Mini-commentary on BJOG-20-1459.R1: Caesarean birth and risk of subsequent preterm birth: retrospective cohort studyDeclarative title to be addedBradley de VriesSchool of Public HealthUniversity of SydneySydneyNew South WalesAustraliaWorldwide, preterm birth occurs in 11% of pregnancies and is the leading cause of childhood mortality. Complications from preterm birth are the most common cause of neonatal death in the United Kingdom, yet the incidence of preterm birth is not falling.In this issue of BJOG, Williams et al (BJOG xxxx) report on an observational study which identifies previous second stage caesarean birth as a risk factor for spontaneous preterm birth, confirming the results of other observational cohorts. Among women with one previous term birth, the adjusted odds ratio was 2.1 (95% confidence interval [CI] 1.3 to 3.1) for preterm birth before 37 weeks gestational age and 7.5 (95% CI 3.4 to 15) for preterm birth before 34 weeks, for previous second stage caesarean birth compared with previous vaginal birth. They adjusted for confounders not addressed in other studies including interpregnancy interval and maternal deprivation index, strengthening the existing evidence. The association is plausible because the cervix and lower uterine segment are anatomically merged in the second stage of labour and inadvertent cervical incision might damage the integrity of the cervix. The association was at least as strong as that described for previous excisional surgery for cervical dysplasia. Current National Institute of Clinical Excellence Guidelines recommend considering prophylactic cervical cerclage for an ultrasound-measured cervical length < 25mm if there is a history of cervical trauma. Given the plausibility and emerging epidemiological evidence, it would seem prudent to offer the same screening and treatment when there is a history of second stage caesarean birth.The observed association is relevant in other ways. Counselling about instrumental versus caesarean birth may be influenced by knowledge of future risks. Additionally, surgeons may need to be aware of the potential importance of avoiding inadvertent cervical incision, while still avoiding upper segment incision and its attendant risk of future intrapartum uterine rupture.The study by Williams et al is well designed, yet there remains potential for confounding not adjusted for in the analysis. Further, missing data for body mass index (1.6%) and cigarette smoking (13%) were classified as unknown and not imputed which can also cause bias. As there are only a handful of observational studies, it would be sensible to confirm the association, and explore potential causative mechanisms (e.g., by monitoring cervical length in subsequent pregnancies).Clinical prediction models for spontaneous preterm labour in asymptomatic women have been developed but need improvement before incorporation into clinical practice. Addition of new risk factors such as second stage caesarean birth and better understanding of the causes of preterm birth could improve these models and ultimately improve outcomes through offering prophylaxis with cervical cerclage, vaginal progesterone, or pessary for women at high risk.Given the massive personal, clinical, and economic burden imposed by preterm birth, the plausibility of the association, and the growing evidence from observational studies, I believe cervical surveillance warranted, with a view to offering prophylactic measures when there is a history of second stage caesarean birth.No disclosures: A completed disclosure of interest form is available to view online as supporting information.
Dear Editor, We really appreciate MN van Ĳsselmuiden et al. for their efforts in conducting the first ever multicenter randomized controlled trial to compare laparoscopic sacrohysteropexy (LSH) with sacrospinous hysteropexy (SSHP).1 However, I have some questions regarding the methodology and results of this trial. What are the reasons for including patients with histories of previous pelvic floor or prolapse surgery in the exclusion criteria? Would randomly and equally allocating these patients into two surgical groups affect the study result or design? Nevertheless, we are really interested in the conduct of anterior or posterior colporrhaphy through the laparoscopic method.Patients presented with anterior vaginal wall prolapse are higher in number: POP-Q stage- Aa or Ba > 0 (LSH group:81%; SSHP group:72.6%) than those presented with apical prolapse (LSH group:46.6%; SSHP:45.6%) in Table 1. The majority of study population appears to have combined anterior and apical compartment prolapse rather than apical prolapse alone. Furthermore, Table 2 shows that the overall anterior compartment failure rates are 50.9% and 56.9% in the LSH and SSHP groups, respectively, in a 1 year follow-up interval. The failure rate is extraordinarily high compared with that in a previous study.2 Hysteropexy surgery is beneficial for patients with apical prolapse. It is not beneficial for patients with combined anterior and apical compartment prolapse with prominent cystocele. Most patients are satisfied with the 1 year surgical results and would recommend surgery to someone else (LSH: 87.7%; SSHP: 89.7%) despite the high recurrence rate of anterior wall prolapse in a 1 year follow-up.In the statistical analysis section, additional anterior