Long-term outcomes of laparoscopic repair of cystocoele.

BACKGROUND: There is little information on the effectiveness of laparoscopic techniques for native tissue repair of cystocoele. AIM: To assess the long-term outcome of laparoscopic cystocoele repair. METHODS: Two hundred and twenty-three women with symptomatic pelvic organ prolapse underwent laparoscopic paravaginal repair and treatment of associated conditions. Women were assessed pre-operatively and postoperatively at 6 weeks, 6 months, 12 months and then annually or biannually with pelvic organ prolapse quantification (POPQ) and subjective assessment at each visit. RESULTS: Median follow-up was 5.2 years (range: 1-12 years) with 140 women (63%) followed for at least 5 years. During follow-up, 79% of women developed prolapse of at least POPQ stage 2 in one or more compartments and 58% became symptomatic again. Overall, 48% underwent further prolapse surgery, but only 24% of women had an anterior prolapse beyond the hymen. Thirty per cent eventually had a further cystocoele repair. CONCLUSION: Long-term follow-up of laparoscopic cystocoele repair shows that cystocoeles are difficult to repair successfully.

Reflections on the maternal mortality millennium goal.

BACKGROUND: Nearly every 2 minutes, somewhere in the world, a woman dies because of complications of pregnancy and childbirth. Every such death is an overwhelming catastrophe for everyone confronted with it. Most deaths occur in developing countries, especially in Africa and southern Asia, but a significant number also occur in the developed world. METHODS: We examined the available data on the progress and the challenges to the United Nations' fifth Millennium Development Goal of achieving a 75 percent worldwide reduction in the maternal mortality by 2015 from what it was in 1990. RESULTS: Some countries, such as Belarus, Egypt, Estonia, Honduras, Iran, Lithuania, Malaysia, Romania, Sri Lanka and Thailand, are likely to meet the target by 2015. Many poor countries with weak health infrastructures and high fertility rates are unlikely to meet the goal. Some, such as Botswana, Cameroon, Chad, Congo, Guyana, Lesotho, Namibia, Somalia, South Africa, Swaziland and Zimbabwe, had worse maternal mortality ratios in 2010 than in 1990, partially because of wars and civil strife. Worldwide, the leading causes of maternal death are still hemorrhage, hypertension, sepsis, obstructed labor, and unsafe abortions, while indirect causes are gaining in importance in developed countries. CONCLUSIONS: Maternal death is especially distressing if it was potentially preventable. However, as there is no single cause, there is no silver bullet to correct the problem. Many countries also face new challenges as their childbearing population is growing in age and in weight. Much remains to be done to make safe motherhood a reality.

Effect of uterine preservation on outcome of laparoscopic uterosacral suspension.

STUDY OBJECTIVE: To compare the objective outcome of laparoscopic uterosacral hysteropexy with that of hysterectomy combined with laparoscopic uterosacral colpopexy. DESIGN: Retrospective cohort study, 1999-2010 (Canadian Task Force classification II-2). SETTING: University hospital in South Australia. PATIENTS: Women with uterovaginal prolapse who had undergone laparoscopic uterosacral hysteropexy (n = 104) or laparovaginal hysterectomy with uterosacral colpopexy (n = 160). Apical suspension procedures were subdivided into prophylactic (Pelvic Organ Prolapse Quantification System [POP-Q] stage 1 apical descent, with stage ≥2 prolapse in an adjacent compartment) and therapeutic (POP-Q stage ≥2 apical descent, with or without adjacent compartment prolapse). INTERVENTIONS: All patients were assessed via POP-Q scoring preoperatively and postoperatively at 6 weeks, 6 months, annually, and then biannually. Recurrence of bulge symptoms and need for repeat treatment were recorded. MEASUREMENTS AND MAIN RESULTS: Demographic data, preoperative degree of prolapse, and percentages of prophylactic and therapeutic procedures were similar in both groups. With a median follow-up of 2.5 years, objective success rates (POP-Q stage <2 in all compartments) for uterosacral hysteropexy were 53% for prophylactic procedures and 41% for therapeutic procedures, and for hysterectomy with uterosacral colpopexy were 66% for prophylactic procedures and 59% for therapeutic procedures. Repeat operation rates overall were 28% for hysteropexy and 21% for hysterectomy with colpopexy. Failures at the apex specifically were 27% for hysteropexy and 11% for hysterectomy with colpopexy (p < .02). CONCLUSION: Hysterectomy with laparoscopic uterosacral colpopexy produced better objective success rates than did laparoscopic uterosacral hysteropexy; however, repeat operation rates were not significantly different.

