Perceptions of obesity and cancer risk in female bariatric surgery candidates: Highlighting the need for physician action for unsuspectingly obese and high risk patients

Objectives

To determine: 1) whether obese women perceive themselves to be obese or at risk for malignancy, 2) perceived impact of obesity on cancer risks, 3) compliance with cancer screening, and 4) rates of menstrual dysfunction.

Methods

Surveys were administered to female patients presenting for bariatric weight loss surgery. Demographics, gynecologic history, perception of cancer risk, and screening history were collected/analyzed. Women were categorized as obese (BMI: 30–39 kg/m²), morbidly obese (40–49 kg/m²), super obese (≥ 50 kg/m²) and compared.

Results

Ninety-three women (mean age: 44.9 years, mean BMI: 48.7 kg/m²) participated and 45.7% felt they were in ‘good’, ‘very good’, or ‘excellent’ health despite frequent medical comorbidities. As BMI increased, women were more likely to correctly identify themselves as obese (23% of obese vs. 77% of morbidly obese vs. 85% of super obese; p < 0.001) but there were no significant differences in comorbidities. Two-thirds of women correctly identified obesity as a risk factor for uterine cancer, yet 48% of those retaining a uterus perceived that it was “not likely/not possible” to develop uterine cancer. Menstrual irregularities were common as was evaluation and interventions for the same; 32% had prior hysterectomy. Participation in cancer screening was robust.

Conclusions

Women presenting for bariatric surgery have high rates of menstrual dysfunction. While they perceive that obesity increases uterine cancer risk, they often do not perceive themselves to be at risk. This disconnect may stem from the fact that many failed to identify themselves as obese perhaps because overweight/obesity has become the norm in U.S. society.     

Prognostic factors for the success of endometrial ablation in the treatment of menorrhagia with special reference to previous cesarean section

Objective

To assess whether, among other prognostic factors, a history of Cesarean section is associated with endometrial ablation failure in the treatment of menorrhagia.Study design We compared women who had failed ablation to women who had successful ablation for menorrhagia in a case–control study. Failed ablation was defined as the need for hysterectomy due to persistent heavy menstrual bleeding after ablation. Successful ablation was defined as an ablation for menorrhagia not needing hysterectomy and the woman being satisfied with the result. Both cases and controls were identified from the surgery registration in the Máxima Medical Center between January 1999 and January 2009. Cases were women that had an endometrial ablation and a hysterectomy, whereas controls only had an endometrial ablation. From the medical files we collected for each patient clinical history, including the presence of a previous Cesarean section, baseline characteristics at the moment of initial ablation, data of the ablation technique and follow-up status. We used univariable and multivariable logistic regression to estimate the risk of failure of endometrial ablation.

Results

We compared 76 cases to 76 controls. Among the cases, 12 women had had a previous Cesarean section versus 15 in the control group (15.8% versus 19.7%; odds ratio (OR) 0.76; 95% CI 0.3–1.8). Factors predictive for failure of ablation were dysmenorrhea (OR 3.0; 95% CI 1.5–6.1), having a submucous myoma (OR 3.2; 95% CI 1.5–6.8) and uterine depth (per cm OR 1.3; 95% CI 1.0–1.6). Presence of intermenstrual bleeding, sterilization and age were not associated with failure of ablation.

Conclusion

A previous Cesarean delivery is not associated with an increased risk of failure of endometrial ablation, but dysmenorrhea, a submucous myoma and longer uterine depth are. This should be incorporated in the counseling of women considering endometrial ablation.     

Gestational weight gain within recommended ranges in consecutive pregnancies: A retrospective cohort study

Objective

to examine whether, among parous women, adherence to gestational weight gain (GWG) recommendations in the most recent previous pregnancy is associated with adherence to GWG recommendations in the current pregnancy.

Design

retrospective cohort study.

Setting

review of labour and delivery records from a Massachusetts tertiary-care centre.

