Multifetal Pregnancy After Implementation of a Publicly Funded Fertility Program

Importance

A publicly funded fertility program was introduced in Ontario, Canada, in 2015 to increase access to fertility treatment. For in vitro fertilization (IVF), the program mandated an elective single-embryo transfer (eSET) policy. However, ovulation induction and intrauterine insemination (OI/IUI)-2 other common forms of fertility treatment-were more difficult to regulate in this manner. Furthermore, prior epidemiologic studies only assessed fetuses at birth and did not account for potential fetal reductions that may have been performed earlier in pregnancy.

Objective

To examine the association between fertility treatment and the risk of multifetal pregnancy in a publicly funded fertility program, accounting for both fetal reductions and all live births and stillbirths.

Design, Setting, and Participants

This population-based, retrospective cohort study used linked administrative health databases at ICES to examine all births and fetal reductions in Ontario, Canada, from April 1, 2006, to March 31, 2021.

Exposure

Mode of conception: (1) unassisted conception, (2) OI/IUI, or (3) IVF.

Main Outcomes and Measures

The main outcome was multifetal pregnancy (ie, a twin or higher-order pregnancy). Modified Poisson regression generated adjusted relative risks (ARRs) and derived population attributable fractions (PAFs) for multifetal pregnancies attributable to fertility treatment. Absolute rate differences (ARDs) were used to compare the era before eSET was promoted (2006-2011) with the era after the introduction of the eSET mandate (2016-2021).

Results

Of all 1 724 899 pregnancies, 1 670 825 (96.9%) were by unassisted conception (mean [SD] maternal age, 30.6 [5.2] years), 24 395 (1.4%) by OI/IUI (mean [SD] maternal age, 33.1 [4.4] years), and 29 679 (1.7%) by IVF (mean [SD] maternal age, 35.8 [4.7] years). In contrast to unassisted conception, individuals who received OI/IUI or IVF tended to be older, reside in a high-income quintile neighborhood, or have preexisting health conditions. Multifetal pregnancy rates were 1.4% (95% CI, 1.4%-1.4%) for unassisted conception, 10.5% (95% CI, 10.2%-10.9%) after OI/IUI, and 15.5% (95% CI, 15.1%-15.9%) after IVF. Compared with unassisted conception, the ARR of any multifetal pregnancy was 7.0 (95% CI, 6.7-7.3) after OI/IUI and 9.9 (95% CI, 9.6-10.3) after IVF, with corresponding PAFs of 7.1% (95% CI, 7.1%-7.2%) and 13.4% (95% CI, 13.3%-13.4%). Between the eras of 2006 to 2011 and 2016 to 2021, multifetal pregnancy rates decreased from 12.9% to 9.1% with OI/IUI (ARD, -3.8%; 95% CI, -4.2% to -3.4%) and from 29.4% to 7.1% with IVF (ARD, -22.3%; 95% CI, -23.2% to -21.6%).

Conclusions and Relevance

In this cohort study of more than 1.7 million pregnancies in Ontario, Canada, a publicly funded IVF program mandating an eSET policy was associated with a reduction in multifetal pregnancy rates. Nevertheless, ongoing strategies are needed to decrease multifetal pregnancy, especially in those undergoing OI/IUI.

Endometriosis and mental health: a population-based cohort study

BACKGROUND

Endometriosis is a chronic gynecologic disorder that leads to considerable pain and a reduced quality of life. Although its physiological manifestations have been explored, its impact on mental health is less well defined. Existing studies of endometriosis and mental health were conducted within diverse healthcare landscapes with varying access to care and with a primary focus on surgically diagnosed endometriosis. A single-payer healthcare system offers a unique environment to investigate this association with fewer barriers to access care while considering the mode of endometriosis diagnosis.

OBJECTIVE

Our objective was to assess the association between endometriosis and the risk for mental health conditions and to evaluate differences between patients diagnosed medically and those diagnosed surgically.

STUDY DESIGN

A matched, population-based retrospective cohort study was conducted in Ontario and included patients aged 18 to 50 years with a first-time endometriosis diagnosis between January 1, 2010, and July 1, 2020. Endometriosis exposure was determined through either medical or surgical diagnostic criteria. A medical diagnosis was defined by the use of the corresponding International Classification of Disease diagnostic codes from outpatient and in-hospital visits, whereas a surgical diagnosis was identified through inpatient or same-day surgeries. Individuals with endometriosis were matched 1:2 on age, sex, and geography to unexposed individuals without a history of endometriosis. The primary outcome was the first occurrence of any mental health condition after an endometriosis diagnosis. Individuals with a mental health diagnosis in the 2 years before study entry were excluded. Cox regression models were used to generate hazard ratios with adjustment for hysterectomy, salpingo-oophorectomy, infertility, pregnancy history, qualifying surgery for study inclusion, immigration status, history of asthma, abnormal uterine bleeding, diabetes, fibroids, hypertension, irritable bowel disorder, migraines, and nulliparity.

RESULTS

A total of 107,832 individuals were included, 35,944 with a diagnosis of endometriosis (29.5% medically diagnosed, 60.5% surgically diagnosed, and 10.0% medically diagnosed with surgical confirmation) and 71,888 unexposed individuals. Over the study period, the incidence rate was 105.3 mental health events per 1000 person-years in the endometriosis group and 66.5 mental health events per 1000 person-year among unexposed individuals. Relative to the unexposed individuals, the adjusted hazard ratio for a mental health diagnosis was 1.28 (95% confidence interval, 1.24-1.33) among patients with medically diagnosed endometriosis, 1.33 (95% confidence interval, 1.16-1.52) among surgically diagnosed patients, and 1.36 (95% confidence interval, 1.2-1.6) among those diagnosed medically with subsequent surgical confirmation. The risk for receiving a mental health diagnosis was highest in the first year after an endometriosis diagnosis and declined in subsequent years. The cumulative incidence of a severe mental health condition requiring hospital visits was 7.0% among patients with endometriosis and 4.6% among unexposed individuals (hazard ratio, 1.56; 95% confidence interval, 1.53-1.59).

CONCLUSION

Endometriosis, regardless of mode of diagnosis, is associated with a marginally increased risk for mental health conditions. The elevated risk, particularly evident in the years immediately following the diagnosis, underscores the need for proactive mental health screening among those newly diagnosed with endometriosis. Future research should investigate the potential benefits of mental health interventions for people with endometriosis with the aim of enhancing their overall quality of life.

Intravenous Ketamine for Pain Control in First-Trimester Surgical Abortion: Interim Analysis of a Randomized Controlled Trial

OBJECTIVES

Surgical abortion is common, with most completed in the first trimester. Gold standard pain control is intravenous (IV) fentanyl and midazolam, requiring continuous cardio-respiratory monitoring, a potential challenge where this monitoring is unavailable. Ketamine is a sedative and analgesic without the cardio-respiratory depression risk associated with IV opioids, representing a potential alternative. Investigating non-opiate pain control methods is imperative given the context of the opioid crisis. This is an interim analysis of 45 participants from a randomized controlled trial comparing IV ketamine, oral morphine, and IV fentanyl for pain control in first-trimester surgical abortion. We hypothesize that ketamine will provide better pain control than morphine.

METHODS

This is a double-blind, single-centre superiority trial of 3 parallel groups. Participants were ≥18 years old with confirmed intrauterine pregnancy of gestational age <12 weeks. Pain was assessed using the Visual Analogue Scale and the Wong-Baker Faces Pain Rating Scale.

RESULTS

In total, 2 participants were excluded post-randomization for 43 treated. Findings indicate that ketamine (n = 14; M = 0.7; 95% CI 0.1-1.3) provides better intra-operative pain control than morphine (n = 15, M = 4.4, 95% CI 2.9-5.9) and fentanyl (n = 14; M = 4.3; 95% CI 3.0-5.6; P < 0.001). The ketamine group was more satisfied with the anaesthetic method than the morphine group (P = 0.017). No group experienced serious adverse events.

CONCLUSIONS

Findings support continuation of the randomized controlled trial and highlight ketamine as a compelling non-opiate pain control option in first-trimester surgical abortion. Ketamine use may represent more optimal pain control in settings where continuous cardio-respiratory monitoring is unavailable.

Regret in the Modern Contraceptive Landscape: Evaluating Regret in Patients Undergoing Tubal Ligation or Bilateral Salpingectomy for Contraception

OBJECTIVE

To estimate the prevalence of regret among Canadians undergoing tubal ligation or bilateral salpingectomy for contraception in the context of widely available, highly effective, and tolerable reversible contraceptive methods including long-acting reversible contraceptives.

