Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study.

OBJECTIVE: To investigate, among women who have had a third- or fourth-degree perineal tear, the mode of delivery in subsequent pregnancies as well as the recurrence rate of third- or fourth-degree tears. DESIGN: A retrospective cohort study of deliveries using a national administrative database. SETTING: The English National Health Service between 1 April 2004 and 31 March 2012. POPULATION: A total of 639,402 primiparous women who had a singleton, term, vaginal live birth between April 2004 and March 2011, and a second birth before April 2012. METHODS: Multivariable logistic regression models were used to estimate odds ratios, adjusted for other risk factors. MAIN OUTCOME MEASURES: Mode of delivery and recurrence of tears at second birth. RESULTS: The rate of elective caesarean at second birth was 24.2% for women with a third- or fourth-degree tear at first birth, and 1.5% for women without (adjusted odds ratio, aOR 18.3, 95% confidence interval, 95% CI 16.4-20.4). Among women who had a vaginal delivery at second birth, the rate of third- or fourth-degree tears was 7.2% for women with a third- or fourth-degree tear at first birth, compared with 1.3% for women without (aOR 5.5, 95% CI 5.2-5.9). CONCLUSIONS: The risk of a severe perineal tear is increased five-fold in women who had a third- or fourth-degree tear in their first delivery. This increased risk should be taken into account when decisions about mode of delivery are made.

A population-based cohort study of the effect of Caesarean section on subsequent fertility.

STUDY QUESTION: Is there an association between Caesarean section and subsequent fertility? SUMMARY ANSWER: There is no or only a slight effect of Caesarean section on future fertility. WHAT IS KNOWN ALREADY: Previous studies have reported that delivery by a Caesarean section is associated with fewer subsequent pregnancies and longer inter-pregnancy intervals. The interpretation of these findings is difficult because of significant weaknesses in study designs and analytical methods, notably the potential effect of the indication for Caesarean section on subsequent delivery. STUDY DESIGN, SIZE, DURATION: Retrospective cohort study of 1 047 644 first births to low-risk women using routinely collected, national administrative data of deliveries in English maternity units between 1 April 2000 and 31 March 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Primiparous women aged 15-40 years who had a singleton, term, live birth in the English National Health Service were included. Women with high-risk pregnancies involving placenta praevia, pre-eclampsia, eclampsia (gestational or pre-existing), hypertension or diabetes were excluded from the main analysis. Kaplan-Meier analyses and Cox proportional hazard models were used to assess the effect of mode of delivery on time to subsequent birth, adjusted for age, ethnicity, socio-economic deprivation and year of index delivery. MAIN RESULTS AND THE ROLE OF CHANCE: Among low-risk primiparous women, 224 024 (21.4%) were delivered by Caesarean section. The Kaplan-Meier estimate of the subsequent birth rate at 10 years for the cohort was 74.7%. Compared with vaginal delivery, subsequent birth rates were marginally lower after elective Caesarean for breech (adjusted hazard ratio, HR 0.96, 95% CI 0.94-0.98). Larger effects were observed after elective Caesarean for other indications (adjusted HR 0.81, 95% CI 0.78-0.83), and emergency Caesarean (adjusted HR 0.91, 95% CI 0.90-0.93). The effect was smallest for elective Caesarean for breech, and this was not statistically significant in women younger than 30 years of age (adjusted HR 0.98, 95% CI 0.96-1.01). LIMITATIONS, REASONS FOR CAUTION: We used birth cohorts from maternity units with good quality parity information. The data are likely to be nationally representative because the characteristics of the deliveries in included and omitted units were similar. There may be residual bias in our adjusted results due to unmeasured maternal factors such as obesity and voluntary absence of conception. Any residual bias would lead to an overestimate of the effect of Caesarean section on fertility, and the true effect is therefore likely to be smaller than the effect reported in our study. WIDER IMPLICATIONS OF THE FINDINGS: Our results provide strong evidence that there is no or only a slight effect of Caesarean section on future fertility. The clinical and social circumstances leading to the Caesarean section have a greater effect on future fertility than the Caesarean section itself. This finding is important in light of rising Caesarean section rates. STUDY FUNDING/COMPETING INTEREST(S): IG-U is supported by the Lindsay Stewart R&D Centre, Royal College of Obstetricians and Gynaecologists, UK. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: n/a.

Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success.

OBJECTIVES: To investigate the demographic and obstetric factors associated with the uptake and success rate of vaginal birth after caesarean section (VBAC). DESIGN: Cohort study using data from Hospital Episode Statistics. SETTING: English National Health Service. POPULATION: Women whose first birth resulted in a live singleton delivery by caesarean section between 1 April 2004 and 31 March 2011, and who had a second birth before 31 March 2012. METHODS: Logistic regression to estimate adjusted odds ratios (OR). MAIN OUTCOME MEASURES: Attempted and successful VBAC. RESULTS: Among the 143,970 women in the cohort, 75,086 (52.2%) attempted a VBAC for their second birth. Younger women, those of non-white ethnicity and those living in a more deprived area had higher rates of attempted VBAC. Overall, 47,602 women (63.4%) who attempted a VBAC had a successful vaginal birth. Younger women and women of white ethnicity had higher success rates. Black women had a particularly low success rate (OR, 0.54; 95% confidence interval [CI], 0.50-0.57). Women who had an emergency caesarean section in their first birth also had a lower VBAC success rate, particularly those with a history of failed induction of labour (OR, 0.59; 95% CI, 0.53-0.67). CONCLUSION: In this national cohort, just over one-half of women with a primary caesarean section who were eligible for a trial of labour attempted a VBAC for their second birth. Of these, almost two-thirds successfully achieved a vaginal delivery.

Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.

OBJECTIVE: To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends. DESIGN: A retrospective cohort study of singleton deliveries from a national administrative database. SETTING: The English National Health Service between 1 April 2000 and 31 March 2012. POPULATION: A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth. METHODS: Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors. MAIN OUTCOME MEASURE: The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears. RESULTS: The rate of reported third- or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia. CONCLUSIONS: Changes in major risk factors are unlikely explanations for the observed increase in the rate of third- or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation.

Rates of subsequent surgery following endometrial ablation among English women with menorrhagia: population-based cohort study.

OBJECTIVE: To assess the risk of further surgery amongst women who had an initial endometrial ablation (EA) for the treatment of heavy menstrual bleeding (HMB). DESIGN: A retrospective cohort study using a national administrative database. SETTING: Population-based study of hospital care in the English National Health Service. POPULATION: A cohort of 114,910 women who had EA for HMB between January 2000 and December 2011. METHODS: Multiple Cox regressions were performed to identify the risks of a further procedure, adjusted for age, social deprivation, year and type of initial EA, and presence of fibroids/polyps. MAIN OUTCOME MEASURES: Time to repeat EA or hysterectomy after initial surgery. RESULTS: Of 114,910 women undergoing EA, 16.7% had at least one subsequent procedure within 5 years. Higher rates of subsequent surgery were associated with younger age at initial EA, with women aged under 35 years having an adjusted hazard ratio of 2.83 (95% CI 2.67-2.99), compared with women aged over 45 years. Women who had radiofrequency ablation were less likely to have subsequent surgery as compared with first-generation techniques (HR 0.69, 95% CI 0.63-0.76). The rate of a subsequent hysterectomy within 5 years was 13.5%. Younger women (OR 0.59, 95% CI 0.51-0.69) and those who had balloon, microwave, or radiofrequency ablation were less likely to have a second EA procedure, rather than a hysterectomy. CONCLUSIONS: One in six women have further surgery after EA for HMB, which is a higher rate than reported in clinical trials. This risk of further surgery decreases with age.

Impact of Caesarean section on subsequent fertility: a systematic review and meta-analysis.

