BJOG perspectives

Gestational diabetes mellitus, pre-eclampsia and future cardiovascular disease: need to consider both BMI and gestational weight gain to investigate the linkLionel Carbillon1, 3, Amélie Benbara1, Emmanuel Cosson2, 31Department of Obstetrics and Gynecology, Paris-Seine Saint Denis University Hospitals, Assistance Publique – Hopitaux de Paris, Paris 13 University, France2 Department of Endocrinology, Diabetology, Nutrition, Paris-Seine Saint Denis University Hospitals, Assistance Publique – Hôpitaux de Paris, France3Sorbonne North Paris University

Gestational diabetes: False dichotomy and slippery slope

Mini-commentary on BJOG-20-0142.R1: Acupuncture for recurrent urinary tract infection in women: A systematic review and meta-analysis

Dear editor, we have read with interest the study by Deo et al.published in BJOG: An International Journal of Obstetrics and Gynaecology 1. We have noted that although the control and VR group were ‘comparable’ regarding previous hysteroscopies, differences in baseline pain expectation scores between patients with a previous hysteroscopy and those without were not given. Each patient has an individual pain experience during hysteroscopy, some may not experience any pain at all, whereas others feel pain during cervical manipulation, distension of the uterus, during pipelle biopsy or delayed pain due to the release of prostaglandins2. Therefore, it could be possible the VR group has patients who do not experience any pain at all. It would be beneficial to know if there was any difference in pain expectation scores between those with prior experience of hysteroscopy and those without. A further study with a group known to have painful hysteroscopies could be of immense clinical value, as this group of patients may experience the greatest benefit.Furthermore, it is mentioned that ‘patients were instructed to self administer analgesics prior to the procedure (either paracetamol or non steroidal anti-inflammatory drugs)’ . It would be useful to ask the patients which specific analgesic they took, the dosage and how long before the procedure they took the medication. As use of analgesia prior to the procedure could potentially affect the pain perceived and therefore the pain scores in both groups; potentially being a confounding factor. Having more information about analgesia used prior to the procedure could allow clinicians to identify significant differences between cohorts with regards to analgesia use and signify a possible correlation to pain scores.Finally, it is mentioned that one patient in the VR group had a previous history of claustrophobia and decided to remove the headset when the procedure started as she felt claustrophobic. Therefore, the patient would not have experienced VR throughout the procedure, rather only for a small period of time, potentially effecting the reported pain score for that patient and the larger results as study populations were only 20 patients per cohort. To avoid this, the patient could have perhaps not been included in the results.Disclosure of Interests: No conflicts to declare.Contribution to Authorship: All authors were involved in the conception, analysis, drafting of intellectual content and final approval of this correspondence letter. All authors are also in agreement to be accountable for all aspects of work in this correspondence letter.Details of Ethics Approval: No ethics approval required.Funding : No funding.