Evidence-based medicine and perinatal care: from dawn to dusk.

Since the concept of "evidence-based medicine" was first launched 20 years ago as a new method of teaching the practice of medicine, it has had an enormous impact on practice in many fields of health care. From the very start, professionals in pregnancy and perinatal care were at the forefront of attempts to collect good evidence systematically on the benefits and harms of health care interventions during pregnancy and in and around childbirth. Perinatal practice has largely benefitted from that endeavor. However, it has also suffered from the ill-effects of the narrow view that evidence, to be good evidence, needs to be randomized evidence. Twenty years on, it may be time to reflect on what is meant by evidence and how to use it, not as a doctrine or dogma, but as a valuable tool and a tremendous asset to improve outcomes for mothers and babies.

In the literature: home birth: safe enough, but not for the first baby.

The "Birthplace in England" study compared low-risk pregnancies by planned place of birth at the onset of labor: home, midwifery unit, or obstetric unit. The study showed that childbirth interventions were less frequent in all nonobstetric settings than in obstetric units, confirming what has been noted elsewhere. For parous women, there was no difference in perinatal outcomes by place of birth. For nulliparous women, perinatal outcomes were similar in midwifery and obstetric units, but the frequency of poor outcomes with planned home births was higher. The major strengths of the study are its prospective design and large sample size. The results support providing choices to women, but suggest that women should not be encouraged to give birth at home for their first baby. (BIRTH 39:2 June 2012).

In the literature: dispelling hallucinations about birthweight: how hard is it?

Birthweight is an important determinant of perinatal outcome and future health well into adulthood. Before weighing newborn infants became enshrined in practice, birthweights tended to be based on an educated guess or, as alleged by Roederer in 1753, on hallucination. Two centuries later, they led to a Babylonic confusion between weight and maturity at birth. Even nowadays, hallucinations about birthweight and its effect on infant health have not entirely disappeared. New hallucinations still emerge and remain as difficult to dispel as they once were.

The language of birth.

Our language both reflects and influences our attitudes and behavior. This Roundtable Discussion explores the language used in obstetrics and in the interactions between caregivers and women or their families: What do practitioners say to mothers and families during labor? At birth? In consultations? To describe what is happening? To encourage a woman's efforts? To lighten the atmosphere? When advising about possible interventions? Medical terminology in perinatal care can often be deceptive or confusing, not only for mothers but for caregivers. The authors of this Roundtable, representing health professionals from different specialties and interests in the field, have examined some examples of such language use, misuse, and abuse in perinatal care. (BIRTH 39:2 June 2012).

Laparoscopic supralevator repair for combined apical and posterior compartment prolapse.

STUDY OBJECTIVE: To analyze the objective outcome of laparoscopic supralevator repair in the treatment of rectoenterocele with the Pelvic Organ Prolapse Quantification (POPQ) system. STUDY DESIGN: Retrospective cohort study 1999-2009 (Canadian Taskforce Classification II-2). SETTING: University hospital in South Australia. PATIENTS: A total of 166 women with a median age of 63 years (range 36-89) who underwent laparoscopic supralevator repair for rectoenterocele and treatment of associated conditions over a 10-year period. INTERVENTIONS: All patients were assessed with the POPQ scoring system before surgery and at 6 weeks, 6 months, annually, and biannually after surgery. MEASUREMENTS AND MAIN RESULTS: The median operating time was 151 minutes (range 35-390); median blood loss was 50 mL (range 50-600); and median hospital stay was 4 days (range 1-14). Four women, 2 of whom required laparotomy, had a major complication. Ten women (6%) needed day surgery to treat vaginal granulations or suture exposure. With a median follow-up time of 45 months (interquartile range 16-67) the overall objective success rate was 63% according to National Institute of Health criteria. The median time to failure was 24 months. Of 61 objective failures, 23 required further prolapse surgery, representing a 14% reoperation rate. CONCLUSION: Laparoscopic supralevator repair is a safe and effective procedure for the treatment of rectoenterocele.