METHODS

We performed an online cross-sectional survey of regret following tubal sterilization using Qualtrics software. A convenience sample was used to recruit Canadian residents between the ages of 18 and 60 years who had undergone tubal ligation or salpingectomy for contraception. The online survey was advertised on 3 social media platforms: Facebook, Twitter, and Instagram.

RESULTS

We obtained survey results for 844 Canadian residents. Regret was reported by 15.9% of respondents. Consistent with existing literature, factors associated with regret included younger age at the time of the procedure, a change in relationship status, and having the procedure performed at the time of a pregnancy. Surprisingly, 9.5% of respondents reported an element of coercion, 4.5% were unaware the procedure was considered permanent contraception, and 33.3% did not recall their provider discussing alternative forms of contraception with them prior to surgery.

CONCLUSION

We found that the prevalence of regret following tubal sterilization has not changed with the widespread availability of highly effective reversible contraceptive methods. However, most patients choosing permanent contraception will be satisfied with their decision. Shared decision-making should respect the autonomy of each patient to make their own decisions regarding the most acceptable family planning method for their circumstances.

Infertility and Risk of Autism Spectrum Disorder in Children

Importance

Previous studies on the risk of childhood autism spectrum disorder (ASD) following fertility treatment did not account for the infertility itself or the mediating effect of obstetrical and neonatal factors.

Objective

To assess the association between infertility and its treatments on the risk of ASD and the mediating effect of selected adverse pregnancy outcomes on that association.

Design, Setting, and Participants

This was a population-based cohort study in Ontario, Canada. Participants were all singleton and multifetal live births at 24 or more weeks' gestation from 2006 to 2018. Data were analyzed from October 2022 to October 2023.

Exposures

The exposure was mode of conception, namely, (1) unassisted conception, (2) infertility without fertility treatment (ie, subfertility), (3) ovulation induction (OI) or intrauterine insemination (IUI), or (4) in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

Main Outcome and Measures

The study outcome was a diagnosis of ASD at age 18 months or older. Cox regression models generated hazard ratios (HR) adjusted for maternal and infant characteristics. Mediation analysis further accounted for the separate effect of (1) preeclampsia, (2) cesarean birth, (3) multifetal pregnancy, (4) preterm birth at less than 37 weeks, and (5) severe neonatal morbidity.

Results

A total of 1 370 152 children (703 407 male [51.3%]) were included: 1 185 024 (86.5%) with unassisted conception, 141 180 (10.3%) with parental subfertility, 20 429 (1.5%) following OI or IUI, and 23 519 (1.7%) following IVF or ICSI. Individuals with subfertility or fertility treatment were older and resided in higher-income areas; the mean (SD) age of each group was as follows: 30.1 (5.2) years in the unassisted conception group, 33.3 (4.7) years in the subfertility group, 33.1 (4.4) years in the OI or IUI group, and 35.8 (4.9) years in the IVF or ICSI group. The incidence rate of ASD was 1.93 per 1000 person-years among children in the unassisted conception group. Relative to the latter, the adjusted HR for ASD was 1.20 (95% CI, 1.15-1.25) in the subfertility group, 1.21 (95% CI, 1.09-1.34) following OI or IUI, and 1.16 (95% CI, 1.04-1.28) after IVF or ICSI. Obstetrical and neonatal factors appeared to mediate a sizeable proportion of the aforementioned association between mode of conception and ASD risk. For example, following IVF or ICSI, the proportion mediated by cesarean birth was 29%, multifetal pregnancy was 78%, preterm birth was 50%, and severe neonatal morbidity was 25%.

Conclusions and Relevance

In this cohort study, a slightly higher risk of ASD was observed in children born to individuals with infertility, which appears partly mediated by certain obstetrical and neonatal factors. To optimize child neurodevelopment, strategies should further explore these other factors in individuals with infertility, even among those not receiving fertility treatment.

Chemotherapy alone vs. chemotherapy plus radiotherapy in female adolescent and young adults with Hodgkin's lymphoma: reproductive health outcomes

PURPOSE

To examine the effects of Hodgkin's lymphoma and its treatment on reproductive health in female adolescent and young adults (AYA).

METHODS

We conducted a retrospective, population-based, matched-cohort study of female patients with Hodgkin's lymphoma diagnosed at 15-39 years of age from 1995 to 2014 in Ontario, Canada. Three female individuals with no history of cancer (unexposed) were matched by birth year and census subdivision to each patient with cancer (exposed). In a subset of the cohort (2005 onwards), the Hodgkin's lymphoma patients were further classified into two groups for analysis based on treatment exposure: (1) chemotherapy alone or (2) combined chemotherapy and radiation. Reproductive health outcomes were infertility, childbirth, and premature ovarian insufficiency (POI). Relative risks (RR) were calculated using modified Poisson regression adjusted for income quintile, immigration status, and parity.

RESULTS

A total of 1443 exposed and 4329 unexposed individuals formed our cohort. Hodgkin's lymphoma patients were at an increased risk of infertility (aRR 1.86; 95% CI 1.57 to 2.20) and POI (aRR 2.81; 95% CI 2.16 to 3.65). While the risk of infertility persisted in both treatment groups (chemotherapy alone, combined chemotherapy plus radiotherapy), the increased risk of POI was only statistically significant in the chemotherapy plus radiotherapy group. No differences in childbirth rates were observed, overall or by treatment exposure compared with unexposed individuals.

CONCLUSIONS

Female AYA survivors of Hodgkin's lymphoma face an increased risk of infertility, independent of exposure to chemotherapy alone, or chemotherapy plus radiotherapy. The risk of POI is higher in those requiring radiotherapy vs. chemotherapy alone.

IMPLICATIONS FOR CANCER SURVIVORS

These results emphasize the importance of pre-treatment fertility counseling and reproductive health surveillance for AYAs diagnosed with Hodgkin's lymphoma.

Prevalence of musculoskeletal pain among gynecologic surgeons performing laparoscopic procedures: A systematic review and meta-analysis

OBJECTIVE

Musculoskeletal discomfort is associated with repetitive movements and constrained body positions. The current meta-analysis was performed to determine the global prevalence of musculoskeletal symptoms among gynecologic surgeons who perform laparoscopy.

METHODS

Sources included Embase, MEDLINE, PubMed, CINAHL, Web of Science Core Collection, Cochrane Central Register of Controlled Clinical Trials, and Google Scholar. Articles published between 1980 and 2022 were considered. Studies that assessed self-reported musculoskeletal symptoms were included. Relevant data were extracted and tabulated.

RESULTS

Twelve studies met the inclusion criteria. In a pooled sample of 1619 surgeons, the estimated prevalence of musculoskeletal symptoms was 82% (95% confidence interval [CI], 70%-89%; I² , 92%). Female sex was a risk factor, as identified by a pooled odds ratio of 4.64 (95% CI, 2.63-8.19; I² , 0%) compared with male surgeons. Among surgeons who reported musculoskeletal symptoms, 30% (95% CI, 14%-52%; I² , 95%) sought treatment and 3% (95% CI, 2%-6%; I² , 0%) required work hour modifications.

CONCLUSION

The current meta-analysis provides preliminary evidence of a high prevalence of musculoskeletal symptoms among gynecologic laparoscopic surgeons. Future research is needed to explore the underlying risk factors and interventional strategies to mitigate this risk.

Use of family history of cardiovascular disease or chronic hypertension to better identify who needs postpartum cardiovascular risk screening

BACKGROUND

Individuals with pregnancies complicated by hypertensive disorders of pregnancy are at increased risk of cardiovascular disease. However, not all who have hypertensive disorders of pregnancy are at risk, and not all who have uncomplicated pregnancies are without risk.

OBJECTIVE

This study aimed to determine if use of first-degree family history of cardiovascular disease or chronic hypertension better identifies individuals who need postpartum cardiovascular risk screening.

STUDY DESIGN

Participants were included if they had pregnancies complicated by hypertensive disorders of pregnancy or uncomplicated, term pregnancies. Individuals with a first-degree relative with chronic hypertension, myocardial infarction, or stroke were deemed to have a positive family history and were thus included.

RESULTS

Four groups were considered: 302 individuals with hypertensive disorders of pregnancy who had a positive family history, 218 individuals with hypertensive disorders of pregnancy with no family history, 39 control individuals with a positive family history, and 63 control individuals with no family history. Among individuals with hypertensive disorders of pregnancy, those with a positive family history were more likely to be diagnosed with chronic hypertension, and to have elevated 30-year lipid, 30-year body mass index, and lifetime cardiovascular disease risk score (all P<.05). Among individuals with uncomplicated pregnancies, those with a positive family history were more likely to be diagnosed with chronic hypertension (P<.05) and meet criteria for metabolic syndrome (P<.05).