vaginal wall repairs are significantly higher in the SSHP group than those in the LSH group (SSHP: n = 61, 98.4%; LSH: n = 55, 85.9%, P = 0.010). I would like to know how this small number difference (61 − 55 = 6) in these groups can cause significant difference in P value and how this P value is calculated. This trial assumes a failure rate of 3% on the basis of the outcomes of SSHP in a previous prospective study. However, the data population is relatively small, and the non-inferiority margin was set at 10%.The primary outcome is defined as a composite outcome of the surgical failure of the apical compartment after 12 months of follow-up and as the recurrence of uterine prolapse (POP-Q ≥ stage 2). Surgical success is defined as the absence of prolapse beyond the hymen. In the POP-Q stage system, POP-Q stage 2 is defined as the most distal prolapse between 1 cm above and 1 cm beyond the hymen.3 The most prominent prolapse, which descends beyond hymen, is the stage 2 prolapse. It elicits clinical controversy and conflicts with regard to the definitions of surgical failure and success. We hope that this letter will deliver the message that precise preoperative patient selection and study design are crucial, as they may have substantial impacts on clinical outcomes and treatment success.Min-syuan Huang,2, 3 Zi-Xi Loo,1Kun- Ling Lin,1, 2 Cheng-Yu Long1, 21 Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan2 Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan3 Department of Obstetrics and Gynecology, Kuo General Hospital, Tainan, Taiwan
Dear Sir, Whilst the primary focus of our commentary was to reflect upon the multitude of clinical and institutional changes prompted by COVID-19 to help adopt a more streamlined approach to healthcare,1we thank Herron et al for highlighting the importance of partner support during labour.2 However, we note that even during the peak of the first wave of infections, the Royal College of Obstetricians and Gynaecologists (RCOG) continued to advocate the presence of a single birth partner throughout labour. Many obstetric units, including our own, managed to successfully adhere to this practice throughout the pandemic. However, guidance from the RCOG for women attending antenatally, for face to face clinic appointments or ultrasound scans, was to attend alone. This was subsequently implemented in most hospitals in order to reduce the number of visitors.1 Whilst necessary during the initial fear and uncertainty surrounding COVID-19, moving forward it is important to consider the potential negative impact of partner non-attendance antenatally, as well as intrapartum. Partners often positively encourage women to seek care and prepare for birth complications, thereby preventing delay in treatment and helping to manage expectations, which have been shown to positively impact outcomes.3 Whilst undoubtedly an exciting time for many, pregnancy and the prospect of motherhood is daunting to others. Partners provide support and facilitate decision making throughout the antenatal process, particularly in difficult circumstances such as following the diagnosis of a missed miscarriage, during counselling for pregnancies affected by genetic abnormalities, or after an intrauterine death. The restrictions on partner attendance may therefore inadvertently prevent a number of women seeking care during pregnancy, for fear of having to face procedures or receiving bad news alone. Evidence from a London hospital supports this notion after demonstrating a significant increase in stillbirth rate during the pandemic compared to pre-pandemic (9.31 per 1000 births Vs 2.38 per 1000 births; p=0.01). Of significance, no cases were affected by COVID-19, nor were there any post-mortem findings suggestive of the virus.4The utilisation of remote consultations with a woman and her partner offers a suitable option in appropriately triaged cases.1 Even in remote consultations where inadvertent difficult decisions arise, the presence and support of their partner facilitates collaborative decision making. Ironically, those with high risk enough pregnancies to warrant in person consultations, where additional support could offer significant value, are those whereby partners are not permitted. Prior to the pandemic, partners often reported feeling excluded, fearful of the uncertainty of pregnancy and labour and frustrated by perceived lack of support from healthcare professionals.5 This may subsequently negatively impact their relationship because of the inability to adequately support their partners. Their exclusion from the majority of antenatal care therefore, may not only negatively impact psychological wellbeing of women which may in turn result in suboptimal outcomes, but also negatively impact their future relationship. As such, we agree with Herron et al and support their notion that attempts should be made towards delivering individualised patient centred care both antenatally and intrapartum.Lorraine S Kasaven1,2, Srdjan Saso1,2, Jen Barcroft1,2, Joseph Yazbek1,2, Karen Joash1, Catriona Stalder1, Jara Ben Nagi,2 J Richard Smith,1,2 Christoph Lees1,2, Tom Bourne1,2, Benjamin P Jones1,21 Queen Charlotte’s and Chelsea Hospital, Department of Cancer and Surgery, Imperial College NHS Trust, W12 0HS London, UK.2 Imperial College London, Department of Cancer and Surgery, London W12 0NN, UK.
