The latest medical research on Obstetrics And Gynecology

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about obstetrics and gynecology gathered by our medical AI research bot.

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IUI for unexplained infertility-a network meta-analysis.

Human Reproduction Update

IUI for unexplained infertility can be performed in a natural cycle or in combination with ovarian stimulation. A disadvantage of ovarian stimulation is an increased risk of multiple pregnancies with its inherent maternal and neonatal complication risks. Stimulation agents for ovarian stimulation are clomiphene citrate (CC), Letrozole or gonadotrophins. Although studies have compared two or three of these drugs to each other in IUI, they have never been compared to one another in one analysis.

The objective of this network meta-analysis was to compare the effectiveness and safety of IUI with CC, Letrozole or gonadotrophins with each other and with natural cycle IUI.

We searched PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL and the Clinical Trial Registration Database indexed up to 16 August 2018. We included randomized controlled trials that compared a stimulation regimen with CC, Letrozole or gonadotrophins to each other or to natural cycle IUI among couples with unexplained infertility. We performed the network meta-analysis within a multivariate random effects model.

We identified 26 studies reporting on 5316 women. The relative risk (RR) for live birth/ongoing pregnancy rates comparing IUI with CC to natural cycle IUI was 1.05 (95% CI 0.63-1.77, low quality of evidence), while comparing IUI with Letrozole to natural cycle IUI was 1.15 (95% CI 0.63-2.08, low quality of evidence) and comparing IUI with gonadotrophins to natural cycle IUI was 1.46 (95% CI 0.92-2.30, low quality of evidence). The RR for live birth/ongoing pregnancy rates comparing gonadotrophins to CC was 1.39 (95% CI 1.09-1.76, moderate quality of evidence), comparing Letrozole to CC was 1.09 (95% CI 0.76-1.57, moderate quality of evidence) and comparing Letrozole to gonadotrophins was 0.79 (95% CI 0.54-1.15, moderate quality of evidence). We did not perform network meta-analysis on multiple pregnancy due to high inconsistency. Pairwise meta-analyses showed an RR for multiple pregnancy rates of 9.11(95% CI 1.18-70.32) comparing IUI with gonadotrophins to natural cycle IUI. There was no data available on multiple pregnancy rates following IUI with CC or Letrozole compared to natural cycle IUI. The RR for multiple pregnancy rates comparing gonadotrophins to CC was 1.42 (95% CI 0.68-2.97), comparing Letrozole to CC was 0.97 (95% CI 0.47-2.01) and comparing Letrozole to gonadotrophins was 0.29 (95% CI 0.14-0.58).In a meta-analysis among studies with adherence to strict cancellation criteria, the RR for live births/ongoing pregnancy rates comparing gonadotrophins to CC was 1.20 (95% CI 0.95-1.51) and the RR for multiple pregnancy rates comparing gonadotropins to CC was 0.80 (95% CI 0.38-1.68).

Based on low to moderate quality of evidence in this network meta-analysis, IUI with gonadotrophins ranked highest on live birth/ongoing pregnancy rates, but women undergoing this treatment protocol were also at risk for multiple pregnancies with high complication rates. IUI regimens with adherence to strict cancellation criteria led to an acceptable multiple pregnancy rate without compromising the effectiveness. Within a protocol with adherence to strict cancellation criteria, gonadotrophins seem to improve live birth/ongoing pregnancy rates compared to CC. We, therefore, suggest performing IUI with ovarian stimulation using gonadotrophins within a protocol that includes strict cancellation criteria. Obviously, this ignores the impact of costs and patients preference.

Total oesophago-gastric dissociation in neurologically impaired children: Laparoscopic vs robotic approach.

Int J Med

To evaluate and compare the feasibility and short-term results of laparoscopic and robotic total oesophago-gastric dissociation (TOGD) with a Roux-en-Y oesophago-jejunostomy. Minimal invasive surgery has multiple advantages in neurologically impaired patients. Robotic approach has overcome disadvantages linked to laparoscopy, in particular, referring to the surgeon fatigue.

A retrospective study comparing five laparoscopic and five robotic TOGD was conducted between February and October 2016 in Giannina Gaslini Children's Hospital and Section of Pediatric Surgery of Siena. Neurologically impaired children scheduled for TOGD were included. Age, sex, weight, symptomatology, presence of epilepsy, and preoperative X-ray contrast were considered. Operative time, hospital stay, postoperative complications, redo surgery, nutrition rehabilitation, and X-ray contrast study after 5 days and after 1 month from the intervention were recorded.

In our series, there were no intraoperative complications, no conversions to open surgery, and no vagal lesions. In two of five robotic cases, a pyloroplasty was necessary. The median operative time was statistically longer in the robotic group. One dehiscence in the robotic group was recorded, and no dumping episodes occurred. No statistical differences in terms of complications were detected.

