Appendectomy during pregnancy: rates, safety, and outcomes over a five-year period. A hospital-based follow-up study

INTRODUCTION

Appendicitis is the most common acute abdominal complication during pregnancy. If appendix perforation occurs there is an increasing risk of preterm delivery and other pregnancy complications.

OBJECTIVE

To assess the outcome of pregnancy after appendectomy, the mode of surgery used, appendectomy rates, and complications.

METHODS

A prospective cohort study of pregnant women with, or without, appendectomy at South Stockholm General Hospital, December 2015 to February 2021 in a setting where pregnant women are prioritized for surgery and laparoscopic surgery was standard of care in first half of pregnancy. Data on preoperative imaging, surgical method, intraoperative findings, microscopic findings, hospital stay, pregnancy, and 30-day complications were prospectively recorded in a local appendectomy register. A non-pregnant control group was gathered comprising women of fertile age in the same study interval.

RESULTS

During the study period 50 pregnant women, of whom 44 gave birth, underwent appendectomy of 38 199 women giving birth. There were no differences between women with or without appendectomy in proportion of preterm delivery (4.5% vs. 5.6%), small-for-gestational age (2.3% vs. 6.2%), or Cesarean delivery (18.2% vs. 20.4%). The rate of appendix perforation was 19% in non-pregnant control group compared to 12% among pregnancy. There was no case of perforated appendix in the second half of pregnancy. However, women with gestational age > 20 weeks more frequently had an unaffected appendix compared to those operated ≤ 20 gestational weeks (4/11 vs. 2/39, p = .005). Laparoscopic surgery was used in 97% of non-pregnant control group, 92% of appendectomies ≤ 20 weeks gestation, and in 27% >20 weeks. As compared to first half, the appendectomy rate was three times lower during the second half of pregnancy. Pregnant women had priority for surgery < 6 h compared to < 24 h among non-pregnant women, this resulted in a shorter time-to-surgery among pregnant women (p < .001).

CONCLUSION

Routine laparoscopic surgery and time priority for pregnant surgery is associated with a low risk of perforation, preterm birth and other complications. However, a low threshold for surgery may increase the risk of a negative exploration.

Combination of Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) with sonographic and demographic characteristics in preoperative prediction of recurrence or progression of endometrial cancer

OBJECTIVE

To evaluate the ability of demographic and sonographic variables and the Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) classification to predict preoperatively tumor recurrence or progression in women with endometrial cancer.

METHODS

The study included 339 women with histologically confirmed endometrial cancer who underwent expert transvaginal ultrasound in a single center before surgery as part of the prospective International Endometrial Tumor Analysis 4 study or who were evaluated using the same protocol. The tumors were classified according to histotype, FIGO (International Federation of Gynecology and Obstetrics) grade and FIGO stage. In addition, molecular analysis was performed for classification into the four ProMisE subtypes: polymerase-ϵ exonuclease domain mutations (POLE EDM), mismatch repair proteins deficiency (MMR-D), protein 53 wild type (p53 wt) and protein 53 abnormal (p53 abn). Demographic and preoperative sonographic characteristics, tumor recurrence or progression and survival were compared between the ProMisE subgroups. Cox regression analysis was used to identify prognostic factors associated with recurrence or progression, using univariable models to study crude associations and multivariable models to study adjusted associations. Logistic regression and receiver-operating-characteristics (ROC)-curve analysis were used to assess the predictive ability of the preoperative prognostic factors regarding recurrence or progression of cancer within 3 years after surgery, and to compare their predictive ability to that of the European Society for Medical Oncology (ESMO) preoperative (based on depth of myometrial invasion, histotype and grade) and postoperative (based on histotype, grade, surgical stage and lymphovascular space invasion) risk classifications. In a separate subanalysis, cases were stratified according to ProMisE p53 abn status (present vs absent) and sonographic tumor size (anteroposterior (AP) diameter < 2 cm vs ≥ 2 cm).

RESULTS

Median follow-up time from surgery was 58 months (interquartile range, 48-71 months; range, 0-102 months). Recurrence or progression of cancer occurred in 51/339 (15%) women, comprising 14% of those with MMR-D, 8% of those with POLE EDM, 9% of those with p53 wt and 45% of those with p53 abn ProMisE subtype. On multivariable analysis, age, waist circumference, ProMisE subtype and tumor extension and AP diameter on ultrasound were associated with tumor recurrence or progression. A multivariable model comprising ProMisE subtype, age, waist circumference and sonographic tumor extension and size (area under the ROC curve (AUC), 0.89 (95% CI, 0.85-0.93)) had comparable ability to predict tumor recurrence/progression to that of a multivariable model comprising histotype, grade, age, waist circumference and sonographic tumor extension and size (AUC, 0.88 (95% CI, 0.83-0.92)), and better predictive ability than both the preoperative (AUC, 0.74 (95% CI, 0.67-0.82); P < 0.01) and postoperative (AUC, 0.79 (95% CI, 0.72-0.86); P < 0.01) ESMO risk classifications. Women with a combination of non-p53 abn subtype and tumor size < 2 cm (164/339 (48%)) had a very low risk (1.8%) of tumor recurrence or progression.

