Obstetrics and Gynaecology

The purple line and its association with cervical dilatation in labour: A systematic review and meta-analysis (2023)

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Type of publication:
Systematic Review

Author(s):
*Papoutsis, Dimitrios; Antonakou, Angeliki; *Gornall, Adam; Tzavara, Chara

Citation:
European Journal of Obstetrics, Gynecology, & Reproductive Biology. 289:91-99, 2023 Aug 25.

Abstract:
BACKGROUND: There is a growing body of evidence that the presence and length of the purple line could represent a non-invasive method of estimating and determining labour progress. OBJECTIVES: The primary outcome was to provide a systematic review and meta-analysis on the association between the purple line length and cervical dilatation in active labour. The secondary outcome was to determine the association between the purple line length and the fetal head descent, and to calculate the pooled mean length of the purple line at a cervical dilatation of 3-4 cm and at a cervical dilatation of 9-10 cm. SEARCH STRATEGY: We searched the Medline, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Clinical Trials.gov and Cochrane Pregnancy and Childbirth's Trials Register databases from inception till March 25, 2023. SELECTION CRITERIA: We included observational studies of pregnant women in active first stage of labour who had their labour progress assessed with the use of regular vaginal examinations and who had the occurrence recorded and length of the purple line measured at the same time. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated study eligibility. We used the random effects and fixed effects model for meta-analysis. MAIN RESULTS: There were six eligible studies included in the systematic review that reported on 982 women in total with the purple line appearing in 760 (77.3%) of cases. We found a moderate positive pooled correlation between the purple line length with cervical dilatation (r = +0.64; 95%CI: 0.41-0.87) and fetal head descent (r = +0.50; 95%CI: 0.32-0.68). For women either in spontaneous or induced labour, the pooled mean length of the purple line was more than 9.4 cm when the cervical dilatation was 9-10 cm, whereas it was more than 7.3 cm when the cervical dilatation was 3-4 cm. CONCLUSIONS: The purple line is a non-invasive method that may potentially be used as an adjunct in labour progress assessment.

The association between menstrual cycle characteristics and cardiometabolic outcomes in later life: a retrospective matched cohort study of 704,743 women from the UK (2023)

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Type of publication:
Journal article

Author(s):
Okoth, Kelvin; *Parry Smith, William; Thomas, G Neil; Nirantharakumar, Krishnarajah; Adderley, Nicola J

Citation:
BMC Medicine, 2023, 21, Article number: 104

Abstract:
Background
Female reproductive factors are gaining prominence as factors that enhance cardiovascular disease (CVD) risk; nonetheless, menstrual cycle characteristics are under-recognized as a factor associated with CVD. Additionally, there is limited data from the UK pertaining to menstrual cycle characteristics and CVD risk.

Methods
A UK retrospective cohort study (1995–2021) using data from a nationwide database (The Health Improvement Network). Women aged 18–40 years at index date were included. 252,325 women with history of abnormal menstruation were matched with up to two controls. Two exposures were examined: regularity and frequency of menstrual cycles; participants were assigned accordingly to one of two separate cohorts. The primary outcome was composite cardiovascular disease (CVD). Secondary outcomes were ischemic heart disease (IHD), cerebrovascular disease, heart failure (HF), hypertension, and type 2 diabetes mellitus (T2DM). Cox proportional hazards regression models were used to derive adjusted hazard ratios (aHR) of cardiometabolic outcomes in women in the exposed groups compared matched controls.

Results
During 26 years of follow-up, 20,605 cardiometabolic events occurred in 704,743 patients. Compared to women with regular menstrual cycles, the aHRs (95% CI) for cardiometabolic outcomes in women with irregular menstrual cycles were as follows: composite CVD 1.08 (95% CI 1.00–1.19), IHD 1.18 (1.01–1.37), cerebrovascular disease 1.04 (0.92–1.17), HF 1.30 (1.02–1.65), hypertension 1.07 (1.03–1.11), T2DM 1.37 (1.29–1.45). The aHR comparing frequent or infrequent menstrual cycles to menstrual cycles of normal frequency were as follows: composite CVD 1.24 (1.02–1.52), IHD 1.13 (0.81–1.57), cerebrovascular disease 1.43 (1.10–1.87), HF 0.99 (0.57–1.75), hypertension 1.31 (1.21–1.43), T2DM 1.74 (1.52–1.98).

Conclusions
History of either menstrual cycle irregularity or frequent or infrequent cycles were associated with an increased risk of cardiometabolic outcomes in later life. Menstrual history may be a useful tool in identifying women eligible for periodic assessment of their cardiometabolic health.