Risk assessment to target aspirin is accurate but not universalLow dose aspirin, for the prevention of early onset pre-eclampsia is an established antenatal intervention; it is safe, effective, cheap and accessible in many health care settings.Optimal implementation strategies including dose, timing and screening are currently debated. The evidence supports starting aspirin early (before 16 weeks), prescribe at night, give up to 150mg and continue until at least 36 weeks gestation ((Poon et al. Int J Gynaecol Obstet. 2019 May;145 Suppl 1(Suppl 1):1-33). From the women’s perspective, many may not be happy to routinely medicate an apparently normal pregnancy, to prevent an unknown or unfamiliar disease.Despite campaigns by APEC and others, too many women only hear of pre-eclampsia when it affects them. Generally, as perceived risks escalate the acceptance of taking aspirin is greater which improves compliance by both physicians prescribing, and by pregnant women. Any strategy that allows targeting of aspirin is likely to prevent unnecessary treatment and would be welcomed. It should be noted that the MBRAACE Report (Knight et al. University of Oxford 2019. ISBN: 978-0-9956854-8-2) called for a national patient direction for midwives to prescribe aspirin which has not yet happened.This current analysis compared two such strategies to target antenatal aspirin NICE guidance uses history to establish risk (Guy et al. BJOG 2020 xxxx). It is relatively simple, requiring either a combination of minor risk factors or a single major risk factor to dictate the need for aspirin. The FMF algorithm uses a combination of tests, including scans, blood pressure and blood markers to dictate risk; this requires skill and more resource which may not be consistently available in lower income settings.When compared in a real-world setting, in a London teaching hospital, the FMF algorithm had a screen positive rate that was half that of NICE, while aspirin was given to far more high-risk women. The FMF algorithm was changed to suit local circumstances, including details of the tests used (PAPPA, rather than PLGF) and thresholds adopted for treatment, but the real-world findings are impressive.The dosage of aspirin was higher in the FMF group, (150mg vs 75mg) which could explain some of the additional clinical benefit. Aspirin has recently been shown to impact on preterm birth when given routinely to all women who have never given birth in a low resource setting. In these settings, the cost and practicalities of implementing the algorithm maybe prohibitive. However, elements of the algorithm such as blood pressure measurement are simple and potentially more generalisable.It is exciting we have an intervention that can impact on one of the world’s most significant pregnancy disorders; but if resources allow, we clearly now have the tools to predict risk and improve outcomes. The challenge is how to deliver this to the global south, where most of pre-eclampsia occurs.At Action on Pre-Eclampsia, in the UK, we will continue to push for easy availability of aspirin. This paper is a welcome piece of the jigsaw and we hope it offers further tools in the armoury to defeat pre-eclampsia.No disclosures: Completed disclosure of interest forms are available to view online as supporting information.

Objective: To assess psychosexual distress among women receiving different human papillomavirus (HPV) and cytology results in the context of the English HPV primary screening pilot, shortly after women received their results and 6 and 12-months later. Design: Longitudinal, between-groups study. Setting: Five sites in England where primary HPV testing was piloted. Population: Women aged 24-65 years (n=1133) who had taken part in the NHS Cervical Screening Programme. Methods: Women were sent a postal questionnaire soon after receiving their screening results and 6 and 12-months later. Data were analysed using linear regression models to compare psychosexual outcomes between groups receiving six possible screening results. Main Outcome Measures: Psychosexual distress, assessed using six items from the Psychosocial Effects of Abnormal Pap Smears Questionnaire (PEAPS-Q). Results: At all three time-points, there was an association between screening result and overall psychosexual distress (all p<0.001). At baseline, psychosexual distress was significantly higher among women with HPV and normal cytology (B=1.15, 95% CI:0.961-1.337), HPV and abnormal cytology (B=1.02, 95% CI:0.783-1.266) and persistent HPV (B=0.90, 95% CI:0.703-1.102) compared with the control group (all p<0.001). At 6 and 12-month follow-up the pattern of results was similar, but coefficients were smaller. Conclusions: Our findings suggest that while simply participating in HPV testing does not appear to cause psychosexual distress, receiving an HPV-positive result does, particularly in the short-term. Developing interventions to minimise the psychosexual burden of testing HPV-positive will be essential to avoiding unnecessary harm to the millions of women taking part in cervical screening.

A document by Alexandra Emms. Click on the document to view its contents.

Gestational surrogacy for women with recurrent pregnancy loss due to refractory chronic histiocytic intervillositis: Research Letter

BJOG commentary for BJOG-21-0466 A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study

A document by Markus Gonser. Click on the document to view its contents.