CONCLUSIONS

The combination of demographic characteristics, sonographic findings and ProMisE subtype had better preoperative predictive ability for tumor recurrence or progression than did the ESMO classification, supporting their use in the preoperative risk stratification of women with endometrial cancer. The combination of p53 status with ultrasound tumor size has the potential to identify preoperatively a large group of women with a very low risk of recurrence or progression. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Ultrasound-based risk model for preoperative prediction of lymph-node metastases in women with endometrial cancer: model-development study

OBJECTIVE

To develop a preoperative risk model, using endometrial biopsy results and clinical and ultrasound variables, to predict the individual risk of lymph-node metastases in women with endometrial cancer.

METHODS

A mixed-effects logistic regression model for prediction of lymph-node metastases was developed in 1501 prospectively included women with endometrial cancer undergoing transvaginal ultrasound examination before surgery, from 16 European centers. Missing data, including missing lymph-node status, were imputed. Discrimination, calibration and clinical utility of the model were evaluated using leave-center-out cross validation. The predictive performance of the model was compared with that of risk classification from endometrial biopsy alone (high-risk defined as endometrioid cancer Grade 3/non-endometrioid cancer) or combined endometrial biopsy and ultrasound (high-risk defined as endometrioid cancer Grade 3/non-endometrioid cancer/deep myometrial invasion/cervical stromal invasion/extrauterine spread).

RESULTS

Lymphadenectomy was performed in 691 women, of whom 127 had lymph-node metastases. The model for prediction of lymph-node metastases included the predictors age, duration of abnormal bleeding, endometrial biopsy result, tumor extension and tumor size according to ultrasound and undefined tumor with an unmeasurable endometrium. The model's area under the curve was 0.73 (95% CI, 0.68-0.78), the calibration slope was 1.06 (95% CI, 0.79-1.34) and the calibration intercept was 0.06 (95% CI, -0.15 to 0.27). Using a risk threshold for lymph-node metastases of 5% compared with 20%, the model had, respectively, a sensitivity of 98% vs 48% and specificity of 11% vs 80%. The model had higher sensitivity and specificity than did classification as high-risk, according to endometrial biopsy alone (50% vs 35% and 80% vs 77%, respectively) or combined endometrial biopsy and ultrasound (80% vs 75% and 53% vs 52%, respectively). The model's clinical utility was higher than that of endometrial biopsy alone or combined endometrial biopsy and ultrasound at any given risk threshold.

CONCLUSIONS

Based on endometrial biopsy results and clinical and ultrasound characteristics, the individual risk of lymph-node metastases in women with endometrial cancer can be estimated reliably before surgery. The model is superior to risk classification by endometrial biopsy alone or in combination with ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Validation of ultrasound strategies to assess tumor extension and to predict high-risk endometrial cancer in women from the prospective IETA (International Endometrial Tumor Analysis)-4 cohort

OBJECTIVES

To compare the performance of ultrasound measurements and subjective ultrasound assessment (SA) in detecting deep myometrial invasion (MI) and cervical stromal invasion (CSI) in women with endometrial cancer, overall and according to whether they had low- or high-grade disease separately, and to validate published measurement cut-offs and prediction models to identify MI, CSI and high-risk disease (Grade-3 endometrioid or non-endometrioid cancer and/or deep MI and/or CSI).

METHODS

The study comprised 1538 patients with endometrial cancer from the International Endometrial Tumor Analysis (IETA)-4 prospective multicenter study, who underwent standardized expert transvaginal ultrasound examination. SA and ultrasound measurements were used to predict deep MI and CSI. We assessed the diagnostic accuracy of the tumor/uterine anteroposterior (AP) diameter ratio for detecting deep MI and that of the distance from the lower margin of the tumor to the outer cervical os (Dist-OCO) for detecting CSI. We also validated two two-step strategies for the prediction of high-risk cancer; in the first step, biopsy-confirmed Grade-3 endometrioid or mucinous or non-endometrioid cancers were classified as high-risk cancer, while the second step encompassed the application of a mathematical model to classify the remaining tumors. The 'subjective prediction model' included biopsy grade (Grade 1 vs Grade 2) and subjective assessment of deep MI or CSI (presence or absence) as variables, while the 'objective prediction model' included biopsy grade (Grade 1 vs Grade 2) and minimal tumor-free margin. The predictive performance of the two two-step strategies was compared with that of simply classifying patients as high risk if either deep MI or CSI was suspected based on SA or if biopsy showed Grade-3 endometrioid or mucinous or non-endometrioid histotype (i.e. combining SA with biopsy grade). Histological assessment from hysterectomy was considered the reference standard.

RESULTS

In 1275 patients with measurable lesions, the sensitivity and specificity of SA for detecting deep MI was 70% and 80%, respectively, in patients with a Grade-1 or -2 endometrioid or mucinous tumor vs 76% and 64% in patients with a Grade-3 endometrioid or mucinous or a non-endometrioid tumor. The corresponding values for the detection of CSI were 51% and 94% vs 50% and 91%. Tumor AP diameter and tumor/uterine AP diameter ratio showed the best performance for predicting deep MI (area under the receiver-operating characteristics curve (AUC) of 0.76 and 0.77, respectively), and Dist-OCO had the best performance for predicting CSI (AUC, 0.72). The proportion of patients classified correctly as having high-risk cancer was 80% when simply combining SA with biopsy grade vs 80% and 74% when using the subjective and objective two-step strategies, respectively. The subjective and objective models had an AUC of 0.76 and 0.75, respectively, when applied to Grade-1 and -2 endometrioid tumors.

