BJOG: An International Journal of Obstetrics & Gynaecology

1. Rate of gestational weight gain, pre-pregnancy body mass index and preterm birth subtypes: a retrospective cohort study from Peru
   Please cite this paper as: Carnero AM, Mejía CR, García PJ. Rate of gestational weight gain, pre-pregnancy body mass index and preterm birth subtypes: a retrospective cohort study from Peru. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03345.x.Objective  To examine the shape (functional form) of the association between the rate of gestational weight gain, pre-pregnancy body mass index (BMI), and preterm birth and its subtypes.Design  Retrospective cohort study.Setting  National reference obstetric centre in Lima, Peru.Population  Pregnant women who delivered singleton babies during the period 2006–2009, resident in Lima, and beginning prenatal care at ≤12 weeks of gestation (n = 8964).Methods  Data were collected from the centre database. The main analyses consisted of logistic regression with fractional polynomial modelling.Main outcome measures  Preterm birth and its subtypes.Results  Preterm birth occurred in 12.2% of women, being mostly idiopathic (85.7%). The rate of gestational weight gain was independently associated with preterm birth, and the shape of this association varied by pre-pregnancy BMI. In women who were underweight, the association was linear (per 0.1 kg/week increase) and protective (OR 0.88; 95% CI 0.82–1.00). In women of normal weight or who were overweight, the association was U-shaped: the odds of delivering preterm increased exponentially with rates <0.10 or >0.66 kg/week, and <0.04 or >0.50 kg/week, respectively. In women who were obese, the association was linear, but non-significant (OR 1.01; 95% CI 0.95–1.06). The association described for preterm birth closely resembled that of idiopathic preterm birth, although the latter was stronger. The rate of gestational weight gain was not associated with indicated preterm birth or preterm prelabour rupture of membranes.Conclusions  In Peruvian pregnant women starting prenatal care at ≤12 weeks of gestation, the rate of gestational weight gain is independently associated with preterm birth, mainly because of its association with idiopathic preterm birth, and the shape of both associations varies by pre-pregnancy BMI.
2. The prognostic profile of subfertile couples and treatment outcome after expectant management, intrauterine insemination and in vitro fertilisation: a study protocol for the meta-analysis of individual patient data
   Please cite this paper as: Boogaard N van den, Hompes P, Barnhart K, Bhattacharya S, Custers I, Coutifaris C, Goverde A, Guzick D, Litvak P, Steures P, Veen F van der, Bossuyt P, Mol B. The prognostic profile of subfertile couples and treatment outcome after expectant management, intrauterine insemination and in vitro fertilisation: a study protocol for the meta-analysis of individual patient data. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03343.x.Objective  The current evidence concerning the best treatment option for couples with unexplained and male subfertility is inconclusive. Most studies that have evaluated the effectiveness of treatment options, such as expectant management (EM), intrauterine insemination (IUI), with or without controlled ovarian stimulation (COS), and in vitro fertilisation (IVF), have not taken the couples’ prognosis into account. It is very likely that the individual prognosis of the couple influences the effect of treatment. Individual patient data analyses allow us to take these prognostic factors into account, and to evaluate their effect on treatment outcome. This study aims to use anonymised data from relevant published trials to perform an individual patient data meta-analysis, evaluating the effect of couples’ prognosis on the effectiveness of EM, IUI, with or without COS, and IVF.Methods  Based on earlier systematic reviews and an updated search, randomised controlled trials will be considered for inclusion. Untreated subfertile couples with unexplained or male subfertility included in trials comparing EM, IUI, with or without COS, and IVF are included. Authors of the included studies will be invited to share their original anonymised data. The data will be assessed on validity, quality and completeness. The prognosis of the individual couple will be calculated with existing prognostic models. The effect of the prognosis on treatment outcome will be analysed with marker-by-treatment predictiveness curves, illustrating the effect of prognosis on treatment outcome. This study is registered in PROSPERO (registration number CRD42011001832).Conclusion  Ultimately, this study may help to select the appropriate fertility treatment, tailored to the needs of an individual couple.
3. A difficult conversation? The views and experiences of parents and professionals on the consent process for perinatal postmortem after stillbirth
   Please cite this paper as: Heazell A, McLaughlin M, Schmidt E, Cox P, Flenady V, Khong T, Downe S. A difficult conversation? The views and experiences of parents and professionals on the consent process for perinatal postmortem after stillbirth. BJOG 2012 DOI: 10.1111/j.1471-0528.2012.03357.xObjective  To describe the experiences, knowledge and views of both parents and professionals regarding the consent process for perinatal postmortem.Design  Internet-based survey.Setting  Obstetricians, midwives and perinatal pathologists currently working in the UK. Parents who have experienced a stillbirth in the UK in the previous 10 years.Sample  Obstetricians, midwives and perinatal pathologists registered with their professional bodies. Parents who accessed the Sands website or online forum.Methods  Online self-completion questionnaire with both fixed-choice and open-ended questions.Results  Responses were analysed from 2256 midwives, 354 obstetricians, 21 perinatal pathologists and 460 parents. The most common reason for parents to request postmortem examination was to find a cause for their baby’s death; the prevention of stillbirths in others also ranked highly. Perinatal pathologists possessed greatest knowledge of the procedure and efficacy of postmortem, but were unlikely to meet bereaved parents. The majority of professionals and parents ranked emotional distress and a lengthy wait for results as barriers to consent. The majority of staff ranked workload, negative publicity, religion and cultural issues as important barriers, whereas most parents did not. Almost twice as many parents who declined postmortem examination later regretted their decision compared with those who accepted the offer (34.4 versus 17.4%).Conclusion  Emotional, practical and psychosocial issues can act as real or perceived barriers for staff and bereaved parents. Education is required for midwives and obstetricians, to increase their knowledge to ensure accurate counselling, with due regard for the highly individual responses of bereaved parents. The contribution of perinatal pathologists to staff education and parental decision-making would be invaluable.