TOGD is feasible both with laparoscopic and robotic-assisted surgery with similar results. Robotic approach is considered feasible. At the same time, high laparoscopic skills allow to reach the same results as robotic approach with shorter operative time.

Severe acute maternal morbidity trends in Victoria, 2001-2017.

Australian and New Zealand Journal

The incidence of severe acute maternal morbidity (SAMM) is one method of measuring the complexity of maternal health and monitoring maternal outcomes. Monitoring trends may provide a quantitative method for assessing health care at local, regional, or jurisdictional levels and identify issues for further investigation.

Identify temporal trends for SAMM event rates and maternal outcomes over 17 years in the state of Victoria, Australia.

All maternal public health service admissions were extracted from an administrative dataset from July 2000 to June 2017. SAMM-related diagnoses were defined by matching as closely as possible with published definitions. Outcomes included annual SAMM event rates, hospital survival, and hospital length of stay (LOS). Temporal trends were analysed using mixed-effects generalised linear models.

There were 854 777 live births and 1.21 million pregnancy-related hospital admissions which included 34 008 SAMM events in 29 273 records and in 3.42% (95%CI = 3.39-3.46) of births. Most common were severe pre-eclampsia (0.87% of births), severe postpartum haemorrhage (0.59%), and sepsis (0.62%). SAMM-related admissions were associated with longer LOS and higher mortality risk (P < 0.001). Maternal mortality ratio remained unchanged at 8.6 fatalities per 100 000 births (P = 0.65).

Over 17 years, there was a significant increase in birth rate and SAMM-related events in Victoria. Administrative data may provide a pragmatic approach for monitoring SAMM-related events in maternal health services.

Induction of labour using prostaglandin E2 as an inpatient versus balloon catheter as an outpatient: a multi-centre randomised controlled trial.

BJOG

To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient.

The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported.

There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% vs 25.8%; RR=0.77, 95% CI 0.51-1.02; p=0.070), cord arterial pH<7.10 (3.5% vs 9.2%; p=0.072), nursery admissions (12.6% vs 15.5%; p=0.379), neonatal antibiotic use (12.1% vs 17.6%; p=0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% vs 31.0%;p=0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% vs 92.3%; p=0.045).

Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low.

Impact of Socioeconomic Deprivation on Pregnancy and Delivery Rates after IVF.

BJOG

Although it is recognized that socioeconomic status (SES) impacts health care delivery and its outcomes, the contribution of this variable to healt...

Rheumatic heart disease in pregnancy: Profile of women admitted to a Western Australian tertiary obstetric hospital.

Australian and New Zealand Journal

This retrospective study assessed maternal and perinatal outcomes for women with rheumatic heart disease (RHD) admitted to the largest tertiary obs...

Gestational age, morbidity and mortality among twin births in New South Wales, Australia 2003-2014: A cohort study.

Australian and New Zealand Journal

Evidence suggests that the trend toward early planned births observed among singletons may be evident among twin pregnancies.

To describe trends in gestational age at birth, pregnancy characteristics, neonatal morbidity and mortality among twin pregnancies.

Population-based data linkage study of twin births of ≥30 weeks of gestation without a major congenital anomaly born in 2003-2014 in New South Wales (NSW), Australia. Linked pregnancy and birth, hospital and mortality data were used. Generalised linear regression was used to assess linear trends. Risk difference (RD) and 95% confidence intervals were estimated.

Among 28 076 eligible twin births (14 038 pregnancies), 49% of births occurred prior to 37 weeks and 69% of births were planned (pre-labour caesarean or induction of labour). There were increases over time in the proportion of twin births at preterm gestations (30-34 weeks (RD 2.1, 95% CI 0.1, 4.0), 35-36 weeks (RD 7.5, 95% CI 5.4, 9.7)) and in the rates of planned births (pre-labour caesarean (RD 6.4, 95% CI 4.0, 8.8), induction (RD 4.6, 95% CI 2.6, 6.6)). There was no significant change in stillbirth or neonatal death rates, but there was an increase in neonatal morbidity over the study period. Concurrently, there were increases in the prevalence of gestational diabetes; and decreases in pregnancy hypertension, assisted reproductive technology use, small-for-gestational age and birthweight discordance.

Gestational age at birth among twin births is decreasing and birth intervention is increasing. There are increasing rates of neonatal morbidity, but no overall change in perinatal mortality.

Maternal lipids are associated with newborn adiposity independent of GDM status, obesity and insulin resistance: a prospective observational cohort study.

BJOG

To determine association between maternal lipaemia and neonatal anthropometrics in Malaysian mother-offspring pairs.