CONCLUSION

First-degree family history of cardiovascular disease and/or chronic hypertension can be used to reliably identify individuals without pregnancy complications who should have postpartum cardiovascular risk screening, and may better determine which individuals who have a pregnancy complicated by hypertensive disorders of pregnancy would most benefit from postpartum cardiovascular risk screening.

Endometriosis and cardiovascular disease: a population-based cohort study

BACKGROUND

Endometriosis, a prevalent condition among females of reproductive age, may be associated with increased risk of cardiovascular disease (CVD) through chronic inflammation and early menopause. The objective of this study was to estimate the association between endometriosis and subsequent risk of CVD.

METHODS

We conducted a population-based cohort study using administrative health data from Ontario residents from 1993 to 2015. We compared the incidence of CVD and cardiovascular health outcomes between females with endometriosis and 2 age-matched females without endometriosis. The primary outcome was hospital admission for CVD. Secondary outcomes included in-hospital CVD events of interest and emergency department visits for CVD. We used Cox proportional hazards models to estimate adjusted hazard ratios (HRs) between endometriosis and CVD events.

RESULTS

We identified 166 835 eligible patients with endometriosis and matched 333 706 patients without endometriosis. The mean age of those with endometriosis was 36.4 years. Patients with endometriosis had a higher incidence of hospital admission for CVD (195 admissions/100 000 person-years) compared with those without endometriosis (163 admissions/100 000 person-years). Similarly, the incidence of secondary CVD events was slightly higher among patients with endometriosis (292 cases/100 000 person-years) than among those without endometriosis (224 cases/100 000 person-years). Females with endometriosis had an increased risk of hospital admission (adjusted HR 1.14, 95% confidence interval [CI] 1.10-1.19) and secondary CVD events (adjusted HR 1.26, 95% CI 1.23-1.30).

INTERPRETATION

In this large, population-based study, endometriosis was associated with a small increased risk of CVD events. Future studies need to investigate potential etiological mechanisms and strategies to decrease long-term CVD risk in patients with endometriosis.

Premature ovarian insufficiency in female adolescent and young adult survivors of non-gynecological cancers: a population-based cohort study

BACKGROUND

The risk of premature ovarian insufficiency (POI) is increased in adolescent and young adult (AYA) cancer survivors, with the prevalence depending on cancer diagnosis, treatment, and patient factors. Prior studies are limited by sample size and type of cancer included. The objective of this study was to assess the risk of POI in female AYA survivors of non-gynecologic cancers, using a population-based approach.

METHODS

This population-based retrospective cohort study comprises 21,666 females, 15-39 years old, diagnosed with a single non-gynecologic cancer in Ontario, Canada from 1995 to 2015. Through health administrative data linkage, participants were followed until their 40th birthday, December 31, 2018, bilateral oophorectomy, loss of health insurance eligibility or death. Each cancer survivor was matched to 5 females who were not diagnosed with cancer (unexposed, n = 108,330). Women with bilateral oophorectomy or a prior menopause diagnosis were excluded. POI was identified through use of the ICD-9 code for menopause (ICD9-627). Modified Poisson regression models were used to calculate the adjusted relative risk (aRR) of POI for AYA cancer survivors compared to unexposed individuals, adjusted for income, parity, age, and immigration status.

RESULTS

The occurrence of POI was higher in survivors of AYA cancer versus unexposed patients (5.4% vs. 2.2%). Survivors of AYA cancer had an increased risk of POI relative to unexposed patients (aRR 2.49; 95% CI 2.32-2.67). Risk varied by type of cancer: breast (4.32; 3.84-4.86), non-Hodgkin's lymphoma (3.77; 2.88-4.94), Hodgkin's lymphoma (2.37; 1.91-2.96), leukemia (14.64; 10.50-20.42), thyroid (1.26; 1.09-1.46) and melanoma (1.04; 0.82-1.32). Risk varied by age at time of cancer diagnosis, with a higher risk among females diagnosed at age 30-39 years (3.07; 2.80-3.35) than aged 15-29 years (1.75; 1.55-1.98).

CONCLUSIONS

AYA survivors of non-gynecologic cancers are at an increased risk of POI, particularly survivors of lymphomas, leukemia, breast, and thyroid cancer. The risk of POI is increased for those diagnosed with cancer at an older age. These results should inform reproductive counseling of female AYAs diagnosed with cancer.

High-sensitivity C-reactive protein use in cardiovascular risk screening at 6 to 12 months postpartum following hypertensive disorders of pregnancy

BACKGROUND

Patients with a hypertensive disorder of pregnancy are more likely to have underlying cardiovascular risk factors and are at increased risk of future cardiovascular disease. These patients are more likely to be diagnosed with new-onset chronic hypertension and meet the criteria for metabolic syndrome postpartum. High-sensitivity C-reactive protein is a marker of general inflammation and may be used to identify increased risk for cardiovascular disease.

OBJECTIVE

This collaborative data-sharing study between Yale University, United States (Yale Hearts Moms study) and Queen's University, Canada (Maternal Health Clinic) aimed to study the utility of high-sensitivity C-reactive protein in postpartum cardiovascular risk screening, as determined by 30-year risk (Framingham) and metabolic syndrome 6 to 12 months postpartum.

STUDY DESIGN

Patients with a hypertensive disorder of pregnancy (n=478) or an uncomplicated, term pregnancy (n=90) had cardiovascular risk screening and risk scoring performed at 6 to 12 months postpartum. Patients were excluded if they had a multiple gestation or chronic hypertension, diabetes mellitus, or cardiovascular disease diagnosed before pregnancy. Patients were categorized according to high-sensitivity C-reactive protein (mg/L) into Normal (<3.0), High (3.1 to <10.0), and Acute (≥10.0) groups. The primary outcome of the study was risk for future cardiovascular events, calculated through surrogate measures such as hypertension and cholesterol. Kruskal-Wallis and chi-square tests were used to compare groups, with post hoc tests corrected using the Bonferroni method. Multivariable logistic regression was used to assess the association between high-sensitivity C-reactive protein and cardiovascular risk, adjusting for relevant medical and sociodemographic variables. Analysis was completed with IBM SPSS Statistics, version 27.

RESULTS

Patients in the High and Acute high-sensitivity C-reactive protein groups were more likely to have a body mass index ≥30, to have experienced a hypertensive disorder of pregnancy, to have a lower household income, and to have not breastfed or to have breastfed for <6 months, when compared with the Normal high-sensitivity C-reactive protein group (all P<.05). Patients in the High and Acute high-sensitivity C-reactive protein groups had higher 30-year cardiovascular risk scores and were more likely to have metabolic syndrome when compared with the Normal high-sensitivity C-reactive protein group (all P<.05). Patients with High high-sensitivity C-reactive protein had 2-fold odds of metabolic syndrome 6 to 12 months after delivery, compared with those in the Normal high-sensitivity C-reactive protein group (adjusted odds ratio, 2.85 [95% confidence interval, 1.66-4.91]), adjusting for hypertensive disorder of pregnancy, body mass index, clinic site, breastfeeding, income, and family history of cardiovascular disease. Those with Acute high-sensitivity C-reactive protein also seemed to have elevated odds of metabolic syndrome compared with the Normal high-sensitivity C-reactive protein group (adjusted odds ratio, 2.52 [95% confidence interval, 1.24-5.12]). The odds of chronic hypertension were significantly higher (P<.05) in the High high-sensitivity C-reactive protein group (adjusted odds ratio, 1.72 [95% confidence interval, 1.12-2.65]) compared with the Normal group.

CONCLUSION

Individuals with elevated postpartum high-sensitivity C-reactive protein are at increased risk of cardiovascular disease 6 to 12 months postpartum after a pregnancy complicated by a hypertensive disorder of pregnancy. Future research is critical to determine the most comprehensive and accurate method and timing of postpartum cardiovascular risk screening to decrease the incidence of preventable cardiovascular mortality among women.

Mode of conception in patients with endometriosis and adverse pregnancy outcomes: a population-based cohort study

OBJECTIVE

To evaluate the association between endometriosis and adverse pregnancy outcomes.

DESIGN

Population-based retrospective cohort study using linked universal health databases through ICES Ontario.

PATIENT(S)

All singleton pregnancies with an estimated date of confinement between October 2006 and February 2014.

