Artificial Intelligence: The Future of Obstetrics and Gynecology

Background

Artificial intelligence or ‘big data’ comprises of algorithms which aid in decision making. It has made an impact on a number of professions including obstetrics and gynecology.

Objective

To make readers aware of where artificial intelligence has a role in obstetrics and gynecology.

Material and methods

A comprehensive review of the literature was undertaken to compile a list of instances where artificial intelligence was applied to obstetrics and gynecology.

Conclusion

Artificial intelligence should be utilized to benefit patient care and assist the physician in providing data for decision making.

     

Placenta previa and placental abruption after assisted reproductive technology in patients with endometriosis: a systematic review and meta-analysis

Background/aims

The self-quantification of patients is extending beyond the daily routine. More and more patients ask about the ‘optimal’ physical condition for an elective surgery. As the hysterectomy is one of the most common surgeries, a literature review was conducted to answer the question for the optimal surgical self preparation (prehabilitation).

Methods

A literature review with the search terms ‘physical activity’ or ‘physical exercise’ or ‘sport’ or ‘prehabilitation’ and ‘hysterectomy’ was conducted in the National Library of Medicine database (PubMed) and Web of science. The search was limited to English or German language and publishing date after 2000. Two independent researchers (SO, FE) reviewed the results and excluded irrelevant or double articles.

Results

After excluding irrelevant articles, five publications were left for review. One article published a study protocol and one a case report. Three articles reported study results. The numbers of patients reported are low. Prehabilitation programs differ depending on the primary study outcome. There seems to be a benefit for earlier discharge if patients undergo prehabilitation.

Conclusion

Unlike other disciplines where prehabilitation has been studied, a gynecologic viewpoint still needs establishing and further studies are needed to clarify the benefit for the patients.

     

Pre-implantation genetic testing: decisional factors to accept or decline among in vitro fertilization patients

Purpose

Embryo testing to improve pregnancy outcomes among individuals who are seeking assisted reproduction technologies is increasing. The purpose of this study was to assess decisional factors through in-depth interviews for why women would accept or decline preimplantation genetic testing for aneuploidy (PGT-A) with in vitro fertilization (IVF).

Methods

Semi-structured telephone interviews were conducted with 37 women who were offered PGT-A with IVF during the summer 2017. Interviews lasted on average 40 min and were audio-recorded, transcribed, and analyzed using a content analysis.

Results

Results identified a number of decisional factors related to values about conception, disability, and pregnancy termination, past pregnancy experiences, optimism toward technology, and cost. Other key issues that were identified include the use of expanded carrier screening prior to IVF, maternal age, and limited education about PGT-A due to the complexity about education for IVF alone.

Conclusion

There is a need to develop decision support tools for the increasing choices of genetic testing options for patients seeking IVF. Including patients’ values, past pregnancy experiences and attitudes toward science into the decision-making process may help promote a more informed decision.

     

Is open surgery the solution to avoid morcellation of uterine sarcomas? A systematic literature review on the effect of tumor morcellation and surgical techniques

Purpose

Today’s surgical standard of care for uterine leiomyomas is laparoscopic and/or vaginal surgery with larger specimens requiring morcellation to avoid open surgery. This is often associated with intra-abdominal dissemination of cellular material which in case of a uterine sarcoma might result in iatrogenic seeding of malignant tumor cells. The aim of this systematic literature review is to evaluate the surgical techniques and the impact of accidental tumor morcellation on the outcome of patients postoperatively diagnosed with malignant uterine sarcomas.

Methods

The National Library of Medicine database (pubmed) and Web of science were searched individually using three different search terms (‘morcel* sarcoma’, ‘survival, sarcoma, treatment, Uter*’, and ‘disease free survival, sarcoma, treatment, uter*’). After excluding duplicates and screening for relevance, 16 articles were left for full-text review, resulting in seven case series with more than 5 patients.

Results

The case numbers range from 14 to 123 patients with the majority of cases being leiomyosarcomas.

Conclusion

There is no reliable diagnostic tool to differentiate a fibroid from a uterine sarcoma preoperatively. Tumor morcellation occurs in various open and closed surgical techniques and is not limited to laparoscopic surgery only. There is an urgent need for a presurgical diagnostic parameter.

     

Evaluation of Severe Maternal Outcomes to Assess Quality of Maternal Health Care at a Tertiary Center

Background

Maternal mortality and near-miss index reflect the quality of care provided by a health facility. The World Health Organization recently published near-miss approach where strict near- miss criteria based on markers of organ dysfunction are defined.

