTERVENTIONS: At operation a Polaroid print was taken of the pelvis. If this was of satisfactory quality, the patient was randomly allocated to either see, or not see, the print during the postoperative consultation. MAIN OUTCOMES: Pain severity and pain belief scores at 3 and 6 months. ANALYSIS: By intention to treat. RESULTS: Postoperative consultations with photographs did not improve immediate understanding and satisfaction with the consultation. In addition, compared to controls, both patients and doctors did not perceive particular benefit for communication from the photograph. There was a consistent trend to more pain in the photographic reinforcement group and more negative pain beliefs. At 3 months, the average within person differences showed some benefit in visual analogue pain scores, McGill affect scores, 'permanence' and 'self-blame' scores. These benefits were not statistically significant. At 6 months, there was a consistent pattern of benefit from pain severity and pain beliefs, again these benefits were not statistically significant. CONCLUSION: No clear benefits result from showing patients photographs of their pelvis.

Plasma MIC-1 and PAPP-a levels are decreased among women presenting to an early pregnancy assessment unit, have fetal viability confirmed but later miscarry.

BACKGROUND: We have recently shown first trimester Macrophage inhibitory cytokine-1 (MIC-1) and Pregnancy Associated Plasma Protein-A (PAPP-A) serum concentrations are depressed among asymptomatic women destined to miscarry. Here we examined whether plasma levels of MIC-1 and PAPP-A are depressed among women presenting to an Early Pregnancy Assessment Unit (EPAU), noted to have a confirmed viable fetus, but subsequently miscarry. METHODS: We performed a prospective cohort study, recruiting 462 women in the first trimester presenting to EPAU and had fetal viability confirmed by ultrasound. We obtained plasma samples on the same day and measured MIC-1, PAPP-A and human chorionic gonadotrophin (hCG), grouping the cohort according to whether they later miscarried or not. To correct for changes in analyte levels across gestation, we expressed the data as Multiples of the normal Median (MoMs). RESULTS: We recruited 462 participants presenting to EPAU at 5-12 weeks gestation. Most (80%) presented with symptoms of threatened miscarriage (e.g. abdominal pain, vaginal bleeding). 34 (7.4%) subsequently miscarried. Median plasma MIC-1 levels among those who miscarried were 50% of those with ongoing pregnancies (Miscarriage cohort MoM 0.50 (25(th)-75(th) centiles: 0.29-1.33) vs ongoing pregnancies MoM 1.00 (0.65-1.38); p=0.0025). Median plasma PAPP-A MoMs among those who miscarried was 0.57 (0.00-1.12), significantly lower than those with ongoing pregnancies (MoMs 1.00 (0.59-1.59); p=0.036). Plasma hCG levels were also significantly depressed among those who miscarried compared to those with ongoing pregnancies. However, the performance of MIC-1 as a diagnostic marker to predict miscarriage in this cohort was modest, and not improved with the addition of hCG. CONCLUSION: MIC-1 and PAPP-A levels are significantly depressed in women presenting to EPAU with ultrasound evidence of fetal viability, but later miscarry. While they are unlikely to be useful as predictive biomarkers in this clinical setting, they probably play important roles in the maintenance of early pregnancy.

Genital prolapse in women.

INTRODUCTION: Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59 years, but spontaneous regression may occur. Risks of genital prolapse increase with advancing parity and age, increasing weight of the largest baby delivered, and hysterectomy. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-surgical treatments in women with genital prolapse? What are the effects of surgical treatments in women with anterior vaginal wall prolapse? What are the effects of surgical treatments in women with posterior vaginal wall prolapse? What are the effects of surgical treatments in women with upper vaginal wall prolapse? What are the effects of using different surgical materials in women with genital prolapse? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 15 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: abdominal Burch colposuspension; abdominal sacral colpopexy; abdominal sacrohysteropexy; anterior colporrhaphy with mesh reinforcement; laparoscopic surgery; mesh or synthetic grafts; native (autologous) tissue; open abdominal surgery; pelvic floor muscle exercises; posterior colporrhaphy (with or without mesh reinforcement); posterior intravaginal slingplasty (infracoccygeal sacropexy); sacrospinous colpopexy (vaginal sacral colpopexy); sutures; traditional anterior colporrhaphy; transanal repair; ultralateral anterior colporrhaphy alone or with cadaveric fascia patch; vaginal hysterectomy; vaginal oestrogen; vaginal pessaries; and vaginal sacrospinous colpopexy.

