Patient acceptance of transvaginal sonographic endometrial thickness assessment compared with hysteroscopy and biopsy for exclusion of endometrial cancer in cases of postmenopausal bleeding

INTRODUCTION

Available examinations for women with postmenopausal bleeding include transvaginal sonography to measure endometrial thickness (TVS-ET), and invasive endometrial assessment using hysteroscopy/endometrial biopsy. However, selection of the examination method seldom involves consideration of patient preferences. The aim of this study was to examine patient preferences for the method used to investigate postmenopausal bleeding.

METHODS

Women were asked to complete an interviewer-administered structured survey before they underwent clinical investigations at a university gynaecology unit from June 2016 to June 2017. Using the standard gamble approach, women were asked to choose between invasive assessment by hysteroscopy/endometrial biopsy (gold standard) or TVS-ET with a risk of missing endometrial cancer. The risk of missing endometrial cancer during TVS-ET was varied until each woman was indifferent to either option.

RESULTS

The median detection rate for endometrial cancer required using TVS-ET was 95% (interquartile range=80%-99.9%). In total, 200 women completed the survey, and 77 (38.5%) women required TVS-ET to have a 99.9% detection rate for endometrial cancer. Prior hysteroscopy experience was the only factor that influenced the women's decisions: a significantly higher detection rate was required by this patient group than by patients without previous hysteroscopy experience (P=0.047).

CONCLUSION

A substantial proportion of women would accept TVS-ET alone for the investigation of postmenopausal bleeding. In the era of patientcentred care, clinicians should incorporate patient preferences and enable women to make informed choices concerning the management of postmenopausal bleeding.

Effectiveness of a childbirth massage programme for labour pain relief in nulliparous pregnant women at term: a randomised controlled trial

INTRODUCTION

The effect of massage for pain relief during labour has been controversial. This study investigated the efficacy of a programme combining intrapartum massage, controlled breathing, and visualisation for non-pharmacological pain relief during labour.

METHODS

This randomised controlled trial was conducted in two public hospitals in Hong Kong. Participants were healthy low-risk nulliparous Chinese women ≥18 years old whose partners were available to learn massage technique. Recruitment was performed at 32 to 36 weeks of gestation; women were randomised to attend a 2-hour childbirth massage class at 36 weeks of gestation or to receive usual care. The primary outcome variable was the intrapartum use of epidural analgesia or intramuscular pethidine injection.

RESULTS

In total, 233 and 246 women were randomised to the massage and control groups, respectively. The use of epidural analgesia or pethidine did not differ between the massage and control groups (12.0% vs 15.9%; P=0.226). Linear-by-linear analysis demonstrated a trend whereby fewer women used strong pharmacological pain relief in the massage group, and a greater proportion of women had analgesic-free labour (29.2% vs 21.5%; P=0.041). Cervical dilatation at the time of pethidine/epidural analgesia request was significantly greater in the massage group (3.8 ± 1.7 cm vs 2.3 ± 1.0 cm; P<0.001).

CONCLUSION

The use of a massage programme appeared to modulate pain perception in labouring women, such that fewer women requested epidural analgesia and a shift was observed towards the use of weaker pain relief modalities; in particular, more women in the massage group were analgesic-free during labour.

External validation of a simple scoring system to predict pregnancy viability in women presenting to an early pregnancy assessment clinic

INTRODUCTION

A scoring system combining clinical history and simple ultrasound parameters was developed to predict early pregnancy viability beyond the first trimester. The scoring system has not yet been externally validated. This study aimed to externally validate this scoring system to predict ongoing pregnancy viability beyond the first trimester.

METHODS

This prospective observational cohort study enrolled women with singleton intrauterine pregnancies before 12 weeks of gestation. Women underwent examination and ultrasound scan to assess gestational sac size, yolk sac size, and fetal pulsation status. A pregnancy-specific viability score was derived in accordance with the Bottomley score. Pregnancy outcomes at 13 to 16 weeks were documented. Receiver-operating characteristic curve analysis was used to assess the discriminatory performance of the scoring system.

