Michael Maresh

A UK multicentre retrospective cohort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium‐term safety and efficacy

Objectives  Comparison of medium‐term safety and efficacy of hysterectomy and uterine artery embolisation (UAE) for symptomatic uterine fibroids.

Life events and low birthweight—analysis by infants preterm and small for gestational age

Summary. Social stress was assessed in 92 women with low‐birthweight babies and 92 controls using the detailed LEDS measure of life events and severe chronic difficulties. The low‐birthweight group was divided into preterm delivery (n = 40), small for gestational age (SGA) (n = 40) and mixed groups. Multivariate analysis was performed using a bino‐mial‐logit model to examine whether social factors were independently and significantly associated with low birthweight once the effect of demographic factors, obstetric factors and smoking/drinking were taken into account. Comparison of preterm births with controls indicated that three factors were significantly associated: a previous low‐birthweight baby, severe life event/difficulty and bleeding during pregnancy. For SGA babies the factors were: previous low‐birthweight baby, low social support and smoking. By using a reliable measure of life events and adequate numbers of low‐birthweight babies, this study overcame the potential inaccuracies of previous studies and indicates a more specific relation between social stress and low birthweight.

Optimal Glycemic Control, Pre-eclampsia, and Gestational Hypertension in Women With Type 1 Diabetes in the Diabetes and Pre-eclampsia Intervention Trial

OBJECTIVE To assess the relationship between glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes. RESEARCH DESIGN AND METHODS Pregnancy outcome (pre-eclampsia or gestational hypertension) was assessed prospectively in 749 women from the randomized controlled Diabetes and Pre-eclampsia Intervention Trial (DAPIT). HbA1c (A1C) values were available up to 6 months before pregnancy (n = 542), at the first antenatal visit (median 9 weeks) (n = 721), at 26 weeks’ gestation (n = 592), and at 34 weeks’ gestation (n = 519) and were categorized as optimal (<6.1%: referent), good (6.1–6.9%), moderate (7.0–7.9%), and poor (≥8.0%) glycemic control, respectively. RESULTS Pre-eclampsia and gestational hypertension developed in 17 and 11% of pregnancies, respectively. Women who developed pre-eclampsia had significantly higher A1C values before and during pregnancy compared with women who did not develop pre-eclampsia (P < 0.05, respectively). In early pregnancy, A1C ≥8.0% was associated with a significantly increased risk of pre-eclampsia (odds ratio 3.68 [95% CI 1.17–11.6]) compared with optimal control. At 26 weeks’ gestation, A1C values ≥6.1% (good: 2.09 [1.03–4.21]; moderate: 3.20 [1.47–7.00]; and poor: 3.81 [1.30–11.1]) and at 34 weeks’ gestation A1C values ≥7.0% (moderate: 3.27 [1.31–8.20] and poor: 8.01 [2.04–31.5]) significantly increased the risk of pre-eclampsia compared with optimal control. The adjusted odds ratios for pre-eclampsia for each 1% decrement in A1C before pregnancy, at the first antenatal visit, at 26 weeks’ gestation, and at 34 weeks’ gestation were 0.88 (0.75–1.03), 0.75 (0.64–0.88), 0.57 (0.42–0.78), and 0.47 (0.31–0.70), respectively. Glycemic control was not significantly associated with gestational hypertension. CONCLUSIONS Women who developed pre-eclampsia had significantly higher A1C values before and during pregnancy. These data suggest that optimal glycemic control both early and throughout pregnancy may reduce the risk of pre-eclampsia in women with type 1 diabetes.

Psychosexual health 5 years after hysterectomy: population-based comparison with endometrial ablation for dysfunctional uterine bleeding.

Background  We report a population‐based comparison of psychosexual health 5 years after contrasting amounts of surgical treatments for heavy periods [dysfunctional uterine bleeding (DUB)]. Womens fears about sexual function after hysterectomy might not be unfounded. The psychosexual problems may return and/or develop with time. The removal of ovaries at the time of hysterectomy is associated with greater deterioration of self‐reported sexual function. Surgical menopause significantly impairs sexual wellbeing. We failed to observe uniform beneficial effects of hormone replacement therapy (HRT) on reported psychosexual health.

Grandmultiparae in a modern setting

Objective To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among women who had previously delivered five or more times (grandmultiparous) with that of age‐matched control women who had previously delivered two or three times (multiparous).

Uterine artery embolisation or hysterectomy for the treatment of symptomatic uterine fibroids: a cost-utility analysis of the HOPEFUL study.

Objectives  To evaluate the relative cost‐effectiveness of uterine artery embolisation (UAE) and hysterectomy in women with symptomatic uterine fibroids from the perspective of the UK NHS.

Alterations in bladder volume and the ultrasound appearance of the cervix

Ultrasound inspection of the cervix in pregnancy has been used in an attempt to predict cervical incompetence and preterm delivery. It is known that ultrasound estimations of cervical lengths increase with increasing bladder volumes, particularly if the bladder is ovcrdistended. To overcome this problem the technique of using a ‘full bladder with care to avoid overdistension’ has been described. The main reason behind this apparent lengthening lies in the fact that a variety of external markers (Mahran 1980; Brook et al. 1981; Parkinson & Wilson 1986; Constantini etal. 1986) have been used to locate the internal os, so that its position depends on the relation of the bladder to the lower uterine segment and cervix. The present study quantifies the effect of alterations in bladder volume on ultrasound observed cervical length, using an internal marker for the internal 0s.

