Anna-Maija Tapper

Preterm delivery after surgical treatment for cervical intraepithelial neoplasia.

OBJECTIVE: To study whether a treatment of cervical intraepithelial neoplasia (CIN) is associated with an adverse outcome in the subsequent pregnancies. METHODS: This study is a register-based retrospective cohort study from Finland. National data of 25,827 women having a surgical treatment of the cervix for CIN in 1986–2003 and their 8,210 subsequent singleton births in 1987–2004 were studied. Main outcome measures were preterm birth rate, low birth weight rate, and perinatal mortality rate. RESULTS: The risk of any preterm delivery (less than 37 weeks of gestation), especially the risk of very preterm delivery (28–31 weeks of gestation), and extremely preterm delivery (less than 28 weeks of gestation) was increased after cervical conization (relative risk [RR] 1.99, 95% confidence interval [CI] 1.81–2.20; RR 2.86, 95% CI 2.22–3.70; and RR 2.10, 95% CI 1.47–2.99, respectively). After cervical ablation, the risk of preterm delivery was also increased. The risk of low birth weight and perinatal death was increased after conization (RR 2.06, 95% CI 1.83–2.31 and RR 1.74, 95% CI 1.30–2.32, respectively). Adjusting for maternal age, parity, and maternal smoking did not affect our results. CONCLUSION: Any treatment for CIN, including loop electrosurgical excision procedure, increases the risk of preterm delivery. It is important to emphasize this when treating young women with CIN. LEVEL OF EVIDENCE: II

Loop electrosurgical excision procedure and the risk for preterm birth.

OBJECTIVE: To study whether loop electrosurgical excision procedure (LEEP) conization is associated with preterm birth and to study the effect of cone size on preterm birth. METHODS: This was a retrospective cohort study from Southern Finland conducted from 1997 to 2003, with a follow-up for subsequent births until 2006. We identified the cases from the Hospital Discharge Register and Medical Birth Register and collected additional information from the hospital records. Our cohort consisted of 624 women who delivered after LEEP conization. We calculated expected preterm birth rates by using the Medical Birth Register data. In subgroup analysis (n=258 women) we used internal controls, ie, deliveries before the treatment. The main outcome measure was preterm birth rate in different subgroups. RESULTS: The risk for preterm delivery (before 37 weeks) was increased almost threefold (relative risk [RR] 2.61, 95% confidence interval [CI] 2.02–3.20; number needed to treat for harm=14) and repeat treatments more than fivefold (RR 5.15, 95% CI 2.45–7.84; number needed to treat for harm=5) after LEEP conization compared with the background rate of preterm birth (4.61%). Large or repeat cones increased the risk twofold (RR 2.45, 95% CI 1.38–3.53) when compared with small or medium-sized cones. For women having a birth before and after LEEP conization, the preterm birth rate was 6.5% before and 12.0% after the procedure (RR 1.94, 95% CI 1.10–3.40; number needed to treat for harm=18). Adjusting for maternal age, parity, or both did not change the results. The risk for preterm birth was especially increased (RR 3.38, 95% CI 2.31–4.94) among women without previous preterm birth. CONCLUSION: Loop electrosurgical excision procedure surgery of the cervix predisposes patients to preterm birth. Loop electrosurgical excision procedure conization increased the risk for preterm birth especially among women without previous preterm birth. The rates were highest after repeat procedures. LEVEL OF EVIDENCE: II

The incidence of preterm deliveries decreases in Finland

Objective  We examined the trends and risk factors of preterm delivery.

A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions

In order to assess the effectiveness and costs of robot-assisted hysterectomy compared with conventional techniques we reviewed the literature separately for benign and malignant conditions, and conducted a cost analysis for different techniques of hysterectomy from a hospital economic database. Unlimited systematic literature search of Medline, Cochrane and CRD databases produced only two randomized trials, both for benign conditions. For the outcome assessment, data from two HTA reports, one systematic review, and 16 original articles were extracted and analyzed. Furthermore, one cost modelling and 13 original cost studies were analyzed. In malignant conditions, less blood loss, fewer complications and a shorter hospital stay were considered as the main advantages of robot-assisted surgery, like any mini-invasive technique when compared to open surgery. There were no significant differences between the techniques regarding oncological outcomes. When compared to laparoscopic hysterectomy, the main benefit of robot-assistance was a shorter learning curve associated with fewer conversions but the length of robotic operation was often longer. In benign conditions, no clinically significant differences were reported and vaginal hysterectomy was considered the optimal choice when feasible. According to Finnish data, the costs of robot-assisted hysterectomies were 1.5-3 times higher than the costs of conventional techniques. In benign conditions the difference in cost was highest. Because of expensive disposable supplies, unit costs were high regardless of the annual number of robotic operations. Hence, in the current distribution of cost pattern, economical effectiveness cannot be markedly improved by increasing the volume of robotic surgery.