Participants

1,325 women who delivered two consecutive singletons from April 2006 to March 2010.

Measurements

pre-pregnancy weight status and adherence to GWG recommendations were categorised using 1990 Institute of Medicine (IOM) guidelines. Analyses were stratified by weight status before the second pregnancy.

Findings

56% and 46% of women gained more than 1990 IOM recommendations during the first and second of consecutive pregnancies; 57% gained within the same adherence category in both pregnancies. Excessive GWG during the first pregnancy was strongly associated with excessive gain during the second pregnancy (adjusted odds ratio [AOR]=5.4 [95% CI: 1.7–16.4] for underweight, 3.7 [95% CI: 2.4–5.5] for normal weight, 3.0 [95% CI: 1.2–7.6] for overweight, and 5.3 [95% CI: 2.4–11.7] for obese women). Inadequate gain in the first of consecutive pregnancies was strongly associated with subsequent inadequate GWG for underweight women (AOR=13.7; 95% CI: 3.9–48.0), normal weight women (AOR=2.9; 95% CI: 1.7–5.1), and obese women (AOR=3.6; 95% CI: 1.4–9.3). Results were similar in sensitivity analyses using IOM 2009 guidelines.

Key conclusions

adherence to GWG recommendations in consecutive pregnancies is highly concordant.

Implications for practice

consideration of GWG during previous pregnancies may facilitate discussions about GWG during prenatal care.     

Impact of prior bariatric surgery on maternal and fetal outcomes among obese and non-obese mothers

Purpose

To assess the association between bariatric surgery and pregnancy-related outcomes among obese and non-obese women in the state of Florida.

Methods

We conducted a population-based, retrospective cohort analysis using vital records and hospital discharge data in Florida during 2004–2007. Women were categorized based on prior bariatric surgery and pre-pregnancy obesity status. Maternal complications (i.e., anemia, pre-eclampsia, gestational diabetes, chronic hypertension, endocrine disorders, cesarean section, prolonged hospital stay) and fetal morbidities [macrosomia, preterm birth, small for gestational age (SGA)] were the outcomes of interest. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were computed.

Results

Mothers with a prior history of bariatric surgery, regardless of obesity status, were more likely to have anemia, chronic hypertension, endocrine disorders, and SGA infants. Classification based on prior history of bariatric surgery and obesity status showed that non-obese mothers with prior bariatric surgery were more likely to have anemia, chronic hypertension, endocrine disorders, and SGA infants, whereas obese mothers without prior bariatric surgery were at greater risk of having gestational diabetes, chronic hypertension, macrosomic infants (AOR = 1.69, 95% CI = 1.65–1.73), and prolonged hospital stay as compared to non-obese mother without prior bariatric surgery.

Conclusions

Although prior bariatric surgery is associated with multiple negative maternal and fetal outcomes, it is protective against infant macrosomia in obese mothers. Our findings support the need for preconception/interconception services tailored for former bariatric surgery patients to improve maternal and feto-infant health outcomes.

     

Does risk of endometrial cancer for women without a germline mutation in a DNA mismatch repair gene depend on family history of endometrial cancer or colorectal cancer?

Objective

To determine whether risk of endometrial cancer for women without a germline mutation in a DNA mismatch repair (MMR) gene depends on family history of endometrial or colorectal cancer.

Methods

We retrospectively followed a cohort of 79,166 women who were recruited to the Colon Cancer Family Registry, after exclusion of women who were relatives of a carrier of a MMR gene mutation. The Kaplan–Meier failure method was used to estimate the cumulative risk of endometrial cancer. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for association between family history of endometrial or colorectal cancer and risk of endometrial cancer.