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Induction of labour for predicted macrosomia: study protocol for the 'Big Baby' randomised controlled trial (2022)

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Type of publication:Journal article

Author(s):Ewington LJ; Gardosi J; Lall R; Underwood M; Fisher JD; Wood S; Griffin R; Harris K; Bick D; Booth K; Brown J; Butler E; Fowler K; Williams M; *Deshpande S; *Gornall A; Dewdney J; Hillyer K; Gates S; Jones C; Mistry H; Petrou S; Slowther AM; Willis A; Quenby S

Citation:BMJ Open, 2022 Nov 11; Vol. 12 (11), pp. e058176. Date of Electronic Publication: 2022 Nov 11.

Abstract:Introduction: Large-for-gestational age (LGA) fetuses have an increased risk of shoulder dystocia. This can lead to adverse neonatal outcomes and death. Early induction of labour in women with a fetus suspected to be macrosomic may mitigate the risk of shoulder dystocia. The Big Baby Trial aims to find if induction of labour at 38+0-38+4 weeks' gestation, in pregnancies with suspected LGA fetuses, reduces the incidence of shoulder dystocia.Methods and Analysis: The Big Baby Trial is a multicentre, prospective, individually randomised controlled trial of induction of labour at 38+0 to 38+4 weeks' gestation vs standard care as per each hospital trust (median gestation of delivery 39+4) among women whose fetuses have an estimated fetal weight >90th customised centile according to ultrasound scan at 35+0 to 38+0 weeks' gestation. There is a parallel cohort study for women who decline randomisation because they opt for induction, expectant management or caesarean section. Up to 4000 women will be recruited and randomised to induction of labour or to standard care. The primary outcome is the incidence of shoulder dystocia; assessed by an independent expert group, blind to treatment allocation, from delivery records. Secondary outcomes include birth trauma, fractures, haemorrhage, caesarean section rate and length of inpatient stay. The main trial is ongoing, following an internal pilot study. A qualitative reporting, health economic evaluation and parallel process evaluation are included.

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Pregnancy and neonatal outcomes of COVID-19: The PAN-COVID study (2022)

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Type of publication:Journal article

Author(s):Mullins E; Perry A; Banerjee J; Townson J; Grozeva D; Milton R; Kirby N; Playle R; Bourne T; Lees C; PAN-COVID Investigators (including *Millward, H.)

Citation:European Journal of Obstetrics, Gynecology, and Reproductive Biology, 2022 Sep; Vol. 276, pp. 161-167.

Abstract:Objective: To assess perinatal outcomes for pregnancies affected by suspected or confirmed SARS-CoV-2 infection.Methods: Prospective, web-based registry. Pregnant women were invited to participate if they had suspected or confirmed SARS-CoV-2 infection between 1st January 2020 and 31st March 2021 to assess the impact of infection on maternal and perinatal outcomes including miscarriage, stillbirth, fetal growth restriction, pre-term birth and transmission to the infant.Results: Between April 2020 and March 2021, the study recruited 8239 participants who had suspected or confirmed SARs-CoV-2 infection episodes in pregnancy between January 2020 and March 2021. Maternal death affected 14/8197 (0.2%) participants, 176/8187 (2.2%) of participants required ventilatory support. Pre-eclampsia affected 389/8189 (4.8%) participants, eclampsia was reported in 40/ 8024 (0.5%) of all participants. Stillbirth affected 35/8187 (0.4 %) participants. In participants delivering within 2 weeks of delivery 21/2686 (0.8 %) were affected by stillbirth compared with 8/4596 (0.2 %) delivering ≥ 2 weeks after infection (95 % CI 0.3-1.0). SGA affected 744/7696 (9.3 %) of livebirths, FGR affected 360/8175 (4.4 %) of all pregnancies. Pre-term birth occurred in 922/8066 (11.5%), the majority of these were indicated pre-term births, 220/7987 (2.8%) participants experienced spontaneous pre-term births. Early neonatal deaths affected 11/8050 livebirths. Of all neonates, 80/7993 (1.0%) tested positive for SARS-CoV-2.Conclusions: Infection was associated with indicated pre-term birth, most commonly for fetal compromise. The overall proportions of women affected by SGA and FGR were not higher than expected, however there was the proportion affected by stillbirth in participants delivering within 2 weeks of infection was significantly higher than those delivering ≥ 2 weeks after infection. We suggest that clinicians' threshold for delivery should be low if there are concerns with fetal movements or fetal heart rate monitoring in the time around infection. The proportion affected by pre-eclampsia amongst participants was not higher than would be expected, although we report a higher than expected proportion affected by eclampsia. There appears to be no effect on birthweight or congenital malformations in women affected by SARS-CoV-2 infection in pregnancy and neonatal infection is uncommon. This study reflects a population with a range of infection severity for SARS-COV-2 in pregnancy, generalisable to whole obstetric populations.