RESULTS

In total, 1508 women were enrolled; 1271 were eligible for analysis. After adjustment for covariates, miscarriage (13%) was significantly associated with age ≥35 years (odds ratio [OR]=1.99, 95% confidence interval [CI]: 1.19-3.34), higher bleeding score (OR=2.34, 95% CI: 1.25-4.38), gestational age (OR=1.17, 95% CI: 1.13-1.22), absence of yolk sac (OR=4.73, 95% CI: 2.11-10.62), absence of fetal heart pulsation (OR=3.57, 95% CI: 1.87-6.84), mean yolk sac size (OR=1.25, 95% CI: 1.06-1.47), and fetal size (OR=0.82, 95% CI: 0.77-0.88). The area under the receiver operating characteristic curve was 0.91 (95% CI: 0.89-0.93). Viability score of ≥1 corresponded to a >90% probability of viable pregnancy.

CONCLUSIONS

The scoring system was easy to use. A score of ≥1 could be used to counsel women who have a high likelihood of viable pregnancy beyond the first trimester.

Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study

OBJECTIVE

To estimate the accuracy of transvaginal ultrasound (TVS) measurement of endometrial thickness (ET) in diagnosing endometrial cancer in postmenopausal women with vaginal bleeding (PMB).

DESIGN

Retrospective cohort study.

SETTING

One-stop PMB clinic in a Hong Kong teaching hospital.

POPULATION

A cohort of 4383 women with PMB.

METHODS

Transvaginal ultrasonic measurement of ET and endometrial biopsies were obtained in women presenting with PMB between 2002 and 2013. Endometrial histology was used as the reference standard to calculate accuracy estimates.

MAIN OUTCOME MEASURES

Accuracy data for TVS ET presented as sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve.

RESULTS

Endometrial cancer was diagnosed in 3.8% of women. The median ET in those with endometrial cancer was significantly higher than those with benign conditions (15.7 versus 3.2 mm, P < 0.001). The area under the ROC curve was 0.92 (95% CI 0.89-0.94). The sensitivity for the detection of endometrial cancer at 3-, 4-, and 5-mm cut-offs were 97.0% (95% CI 94.5-99.6%), 94.1% (95% CI 90.5-97.6%), and 93.5% (95% CI 89.7-97.2%), respectively. The corresponding estimates of specificity at these thresholds were 45.3% (95% CI 43.8-46.8%), 66.8% (65.4-68.2%), and 74.0% (72.7-75.4%).

CONCLUSIONS

Transvaginal ultrasound using a 3-mm cut-off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy.

Early third trimester maternal response to glucose challenge and pregnancy outcome in Chinese women-relationship between upper distribution level and recommended diagnostic criteria

BACKGROUND/OBJECTIVES

The objective of this study was to examine the relationship between upper distribution levels of glucose values in the 75-g oral glucose tolerance test (OGTT) and recommended diagnostic criteria for gestational diabetes mellitus (GDM) and adverse pregnancy outcomes.

SUBJECTS/METHODS

The distribution of the OGTT 2-h values of 13,501 pregnant women, which were below the World Health Organization (WHO) threshold for overt diabetes mellitus (DM), and managed in one teaching hospital in China, was reviewed and related to maternal characteristics and pregnancy outcomes.

RESULTS

For the entire group, the 90th and 95th percentile values of the OGTT 2-h glucose level, respectively, were close to the diagnostic cutoff values of the WHO and International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. For adverse maternal outcomes, glucose level above the 90th percentile value was associated with increased hypertensive disorders, whereas no difference was seen with cutoff using the 95th percentile value. For perinatal outcomes, the 90th percentile was associated with increased neonatal intensive care unit admission and hypoglycemia, whereas the 95th percentile showed in addition association with phototherapy for jaundice and 5th-minute Apgar score <7. Although no differences in the incidence of adverse pregnancy outcomes were found using the different cutoffs, the >95th percentile cutoff value would have missed out 33.3-56.7% of the cases of adverse outcomes that would otherwise have been attributed to GDM.