Results

A total of 628 endometrial cancer cases were observed, with mean age at diagnosis of 54.4 (standard deviation: 15.7) years. The cumulative risk of endometrial cancer to age 70 years was estimated to be 0.94% (95% CI 0.83–1.05) for women with no family history of endometrial cancer, and 3.80% (95% CI 2.75–4.98) for women with at least one first- or second-degree relative with endometrial cancer. Compared with women without family history, we found an increased risk of endometrial cancer for women with at least one first- or second-degree relative with endometrial cancer (HR 3.66, 95% CI 2.63–5.08), and for women with one first-degree relative with colorectal cancer diagnosed at age < 50 years (HR 1.48, 95% CI 1.15–1.91).

Conclusion

An increased risk of endometrial cancer is associated with a family history of endometrial cancer or early-onset colorectal cancer for women without a MMR gene mutation, indicating for potential underlying genetic and environmental factors shared by colorectal and endometrial cancers other than caused by MMR gene mutations.     

Factors affecting compliance in the first year of postcolposcopy surveillance among women with a high incidence of cervical cancer

Objective

To assess postcolposcopy compliance among women with abnormal cervical screening results and to identify factors associated with noncompliance for postcolposcopy follow-up.

Methods

In a retrospective study, the records of women who underwent colposcopy at Srinagarind Hospital, Thailand, between January and December 2010 were reviewed. Women were considered to be noncompliant if their total follow-up time after colposcopy was less than 12 months. Univariate and multivariate logistic regression methods were used to determine factors significantly predicting noncompliance.

Results

Among 548 women who underwent colposcopy, the percentage of noncompliance was 49.5% (95% confidence interval [CI], 45.1%–53.7%). The risk for noncompliance rose significantly among those without intraepithelial lesions (OR, 2.19; 95% CI, 1.53–3.13), younger age (OR, 1.79; 95% CI, 1.19–2.67), and low education level (OR, 1.58; 95% CI, 1.11–2.24). Risk for noncompliance was significantly lower among those with a previous history of abnormal smear (OR, 0.39; 95% CI, 0.24–0.64).

Conclusion

The percentage of noncompliance with postcolposcopy follow-up was high among the study women. The significant independent factors predicting noncompliance were previous history of abnormal smear, severity of cervical histopathology, age, and education level.     

Factores de riesgo del parto pretérmino

Objective

To determine the risk factors for preterm births occurring spontaneously or due to premature rupture of membranes in our environment.

Patients and method

We performed a retrospective case-control study at the Complejo Hospitalario Universitario de Albacete (Spain) that compared 315 pregnant women with preterm labor occurring spontaneously or due to premature rupture of membranes with 315 women selected as controls who delivered at term. The variables were grouped into sociobiological parameters, obstetric history, and characteristics of the current pregnancy.

Results

Previous preterm birth (OR = 3.4; 95% CI, 1.7-6.7), prior abortions (p = 0.002), multiple gestation (OR = 28.1; 95% CI, 6.7-116.8), assisted reproductive technology (ART) (OR = 5.8; 95% CI, 2.3-14.1), hospitalization and tocolytic therapy (OR = 10.8; 95% CI, 4.2-27.7), and cerclage (OR = 5.6; 95% CI, 1.2-25.7) were more frequent in cases. However, when OR were adjusted (aOR) by other variables, the risk for cerclage disappeared (aOR = 2.8; 95% CI, 0.5-14).

Conclusions

Risk factors for preterm birth in our population were a history of preterm birth and abortions, multiple gestation, ART, and hospitalization with tocolytic therapy.     

Effects of bariatric surgery on pelvic floor disorders in obese women: a meta-analysis

Purpose

Obesity is an established risk factor for pelvic floor disorders (PFD) but the effects of bariatric surgery on PFD are uncertain. This meta-analysis was conducted to evaluate the effects of bariatric surgery on PFD in obese women.

Methods

A systematic search of PubMed, Cochrane Library, CNKI and CBM databases up to October 2016 was performed, and studies reporting pre-operative and post-operative outcomes in obese women undergoing bariatric surgery were included. The Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Incontinence Questionnaire (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Female Sexual Function Index and the International Consultation on Incontinence Questionnaire-Urinary Incontinence short form score were used for evaluating pelvic floor dysfunction after bariatric surgery.