CONCLUSIONS

In the hands of experienced ultrasound examiners, SA was superior to ultrasound measurements for the prediction of deep MI and CSI of endometrial cancer, especially in patients with a Grade-1 or -2 tumor. The mathematical models for the prediction of high-risk cancer performed as expected. The best strategies for predicting high-risk endometrial cancer were combining SA with biopsy grade and the subjective two-step strategy, both having an accuracy of 80%. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study

OBJECTIVE

International comparison of complete uterine rupture.

DESIGN

Descriptive multi-country population-based study.

SETTING

International.

POPULATION

International Network of Obstetric Survey Systems (INOSS).

METHODS

We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes.

MAIN OUTCOME MEASURES

Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality.

RESULTS

We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived.

CONCLUSIONS

Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.

Ultrasound characteristics of endometrial cancer as defined by International Endometrial Tumor Analysis (IETA) consensus nomenclature: prospective multicenter study

OBJECTIVE

To describe the sonographic features of endometrial cancer in relation to tumor stage, grade and histological type, using the International Endometrial Tumor Analysis (IETA) terminology.

METHODS

This was a prospective multicenter study of 1714 women with biopsy-confirmed endometrial cancer undergoing standardized transvaginal grayscale and Doppler ultrasound examination according to the IETA study protocol, by experienced ultrasound examiners using high-end ultrasound equipment. Clinical and sonographic data were entered into a web-based database. We assessed how strongly sonographic characteristics, according to IETA, were associated with outcome at hysterectomy, i.e. tumor stage, grade and histological type, using univariable logistic regression and the c-statistic.

RESULTS

In total, 1538 women were included in the final analysis. Median age was 65 (range, 27-98) years, median body mass index was 28.4 (range 16-67) kg/m² , 1377 (89.5%) women were postmenopausal and 1296 (84.3%) reported abnormal vaginal bleeding. Grayscale and color Doppler features varied according to grade and stage of tumor. High-risk tumors, compared with low-risk tumors, were less likely to have regular endometrial-myometrial junction (difference of -23%; 95% CI, -27 to -18%), were larger (mean endometrial thickness; difference of +9%; 95% CI, +8 to +11%), and were more likely to have non-uniform echogenicity (difference of +7%; 95% CI, +1 to +13%), a multiple, multifocal vessel pattern (difference of +21%; 95% CI, +16 to +26%) and a moderate or high color score (difference of +22%; 95% CI, +18 to +27%).

CONCLUSION

Grayscale and color Doppler sonographic features are associated with grade and stage of tumor, and differ between high- and low-risk endometrial cancer. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Low maternal circulating levels of vitamin D as potential determinant in the development of gestational diabetes mellitus

Gestational diabetes mellitus (GDM), defined as any glucose intolerance with the onset or first recognition during pregnancy, is characterized by rising incidence, fostered by the worldwide increase of pathological nutritional status from young age. Clinical research has intended to identify potential risk factors, suggested improvements in screening strategies, and recommended the combination between promotion of an appropriate lifestyle before and during pregnancy and selected therapeutic approaches. Preventing pathological hyperglycemia could have several benefits, ranging from clinical side (reduction in the risk of adverse perinatal and long-term sequelae) to financial side (cost reduction to healthcare systems). Among risk factors recognized, deficiency in 25-hydroxyvitamin D [25(OH)D], already acknowledged as involved in calcium homeostasis, pathogenesis of cardiovascular, oncological, infective and immunity diseases, could predispose to the development of both type 1 and 2 diabetes, modifying the activity of pancreatic β-cells vitamin D (VD) receptor. In pregnant women, lower 25(OH)D concentrations have been suggested to present an inverse association with maternal glycaemia, insulin resistance, and increased risk of GDM. In spite of growing body of evidence, there is not full agreement on the therapeutic association between GDM based on VD deficiency and 25(OH)D supplementation. In the attempt to bring up-to-date the role of low VD levels on subsequent development of GDM, this narrative review, based on medium-high-quality randomized clinical trials, systematic reviews, and meta-analysis published in last decade, has a twofold purpose: firstly, to elucidate the relationship between maternal VD status and GDM; and secondly, to illuminate the impact of VD supplementation on GDM onset.

Avoidance of sun exposure as a risk factor for major causes of death: a competing risk analysis of the Melanoma in Southern Sweden cohort

OBJECTIVE

Women with active sunlight exposure habits experience a lower mortality rate than women who avoid sun exposure; however, they are at an increased risk of skin cancer. We aimed to explore the differences in main causes of death according to sun exposure.

METHODS

We assessed the differences in sun exposure as a risk factor for all-cause mortality in a competing risk scenario for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 (aged 25-64 years at the start of the study). We obtained detailed information at baseline on sun exposure habits and potential confounders. The data were analysed using modern survival statistics.