STUDY QUESTION: Is there an association between a Caesarean section and subsequent fertility? SUMMARY ANSWER: Most studies report that fertility is reduced after Caesarean section compared with vaginal delivery. However, studies with a more robust design show smaller effects and it is uncertain whether the association is causal. WHAT IS KNOWN ALREADY: A previous systematic review published in 1996 summarizing six studies including 85 728 women suggested that Caesarean section reduces subsequent fertility. The included studies suffer from severe methodological limitations. STUDY DESIGN, SIZE, DURATION: Systematic review and meta-analysis of cohort studies comparing subsequent reproductive outcomes of women who had a Caesarean section with those who delivered vaginally. PARTICIPANTS/MATERIALS, SETTING, METHODS: Searches of Cochrane Library, Medline, Embase, CINAHL Plus and Maternity and Infant Care databases were conducted in December 2011 to identify randomized and non-randomized studies that compared the subsequent fertility outcomes after a Caesarean section and after a vaginal delivery. Eighteen cohort studies including 591 850 women matched the inclusion criteria. Risk of bias was assessed by the Newcastle-Ottawa scale (NOS). Data extraction was done independently by two reviewers. The meta-analysis was based on a random-effects model. Subgroup analyses were performed to assess whether the estimated effect was influenced by parity, risk adjustment, maternal choice, cohort period, and study quality and size. MAIN RESULTS AND THE ROLE OF CHANCE: The impact of Caesarean section on subsequent pregnancies could be analysed in 10 studies and on subsequent births in 16 studies. A meta-analysis suggests that patients who had undergone a Caesarean section had a 9% lower subsequent pregnancy rate [risk ratio (RR) 0.91, 95% confidence interval (CI) (0.87, 0.95)] and 11% lower birth rate [RR 0.89, 95% CI (0.87, 0.92)], compared with patients who had delivered vaginally. Studies that controlled for maternal age or specifically analysed primary elective Caesarean section for breech delivery, and those that were least prone to bias according to the NOS reported smaller effects. LIMITATIONS, REASONS FOR CAUTION: There is significant variation in the design and methods of included studies. Residual bias in the adjusted results is likely as no study was able to control for a number of important maternal characteristics, such as a history of infertility or maternal obesity. WIDER IMPLICATIONS OF THE FINDINGS: Further research is needed to reduce the impact of selection bias by indication through creating more comparable patient groups and applying risk adjustment.

Surgery for menorrhagia within English regions: variation in rates of endometrial ablation and hysterectomy.

OBJECTIVE: To examine variation between English regions in the use of surgery (endometrial ablation or hysterectomy) for the treatment of menorrhagia. DESIGN: Analysis of Hospital Episodes Statistics (HES) data to produce rates of surgery for English Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs). POPULATION: Women aged between 25 and 59 years who had endometrial ablation or hysterectomy for menorrhagia between April 2003 and March 2006 in English NHS hospitals. METHODS: Multilevel Poisson regression was used to determine the level of systematic variation in the regional rates of surgery and their association with regional characteristics (deprivation, service provision and mix of surgical procedures). MAIN OUTCOME MEASURE: Age-standardised annual rates of surgery. RESULTS: The English rate of surgery for menorrhagia was 143 procedures per 100 000 women. Surgical rates within SHAs ranged from 52 to 230 procedures per 100 000 women, while rates within PCTs ranged from 20 to 420 procedures per 100 000 women. While, 60% of all procedures were endometrial ablations, the proportion across SHAs varied, ranging from 46% to 75%. Surgery rates were associated with the regional characteristics, but only weakly, and risk adjustment reduced the amount of unexplained variation by <15% at both SHA and PCT levels. CONCLUSION: Regional differences in surgical rates for menorrhagia have persisted despite changes in practice and improved evidence, suggesting there is scope for improving the management of menorrhagia within England.

Tension-free vaginal tape: 162 cases in a district general hospital.

From March 1999 to July 2002 a prospective study was carried out of 162 consecutive cases of urodynamically confirmed stress and mixed incontinence who underwent the tension-free vaginal tape (TVT) procedure. Patients were followed up at 6 weeks and 6 months and with a quality of life questionnaire at 1 year. The intraoperative complication rate was 7.6% and the postoperative complication rate was 18.8%. The subjective cure rate for patients suffering from urodynamic stress incontinence was 85%, with a further 11% experiencing significant improvement in their symptoms. The subjective cure rate for patients with mixed incontinence was 88%, with a further 9% experiencing significant improvement. The TVT procedure appears to be safe and effective for both stress and mixed incontinence for up to three years in a district general hospital. Complications in the short term are uncommon and can be managed easily.

Evaluation of an experimental midwife-led unit in Scotland.