The Diabetes and Pre-eclampsia Intervention Trial.

Rates of pre‐eclampsia in women with type 1 diabetes are two to four times higher than in normal pregnancies. Diabetes is associated with antioxidant depletion and increased free radical production, and an increasing body of evidence suggests that oxidative stress and endothelial cell activation may be relevant to disease pathogenesis in pre‐eclampsia. The Diabetes and Pre‐eclampsia Intervention Trial (DAPIT) aims to establish if pregnant women with type 1 diabetes supplemented with vitamins C and E have lower rates of pre‐eclampsia and endothelial activation compared with placebo treatment. Methods: DAPIT is a randomised multicentre double‐blind placebo‐controlled trial that will recruit 756 pregnant women with type 1 diabetes from 20 metabolic‐antenatal clinics in the UK over 4 years. Women are randomised to daily vitamin C (1000 mg) and vitamin E (400 IU) or placebo at 8–22 weeks of gestation until delivery. Maternal venous blood is obtained at randomisation, 26 and 34 weeks, for markers of endothelial activation and oxidative stress and to assess glycaemic control. The primary outcome of DAPIT is pre‐eclampsia. Secondary outcomes include endothelial activation (PAI‐1/PAI‐2) and birthweight centile.

The Role of Angiogenic and Antiangiogenic Factors in the Second Trimester in the Prediction of Preeclampsia in Pregnant Women With Type 1 Diabetes

OBJECTIVE To assess the association between circulating angiogenic and antiangiogenic factors in the second trimester and risk of preeclampsia in women with type 1 diabetes. RESEARCH DESIGN AND METHODS Maternal plasma concentrations of placental growth factor (PlGF), soluble fms-like tyrosine kinase 1 (sFlt-1), and soluble endoglin (sEng) were available at 26 weeks of gestation in 540 women with type 1 diabetes enrolled in the Diabetes and Preeclampsia Intervention Trial. RESULTS Preeclampsia developed in 17% of pregnancies (n = 94). At 26 weeks of gestation, women in whom preeclampsia developed later had significantly lower PlGF (median [interquartile range]: 231 pg/mL [120–423] vs. 365 pg/mL [237–582]; P < 0.001), higher sFlt-1 (1,522 pg/mL [1,108–3,393] vs. 1,193 pg/mL [844–1,630] P < 0.001), and higher sEng (6.2 ng/mL [4.9–7.9] vs. 5.1 ng/mL[(4.3–6.2]; P < 0.001) compared with women who did not have preeclampsia. In addition, the ratio of PlGF to sEng was significantly lower (40 [17–71] vs. 71 [44–114]; P < 0.001) and the ratio of sFlt-1 to PlGF was significantly higher (6.3 [3.4–15.7] vs. 3.1 [1.8–5.8]; P < 0.001) in women who later developed preeclampsia. The addition of the ratio of PlGF to sEng or the ratio of sFlt-1 to PlGF to a logistic model containing established risk factors (area under the curve [AUC], 0.813) significantly improved the predictive value (AUC, 0.850 and 0.846, respectively; P < 0.01) and significantly improved reclassification according to the integrated discrimination improvement index (IDI) (IDI scores 0.086 and 0.065, respectively; P < 0.001). CONCLUSIONS These data suggest that angiogenic and antiangiogenic factors measured during the second trimester are predictive of preeclampsia in women with type 1 diabetes. The addition of the ratio of PlGF to sEng or the ratio of sFlt-1 to PlGF to established clinical risk factors significantly improves the prediction of preeclampsia in women with type 1 diabetes.

Exploring the needs, concerns and knowledge of women diagnosed with gestational diabetes: A qualitative study

OBJECTIVE to explore the concerns, needs and knowledge of women diagnosed with Gestational Diabetes Mellitus (GDM). DESIGN a qualitative study of women with GDM or a history of GDM. METHODS nineteen women who were both pregnant and recently diagnosed with GDM or post- natal with a recent history of GDM were recruited from outpatient diabetes care clinics. This qualitative study utilised focus groups. Participants were asked a series of open-ended questions to explore (1) current knowledge of GDM; (2) anxiety when diagnosed with GDM, and whether this changed overtime; (3) understanding and managing GDM and (4) the future impact of GDM. The data were analysed using a conventional content analysis approach. FINDINGS women experienced a steep learning curve when initially diagnosed and eventually became skilled at managing their disease effectively. The use of insulin was associated with fear and guilt. Diet advice was sometimes complex and not culturally appropriate. Women appeared not to be fully aware of the short or long-term consequences of a diagnosis of GDM. CONCLUSIONS midwives and other Health Care Professionals need to be cognisant of the impact of a diagnosis of GDM and give individual and culturally appropriate advice (especially with regards to diet). High quality, evidence based information resources need to be made available to this group of women. Future health risks and lifestyle changes need to be discussed at diagnosis to ensure women have the opportunity to improve their health.