4. Secondary cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent epithelial ovarian cancer: a multi-institutional study
   Please cite this paper as: Deraco M, Virzì S, Raspagliesi F, Iusco D, Puccio F, Macrì A, Famulari C, Solazzo M, Bonomi S, Grassi A, Baratti D, Kusamura S. Secondary cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent epithelial ovarian cancer: a multi-institutional study. BJOG 2012;119:800–809.Objective  To assess the efficacy and morbidity and mortality of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in recurrent epithelial ovarian cancer (EOC).Design  A retrospective study conducted using information extracted from a multi-institutional prospective database on peritoneal surface malignancies (PSMs).Setting Four Italian centres specializing in locoregional treatment of PSM.Population  Patients with recurrent EOC.Methods  Fifty-six patients underwent 57 combined procedures. CRS was performed using peritonectomy procedures and HIPEC using the closed-abdomen technique with cisplatin and doxorubicin or cisplatin and mitomycin-C.Main outcome measures  Overall survival (OS), progression-free survival (PFS), morbidity and mortality rates.Results  The median age of the patients was 55.2 years (range 30–75 years). The median peritoneal cancer index was 15.2 (range 4–30). Forty-seven patients had microscopic residual disease (completeness of cytoreduction, CC-0), seven had residual disease ≤2.5 mm (CC-1) and one had residual disease >2.5 mm (CC>2). Major complications occurred in 15 patients (26.3%), and procedure-related mortality occurred in three patients (5.3%). The median follow-up time was 23.1 months. The median OS and PFS were 25.7 (95% CI 20.3–31.0) and 10.8 (95% CI 5.4–16.2) months, respectively. The 5-year OS and PFS were 23% and 7%, respectively. Independent prognostic factors affecting OS according to the multivariate analysis were Eastern Cooperative Oncology Group performance status, preoperative serum albumin, and completeness of cytoreduction.Conclusions  Patients with recurrent EOC treated with CRS and HIPEC showed promising results in terms of outcome. The combined treatment strategy could benefit subsets of patients wider than that defined for conventional secondary debulking surgery without HIPEC. These data warrant further evaluation in randomised clinical trials.
5. Is laparoscopic sterilisation an anachronism?
   Please cite this paper as: Clark T. Is laparoscopic sterilisation an anachronism?. BJOG 2012;119:775–777.
6. A relationship between female genital piercings and genital mutilation?
7. What’s new in the other journals?
8. What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe
   Please cite this paper as: Bouvier-Colle M, Mohangoo A, Gissler M, Novak-Antolic Z, Vutuc C, Szamotulska K, Zeitlin J for The Euro-Peristat Scientific Committee. What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG 2012;119:880–890.Objective  To assess capacity to develop routine monitoring of maternal health in the European Union using indicators of maternal mortality and severe morbidity.Design  Analysis of aggregate data from routine statistical systems compiled by the EURO-PERISTAT project and comparison with data from national enquiries.Setting  Twenty-five countries in the European Union and Norway.Population  Women giving birth in participating countries in 2003 and 2004.Methods  Application of a common collection of data by selecting specific International Classification of Disease codes from the ‘Pregnancy, childbirth and the puerperium’ chapter. External validity was assessed by reviewing the results of national confidential enquiries and linkage studies.Main outcome measures  Maternal mortality ratio, with distribution of specific obstetric causes, and severe acute maternal morbidity, which included: eclampsia, surgery and blood transfusion for obstetric haemorrhage, and intensive-care unit admission.Results  In 22 countries that provided data, the maternal mortality ratio was 6.3 per 100 000 live births overall and ranged from 0 to 29.6. Under-ascertainment was evident from comparisons with studies that use enhanced identification of deaths. Furthermore, routine cause of death registration systems in countries with specific systems for audit reported higher maternal mortality ratio than those in countries without audits. For severe acute maternal morbidity, 16 countries provided data about at least one category of morbidity, and only three provided data for all categories. Reported values ranged widely (from 0.2 to 1.6 women with eclampsia per 1000 women giving birth and from 0.2 to 1.0 hysterectomies per 1000 women).Conclusions  Currently available data on maternal mortality and morbidity are insufficient for monitoring trends over time in Europe and for comparison between countries. Confidential enquiries into maternal deaths are recommended.
9. Intra-operative frozen section analysis for suspected early-stage ovarian cancer
10. The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51 519 consecutive validated samples
    Please cite this paper as: Yeh P, Emary K, Impey L. The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51 519 consecutive validated samples. BJOG 2012;119:824–831.Objective  To examine the relationship between umbilical cord pH at term and serious neonatal outcomes.Design  Observational cohort study.Settings  Deliveries within the Oxford Radcliffe Hospital NHS Trust between 1991 and 2009.Population  In all, 51 519 singleton, term, nonanomalous live neonates with validated umbilical cord arterial pH values.Methods  Absolute risks, relative risks with 95% confidence intervals, and numbers needed to harm were calculated for different levels of arterial pH across the entire range.Main outcome measures  Neonatal encephalopathy with seizures and/or death, encephalopathy within 24 hours of birth, 5-minute Apgar scores and neonatal unit admission.Results  The median arterial pH was 7.22, interquartile range 7.17–7.27. The absolute risk of an adverse neurological outcome was significantly increased below 7.10 (0.36%) and was lowest between 7.26 and 7.30 (0.16%). Even below 7.00, the risk was only 2.95%. However, more than 75% of neonates with neurological outcomes examined, including seizures within 24 hours of birth, had a pH above 7.10. A small increase in risk was evident at higher pH levels.Conclusion  The threshold pH for adverse neurological outcomes is 7.10 and the ‘ideal’ cord pH is 7.26–7.30. Above 7.00, however, neonatal acidaemia is weakly associated with adverse outcomes. Most neonates with neurological morbidity have normal cord pH values. Other variables must influence adverse outcomes and account for more of these than acidaemia. A better understanding of these is required before intrapartum fetal monitoring can improve.
