Bwj Mol

Macrosomia despite good glycaemic control in Type I diabetic pregnancy; results of a nationwide study in The Netherlands.

Abstractn Aims/hypothesis. To investigate the incidence of foetal macrosomia (i.e. birth weight >90th percentile) in a non-selected nationwide cohort of women with Type I (insulin-dependent) diabetes mellitus in The Netherlands and to identify risk indicators predictive for macrosomia.n Methods. We conducted a prospective nationwide cohort based survey regarding the outcome of Type I diabetic pregnancy in The Netherlands. Data of 289 women who gave birth to a live singleton infant without major congenital malformations at more than or equal to 28 weeks of gestation are shown.n Results. The incidence of foetal macrosomia was very high (48.8%), with 26.6% of infants weighing more than 97.7th percentile. Glycaemic control during pregnancy was good (i.e. mean HbA1c ≤7.0%), in almost all (84%) women. Multiple logistic regression analysis resulted in a predictive model for macrosomia that incorporated five variables: third trimester HbA1c (Odds Ratio [95% Confidence Interval]: (1.6[1.1–2.4]), absence of third trimester severe hypoglycaemia (3.0[1.2–7.3]), the use of insulin lispro (3.1[0.9–10.4]), weight gain during pregnancy (1.1[1.0–1.2]) and non-smoking (2.8[0.9–9.3]). Third trimester HbA1c was the most powerful predictor for the occurrence of macrosomia, but its predictive capacity was weak (explained variance <5%).n Conclusion/interpretation. Despite apparent good glycaemic control, the incidence of foetal macrosomia in this non-selected prospective nationwide cohort of 289 Type I diabetic women was very high. Third trimester HbA1c was the most powerful predictor, but its predictive capacity was weak. Thus, future research should focus on new more detailed glucose monitoring techniques (such as a continuous glucose monitoring system) as well as to alternative factors to reduce macrosomia.

Accuracy of circulating placental growth factor, vascular endothelial growth factor, soluble fms‐like tyrosine kinase 1 and soluble endoglin in the prediction of pre‐eclampsia: a systematic review and meta‐analysis

Please cite this paper as: Kleinrouweler C, Wiegerinck M, Ris‐Stalpers C, Bossuyt P, van der Post J, von Dadelszen P, Mol B, Pajkrt E, for the EBM CONNECT Collaboration. Accuracy of circulating placental growth factor, vascular endothelial growth factor, soluble fms‐like tyrosine kinase 1 and soluble endoglin in the prediction of pre‐eclampsia: a systematic review and meta‐analysis. BJOG 2012;119:778–787.

Contraception and the risk of ectopic pregnancy: a meta-analysis.

The current knowledge of the association between contraceptive methods and the risk of ectopic pregnancy was evaluated by means of a meta-analysis. Case-control and cohort studies published between 1978 and 1994 in English, French, German and Dutch were retrieved by a search in Medline, a hand-search on recent medical journals and cross-references. Papers reporting on the association between contraceptives and ectopic pregnancy were judged according to predefined entrance criteria concerning selection of control groups, and retractability of raw data enabling the calculation of crude odds ratios. Common Odds Ratios (COR) and 95% confidence intervals were calculated if homogeneity was not rejected. Twelve case-control studies and one cohort study were detected. CORs could be calculated for current and past use of oral contraceptives, past IUCD use and tubal sterilization. All assessed contraceptives protect against ectopic pregnancy. Women becoming pregnant after sterilization or while currently using an IUCD are at an increased risk. The IUCD is the only contraceptive method associated with an increased risk after discontinuation of its use.

Glucose challenge test for detecting gestational diabetes mellitus: a systematic review

Please cite this paper as: van Leeuwen M, Louwerse M, Opmeer B, Limpens J, Serlie M, Reitsma J, Mol B. Glucose challenge test for detecting gestational diabetes mellitus: a systematic review. BJOG 2012;119:393–401.

Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison

STUDY QUESTIONnWhat is the treatment success rate of systemic methotrexate (MTX) compared with expectant management in women with an ectopic pregnancy or a pregnancy of unknown location (PUL) with low and plateauing serum hCG concentrations?nnnSUMMARY ANSWERnIn women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations, expectant management is an alternative to medical treatment with single-dose systemic MTX.nnnWHAT IS KNOWN AND WHAT THIS PAPER ADDSnMTX is often used in asymptomatic women with an ectopic pregnancy or a PUL with low and plateauing serum hCG concentrations. These pregnancies may be self-limiting and watchful waiting is suggested as an alternative, but evidence from RCTs is lacking. The results of this RCT show that expectant management is an alternative to treatment with systemic MTX in a single-dose regimen in these women.nnnSTUDY DESIGN, SIZE, DURATIONnA multicentre RCT women were assigned to systemic MTX (single dose) treatment or expectant management, using a web-based randomization program, block randomization with stratification for hospital and serum hCG concentration (<1000 versus 1000-2000 IU/l). The primary outcome measure was an uneventful decline of serum hCG to an undetectable level (<2 IU/l) by the initial intervention strategy. Secondary outcome measures included additional treatment, side effects and serum hCG clearance time.nnnPARTICIPANTS, SETTING, METHODSnFrom April 2007 to January 2012, we performed a multicentre study in The Netherlands. All haemodynamically stable women >18 years old with both an ectopic pregnancy visible on transvaginal sonography and a plateauing serum hCG concentration <1500 IU/l or with a PUL and a plateauing serum hCG concentration <2000 IU/l were eligible for the trial.nnnMAIN RESULTSnWe included 73 women of whom 41 were allocated to single-dose MTX and 32 to expectant management. There was no difference in primary treatment success rate of single-dose MTX versus expectant management, 31/41 (76%) and 19/32 (59%), respectively [relative risk (RR) 1.3 95% confidence interval (CI) 0.9-1.8]. In nine women (22%), additional MTX injections were needed, compared with nine women (28%) in whom systemic MTX was administered after initial expectant management (RR 0.8; 95% CI 0.4-1.7). One woman (2%) from the MTX group underwent surgery compared with four women (13%) in the expectant management group (RR 0.2; 95% CI 0.02-1.7), all after experiencing abdominal pain within the first week of follow-up. In the MTX group, nine women reported side effects versus none in the expectant management group. No serious adverse events were reported. Single-dose systemic MTX does not have a larger treatment effect compared with expectant management in women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations.nnnWIDER IMPLICATIONS OF THE FINDINGSnSixty percent of women after expectant management had an uneventful clinical course with steadily declining serum hCG levels without any intervention, which means that MTX, a potentially harmful drug, can be withheld in these women. BIAS, LIMITATION AND GENERALISABILITY: A limitation of this RCT is that it was an open (not placebo controlled) trial. Nevertheless, introduction of bias was probably limited by the strict criteria to be fulfilled for treatment with MTX.nnnSTUDY FUNDINGnThis trial is supported by a grant of the Netherlands Organization for Health Research and Development (ZonMw Clinical fellow grant 90700154).nnnTRIAL REGISTRATIONnISRCTN 48210491.

Transfusion policy after severe postpartum haemorrhage: a randomised non-inferiority trial

To assess the effect of red blood cell (RBC) transfusion on quality of life in acutely anaemic women after postpartum haemorrhage.

Accuracy of body mass index in predicting pre-eclampsia: bivariate meta-analysis

Objectiveu2002 The objective of this study was to determine the accuracy of body mass index (BMI) (pre‐pregnancy or at booking) in predicting pre‐eclampsia and to explore its potential for clinical application.

Improving the existing diagnostic strategy by accounting for characteristics of the women in the diagnostic work up for postmenopausal bleeding

Sir, We read with interest the article of Opmeer et al.1 on improving the existing diagnostic strategy for postmenopausal bleeding (PMB) by accounting for characteristics of the women. However, certain issues need to be clarified. Abnormal endometrial sonographic textures such as inhomogeneous echotexture or obvious invasion of the underlying myometrium are consistent with malignancy detected by transvaginal sonography (TVS).2 A meta-analysis confirmed the utility of TVS as a means to exclude endometrial carcinoma.3 Could the authors kindly comment on the incidence of abnormal endometrial sonographic texture in their population? We agree that the main objective in the diagnostic workup of women with PMB is to detect or rule out endometrial cancer, but neither there was mention of cervical cancer in the article by Opmeer et al. nor did they exclude women with cervical cancer. Although cervical cancer is relatively uncommon in developed countries, it is the third most common form of cancer in women worldwide and the leading cancer of women in sub-Saharan Africa, central and South America, and South-East Asia.4 In the study by Ergete and Tesfaye,5 the most common cause of PMB was cervical carcinoma, which accounted for 51.6% cases, which correlates with reports from other developing countries.4 We therefore suggest that the PMB diagnostic workup should include cytological screening or visual inspection with acetic acid with endocervical sampling in addition to TVS and/ or endometrial biopsy, especially in developing countries. j

Risk factors for postpartum urinary retention: a systematic review and meta-analysis.

Please cite this paper as: Mulder F, Schoffelmeer M, Hakvoort R, Limpens J, Mol B, van der Post J, Roovers J. Risk factors for postpartum urinary retention: a systematic review and meta‐analysis. BJOG 2012;119:1440–1446.

Diagnostic Strategies for Postmenopausal Bleeding

Postmenopausal bleeding (PMB) is a common clinical problem. Patients with PMB have 10%–15% chance of having endometrial carcinoma and therefore the diagnostic workup is aimed at excluding malignancy. Patient characteristics can alter the probability of having endometrial carcinoma in patients with PMB; in certain groups of patients the incidence has been reported to be as high as 29%. Transvaginal sonography (TVS) is used as a first step in the diagnostic workup, but different authors have come to different conclusions assessing the accuracy of TVS for excluding endometrial carcinoma. Diagnostic procedures obtaining material for histological assessment (e.g., dilatation and curettage, hysteroscopy, and endometrial biopsy) can be more accurate but are also more invasive. The best diagnostic strategy for diagnosing endometrial carcinoma in patients with PMB still remains controversial. Future research should be focussed on achieving a higher accuracy of different diagnostic strategies.