Reproductive performance of women with müllerian anomalies

PURPOSE OF REVIEW: This review discusses current diagnostic techniques for müllerian anomalies, reproductive outcome data, and management options in reproductive-age women. RECENT FINDINGS: Multiple retrospective studies have investigated reproductive outcomes with müllerian anomalies, but few current prospective studies exist. Uterine anomalies are associated with normal and adverse reproductive outcomes such as recurrent pregnancy loss and preterm delivery, but not infertility. Furthermore, unicornuate, didelphic, bicornuate, septate, arcuate, and diethylstilbestrol-exposed uteri have their own reproductive implications and associated abnormalities. Common presentations of müllerian anomalies and current diagnostic techniques are reviewed. Surgical intervention for müllerian anomalies is indicated in women with pelvic pain, endometriosis, obstructive anomalies, recurrent pregnancy loss, and preterm delivery. Although surgery for most uterine anomalies is a major intervention, the uterine septum is preferentially managed with a hysteroscopic procedure. Several recent studies and review articles discuss management of the septate uterus in asymptomatic women, infertile women, and women with a history of poor reproductive outcomes. Current assessment of reproductive outcomes with uterine anomalies and management techniques is warranted. SUMMARY: Müllerian anomalies, especially uterine anomalies, are associated with both normal and adverse reproductive outcomes, and management in infertile women remains controversial.     

Efficacy of Essure hysteroscopic sterilization – 5 years follow up of 1200 women

Abstract

Objective: To assess the efficacy of the Essure hysteroscopic birth control device after 5 years follow up.

Study design: Retrospective analysis of case series.

Setting: Outpatient hysteroscopy facility in a large teaching hospital.

Subjects: One-thousand three-hundred and twenty-one women who underwent hysteroscopic sterilization with Essure device (Conceptus, Inc., Mountain View, CA) between January 2003 and May 2005

Intervention(s): Hysteroscopic tubal sterilization using Essure system.

Main outcome measure: Efficacy/effectiveness, failure rate.

Results: Satisfactory insertion was accomplished in the first attempt in 1166 women (97.16%). After the second attempt, successful insertion rate rise to 98.6%. (n?=?31, 2.6%). Three pregnancies had been reported after 5 years follow up, which implies an overall absolute rate of 0.25%. This represents a Pearl index of 0.05 after 72?000 months of surveillance. All of them occurred in the first year of use of the microinsert. There has been no unintended pregnancy in the next 4 years.

Conclusion(s): Essure has the lowest Pearl index never published being the most effective permanent birth control system to date. Unintended pregnancies tend to occur in the first year after the insertion, and can be avoided encouraging women to accomplish the protocol.     

Thyroid screening in pregnancy — A study of 82 women

Objectives

To create awareness, lay down a new criterion to pick up probable cases, and draw a proper management protocol for hypothyroidism in pregnancy.

Methods

Inclusion criteria — All normal pregnant women and those with thyroid problems were included in the study. Exclusion criteria — All others who had diabetes, collagen disease, heart disease with pregnancy were excluded from the study. Eighty two women were screened for hypothyroidism in pregnancy using T3, T4, TSH and FT4. A new screening criterion was followed [TSH value — 0.5–1.5 mIU/ml i.e biological range]. Women with TSH in pregnancy were followed up. Women with TSH value above 3mIU/ml, were considered hypothyroid and received treatment with L-Thyroxin. The group with a TSH value 2–3 mIU/ml was assessed with FT4. Those with low values or those with increasing TSH value on subsequent follow up received treatment.

Results

Study group consisted of 62 Primigravidae and 20 multigravidae. A. 40[32P + 8M] > 3 TSH value, these women received treatment with L-Thyroxin B. 24[16P + 8M] 2–3 TSH value, C. 18[14P + 4M] <2 TSH value. According to thyroid status, they were categorized into euthyroid — [27 true euthyroid + 4 potential hypothyroid] and overt hypothyroid — [43 adequately treated and 6 inadequately treated], two were untreated. Inadequately treated and potential hypothyroid pregnant women landed with miscarriages or pregnancy inducted hypertension, oligohydramnios and IUGR.