11. Editor’s choice
12. Women’s health—what’s new worldwide
13. Intra-operative frozen section analysis for suspected early-stage ovarian cancer
14. Low-molecular-weight heparin or warfarin for anticoagulation in pregnant women with mechanical heart valves: what are the risks? A retrospective observational study
    Please cite this paper as: Basude S, Hein C, Curtis S, Clark A, Trinder J. Low-molecular-weight heparin or warfarin for anticoagulation in pregnant women with mechanical heart valves: what are the risks? A retrospective observational study. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03359.xThe management of anticoagulation in pregnant women with mechanical heart valves is complex. The maternal and fetal outcomes of 32 pregnancies in 15 women on three different anticoagulation regimens were compared. Anticoagulation with low-molecular-weight heparin (n = 4), warfarin (n = 22) and combination therapy (n = 6) resulted in adverse maternal events in four (100%), three (50%) and three (14%) women, and resulted in fetal losses in one (25%), 17(77%) and three (50%) pregnancies, respectively. Whereas the rate of fetal loss in the warfarin group was high, all women in the LMWH and half of those in the combination group had serious adverse maternal events, including valve thrombosis, maternal death and postpartum haemorrhage.
15. Having a Pap smear, quality of life before and after cervical screening: a questionnaire study
    Please cite this paper as: Korfage I, van Ballegooijen M, Wauben B, Looman C, Habbema J, Essink-Bot M. Having a Pap smear, quality of life before and after cervical screening: a questionnaire study. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03344.xObjective  To assess the health-related quality of life (HRQoL) impact of cervical cancer screening in women with normal test results.Design  Questionnaire study.Setting  Maastricht, the Netherlands.Population  A cohort of 789 women were followed from screening invitation until after the receipt of screening results. A female age-matched reference group (n = 567) was included.Methods  Questionnaires were sent to the home address of the women before screening, after screening, and again with the screening results.Main outcome measures  Generic HRQoL (SF-12, EQ-5D), generic anxiety (STAI-6), screen-specific anxiety (PCQ), and potential symptoms and feelings related to the smear-taking procedure.Results  A total of 60% of screening participants completed questionnaire 1(n = 924): 803 of these women granted permission to access their files; 789 of these 803 women had normal test results (Pap 1), and were included in the analyses. Generic HRQoL (SF-12, EQ-5D) and anxiety (STAI-6) scores were similar in the study and reference groups. Before screening, after screening, and also after the receipt of test results, screening participants reported less screen-specific anxiety (PCQ, P < 0.001) than the reference group (n = 567), with differences indicating clinical relevance. 19% of screening participants were bothered by feelings of shame, pain, inconvenience, or nervousness during smear taking, and 8 and 5% of women experienced lower abdominal pain, vaginal bleeding, discharge, or urinary problems for 2–3 and 4–7 days, respectively, following the Pap smear.Conclusion  The reduced levels of screen-specific anxiety in screening participants, possibly indicating reassurance, are worthwhile addressing in more depth. We conclude that although considerable numbers of women reported unpleasant effects, there were no adverse HRQoL consequences of cervical screening in women with normal test results.
16. Impact of stress coping capacity on recovery from abdominal hysterectomy in a fast-track programme: a prospective longitudinal study
    Please cite this paper as: Kjølhede P, Borendal Wodlin N, Nilsson L, Fredrikson M, Wijma K. Impact of stress coping capacity on recovery from abdominal hysterectomy in a fast-track programme: a prospective longitudinal study. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03342.xObjective  To evaluate the effect of stress coping capacity in combination with mode of anaesthesia on postoperative recovery in fast-track abdominal hysterectomy.Design  Prospective longitudinal study.Setting  Five hospitals in the south-east of Sweden.Population  A cohort of 162 women undergoing fast-track abdominal hysterectomy for benign conditions.Methods  Self-administered questionnaires, the Stress Coping Inventory (SCI) and the Swedish Postoperative Symptom Questionnaire (SPSQ), and clinical information were collected prospectively. Stress coping capacity was categorised as high or low according to the summed score of the SCI. Comparisons of effect variables were adjusted using a propensity score-matching model.Main outcome measures  Associations between stress coping capacity and hospital stay, sick leave, use of analgesic and self-reported postoperative symptoms.Results  Women with high stress coping capacity had a significantly shorter sick leave, experienced postoperative symptoms significantly less often, and with lower intensity, than women with low stress coping capacity. With the exception of symptom intensity, these findings were related to having had the operation under spinal anaesthesia as opposed to general anaesthesia. Hospital stay, use of analgesics and abdominal pain were not related to stress coping capacity.Conclusions  In patients for whom spinal anaesthesia was applied, high stress coping seems to be a quality that helps patients manage the burden of surgery. It is desirable for the individual, as well as for the healthcare system, to enhance recovery by using intervention programmes designed to improve or manage stress coping, particularly for individuals with low stress coping capacity. This recommendation merits further investigation.