Results

Eleven cohort studies were finally included. Pooled results revealed that bariatric surgery was associated with a significant improvement in PFD for obese women on the whole [PFDI-20: SMD = 0.89, 95% CI (0.44, 1.34), P < 0.001; PFIQ-7: SMD = 1.23, 95% CI (0.17, 2.29), P = 0.023]. In the subscale analysis, there was significant improvement in urinary incontinence and pelvic organ prolapse. However, no significant improvement was found in fecal incontinence and sexual function.

Conclusions

Bariatric surgery is associated with significant improvement in urinary incontinence, and has a benefit on pelvic organ prolapse for obese women. However, there is no significant improvement in fecal incontinence and sexual function. Further multi-center, large-scale and longer-term randomized controlled trials are needed to confirm these results.

     

Pregnancy outcomes among chronic carriers of hepatitis B virus

Objective

To compare pregnancy outcomes of women with chronic HBV infection with those of HBV-negative women.

Methods

A retrospective cohort study was undertaken to analyze singleton pregnancies of women without medical/surgical disease and with known HBsAg status. Pregnancy outcome measures were compared among the control group, women with positive HBsAg status (case group), and those with positive HBeAg status.

Results

Among 26 350 enrolled pregnant women, 21 812 in the control group and 1446 in the case group were compared. Only the proportion of preterm births was significantly higher among pregnancies with positive HBsAg status (RR 1.013 [95% CI, 1.001–1.025]). Among women with positive HBsAg status who had been screened for HBeAg, GDM was significantly higher among women with positive HBeAg status (RR 1.434 [95% CI, 0.999–2.057]). Preterm births and low birth weight were also significantly higher among women with positive HBeAg status (RR 1.250 [95% CI, 1.000–1.563] and 1.258 [95% CI, 1.053–1.505], respectively).

Conclusion

Chronic carriers of HBV had a minimally increased risk of preterm birth and low birth weight but the risk was more pronounced in women with positive HBeAg status. Women with positive HBeAg status also had an increased risk of GDM.     

Long-term outcomes for mothers who have or have not held their stillborn baby

Objectives

to investigate long-term outcomes of mothers who have or have not held their stillborn baby, and predictors of having held the baby.

Design

postal questionnaires.

Setting

a nation-wide cohort study of mothers who gave birth to a singleton stillborn baby in Sweden in 1991.

Participants

314 out of 380 women answered the questionnaire and 309 reported whether or not they had held their baby.

Measurements

scales measuring anxiety, depression and well-being.

Findings

126 (68%) mothers of 185 babies stillborn after 37 gestational weeks had held their baby and 82 (68%) mothers of 120 babies stillborn at gestational weeks 28–37 had also done so. Compared with mothers who agreed completely with the statement that staff gave enough support to hold the baby, mothers who did not agree were less likely to have held their baby [relative risk (RR) 4.1; 95% confidence interval (CI) 2.7–6.1], and mothers with a low level of education were less likely to have held their baby than mothers with a higher level of education (RR 2.2; 95% CI 1.3–3.8). Mothers who had not held their babies born after 37 gestational weeks had an increased risk of headache (RR 4.3; 95% CI 1.1–16.5), and they were less satisfied with their sleep (RR 2.7; 95% CI 1.5–5.0). The increased risk of long-term outcomes associated with not holding, compared with holding, a stillborn baby were less pronounced for women who gave birth at gestational week 28–37 compared with women who gave birth after 37 gestational weeks.

Key conclusions

in this cohort, we found an overall beneficial effect of having held a stillborn baby born after 37 gestational weeks, whereas findings for having held a stillborn baby born at gestational weeks 28–37 are uncertain. The attitude of staff influenced whether or not the mother held her stillborn baby.