RESULTS

Women with active sun exposure habits were mainly at a lower risk of cardiovascular disease (CVD) and noncancer/non-CVD death as compared to those who avoided sun exposure. As a result of their increased survival, the relative contribution of cancer death increased in these women. Nonsmokers who avoided sun exposure had a life expectancy similar to smokers in the highest sun exposure group, indicating that avoidance of sun exposure is a risk factor for death of a similar magnitude as smoking. Compared to the highest sun exposure group, life expectancy of avoiders of sun exposure was reduced by 0.6-2.1 years.

CONCLUSION

The longer life expectancy amongst women with active sun exposure habits was related to a decrease in CVD and noncancer/non-CVD mortality, causing the relative contribution of death due to cancer to increase.

On the evolutionary advantage of coagulation factor V Leiden (FVL)

Carriership of coagulation factor V Leiden (FVL) is by far the most common thrombophilia in Western populations. FVL is caused by a single point mutation in the gene coding for coagulation factor V (FV) causing a lifelong procoagulatory state with an increased risk of venous thromboembolism (VTE) which might be fatal. It is believed that the mutation occurred in one person 21,000 years ago and today 3% to 15% of the Western populations are carriers. A potentially dangerous mutation such as FVL ought to be rare and should have been reduced, if not eradicated, by selection during the course of human evolution. Thus, FVL must confer the carriers with an evolutionary advantage in order to be so prevalent. Lower risk of profuse bleeding and increased fecundity might give carriers an advantage. In this paper we give an updated short background and discuss possible evolutionary advantages and disadvantages.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries

OBJECTIVE

The objective was to investigate prevalence, estimate risk factors, and antenatal suspicion of abnormally invasive placenta (AIP) associated with laparotomy in women in the Nordic countries.

DESIGN

Population-based cohort study.

SETTING AND POPULATION

A 3-year Nordic collaboration among obstetricians to identify and report on uterine rupture, peripartum hysterectomy, excessive blood loss, and AIP from 2009 to 2012 The Nordic Obstetric Surveillance Study (NOSS).

METHODS

In the NOSS study, clinicians reported AIP cases from maternity wards and the data were validated against National health registries.

MAIN OUTCOME MEASURES

Prevalence, risk factors, antenatal suspicion, birth complications, and risk estimations using aggregated national data.

RESULTS

A total of 205 cases of AIP in association with laparotomy were identified, representing 3.4 per 10 000 deliveries. The single most important risk factor, which was reported in 49% of all cases of AIP, was placenta praevia. The risk of AIP increased seven-fold after one prior caesarean section (CS) to 56-fold after three or more CS. Prior postpartum haemorrhage was associated with six-fold increased risk of AIP (95% confidence interval 3.7-10.9). Approximately 70% of all cases were not diagnosed antepartum. Of these, 39% had prior CS and 33% had placenta praevia.

CONCLUSION

Our findings indicate that a lower CS rate in the population may be the most effective way to lower the incidence of AIP. Focused ultrasound assessment of women at high risk will likely strengthen antenatal suspicion. Prior PPH is a novel risk factor associated with an increased prevalence of AIP.

TWEETABLE ABSTRACT

An ultrasound assessment in women with placenta praevia or prior CS may double the awareness for AIP.

Transvaginal ultrasound assessment of myometrial and cervical stromal invasion in women with endometrial cancer: interobserver reproducibility among ultrasound experts and gynecologists

OBJECTIVES

To assess interobserver reproducibility among ultrasound experts and gynecologists in the prediction by transvaginal ultrasound of deep myometrial and cervical stromal invasion in women with endometrial cancer.

METHODS

Sonographic videoclips of the uterine corpus and cervix of 53 women with endometrial cancer, examined preoperatively by the same ultrasound expert, were integrated into a digitalized survey. Nine ultrasound experts and nine gynecologists evaluated presence or absence of deep myometrial and cervical stromal invasion. Histopathology from hysterectomy specimens was used as the gold standard.

RESULTS

Compared with gynecologists, ultrasound experts showed higher sensitivity, specificity and agreement with histopathology in the assessment of cervical stromal invasion (42% (95% CI, 31-53%) vs 57% (95% CI, 45-68%), P < 0.01; 83% (95% CI, 78-86%) vs 87% (95% CI, 83-90%), P = 0.02; and kappa, 0.45 (95% CI, 0.40-0.49) vs 0.58 (95% CI, 0.53-0.62), P < 0.001, respectively) but not of deep myometrial invasion (73% (95% CI, 66-79%) vs 73% (95% CI, 66-79%), P = 1.0; 70% (95% CI, 65-75%) vs 69% (95% CI, 63-74%), P = 0.68; and kappa, 0.48 (95% CI, 0.44-0.53) vs 0.52 (95% CI, 0.48-0.57), P = 0.11, respectively). Though interobserver reproducibility (in the context of test proportions 'good' and 'very good', according to kappa) regarding deep myometrial invasion did not differ between the groups (experts, 34% vs gynecologists, 22%, P = 0.13), ultrasound experts assessed cervical stromal invasion with significantly greater interobserver reproducibility than did gynecologists (53% vs 14%, P < 0.001).