Objectives

The aim of the study was to determine the frequency of severe maternal complications, maternal near-miss cases and maternal deaths, to analyze causes of near-miss and maternal mortality and to determine the values of maternal near-miss indicators.

Methods

This was a prospective observational study conducted at a tertiary care centre in North India from January 2012 – March 2013. WHO's near-miss approach was implemented for evaluation of severe maternal outcomes and to assess the quality of maternal health care.

Results

The number of women attending our facility with severe maternal complications was low (205 in 6,767 live births); as a result maternal near-miss ratio (MNMR) was low; 3.98/1,000 live births; Overall Maternal near-miss mortality ratio (MNM:1MD) was also low, 3.37:1, because of strict criterion of labeling near-miss and delay in referral to the hospital. Hypertensive disorder (37.5 %) was the commonest underlying cause for maternal mortality.

Conclusion

Basic implementation of WHO near-miss approach helped in the systematic identification and evidence-based management of severe maternal complications thereby improving the quality of maternal health in a developing country.

     

Primary ovarian Burkitt’s lymphoma: a rare oncological problem in gynaecology: a review of literature

Purpose

This review presents the information about epidemiology, clinical manifestation, diagnosis and treatment of primary ovarian Burkitt’s lymphoma (BL), including a literature search of available BL cases. The purpose of this review is to draw clinicians’ attention to the possibility of ovarian BL occurrence, which may be important in the differential diagnosis of ovarian tumours.

Methods

PubMed and Web of Science databases were searched using the keywords ‘‘Burkitt’s’’, ‘‘Lymphoma’’, ‘‘Ovarian’’, ‘‘Primary’’, ‘‘Burkitt’s lymphoma’’. Only cases with histopathologically confirmed diagnosis of primary ovarian BL were included in this review.

Results

Fifty articles, reporting cases with an ovarian manifestation of primary non-Hodgkin’s lymphoma, were found. Twenty-one cases with a histopathologically confirmed BL were evaluated to compare various manifestations, treatment and prognosis in ovarian BL.

Conclusions

Primary ovarian BL is a rare condition, included in the entity of non-Hodgkin lymphoma. The tumour can occur uni- or bilaterally in the ovaries with major symptoms such as abdominal pain or a large abdominal mass. Differential diagnosis, based on imaging features and pathological examination of the specimens, is essential for further treatment due to various aetiology of ovarian tumours. Although most of the patients suffering from ovarian BL underwent surgery after the ovarian tumour had been detected, surgical treatment is not the treatment of choice in patients with ovarian lymphoma. The mainstay of therapy is chemotherapy without further surgery. The prognosis is better if the chemotherapy protocol is more aggressive and followed by prophylactic central nervous system chemotherapy. Nowadays, multiagent protocols are administered, which improves the survival rate.

     

Paternal factors contributing to embryo quality

Purpose

Advancing maternal and paternal age leads to a decrease in fertility, and hence, many infertile couples opt for assisted reproductive technologies [ART] to achieve biological parenthood. One of the key determinants of achieving a live outcome of ART, embryo quality, depends on both the quality of the oocyte and sperm that have created the embryo. Several studies have explored the effect of oocyte parameters on embryo quality, but the effects of sperm quality on the embryo have not been comprehensively evaluated.

Method

In this review, we assess the effect of various genetic factors of paternal origin on the quality and development of the embryo.

Results

The effects of sperm aneuploidy, sperm chromatin structure, deoxyribonucleic acid [DNA] fragmentation, role of protamines and histones, sperm epigenetic profile, and Y chromosome microdeletions were explored and found to negatively affect embryo quality.

Conclusion

We propose that careful assessment of spermatozoal parameters is essential to achieve embryo development and a healthy live birth. However, the heterogeneity in test results and the different approaches of assessing a single sperm parameter highlight the need for more research and the development of standardized protocols to assess the role of sperm factors affecting embryo quality.

     

Adverse neonatal and maternal outcome following vacuum-assisted vaginal delivery: does indication matter?

Purpose

To estimate the impact of indication for vacuum-assisted vaginal delivery on neonatal and maternal adverse outcome.

Methods

Retrospective analysis of women carrying singleton-term pregnancies undergoing vacuum-assisted vaginal delivery in a tertiary hospital (2007–2014). Cohort was stratified by indication: non-reassuring fetal heart rate or prolonged second stage. Primary outcome was adverse neonatal outcome and secondary outcome was maternal morbidity. Logistic regression analysis was utilized to adjust for potential confounders.