Implications for practice

if the mother is guided by staff in a sensitive way to hold her stillborn term baby, the experience will possibly be beneficial for her in the long term.     

Incidence of ano-genital and head and neck malignancies in women with a previous diagnosis of cervical intraepithelial neoplasia

Objective

The objective of this study was to determine if women with a history of Cervical Intraepithelial Neoplasia grades 2 and 3 (CIN2 and CIN3) are at increased long-term risk for developing non-cervix HPV-related malignancies.

Material and methods

Women diagnosed with CIN2 or CIN3 between 1980 and 2005 were identified from the British Columbia (BC) Cancer Agency Cervical Cancer Screening Program's database. These patients' records were then cross-referenced with the BC Cancer Registry for diagnosis of vulvar, vaginal, anal or head and neck (HN) cancers during the period subsequent to their diagnosis of CIN. Standardized incidence ratios (SIR) were generated according to expected rates of each cancer.

Results

54,320 women with a diagnosis of CIN2 or CIN3 were identified between 1985 and 2005. The crude incidence rate for non-cervix HPV-related cancers was 35.4 per 100,000 person-years (8.6 for vagina, 17.6 for vulva, 3.7 for anal canal and 5.5 for HN). The SIR was 1.9 (95% CI 1.3–2.7) for all non-cervix cancers, 6.7 (95% CI: 3.0–12.8) for vagina, 2.9 (95% CI: 1.7–4.6) for vulva, 1.8 (95% CI: 0.4–4.7) for anal canal, and 0.6 (95% CI: 0.2–1.4) for HN. There were statistically significant increases in anal cancers for years 5–9 and in HN cancers for years 0.5–5.

Conclusion

BC women with a history of CIN2 or CIN3 are at relatively high risk of developing non-cervical HPV-related malignancies. The findings of this study suggest that interventions such as vaccination against high-risk HPV or long-term screening for these other cancers should be evaluated.     

Maternal obesity and rate of cesarean delivery in Djibouti

Objective

To calculate the prevalence of maternal obesity and to determine the relation between obesity and cesarean delivery in an urban hospital in Djibouti.

Methods

In an observational cohort study, all women who had a live birth or stillbirth between October 2012 and November 2013 were considered for inclusion. Body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was calculated throughout pregnancy, and women with a BMI of at least 30.0 were deemed to be obese. Multivariate logistic regression analyses were used to evaluate the relation between cesarean and obesity.

Results

Overall, 100 (24.8%) of 404 women were obese before 14 weeks of pregnancy, as were 112 (25.2%) of 445 before 22 weeks, and 200 (43.2%) of 463 at delivery. Obesity before 22 weeks was associated with a 127% excess risk of cesarean delivery (adjusted odds ratio 2.27; 95% CI 1.07–4.82; P = 0.032). Similar trends were found when the analyses were limited to the subgroup of women without a previous cesarean delivery or primiparae.

Conclusion

Prevalence of maternal obesity is high in Djibouti City and is related to an excess risk of cesarean delivery, even after controlling for a range of medical and socioeconomic variables.     

Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation to maternal body mass index

Objective

To assess whether non-elective caesarean section due to obstructed labour and/or ineffective uterine contractility was associated with maternal body mass index (BMI).

Study design

The prospective dataset from the Swedish Medical Birth Registry consisted of 233,887 nulliparous women with a spontaneous onset of labour categorized in six classes of pre-pregnancy BMI, who delivered in Sweden between, January 1, 1999 and December 31, 2005. The mode of delivery was classified as either vaginal or by caesarean section. The caesarean section was classified as either elective or non-elective. Adjusted risks for non-elective caesarean section due to ineffective uterine contractility, or obstructed labour or fetal distress were determined using Mantel–Haenszel technique.