INTERVENTION(S)

Endometriosis was determined based on a surgical and/or medical diagnosis (defined as an in-hospital admission or surgery with a diagnosis code of International Classification of Diseases [ICD]9-617 or ICD10-N80 and/or 2 medical consults billed as ICD9-617).

MAIN OUTCOME MEASURE(S)

The association between endometriosis and pregnancy outcomes was quantified by relative risks, derived using modified Poisson regression, and adjusted for maternal age, income quintiles, and history of fibroids (aRR). Mediation analysis was conducted to estimate direct effects of endometriosis diagnosis and indirect effects through mode of conception, namely: infertility without fertility treatment (known infertility but conceived without assistance), ovulation induction or intrauterine insemination, and in vitro fertilization or intracytoplasmic sperm injection, relative to unassisted conception.

RESULT(S)

A total of 19,099 pregnancies had an antecedent diagnosis of endometriosis, while 768,350 did not. Mean time (standard deviation) from endometriosis diagnosis to the index pregnancy was 5.6 (4.3) years. Endometriosis was associated with an increased risk of hypertensive disorders of pregnancy (aRR, 1.09; 95% confidence interval [CI], 1.02-1.16), preterm birth <37 weeks (aRR, 1.26; 95% CI, 1.20-1.33), early preterm birth <34 weeks (aRR, 1.33; 95% CI, 1.17-1.50), placenta previa (aRR, 2.07; 95% CI, 1.84-2.33), placenta abruption (aRR, 1.55; 95% CI, 1.31-1.83), other placental disorders (aRR, 1.77; 95% CI, 1.36-2.30), cesarean delivery (aRR, 1.18; 95% CI, 1.16-1.21), and stillbirth (aRR, 1.32; 95% CI, 1.09-1.59). Mediation analysis suggests that endometriosis directly affects most adverse pregnancy outcomes studied, except for stillbirth where infertility diagnosis or fertility treatment indirectly accounted for part of the increased risk.

CONCLUSION(S)

Endometriosis was associated with adverse pregnancy, independent of infertility diagnosis, or fertility treatment. Future studies should investigate the mechanisms of action and potential interventions.

Mode of conception and risk of spontaneous vs. provider-initiated preterm birth: population-based cohort study

OBJECTIVE

To study the association between mode of conception and risk of preterm birth, including, spontaneous and provider-initiated subtypes.

DESIGN

Population-based retrospective cohort study.

SETTING

Not applicable.

PATIENTS

All singleton livebirths and stillbirth in Ontario, Canada, 2006-2014.

INTERVENTION

The main exposure was mode of conception, namely unassisted conception, infertility without fertility treatment (i.e., known infertility but conceived without assistance), ovulation induction (OI) or intrauterine insemination (IUI), and in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Modified Poisson regression generated risk ratios (RRs) and 95% confidence intervals for the association between exposure categories and preterm birth adjusted for clinically relevant covariates using a propensity score.

MAIN OUTCOME MEASURE(S)

The primary outcome was preterm birth <37 weeks, further categorized as spontaneous or provider-initiated subtypes. The secondary outcome was preterm birth <34 weeks.

RESULTS

We included 732,810 singleton births born to 649,918 mothers, of which 646,926 (88.3%) were from an unassisted conception, 68,822 (9.4%) with infertility but no fertility treatment, 9,024 (1.2%) following OI/IUI, and 8,038 (1.1%) following IVF/ICSI. Preterm birth <37 weeks occurred among 6.0% of births by unassisted conception, 7.7% with infertility without fertility treatment, 8.0% with OI/IUI, and 10.8% following IVF/ICSI. Relative to unassisted conception, the unadjusted RR of provider-initiated preterm birth was 1.30 (1.26-1.33) in women with infertility without fertility treatment, 1.36 (1.26-1.45) after OI/IUI, and 1.82 (1.70-1.93) after IVF/ICSI. The corresponding adjusted RRs (aRR) were 1.23 (1.16-1.31), 1.48 (1.29-1.69), and 2.35 (2.09-2.64). The unadjusted RR of spontaneous preterm birth was 1.22 (1.18-1.27) in women with infertility without fertility treatment, 1.22 (1.12-1.34) after OI/IUI, and 1.47 (1.35-1.60) after IVF/ICSI. The corresponding aRR were 1.15 (1.10-1.19), 1.19 (1.09-1.31), and 1.40 (1.27-1.53). For preterm birth <34 weeks, the RRs followed a similar pattern as for preterm birth <37 weeks, with the exception of women with infertility without fertility treatment (aRR 1.08; confidence interval, 0.95-1.23).

CONCLUSIONS

Infertility and receipt of fertility treatment are each associated with a higher risk of preterm birth, spontaneous and provider-initiated subtypes, even in singleton pregnancies. Strategies are needed to reduce the risk for preterm birth in these women.

Therapeutic journey of adolescents and young adults with severe dysmenorrhea and endometriosis

Introduction:

We aimed to appreciate the diagnostic and therapeutic journey of young women with endometriosis including disease presentation, obstacles to diagnosis and management, and impact on their life.

Methods:

We employed a mixed-method design, including chart review, 94-item questionnaire assembled from components of the EPHect EPQ-S and semi-structured interviews. The study setting was Kingston Health Sciences Centre in Kingston, Ontario. Participants were women under 28 years with severe dysmenorrhea. Questionnaire data was analyzed using descriptive statistics. Interviews were coded using the constant comparative analysis method by two analyzers and inter-rater reliability was calculated, then data were compared using a cross-sectional method.

Results:

Twenty-four participants were identified through chart review, 10 completed the questionnaire, and 5 participated in the interviews. Questionnaire participants, mean age 24.5 years ± 2.3, reported initial pelvic pain at a mean age of 13.9 years (SD 1.9). Fifty percent of participants have an endometriosis diagnosis, at a mean age of 19.2 years (SD 2.6). Three major themes emerged from our analysis. The journey with disease and therapy begins long before diagnosis and creates a culture of self-directed care. Lack of knowledge about endometriosis and women’s health by health care professionals and the public delays diagnosis and therapy. Endometriosis broadly impacts every aspect of an individual’s life.

Conclusion:

We found that young adults with severe dysmenorrhea and/or endometriosis present with symptoms at a young age. They encounter multiple obstacles in reaching a diagnosis and obtaining therapy. They often self-manage their pelvic pain and experience reduced quality of life.

Attention-deficit hyperactivity disorder in children born to mothers with infertility: a population-based cohort study

STUDY QUESTION

Is the risk of attention-deficit hyperactivity disorder (ADHD) increased in children born to mothers with infertility, or after receipt of fertility treatment, compared to mothers with unassisted conception?

SUMMARY ANSWER

Infertility itself may be associated with ADHD in the offspring, which is not amplified by the use of fertility treatment.

WHAT IS KNOWN ALREADY

Infertility, and use of fertility treatment, is common. The long-term neurodevelopmental outcome of a child born to a mother with infertility, including the risk of ADHD, remains unclear.

STUDY DESIGN, SIZE, DURATION

This population-based cohort study comprised all singleton and multiple hospital births in Ontario, Canada, 2006–2014. Outcomes were assessed up to June 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Linked administrative datasets were used to capture all hospital births in Ontario, maternal health and pregnancy measures, fertility treatment and child outcomes. Included were all children born at ≥24 weeks gestation between 2006 and 2014, and who were alive at age 4 years. The main exposure was mode of conception, namely (i) unassisted conception (reference group), (ii) infertility without fertility treatment (history of an infertility consultation with a physician within 2 years prior to conception but no fertility treatment), (iii) ovulation induction (OI) or intrauterine insemination (IUI) and (iv) IVF or intracytoplasmic sperm injection (ICSI). The main outcome was a diagnosis of ADHD after age 4 years and assessed up to June 2020. Hazard ratios (HRs) were adjusted for maternal age, income quintile, rurality, immigration status, smoking, obesity, parity, any drug or alcohol use, maternal history of mental illness including ADHD, pre-pregnancy diabetes mellitus or chronic hypertension and infant sex. In addition, we performed pre-planned stratified analyses by mode of delivery (vaginal or caesarean delivery), infant sex, multiplicity (singleton or multiple), timing of birth (term or preterm <37 weeks) and neonatal adverse morbidity (absent or present).