Refusal of blood transfusion by Jehovah's Witness women: a survey of current management in obstetric and gynaecological practice in the U.K.

BACKGROUND: Refusal of blood transfusion by Jehovah's Witness (JW) women poses potential problems for obstetrics worldwide as haemorrhage remains a major cause of maternal morbidity and mortality. There is a general consensus that morbidity and mortality rates in association with childbirth and gynaecological interventions are higher in these women than in the general population. We conducted a postal questionnaire survey of current practice among U.K. consultant obstetricians and gynaecologists to establish the practices that could contribute to poor outcomes in these women. MATERIALS AND METHODS: The main variables of interest were: use of a multi-disciplinary approach; the acceptable minimum haemoglobin (Hb) concentration before vaginal delivery and abdominal hysterectomy as low to medium risk scenarios and open myomectomy as a high risk scenario for haemorrhage; Hb concentration thresholds for iron supplementation; and the use of oral iron, intravenous iron, erythropoietin and cell salvage as potential management tools. RESULTS: The response rate was 28%. Sixty percent of gynaecologists and 85% of obstetricians reported having a protocol for the management of JW women. Forty-six percent of consultants adopt a multi-disciplinary approach which include anaesthetists and haematologists. A Hb concentration of >11-12 g/dL is considered the minimum acceptable level by a majority (47%) prior to normal delivery and by 42% of gynaecologists prior to abdominal hysterectomy. For open myomectomy 28% of gynaecologists prefer a minimum level of 11-12 g/dL but a further 31% of gynaecologists prefer a minimum level of 12-13 g/dL. DISCUSSION: A small but substantial proportion of consultants do not have protocols, operate on JW women with low Hb concentrations, do not use a lower Hb concentration threshold for supplementation, and do not adopt a multi-disciplinary approach, all of which could contribute to the reported poor outcomes in these women.

Capillary remodelling in normal pregnancy: Can it mediate the progressive but reversible rise in blood pressure? Novel insights into cardiovascular adaptation in pregnancy.

OBJECTIVE: To conduct a longitudinal study of skin capillary density changes throughout normal pregnancy and correlate them to changes in blood pressure. DESIGN: Prospective, longitudinal cohort study. SETTING: London teaching hospital. STUDY DESIGN: Two hundred and twenty-five Caucasian, Primigravid women with singleton pregnancy, normotensive throughout pregnancy, and with normal pregnancy outcomes. We used intra-vital video microscopy to measure basal (i.e. functional) and maximal (i.e. structural) skin capillary density (CD) according to a well-validated protocol. The subjects were studied at baseline (11-16weeks gestation) and at four consecutive visits (20-24weeks, 27-32weeks, 34-38weeks, and 5-15weeks postpartum). Blood pressure measurements were taken during the same visits. RESULTS: We found that normal pregnancy was associated with progressive capillary rarefaction, with the overall trend in the fall in both functional and structural CD being statistically significant (p<0.001). The fall in CD was a remarkable mirror image to a progressive rise in systolic and diastolic blood pressures, there being a significant correlation between systolic blood pressure and structural CD. Postpartum measurements of both CD and blood pressure were similar to base line levels. CONCLUSIONS: Progressive capillary rarefaction is a normal accompaniment of human pregnancy that may mediate the progressive rise in systolic and diastolic pressures. Both the CD and blood pressure changes are reversible, returning to baseline in the puerperium.