CONCLUSION

Preoperative ultrasound assessment of deep myometrial and cervical stromal invasion in endometrial cancer is best performed by ultrasound experts, as, compared with gynecologists, they showed a greater degree of agreement with histopathology and greater interobserver reproducibility in the assessment of cervical stromal invasion.

Selective serotonin reuptake inhibitor use during pregnancy increases the risk of postpartum hemorrhage and anemia: a hospital-based cohort study

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are known to increase the risk of gastrointestinal bleeding.

OBJECTIVE

Study the risk of bleeding-related complications in relation to SSRI in pregnancy.

PATIENTS/METHODS

This was a hospital-based cohort study. All women who gave birth at Karolinska University Hospital in Stockholm over a 5-year period (2007 to 2011) were included in the study. Those women who the electronic maternal health record indicated were using SSRI (n = 500) were considered exposed, and all other women formed a control population (n = 39,594). The main outcome measures were blood loss, postpartum hemorrhage (PPH), PP anemia and length of hospitalization.

RESULTS

The absolute risk of PPH and PP anemia for the 1.2% exposed to SSRI were 18.0% and 12.8%, respectively. Women with a vaginal non-surgical delivery who reported use of SSRI during pregnancy had approximately a 2-fold increased risk of both PPH (OR, 2.6; 95% CI, 2.0-3.5) and PP anemia (OR, 2.1; 95% CI, 1.5-2.9), as compared with controls. Blood loss and length of hospitalization were significantly higher among women using SSRI than non-users (arithmetic mean 484 mL vs. 398 mL, 3.8 days vs. 2.4 days, respectively).

CONCLUSION

The use of SSRI during pregnancy increases blood loss and doubles the risk of PPH and PP anemia in a setting where SSRI had not been considered a risk factor for increased blood loss. Because PPH is a leading cause of maternal mortality and morbidity, the awareness of bleeding-related complications is important, both in relation to pregnancy and to surgery in general.

Avoidance of sun exposure is a risk factor for all-cause mortality: results from the Melanoma in Southern Sweden cohort

BACKGROUND

Sunlight exposure and fair skin are major determinants of human vitamin D production, but they are also risk factors for cutaneous malignant melanoma (MM). There is epidemiological evidence that all-cause mortality is related to low vitamin D levels.

METHODS

We assessed the avoidance of sun exposure as a risk factor for all-cause mortality for 29 518 Swedish women in a prospective 20-year follow-up of the Melanoma in Southern Sweden (MISS) cohort. Women were recruited from 1990 to 1992 and were aged 25 to 64 years at the start of the study. We obtained detailed information at baseline on their sun exposure habits and potential confounders. Multivariable flexible parametric survival analysis was applied to the data.

RESULTS

There were 2545 deaths amongst the 29 518 women who responded to the initial questionnaire. We found that all-cause mortality was inversely related to sun exposure habits. The mortality rate amongst avoiders of sun exposure was approximately twofold higher compared with the highest sun exposure group, resulting in excess mortality with a population attributable risk of 3%.

CONCLUSION

The results of this study provide observational evidence that avoiding sun exposure is a risk factor for all-cause mortality. Following sun exposure advice that is very restrictive in countries with low solar intensity might in fact be harmful to women's health.

ABO and RhD blood groups and gestational hypertensive disorders: a population-based cohort study

OBJECTIVE

To examine the association between ABO and RhD blood groups and gestational hypertensive disorders in a large population-based cohort.

DESIGN

Cohort study. Risks of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia, estimated by odds ratios for maternal ABO blood group and RhD status.

SETTING

National health registers of Sweden.

POPULATION

All singleton deliveries in Sweden born to first-time mothers during the period 1987-2002 [total n = 641 926; any gestational hypertensive disorders, n = 39 011 (6.1%); pre-eclampsia cases, n = 29 337 (4.6%); severe pre-eclampsia cases, n = 8477 (1.3%)].

METHODS

Using blood group O as a reference, odds ratios of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia were obtained from logistic regression models adjusted for potential confounding factors.

MAIN OUTCOME MEASURES

Gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia.

RESULTS

Compared with blood group O, all non-O blood groups had modest but statistically significantly higher odds of pre-eclampsia. Blood group AB had the highest risk for pre-eclampsia (OR = 1.10, 95% CI 1.04-1.16) and severe pre-eclampsia (OR = 1.18, 95% CI 1.07-1.30). RhD-positive mothers had a small increased risk for pre-eclampsia (OR = 1.07, 95% CI 1.03-1.10).

CONCLUSIONS

In the largest study on this topic to date, women with AB blood group have the highest risks of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia, whereas women with O blood group have the lowest risks of developing these disorders. Although the magnitude of increased risk is small, this finding may help improve our understanding of the etiology of pre-eclampsia.

Sonographic characteristics of squamous cell cancer and adenocarcinoma of the uterine cervix

OBJECTIVE

The objective of this study was to describe the sonographic characteristics of squamous cell cancer (SCC) and adenocarcinoma (AC) of the cervix using transvaginal ultrasound.

