BJOG: An International Journal of Obstetrics and Gynaecology

Published by Wiley and Royal College of Obstetricians and Gynaecologists
Online ISSN: 1471-0528
Discipline: Obstetrics & Gynecology
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Aims and scope

BJOG is the official academic research journal of the Royal College of Obstetricians and Gynaecologists (RCOG). The Journal publishes original, peer-reviewed work in all areas of obstetrics and gynaecology, including contraception, urogynaecology, fertility, oncology and clinical practice. Its aim is to publish the highest quality medical research in women's health, worldwide.



Recent publications
Plain language summary Biomarkers may offer unforeseen insights into clinical diagnosis, as well as the likely course and outcome of a condition. In this paper, the focus is on the use of biological molecules found in body fluids or tissues for diagnosis and prediction of outcome in ovarian cancer patients. In cancer care, biomarkers are being used to develop personalised treatment plans for patients based on the unique characteristics of their tumour. This tailoring of care can be used to pursue specific targets identified by biomarkers, or treat the patient according to specific tumour characteristics. Surgery is one of the core treatments for ovarian cancer, whether it is offered in primary surgery or following chemotherapy in delayed surgery. Biomarkers already exist to guide the treatment of tumours with chemotherapy, but very little research has determined the value of biomarkers in tailoring surgical care for ovarian cancer. Such research is required to identify new biomarkers and assess their effectiveness in a clinical setting as well as to help identify specific tumour types to guide surgery. Biomarkers could help to determine the success of removing the disease surgically, or help to identify tumour deposits that persist after chemotherapy. All of these aspects would improve current practice. This Scientific Impact Paper highlights research that may pave the way towards bespoke surgery according to the biological characteristics of a tumour and aid gynaecological oncologists to provide surgical treatment according to individual need, rather than a blanket approach for all.
Study selection
Objective: To compare the management and outcomes of women with Placenta Accreta Spectrum (PAS) in France and the UK. Design: Two population-based cohorts. Setting: All obstetrician-led hospitals in the UK and maternity hospitals in eight French regions. Population: Two-hundred and nineteen women with PAS in France and one-hundred and thirty-four women in the UK. Methods: The management and outcomes of women with PAS were compared between the UK and France. Main outcome measures: Median blood loss, severe postpartum haemorrhage (≥3 litres), postpartum infection and damage to surrounding organs. Results: The management differed between the two countries; a larger proportion of women with PAS in UK had a caesarean hysterectomy compared to France (43% vs. 26%, P<0.001), while in France, a larger proportion of women with PAS had a uterus conserving approach compared to the UK (36% vs. 19%, <0.001). The 24-hour median blood loss in the UK was 3 litres (IQR:1.7-6.5) compared to 1 litre (IQR:0.5-2.5) in France; more women in the UK had a severe PPH compared to women with PAS in France (58% vs. 21%, P<0.001). There was no difference between the UK and French populations for postpartum infection or organ damage. Discussion: UK and France have very different approaches to managing PAS, with more women in France receiving a uterine conserving and more women undergoing caesarean hysterectomy in the UK. A life-threatening haemorrhage was more common in the UK than in France, which may be the result of differential management and/or the organisation of healthcare systems.
Linked article: This is a mini commentary on Stephen J. McCall et al., pp. 1676–1685 in this issue. To view this article visit https://doi.org/10.1111/1471-0528.17169
Prevalence of special educational need by gestation at delivery (McKay et al. PLoS Med 2010;7:e1000289)
Linked article: This is a mini commentary on Alice Beardmore‐Gray et al., pp. 1654–1663 in this issue. To view this article visit https://doi.org/10.1111/1471-0528.17167
Consolidated Standards of Reporting Trials (CONSORT) flow diagram of participants
Primary infant long‐term outcome non‐inferiority comparison: imputed standardised Parent Report of Children’s Abilities – Revised (PARCA‐R) at 2 years follow‐up. Standardised scores were imputed for responders who had raw PARCA‐R scores outside of the time window used for standardisation. The p‐values are for one‐sided 2.5% significance non‐inferiority tests based on a margin of four standardised score points. The dashed line shows the non‐inferiority margin. The solid line shows the line of no difference. CI, confidence interval; SD, standard deviation
Maternal secondary long‐term outcomes: SF‐12 Health Survey Summary Scale at follow‐up at 6 months and at 2 years. The solid line shows the line of no difference. CI, confidence interval; MCS‐12, Mental Component Summary Scale Score; PCS‐12, Physical Component Summary Scale Score; SD, standard deviation
Objective: We evaluated the best time to initiate delivery in late preterm pre-eclampsia in order to optimise long-term infant and maternal outcomes. Design: Parallel-group, non-masked, randomised controlled trial SETTING: 46 UK maternity units POPULATION: Women with pre-eclampsia between 34+0 and 36+6 weeks' gestation, without severe disease, were randomised to planned delivery or expectant management. Primary long-term outcome: Infant neurodevelopmental outcome at 2 years of age, using the PARCA-R (Parent Report of Children's Abilities-Revised) composite score. Results: Between Sept 29, 2014, and Dec 10, 2018, 901 women were enrolled in the trial, with 450 allocated to planned delivery and 451 to expectant management. At 2-year follow-up, the intention-to-treat analysis population included 276 women (290 infants) allocated to planned delivery and 251 women (256 infants) to expectant management. The mean composite standardised PARCA-R scores were 89.5 (standard deviation (SD) 18.2) in the planned delivery group and 91.9 (SD 18.4) in the expectant management group, with an adjusted mean difference of -2.4 (95% CI -5.4 to 0.5) points. Conclusion: In infants of women with late preterm pre-eclampsia, average neurodevelopmental assessment at 2 years lies within the normal range, regardless of whether planned delivery or expectant management is pursued. Because of lower than anticipated follow-up, there was limited power to demonstrate these scores were not different, but the small between-group difference in PARCA-R scores is unlikely to be clinically important.
Flow chart of study selection
Background: Pregnancy and liver cirrhosis is a rare but increasing combination. Liver cirrhosis can raise the chance of maternal and fetal mortality and morbidity, although the exact risks remain unclear. Objective: To provide a systematic literature review and meta-analysis on maternal, fetal and obstetric complications among pregnant women with liver cirrhosis. Search strategy: We performed a systematic literature search in the databases PubMed/MEDLINE and EMBASE (Ovid) from inception through 25 January 2021. Selection criteria: Studies including pregnancies with liver cirrhosis and controls were eligible. Data collection and analysis: Two reviewers independently evaluated study eligibility. We used the random-effects model for meta-analysis. Main results: Our search yielded 3118 unique papers. We included 11 studies, including 2912 pregnancies in women with cirrhosis from 1982-2020. Seven studies were eligible for inclusion in the meta-analysis. The overall maternal mortality rate was 0.89%. Maternal mortality and variceal hemorrhage were lower in recent than in older studies. Most cases of maternal mortality due to variceal hemorrhage (70%) occurred during vaginal delivery. Pregnant women with liver cirrhosis had a higher chance of preterm delivery (OR 6.7 95% CI 5.1- 9.1), cesarean section (OR 2.6, 95% CI 1.7-3.9), preeclampsia (OR 3.8, 95% CI 2.2-6.5) and small for gestational age neonates (OR 2.6, 95% CI 1.6-4.2) compared to the general obstetric population. Subgroup-analyses could not be conducted. Conclusions: Liver cirrhosis in pregnant women is associated with increases in maternal mortality and obstetric and fetal complications. Large international prospective studies are needed to identify risk factors for unfavorable outcome.