Results

The risk of a non-elective caesarean section due to obstructed labour was not significantly associated with maternal BMI. However, ineffective uterine contractility was significantly associated with maternal BMI and the risk of non-elective caesarean delivery due to labour arrest disorders increased with increasing BMI, reaching a 4-fold increased risk among the morbidly obese women. The risk of non-elective caesarean section due to fetal distress also increased significantly with increasing maternal BMI.

Conclusions

It appears that ineffective labour could be a factor leading to the increased risk of non-elective caesarean section among obese and morbidly obese women. These findings challenge obstetricians to learn more about how to manage oxytocin infusions during labour in relation to maternal BMI.     

Effect of bariatric surgery on pregnancy outcome

Objective

To compare the perinatal outcomes of women who delivered before with women who delivered after bariatric surgery.

Methods

A retrospective study was undertaken to compare perinatal outcomes of women who delivered before with women who delivered after bariatric surgery in a tertiary medical center between 1988 and 2006. A multivariate logistic regression model was constructed to control for confounders.

Results

During the study period, 301 deliveries preceded bariatric surgery and 507 followed surgery. A significant reduction in rates of diabetes mellitus (17.3% vs 11.0; P = 0.009), hypertensive disorders (23.6% vs 11.2%; P < 0.001), and fetal macrosomia (7.6% vs 3.2%; P = 0.004) were noted after bariatric surgery. Bariatric surgery was found to be independently associated with a reduction in diabetes mellitus (OR 0.42, 95% CI 0.26-0.67; P < 0.001), hypertensive disorders (OR 0.38, 95% CI 0.25-0.59; P < 0.001), and fetal macrosomia (OR 0.45, 95% CI 0.21-0.94; P = 0.033).

Conclusion

A decrease in maternal complications, such as diabetes mellitus and hypertensive disorders, as well as a decrease in the rate of fetal macrosomia is achieved following bariatric surgery.     

Clinical significance of tumor volume in endometrial cancer: A Japan–Korea cooperative study

Objective

The aim of this study was to elucidate the significance of tumor volume as a risk factor for predicting lymph node metastasis.

Methods

We applied the tumor volume index to the data that were collected for 327 Korean patients with endometrial cancer who underwent preoperative assessment including magnetic resonance imaging (MRI) and subsequent surgery including systematic lymphadenectomy. The volume index, which we previously reported in the literature, was defined as the product of maximum longitudinal diameter along the uterine axis, maximum anteroposterior diameter in a sagittal section image, and maximum horizontal diameter in a horizontal section image according to MRI data, from 425 Japanese women with endometrial cancer. Relationships between lymph node metastasis and results of preoperative examinations including volume index were analyzed by logistic regression analysis.

Results

The prevalence of affected lymph nodes was 14.2%. Multivariate analysis showed that high-grade histology assessed by endometrial biopsy [odds ratio (OR); 2.9, 95% confidence interval (CI): 1.4–6.4], volume index (OR; 2.4, 95% CI: 1.1–5.3), node enlargement assessed by MRI (OR; 4.2, 95% CI: 1.4–13.2), and high serum cancer antigen (CA)125 level (OR; 3.6, 95% CI: 1.6–8.1) were significantly and independently related to lymph node metastasis. When volume index was excluded from the analysis, myoinvasion assessed by MRI was an independent risk factor for lymph node metastasis as well as high-grade histology, node enlargement, and high serum CA125 level.

Conclusion

Volume index is compatible with myometrial invasion as a factor for predicting lymph node metastasis in endometrial cancer.     

Clinical and pathological characteristics,pathological reevaluation and recurrence patterns of cellular leiomyomas: a retrospective study in 76 patients

Objectives

To analyze clinical and pathologic features as well as recurrence patterns of cellular leiomyomas (CL) in women who underwent surgical therapy for symptomatic disease.

Study design

This retrospective study was conducted at the Department of Obstetrics and Gynecology, University Women's Clinic, Tuebingen, Germany. We identified all women who had CL on final diagnosis after surgery between January 1, 2000, and December 31, 2010.