The Nordic medical birth registers – a potential goldmine for clinical research

The Nordic medical birth registers have long been used for valuable clinical research. Their collection of data for more than four decades offers unusual possibilities for research across generations. At the same time, serum and blotting paper blood samples have been stored from most neonates. Two large cohorts (approximately 100 000 births) in Denmark and Norway have been described by questionnaires, interviews and collection of biological samples (blood, urine and milk teeth), as well as a systematic prospective follow‐up of the offspring. National patient registers provide information on preceding, underlying and present health problems of the parents and their offspring. Researchers may, with permission from the national authorities, obtain access to individualized or anonymized data from the registers and tissue‐banks. These data allow for multivariate analyses but their usefulness depends on knowledge of the specific registers and biological sample banks and on proper validation of the registers.

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

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.

The Nordic Obstetric Surveillance Study: a study of complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery

To assess the rates and characteristics of women with complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery in the Nordic countries.

Costs and health‐related quality of life effects of hysterectomy in patients with benign uterine disorders

Objective. To gain knowledge about the utility of hysterectomy in a real‐world setting and to relate the utility of the intervention to its costs. Design. Prospective observational study. Setting. University referral hospital in Helsinki. Population. A total of 337 women entering for routine hysterectomy due to a benign disease (210 benign uterine or ovarian cause, 20 endometriosis, 51 uterovaginal prolapse, 56 menorrhagia). Methods. Patients filled in the 15D health‐related quality of life (HRQoL) questionnaire before and six months after the operation. Costs were examined from the perspective of secondary care provider. Benefits of surgery were extrapolated till the end of remaining statistical life expectancy of each woman in the prolapse group and until menopause in the other groups. Main outcome measures. HRQoL and cost per quality‐adjusted life year (QALY) gained. Results. Mean [standard deviation (SD)] HRQoL score (on a 0–1 scale) in the whole group improved from the preoperative of 0.905 (0.073) to 0.925 (0.077) six months after the operation (p < 0.001). The largest mean (SD) improvement was seen in patients with endometriosis [0.048 (0.067)] followed by those with menorrhagia [0.024 (0.054)], benign uterine or ovarian cause [0.018 (0.071)], and prolapse [0.017 (0.055)]. In the whole group, the intervention produced a mean (SD) of 0.222 (1.270) QALYs at mean (SD) direct hospital cost of €3,138 (2,098). Consequently, the cost per QALY gained in the whole group was €14,135 varying from €3,720 to 31,570 in the disease groups. Conclusions. The cost per QALY gained for hysterectomy for benign uterine disorders is strongly dependent on the indication for surgery.

Long-term mortality in women treated for cervical intraepithelial neoplasia

Objective  The objective of this study was to study whether women surgically treated for cervical intraepithelial neoplasia (CIN) have increased mortality later in life. We also wanted to study whether pregnancy beyond 22 weeks post‐treatment affects the risk.

Risk factors for blood transfusion at delivery in Finland

Objective. To examine the prevalence and risk factors for blood transfusion during delivery. Design. Register‐based retrospective cohort study from Finland. Setting. National Medical Birth Register data during 2006–2008. Sample. A total of 171 731 women having singleton deliveries, of whom 3394 (1.98%) received blood transfusion. Methods. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) by multivariate logistic regression to adjust for confounders related to maternal background and mode of delivery. Main outcome measures. Blood transfusion rates by risk factors. Results. Blood transfusion rate during labor increased slightly, from 1.83% in 2006 to 2.27% in 2008 (p < 0.001), during the study period. The highest rate, almost 4%, was reported in central hospitals. Advanced maternal age and primiparity predisposed to blood transfusion. A previous cesarean section increased these rates also in subsequent vaginal delivery (2.64%) compared with women who had vaginal deliveries only (0.86%, OR 3.14, 95% CI 2.65–3.72). Induction of labor almost doubled the risk for blood transfusion (adjusted OR 1.74, 95% CI 1.60–1.89). All instrumental vaginal deliveries (adjusted OR 2.46, 95% CI 2.25–2.69) and any cesarean sections (adjusted OR 1.80, 95% CI 1.66–1.96) increased this risk. Delivery of a large‐for‐gestational age newborn increased the blood transfusion risk over twofold. Conclusions. As previous cesarean section includes an increased risk for blood transfusion, even in subsequent deliveries, it is essential to consider the mode of labor carefully. The blood transfusion rate was the highest in central hospitals, suggesting differences in blood transfusion practice.