METHODS

Women with early stage cervical cancer undergoing transvaginal ultrasound examination before surgery were prospectively included. The sonographic characteristics were assessed with regard to tumor morphology, vascularization, size, extension and location. Histological assessment of tumor subtype, size, growth pattern, extension and location was performed. Both sonographic and histological assessments were carried out according to a standardized protocol.

RESULTS

Fifty-five women were recruited. Ten were excluded because no tumor was seen on ultrasound examination and five were excluded because radical surgery was aborted as a result of positive lymph nodes, detected using the sentinel node technique. Among the remaining 40 women, 20 had AC and 20 had SCC. At pathological examination, 34 women had tumors confined to the cervix, three had parametrial invasion and three had vaginal invasion. Hypoechogenicity was associated with SCC in 73% (11/15) of the women, while isoechogenicity indicated AC in 68% (13/19) of the women (P = 0.03). Mixed echogenicity (n = 4) showed a non-significant association with larger tumor volume (P = 0.23). Hyperechogenicity was found in two women, both of whom had the less malignant villoglandular AC. Color Doppler signals were found in all cases of AC and in 90% (18/20) of cases of SCC, compared with most normal cervical tissue in which virtually no detectable vascularization was found.

CONCLUSION

We found that the sonographic appearance of SCC and AC differs. This knowledge should be useful in the clinical evaluation of cervical tumors.

Does an active sun exposure habit lower the risk of venous thrombotic events? A D-lightful hypothesis

BACKGROUND

Venous and arterial thrombotic complications exhibit a seasonal variation, with risk peaking in winter and dropping to a nadir in summer. We sought a possible correlation between sun exposure habits and venous thromboembolism (VTE) events.

METHODS

This was a cohort study comprising 40,000 women (1000 per year of age from 25 to 64 years) who were drawn from the southern Swedish population registry for 1990 and followed for a mean of 11 years. Seventy-four per cent answered an inquiry at the inception of the study (n=29,518), and provided detailed information on their sun exposure habits. Cox regression analysis was used with the presence of VTE as a dependent variable and selected demographics as independent variables. The main outcome was the relationship between VTE and sun exposure habits.

RESULTS

Swedish women who sunbathed during the summer, on winter vacations, or when abroad, or used a tanning bed, were at 30% lower risk of VTE than those who did not. Risk estimates did not change substantially after adjustment for demographic variables. The risk of VTE increased by 50% in winter as compared to the other seasons; the lowest risk was found in the summer.

CONCLUSIONS

Women with more active sun exposure habits were at a significantly lower risk of VTE. We speculate that greater ultraviolet B light exposure improves a person's vitamin D status, which in turn enhances anticoagulant properties and enhances the cytokine profile.

A 2-year follow-up study of anxiety and depression in women referred for colposcopy after an abnormal cervical smear

OBJECTIVES

The aim of this study was to determine if there were any long-lasting elevated anxiety levels in women attending colposcopy after an abnormal cervical smear.

DESIGN

Prospective study.

SETTING

Department of Obstetrics and Gynaecology, Malmö University Hospital, Sweden.

POPULATION

One hundred consecutive women were invited to participate when referred for colposcopy.

METHODS

Women in the study group completed the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale-self-rate (MADRS-S) and had a psychosocial interview prior to colposcopy at their two follow-up visits.

MAIN OUTCOME MEASURES

State anxiety levels and depression scores at first visit, 6 months and 2 years.

RESULTS

At follow up, levels of state anxiety and the depression scores of the women studied had decreased and were comparable to those of Swedish normative data. Two variables from the MADRS-S, 'ability to focus on different activities' and 'emotional involvement with others and in activities' were the most prominent for women with moderate to severe depression. At the 2-year visit, 30% of the women still had a fear of cancer.

CONCLUSIONS

Referral for colposcopy after an abnormal cervical smear does not seem to result in long-lasting anxiety and depression. However, a subgroup of women, with the initially highest depression scores, still had at 2-year state anxiety levels and depression scores significantly higher than normal. Almost one-third of the women still had a fear of cancer in spite of lower 2-year state anxiety levels.

A longitudinal study of sexual functioning in women referred for colposcopy: a 2-year follow up

OBJECTIVE

To elucidate psychosexual problems in women referred for colposcopy after an abnormal cervical smear and a 6-month and 2-year follow up.

DESIGN

Prospective study.

SETTING

Department of Gynaecology, Malmö University Hospital, Sweden.

POPULATION

One hundred consecutive women referred for colposcopy for the first time subsequent to receiving notification of an abnormal cervical smear.

METHODS

The women completed the State-Trait Anxiety Inventory, a psychosexual questionnaire and had one psychosocial interview prior to colposcopy at all three visits.

MAIN OUTCOME MEASURES

Depending upon the result of the cervical biopsy, women had either a loop electrosurgical excision procedure (LEEP) or not. Psychosexual variables, anxiety measures, and psychosocial variables were used to estimate sexual functioning at the beginning of the study and at follow up. Differences in sexual functioning between LEEP and non-LEEP groups were estimated.

RESULTS

'Spontaneous interest in sex', 'frequency of intercourse', and 'sexual arousal' were reported to be statistically significant lower at 6 months compared with the first visit, and at 2 years, 'spontaneous interest in sex' and 'frequency of intercourse' still remained low. There was no difference in sexual functioning between the LEEP and non-LEEP groups at follow up.