CONCLUSIONS

Further studies are warranted to clarify which diagnostic criterion is most appropriate universally to identify adverse pregnancy outcomes attributed to GDM, and which could be mitigated with treatment specific for GDM.

Diabetes and pregnancy: perspectives from Asia

There has been a marked increase in the prevalence of diabetes in Asia over recent years. Diabetes complicating pregnancy, in particular gestational diabetes, has also increased markedly in the region. Multi-ethnic studies have highlighted the increased risk of gestational diabetes mellitus among the different Asian populations. Prevalence of gestational diabetes in Asian countries varies substantially according to the screening strategy and diagnostic criteria applied, and ranges from 1% to 20%, with evidence of an increasing trend over recent years. The International Association for Diabetes in Pregnancy Study group criteria have been adopted by some Asian countries, although they present significant challenges in implementation, especially in low-resource settings. Studies on offspring of mothers with gestational diabetes have reported adverse cardiometabolic profiles and increased risk of diabetes and obesity. Gestational diabetes is likely to be a significant factor contributing to the epidemic of diabetes and other non-communicable diseases in the Asian region. In recognition of this, several large-scale prevention and intervention programmes are currently being implemented in different Asian countries in order to improve glucose control during pregnancy, as well as overall maternal health. Lessons emerging from gestational diabetes studies in Asia may help inform and provide insights on the overall burden and treatment strategies to target gestational diabetes, with the ultimate aim to reduce its adverse short- and long-term consequences.

PP103. Arterial stiffness in women with previous GDM - A follow up of Chinese HAPO study cohort

INTRODUCTION

It is well known that women with history of gestational diabetes (GDM) are at risk of future DM. Whether they are at a higher risk of hypertension and cardiovascular risk remained to be determined.

OBJECTIVES

To determine whether Chinese women who have been diagnosed GDM according to the new IADPSG criteria have a higher risk of hypertension & arterial stiffness than women with normal glucose tolerance (NGT) during pregnancy.

METHODS

Chinese women who had participated in the HAPO study between 2001 and 2006 in Hong Kong were followed up at a median of 6years postpartum. All underwent anthropometric & BP measurements. Central systolic and diastolic blood pressures (SBP & DBP), augmentation index (AI) and pulse wave velocity (PWV) were assessed by using SphygmoCor(®) PVx.A total of 608 women (494 NGT, 114 GDM) were followed up till early 2012.

RESULTS

Although there was no significant difference in the rate of hypertension, the central SBP (106±12 vs 102±13mmHg, p=0.03), AI (22.1±8.3 vs 18.9±8.5%, p<0.001) and PWV (6.8±1.0 vs 6.6±0.8, p=0.03) were all higher in women with history of GDM.

CONCLUSION

The findings suggest a higher risk of subclinical atherosclerosis amongst women with GDM despite the blood pressure may appear normal at the time of follow up.

Chronic hepatitis B virus infection and rubella susceptibility in pregnant women

Increased rubella susceptibility has been shown in subjects from the Asian-Pacific region where chronic hepatitis B virus (HBV) infection is endemic. This study was performed to explore the relationship between chronic HBV infection and rubella susceptibility in the obstetric population. We conducted a retrospective cohort study on 50556 pregnant women delivered in a university obstetric unit from January 1998 to June 2008. The incidence of rubella susceptibility according to maternal HBV carrier status was examined. HBV infection and rubella susceptibility were found in 5105 (10.1%) and 6102 (12.1%) women, respectively. Rubella susceptibility was more common in women with HBV (13.1%vs 12.0%, P = 0.017), even after adjusting for other confounding factors (odds ratio 1.11, 95% confidence interval 1.01-1.21). Advancing age was associated with progressively decreasing odds of rubella susceptibility, from 0.48 at age 20-24 years to 0.34 at age ≥ 40 years in women without HBV infection, but had no effect in women with hepatitis B. In conclusion, our study is the first to demonstrate an association between chronic HBV infection with rubella susceptibility. Further studies are warranted to confirm whether chronic HBV infection, especially that acquired by vertical transmission, may impair the immune response to rubella vaccine or natural infection throughout the reproductive age.