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Recurrence of a second trimester fundal uterine rupture at the old scar site: A case report (2022)

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Type of publication:Journal article

Author(s):*Panesar H.; *Patel R.; Dhaliwal H.

Citation:Radiology Case Reports. 17(11) (pp 4445-4448), 2022. Date of Publication: November 2022.

Abstract:Uterine rupture is a rare life-threatening complication. It can occur in all 3 trimesters with the first and the second being a rarity. It mainly occurs in the third trimester or during labor in a previously scarred uterus. It is rare in an unscarred uterus. The risk fold is further enhanced by the induction and augmentation with prostaglandins and oxytocin. The clinical diagnosis at this early gestation can be a dilemma to the attending physician as in this case. (1) The patient was a holidaymaker with no documented evidence of a dating scan to suggest any evidence of an ovarian/placental pathology at that stage. (2) The ultrasound findings in our department did suggest a viable intrauterine pregnancy with free fluid within both the adnexa. A 6 cm solid homogenous mass in the midline/right adnexa suggested an ovarian torsion or bowel pathology. The differentials in this particular case were that of a ruptured hemorrhagic cyst, ovarian torsion and even a heterotrophic pregnancy as there had been a few documented cases in the department. Ultrasound diagnosis of an intrauterine pregnancy together with a fluid collection does not suggest by any means that the uterus is intact or there is no ectopic pregnancy.

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Womens' labour and birth experiences in Greece: A cross-sectional study (2022)

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Type of publication:Conference abstract

Author(s):Ioannidou M.; Antonakou A.; *Papoutsis D.

Citation:BJOG: An International Journal of Obstetrics and Gynaecology. Conference: Royal College of Obstetricians and Gynaecologists World Congress, RCOG 2022. London United Kingdom. 129(Supplement 1) (pp 220-221), 2022. Date of Publication: June 2022.

Abstract:Objective: We aimed to investigate womens' emotional status, labour and childbirth data, pain relief methods, satisfaction from the midwifery-obstetric team, and the nutrition methods of newborns in Greece. Design(s): We used a modified version of the validated Early Labour and Experience Questionnaire (ELEQ) to capture the experiences of women and events during their labour and childbirth. Method(s): The questionnaire consisted of 64 items and was posted online through the social media between March to May 2021. All women who had given birth were eligible for the study. Upon closure of the study period, statistical analysis was applied to the collected data. Result(s): A total of 3.127 participants responded to the online questionnaire. Increased intervention rates were recorded with 41.1% of participants having an induction of labour, 58.7% having an epidural analgesia and 33.5% a cesarean section. Only 37.6% of respondents reported a spontaneous onset of labor with no interventions at all and a normal vaginal birth. 42.8% of women reported attending prenatal classes, with these women experiencing higher rates of normal vaginal birth. Higher rates of breastfeeding were observed when women had attended prenatal classes and when their vaginal birth had a spontaneous onset of labor. Women who gave birth at home or in a private maternity hospital were more satisfied when compared to women delivering in public hospitals. Women who had a spontaneous vaginal birth had more positive emotions and greater satisfaction levels from their midwife and obstetrician when compared to an induced vaginal birth or a cesarean section. Conclusion(s): Women in Greece experience high rates of interventions during labour and childbirth, which seems to negatively affect their emotional state. Prenatal classes are important as they are correlated with higher rates of normal deliveries and exclusive breastfeeding. Further research is needed to identify the factors that affect womens' experiences during labour and childbirth within the Greek maternity healthcare system in order to improve and shape the current midwifery-obstetric care policy.

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High-fidelity simulation on shoulder dystocia management in Greek Midwives: the SAFE study (2022)

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Type of publication:
Conference abstract

Author(s):
*Papoutsis D.; Klazoglou P.; Valasoulis G.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology. Conference: Royal College of Obstetricians and Gynaecologists World Congress, RCOG 2022. London United Kingdom. 129(Supplement 1) (pp 128), 2022. Date of Publication: June 2022.