This paper reports on the outcome of pregnancy among 3322 low-risk women managed in an 'experimental midwife-led unit' at Forth Park Hospital, Kirkcaldy, Scotland. All women were allocated to receive midwife-led antenatal and intrapartum care. Of the 3322 women, 1786 were nulliparous and 1536 were parous. Of the 1786 nulliparous women, 532 (30%) were transferred to consultant care antepartum, 488 (27%) were transferred intrapartum and the remaining 766 (43%) were delivered in the midwife-led unit (MLU). Of the 1536 multiparous women, 343 (22%) were transferred to consultant care antepartum, 158 (10%) were transferred intrapartum and the remaining 1035 (68%) were delivered in the MLU. Among the intrapartum transfer group, 14% delivered during the first hour after the decision to transfer and another 14% gave birth during the second hour (28% between 0-2 hours). More than half of the women transferred during the second stage delivered within the first hour. Of the 2447 admitted to the MLU, 32% were seen by obstetric team on more than one occasion. Of the 1801 babies delivered in the MLU, 9% required resuscitation and 2% of all the babies were admitted to the special care baby unit. This study suggests that present antenatal criteria are unable to determine who will remain at low risk throughout pregnancy and labour, especially among nulliparous women. The clinical situation could change adversely during labour, requiring the involvement of medical staff. Commissioners of maternity services may wish to utilise these data to formulate local protocols for stand-alone midwife-led units.

A biodegradable composite scaffold for cell transplantation.

Cell transplantation is rapidly becoming a therapeutic option to treat disease and injury. However, standard techniques for cell seeding on non-woven polymer meshes or within gels may not be suitable for immediate implantation or surgical manipulations of freshly isolated cells. Therefore, a biodegradable composite system was developed as a way to rapidly entrap cells within a support of predefined shape to potentially facilitate cell delivery into a target site (e.g. meniscal tears in the avascular zone). The composite construct consisted of freshly isolated cells, in this case pig chondrocytes, entrapped in a fibrin gel phase and dispersed throughout the void volume of a polyglycolic acid (PGA) non-woven mesh. Composites were cultured for up to 4 weeks. In vitro degradation of fibrin gel was evaluated via gel-entrapped urokinase. At 28 days in culture, glycosaminoglycan (GAG) content per cell in the composite scaffolds was 2.6 times that of the PGA-only cell construct group and 88% that of native pig cartilage. Total collagen content per cell in the composite scaffolds was not significantly different from the PGA-only cell construct group (P > 0.02) and represented 40% of the value determined for native cartilage. Varying the concentration of entrapped urokinase could effect controlled degradation of fibrin gel.

Current practice of hysterectomy and oophorectomy in the United Kingdom and Republic of Ireland.

The purpose of this study was to estimate current surgical practice of hysterectomy and prophylactic oophorectomy of UK and Irish consultant gynaecologists. Individual and regional variation in surgical practice and factors influencing surgical practice were assessed. A postal questionnaire was sent to all 1536 consultants in obstetrics and gynaecology currently practising in the United Kingdom and Ireland, with a 52.7% response rate. Approximately 60% of hysterectomies were abdominal, 37% vaginal and 4% laparoscopic-assisted, with junior consultants performing a greater proportion of hysterectomies vaginally. There was a wide variation in method of hysterectomy, both individually and regionally. Only 21% of consultants would routinely consider performing prophylactic oophorectomy and of these the majority would perform this procedure in women aged between 46 and 50 years old. This large variation in surgical practice indicates a need to form a consensus on optimal surgical techniques and to ensure adequate surgical training for all gynaecologists.

Medium-term clinical outcome of women with menorrhagia treated by rollerball endometrial ablation versus abdominal hysterectomy with conservation of at least one ovary.

BACKGROUND: To compare patients' satisfaction, health related quality of life, and sexual function among women who were either treated with rollerball endometrial ablation or abdominal hysterectomy with conservation of at least one ovary for the treatment of menorrhagia. METHOD: Between March 1992 to June 1997, 91 women underwent rollerball endometrial ablation and 78 women had abdominal hysterectomy with preservation of at least one ovary for the treatment of intractable menorrhagia. Each was sent a detailed questionnaire at least 18 months (range 18-60) after surgery. Case notes were reviewed to collect additional data relating to pre-operative management and operative details. RESULTS: Of 169 women, 120 (71%) returned a completed questionnaire [80/91 women (88%) had ablation and 40/78 women (51%) had hysterectomy]. Non-response analysis did not reveal any differences in prognostic characteristics between responders and non-responders. The length of hospital stay and time taken to return to normal daily activity were significantly less in the ablation group. Pre-menstrual symptoms improved over time but more so in the hysterectomy group, who also rated their improvement in general health higher. Women who had hysterectomy were more satisfied (100% versus 79%) and would be more likely to recommend it to a friend (100% versus 91%). CONCLUSION: Both procedures are effective for the treatment of menorrhagia but hysterectomy is associated with better general health and fewer pre-menstrual symptoms. Rollerball ablation is a useful alternative with many short term benefits and acceptable satisfaction rate. Further work is required to evaluate long term effects.