17. A clinical prediction model to assess the risk of operative delivery
    Please cite this paper as: Schuit E, Kwee A, Westerhuis M, Van Dessel H, Graziosi G, Van Lith J, Nijhuis J, Oei S, Oosterbaan H, Schuitemaker N, Wouters M, Visser G, Mol B, Moons K, Groenwold R. A clinical prediction model to assess the risk of operative delivery. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03334.x.Objective  To predict instrumental vaginal delivery or caesarean section for suspected fetal distress or failure to progress.Design  Secondary analysis of a randomised trial.Setting  Three academic and six non-academic teaching hospitals in the Netherlands.Population  5667 labouring women with a singleton term pregnancy in cephalic presentation.Methods  We developed multinomial prediction models to assess the risk of operative delivery using both antepartum (model 1) and antepartum plus intrapartum characteristics (model 2). The models were validated by bootstrapping techniques and adjusted for overfitting. Predictive performance was assessed by calibration and discrimination (area under the receiver operating characteristic), and easy-to-use nomograms were developed.Main outcome measures  Incidence of instrumental vaginal delivery or caesarean section for fetal distress or failure to progress with respect to a spontaneous vaginal delivery (reference).Results  375 (6.6%) and 212 (3.6%) women had an instrumental vaginal delivery or caesarean section due to fetal distress, and 433 (7.6%) and 571 (10.1%) due to failure to progress, respectively. Predictors were age, parity, previous caesarean section, diabetes, gestational age, gender, estimated birthweight (model 1) and induction of labour, oxytocin augmentation, intrapartum fever, prolonged rupture of membranes, meconium stained amniotic fluid, epidural anaesthesia, and use of ST-analysis (model 2). Both models showed excellent calibration and the receiver operating characteristics areas were 0.70–0.78 and 0.73–0.81, respectively.Conclusion  In Dutch women with a singleton term pregnancy in cephalic presentation, antepartum and intrapartum characteristics can assist in the prediction of the need for an instrumental vaginal delivery or caesarean section for fetal distress or failure to progress.
18. Heavy prenatal alcohol exposure and increased risk of stillbirth
    Please cite this paper as: O’Leary C, Jacoby P, D’Antoine H, Bartu A, Bower C. Heavy prenatal alcohol exposure and increased risk of stillbirth. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03333.x.Objective  To investigate the association between heavy prenatal alcohol exposure and stillbirth.Design  Data linkage cohort study.Setting  Western Australia (WA).Population  The exposed cohort included mothers with an alcohol-related diagnosis (International Classification of Diseases, ninth/tenth revisions) recorded in health data sets and all their offspring born in WA (1983–2007). Mothers without an alcohol-related diagnosis and their offspring comprised the comparison cohort.Methods  Exposed and comparison mothers were identified through the WA Data Linkage System. Odds ratios for stillbirth at 20 + weeks of gestation were estimated by logistic regression, stratified by Aboriginal status.Main outcome measures  The proportion of stillbirths at 20 + weeks of gestation is presented per 1000 births, as well as adjusted odds ratios (aOR) and 95% confidence intervals (95% CI), and population-attributable fractions.Results  Increased odds of stillbirth were observed for mothers with an alcohol-related diagnosis at any stage of their life for both non-Aboriginal (aOR 1.36; 95% CI 1.05–1.76) and Aboriginal (aOR 1.33; 95% CI 1.08–1.64) births. When an alcohol diagnosis was recorded during pregnancy, increased odds were observed for non-Aboriginal births (aOR 2.24; 95% CI 1.09–4.60), with the highest odds of Aboriginal stillbirth occurring when an alcohol diagnosis was recorded within 1 year postpregnancy (aOR 2.88; 95% CI 1.75–4.73). The population-attributable fractions indicate that 0.8% of non-Aboriginal and 7.9% of Aboriginal stillbirths are the result of heavy alcohol consumption.Conclusions  Prevention of heavy maternal alcohol use has the potential to reduce stillbirths. The lack of an association between exposure during pregnancy and Aboriginal stillbirth in this study needs further investigation.
19. Early menopause and risk of osteoporosis, fracture and mortality: a 34-year prospective observational study in 390 women
    Please cite this paper as: Svejme O, Ahlborg H, Nilsson J, Karlsson M. Early menopause and risk of osteoporosis, fracture and mortality: a 34-year prospective observational study in 390 women. BJOG 2012;119:810–816.Objective  A prospective evaluation of the long-term effects of early menopause on mortality, risk of fragility fracture and osteoporosis.Design  Prospective population-based observational study.Setting  Malmö, Sweden.Population  A total of 390 white north European women aged 48 years at the start of the study.Methods  At baseline, bone mineral density (BMD) was measured by single-photon absorptiometry (SPA) in the distal forearm and menopausal status was noted. Menopause was determined according to the World Health Organization criterion of a minimum of 12 months of continuous amenorrhoea. Women were divided into early menopause (occurring before age 47 years) and late menopause (occurring at age 47 years or later). At age 77, forearm BMD was re-measured by SPA and proximal femur and lumbar spine BMD were measured by dual-energy X-ray absorptiometry (DXA). The prevalence of osteoporosis was determined using the DXA data. Mortality rate and the incidence of fractures were registered up until age 82. Data are presented as means with 95% confidence intervals (95% CI).Main outcome measures  Incidence of fragility fractures, mortality, prevalence of osteoporosis at age 77.Results  Women with early menopause had a risk ratio of 1.83 (95% CI 1.22–2.74) for osteoporosis at age 77, a risk ratio of 1.68 (95% CI 1.05–2.57) for fragility fracture and a mortality risk of 1.59 (95% CI 1.04–2.36).Conclusions  Menopause before age 47 is associated with increased mortality risk and increased risk of sustaining fragility fractures and of osteoporosis at age 77.