Results

Our study sample comprised 76 women with a diagnosis of CL. A single uterine mass was present in 51.3% of the cases; in uteri with both CL and uterine leiomyomas (UL), the CL constituted the largest uterine mass in 20 of 21 (95.2%) cases. Additionally, in 98% of the uteri, CL were either the largest or the only uterine mass. Five women (6.6%; 5/76) had reported surgical procedures for symptomatic leiomyoma before the index surgery in our analysis. Three women underwent hysteroscopic resection of the leiomyomas and 2 women underwent abdominal myomectomy. Mean time to recurrence was 14.0 months (median 6.0; range, 4.0–52.0). Over the follow-up period, 6 women who underwent uterus-conserving surgery (12.0%; 6/50) with CL had leiomyoma recurrence. Five women underwent abdominal myomectomy and one underwent hysteroscopic resection of the CL. One patient had recurrence of a CL 43 months after abdominal myomectomy and underwent vaginal hysterectomy; the other five women had recurrences of UL. Mean time to recurrence was 28.6 months (median 12.5; range, 4.0–83.0).

Conclusions

Recurrence rates of CL in our study group resemble recurrence rates of UL.     

Pre-eclampsia in the first pregnancy and subsequent risk of stillbirth in black and white gravidas

Objective

To examine the association between prior pre-eclampsia and subsequent stillbirth in black women and white women.

Study design

This is a population-based retrospective study of Missouri maternally linked birth cohort files from 1989 to 2005. We analyzed singleton first and second births to mothers in the state of Missouri. The study population comprised women who experienced pre-eclampsia in their first pregnancy and a comparison group consisting of women who did not. The two groups were followed to their second pregnancy to document stillbirth occurrence. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between prior pre-eclampsia and subsequent stillbirth were obtained from logistic regression models.

Results

Women who experienced prior pre-eclampsia had a 43% increased risk of subsequent stillbirth [OR = 1.43; 95% CI = 1.08–1.89]. Whereas women with a history of late-onset pre-eclampsia had no elevated risk for subsequent stillbirth, those whose first pregnancy resulted in early-onset pre-eclampsia had a more than 4-fold increased risk of stillbirth in their second pregnancy [OR = 4.07; 95% CI = 2.32–7.14]. When sub-analysis was performed on the two main racial groups in the State, we found that elevated risk for subsequent stillbirth in a second pregnancy was observed among black women with prior early-onset pre-eclampsia (OR = 8.21; 95% CI = 4.03–16.70) but not in whites (OR = 1.95; 95% CI = 0.72–5.26).

Conclusion

Initiation of pregnancy with pre-eclampsia elevates the risk for subsequent stillbirth. The risk elevation is most pronounced in black women with early-onset pre-eclampsia in their first pregnancy. This information is valuable for inter-pregnancy counseling of affected women.     

Menopausal status: A possible predictive factor for recurrence in women with cancer of the uterine cervix without pelvic lymph node metastasis

Objectives

To evaluate risk factors for recurrence of carcinoma of the uterine cervix among women who had undergone radical hysterectomy without pelvic lymph node metastasis, while taking into consideration not only the classical histopathological factors but also sociodemographic, clinical and treatment-related factors.

Study design

This was an exploratory analysis on 233 women with carcinoma of the uterine cervix (stages IB and IIA) who were treated by means of radical hysterectomy and pelvic lymphadenectomy, with free surgical margins and without lymph node metastases on conventional histopathological examination. Women with histologically normal lymph nodes but with micrometastases in the immunohistochemical analysis (AE1/AE3) were excluded. Disease-free survival for sociodemographic, clinical and histopathological variables was calculated using the Kaplan–Meier method. The Cox proportional hazards model was used to identify the independent risk factors for recurrence.