Effect of motherhood on women's preferences for sources of health information: a prospective cohort study.

To examine what sources of health information are preferred by first-time mothers-to-be and how these preferences change by the time their child reaches school age. Women expecting their first child (n = 649), recruited in a randomized trial of early childhood caries prevention at all five public maternity hospitals in Adelaide, were questioned about their preferences for health information. Their preferences were assessed again 4 and 7 years later. Answers at 7 years were compared with those of a population-based cohort of mothers with a first child of the same age. Parents were listed most frequently as a preferred source of health information during pregnancy (67.8%) followed by health care practitioners (48.8%). By the time the child reached school age, 78% listed health care practitioners as their preferred source compared with 15.5% listing parents, 21.7% friends and relatives, and 13% the Internet. Data from the population-based comparison group of mothers with a first child of similar age mimicked those of mothers enrolled in the trial. Mothers put a lot more trust in information received from health care professionals than they did before their child was born. This can create opportunities for enhancing the effectiveness of community health initiatives.

Precise mid-trimester placenta localisation: does it predict adverse outcomes?

BACKGROUND: A low-lying placenta detected at the mid-pregnancy ultrasound is commonly reported to warn against potential morbidity associated with placenta praevia. There is no information on what distance away from the internal cervical os is safe. AIMS: We examined whether a low-lying placenta not overlapping the cervical os in the second trimester increases the risk of obstetric complications and whether there is a cut-off point at which that increase occurs. METHODS: Adverse perinatal outcomes were examined prospectively in a cohort of women with a placenta 0-30 mm from the internal cervical os ('low-lying') at the routine mid-trimester ultrasound and compared to those with a placenta further away. Two composite outcomes of 'major' and 'minor' adverse events were predefined as primary outcome measures, requiring a sample size of 480 women with a low-lying placenta. Chi-square and Fisher's exact tests were used for statistical analysis. RESULTS: In 1662 pregnancies ('low-lying': n = 484; 'normal': n = 1178), there was no increase in composite adverse outcomes with a low-lying placenta and no cut-off distance within 30 mm from the cervical os at which risks increased. Postpartum haemorrhage ≥ 1000 mL was more frequent with a low-lying placenta (7.6% vs 4.7%, P < 0.05). CONCLUSIONS: Women with a low-lying placenta, not overlapping the cervical os, in mid-pregnancy are at no higher risk of adverse outcomes than those with a normally located placenta, except postpartum haemorrhage. This suggests that the high-risk label can be removed from pregnancies with a low-lying placenta not overlapping the cervical os in mid-pregnancy, reducing anxiety and resource utilisation.

Discovering the Holy Grail in postpartum uterine involution.

A Swiss study attempted to establish normal values for the uterine involution expected during the first 5 days postpartum. Two methods were used, apparently independently and without validation. One, named the finger method, consisted of estimating the height of the uterine fundus in finger breadths above or below the umbilicus. The other, the tape method, consisted of marking the distance between the uterine fundus and the pubic symphysis on a blank tape, which was subsequently read in centimeters against a measuring tape. The authors contend that normal uterine involution postpartum is governed by different factors according to whether it is measured by fingers or by tape. Thus, gestational age affected uterine involution when measured with fingers, but not when measured with a tape, whereas maternal age did the reverse. Apart from being based on a study population that defies any criteria of normality, a comparison of the results from finger and tape methods shows data that are incompatible with the anatomy of human fingers and the uterus postpartum. Yet, the authors suggest that these data should be used to differentiate electronically between normal and abnormal uterine involution, without considering what the consequences of such nonvalidated programming might be.