Understanding factors influencing request for a repeat termination of pregnancy.

OBJECTIVE: To assess factors influencing request for a termination of pregnancy (TOP). DESIGN: A questionnaire based, prospective study of 150 women requesting a TOP. This questionnaire contained a modified version of the Edinburgh Postnatal Depression Scale (EPDS). SUBJECTS: Of the 150 women requesting a TOP, 100 were seeking a TOP for the first time and the remaining 50 had at least one TOP in the past. RESULTS: Forty-five percent of women requesting termination of the first pregnancy were under the age of 20, 62% earned less than 10,000 Pounds per year and 12% did not use any form of contraception. Ninety-eight percent knew about emergency contraception but only 3% used it. The repeat termination group were older (only 24% under the age of 20). Fifty-five percent earned less than 10,000 Pounds per year, 15% did not use any contraception, 92% knew about emergency contraception but only 10% used it. Both groups were highly satisfied with the counselling, explanation about the procedure and future contraception advice. However, about 60% of women in both groups had suffered from mild to moderate depression as a consequence of termination. CONCLUSION: This study confirms the need for easy availability of emergency contraception and emphasises the importance of education about contraception in general.

Do practice guidelines guide practice? A prospective audit of induction of labor three years experience.

BACKGROUND: To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures. METHOD: Guidelines for induction of labor were implemented in January 1996 following an audit report identifying inconsistency in clinical practice. A prospective audit was carried out following the implementation of a new strategy directed towards pre-induction cervical ripening in nulliparae with unfavorable cervices and the use of low dosages of vaginal prostaglandin E2 for induction of labor. Level of compliance and outcome measures were compared before and after implementation of guidelines. RESULTS: In the period of January 1995 to November 1997, 1,230 women were induced with a singleton viable pregnancy in a cephalic presentation with a gestational age > or = 37 weeks with no history of rupture of membranes or cesarean section. Completed forms were available for 1,147 women (370, 421 and 356 in 1995, 1996 and 1997, respectively). Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit. CONCLUSION: Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Simultaneous presentation of ectopic pregnancy and hyperthyroidism.

Hyperthyroidism is known to occur uncommonly in pregnancy (about 0.5 per 1000). The incidence of ectopic pregnancy is approximately 9.6 per 1000 pregnancies. Both conditions, if unrecognised and untreated can have potentially fatal consequences. We describe a case of hyperthyroidism and ectopic pregnancy presenting concurrently, and highlight the difficulties encountered in diagnosis when two clinical conditions present with indistinguishable clinical signs.

Incorporation of amino acids within the surface reactive layers of bioactive glass in vitro: an XPS study.

Surface reaction layers grown on bioactive glass (Bioglass), by immersion in either simulated body fluid (SBF) or minimal essential medium (alpha-MEM) for 2, 5, 32 and 72 h, were analyzed by scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS). Layers grown in alpha-MEM exhibited delamination when observed in SEM. Low resolution XPS analysis detected nitrogen at the surface of the Bioglass exposed to alpha-MEM for 72 h (8 relative at%), whereas insignificant nitrogen was found at the surface of any sample immersed in SBF. XPS depth profiling (argon) showed the presence of nitrogen throughout the depth of the surface layer of the sample incubated in alpha-MEM for 72 h. Deconvolution of the nitrogen envelope in a high resolution XPS spectrum demonstrated nitrogen characteristic of the amine bonds present in amino acids. Carbon concentration also considerably increased over time with exposure to alpha-MEM (24-55%), whereas it remained in the 20-25% range in SBF. These results demonstrate that the amino acids contained in the culture medium were incorporated within the growing calcium phosphate rich surface reaction layer of Bioglass.