Macrosomia, large for gestational age (LGA) status, cohort-specific birth weight (BW), neonatal fat mass (NFM), sum of skinfold thickness (SSFT) >90th centile.

Fasting Tg>95th centile (3.6 mmol/L) at screening OGTT was independently associated with LGA (adjusted odds ratio [aOR] 10.82, 95% CI 1.26-93.37) after adjustment for maternal glucose, pregravid BMI and insulin sensitivity. Fasting glucose was independently associated with BWR >90th centile(aOR 2..06 95% CI 1.17-3.64) but not LGA status in this well-treated GDM cohort with pre-delivery HbA1c of 5.27%. 45% mothers had pregravid BMI<23 kg/m2 and 61% BMI ≤ 25 kg/m2 ; yet GWG>10kg was associated with 4.25-fold-risk(95% CI 1.71-10.53) of BW>90th centile.

Maternal lipaemia and GWG at a low threshold (>10kg) adversely impact neonatal adiposity in Asian offspring independent of glucose/insulin resistance/pregravid BMI. These may therefore be important modifiable metabolic targets in pregnancy.

Development of the FAST-M maternal sepsis care bundle: Requires proof of validity in low resource settings.

BJOG

The article by Coomarasamy et al in this issue of BJOG (BJOG xxxx) makes interesting reading. The paper reports a study that describes the process ...

Placental infection by Zika virus in French Guiana.

Ultrasound in Obstetrics and Gynecology

To correlate placental thickness during pregnancy and histopathological results with placental Zika virus (ZIKV) infection.

During the ZIKV epidemic in French Guiana, trans-placental contamination was defined either by a positive RT-PCR or identification of specific IgM in at least one placental, fetal or neonatal sample. Placentas were classified as non-exposed (from non-infected pregnant woman), exposed (from ZIKV-infected pregnant women without trans-placental contamination) or infected (from ZIKV-infected pregnant women with proven trans-placental contamination). Placentas were assessed by monthly prenatal ultrasound, measuring placental thickness and umbilical artery Doppler, and anatomopathologic examination after birth or IUFD. Placental thickness during pregnancy and anatomopathologic findings were correlated to the ZIKV-status of the placenta.

Among 291 fetuses/placentas from proven infected mothers, trans-placental infection was confirmed in 76 cases, of which 16 resulted in Congenital Zika Syndrome (CZS) and 11 in fetal loss. The 215 remaining placentas without evidence of ZIKV infection represented the exposed group. A total of 334 placentas from ZIKV-negative pregnant women represented the non-exposed group. Placentomegaly (thickness>40 mm) was observed more frequently in infected placentas (39.5%) compared to exposed placentas (17.2%) or controls (7.2%), even when considering gestational age at diagnosis and co-morbidities (adjusted Hazard Ratio [aHR] 2.02 [95%CI 1.22-3.36] and aHR 3.23 [95%CI 1.86-5.61], respectively), and appeared earlier in infected placentas. Placentomegaly was observed even more frequently in case of CZS (62.5%) or fetal loss (45.5%) compared to asymptomatic congenital infection (30.6%) (aHR 5.43 [95%CI 2.17-13.56] and aHR 4.95 [95%CI 1.65-14.83], respectively). Umbilical artery Doppler anomaly was observed more frequently in case of trans-placental infection resulting in fetal loss (30.0% vs 6.1%; adjusted Relative Risk [aRR] 4.83 [95%CI 1.09-20.64]). Infected placentas also exhibited a higher risk of any pathological anomalies than exposed placentas (aRR 2.60 [1.40-4.83]).

Early placentomegaly may represent the first sign of trans-placental contamination and should lead to an enhanced follow-up of these pregnancies. This article is protected by copyright. All rights reserved.

Increased nuchal translucency at 11-13 weeks' gestation and pregnancy outcome in twin pregnancies.

Ultrasound in Obstetrics and Gynecology

To investigate the value of increased fetal nuchal translucency thickness (NT) at the 11-13 weeks scan in the prediction of adverse outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies.

This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major defects or chromosomal abnormalities we examined the value of increased NT ≥95th percentile in one or both fetuses in the prediction of first, miscarriage or death of one or both fetuses at <20 and <24 weeks' gestation in DC, MCDA and MCMA twin pregnancies, second, death of one or both fetuses or neonates at ≥24 weeks in DC, MCDA and MCMA twin pregnancies, third, development of twin-to-twin transfusion syndrome (TTTS) or selective fetal growth restriction (sFGR) treated by endoscopic laser surgery at <20 and ≥20 weeks' gestation in MCDA pregnancies, and fourth, either fetal loss or laser surgery at <20 weeks' gestation.