The author’s son, Wilder Daniel Leisher, stillborn 13 July 1999.
Linked article: This is a mini commentary on Bethany Atkins et al., pp. 1731–1739 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17138
Linked article: This is a mini commentary on Laurine L. van der Slink et al., pp. 1644–1652 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17156
Linked article: This is a mini commentary on Tuija Hautakangas et al. pp. 1790–1797 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17128
Linked article: This is a mini commentary on Bethany Atkins et al., pp. 1731–1739 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17138
Parents’ experiences of seven aspects of care quality after stillbirth, by geographical region
Care practices after stillbirth: parents' desires and unmet needs
Objective: To quantify parents' experiences of respectful care around stillbirth globally. Design: Multi-country, online, cross-sectional survey. Setting and population: Self-identified bereaved parents (n=3769) of stillborn babies from 44 high- and middle-income countries. Methods: Parents' perspectives of 7 aspects of care quality, factors associated with respectful care, and 7 bereavement care practices were compared across geographical regions using descriptive statistics. Respectful care was compared between country income groups using multivariable logistic regression. Main outcome measures: Self-reported experience of care around the time of stillbirth RESULTS: A quarter (25.4%) of 3769 respondents reported disrespectful care after stillbirth and 23.5% reported disrespectful care of their baby. Gestation <30 weeks, and primiparity were associated with disrespect. Reported respectful care was lower in middle-income countries (MICs) than in high-income countries (HICs) (aOR=0.35, 95%CI (0.29-0.42), p <0.01). In many countries, aspects of care quality need improvement, such as ensuring families have enough time with providers. Participating respondents from Latin America and Southern Europe reported lower satisfaction across all aspects of care quality compared to Northern Europe. Unmet need for memory-making activities in MICs is high. Conclusions: Many parents experience disrespectful care around stillbirth. Provider training, and system-level support to address practical barriers are urgently needed. However, some practices (which are important to parents) can be readily implemented such as memory-making activities and referring to the baby by name.
Intrauterine pressure and use of oxytocin at different time points during the last 4 hours before vaginal birth or before a decision on caesarean section, with a BMI limit of 35 kg/m²; blue line <35 kg/m², red line ≥35 kg/m²
Objective: To investigate the impact of severe obesity (BMI ≥35 kg/m² ) on uterine contractile activity. The hypothesis was that obese parturients might have weaker uterine activity and need more oxytocin than leaner parturients. Design: Exploratory, blinded analysis of a randomised controlled trial cohort. Setting: Two labour wards, in a university tertiary hospital and a central hospital. Population: 686 parturients with singleton pregnancies, gestational age ≥ 37 weeks, foetus in cephalic presentation, and intrauterine tocodynamometry during labour. Methods: Uterine contractile activity was assessed as intrauterine pressure, frequency of contractions and basal tonus of uterine muscle. The use of oxytocin and cervical dilatation were recorded simultaneously. Main outcome measures: Primary Outcome: uterine contractile activity. Secondary outcomes: use of oxytocin, labour outcomes. Results: Obese parturients reached intrauterine pressure ≥ 200 MVUs during the first stage of labour more often than leaner parturients; 62% vs. 49%; OR 1.67 (95%CI 1.05-2.67) and had higher basal tone of uterine muscle. However, obese parturients without previous vaginal delivery were not able to reach the active stage of labour as often as leaner ones, and their vaginal delivery success rate was lower. If a parturient had had previous vaginal delivery, obesity did not influence uterine activity, nor was it a risk of caesarean section. Doses and total consumption of oxytocin did not differ between BMI groups. Conclusions: Obese nulliparas have stronger uterine contractile activity than leaner ones, but they more often fail to reach the active phase of labour and their vaginal delivery success rate is lower.
Cumulative number of trained and retained Obstetricians/Gynaecologists in Ghana; GC, Ghana College of Surgeons and Physicians; WAC, West African College of Surgeons
Practice locations of graduates in 2010 and 2017
Objectives: Our primary objectives are to determine the cumulative retention of Ob/Gyns since the inception of the Ghana post-graduate Ob/Gyn programs, to determine the demographic and practice characteristics of all Ob/Gyns who have been trained, and to compare the geographic distribution of Ob/Gyns throughout Ghana between 2010 when a prior study was conducted and the current practice locations of all graduates in 2017. Design: Cross-sectional, Quantitative Investigation SETTING: Fieldwork for this study was conducted in Ghana between June 21, 2017, and August 20, 2017. Methods: A roster of certified Ob/Gyns, year certified, and email contact information was obtained from the Ghana College of Physicians and Surgeons, a roster of practice locations was obtained from Ghana Medical Board. Main outcome measures: retention of Ob/Gyns, geographic distribution of providers, and comparison of geographic spread between 2010 and 2017 practice locations RESULTS: Significant geographic spread and increase in in-country medical programs have occurred over the seven-year period. In recent years, Ob/Gyn certifications through the Ghana College of Physicians and Surgeons have significantly increased. Conclusion: The establishment of the GCPS created a national certification opportunity that made Ob/Gyn certification more accessible. This provides a cadre of certified Ob/Gyns that can be trained and retained in low-income settings, and allows for long term commitment in multiple relevant sectors that may serve to establish a comprehensive obstetric and gynecology capacity beyond urban centers.