MAIN RESULTS AND THE ROLE OF CHANCE

The study included 925 488 children born to 663 144 mothers, of whom 805 748 (87%) were from an unassisted conception, 94 206 (10.2%) followed infertility but no fertility treatment, 11 777 (1.3%) followed OI/IUI and 13 757 (1.5%) followed IVF/ICSI. Starting at age 4 years, children were followed for a median (interquartile range) of 6 (4–8) years. ADHD occurred among 7.0% of offspring in the unassisted conception group, 7.5% in the infertility without fertility treatment group, 6.8% in the OI/IUI group and 6.3% in the IVF/ICSI group. The incidence rate (per 1000 person-years) of ADHD was 12.0 among children in the unassisted conception group, 12.8 in the infertility without fertility treatment group, 12.9 in the OI/IUI group and 12.2 in the IVF/ICSI group. Relative to the unassisted conception group, the adjusted HR for ADHD was 1.19 (95% CI 1.16–1.22) in the infertility without fertility treatment group, 1.09 (95% CI 1.01–1.17) in the OI/IUI group and 1.12 (95% CI 1.04–1.20) in the IVF/ICSI group. In the stratified analyses, these patterns of risk for ADHD were largely preserved. An exception was seen in the sex-stratified analyses, wherein females had lower absolute rates of ADHD but relatively higher HRs compared with that seen among males.

LIMITATIONS, REASONS FOR CAUTION

Some mothers in the isolated infertility group may have received undocumented OI oral therapy, thereby leading to possible misclassification of their exposure status. Parenting behaviour, schooling and paternal mental health measures were not known, leading to potential residual confounding.

WIDER IMPLICATIONS OF THE FINDINGS

Infertility, even without treatment, is a modest risk factor for the development of ADHD in childhood. The reason underlying this finding warrants further study.

STUDY FUNDING/COMPETING INTEREST(s)

This study was made possible with funding from the Canadian Institutes of Health Research, Grant number PJT 165840. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Before and After Legalization: Cannabis Use Among Pregnant Patients at a Tertiary Care Center in Ontario

We compared levels of cannabis and other substance use before and after the legalization of cannabis in the obstetric population of the Kingston General Hospital (KGH). Urine samples were collected from patients admitted to KGH labour and delivery in September/October 2018 and September/October 2019. Urine was anonymously screened for cannabis and other substances. Approximately 9.5%-10% of patients screened positive for cannabis. We found no difference in the prevalence of cannabis use in our sample after legalization. Health care providers should discuss cannabis with patients who are pregnant or planning a pregnancy.

Infertility treatment and postpartum mental illness: a population-based cohort study

BACKGROUND

Subfertility and infertility treatment can be stressful experiences, but it is unknown whether each predisposes to postpartum mental illness. We sought to evaluate associations between subfertility or infertility treatment and postpartum mental illness.

METHODS

We conducted a population-based cohort study of individuals without pre-existing mental illness who gave birth in Ontario, Canada, from 2006 to 2014, stratified by fertility exposure: subfertility without infertility treatment; noninvasive infertility treatment (intrauterine insemination); invasive infertility treatment (in vitro fertilization); and no reproductive assistance. The primary outcome was mental illness occurring 365 days or sooner after birth (defined as ≥ 2 outpatient visits, an emergency department visit or a hospital admission with a mood, anxiety, psychotic, or substance use disorder, self-harm event or other mental illness). We used multivariable Poisson regression with robust error variance to assess associations between fertility exposure and postpartum mental illness.

RESULTS

The study cohort comprised 786 064 births (mean age 30.42 yr, standard deviation 5.30 yr), including 78 283 with subfertility without treatment, 9178 with noninvasive infertility treatment, 9633 with invasive infertility treatment and 688 970 without reproductive assistance. Postpartum mental illness occurred in 60.8 per 1000 births among individuals without reproductive assistance. Relative to individuals without reproductive assistance, those with subfertility had a higher adjusted relative risk of postpartum mental illness (1.14, 95% confidence interval 1.10-1.17), which was similar in noninvasive and invasive infertility treatment groups.

INTERPRETATION

Subfertility or infertility treatment conferred a slightly higher risk of postpartum mental illness compared with no reproductive assistance. Further research should elucidate whether the stress of infertility, its treatment or physician selection contributes to this association.

Magnesium-based trigger point infiltrations versus local anesthetic infiltrations in chronic pelvic myofascial pain: A randomized, double-blind control study

OBJECTIVE

To determine if a novel, magnesium-based trigger point infiltration formulation is more effective in treating chronic myofascial pelvic pain than lidocaine-only infiltration.

METHODS

This was a single-centre, double-blind, randomized controlled trial of women diagnosed with chronic pelvic myofascial pain associated with trigger points. We compared a novel magnesium-based infiltration formulation with lidocaine infiltration of trigger points and with a control group of participants who were waitlisted for a chronic pain clinic. Treatment groups completed a 12-week program that included 8 trigger point injection treatments and nine visits during which pain scores were recorded and questionnaires administered. The primary outcome measure was change in mean pain score between baseline and the final visit. Secondary outcomes included pain with function scores, scores on the World Health Organization Quality of Life questionnaire, procedural pain, concomitant medication use, and complications.

RESULTS

We assigned 44 women diagnosed with chronic myofascial pelvic pain associated with trigger points to either the magnesium-based infiltrate (n = 15), lidocaine infiltrate (n = 17), or waitlist (n = 12) group. In the intent-to-treat analysis, a clinically relevant decrease in mean pain score out of 10 was observed in the magnesium-based (-2.6 ± 3.2) and lidocaine (-2.9 ± 3.1) infiltration groups, but not in the waitlist group (-0.5 ± 2.3). The per protocol analysis post-hoc tests, adjusted for multiple comparisons, found a significant difference in the average change in pain score between the magnesium-based infiltrate and the waitlist groups (P = 0.045), while differences between the lidocaine infiltrate and waitlist groups approached statistical significance (P = 0.052). Both treatment groups saw improvements in pain with function and quality of life scores.

CONCLUSION

While this study is underpowered, it does not support the use of a magnesium-based trigger point infiltrate in the treatment of chronic myofascial pelvic pain over lidocaine-only infiltration. Nonetheless, these results are consistent with current management recommendations and suggest improvements in pain, pain with function, and quality of life scores with either magnesium-based or lidocaine-only infiltration. We outline an approach to assessment and treatment that can be adopted by general gynaecologists.

Infertility Consults in Immigrant and Refugee Women in Ontario: Population-Based Cohort Study

Though immigrant women comprise a growing portion of the Canadian population, there remains a lack of information on the rates of infertility diagnosis in this group. Our study aimed to investigate the differences in rates of infertility consults between refugee, non-refugee immigrant, and Canadian-born women. We conducted a population-based matched cohort study in women 15-45 years of age in Ontario. Immigration status was defined as refugee, non-refugee immigrant, and Canadian-born woman. Refugee and non-refugee immigrant women were matched by age and residence in the same Local Health Integration Network (LHIN) to two Canadian-born women. The cohort was followed for 2 years for occurrence of infertility consult. Proportion of infertility consults by immigration status was calculated and differences between groups were assessed using standardized differences (SD). Modified Poisson regression was used to calculate the relative risk (RR) for infertility consults by immigration status after adjusting for confounding variables. Our results showed an increased proportion of infertility consults among both refugees (4.7%) and non-refugee immigrant women (5.8%) compared to their Canadian-born matches (2.8% and 3.2%, respectively), with SD ≧ 0.1 in most stratified age groups, denoting a meaningful statistical difference. In the multivariable analysis, relative to Canadian-born women, the RR for fertility consults was increased in refugee women (RR 1.66, CI 95% 1.58-1.75), and non-refugee immigrants (RR 1.77, 95% CI 1.74-1.80). These findings may be explained by immigrant women originating from areas with higher infertility rates, or their experience of higher than average stress levels, a known risk factor for infertility.

Caesarean birth in women with infertility: population-based cohort study

Objective

Caesarean section (CS) is more common following infertility treatment (IT) but the reasons why remain unclear and confounded. The Robson 10‐Group Classification System (TGCS) may further explain variation in CS rates. We assessed the association between mode of conception and CS across Robson groups.

Design

Population‐based cohort study.

Setting

Ontario, Canada, in a public healthcare system.

Population

921 023 births, 2006–2014.

Methods

Modified Poisson regression produced relative risks (RR) and 95% confidence intervals, comparing the risk of CS among women with (1) subfertility without IT, (2) non‐invasive IT (OI, IUI) or (3) invasive IT (IVF)—each relative to (4) spontaneous conception (SC).

Main outcome measures

CS rate according to one of four modes of conception, overall and stratified by each of the TGCS groups.