CONCLUSIONS

Two years after referral for colposcopy, women still had an effect on sexual functioning, that is, lesser 'spontaneous interest' and decreased 'frequency of intercourse'. We found no support for a relationship between treatment of cervical intraepithelial neoplasia by LEEP and deterioration in sexual functioning.

A prospective Swedish cohort study on psychosocial factors influencing anxiety in women referred for colposcopy*

OBJECTIVES

To elucidate risk factors for high state anxiety in women referred for colposcopy.

DESIGN

Prospective cohort study.

SETTING

Department of Gynaecology, Malmö University Hospital, Sweden.

POPULATION

A total of 100 consecutive women referred for colposcopy for the first time after an abnormal cervical smear.

METHODS

Women in the study group completed prior to colposcopy the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale-self-rate, and were interviewed about their psychosocial situation.

MAIN OUTCOME MEASURES

Variables related to high state anxiety were determined in bivariate and multiple logistic regression analysis.

RESULTS

High depression scores and the wording of the referral letter for colposcopy were related to high state anxiety in a multivariate analysis. Women with high depression scores had a nine-fold risk for higher levels of state anxiety and did not respond with lower state anxiety levels after information and examination. Women who received a letter stating 'some changes' were at a five-fold increased risk for high levels of state anxiety than those who received a letter stating 'light changes'.

CONCLUSION

A depressive mood and the wording of the referral letter for colposcopy after an abnormal smear were predictive of high state anxiety levels.

Activated protein C resistance -- in the absence of factor V Leiden -- and pregnancy

BACKGROUND

Activated protein C (APC) resistance with or without factor V Leiden (FVL) is a major risk factor for venous thromboembolism. Many previous pregnancy studies have been focused on APC resistance caused by FVL. Very few have investigated APC resistance in the absence of FVL (APCR(FVL-)).

MATERIAL AND METHODS

In a prospective study of 2480 unselected gravidae, blood was drawn in early pregnancy (mean = 12 weeks of gestation). APC resistance was analyzed by an APTT-based method (Coatest) APC-resistance) and the presence of FVL was determined by PCR. The APCR(FVL-) group had similar mean APC resistance ratio as the heterozygous carriers of FVL. The analyses were carried out no earlier than 3 months after delivery when all data were recorded. Small-for-gestational age (SGA) was used as a proxy for intrauterine growth restriction.

RESULTS

When compared with the control group, women with APCR(FVL-) had no increased risk of SGA, pre-eclampsia, first trimester fetal loss or venous thromboembolism. However, they had an increased risk of second trimester fetal loss (7.3% vs. 2.7%, P = 0.01), and a tendency of being overweight (17.3% vs. 12.6%, P = 0.19) and of delivering extremely preterm (2.8% vs. 1.0%, P = 0.11).

CONCLUSION

Women with APC resistance not caused by FVL were not at increased risk for SGA, pre-eclampsia, first trimester fetal loss, or abnormal blood loss. However, they showed an increased prevalence of second trimester fetal loss.

Does antenatal identification of small-for-gestational age fetuses significantly improve their outcome?

OBJECTIVES

Most obstetric clinics have a program for the identification of small-for-gestational age (SGA) fetuses because of the increased risk of fetal complications that they present. We have a structured model for the identification and follow-up of SGA pregnancies. We aimed to determine whether the recognition of SGA antepartum improves fetal outcome.

METHODS

All pregnancies at Malmö University Hospital from 1990 to 1998 (n = 26 968) were reviewed. SGA fetuses identified prior to delivery (n = 681) were compared with those not identified (n = 573). Also, all pregnancies with SGA fetuses were compared with those appropriate-for-gestational age (AGA) (n = 24 585). The risk of serious fetal complications (hypoxic encephalopathy grade 2 or 3, intracranial hemorrhage, Apgar score <4 at 5 min, neonatal convulsions, umbilical pH <7.0, cerebral palsy, mental retardation, stillbirth, intrapartum or infant death) was assessed with cross-tabulation and logistic regression analysis, adjusted for gestational age and degree of SGA.

RESULTS

When compared with SGA fetuses identified before delivery (54%), SGA fetuses not identified before delivery were characterized by a four-fold increased risk of adverse fetal outcome (odds ratio, 4.1; 95% CI, 2.5-6.8). Similarly, compared with AGA fetuses, SGA fetuses were associated with a four-fold increased risk of serious fetal complications.

CONCLUSIONS

A structured antenatal surveillance program for fetuses identified as SGA results in a lower risk of adverse fetal outcome, compared with cases of SGA fetuses not identified antepartum.

Thermal response to submaximal exercise before, during and after pregnancy: a longitudinal study

BACKGROUND

Heat stress in early pregnancy is known to have a teratogenic effect. Exercise produces excess heat and during pregnancy might therefore present a theoretical risk of malformations. Our aim was to assess the thermal response to exercise of healthy pregnant women in a longitudinal study.