Objective: In Europe, migrant women, especially from sub-Saharan Africa, have higher risks of adverse maternal outcomes than non-migrants. Legal status, a component of migrant condition, may be an important, and potentially actionable, risk factor. We aimed to assess the risk of severe maternal outcomes among migrant women, considering both their legal status and birthplace. Design: Prospective cohort study. Setting: Four maternity units around Paris in 2010-2012. Sample: 9599 women with singleton pregnancies. Methods: Legal status was categorized in four groups: reference group of non-migrant native Frenchwomen, legal migrants with French or European citizenship, other legal migrants with non-European citizenship, and undocumented migrants. The risk of severe maternal morbidity was assessed with multivariable logistic regression models according to women's legal status and birthplace. Main outcome measure: Binary composite criterion of severe maternal morbidity. Results: Undocumented migrants had resided less time in France, experienced social isolation, linguistic barriers and poor housing conditions more frequently, and had a prepregnancy medical history at lower risk than other migrants. The multivariable analysis showed they had a higher risk of severe maternal morbidity than non-migrants (33/715 (4.6%) versus 129/4523 (2.9%), adjusted odds ratio [aOR] 1.68; 95% confidence interval [CI] 1.12-2.53). This increased risk was significant for undocumented women from sub-Saharan Africa (18/308 (5.8%) versus 129/4523 (2.9%), aOR 2.26; 95%CI 1.30-3.91), and not for those born elsewhere (15/407 (3.7%) versus 129/4523 (2.9%), aOR 1.44; 95%CI 0.82-2.53). Conclusion: Undocumented migrants are the migrant subgroup at highest risk of severe maternal morbidity, while the prevalence of risk factors does not appear to be higher in this subgroup. This finding suggests that their interaction with maternity care services may be non-optimal.
Change in mean factor levels or activity throughout pregnancy in woman with inherited bleeding disorders
Percentage of women by inherited bleeding disorder that experienced a primary postpartum haemorrhage (PPH)
Objective: To describe the characteristics and outcomes of women with inherited bleeding disorder during pregnancy and birth. Design: Retrospective cohort study. Setting: Tertiary care hospitals, NSW and Victoria Australia. Population: 100 women with inherited bleeding disorders, who birthed 134 live infants from 132 pregnancies. Methods: Data was retrospectively obtained from the patient and neonatal medical records. Descriptive analysis was used to report maternal and pregnancy characteristics, birth and neonatal outcomes. Main outcome measures: Factor replacement, neuraxial analgesia use and complications, post-partum haemorrhage and neonatal complications. Results: PPH occurred in 22% of deliveries with primary PPH occurring in 20% and secondary PPH in 2% of births. 48% of PPHs were classified as major. PPHs occurred across the spectrum of IBD and was evenly distributed between women who had "normalised" (46%) their factor levels in pregnancy compared to those requiring factor at the time of birth (50%). An obstetric cause was identified in almost half of PPHs (46%). Neuraxial analgesia was administered in 40% of births without complication and refused on 3% of births despite documented adequate haemostatic potential. Conclusions: Women with inherited bleeding disorders can deliver safely and receive neuraxial analgesia without complication when best practices are adhered to. PPH appears to occur at higher rates than the general population despite adequate factor levels or planned replacement. Whilst an obstetric cause was demonstrable in the many cases, these findings raise concern over the current definition of "adequate" factor levels at the time of birth.
Structure of original cost‐utility model. BPD, bronchopulmonary dysplasia; DD, developmental delay; NDI, neurodevelopmental impairment; NI, neurological impairment; RDS, respiratory distress syndrome. The model comprises three independent decision trees, simulating: (A) infections and their sequelae; (B) RDS and its sequelae; and (C) mode of birth and its impact on subsequent pregnancies
Differences in expected events, QALYs and costs per birth between the two approaches. AEs, adverse events; NICU, neonatal intensive care unit; QoL, quality of life; RDS, respiratory distress syndrome
Probabilistic sensitivity analysis plots. Upper panel, cost–utility scatter plot; lower panel, cost‐effectiveness acceptability curve
Objective What are the costs, benefits and harms of immediate birth compared with expectant management in women with preterm prelabour prolonged rupture of membranes (PPROM) between 34+0-36+6 weeks’ gestation and vaginal or urine group B streptococcus (GBS) detection? Design Mathematical decision-model comprising 3 independent decision-trees. Setting UK NHS and personal social services perspective. Population GBS-positive women with PPROM between 34+0-36+6 weeks’ gestation. Methods The model estimates lifetime costs and quality-adjusted life-years (QALYs) using evidence from randomised trials, UK NHS datasources, and further observational studies. Simulated events include neonatal infections, morbidity associated with preterm birth and consequences of caesarean birth. Deterministic and probabilistic sensitivity analyses (PSA) were performed. Main Outcome Measures QALYs, costs and incremental cost-effectiveness ratio (ICER) Results In this population, immediate birth dominates expectant management. It is more effective (average lifetime QALYs: 24.705 vs 24.371) and cheaper (average lifetime costs: £14,372 vs £19,311). In one-way sensitivity analysis, results are robust to all but the odds ratio estimating the relative effect on incidence of infections. Threshold analysis shows that the odds of infection only must be >1.5% with expectant management for the benefit of avoiding infections to outweigh the disadvantages of immediate birth. In PSA, immediate birth is the preferred option in >80% of simulations. Conclusions Neonatal GBS infections are expensive to treat and may result in substantial adverse health consequences. Therefore, immediate birth, which is associated with a reduced risk of neonatal infection compared with expectant management, is expected to generate better health and decreased lifetime costs.
The associations of maternal liver dysfunction and individual LFBs in early pregnancy with GDM. Odds ratios for abnormal liver function (defined as having any one of elevated LFBs) and for one standard deviation (SD) increase in liver function biomarkers (GGT, AST, ALT, ALP, total bilirubin, albumin, globulin) were derived from logistic regression models for GDM. Bonferroni adjustment was used to adjust multiple testing for the p values of adjusted models (eight tests). ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GDM, gestational diabetes mellitus; GGT, γ‐glutamyl transferase; LFB, liver function biomarker; OR, odds ratio
Non‐linear relationship between maternal GGT, ALT, ALP and albumin levels in early pregnancy with GDM. (A) Mean of GGT 13.0 U/L was selected as the reference level. (B) Mean of ALT 14.0 U/L was selected as the reference level. (C) Mean of ALP 51.0 U/L was selected as the reference level. (D) Mean of albumin 44.0 g/L was selected as the reference level. The lines indicate estimated odds ratios, and the light blue shaded areas represent 95% CIs.; ALP, alkaline phosphatase; ALT, alanine aminotransferase; GGT, γ‐glutamyl transferase
Stratification analysis of overweight for maternal liver dysfunction and LFBs in early pregnancy with GDM. ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GDM, gestational diabetes mellitus; GGT, γ‐glutamyl transferase; globulin, globulin; LFBV, liver function biomarker
Objective: To evaluate whether the associations of maternal liver dysfunction and liver function biomarkers (LFBs) with GDM are independent of overweight. Design: Prospective cohort study. Methods: A sub-cohort of pregnant women with seven LFBs examined at 9-13 gestational weeks and with complete GDM evaluation at mid-gestation were extracted from the prospective Shanghai Preconception Cohort Study. Associations of liver dysfunction, defined as having any elevated LFBs levels, and individual LFBs levels with GDM incidence were assessed by adjusting BMI and other covariates in the multivariable logistic regression model. Odds ratios (ORs) and 95% confidence intervals (CI) were reported. Main outcome measures: Incident GDM RESULTS: Among 6211 pregnant women 975 (15.7%) developed GDM. Liver dysfunction was associated with increased odds of GDM (OR 1.63; 95% CI 1.38-1.92). This association persisted after adjustment for BMI (adjusted OR [aOR] 1.37; 95% CI 1.15-1.63). Higher GGT, alanine aminotransferase, alkaline phosphatase, and albumin levels were also linked with GDM (aOR per 1 SD: 1.15, 95% CI 1.08-1.23; 1.10, 1.03-1.17; 1.21, 1.13-1.29, and 1.19, 1.11-1.27). Similar magnitudes of associations were observed between normal weight and overweight pregnant women. Conclusion: Maternal liver dysfunction in early pregnancy predisposes subsequent GDM, and this association is independent of preconception overweight. Our findings of an increased risk even in normal weight pregnant women adds new mechanistic insights about the pathophysiological role of liver function in GDM etiology.