Results

Relative to SC (26.9%), the risk of CS increased in those with subfertility without IT (RR 1.17, 95% CI 1.16–1.18), non‐invasive IT (RR 1.21, 95% CI 1.18–1.24) and invasive IT (RR 1.39, 95% CI 1.36–1.42). Within each Robson group, similar patterns of RRs were seen, but with markedly differing rates. For example, in Group 1 (nulliparous, singleton, cephalic at ≥37 weeks, with spontaneous labour), the respective rates were 15.0, 19.4, 18.7 and 21.9%; in Group 2 (nulliparous, singleton, cephalic at ≥37 weeks, without spontaneous labour), the rates were 35.9, 44.4, 43.2 and 54.1%; and in Group 8 (multiple pregnancy), they were 55.9, 67.5, 65.0 and 69.3%, respectively.

Conclusions

CS is relatively more common in women with subfertility and those receiving IT, an effect that persists across Robson groups.

Tweetable abstract

Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions.

Caesarean delivery is more common in women with infertility independent of demographics and prenatal conditions.

Long-term follow-up of endometriosis surgery in Ontario: a population-based cohort study

BACKGROUND

Endometriosis is a chronic gynecological disease affecting approximately 10% of reproductive aged females and leads to decreased quality of life and productivity. Despite effective medical options, many women do require surgery for endometriosis. There is limited literature examining long term outcomes of endometriosis surgery.

OBJECTIVE

This study aimed to characterize the long-term outcomes, including recurrence of symptoms, fertility outcomes, and need for reoperation, of patients who underwent surgical management for endometriosis.

STUDY DESIGN

This was a population-based cohort study in which the universal coverage health database for the province of Ontario, Canada, was used to identify women aged 18 to 50 years who underwent surgery for endometriosis from April 1, 2002, through March 31, 2018. Surgery was classified as diagnostic laparoscopy, conservative or uterine preserving (minor or major, with and without ovarian preservation), or hysterectomy (with and without ovarian preservation). The outcomes were evaluated from 30 days after the index surgery to the end of the study period or at censoring. Cox proportional hazard regression models were used to estimate the hazard ratios between exposures and outcomes following adjustment for confounders.

RESULTS

A total of 84,885 women 2,718 (3.2%) diagnostic laparoscopy, 21,594 (25.4%) minor conservative surgery, 28,484 (33.6%); major conservative with ovarian preservation, 2,102 (2.5%) major conservative without ovarian preservation, 21,609 (25.5%) hysterectomy with ovarian preservation, and 8,378 (9.9%) hysterectomy without ovarian preservation) were included in the cohort and followed for a median of 10 years (interquartile range, 6-13 years). In the first postoperative year, women who underwent diagnostic laparoscopy were significantly more likely to require repeat surgery (adjusted hazard ratio, 1.68; 95% confidence interval, 1.51-1.87), whereas those who underwent major conservative surgery were significantly less likely to require repeat surgery (with ovarian preservation: adjusted hazard ratio, 0.44; 95% confidence interval, 0.41-0.48; without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.09). Among women who did not receive repeat surgery in the first year, those who underwent a diagnostic laparoscopy (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95) and major conservative surgery without ovarian preservation were less likely to undergo repeat surgery (adjusted hazard ratio, 0.12; 95% confidence interval, 0.09-0.18) than those who initially had minor surgery. Compared with those who initially underwent minor surgery, patients who underwent other treatment modalities were less likely to undergo a hysterectomy (diagnostic laparoscopy: adjusted hazard ratio, 0.85; 95% confidence interval, 0.75-0.96; major surgery with ovarian preservation: adjusted hazard ratio, 0.60; 95% confidence interval, 0.57-0.64; major surgery without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.08). Following minor and major conservative with ovarian preservation surgery, 8,331 (38.6%) and 9,498 (33.3%) of patients sought an infertility consult within 1 year, respectively. By 5 years after the index surgery, 5,290 (29.4%) of patients who had minor conservative surgery and 4,528 (20.7%) of those who had major conservative with ovarian preservation surgery had given birth at least once.

CONCLUSION

Our study suggests that only a few endometriosis patients who undergo hysterectomy surgery require repeat surgery; however, up to 1 in 4 who undergo minor surgery and 1 in 5 who undergo major conservative surgery with ovarian preservation require additional endometriosis surgery. Up to 1 in 3 patients who had uterine sparing endometriosis surgery subsequently sought an infertility assessment. These findings may inform preoperative counseling in terms of recurrence of symptoms, fertility outcomes, and need for reoperation of women seeking surgical management for endometriosis. Future studies should consider the outcomes of patient satisfaction and quality of life based on the current practices for management of endometriosis.

Acute fetal response to high-intensity interval training in the second and third trimesters of pregnancy

The majority of women do not meet the recommended levels of exercise during their pregnancies, frequently due to a lack of time. High-intensity interval training offers a potential solution, providing an effective, time-efficient exercise modality. This exercise modality has not been studied in pregnancy therefore, the objective of this study was to evaluate fetal response to a high-intensity interval training resistance circuit in the late second and early third trimesters of pregnancy. Fourteen active, healthy women with uncomplicated, singleton pregnancies participated in a high-intensity interval training resistance circuit between 28 + 0/7 and 32 + 0/7 weeks. A Borg rating of perceived exertion of 15-17/20 and an estimated heart rate of 80%-90% of maternal heart-rate maximum was targeted. Fetal well-being was evaluated continuously with fetal heart-rate tracings and umbilical artery Doppler velocimetry conducted pre-and post-exercise. Fetal heart rate tracings were normal throughout the exercise circuit. Post-exercise, umbilical artery end-diastolic flow was normal and significant decreases were observed in the mean systolic/diastolic ratios, pulsatility indexes and resistance indexes. Therefore, in a small cohort of active pregnant women, a high-intensity interval training resistance circuit in the late second and early third trimesters of pregnancy appears to be a safe exercise modality with no acute, adverse fetal effects but further study is required. Novelty: High-intensity interval training, at an intensity in excess of current recommendations, does not appear to be associated with any adverse fetal effects in previously active pregnant women. High-intensity interval training is an enjoyable and effective exercise modality in previously active pregnant women.

Evaluation of a Postpartum Cardiovascular Risk Screening Clinic: An Analysis of Interpregnancy and Subsequent Pregnancy Outcomes

OBJECTIVE

At the Maternal Health Clinic (MHC), women with certain pregnancy complications are seen for appointments focusing on lifestyle modification and future pregnancy counselling. This study's objective is to determine whether women who attended the MHC following a pregnancy complicated by gestational diabetes mellitus (GDM) or a hypertensive disorder of pregnancy (HDP) have improved interpregnancy and subsequent pregnancy outcomes, compared with non-attendees.

METHODS

A retrospective cohort study was conducted including all pregnancies ≥20 weeks gestation at Kingston Health Sciences Centre (KHSC) from April 2010 to Dec 2019. Women with ≥2 deliveries were eligible for inclusion, with 2 pregnancies per woman included. These criteria identified 178 patients who attended the MHC and 133 who did not. Continuous variables with normal distribution were assessed with independent sample t tests. Continuous variables without normal distribution and ordinal variables were assessed with Mann-Whitney U tests. Categorical variables were assessed with Pearson's χ² tests. Preterm delivery, HDP and GDM recurrence, HDP and GDM progression, and change in first-trimester blood pressure and pre-pregnancy weight were examined using multivariate regression modelling. Probability values <0.05 determined significance.

RESULTS

MHC attendance was associated with improvements in interpregnancy weight reduction (P = 0.002), fewer interpregnancy type II diabetes diagnoses (P < 0.001), and a later gestational age at delivery (P < 0.001). There were no differences in subsequent pregnancy complication recurrence rates of GDM (P = 0.731) or an HDP (P = 0.139) between cohorts.

CONCLUSION

In our examination of MHC outcomes, we found improvements in certain interpregnancy and subsequent pregnancy outcomes. These results support the continued development and funding of these clinics.

Cardiovascular Risk Screening and Pregnancy Complications: A Comparison of Two Canadian Maternal Health Clinic Populations

OBJECTIVE

This study compared pregnancy-related cardiovascular disease risk indicators between women who attended 2 different postpartum screening and education clinics: 1 at an urban tertiary care centre and 1 at a northern, rural community hospital. Risk differences associated with ethnicity were also examined.

METHODS

We conducted a retrospective record review that compared data from an urban clinic in Kingston, Ontario (n = 675) with those from a rural clinic in Prince Rupert, British Columbia (n = 65). Patients who had a hypertensive disorder of pregnancy, gestational diabetes, intrauterine growth restriction, idiopathic preterm birth, or placental abruption attended the clinics at 6 months postpartum. Demographic information, personal and family history, physical examination findings, and laboratory results were collected and used to generate cardiovascular risk estimates using validated scoring systems. These estimates were compared between clinic populations and between ethnic subsets.