Mothers' level of education and childbirth interventions: A population-based study in Flanders, Northern Belgium.

BACKGROUND: Interventions to influence the time and way to be born have been a global concern for decades. Yet, limited information is available on what drives these interventions and their variation in frequency among countries, institutions, and practitioners. The objective of this study was to examine to what extent first-time mothers' educational achievement contributes to the frequency of childbirth interventions. METHODS: Childbirth interventions, including induction of labor, cesarean section, instrumental delivery, and epidural analgesia, registered by the Flemish Study Center for Perinatal Epidemiology for Belgian-born nulliparous women from 1999 to 2006, were linked to the level of maternal education, recorded by the Belgian civil birth registration. Education was divided into four levels based on the highest diploma attained and adjusted for marital and occupational status. RESULTS: Frequencies of all interventions were inversely related to the level of maternal education. The effect remained after adjustment for birth year, maternal age, marital status, occupation, infant birthweight, gestational age, assisted conception, and type of hospital. Effect sizes between highest and lowest levels of education were relatively small for operative (31% vs 36%) and instrumental vaginal birth (20.7% vs 22.3%) compared with "initiated delivery" (defined as labor induction and prelabor cesarean section; 30.2% vs 40.3%) and epidural analgesia (66.8% vs 78.0%). The educational gradient in initiated delivery occurred at all gestational ages, contributing to lower gestational age and lower birthweight of term infants with decreasing levels of education. CONCLUSIONS: In an affluent society with universal and equitable access to maternity care, the more educated women are, the more likely they are to have a spontaneous labor and spontaneous birth without intervention. (BIRTH 38:3 September 2011).

Home birth: gone away, gone astray, and here to stay.

Home birth has attracted a great deal of attention of late, culminating in a meta-analysis to assess its risks for mother and baby. Mothers were estimated to be 2.6 times more likely to die and babies 3 times more likely to die from a planned home birth than from a planned hospital birth. The actual data on which these estimates were based demonstrate that meta-analysis can be developed into an art that suits whatever purpose its authors hope to achieve. Combining studies of home versus hospital, without differentiating what is inside them, where they are, and what is around them, is akin to producing a fruit salad with potatoes, pineapples, and celery.

Elective induction, selective deduction, and cesarean section.

A recent systematic review found no "good quality evidence" that elective induction of labor confers substantial benefits to either mothers or babies, but concluded that elective induction is associated with a decreased risk of "cesarean delivery." Admittedly, elective induction was qualified as "at 41 weeks of gestation and beyond" with 42 weeks being proclaimed as the cutoff point between "elective" and "medically indicated." Major predictors of the success of any induction and the subsequent mode of delivery, such as parity and cervical status, were not taken into account. Crucial boundaries between what is elective and what is selective, what is medically indicated and what is not, and what is maternal request or persuasive coercion, remain as vague as ever.

Women's attitudes to and perceptions of oral health and dental care during pregnancy.

AIMS: To assess pregnant women's opinions on and perceptions of oral health and their relationship to oral hygiene and dental care practices. METHODS: Questionnaire survey on perceived oral health, oral hygiene and utilization of dental services among 649 nulliparae attending for antenatal care at all public antenatal clinics in Adelaide, South Australia. RESULTS: Women rated their general health significantly better than their oral health (P<0.001) and attributed more importance to healthy teeth for their baby than for themselves (P<0.001). Only 35% had dental care during pregnancy; 35% had no dental visit for at least two years and 27% reported cost as a major deterrent. Eighteen percent had experienced gingival bleeding before pregnancy and 41% during pregnancy. Gingival bleeding outside pregnancy was clearly related to perceived oral health (P<0.001), but this was less so for bleeding during pregnancy. The latter was not related to age, level of education, employment, marital status, or smoking habits. Only 38% of women with gingival bleeding in pregnancy had a dental care visit in pregnancy and 28% considered their oral health as very good. CONCLUSIONS: Many pregnant women do not perceive gingival bleeding as indicating inflammatory disease and seek no professional help for it. Maternity care providers need to devote more attention to oral health in antenatal clinics and antenatal education.