Composition of the study population
Association of significant parturition‐related risk factors for RhD immunisation
Objective: To evaluate which risk factors for RhD immunisation remain, despite adequate routine antenatal and postnatal RhIg prophylaxis (1000 IU RhIg) and additional administration of RhIg. The second objective was assessment of the current prevalence of RhD immunisations. Design: Prospective cohort study. Setting: The Netherlands. Population: Two-year nationwide cohort of alloimmunised RhD-negative women. Methods: RhD-negative women in their first RhD immunised pregnancy were included for risk factor analysis. We compared risk factors for RhD immunisation, occurring either in the previous non-immunised pregnancy or in the index pregnancy, with national population data derived from the Dutch perinatal registration (Perined). Results: In the two-year cohort, data from 193 women were eligible for analysis. Significant risk factors in women previously experiencing a pregnancy of an RhD positive child (N=113) were: caesarean section (CS) (OR 1.7, 95% CI 1.1-2.6), perinatal death (OR 3.5, 95% CI 1.1-10.9), gestational age over 42 weeks (OR 6.1, 95% CI 2.2-16.6), postnatal bleeding (>1000 mL) (OR 2.0, 95% CI 1.1-3.6), manual removal of the placenta (MRP) (OR 4.3, 95% CI 2.0-9.3); these factors often occurred in combination. The miscarriage rate was significantly higher than in the Dutch population (35% vs 12.5% p<0.001). Conclusion: Complicated deliveries, including cases of major bleeding and surgical interventions (CS, MRP) need to be recognised as risk factor, requiring estimation of foetomaternal haemorrhage volume and adjustment of RhIg dosing. The higher miscarriage rate suggests that existing RhIg protocols either need adjustment or better compliance.
Sample selection
Forest plot of the risk of early birth by body mass index group in propensity‐matched sample. aOnly significant results are displayed
Objective: Evaluate the risk of preterm (<37 weeks) or early term birth (37 or 38 weeks) by body mass index (BMI) in a propensity score matched sample. Design: Retrospective cohort analysis SETTING: California, USA POPULATION: Singleton live births from 2011 - 2017. Methods: Propensity scores were calculated for BMI groups using maternal factors. A referent sample of women with a BMI between 18.5 - <25.0 kg/m2 was selected using exact propensity score matching. Risk ratios for preterm and early term birth were calculated. Main outcome measures: Early birth RESULTS: Women with a BMI <18.5 kg/m2 were at elevated risk of birth between 28-31 weeks (RR 1.2, 95% confidence interval (CI) 1.1-1.4), 32 - 36 weeks (RR 1.3, 95% CI 1.2-1.3), and 37 or 38 weeks (RR 1.1, 95% CI 1.1-1.1). Women with BMIs ≥25.0 kg/m2 were at 1.2-1.4-times higher risk of a birth <28 weeks, and were at reduced risk of a birth between 32-36 weeks (RRs 0.8-0.9) and birth during the 37th or 38th week (RRs 0.9). Conclusion: Women with a BMI <18.5 kg/m2 were at elevated risk of a preterm or early term birth. Women with BMIs ≥25.0 kg/m2 were at elevated risk of a birth <28 weeks. Propensity score matched women with BMIs ≥30.0 kg/m2 were at decreased risk of a spontaneous preterm birth with intact membranes between 32-36 weeks, supporting the complexity of BMI as a risk factor for preterm birth.
Rates of reported cannabis use in pregnancy in Nova Scotia by conception year
Objective: To examine the relationship between reported prenatal cannabis use and neonatal and maternal outcomes and whether the legalisation of cannabis in Canada affected the rates of reported use or the association with maternal and neonatal outcomes. Design: Population-based retrospective cohort study SETTING: Routinely collected data in a real-world setting POPULATION: All women in the Canadian province of Nova Scotia with singleton births between January 1, 2004, and June 30, 2021. Methods: The association between cannabis use and maternal and neonatal outcomes was examined using generalized linear models with inverse probability weighting. Main outcome measures: Maternal and neonatal outcomes in the peri- and post-partum period. Results: Rates of reported cannabis use in pregnancy increased from 1.3% to 7.5% over the study period with no appreciable change in slope after legalisation in 2018. Infants of mothers reporting cannabis use in pregnancy were more likely to have major anomalies and a 5-minute Apgar score ≤ 7, require NICU admission, and had lower birth weight, head circumference, and birth length than infants of mothers not reporting cannabis use. These associations did not differ before and after legalisation. Conclusions: Reported cannabis use during pregnancy is associated with early postnatal complications and reduced fetal growth, even after taking into account a range of confounding factors. Rates of reported cannabis use during pregnancy increased over the past five years in Nova Scotia with no apparent additional effect of legalisation.
Comparison of the incidence of adverse perinatal outcomes in AGA pregnancies (birthweight ≥10th percentile), in women undergoing routine antenatal care and in SGA pregnancies (birthweight <10th percentile) at Kagadi Hospital, Uganda
Objective: We aimed to determine the prevalence of abnormal umbilical artery (UA), uterine artery (UtA), middle cerebral artery (MCA), and cerebroplacental ratio (CPR) Dopplers, and their relationship with adverse perinatal outcomes in women undergoing routine antenatal care in the third trimester. Design: Prospective cohort SETTING: Kagadi Hospital, Uganda POPULATION: Non-anomalous singleton pregnancies. Methods: Women underwent an early dating ultrasound and a third trimester Doppler scan between 32 and 40 weeks, from 2018 - 2020. We handled missing data using multiple imputation and analyzed the data using descriptive methods and binary logistic regression model. Main outcome measures: Composite adverse perinatal outcome (CAPO), perinatal death, and stillbirth. Results: We included 995 women. Mean gestational age at Doppler scan was 36.9 (SD, 1.02) and 88.9% of the women gave birth in a health facility. About 4.4% and 5.6% of the UA PI and UtA PI were > 95th percentile, while 16.4% and 10.4% of the MCA PI and CPR were < 5th percentile, respectively. Low CPR was strongly associated with stillbirth (OR= 4.82, 95% CI: 1.09 - 21.30). CPR and MCA PI <5th percentiles were independently associated with CAPO; the association with MCA PI was stronger in small for gestational age neonates, (OR= 3.75, 95% CI: 1.18- 11.88). Conclusion: In late gestation, abnormal UA PI was rare. Fetuses with cerebral blood flow redistribution were at increased risk of stillbirth and perinatal complications. Further studies examining its predictive accuracy and effectiveness in reducing the risk of perinatal deaths in LMICs are warranted.