RESULTS

Fifty-five percent of the Prince Rupert cohort were Indigenous, while 87% of the Kingston cohort were White (P < 0.001). A greater proportion of the Kingston cohort had experienced hypertensive disorders of pregnancy (P = 0.002), while a greater proportion of the Prince Rupert cohort had developed gestational diabetes (P=0.010). The Prince Rupert population had higher lifetime and 30-year cardiovascular disease risk scores (P = 0.008 and P = 0.005, respectively). Indigenous patients had more major cardiovascular risk factors as well as higher lifetime and 30-year cardiovascular risk scores (P = 0.001 and P = 0.008, respectively) than White and Asian patients.

CONCLUSION

The increased cardiovascular disease risk in both rural and Indigenous women supports the need for better postpartum care, long-term follow-up, and early promotion of cardiovascular health in these populations.

Preoperative Factors of Endometrial Carcinoma in Patients Undergoing Hysterectomy for Atypical Endometrial Hyperplasia

OBJECTIVE

To identify clinicopathological preoperative factors associated with concurrent endometrial carcinoma in patients undergoing surgical management of atypical endometrial hyperplasia.

METHODS

The records of all patients who underwent hysterectomy for preoperatively diagnosed atypical endometrial hyperplasia at a tertiary care hospital from April 2017 to April 2020 were retrospectively reviewed. Clinicopathological characteristics of patients were extracted. Patients who did not undergo hysterectomy or who had evidence of simple hyperplasia or carcinoma on initial biopsy were excluded. Univariate analysis was performed. A multivariate regression model for progression to endometrial carcinoma was developed.

RESULTS

A total of 126 patients were included. Of these patients, 19 (15.1%) had a final diagnosis of endometrial carcinoma, whereas 86 (68.2%) retained the diagnosis of atypical endometrial hyperplasia and 21 (16.7%) were found to have no residual atypical endometrial hyperplasia. The odds of a patient being diagnosed with endometrial carcinoma were 6.1 times higher (95% CI 1.32-27.68) if they had an endometrial stripe thickness >1.1 cm and 13.5 times higher (95% CI 3.56-51.1) if there was histological suspicion of carcinoma. The odds of a patient being diagnosed with endometrial carcinoma were significantly lower if the patient had an initial diagnosis of atypical endometrial hyperplasia in a polyp (OR 0.07; 95% CI 0.02-0.34).

CONCLUSION

Our results suggest that an endometrial stripe thickness >1.1 cm, a histological suspicion of carcinoma on preoperative pathology, and the absence of polyp involvement on initial diagnosis are the strongest predictors of endometrial carcinoma at the time of hysterectomy in patients with atypical endometrial hyperplasia.

Standardized Postpartum Follow-Up for Women with Pregnancy Complications: Barriers to Access and Perceptions of Maternal Cardiovascular Risk

OBJECTIVE

Certain obstetrical complications are known to increase a woman's risk of future cardiovascular disease (CVD). The Maternal Health Clinic (MHC) provides postpartum cardiovascular risk counselling and follow-up; however, half of women referred do not attend. This study aimed to identify barriers to access, as well as whether attendance at the MHC improved the accuracy of patients' CVD risk perception.

METHODS

MHC patients completed a CVD risk perception questionnaire prior to being assessed and 3 months after their appointment ("attendees"). Calculated lifetime CVD risk scores were compared with perceived risk to assess accuracy of risk perception. Patients who did not attend their MHC appointment ("non-attendees") were administered the questionnaire by phone and asked about perceived barriers to access.

RESULTS

Sixty-seven of 137 eligible attendees (48.9%) completed both the pre- and post-MHC questionnaires. Significantly more participants accurately estimated their absolute CVD risk after their MHC appointment, although the majority continued to underestimate their risk. Among non-attendees, 81 of 130 women (62.3%) completed the questionnaire. The most common barriers to access cited were being too busy with childcare, accessing follow-up with the patient's family doctor instead, and difficulty attending their appointment.

CONCLUSION

Lack of time and inconvenience were two common barriers to accessing the MHC. Improved collaboration with primary care providers and use of telemedicine may help to mitigate these issues. Both attendees and non-attendees appeared to have an inadequate perception of CVD risk. Standardized postpartum CVD risk screening and counselling may be an effective method of providing these women with risk education and improving the accuracy of their risk perception.

Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

Background

Caesarean section rates are higher among pregnancies conceived by assisted reproductive technology (ART) compared to spontaneous conceptions (SC), implying an increase in neonatal and maternal morbidity. We aimed to compare caesarean section rates in ART pregnancies versus SC, overall, by indication (elective versus emergent), and by type of ART treatment (in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), fresh embryo transfer, frozen embryo transfer) in a systematic review and meta-analysis.

Methods

We searched Medline, EMBASE and CINAHL databases using the OVID Platform from 1993 to 2019, and the search was completed in January 2020. The eligibility criteria were cohort studies with singleton conceptions after in-vitro fertilization and/or intracytoplasmic sperm injection using autologous oocytes versus spontaneous conceptions. The study quality was assessed using the Newcastle Ottawa Scale and GRADE approach. Meta-analyses were performed using odds ratios (OR) with a 95% confidence interval (CI) using random effect models in RevMan 5.3, and I-squared (I²) test > 75% was considered as high heterogeneity.

Results

One thousand seven hundred fifty studies were identified from the search of which 34 met the inclusion criteria. Compared to spontaneous conceptions, IVF/ICSI pregnancies were associated with a 1.90-fold increase of odds of caesarean section (95% CI 1.76, 2.06). When stratified by indication, IVF/ICSI pregnancies were associated with a 1.91-fold increase of odds of elective caesarean section (95% CI 1.37, 2.67) and 1.38-fold increase of odds of emergent caesarean section (95% CI 1.09, 1.75). The heterogeneity of the studies was high and the GRADE assessment moderate to low, which can be explained by the observational design of the included studies.

Conclusions

The odds of delivering by caesarean section are greater for ART singleton pregnancies compared to spontaneous conceptions. Preconception and pregnancy care plans should focus on minimizing the risks that may lead to emergency caesarean sections and finding strategies to understand and decrease the rate of elective caesarean sections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03711-x.

Short-term outcomes of endometriosis surgery in Ontario: A population-based cohort study

INTRODUCTION

Our objective was to compare the short-term outcomes by type of surgical management of endometriosis in Ontario, Canada and to characterize the population of women undergoing surgical management of endometriosis.

MATERIAL AND METHODS

We conducted a population-based cohort study including women aged 18-50 years undergoing same-day or inpatient surgery for endometriosis from 1 April 2002 through 31 March 2018. Surgery was classified as minimally invasive hysterectomy (MIH), total abdominal hysterectomy (TAH) or minor or major conservative (uterus-preserving) surgery. Outcomes examined included length of stay, intraoperative complications, postoperative complications, emergency department visits, ambulatory care visits, and readmission. We estimated the relative risk of these outcomes in minor, major conservative surgery and TAH vs MIH adjusted for age, income quintile, parity, and comorbidities.

RESULTS

A total of 85 605 patients underwent surgery, 12.9% MIH, 22.1% TAH, 36.3% major conservative, and 28.6% minor conservative. The mean age at index surgery was 37.6 ± 7.7 years. Before surgery, 70.6% of patients had visited a physician for pain at least once (64.7% MIH, 69.5% TAH, 71.1% major conservative and 73.4% minor conservative) and 23.5% of patients had sought infertility consultation (5.7% MIH, 6.6% TAH, 29.3% major conservative and 37.1% minor conservative). The overall risk of intraoperative and postoperative complications was 1.5% and 4.7%, respectively. In adjusted models, compared with those undergoing minor conservative surgery, those having major conservative surgery were 1.77 (95% CI 1.49-2.11) times as likely to experience an intraoperative complication, those having MIH and TAH were 2.55 (95% CI 2.08-3.13) and 2.34 (95% CI 1.93-2.82) times as likely to do so, respectively. Similarly, compared with those undergoing minor conservative surgery, those having major conservative surgery were 2.60 (95% CI 2.30, 2.93) times as likely to experience any postoperative complication, and those having MIH and TAH were 4.69 (95% CI 4.11-5.36) and 5.38 (95% CI 4.76-6.09) times as likely to do so, respectively.