20. Prediction of spontaneous preterm delivery in women with threatened preterm labour: a prospective cohort study of multiple proteins in maternal serum
    Please cite this paper as: Tsiartas P, Holst R, Wennerholm U, Hagberg H, Hougaard D, Skogstrand K, Pearce B, Thorsen P, Kacerovsky M, Jacobsson B. Prediction of spontaneous preterm delivery in women with threatened preterm labour: a prospective cohort study of multiple proteins in maternal serum. BJOG 2012;119:866–873.Objective  To analyse whether specific proteins in maternal serum and cervical length, alone or in combination, can predict the likelihood that women with intact membranes with threatened preterm labour will deliver spontaneously within 7 days of sampling.Design  Cohort study.Setting  Sahlgrenska University Hospital, Gothenburg, Sweden.Population  Women at between 22 and 33 weeks of gestation with threatened preterm labour (n = 142) admitted to the Sahlgrenska University Hospital, Gothenburg, Sweden, in 1995–2005.Methods  Maternal serum was tested for 27 proteins using multiplex xMAP technology. Individual levels of each protein were compared, and calculations were performed to investigate potential associations between different proteins, cervical length and spontaneous preterm delivery. Receiver operating characteristic curves were used to find the best cut-off values for continuous variables in relation to spontaneous preterm delivery within 7 days of sampling. Prediction models were created based on a stepwise logistic regression using binary variables.Main outcome measure  Spontaneous preterm delivery within 7 days.Results  In order to determine the best prediction model, we analysed models of serum proteins alone, cervical length alone, and the combination of serum proteins and cervical length. We found one multivariable combined model through the data analysis that more accurately predicted spontaneous preterm delivery within 7 days. This model was based on serum interleukin-10 (IL-10) levels, serum RANTES levels and cervical length (sensitivity 74%, specificity 87%, positive predictive value 76%, negative predictive value 86%, likelihood ratio 5.8 and area under the curve 0.88).Conclusions  A combination of maternal serum proteins and cervical length constituted the best prediction model, and would help determine whether women with threatened preterm labour are likely to deliver within 7 days of measurement.
21. The usefulness of HbA1c in postpartum reclassification of gestational diabetes
    Please cite this paper as: Megia A, Näf S, Herranz L, Serrat N, Yañez R, Simón I, Vendrell J. The usefulness of HbA1c in postpartum reclassification of gestational diabetes. BJOG 2012;119:891–894.To investigate the role of HbA1c in postpartum reclassification of gestational diabetes (GDM) we studied 364 women with GDM attending the postpartum reclassification assessment of their glucose tolerance status. A 75-g oral glucose tolerance test (OGTT) was performed and HbA1c was determined. Diabetes was diagnosed in 12 (3.3%), 7 (1.9%) and 2 (0.6%) women according to the fasting plasma glucose (FPG) and/or the 2-hour OGTT, the FPG alone and HbA1c levels, respectively. The sensitivity and specificity for HbA1c to diagnose diabetes was 16.7% and 100%, respectively, for FPG and OGTT criteria. The combination of a cutoff value of 5.5% for HbA1c and FPG allowed us to identify 95.1% of women with any kind of glucose intolerance. We conclude that in the early postpartum period, the cutoff of 6.5% for HbA1c alone has low sensitivity for the diagnosis of diabetes compared with OGTT, but the combination of FPG and HbA1c at a lower cutoff value is very useful to identify women with any kind of glucose intolerance.
22. Amniotic fluid embolism: incidence, risk factors, and impact on perinatal outcome
    Please cite this paper as: Kramer M, Rouleau J, Liu S, Bartholomew S, Joseph K for the Maternal Health Study Group of the Canadian Perinatal Surveillance System. Amniotic fluid embolism: incidence, risk factors, and impact on perinatal outcome. BJOG 2012;119:874–879.Objective  To extend our previous work on AFE in Canada by including stricter criteria for case identification and by examining risks for stillbirth, neonatal mortality and serious maternal and neonatal morbidity.Design  Population-based cohort study.Setting  Canada.Population or sample  In all, 4 508 462 hospital deliveries from fiscal year 1991/92 to 2008/09.Methods  To reduce false-positive diagnoses, we restricted our analysis to AFE cases with cardiac arrest, shock or severe hypertension, respiratory distress, mechanical ventilation, coma, seizure, or coagulation disorder. Linkage of maternal and neonatal records, available since 2001/02, enabled us to examine the effects of AFE on neonatal outcomes. Detailed demographic and clinical data facilitated control for a broad array of potential confounding variables.Main outcome measures  Amniotic fluid embolism, in-hospital neonatal death, asphyxia, mechanical ventilation, bacterial sepsis, seizure, nonimmune haemolytic or traumatic jaundice and length of hospital stay.Results  A total of 292 AFE cases were identified, of which only 120 (40%) were confirmed after applying our additional diagnostic criteria, yielding an AFE incidence of 2.5 per 100 000 deliveries. Of the 120 confirmed cases, 33 (27%) were fatal. Significant modifiable risk factors included medical induction, caesarean delivery, instrumental vaginal delivery, and uterine or cervical trauma. Amniotic fluid embolism was associated with significantly increased risks of stillbirth and neonatal asphyxia, mechanical ventilation, sepsis, seizures and prolonged length of hospital stay.Conclusions  Amniotic fluid embolism remains a rare but serious obstetric outcome, with several important modifiable risk factors and major implications for maternal, fetal and neonatal health.