Result

Overall, 4931 women met inclusion criteria. Delivery indication was prolonged second stage in 3143 (64%) cases and non-reassuring fetal heart rate in 1788 (36%). In the non-reassuring fetal heart rate group, there were higher rates of cephalohematoma, low 5-min Apgar-score, and asphyxia. In the prolonged second-stage group, there were higher rates of sepsis and post-partum hemorrhage. Composite neonatal birth trauma and maternal morbidity were higher for vacuum-assisted vaginal delivery following prolonged second stage. Following adjustment for confounders cephalohematoma (aOR 1.21, 95% CI 1.04–1.41), low 5-min Apgar-score (aOR 2.91, 95% CI 1.26–4.67) and asphyxia (aOR 1.81 95% CI 1.35–2.44) remained significant in the non-reassuring fetal heart rate group and neonatal sepsis remained significant for the prolonged second-stage group (aOR 1.77, 95% CI 1.38–2.27), p?<?0.05 for all. However, there was no longer difference in the composite birth trauma, other neonatal or maternal morbidity.

Conclusion

The indication for vacuum-assisted vaginal delivery has an impact on neonatal outcome. While cephalohematoma, low 5′ Apgar score, and asphyxia were more common in the non-reassuring fetal heart rate group, neonatal sepsis was more common in cases of prolonged second stage of labor.

     

A dose–response relation exists between different classes of pre-gravid obesity and selected perinatal outcomes

Objective

To examine if a “dose–response” relation exists between different classes of pre-gravid obesity and selected perinatal outcomes.

Methods

We evaluated 16,566 obese mothers, including 12,064 (72.8%), 3410 (20.6%), and 1092 (6.6%) with obesity class I, II, and III, respectively. We compared maternal age, primiparity, gestational age at birth, birth weight, GDM, hypertensive disorders, and the incidence of cesarean sections.

Results

There was a significantly increased incidence (from class I to class III) for GDM (8.5–14.4%), chronic hypertension (2.8–9.0%), gestational hypertension (6.7–14.2%), and for preeclampsia (5.3–9.3%). No such relationship existed for birth weight and gestational duration.

Conclusion

Classes of obesity during pregnancy exhibit a “dose–response” relationship with maternal morbidity, but no such relationship was found with pregnancy duration and birth weight.

     

Validation of Canadian mothers’ recall of events in labour and delivery with electronic health records

Background

Maternal report of events that occur during labour and delivery are used extensively in epidemiological research; however, the validity of these data are rarely confirmed. This study aimed to validate maternal self-report of events that occurred in labour and delivery with data found in electronic health records in a Canadian setting.

Methods

Data from the All Our Babies study, a prospective community-based cohort of women’s experiences during pregnancy, were linked to electronic health records to assess the validity of maternal recall at four months post-partum of events that occurred during labour and delivery. Sensitivity, specificity and kappa scores were calculated. Results were stratified by maternal age, gravidity and educational attainment.

Results

Maternal recall at four months post-partum was excellent for infant characteristics (gender, birth weight, gestational age, multiple births) and variables related to labour and delivery (mode of delivery, epidural, labour induction) (sensitivity and specificity >85%). Women who had completed a university degree had significantly better recall of labour induction and use of an epidural.

Conclusion

Maternal recall of infant characteristics and events that occurred during labour and delivery is excellent at four months post-partum and is a valid source of information for research purposes.

     

Comparison of alternative βhCG follow-up protocols after single-dose methotrexate therapy for tubal ectopic pregnancy

Purpose

To evaluate the performances of five different βhCG follow-up protocols after single-dose methotrexate therapy for tubal ectopic pregnancy (EP).

Methods

Data of patients who received single-dose methotrexate therapy for tubal EP at a university hospital between January 2011 and July 2016 were reviewed. A ‘successful methotrexate treatment’ was defined if the EP treated with no need for surgery. The performances of different protocols were tested by comparing with the currently used ‘15% βhCG decrease between days 4 and 7’ protocol. The tested follow-up protocols were ‘20, 25%, and any βhCG decrease between days 0/1 and 7’ and ‘20% and any βhCG decrease between days 0/1 and 4’.