Flowchart of the study population
Objective: To investigate if a hospital-initiated home-based rebozo intervention performed by the pregnant woman and her partner prior to external cephalic version (ECV) would increase the rate of cephalic presentations at birth. Design: A multicentre randomized controlled trial. Setting: Three university hospitals in Copenhagen, Denmark. Population: Pregnant women with a breech or transverse presentation at GA ≥35 weeks eligible for ECV. Methods: We compared rebozo prior to ECV with ECV alone. The randomization was computer-generated in blocks and stratified by parity. The woman and her partner were instructed in the technique by a project midwife and performed the technique at home 3 times daily for 3-5 days before the scheduled ECV. Analyses were by intention-to-treat. Main outcome measure: The number of cephalic presentations at the time of birth. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Results: 372 women were randomly assigned (1:1) to either rebozo intervention (n=187) or control (n=185). At birth, 95 (51%) in the intervention group vs. 112 (62%) in the control group had a fetus in cephalic presentation (OR 0.61; 95% CI 0.40-0.95). No adverse events were observed in relation to the intervention. Conclusions: In breech or transverse presentation, home-based rebozo exercise before ECV lowered the overall rate of cephalic presentation at birth..
Graph showing absolute rates (95% confidence intervals) of perinatal death in the women who underwent NICE and FMF screening, stratified by whether there was a diagnosis of hypertensive disorders of pregnancy (HDP) and/or fetal growth restriction (FGR)
Graph showing absolute rates (95% confidence intervals) of perinatal death in the White and non‐White populations, stratified by method of screening
Objective: To assess the impact of the Fetal Medicine Foundation (FMF) first trimester screening algorithm for pre-eclampsia on health disparities for perinatal death amongst minority ethnic groups. Design: A retrospective cohort study from July 2016 to December 2020. Setting: A large London teaching hospital. Patients and methods: All women who underwent first trimester pre-eclampsia risk assessment using either the NICE screening checklist or the FMF multimodal approach. Women considered at high-risk in the FMF cohort were offered 150mg aspirin before 16 weeks' gestation, serial growth scans and elective birth at 40 weeks. Main outcome measures: Stillbirth, neonatal death and perinatal death rates stratified by screening method and maternal ethnicity. Results: In the NICE cohort, the perinatal death rate was significantly higher in non-White versus White women (7.95/1000 vs 2.63/1000 births, OR 3.035, 95% CI 1.551 to 5.941). Following the introduction of FMF screening, the perinatal death rate in non-White women fell from 7.95 to 3.22/1000 births (OR 0.403, 95% CI 0.206 to 0.789), such that it was no longer significantly different from the perinatal mortality rate in White women (3.22/1000 vs 2.55/1000 births, OR 1.261, 95% CI 0.641 to 2.483). Conclusions: First trimester combined screening for placental dysfunction is associated with a significant reduction in perinatal death in minority ethnic women. Health disparity for perinatal death amongst ethnic minority women demands urgent attention from both clinicians and health policy makers. The data of this study suggests that this ethnic health inequality may be avoidable.
PRISMA diagram
Background: There is concern regarding the psychological impact of the perinatal period on LGBTQ2S+ childbearing individuals. Objectives: To characterize and synthesize the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care, and care-seeking. Search strategy: We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, Medline-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to March 1st, 2021. Selection criteria: Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments, and surrogacy). Data collection and analysis: Findings were synthesized qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach. Main results: Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesized as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, and distressing situations from the gendered nature of pregnancy. LGBTQ2S+ childbearing individuals described barriers to accessing mental healthcare, and gaps in health systems. Strategies to improve care include avoidance of gendered language, documentation of correct pronouns, cultural humility training, and tailored care. Conclusions: There are unique considerations for LGBTQ2S+ childbearing individuals during the perinatal period and providers should implement the identified strategies to improve perinatal care.
Schematic flow chart of patient inclusion in the study
Kaplan–Meier curves of spontaneous preterm birth in the second gestation by mode of birth in the first pregnancy
Objectives: To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labor in the first term delivery. Design: Retrospective cohort study. Setting: University hospital. Population: Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labor in the first delivery were excluded. Methods: Charts from 2007-2019 were reviewed. Main outcome measures: Rate of sPTB (<37 weeks gestation) in the second delivery. Results: Of 13,958 women who met study inclusion criteria, 1,464 (10.5%) parturients had a prolonged second-stage (≥180 minutes) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% vs. 2.8%; aOR [95% CI]: 1.35 (0.96, 1.90)). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage cesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%, aOR [95% CI]: 2.66 (1.71, 4.12), P<0.001), with a more pronounced risk in those with second-stage cesarean following a prolonged second stage of labor (15/259, 5.8%, aOR [95% CI]: 3.40 (1.94, 5.94), P<0.001). Conclusion: Second stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage cesarean section, particularly if performed after a prolonged second-stage.
Randomisation, treatment and follow‐up.
Maternal pain evaluated by numerical rating scale over time.
Objective: To investigate whether perineal infiltration of ropivacaine after episiotomy would decrease the incidence of postpartum pain compared to placebo. Design: Two-centre, double-blind, randomised, controlled trial. Setting: Two French maternity units, October 2017 to April 2020. Population: 272 women undergoing epidural analgesia with vaginal singleton delivery and mediolateral episiotomy at term (≥ 37 weeks) were randomly allocated perineal infiltration of ropivacaine (n=135) or placebo (n=137) in a 1:1 ratio before episiotomy repair. Methods: patients were followed at short term (12, 24, 48 hours), mid-term (day 7) and long term (3 and 6 months). Main outcome measures: The primary outcome was the rate of perineal pain, defined by a Numerical Pain Rating Scale (NPRS) exceeding 3/10, in the mid-term (day 7) postpartum period. Secondary outcomes were perineal pain (NPRS) and analgesic intake; quality of life (SF-36), postpartum depression (EPDS), pain neuropathic component (DN4) and sexual health (FSFI). Results: Perineal pain occurred to equal extent in the ropivacaine and placebo groups at day 7 (34.2% vs. 30.4%, OR 1.1(95%CI 0.7-1.8), p=0.63). Similar results were recorded in the short and long term. High rates of dyspareunia and postpartum depression were documented in both groups. No differences were highlighted between the groups in terms of analgesic intake, adverse events, pain neuropathic component and postpartum quality of life. Conclusions: This study did not demonstrate any benefit with ropivacaine infiltration compared to placebo.