23. Breast cancer metastasising to the pelvis and abdomen: what the gynaecologist needs to know
    Please cite this paper as: Moore EK, Roylance R, Rosenthal AN. Breast cancer metastasising to the pelvis and abdomen: what the gynaecologist needs to know. BJOG 2012;119:788–794.A small proportion of breast cancers metastasise within the peritoneal cavity. With increasing breast cancer incidence rates, gynaecologists and oncologists will encounter such women more frequently. Most women with intraperitoneal breast cancer are premenopausal. Although data are limited and are likely to be subject to selection bias, the median survival of women undergoing resection appears superior to those not undergoing surgery. Furthermore, survival is broadly similar to that for women undergoing advanced ovarian cancer surgery, particularly when tumour debulking is optimal. Obtaining data via randomised trials is unlikely to be feasible and therefore we recommend prospective data collection via the establishment of an international intraperitoneal breast cancer patient registry. For individual women where survival is anticipated to be more than a few months, we suggest considering referral to a gynaecological oncology team for discussion of surgical options.
24. Evaluation of selection criteria for validating paired umbilical cord blood gas samples: an observational study
    Please cite this paper as: White C, Doherty D, Kohan R, Newnham J, Pennell C. Evaluation of selection criteria for validating paired umbilical cord blood gas samples: an observational study. BJOG 2012;119:857–865.Objective  To compare six validation criteria for umbilical cord blood gas (UCBG) values in vigorous and nonvigorous neonates.Design  Retrospective cohort study.Setting  Single tertiary obstetric centre, King Edward Memorial Hospital (KEMH), Perth, Western Australia.Sample  A total of 37 763 consecutive deliveries at >23 weeks of gestation.Methods  Six validation criteria were compared to evaluate the proportion of deliveries with ‘valid’ UCBG data; and the proportion of vigorous and nonvigorous neonates with metabolic acidaemia.Main outcomes  Proportion of deliveries with ‘valid’ UCBG values; proportions of vigorous and nonvigorous neonates with normal, borderline and abnormal UCBG values.Results  The criteria based on KEMH 5th centile arteriovenous pH and Pco2 differences resulted in a higher proportion of neonates with ‘valid’ UCBG values than the previously described Westgate and Kro criteria. The increase in ‘valid’ UCBG values occurred across the entire study population including vigorous and nonvigorous neonates. Among neonates with short-term neonatal complications there was an increase in nonvigorous neonates with umbilical artery metabolic acidaemia. There was no corresponding increase in vigorous neonates diagnosed with abnormal UCBG values.Conclusions  Use of the KEMH criteria results in an increase in the proportion of nonvigorous term neonates with UCBG data considered ‘valid’ to aid clinicians in the management of the neonate shortly after delivery. This change occurs without increasing the rate of false-positive diagnoses of acidaemia in vigorous neonates. The KEMH ‘validation’ criteria were developed from an entire presenting population and provide a simple algorithm that can be universally applied to identify neonates with nonphysiological UCBG values.
25. Maternal and pathological pregnancy characteristics in customised birthweight centiles and identification of at-risk small-for-gestational-age infants: a retrospective cohort study
    Please cite this paper as: Anderson N, Sadler L, Stewart A, McCowan LE. Maternal and pathological pregnancy characteristics in customised birthweight centiles and identification of at-risk small-for-gestational-age infants: a retrospective cohort study. BJOG 2012;119:848–856.Objective  To regenerate coefficients for the New Zealand customised birthweight centile calculator using an updated birth cohort, and compare the identification of at-risk small-for-gestational-age (SGA) infants between full customisation (including maternal characteristics) and an ultrasound-based fetal weight and infant gender partial customisation.Design  Retrospective cohort study of prospectively collected maternity data.Setting  National Women’s Health Auckland, New Zealand.Population  Singleton pregnancies in the period 2006–2009; n = 24 176.Methods  Multiple linear regression analysis was performed for full customisation (adjusted for gestation, infant gender, maternal characteristics and pathological variables) and ultrasound-and-gender customisation (adjusted for gestation and infant gender).Main outcome measures  Risks of SGA-related perinatal death were compared between models.Results  Changes occurred in some ethnicity coefficients, including Chinese (−135 g), Tongan (−101 g) and Samoan (−89 g), and ten ethnicities were added. Overall, full customisation identified SGA infants with higher odds of perinatal death (OR 5.6, 95% CI 3.6–8.7) than infants classed as SGA by ultrasound-and-gender customisation (OR 2.1, 95% CI 1.4–3.3) (P = 0.02). In subgroup analyses, infants classed as SGA by full but not ultrasound-and-gender customisation (n = 888, 3.4%) had an increased risk of perinatal death (RR 4.7, 95% CI 2.7–7.9); however, those identified as SGA by ultrasound-and-gender customisation alone were not at an increased risk (n = 676, 2.6%, RR 1.1, 95% CI 0.4–3.6). The population attributable risk (PAR) of SGA-related perinatal death was higher for full (49.8%) than for ultrasound-and-gender (43.0%) customisation.Conclusions  Updating the New Zealand customised birthweight centile calculator resulted in revised coefficients that better reflect a contemporary birth cohort. Inclusion of maternal characteristics in a birthweight customisation model increases the detection of SGA infants at risk of perinatal death.