Abstract:
Objective: The SAFE study is funded from the Hellenic Foundation for Research and Innovation and its primary objective is to explore and quantify how the knowledge and skills on shoulder dystocia management of Greek Midwives may improve following high-fidelity simulation. Design(s): A high-fidelity simulator that consisted of a pelvic model and a computerised neonatal mannequin with a built in force-monitoring system was utilised for the purposes of shoulder dystocia management in a one-day workshop. Registered midwives were invited to participate in groups of five in a 90-min training session during the workshop. Method(s): The training session consisted of a 30-minute initial assessment, a 30-minute theoretical and hands-on training from the instructor, and a 30-minute final assessment of participants. The outcomes measured involved the performance of maneuvers, the force applied on the neonatal head, the level of communication skills and self-reported confidence. These outcomes were recorded at the start and end of the training session. The checklist of performance involved 20 items in accordance with the RCOG guideline on shoulder dystocia. The force applied on the neonatal head was recorded with the force-monitoring system of the simulator. The communication skills and the self reported confidence of participants were measured on a numerical scale. The pre-and after-training scores of all four outcomes were compared and statistical analysis was applied. Result(s): There were n = 6 one-day workshops with 81 midwives participating in total (October-November 2021). Their mean age was 30.6 +/- 11.1 years old (median:25 years). Prior to training, only 6/81 (7.4%) managed to successfully deliver the impacted shoulder (defined as successful delivery of the posterior arm), with this increasing to 77/81 (95%) after training. The force applied to the neonatal head was similar pre-and after-training (pre:102.20 +/- 38.1 Newtons vs after: 102.13 +/- 27.7 Newtons), with a convergence of the outliers to the mean value. Performance scores (scale:0- 20) improved significantly almost three-fold (pre:5.75 +/- 3.8 vs after:15.63 +/- 2.5), and the self-reported confidence of participants (scale:0-10) increased almost two-fold (pre:3.2 +/- 1.9 vs after: 7.8 +/- 1.4). The communication skills of the participants (scale:0-5) also improved (pre: 2.90 +/- 1.1 vs after: 4.78 +/- 0.5). Those with the most improvement in their confidence were the participants with less clinical experience (r = ?0.329, p = 0.03). Conclusion(s): High-fidelity simulation on the management of shoulder dystocia at childbirth, even after a single training session, can significantly improve the performance score of maneuvers, the levels of confidence and the communication skills of Midwives.

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Factors affecting womens' sexual function during the first-year after childbirth in Greece (2022)

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Type of publication:Conference abstract

Author(s):Haritopoulou E.; Papatheodorou D.; Nitsa E.; Antonakou A.; *Papoutsis D.

Citation:BJOG: An International Journal of Obstetrics and Gynaecology. Conference: Royal College of Obstetricians and Gynaecologists World Congress, RCOG 2022. London United Kingdom. 129(Supplement 1) (pp 204), 2022. Date of Publication: June 2022.

Abstract:Objective: Sexual dysfunction after childbirth has been related to the number of vaginal births, the mode of delivery, and to the severity of perineal trauma. The present cross-sectional study was designed to identify the factors that affect the quality of sexual function during the first year after delivery in Greek women. <Design(s): We constructed an 81-item questionnaire that was posted online via the social media for the time period of February-April 2021. Women residing in Greece who had delivered more than 4 weeks ago but not more than 12 months ago were considered eligible for the study. Method(s): Data that was collected included patients' demographics, and data regarding their labour and childbirth. Information on their sexual life before, during and after pregnancy was also collected and the Female Sexual Function Index (FSFI) was used to quantify the sexual function of women during the 4 weeks prior to answering the questionnaire (score range:0-36, with a score of 26 or less indicating sexual dysfunction). After data collection was completed statistical analysis was applied. Result(s): In total there were 441 women responding to the questionnaire with a mean age of 32.5+/-4.4 years old. Approximately half of women delivered 6 months ago and 55.2% were first time mothers. The caesarean section rate in the total sample was 47.9%, and only 34.2% had a spontaneous onset vaginal birth. At childbirth, more than 85% of women sustained perineal trauma, of which 39.3% had an episiotomy. During pregnancy 76% of women had sexual intercourse with their partners, with half of them having a frequency of 2-3 times a month. The mean score of the FSFI index in the total sample was 21.8 +/- 10.7. There was a significant correlation of sexual dysfunction postpartum with exclusive breastfeeding, with increasing maternal age, with reduced number of sleeping hours, with the limited support from their family environment, and with the presence of incontinence. Conversely, the increased frequency of sexual intercourse before and during pregnancy was correlated with a higher score of sexual function postpartum. Perineal trauma, a high body mass index, smoking, and the mode of delivery did not seem to affect the sexual function after delivery. Conclusion(s): We have identified factors that seem to modify the sexual function of Greek women postpartum. These factors should be taken in consideration when providing midwifery care to women after birth.

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