To compare the incidences of early and late‐onset neonatal sepsis, including group B streptococcus (GBS) and Escherichia coli (E.coli) before and after implementation of universal screening and intrapartum antibiotics prophylaxis (IAP). Retrospective cohort study Eight public hospitals and 31 Maternal and Child Health Centres (MCHC) in Hong Kong 460552 women attending routine antenatal service from 2009 to 2020. Universal culture‐based GBS screening was offered to eligible women since 2012. Total births, GBS screening tests, maternal GBS colonisation, neonatal sepsis with positive blood or cerebrospinal fluid were retrieved from clinical and laboratory database. Maternal GBS colonisation rate, early and late onset neonatal sepsis (including GBS and E.coli) Of 318740 women with universal culture‐based screening, 63767 women (20.0%) were screened positive. After implementation of GBS screening and IAP, the incidence of early‐onset neonatal sepsis decreased (3.25 vs 2.26 per 1000 live births (P< 0.05) , including those caused by GBS (1.03 vs 0.26 per 1000 live births, P<0.05). Segmented regression showed that change in early GBS sepsis incidence after screening was the only significant variable in the outcome trend. There was no significant evidence of increase in incidence of late‐onset neonatal sepsis including those caused by GBS. Universal culture‐based GBS screening and IAP were associated with reduction in early‐onset neonatal sepsis including GBS disease. Whilst an increase in incidence of late‐onset neonatal sepsis including those caused by GBS cannot be totally ruled out, we did not identify significant evidence that this occurred.
To examine the association between lifetime lactation and risk and duration of frequent vasomotor symptoms (VMS). Prospective cohort. USA, 1995‐2008. 2,356 parous midlife women in the Study of Women’s Health Across the Nation. Lifetime lactation was defined as the duration of breastfeeding across all births in months. We used generalized estimating equations to analyze risk of frequent VMS and Cox regression to analyze duration of frequent VMS in years. Frequent VMS (hot flashes and night sweats) were measured annually for 10 years, defined as occurring ≥6 days in the past 2 weeks. Overall, 57.1% of women reported hot flashes and 43.0% reported night sweats during follow‐up. Lifetime lactation was inversely associated with hot flashes plateauing at 12 months of breastfeeding (6 months: adjusted odds ratio [AOR] 0.85, 95% CI 0.75‐0.96; 12 months: AOR 0.78, 95% CI 0.65‐0.93), and was inversely associated with night sweats in a downward linear fashion (6 months: AOR 0.93, 95% CI 0.81‐1.08; 18 months: AOR 0.82, 95% CI 0.67‐1.02; 30 months: AOR 0.73, 95% CI 0.56‐0.97). Lifetime lactation was associated with shorter duration of hot flashes and night sweats in a quadratic (bell‐shaped) fashion. The association was strongest at 12‐18 months of breastfeeding and significant for hot flashes (6 months: adjusted hazard ratio [AHR] 1.35, 95% CI 1.11‐1.65; 18 months: AHR 1.54, 95% CI 1.16‐2.03; 30 months: AHR 1.18, 95% CI 0.83‐1.68). Longer lifetime lactation is associated with decreased risk and duration of frequent VMS.
Confounder‐adjusted odds ratios (aORs) for the effect of current use of individual progestogens on venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE), using levonorgestrel with <50 μg ethinylestradiol as a reference.
Confounder‐adjusted odds ratios (aORs) for the effect of current use of individual progestogens on venous thromboembolism (VTE) in the main analysis compared with various sensitivity analyses (sensitivity analyses: 1, exclusion of girls/young women who used anticoagulants; 2, exclusion of girls/women with oophorectomy, hysterectomy or sterilization; 3, exclusion of comorbidity increasing the risk of VTE; 4, only cases occurring within 90 days after entry to the cohort considered).
Objective: To compare the risk of venous thromboembolism (VTE) among young women for nine combined oral contraceptives (COCs) including progestogens with as yet unclear risk of VTE such as chlormadinone and nomegestrol using COCs containing levonorgestrel with low ethinylestradiol (< 50μg) as reference. Design: Case-control study nested in a cohort of new users of COCs SETTING: German claims data POPULATION: 1,166 cases of VTE matched to 11,660 controls nested in a cohort of 677,331 girls and young women aged 10-19 years with ≥ 1 COC dispensing between 2005 and 2017 after a one-year period without such a dispensing. Methods: Confounder-adjusted odds ratios (ORs) of VTE associated with current use of the respective COC were calculated using conditional logistic regression. Main outcome measures: VTE defined as diagnosis of pulmonary embolism or deep vein thrombosis. Results: Compared to levonorgestrel with low ethinylestradiol (< 50μg), the risk of VTE was two-fold increased for COCs containing dienogest (2.23, 95% confidence interval 1.77-2.80), cyproterone (2.15, 1.43-3.25), chlormadinone (OR 2.06, 1.58-2.68), desogestrel (1.93, 1.44-2.61), and drospirenone (1.89, 1.41-2.55) and five-fold increased for gestodene (5.05, 1.23-20.74). For norgestimate and nomegestrol, respectively, the point estimates suggest a two-fold and 40% increased risk (1.90, 0.62-5.81 and 1.41, 0.52-3.81). Conclusion: Our study confirms that levonorgestrel with low ethinylestradiol (< 50μg) is the COC associated with the lowest risk of VTE and suggests that for chlormadinone, the risk of VTE is two times higher and thus in the same range as for desogestrel and drospirenone.
Objective: To investigate the effect of an antenatal diet and exercise intervention during pregnancy on sleep duration. As a secondary objective, relationships between sleep duration and gestational weight gain (GWG), maternal metabolic parameters and pregnancy outcomes were assessed. Design: Secondary analysis SETTING: Large tertiary Maternity Hospital in Dublin, Ireland POPULATION: 326 women with overweight or obesity who participated in the Pregnancy Exercise And Nutrition Research Study (PEARS) randomized controlled trial between March 2013-August 2016 METHODS: secondary analysis of a randomized trial MAIN OUTCOME MEASURES: impact of the PEARS intervention on sleep duration, and relationship of sleep duration and maternal metabolic parameters, pregnancy outcomes RESULTS: Participants had a mean age of 32.5±4.5 years and median (IQR) BMI of 28.3 (26.6 - 31.2) Kg/m2. The intervention group had a longer sleep duration in late pregnancy (mean difference 17.1 minutes (95% CI 0.5, 33.7) and a higher proportion achieving optimum sleep duration of 7-9 hours (54.3 vs 42.9%, RR 1.28 (95% CI 1.01, 1.62). In late pregnancy, sleep duration of <6 hours was associated with lower breastfeeding rates on discharge (RR 0.74 (95% CI 0.57, 0.95)) and higher triglyceride levels (mean difference 0.24 (95% CI 0.10, 0.38). There were no significant relationships between sleep and incidence of GDM or PET, or other metabolic parameters assessed (insulin, fasting glucose, HOMA-IR). Conclusion: A diet and exercise intervention from early pregnancy may promote longer and optimal sleep duration, with maternal benefits such as lower triglyceride levels and higher breastfeeding rates.