Time for action- oxytocin & uterotonics are life-saving AND dangerous: a commentaryDeborah ArmbrusterUnited States Agency for International DevelopmentWashington, DC (currently based in Indonesia)Global Health Bureau/Maternal, Child and Nutrition Office/Maternal and Newborn Division+1 202 746-5453darmbruster@usaid.gov

Recent trends regarding GDM medication use have not been well described in prior literature. We identified pregnant patients enrolled in Tennessee Medicaid with a GDM diagnosis who a delivered in 2007 to 2019. We studied initial GDM medication use by delivery year (overall and by medication type). Over twenty percent of patients filled at least one prescription for GDM medication in the study period, with a significantly increasing prescribing trend over time. Starting in 2016, metformin replaced glyburide as the most common medication prescribed, which corresponds temporally with the emergence of evidence on the safety and effectiveness of different oral hypoglycemic medications and related changes in ACOG practice recommendations. These findings highlight how practice patterns have potential to shift quickly in response to evolving data.

Letter to the Editor, BJOG Exchange

Objective: To determine the incidence of and risk factors for perioperative blood transfusions after urogenital fistula repairs in Uganda. Design: A retrospective cohort study. Setting: A community hospital in Masaka, Uganda. Population: Women who underwent fistula repair at the Kitovu Hospital between 2013 and 2019. Methods: Retrospective review of demographics, and clinical perioperative characteristics of patients surgically treated for urogenital fistula. Patient characteristics were compared between those who did and did not require a blood transfusion. Main Outcome Measures: need for perioperative blood transfusion, risk factors Results: 546 patients treated for urogenital fistulas were included in this study. The median age was 31.1 ± 13.2. A vaginal surgical approach was used in the majority of patients (84.6%). Complications occurred in 3.5% of surgical repairs, and the incidence of blood transfusions was 6.2%. In multivariable analyses, women with fistula repairs approached abdominally were 4.3 (95% CI: 1.85–10.00) times more likely to require transfusions than vaginal operations. A borderline association was observed between timing of repair and perioperative transfusions such that patients who underwent repair after three months from the time of developing the fistula were at lower risk of perioperative transfusions (aOR: 0.48, 95% CI: 0.22–1.04). Conclusions: The incidence of blood transfusions among urogenital fistula repairs in our population is twice that of developed nations. An abdominal surgical approach to urogenital fistula is a significant risk factor for perioperative blood transfusions. Timing of repair may warrant further study.

Letter to the Editor, BJOG Exchange

Objective To examine the association of DNA copy number variants (CNVs) with pathologic placental lesions (PPLs) in stillborn fetuses. Design A secondary analysis of stillbirth cases in the Stillbirth Collaborative Research Network case-control study. Setting Multicenter, 59 hospitals in 5 geographic regions in the USA. Population 387 stillbirth cases (2006-2008). Methods Using standard definitions, PPLs were categorized by type including maternal and fetal vascular, inflammatory and immune/idiopathic lesions. Using single-nucleotide polymorphism array, CNVs of at least 500 kb were detected. CNVs were classified into two groups: normal, defined as no CNVs>500 kb or benign CNVs, and abnormal, defined as pathogenic or variants of unknown clinical significance. Main outcome measures The proportions of abnormal CNVs and normal CNVs were compared between stillbirth cases with and without PPLs using the Wald Chi-squared test. Results Of 387 stillborn fetuses, 327 (84.5%) had maternal vascular PPLs and 60 (15.6%) had abnormal CNVs. Maternal vascular PPLs were more common in stillborn fetuses with abnormal CNVs compared with those with normal CNVs (81.7% vs. 64.2%; p=0.008). The proportions of fetal vascular, maternal/fetal inflammatory, and immune/idiopathic PPLs were similar among stillborn fetuses with abnormal CNVs compared to those with normal CNVs. Pathogenic CNVs in stillborn fetuses with maternal vascular PPLs spanned several genes with known relevant mechanisms. Conclusions Abnormal placental/fetal CNVs were associated with maternal vascular PPLs in stillborn fetuses. Findings may provide insight on the mechanisms of specific genetic abnormalities associated with placental dysfunction and stillbirth.

Letter to the Editor, BJOG Exchange