Trends in preterm births in Flanders, Belgium, from 1991 to 2002.

Changes in the preterm birth rate have been attributed predominantly to increases in multiple pregnancies, associated with advanced maternal age and assisted reproduction, and to obstetric intervention. We examined their contribution to the frequencies of preterm (<37 weeks), very preterm (<32 weeks) and severely preterm (<28 weeks) birth among 700 383 singleton and twin births in Flanders from 1991 to 2002. We examined changes across four 3-year periods (triennia) with confidence interval [CI] analysis and yearly incremental rates using linear and logistic regression analyses. Over the 12 years, twin pregnancies increased from 1.5% to 2.0%, averaging 1.6% [95% CI 1.54, 1.66] in 1991-93 and 1.9% [95% CI 1.81, 1.94] in 2000-02 (P < 0.001). The proportion of women aged 35 years or more increased from 6.8% [95% CI 6.69, 6.92] in 1991-93 to 11.3% [95% CI 11.2, 11.5] in 2000-02 (P < 0.001) and those aged under 20 from 1.9% [95% CI 1.81, 1.93] to 2.3% [95% CI 2.26, 2.41] (P < 0.001). Assisted reproduction increased from 2.6% [95% CI 2.48, 2.62] to 4.2% [95% CI 4.11, 4.30] (P < 0.001) and obstetric intervention to end pregnancy from 36.2% [95% CI 36.0, 36.4] to 40.3% [95% CI 40.1, 40.6] (P < 0.001). These increases related to an annual increase of 0.23% in the preterm birth rate from 5.5% [95% CI 5.4, 5.6] in 1991-93 to 7.2% [95% CI 7.1, 7.3] in 2000-02 (P < 0.001). The proportions of very and severely preterm births also increased by nearly a third, but their contribution to the total preterm birth rate remained stable at 15% and 5%, respectively. Odds ratios for the increases per year were 1.035 [95% CI 1.032, 1.038] for preterm birth, 1.024 [95% CI 1.018, 1.031] for very preterm and 1.028 [95% CI 1.017, 1.040] for severely preterm births after adjusting for other changes in the population. Overall, the data show, first, marked increases in the frequency of known contributors to the preterm birth rate, including twin pregnancies, advanced maternal age, assisted reproduction and obstetric intervention. Second, the preterm birth rate further increased significantly within subgroups of women with one or more of these characteristics. Third, the preterm birth rate also rose, from 4.4% [95% CI 4.2, 4.5] in 1991-93 to 5.6% [95% CI 5.5, 5.8] in 2000-02 (P < 0.001), in women with none of these contributing factors. This indicates that changes in the frequency of these known predictors are insufficient to explain the steady increase in preterm, very preterm and severely preterm births over more than a decade.

Relevance of gastrointestinal symptoms in endometriosis.

BACKGROUND: Endometriosis commonly presents with a range of symptoms none of which are particularly specific for the condition, often resulting in misdiagnosis or delay in diagnosis. AIM: To investigate gastrointestinal symptoms in women with endometriosis and compare their frequency with that of the classical gynaecological symptoms. METHODS: Systematic exploration of symptoms in a consecutive series of 355 women undergoing operative laparoscopy for suspected endometriosis. RESULTS: Endometriosis was confirmed by histology in 290 women (84.5%). Bowel lesions were present in only 7.6%. Ninety per cent of women had gastrointestinal symptoms, of which bloating was the most common (82.8%), but 71.3% also had other bowel symptoms. All gastrointestinal symptoms were similarly predictive of histologically confirmed endometriosis. Seventy-six women (21.4%) had previously been diagnosed with irritable bowel syndrome and 79% of them had endometriosis confirmed. CONCLUSION: Gastrointestinal symptoms are nearly as common as gynaecological symptoms in women with endometriosis and do not necessarily reflect bowel involvement.