Lactate during labour and delivery. Histogram displaying the distribution of 1279 lactate measurements, with a box‐and‐whisker plot summarising the 25th, 50th and 75th centiles, and minimum‐maximum range.
Lactate and haemoconcentration. Scatter charts overlaid with univariate linear estimates between lactate, haemoglobin and body mass index. Caption: Red lines denote linear estimates with 95% confidence intervals around the mean.
Lactate and mode of birth. Box‐and‐whisker plots for lactate measurements according to mode of birth: elective caesarean (n = 96), emergency caesarean (n = 397), operative vaginal delivery (n = 397) or spontaneous vaginal delivery (n = 389). Caption: Red dotted line denotes the median for all women, and crosses (+) represent the group‐specific averages. Boxes on the distribution plots represent the 25th, 50th and 75th centiles, and whiskers demarcate the minimum–maximum values.
Objective: To investigate maternal lactate concentrations in labour and the puerperium DESIGN: Reference study SETTING: Tertiary obstetric unit POPULATION: 1,279 pregnant women with good perinatal outcomes at term METHODS: Electronic patient records were searched for women who had lactate measured on the day of delivery or in the following 24 hours, but who were subsequently found to have a very low likelihood of sepsis, based on their outcomes. Main outcome measures: The normative distribution of lactate and C-reactive protein (CRP), differences according to the mode of birth, and the proportion of results above the commonly used cut-offs (≥2 and ≥4 mmol/L). Results: Lactate varied between 0.4-5.4 mmol/L (median 1.8 mmol/L, IQR 1.3-2.5). It was higher in women who had vaginal deliveries than Caesarean sections (median 1.9 vs. 1.6 mmol/L, pdiff <0.001), demonstrating the relationship with labour (particularly active pushing in the second stage). In contrast, CRP was more elevated in women who had Caesarean sections (median 71.8 mg/L) than those who had vaginal deliveries (33.4 mg/L, pdiff <0.001). In total, 40.8% had a lactate ≥2 mmol/L, but 95.3% were <4 mmol/L. Conclusions: Lactate in labour and the puerperium is commonly elevated above the levels expected in healthy pregnant or non-pregnant women. There is a paucity of evidence to support using lactate or CRP to make decisions about antibiotics around the time of delivery but, as lactate is rarely higher than 4 mmol/L, this upper limit may still represent a useful severity marker for the investigation and management of sepsis in labour.
To assess the association between trajectories of comorbid anxiety and depressive (CAD) symptoms assessed at each pregnancy trimester and physiological birth. Large longitudinal prospective cohort study with recruitment between January 2013 and September 2014. Primary care, in the Netherlands. Dutch speaking pregnant women with gestational age at birth ≥37 weeks, and without multiple pregnancy, severe psychiatric disorder, and chronic disease history. Pregnancy‐specific anxiety and depressive symptoms were measured prospectively at each trimester of pregnancy using the negative affect subscale of the Tilburg Pregnancy Distress Scale and Edinburgh (Postnatal) Depression Scale. Data on physiological birth were obtained from obstetric records. Multivariate growth mixture modeling was performed in Mplus to determine longitudinal trajectories of CAD symptoms. Multiple logistic regression analysis was used to examine the association between trajectories and physiological birth. Trajectories of CAD symptoms and physiological birth. Seven trajectories (classes) of CAD symptoms were identified in 1682 women and subsequently merged into three groups: group 1) persistently low symptoms (reference class 1; 79.0%), group 2) intermittently high symptoms (class 3‐6‐7; 11.2%), and group 3) persistently high symptoms (class 2‐4‐5; 9.8%). Persistently high CAD symptoms (group 3) were associated with a lower likelihood of physiological birth (OR=0.67, 95%CI [0.47, 0.95], p=.027) compared to the reference group (persistently low symptoms), after adjusting for confounders. This study is the first showing evidence that persistently high CAD levels, assessed at each pregnancy trimester, are associated with a lower likelihood of physiological birth.
Abstract To describe outcomes in the first 2 years of life for the children born in the Dallas UtErus Transplant Study. Cohort study comprising all live births from uterus transplantation at a single center. Baylor University Medical Center, Dallas, Texas. A total of 14 children from 12 uterus transplantation recipients. Retrospective review of data through 2 years of life. Information on children’s development was collected based on the Bright Futures Guideline and the Bright Futures Previsit Questionnaire. Primary outcomes were anthropometric measures (children’s body length, weight, head circumference), neurological status, cognitive status, and physical development at 6, 12, 18, and 24 months of age. The median gestational age at delivery was 366/7 weeks, with a median birth weight of 2940 g. Follow‐up data were available for 13 offspring. Physical and neurological developmental milestones were met and were age appropriate in all children within the first 24 months. General health was good, and no abnormalities in immune development were found. Cognitive deviations were only mild and temporary and improved with interventions. The children’s growth and physical, neurological, and cognitive development was age appropriate within the first 2 years of life. To confirm these outcomes, further data should be collected in collaboration with other centers.
Cytology performed directly on hrHPV‐positive self‐samples (reflex‐cytology) is feasible and for women with abnormal cytology, an additional cytology test at the general practitioner could be omitted. The aim of this study is to assess the added‐value of digital‐imaging (ThinPrep® Imaging System) on the clinical utility of reflex‐cytology by reducing screening‐error. A secondary analysis of a prospective cohort‐study. One out of five Dutch screening laboratories. Women tested hrHPV‐positive on self‐samples between December 2018 and August 2019. Self‐samples were used for reflex‐cytology with and without digital‐imaging. The follow‐up data (cytological and histological results within one year of follow‐up) were obtained through the Dutch Pathology Registry (PALGA). Test performance of the reflex‐cytology was determined by comparing it with physician‐collected follow‐up results. The sensitivity for detecting abnormal cells by reflex‐cytology on self‐samples increased significantly from 26.3% (42/160; 95%CI19.6‐33.8) without digital‐imaging to 35.4% (56/158; 95%CI28‐43.4) with digital‐imaging (p <0.05) without compromising specificity. Importantly, 41.7% of women with ≥CIN2 (35/84) and 45.6% with ≥CIN3 (26/57) were detected by reflex‐cytology with digital‐imaging on hrHPV‐positive self‐samples. Digital‐imaging is of added‐value to reflex‐cytology on hrHPV‐positive self‐samples with a 9% increase in sensitivity. If reflex‐cytology on self‐samples analysed with digital‐imaging would be implemented in the screening programme, 35.4% of the hrHPV‐positive women with abnormal cytology on additional physician‐collected samples could have been referred directly for colposcopy.