Conclusions

Potential and inadequately treated hypothyroid patients present with problems in pregnancy, while adequately treated hypothyroid and true euthyroid women get normal ongoing pregnancies. So to identify these potential or overt hypothyroid women, thyroid screening with T3, T4, TSH and FT4 must be done during prenatal period, at first booking, and repeated at 8 weeks interval thereafter, in pregnancy. TSH value should be kept below 2mIU/ml to get adequate control.     

Continuity of carer: what matters to women? A review of the evidence

OBJECTIVES: To consider how 'continuity of carer' has been defined in the literature and to review the literature on what aspects of continuity matter to women. DESIGN: Structured literature review. SETTING: The first objective was addressed within the context of a review of the organisation of midwifery services in the UK; for the second objective a wider literature was drawn on. MEASUREMENTS AND FINDINGS: Data were systematically extracted from the identified 'core' studies on the methods used for assessing continuity of carer and on women's satisfaction with periods of care. Continuity of carer was found to be defined in these studies as fewer caregivers, either overall or during pregnancy, or as a known caregiver in labour. Little attention was paid to other possible interpretations of continuity of carer. The literature on what is important to women was found to have used four distinct methods and findings were consistent within methods. Studies comparing women who had and had not had a known carer in labour found no significant differences in satisfaction; those using rankings or ratings found that a known intrapartum carer was a relatively low priority and most of those using open-ended questions found that few women mentioned continuity. In contrast, all studies which asked postnatal women whether a known intrapartum carer was important reported that those who had experienced it said 'yes', while those who had not, generally thought it unimportant. KEY CONCLUSIONS: There has been an emphasis in existing literature on continuity of carer but little attempt to assess continuity or quality of care. Limited definitions of continuity of carer have been used. There is no evidence that women who were cared for in labour by a midwife that they had already met were more satisfied than those who were not. Other aspects of woman-centred care were likely to be more important. Women wanted consistent care from caregivers that they trust, but most did not value continuity of carer for its own sake. IMPLICATIONS FOR PRACTICE: Limited definitions of continuity of carer seem to be becoming ends in themselves. This has particularly been the case with defining continuity as 'having a known carer in labour'. The available evidence does not justify prioritising this definition of continuity--rather the reverse. This is important for both women and midwives since it opens up other possibilities for organising services that put less strain on midwives' lives and may be equally satisfying for both women and midwives.     

The influence of planned kinds of delivery on pregnant women’s emotional state

Objective: To evaluate if labour induction and elective caesarean section could influence anxiety and depression in pregnant women. Methods: One hundred and sixteen consecutive pregnant women with uncomplicated singleton pregnancy at term, scheduled for these two obstetric procedures were enrolled. An anonymous questionnaire with two self-rating instruments STAI and HAM-A for anxiety and HAM-D for depression was administered. Results: Anxiety levels did not show significant differences while a light depressive mood was evidenced among pregnant women waiting for labour induction (p?=?0.01). Conclusions: An adequate psychological support could be considered a helpful tool for pregnant women scheduled for labour induction.     

Effect of perceptions of menstrual blood loss and menstrual pain on women’s quality of life

Objectives: The aim of the study was to explore Australian women’s experiences of menstruation and effect on quality of life (QoL).

Methods: A representative sample of women recruited through a commercial social research sampling organisation completed a detailed online questionnaire about menstruation. Specific detailed questions were asked about perceptions of heavy menstrual bleeding (HMB) and menstrual pain.

Results: The questionnaire was completed by 1575 women aged 20–39 years. Most perceived their bleeding to be light (11.6%) or moderate (60.5%); 363 (22.5%) perceived it to be heavy and 86 (5.3%) very heavy. Women who experienced severe or very severe menstrual pain were significantly more likely to report periods as heavy or very heavy (p?12 times more likely to be confined to bed for 0.5–1?day during menstruation than if they reported HMB without pain.

Conclusion: Severe menstrual pain with HMB has a much more profound effect on all aspects of women’s QoL than HMB alone; it accounts for more days in bed and for loss of productivity.     

High frequency of congenital thrombophilia in women with pathological pregnancies?