Results

Among the 96 patients evaluated, 12 (12.5%) required second dose. Totally, 91 (94.8%) patients treated successfully with no need for surgery. Four patients were operated within 4 days following the second dose. One patient who did not need second dose according to the standard follow-up protocol was operated on the 10th day due to rupture (specificity = 80%). Two protocols, namely ‘20% βhCG decrease between days 0/1 and 7’ and ‘any βhCG decrease between days 0/1 and 7’ did not show statistically significant differences from the index protocol regarding the number of patients who should be assigned to 2nd dose.

Conclusions

‘Any βhCG decrease between days 0/1 and 7’ protocol may substitute the currently used one to decide second dose methotrexate in tubal EP management. Omitting 4th day measurement seems to be more convenient and cost effective.

     

A long-standing incomprehensible matter of obstetrics: meconium-stained amniotic fluid,a new approach to reason

Objective

We sought to determine whether meconium-stained amniotic fluid is based on chronic hypoxia or not? In case of chronic hypoxia, higher red blood cell (Rbc) count and/or total hemoglobin levels (Hgb) and/or higher fetal hemoglobin (HbF) and/or lower adult hemoglobin (HbA) levels were expected when compared with controls.

Design

Case–control study.

Setting

Obstetric unit of a tertiary ministry of health hospital.

Sample

Fifty singleton pregnancies with meconium-stained amniotic fluid and 50 singleton pregnancies with clear amniotic fluid at all stages of labor.

Methods

Umbilical cord blood samples were collected for determination of total blood parameters and hemoglobin electrophoresis.

Main outcome measures

Red blood cell count, total hemoglobin, fetal and adult hemoglobin contents (HbF and HbA).

Results

Red blood cell count, total hemoglobin, fetal hemoglobin (HbF) and adult hemoglobin (HbA) contents were not different between meconium stained and clear amniotic fluid groups.

Conclusion

These results suggest that meconium passage may not be associated with chronic fetal hypoxia as demonstrated by similar red blood cell count, total hemoglobin values and fetal hemoglobin (HbF) and adult hemoglobin (HbA) contents.

     

A global view of severe maternal morbidity: moving beyond maternal mortality

Background

Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

Severe maternal morbidity in high-income countries

Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify “high risk” status, delays in diagnosis, and delays in treatment.

Severe maternal morbidity in low and middle income countries

The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity.

Effects of SMM on delivery outcomes and infants

Severe maternal morbidity not only puts the woman’s life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn.

Conclusion

Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women’s and infants’ health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

     

The risk of placenta accreta following primary cesarean delivery

Objective

To (a) evaluate the risk for placenta accreta following primary cesarean section (CS), in regard to the stage of labor, the cesarean section was taken (elective prelabor vs. unplanned during labor); and (b) investigate whether the association between placenta accreta and maternal and neonatal complications is modified by the type of the primary CS.

Study design

In a population-based retrospective cohort study, we included all singleton deliveries occurred in Soroka University Medical Center between 1991 and 2015, of women who had a history of a single CS. The deliveries were divided into three groups according to the delivery stage the primary CS was carried out: ‘Unplanned 1’ (first stage—up to 10 cm), ‘Unplanned 2’ (second stage—10 cm) and ‘Elective’ prelabor CS. We assessed the association between the study group and placenta accreta using logistic generalized estimation equation (GEE) models. We additionally assessed maternal and neonatal complications associated with placenta accreta among women who had elective and unplanned CS separately.

Results

We included 22,036 deliveries to 13,727 women with a history of one CS, of which 0.9% (n = 207) had placenta accreta in the following pregnancies: 12% (n = 25) in the ‘Unplanned 1’ group, 7.2% (n = 15) in the ‘ Unplanned 2’ group and 80.8% (n = 167) in the ‘elective’ group. We found no difference in the risk for subsequent placenta accreta between the groups. In a stratified analysis by the timing of the primary cesarean delivery, the risk for maternal complications, associated with placenta accreta, was more pronounced among women who had an unplanned CS (OR 27.96, P < 0.01) compared to women who had an elective cesarean delivery (OR 13.72, P < 0.01).

Conclusions

The stage in which CS is performed has no influence on the risk for placenta accreta in the following pregnancies, women who had an unplanned CS are in a higher risk for placenta accrete-associated maternal complications. This should be taken into consideration while counselling women about their risk while considering trial of labor after cesarean section.