26. Prediction of recurrence of hypertensive disorders of pregnancy between 34 and 37 weeks of gestation: a retrospective cohort study
    Please cite this paper as: van Oostwaard M, Langenveld J, Bijloo R, Wong K, Scholten I, Loix S, Hukkelhoven C, Vergouwe Y, Papatsonis D, Mol B, Ganzevoort W. Prediction of recurrence of hypertensive disorders of pregnancy between 34 and 37 weeks of gestation: a retrospective cohort study. BJOG 2012;119:840–847.Objective  To assess the recurrence risk of late-preterm hypertensive disease of pregnancy, and to determine whether potential risk factors are predictive.Design  Retrospective cohort study.Setting  Three secondary and three tertiary care hospitals in the Netherlands.Population  We identified women with a hypertensive disorder in the index pregnancy and delivery at 34–37 weeks of gestation, between January 2000 and December 2002.Methods  Data were extracted from medical files and women were approached for additional information on subsequent pregnancies. An adverse outcome was defined as the recurrence of a hypertensive disorder in the next subsequent pregnancy.Main outcome measures  Absolute risk of recurrence and a prediction model containing demographic and clinical factors predictive for adverse outcome.Results  We identified 425 women who matched the criteria, of whom 351 could be contacted. Of these women, 189 (54%) had had a subsequent pregnancy. Hypertensive disorders recurred in 96 (51%, 95% CI 43–58%) women, of whom 17 (9%, 95% CI 5–14%) delivered again before 37 weeks of gestation. Chronic hypertension and maternal age were the strongest predictors for recurrence. Women undergoing recurrence had a nine-fold chance of developing chronic hypertension (37% versus 6%, OR 8.7, 95% CI 3.3–23).Conclusions  Women with hypertensive disorders and late-preterm delivery have a 50% chance of recurrence, but only a 9% chance of recurrence resulting in delivery before 37 weeks of gestation. Women with chronic hypertension are prone to develop recurrence, and women with a recurrence more often developed chronic hypertension.
27. Longitudinal vitamin D status in pregnancy and the risk of pre-eclampsia
    Please cite this paper as: Dr Wei SQ, Audibert F, Hidiroglou N, Sarafin K, Julien P, Wu Y, Luo ZC, Fraser WD. Longitudinal vitamin D status in pregnancy and the risk of pre-eclampsia. BJOG 2012;119:832–839.Objective  Whether vitamin D deficiency in pregnancy is a cause of pre-eclampsia remains controversial. Most previous studies to date have assessed exposure at only one time-point in pregnancy. We assessed longitudinal vitamin D status during pregnancy and the risk of pre-eclampsia.Design  Prospective cohort study.Setting  Seventeen urban obstetric hospitals, Canada.Population  Pregnant women who were participants in a trial of vitamin C and E supplementation for the prevention of pre-eclampsia. Canadian participants who consented to participate in a biobank with plasma specimens available at the baseline visit were included (n = 697).Methods  Maternal plasma 25-hydroxyvitamin D (25(OH)D) concentrations were measured at 12–18 and 24–26 weeks of gestation using chemiluminescence immunoassay.Main outcome measures  Pre-eclampsia.Results  Of the women, 39% were vitamin D deficient (25(OH)D <50 nmol/l). A strong positive correlation was observed in maternal 25(OH)D concentrations between the two gestational age windows (r = 0.69, P < 0.0001). Mean maternal 25(OH)D concentrations at 24–26 weeks of gestation were significantly lower in women who subsequently developed pre-eclampsia compared with those who did not (mean ± SD: 48.9 ± 16.8 versus 57.0 ± 19.1 nmol/l, P = 0.03). Women with 25(OH)D < 50 nmol/l at 24–26 weeks gestation experienced an increased risk of pre-eclampsia (adjusted odds ratio 3.24, 95% confidence interval 1.37–7.69), whereas the association was not statistically significant for maternal 25(OH)D level at 12–18 weeks of gestation.Conclusions  Lower maternal 25(OH)D levels at late mid-trimester were associated with an increased risk of pre-eclampsia.
28. Accuracy of circulating placental growth factor, vascular endothelial growth factor, soluble fms-like tyrosine kinase 1 and soluble endoglin in the prediction of pre-eclampsia: a systematic review and meta-analysis
    Please cite this paper as: Kleinrouweler C, Wiegerinck M, Ris-Stalpers C, Bossuyt P, van der Post J, von Dadelszen P, Mol B, Pajkrt E, for the EBM CONNECT Collaboration. Accuracy of circulating placental growth factor, vascular endothelial growth factor, soluble fms-like tyrosine kinase 1 and soluble endoglin in the prediction of pre-eclampsia: a systematic review and meta-analysis. BJOG 2012;119:778–787.Background  Biomarkers have been proposed for identification of women at increased risk of developing pre-eclampsia.Objectives  To investigate the capacity of circulating placental growth factor (PlGF), vascular endothelial growth factor (VEGF), soluble fms-like tyrosine kinase-1 (sFLT1) and soluble endoglin (sENG) to predict pre-eclampsia.Search strategy  Medline and Embase through October 2010 and reference lists of reviews, without constraints.Selection criteria  We included original publications on testing of PlGF, VEGF, sFLT1 and sENG in serum or plasma of pregnant women at <30 weeks of gestation and before clinical onset of pre-eclampsia.Data collection and analysis  Two reviewers independently identified eligible studies, extracted descriptive and test accuracy data and assessed methodological quality. Summary estimates of discriminatory performance were obtained.Main results  We included 34 studies. Concentrations of PlGF (27 studies) and VEGF (three studies) were lower in women who developed pre-eclampsia: standardised mean differences (SMD) −0.56 (95% CI −0.77 to −0.35) and −1.25 (95% CI −2.73 to 0.23). Concentrations of sFLT1 (19 studies) and sENG (ten studies) were higher: SMD 0.48 (95% CI 0.21–0.75) and SMD 0.54 (95% CI 0.24–0.84). The summary diagnostic odds ratios were: PlGF 9.0 (95% CI 5.6–14.5), sFLT1 6.6 (95% CI 3.1–13.7), sENG 4.2 (95% CI 2.4–7.2), which correspond to sensitivities of 32%, 26% and 18%, respectively, for a 5% false-positive rate.Author’s conclusions  PlGF, sFLT1 and sENG showed modest but significantly different concentrations before 30 weeks of gestation in women who developed pre-eclampsia. Test accuracies of all four markers, however, are too poor for accurate prediction of pre-eclampsia in clinical practice.