The obstetrical complications preeclampsia, intrauterine growth restriction (IUGR), placental abruption and fetal loss are major causes of maternal and fetal morbidity and mortality. Much recent research has focused on to what extent congenital thrombophilia contributes to these obstetrical complications. Combined with the hypercoagulable state of pregnancy, thrombophilia has the potential to induce placental thrombosis and cause placental insufficiency with subsequent obstetrical complications. This article aims to review and discuss published clinical studies of the relationship between congenital thrombophilia and preeclampsia, IUGR, placental abruption and fetal loss. In addition, the few published clinical trials of prophylactic antithrombotic treatment to prevent severe obstetrical complications in thrombophilic women are discussed. The studies have shown variable results evaluated mainly as a result of the limited number of case reports published. However, the strongest association was found to be between congenital thrombophilia and preeclampsia and late fetal loss. Early fetal loss was not found to be associated with congenital thrombophilia. At present, the question remains open as to whether IUGR and placental abruption is directly associated with thrombophilia or mediated through preeclampsia. In conclusion, the associations between congenital thrombophilia and preeclampsia, IUGR, placental abruption and fetal loss only reaches evidence grade 4. Present recommendations and clinical guidelines are thus based on weak scientific proof.     

How do women of diverse backgrounds value prenatal testing outcomes?

OBJECTIVES: To describe women's preferences for prenatal testing outcomes and to explore their association with sociodemographic characteristics and attitudes. METHODS: We conducted a cross-sectional study of 584 racially/ethnically and socioeconomically diverse pregnant women aged 16 to 47 years recruited from 23 San Francisco Bay Area practices. We assessed preferences for 12 potential prenatal testing outcomes using the time trade-off metric for all outcomes and the standard gamble metric for two outcomes. Preferences were calculated on a scale of 0 (death) to 1 (perfect health). Participants also completed a sociodemographic and attitude survey. RESULTS: Highest preference scores were assigned to outcomes resulting in the birth of a chromosomally normal infant (mean = 0.91-0.93; median = 0.99-1.00). Lower scores were obtained for outcomes involving pregnancy loss (mean = 0.69-0.87; median = 0.76-0.92), which were correlated with attitudes regarding miscarriage, pregnancy termination, and Down syndrome. The lowest scores were assigned to Down syndrome-affected births (mean = 0.67-0.69; median = 0.73-0.75), which also were correlated with attitudes toward Down syndrome. We did not find a statistically significant relationship between participants' preference scores and age. CONCLUSION: Preferences for prenatal testing outcomes vary according to the pregnant women's underlying attitudes about pregnancy loss and Down syndrome, and not according to her age. Current age/risk-based guidelines should account for individual variation in patient preferences.     

Are pregnant women of non-Northern European descent more anaemic than women of Northern European descent?: A study into the prevalence of anaemia in pregnant women in Amsterdam

Objectives

to investigate the prevalence of anaemia in pregnancy according to the cut-off points used in the national clinical guideline ‘Anaemia in Primary Care Midwifery Practice’, and to investigate a possible difference in prevalence between pregnant women of Northern European descent compared with women of non-Northern European descent. The study also investigated whether any difference in prevalence resulted in a higher risk of a transferred home delivery, thus reducing the chance for women to choose the place of birth.

Design

retrospective cohort study.

Setting

primary care midwifery practices in a highly urbanised area in Amsterdam, the Netherlands.

Participants

all patients in three midwifery practices over 1 year were selected provided that they met the inclusion and exclusion criteria. The practices were selected on the basis of urbanisation, resulting in an adequate ethnic population which was comparable with the ethnic mix in other similarly urbanised areas in the Netherlands. This resulted in a study population of 828 pregnant women of Northern European and non-Northern European descent with low-risk singleton pregnancies during 2003.

Analysis

mean haemoglobin level and anaemia rate were computed for the total study population as well as separate ethnic groups. Differences between groups were determined using χ² tests, and effect sizes were expressed in relative risks including 95% confidence intervals (CI).

Findings

the prevalence of anaemia in pregnancy was 3.4% (n=28) at booking (first visit) and 2.7% (n=22) at approximately 30 weeks of gestation. The relative risk of anaemia at booking was 5.9 (95% CI 2.1–16.7) for pregnant women of non-Northern European descent compared with those of Northern European descent. The relative risk of anaemia at approximately 30 weeks of gestation was 22 (95% CI 3–162) for pregnant women of non-Northern European descent compared with those of Northern European descent. The incidence of transferred home delivery was 3.1% in the study population. The relative risk for transferred home delivery was 24.1 (95% CI 3.3–176.7) for pregnant women of non-Northern European descent compared with those of Northern European descent.