     

Comparison of maternal and fetal complications in elective and emergency cesarean section: a systematic review and meta-analysis

Background

Though the same types of complication were found in both elective cesarean section (ElCS) and emergence cesarean section (EmCS), the aim of this study is to compare the rates of maternal and fetal morbidity and mortality between ElCS and EmCS.

Methods

Full-text articles involved in the maternal and fetal complications and outcomes of ElCS and EmCS were searched in multiple database. Review Manager 5.0 was adopted for meta-analysis, sensitivity analysis, and bias analysis. Funnel plots and Egger’s tests were also applied with STATA 10.0 software to assess possible publication bias.

Results

Totally nine articles were included in this study. Among these articles, seven, three, and four studies were involved in the maternal complication, fetal complication, and fetal outcomes, respectively. The combined analyses showed that both rates of maternal complication and fetal complication in EmCS were higher than those in ElCS. The rates of infection, fever, UTI (urinary tract infection), wound dehiscence, DIC (disseminated intravascular coagulation), and reoperation of postpartum women with EmCS were much higher than those with ElCS. Larger infant mortality rate of EmCS was also observed.

Conclusion

Emergency cesarean sections showed significantly more maternal and fetal complications and mortality than elective cesarean sections in this study. Certain plans should be worked out by obstetric practitioners to avoid the post-operative complications.

     

Hypotension due to spinal anesthesia influences fetal circulation in primary caesarean sections

Purpose

Hypotension due to spinal anesthesia is a well-known side effect in pregnant women receiving caesarean section. Little is known about its impact on fetal blood circulation.

Methods

40 women with uncomplicated singleton term pregnancies prepared for caesarean section were prospectively evaluated by Doppler sonography before and immediately after spinal anesthesia.

Results

In 90% of the women, blood pressure significantly decreased after spinal anesthesia and 42.5% of the patients suffered from severe hypotension. We found a significant negative correlation between maternal blood pressure change and the resistant index (RI) of the umbilical artery (r_s = ? 0.376, p = 0.017) and a significant positive correlation between maternal blood pressure and fetal middle cerebral artery.

Conclusion

Healthy fetuses seem to compensate well in situations with decreased uteroplacental blood flow due to maternal hypotension measured by means of RI changes in the fetal umbilical and middle cerebral artery. This raises the question if growth-restricted and/or preterm fetuses are able to compensate similarly or if general anesthesia would be a method of choice.

     

Auscultation of the fetal heart in early pregnancy

Introduction

Auscultation of the fetal heart is a common event in antenatal care, in early pregnancy it may be associated with false negative results, which require ultrasound scan to confirm fetal viability.

Methods

We studied 197 women in early pregnancy to determine the gestational age at which the fetal heart can be reliably identified and the factors which determined the accuracy of the test.

Results

The proportion of successful auscultations increased with advancing gestation (p < 0.001). There was no effect of maternal body mass index or the level of midwifery experience.

Conclusion

For a sensitivity of 90%, the fetal heart should be auscultated after 13 week gestation. If a sensitivity of 80% is acceptable the fetal heart can be auscultated after 12 + 1 week gestation.

     

A Review of Outcomes in Pregnant Women with Portal Hypertension

Background

The course of pregnancy in a woman with portal hypertension is a difficult one as it is associated with complications like variceal bleeding, splenic artery rupture and coagulopathy. All these pose a threat to a woman’s life. Although this condition is rare, every obstetrician should have a high index of suspicion when an antenatal mother presents with splenomegaly, thrombocytopenia or hematemesis. Hence, we aimed to review maternal and fetal outcomes in pregnant women with portal hypertension.

Methods

In a retrospective observational study, 41 women and 47 pregnancies were evaluated, from January 2000–December 2015 at Fernandez Hospital, a tertiary referral perinatal center. Maternal outcomes studied were variceal bleed during pregnancy, surgical procedures, morbidity and mortality. Neonatal variables were gestational age at delivery, birth weight and morbidities.

Results

Mean maternal age was 26.4 years. Average gestational age at delivery was 36.5 weeks. Mean birth weight was 2507.5 g. There were three maternal deaths out of 47 deliveries, the cause of death was massive variceal bleed in one, the second one was due to cardiac arrest on MRI table, and the third death was due to splenic hilar vessel bleed. There was one stillbirth, and no neonatal deaths.

Conclusion

A multidisciplinary approach is essential to improve perinatal outcomes in pregnancy complicated by portal hypertension. Surgical measures to reduce portal venous pressure done before pregnancy or beta blockers during pregnancy might help reduce sudden variceal bleeds.