METHODS

Fourteen women were examined before pregnancy, and followed five times during, and twice after pregnancy, using a submaximal bicycle test with a target heart rate of 85% of the predicted age-adjusted maximum. The main aim was to present reference values.

RESULTS

The temperature at submaximal work load declined continuously from preconception to postpartum levels (37.8 degrees C vs. 36.9 degrees C, p = 0.04). The difference between peak and basal core temperature fell from 0.6 degrees C to 0.05 degrees C at 29 and 36 weeks of gestation, reaching preconception levels at 24 weeks after delivery (0.8 degrees C lower).

CONCLUSION

During submaximal exercise the temperature response seemed to provide thermal protection for the embryo and the fetus.

Maternal carriership of factor V Leiden associated with pathological uterine artery doppler measurements during pregnancy

To determine whether increased vascular resistance in the uterine artery is associated with carriership of factor V Leiden, a retrospective study was undertaken of 231 pregnant women who were monitored with Doppler velocimetry of the uterine arteries. These women had been part of a prospective study of 2,480 pregnant women in whom factor V Leiden had been analysed. When compared with non-carriers of factor V Leiden, carriers had a tendency towards an increased proportion of pathological Doppler measurements, including a significant increase in bilateral uterine artery notches (7/33 vs 16/198, relative risk 3.1; 95% CI 1.2-8.1). This suggests an increased vascular resistance in the uteroplacental circulation among carriers of factor V Leiden.

Moderate smoking during pregnancy is associated with a reduced risk of preeclampsia

BACKGROUND

To investigate the effects of maternal smoking during pregnancy on the development of preeclampsia (PE).

METHODS

The study comprised two populations with singleton pregnancies, one collected from 1990 to 1994 at the Malmö University Hospital (Malmö series, n=14,510) and the other from the National Birth Registry of Sweden 1993 (National series, n=113,211). Women with PE (n=281 and n=2,865, respectively) were compared to those without PE, delivered in 1993 (n=2,811 and n=110,346, respectively). The subgroups of women who had PE associated with preterm birth (n=58 and n=693, respectively) were compared with the same control groups in both series.

RESULTS

Multiple logistic regression analysis showed that, in comparison with non-smokers, moderate smokers (1-9 cigarettes per day) were characterized by a lower incidence of PE (odds ratio (OR) 0.4; 95% confidence interval (CI) 0.22-0.60), and PE associated with preterm birth (OR 0.1; 95% CI 0.01-0.67). The corresponding figures in the validating National series were also significantly lower for moderate smokers (OR 0.6; 95% CI 0.5-0.7 and OR 0.6; 95% CI 0.5-0.8, respectively).

CONCLUSION

Moderate smoking during pregnancy seems to protect against the development of PE and PE associated with preterm birth. Nicotine might be the agent responsible for this protective effect.

Activated protein C resistance (FV:Q506) and pregnancy

Activated protein C (APC) resistance, due to a point mutation in the factor V gene (FV:Q506), is a major risk factor for venous thromboembolism. To determine the prevalence of APC resistance in a large series of pregnant women, and to elucidate its obstetric consequences, we performed a prospective study in Malmo, Sweden, comprising 2,480 women enrolled in early pregnancy. The presence of APC resistance (the FV:Q506 allele) was determined. The women were interviewed about their medical histories including venous thromboembolic events (VTE) in relatives. The outcome variables were the VTE rate, intrapartum blood loss, and the prevalence of selected pregnancy complications such as fetal loss, pre-eclampsia. and intrauterine growth retardation. The overall prevalence of APC resistance was 11% (270/2480). The APC-resistant subgroup did not differ significantly from the non-APC-resistant subgroup in terms of pregnancy complications, but was characterized by an 8-fold higher risk of VTE (3/270 vs. 3/2210), a lower rate of profuse intrapartum haemorrhage (3.7% vs. 7.9%) (p = 0.02), and less intrapartum blood loss (340 ml vs. 361 ml) (p = 0.04). Despite the high prevalence of APC resistance in this series of gravidae (11%), its presence was unrelated to adverse pregnancy outcome apart from an 8-fold increased risk of VTE.

Factor V Q506 mutation (activated protein C resistance) associated with reduced intrapartum blood loss--a possible evolutionary selection mechanism

OBJECTIVES

To ascertain whether relationship exists between the presence of APC resistance [a hypercoagulable state due to a mutation (R506Q) in the factor V gene] and the occurrence of pre-eclampsia (PE), intrauterine growth retardation (IUGR), and pregnancy bleeding complications.

DESIGN

A retrospective study.

SUBJECTS

A study group of 122 women with PE and/or IUGR during a recent pregnancy and a control group of 465 healthy pregnant women.

RESULTS

A significantly reduced risk of intrapartum bleeding complications in the APC-resistant subgroup as compared to the non-APC-resistant subgroup was suggested by reduced intrapartum blood loss, and pre- and postpartum haemoglobin measurements. The prevalence of APC resistance in the PE and IUGR subgroups did not differ significantly from that in the control group.

CONCLUSION

The remarkably high prevalence of the potentially harmful factor V gene mutation in the general population may be the result of an evolutionary selection mechanism conferring such survival advantages as reduction in the risk of intrapartum bleeding on carriers of the FV:Q506 allele.