Key conclusions and implications for practice

pregnant women of non-Northern European descent are a specific group in terms of anaemia and are at high risk of a low haemoglobin level for all cut-off values; they have a higher chance of becoming anaemic in pregnancy than women of Northern European descent. As a result, they have a higher risk of a transferred home delivery, taking away their opportunity to choose the place of birth. Haemoglobinopathies did not explain the higher risk of anaemia in pregnant women of non-Northern European descent. Being of non-Northern European descent should be added as a risk factor for anaemia in pregnancy until more is known about the background of this risk factor.     

Screening history of women in Malmö with invasive cervical cancer

Objectives

Cervical cancer is one of the most common forms of cancer among women. Cytological screening and follow-up are potentially effective procedures for preventing the development of – and mortality from – cervical cancer. The purpose of this study was to investigate the screening history of women diagnosed with cervical cancer with the aim of improving the screening programme.

Study design

All of the 187 women diagnosed with invasive cervical cancer in Malmö between 1991 and 2000 were identified, and those below 61 years of age (n = 130) were included in the analysis. The cytological and histological screening history of these women prior to their diagnosis was scrutinized. We analyzed shortcomings related to the cervical screening with special attention to participation defined as having had a cervical smear within 1 year of the scheduled time.

Results

Of the non-participants who developed cervical cancer (n = 70), roughly one-third “never participated,” half were “sub-optimal participants,” and one-sixth were “decliners,” i.e., women who declined the recommended measures. Among participants (n = 60), 80% were either “unexplained” (n = 35) or “misread as normal” (n = 13). The 9.5% subgroup of non-participants was at an 11-fold increased risk of being diagnosed with invasive cervical cancer.

Conclusion

The greatest reduction in cervical cancer would be realized if non-participants could be brought into the screening program.     

Reproductive outcome of women with rare Müllerian anomaly: report of 2 cases

Two patients had a rare uterine anomaly characterized by longitudinal vaginal septum, double cervix, and incomplete septum of the uterus with normal fundus. This report is, to our knowledge, the third in the literature. There are some other works describing a similar anomaly, with a complete uterine septum. These cases challenge the classic unidirectional theory of müllerian development and support an alternative bidirectional hypothesis. After definitive diagnosis, the vaginal and uterine septa were successfully resected. Both patients conceived spontaneously and had an uneventful obstetric outcome. Surgical treatment might be an alternative treatment in the case of infertility or recurrent pregnancy loss in patients with such a rare müllerian anomaly. The hysteroscopic uterine reunification should be the preferable surgical method and can improve the poor reproductive outcome.     

Does adjunctive use of progesterone in women with cerclage improve prevention of preterm birth?*

Objective: To evaluate outcomes among pregnancies with cerclage as compared to cerclage and adjunctive progesterone.

Methods: A retrospective cohort study was performed from 1 October 2011–30 June 2015 including women with a singleton gestation with vaginal cerclage. Exclusion criteria included multiple gestations, simultaneous 17-alpha hydroxyprogesterone caproate (17-OHPC) and vaginal progesterone (vag-p) use, and patients lost to follow-up. Primary outcome was prevention of preterm birth less than 35 (PTB <35) weeks gestational age (GA).

Results: One hundred thirty-six patients met inclusion criteria; 73 women had cerclage only, 53 had cerclage and 17-OHPC, 10 had cerclage and vag-p. GA at cerclage placement was similar across groups (p?=?0.068). There was a difference in prevention of PTB <35 weeks GA among groups (p?=?0.035) with a trend toward earlier delivery among patients with cerclage and vag-p. Rates of PTB <35 weeks in the cerclage (29%) and cerclage and 17-OHPC groups (34%) were similar (p?=?0.533). The odds ratio for risk of PTB <35 weeks among women with cerclage and vag-p as compared to all other patients was 5.21 (95%CI: 1.3–21.2).

Conclusion: The combination of cerclage with intramuscular progesterone resulted in similar PTB prevention as compared to cerclage alone. There may be an association between cerclage, vaginal progesterone and higher rates of PTB which may be attributed to characteristics of the group rather than the therapies studied.