Results

Twenty-seven recurrences were recorded (11.6%), of which 18 were pelvic, four were distant, four were pelvic + distant and one was of unknown location. The five-year disease-free survival rate among the study population was 88.4%. The independent risk factors for recurrence in the multivariate analysis were: postmenopausal status (HR 14.1; 95% CI: 3.7–53.6; P < 0.001), absence of or slight inflammatory reaction (HR 7.9; 95% CI: 1.7–36.5; P = 0.008) and invasion of the deepest third of the cervix (HR 6.1; 95% CI: 1.3–29.1; P = 0.021). Postoperative radiotherapy was identified as a protective factor against recurrence (HR 0.02; 95% CI: 0.001–0.25; P = 0.003).

Conclusion

Postmenopausal status is a possible independent risk factor for recurrence even when adjusted for classical prognostic factors (such as tumour size, depth of tumour invasion, capillary embolisation) and treatment-related factors (period of treatment and postoperative radiotherapy status).     

Patterns of care,predictors, and outcomes of chemotherapy in elderly women with early-stage uterine carcinosarcoma: A population-based analysis

Objective

To examine the patterns of care, predictors, and impact of chemotherapy on survival in elderly women diagnosed with early-stage uterine carcinosarcoma.

Methods

The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify women 65 years or older diagnosed with stage I–II uterine carcinosarcomas from 1991 through 2007. Multivariable logistic regression and Cox-proportional hazards models were used for statistical analysis.

Results

A total of 462 women met the eligibility criteria; 374 had stage I, and 88 had stage II uterine carcinosarcomas. There were no appreciable differences over time in the percentages of women administered chemotherapy for early stage uterine carcinosarcoma (14.7% in 1991–1995, 14.9% in 1996–2000, and 17.9% in 2001–2007, P = 0.67). On multivariable analysis, the factors positively associated with receipt of chemotherapy were younger age at diagnosis, higher disease stage, residence in the eastern part of the United States, and lack of administration of external beam radiation (P < 0.05). In the adjusted Cox-proportional hazards regression models, administration of three or more cycles of chemotherapy did not reduce the risk of death in stage I patients (HR: 1.45, 95% CI: 0.83–2.39) but was associated with non-significant decreased mortality in stage II patients (HR: 0.83, 95% CI: 0.32–1.95).

Conclusions

Approximately 15–18% of elderly patients diagnosed with early-stage uterine carcinosarcoma were treated with chemotherapy. This trend remained stable over time, and chemotherapy was not associated with any significant survival benefit in this patient population.     

Familial predisposition to pelvic floor dysfunction: prolapse and incontinence surgery among family members and its relationship with age or parity in a Swedish population

Objective

To estimate the relationship between heredity and proband's age/parity on the risk of undergoing surgery for pelvic organ prolapse and stress incontinence.Study design: Swedish population based study. Data from two national Swedish registers were used: the Hospital Discharge Register, National Board of Health and Welfare, containing information on all in-patient surgical procedures on Swedish hospitals, and the Multi-Generation Register, Statistics Sweden, containing information on individuals belonging to the same family. Women who had a surgical procedure for urinary incontinence or genital organ prolapse between the years 1987 and 2002 were identified (probands). Mothers and sisters of the probands were identified and information on incontinence or prolapse operations was linked to those relatives from the Hospital Discharge file, after which adjusted analyses were performed.

Results

Sisters to probands had a relative risk (RR) of 4.69 (95% confidence intervals (CI) 4.49–48.9) and mothers a RR of 2.17 (95% CI 2.07–2.27) for pelvic floor surgery. For sisters the risk decreased with increasing age and parity of the proband.

Conclusion

Sisters and mothers of women operated for urinary incontinence/urogenital prolapse had a higher risk of surgery for pelvic floor conditions, in particular sisters of women operated at a young age (<50) and with a low parity. This suggests that heredity plays a lesser role for the development of pelvic floor dysfunction at older age and with increasing parity.