Dear Editor in ChiefWe read with interest “The outcome of pregnancy in women with cystic fibrosis: a UK population based descriptive study1.” We thank the authors for this timely paper which highlights the growing need for robust clinical data capture for Cystic Fibrosis maternal and infant health.This is a rapidly expanding area of interest as the landscape of CF care is changing dramatically, particularly in the era of CFTR modulation. Clinical teams caring for people living with CF are increasingly being asked about pregnancy and potential risks to mothers and their babies. As the authors highlight data on pregnancy in CF historically has mainly been small case series from single sites carried out before CFTR modulators were widely available. The guidelines referenced are somewhat dated as the authors allude to.The authors describe the strength of the data collection in the form of the UK OSS. However, over the 24 month period only 71 cases are collected. The authors also reference around 30 -40 women with CF being pregnant per year in the UK.* We suspect that there are a significant proportion of missing cases within this study suggested by an interrogation of the UK CF Registry data. The UK CF Registry has been sponsored and hosted by the CF Trust since 2007. CF clinical care teams enter data at every specialist centre and clinic across the UK, with over 99% of people with CF consenting to their data being submitted. Data from the UK CF Registry over the time period reported by this study revealed 64, 71 and 58 women having babies in 2015, 2016 and 2017 respectively. Although it is not possible to exactly match the dates (March 2015 to February 2017) described within this study to the CF registry data it is likely that there were considerably more than 71 cases in a two year period. **There remain queries regarding the clinical details of those women reported in this study. Eight of the 71 (11%) had no underlying CFTR mutation available and 51% were reported as pancreatic sufficient which is much higher than would be expected from a cohort of adults with CF in the UK. For 15 of the women included in the case series, lung function is not described.One of the main conclusions of the paper is that gestational age is highly correlated with FEV1. We find the presentation of this misleading as this is most likely the case because women with poorer lung function had pre-term caesareans or had labour induced earlier. Although this doesn’t change the correlation it may mean that it is due to the intervention.There is an ongoing UK Government funded project, CF Prosper, looking at pregnancies in women with CF using UK CF Registry and US CF Foundation registry data from 2003 to current (https://cfprosper.yolasite.com). We expect to be able to report on over 1000 pregnancies and help to delineate predictive factors for successful pregnancies and examine subsequent maternal disease trajectory after starting a family. Using the largest dataset yet available we also hope to develop a decision-making tool in conjunction with women living with CF and their clinical care teams to enable women with CF to make more informed choices regarding pregnancy and starting a family.Yours faithfully,Jamie Duckers, Cardiff and Vale University Health Board, UKDaniela Schlueter, Liverpool University, UKRhiannon Phillips, Cardiff Metropolitan University, UKRebecca Cosgriff, Cystic Fibrosis Trust, UKEsan Oluwaseun, Liverpool University, UKShantini Paranjothy, Aberdeen University, UKDeni Williams, Cardiff Metropolitan University, UKRachel Norman Cardiff and Vale University Health Board, UKDavid Taylor Robinson, Liverpool University, UKSiobhan Carr, Royal Brompton Hospital, London UK1) Ashcroft A, Chapman SJ, Mackillop L. The outcome of pregnancy in women with cystic fibrosis: a UK population-based descriptive study. BJOG. 2020 Jul 19. doi: 10.1111/1471-0528.16423. Epub ahead of print. PMID: 32683738.*There appears to be an error in the referencing numbering within the article as no reference 13 exists**Details on how to request data from the UK CF Registry are available via www.cysticfibrosis.org.uk/registry
Dear Sir,We read with interest Kasaven et al., (1) who eloquently describe some of the implications to the practice of obstetrics and gynaecology. They correctly identify the heightened anxiety that patient’s face when attending hospital during pregnancy. During this time the reduction in patient attendance can be multifactorial. However, we feel one area which has been neglected is partner support. There is evidence that having a partner present during a birth can reduce a woman’s anxiety and additionally be beneficial to the partner (2). Father’s also can experience significant anxiety in the peri-natal period (2) and maternal stress particularly with relationship strain can be harmful to the baby. Parental presence during CPR for a child is beneficial for parents as they can make sense of the situation. It logically would also be beneficial to partners with maternal emergency caesarean sections and of course postnatally to bond with the baby (3). Current policy dictates that fathers can only be present during the birth, however in a multiparous woman or a woman requiring a crash caesarean section the timeframe allowing for partner’s attendance is not reasonable or feasible. COVID-19 is clearly the reason for this policy, however, examining the risk of a couple, who have both been screened as negative on a COVID-19 test and live in the same household. If the male member of the couple has COVID-19 the female is likely to have a high viral load from the partner due to kissing or sexual intercourse (4), a common practice in an attempt to induce labour. The early knowledge of infection can allow for appropriate infection control measures to be put in place. The rate of a false negative is 4-30% (4) but this is still a risk with the mother. The risk to staff with correct personal protective equipment and training is minimal (4). Additionally, women who do not have continuous support are more likely to have an instrumental/surgical delivery, use more pain medication, prolonged labours which may result in complications such as postpartem haemorrhage (5), which ultimately places hospitals and clinicians at greater risk of litigation. With risk of domestic violence and risk of increased mental health issues as highlighted by Kasaven et al., are we doing more harm than good and is this an unintended consequence of COVID-19 that could be prevented? The implication to patient care is huge for what appears to be little benefit. Have we forgotten that we should be delivering patient centred care? Perhaps it is time for change.Herron JBT (1), Herron RL (2)1. University of Sunderland, Faculty of health science and wellbeing, Chester Road, Sunderland SR1 3SD.2. Northumbria University, School of Nursing, Midwifery and Health, 2 Sandyford Rd, Newcastle upon Tyne NE1 8QH.
We describe a novel surgical technique of 31 patients with histopathologically–confirmed placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team using prophylactic infrarenal abdominal aortic cross-clamping technique during cesarean hysterectomy. We conclude that this new surgical procedure is a safe and effective technique to reduce operative blood loss. Hopefully, our pioneer work will stimulate others to develop protocols assessing this innovative technique to improve surgical outcome of PAS disorders.