The study population of 6,225 twin pregnancies included 4,896 (78.7%) DC, 1,274 (20.4%) MCDA and 55 (0.9%) MCMA. The incidence of NT ≥95th percentile in one or both fetuses in DC twin pregnancies was 8.3%; in MCDA twins the incidence was significantly higher (10.4%, P=0.016), but in MCMA twins it was not significantly different from that in DC twins (9.1% P=0.804). In DC twin pregnancies the incidence of high NT was not significantly different between those with two survivors and those with adverse outcome. In MCMA twin pregnancies the number of cases was too small for meaningful assessment of the relation between high NT and adverse outcome. In MCDA twin pregnancies with ≥1 fetal death or need for endoscopic laser surgery at <20 weeks' gestation the incidence of NT ≥95th percentile was significantly higher than in pregnancies with two survivors (23.5% versus 9.8%, P <0.0001). Kaplan-Meier analysis in MCDA twin pregnancies showed that in those with NT ≥95th percentile there was a significantly lower survival at <20 weeks' gestation than in those with NT <95th percentile (P=0.001); this was not the case for survival at ≥20 weeks (P=0.960). The performance of screening by fetal NT ≥95th for prediction of either fetal loss or need for endoscopic laser surgery at <20 weeks' gestation was poor with detection rate of 23.5% at false positive rate of 8.9% and the relative risk, by comparison with fetal NT <95th percentile was 2.640 (95% CI, 1.854-3.758; P<0.0001). In MCDA twin pregnancies the overall rate of fetal loss or need for laser surgery at <20 weeks' gestation was 10.7% but in the subgroups with NT ≥95th and NT ≥99th percentiles, which constituted 10.4% and 3.3% of the total, the rates increased to 24.1% and 40.5%, respectively.

In MCDA twin pregnancies with no major fetal abnormalities measurement of NT at the 11-13 weeks scan is a poor screening test for adverse pregnancy outcome. However, the finding in one or both fetuses of NT ≥95th percentile, and more so ≥99th percentile, is associated with a substantially increased risk of fetal loss or need for endoscopic laser surgery at <20 weeks' gestation. The extent to which closer monitoring and earlier intervention in the high-risk group can reduce these complications remains to be determined. This article is protected by copyright. All rights reserved.

Twin pregnancies with two live fetuses at 11-13 weeks: effect of one fetal death on pregnancy outcome.

Ultrasound in Obstetrics and Gynecology

First, to compare the incidence of single and double fetal death in monochorionic (MC) and dichorionic (DC) twin pregnancies with two live fetuses at 11-13 weeks' gestation and no major abnormalities, second, to investigate the relationship between the gestational age at single fetal death and interval to delivery of the co-twin, and third, to determine the rate of early preterm birth in DC and MC twin pregnancies with two live fetuses and those with single fetal death.

This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. The outcome measures, which were stratified by chorionicity, were: first, death of both fetuses at presentation or death of one fetus followed by delivery of a live or dead co-twin within the subsequent 3 days at <34 weeks' gestation; second, in pregnancies with single fetal death at <34 weeks' gestation and the co-twin being alive for ≥3 days, subsequent risk of fetal death and gestational age distribution at birth of the co-twin; and third, gestational age distribution at birth of pregnancies with two live fetuses.

The main findings of this study of 4,896 DC and 1,329 MC twin pregnancies with two live fetuses at 11-13 weeks' gestation were: first, the rate of death of both twins or death of one fetus and delivery of the live or dead co-twin within 3 days was higher in MC than in DC twin pregnancies; second, the rate of single fetal death with the co-twin being alive for ≥3 days was higher in MC than in DC twin pregnancies, but the rate of subsequent co-twin death in MC twin pregnancies was not significantly different from that in DC twin pregnancies; third, in pregnancies with two live fetuses the rate of early preterm birth was significantly higher in MC than in DC twin pregnancies; fourth, the rates of early preterm birth in pregnancies with single fetal death and the co-twin being alive at ≥3 days later was not significantly different between MC and DC twin pregnancies but the rates were substantially higher than in those with two live fetuses; and fifth, in both MC and DC pregnancies with single fetal death and the co-twin being alive at ≥3 days later there was a significant inverse association between the gestational age at death and interval to delivery (mean interval of 19 weeks for death at 15 weeks and interval of 2.5 weeks for death at 30 weeks).

First, in MC twin pregnancies the risk of single or double fetal death is higher than in DC twins, second, in both MC and DC twin pregnancies the rate of early preterm birth is higher in those with one fetal death than in those with two live fetuses, and third, in both MC and DC twins with one fetal death the interval to delivery is inversely related to the gestational age at fetal death. These data would be useful in counselling parents as to the likely outcome of their pregnancy after single fetal death and in defining strategies for surveillance in the management of these types of twin pregnancies. This article is protected by copyright. All rights reserved.