Associations of CNVs with placental pathological lesions in stillborn fetuses.
Objective: To examine the association of fetal/placental DNA copy number variants (CNVs) with pathologic placental lesions (PPLs) in pregnancies complicated by stillbirth. Design: A secondary analysis of stillbirth cases in the Stillbirth Collaborative Research Network case-control study. Setting: Multicenter, 59 hospitals in 5 geographic regions in the USA. Population: 387 stillbirth cases (2006-2008). Methods: Using standard definitions, PPLs were categorized by type including maternal vascular, fetal vascular, inflammatory and immune/idiopathic lesions. Single-nucleotide polymorphism array detected CNVs of at least 500kb. CNVs were classified into two groups: normal, defined as no CNVs>500kb or benign CNVs, and abnormal, defined as pathogenic or variants of unknown clinical significance. Main outcome measures: The proportions of abnormal CNVs and normal CNVs compared between stillbirth cases with and without PPLs using the Wald Chi-squared test. Results: Of 387 stillborn fetuses, 327 (84.5%) had maternal vascular PPLs and 60 (15.6%) had abnormal CNVs. Maternal vascular PPLs were more common in stillborn fetuses with abnormal CNVs compared with those with normal CNVs (81.7% vs. 64.2%; p=0.008). The proportions of fetal vascular, maternal/fetal inflammatory, and immune/idiopathic PPLs were similar among stillborn fetuses with abnormal CNVs compared to those with normal CNVs. Pathogenic CNVs in stillborn fetuses with maternal vascular PPLs spanned several known genes. Conclusions: Abnormal placental/fetal CNVs were associated with maternal vascular PPLs in stillbirth cases. Findings may provide insight on the mechanisms of specific genetic abnormalities associated with placental dysfunction and stillbirth.
Flow diagram of participants through the study.
Proportion of participants who responded to each question, pertaining to each outcome of sexual enjoyment, sexual frequency and sex‐related pain at each timepoint.
Adjusted odds ratio of being at a higher level of the ranked outcome, comparing caesarean section with vaginal delivery for each outcome: sexual enjoyment, sexual frequency and sex‐related pain at each timepoint (n = 10 324). Models adjusted for: maternal age at delivery, maternal BMI (12 weeks' gestation), maternal diabetes (12 weeks' gestation), maternal anxiety (18 weeks' gestation), maternal depression (18 weeks' gestation), parity (18 weeks' gestation) and maternal educational attainment (32 weeks' gestation).
Objectives: To investigate the relationship between mode of delivery and subsequent maternal sexual wellbeing. Design: Prospective birth cohort study. Setting: Avon (in Bristol area), UK. Population: Participants of the Avon Longitudinal Study of Parents And Children (ALSPAC). Methods: Mode of delivery was abstracted from obstretric records and sexual wellbeing measures were collected via self-report questionnaire. Missing data were imputed using multiple imputation and ordinal logistic regression models for ordered categorical outcomes were adjusted for covariates maternal age at delivery, pre-pregnancy body mass index, diabetes during pregnancy, socioeconomic position, parity, depression, and anxiety. Main outcome measures: Sexual enjoyment and frequency at four timepoints postpartum (between 33 months and 18 years), and two types of sex-related pain (pain in the vagina during sex and elsewhere after sex) at 11 years postpartum. Results: We found no association between mode of delivery and sexual enjoyment (e.g., adjusted odds ratio (OR) 1.11, 95% confidence interval (95% CI) 0.97-1.27 at 33 months) nor sexual frequency (OR 0.99, 95% CI 0.88-1.12 at 33 months). Caesarean section was associated with an increased odds of pain in the vagina during sex at 11 years postpartum as compared with vaginal delivery in the adjusted model (OR 1.74, 95% CI 1.46-2.08). Conclusions: These findings provide no evidence supporting associations between caesarean section and sexual enjoyment or frequency. However, mode of delivery was shown to be associated with dyspareunia, that may not be limited to abdominal scarring.
To investigate women’s preference for modified Manchester(MM) or sacrospinous hysteropexy(SH) as surgery for uterine prolapse. Labelled discrete choice experiment(DCE). Eight Dutch hospitals. Women with uterine prolapse, eligible for primary surgery and preference for uterus preservation. DCEs are attribute‐based surveys. The two treatment options were labelled as MM and SH. Attributes in this survey were treatment success(SH: 84; 89; 94%, MM: 89; 93; 96%), dyspareunia(0; 5; 10%), cervical stenosis(1; 6; 11%) and severe buttock pain(0; 1%). Women completed nine choice sets, making a choice based on attribute levels. Data were analysed in multinomial logit models. Women’s preference for MM or SH. 137 DCEs were completed(1233 choice sets). SH was chosen in 49% of the choice sets, MM in 51%. Of all women, 39(28%) always chose the same surgery. After exclusion of this group, 882 choice sets were analysed, in which women preferred MM, likely associated with a labelling effect i.e. description of the procedure, rather than the tested attributes. In that group, MM was chosen in 53% of the choice sets and SH in 47%. When choosing MM, next to the label, dyspareunia was relevant for decision‐making. For SH, all attributes were relevant for decision‐making. The preference of women for MM or SH seems almost equally divided. The variety in preference supports the importance of individualized healthcare.
To study the impact of shoulder dystocia (SD) simulation training on the SD management and the incidence of permanent brachial plexus birth injury (BPBI). Retrospective observational study Helsinki University Women’s Hospital, Finland Deliveries with SD Multi‐professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010–2014 were considered the pre‐training period and 2015–2019 the post‐training period. The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the SD management were also analysed. During the study period, 113,085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these (p <0.001) during the post‐training period. The incidence of SD also increased significantly (0.01 vs 0.3%, p <0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05 vs 0.02%, p <0.001). The most significant change in the management of SD was increased incidence of successful delivery of the posterior arm. Systematic simulation‐based training of midwives and doctors can translate into improved individual and team performance and significantly reduce the incidence of permanent BPBI.
Journal metrics
21 days
Submission to first decision
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$4,200 / £2,800 / €3,500
7.331 (2021)
Journal Impact Factor™
9.6 (2021)
Top-cited authors
Marian Knight
  • University of Oxford
Ahmet Metin Gülmezoglu
  • Concept Foundation
Ben W Mol
  • Monash University (Australia)
João Paulo Souza
  • University of São Paulo
Özge Tunçalp
  • World Health Organization WHO