29. Acceptability of misoprostol-only medical termination of pregnancy compared with vacuum aspiration: an international, multicentre trial
    Please cite this paper as: Rodriguez M, Seuc A, Kapp N, von Hertzen H, Huong N, Wojdyla D, Mittal S, Arustamyan K, Shah R, the World Health Organization Research Group on Post-Ovulatory Methods of Fertility Regulation. Acceptability of misoprostol-only medical termination of pregnancy compared with vacuum aspiration: an international, multicentre trial. BJOG 2012;119:817–823.Objective  To compare women’s acceptance of misoprostol-only medical termination of pregnancy (TOP) with surgical TOP.Design  Prospective cohort study.Setting  Termination of pregnancy clinics in New Delhi, Mumbai, Hanoi, Tbilisi, Trivandrum and Yerevan.Population  Women requesting TOP, at 63 days of gestation or less, at study sites where both medical and surgical methods were available.Methods  Serial surveys eliciting measures of women’s satisfaction and acceptance of TOP method were administered. Data were analysed using cross-tabulation and logistic regression to determine if TOP method was predictive of acceptability.Main outcome measures  Patient acceptance.Results  High acceptability of both surgical and misoprostol-only TOP.Conclusions  Where medical TOP with mifepristone is not available, misoprostol-only medical TOP is acceptable to women who have the choice between medical or surgical techniques.
30. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery
    Please cite this paper as: Gyhagen M, Bullarbo M, Nielsen T, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03301.x.Objective  To investigate the prevalence and risk factors for urinary incontinence (UI) 20 years after one vaginal delivery or one caesarean section.Design  Registry-based national cohort study.Setting  Women who returned postal questionnaires (response rate 65.2%) in 2008.Population  Singleton primiparae who delivered in the period 1985–1988 with no further births (n = 5236).Methods  The Swedish Pregnancy, Obesity and Pelvic Floor (SWEPOP) study linked Medical Birth Register (MBR) data to a questionnaire about UI.Main outcome measures  Prevalence of UI and UI for more than 10 years (UI > 10 years) were assessed 20 years after childbirth.Results  The prevalence of UI (40.3 versus 28.8%; OR 1.67; 95% CI 1.45–1.92) and UI > 10 years (10.1 versus 3.9%; OR 2.75; 95% CI 2.02–3.75) was higher in women after vaginal delivery than after caesarean section. There was no difference in the prevalence of UI or UI > 10 years after an acute caesarean section or an elective caesarean section. We found an 8% increased risk of UI per current body mass index (BMI) unit, and age at delivery increased the UI risk by 3% annually.Conclusions  Two decades after one birth, vaginal delivery was associated with a 67% increased risk of UI, and UI > 10 years increased by 275% compared with caesarean section. Our data indicate that it is necessary to perform eight or nine caesarean sections to avoid one case of UI. Weight control is an important prophylactic measure to reduce UI. Current BMI was the most important BMI-determinant for UI, which is important, as BMI is modifiable.
31. Complications of hysteroscopic Essure® sterilisation: report on 4306 procedures performed in a single centre
    Please cite this paper as: Povedano B, Arjona J, Velasco E, Monserrat J, Lorente J, Castelo-Branco C. Complications of hysteroscopic Essure® sterilisation: report on 4306 procedures performed in a single centre. BJOG 2012;119:795–799.Objective  To analyse the short-, medium- and long-term complications in women undergoing hysteroscopic tubal sterilisation with the Essure® device.Design  Retrospective 7-year study.Setting  Office hysteroscopic unit in a teaching hospital.Sample  A total of 4306 women whoe underwent the Essure® sterilisation procedure from 2003 to 2010.Methods  Data on the success of the procedure and complications arising from outpatient hysteroscopic sterilisation using the Essure® system were collected from consecutive women undergoing the procedure over a 7-year period.Main outcome measures  Placement rate, successful bilateral tubal occlusion, perioperative adverse events, early postoperative (during the first 3 months of follow-up) and late complications (after the initial 3 months of follow-up).Results  A total of 4108 (96.8%) women completed the standard 3-month follow-up protocol. Only 534 (13%) women had undergone the procedure within the previous year. There were 115 (out of 4306; 2.7%) recorded complications, none of which resulted in the need for hospitalisation or discharge later than 2 hours after the procedure. Vasovagal syncope was the most frequently encountered adverse event, occurring in 85 (2.0%) of 4306 cases. In 19 cases, one device was expelled, with most expulsions (14 out of 19) being detected before or during the 3-month follow-up.Conclusions  Outpatient hysteroscopic sterilisation using the Essure® system is safe, with a low rate of complications.
32. Corrigendum