CONCLUSIONS

Approximately one-third of patients undergoing surgical management for endometriosis in Ontario between 2002 and 2018 had a hysterectomy. Overall, complications following surgery were low, and dependent on extent of surgery. These results should help to inform preoperative counseling for patients and health policy development for providers.

Postpartum microvascular functional alterations following severe preeclampsia

Preeclampsia is associated with adverse maternal health outcomes later in life. Vascular endothelial dysfunction has been previously described following preeclampsia. We hypothesized that microvascular endothelial dysfunction associated with preeclampsia persists postpartum and may identify those at greatest risk of future cardiovascular disease. The objective of this study was to examine postpartum microvascular endothelial function in women after a pregnancy complicated by preeclampsia. Women with previous preeclampsia (n = 30) and normotensive controls (n = 30) between 6 mo and 5 yr postpartum were recruited. Severity of preeclampsia [severe (n = 16) and mild (n = 14)] was determined by standardized chart review. Microvascular reactivity in the forearm was measured with laser speckle contrast imaging, coupled with iontophoresis; endothelium-dependent and endothelium-independent vasodilation was induced with 1% acetylcholine and sodium nitroprusside solutions, respectively. A postocclusive reactive hyperemia test assessed vasodilatory response following three minutes of suprasystolic (200 mmHg) occlusion with a mechanized cuff. Women with prior severe preeclampsia exhibited significantly higher vasodilation to acetylcholine and sodium nitroprusside compared to controls (P < 0.01; P = 0.03) and prior mild preeclampsia (P = 0.03; P < 0.01). Neither the degree of postocclusive reactive hyperemia (P = 0.98), nor time to return halfway to baseline [OR = 1.026 (0.612, 1.72); P = 0.92], differed between preeclampsia and controls. In conclusion, severe preeclampsia is associated with heightened postpartum microvascular endothelium-dependent and endothelium-independent vasoreactivity. These changes, or a common antecedent, may be linked to postpartum alterations in vascular function that predispose women to disease after preeclampsia. Further investigation should identify the contributing mechanism and the degree to which it could be amenable to medical intervention.NEW & NOTEWORTHY We examine maternal microvascular function after preeclampsia, identifying heightened endothelium-dependent and endothelium-independent microvascular reactivity following severe disease. Our study represents a noteworthy addition to the existing literature with the use of a novel imaging modality, vascular perturbation, postpartum time point, and patient population with differentiation of preeclampsia into severe and nonsevere subtypes. These results represent a novel addition to the growing clinical and academic understanding of maternal health outcomes following preeclampsia.

Prevalence of Chlamydia and Gonorrhea Among Pregnant Adolescents Screened in the Third Trimester Using a Urine PCR Test: A Retrospective Review

OBJECTIVE

Our study assessed the rate of new and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections in the third trimester at an adolescent obstetrics clinic.

METHOD

Between October 2016 and June 2020, routine third-trimester screening for C. trachomatis and N. gonorrhoeae was implemented according to new Canadian recommendations. Urine nucleic acid amplification was performed. Patient records were reviewed retrospectively, and demographic data; pregnancy and delivery characteristics; and information on screening at presentation to care, third-trimester screening (33-38 weeks), and other STI testing was recorded.

RESULTS

A total of 115 adolescents (mean age 17.90 ± 1.43 y) with 125 pregnancies presented for care. Twenty-three pregnancies were excluded (12 transferred out and 11 experienced a pregnancy loss). At presentation, screening was performed in 100 of 102 pregnancies: 64 of 100 at <13 weeks, 32 of 100 at 13-27 weeks, and 4 of 100 at 28-30 weeks. Nine tested positive for C. trachomatis and none tested positive for N. gonorrhoeae. In the third trimester, there were 3 positive C. trachomatis tests, but all were indicated: test of cure was due for 1 patient, 1 patient had a new sexual partner, and 1 patient presented with symptoms. The remaining 89 of 102 pregnancies were screened (with no other indication) and none were positive for C. trachomatis or N. gonorrhoeae. Ten patients could not be sampled (5 missed, 4 pre-term deliveries, and 1 non-compliant with testing).

CONCLUSION

No cases of C. trachomatis or N. gonorrhoeae infection were identified on third-trimester screening in our study. Adolescent obstetrics providers implementing Canadian screening guidelines may want to monitor their screening results to determine whether their yield warrants universal implementation.

Delay of Fetal Anatomy Ultrasound Assessment Based on Maternal Body Mass Index Does Not Reduce the Rate of Inadequate Visualization

OBJECTIVES

To determine whether delay of initial anatomy ultrasound based on the maternal body mass index (BMI) reduces the rate of inadequate visualization compared to standard timing at 18^0/7 to 19^6/7 weeks.

METHODS

A retrospective study of singleton anatomy assessments was conducted at a tertiary care center in the 2-year period before (A, 2012-2014) and after (B, 2014-2016) protocol initiation. Assessments in period B were scheduled on the basis of the BMI in the first trimester: lower than 25 kg/m² , 18^0/7 to 19^6/7 weeks; 25 to 29.9 kg/m² , 19^0/7 to 20^6/7 weeks; 30 to 34.9 kg/m² , 20^0/7 to 21^6/7 weeks; 35 to 39.9 kg/m² , 21^0/7 to 22^6/7 weeks; and 40 kg/m² or higher, 22^0/7 to 23^6/7 weeks. In period A, assessments were scheduled between 18^0/7 and 19^6/7 weeks. The rate of inadequate visualization and repeated assessments in periods A and B were compared. Multivariable logistic regression, per-protocol, and BMI subgroup analyses were completed.

RESULTS

In total, 3491 pregnancies in period A and 3672 in period B were included. In period B, 74% were scheduled per protocol; however, this rate decreased for higher-BMI categories (52% for BMI ≥40 kg/m² ). The inadequate visualization rate was slightly higher in period B versus A (16.9% versus 15.0%; P = .03) and exceeded 35% for a BMI of 40 kg/m² or higher, with or without delay. After adjusting for maternal age and fetal presentation, period B had small increased odds of inadequate visualization versus period A (adjusted odds ratio, 1.2; 95% confidence interval, 1.02-1.38). Repeated assessment rates were similar in periods B and A (14.0% versus 13.1%; P = .25).

CONCLUSIONS

In pregnancies with obesity, a protocol delaying the initial assessment beyond 19^6/7 weeks based on the maternal BMI does not reduce the rate of inadequate visualization.

Modest Increase in Fertility Consultations in Female Adolescents and Young Adults with Lymphoma: A Population-Based Study

While survival after hematological malignancies in adolescent and young adult patients is improving, patients report poor oncofertility care. This population-based, retrospective, cohort study used data from the Ontario Cancer Registry and billing codes to identify fertility consultations for lymphoma patients between 2000 and 2018. Consultation trends across time and different patient and physician characteristics were analyzed. We identified 2088 patients and a consultation rate of 3.4% (increasing from 1% in 2000–2006 to 8% in 2014–2018). Patient parity and regional deprivation scores decreased rates. Despite mild improvement, there is ample missed opportunity for fertility discussions.

Retrospective Comparison of PGE2 Vaginal Insert and Foley Catheter for Outpatient Cervical Ripening

OBJECTIVE

To compare the efficacy of two methods of outpatient cervical ripening (CR): an intracervical Foley catheter and a prostaglandin E₂ (PGE)₂ slow-release vaginal insert.

METHODS

All records of women receiving outpatient CR at a tertiary care hospital from January 2017 to June 2018 were retrospectively reviewed. We compared time from insertion of first CR agent until delivery between groups using a Cox proportional hazards (CPH) model. Exclusion criteria included age <18 years, multiple gestation, or contraindication to either CR method. Secondary outcomes included time from removal of agent and time from admission until delivery, additional CR used, uterine tachysystole, labour and delivery complications, type of delivery, and adverse neonatal outcomes.

RESULTS

A total of 153 patients were included (82 Foley; 71 PGE₂). Baseline characteristics were comparable except for lower dilation in the PGE₂ group (16% vs. 38% <1cm dilated; P < 0.05). In the CPH model, time from insertion to delivery was not different between PGE₂ and Foley catheter groups (median 27 vs. 33 h), controlling for parity, gestational age, initial dilation, and use of oxytocin (HR 1.13, 95% confidence interval 0.77-1.68). Patients in the PGE₂ group were more likely to experience uterine tachysystole (9% vs. 0%; P < 0.01) and require another method of CR (34% vs. 1%; P < 0.001). There were no differences in neonatal or maternal adverse outcomes between groups.

CONCLUSION

Our results suggest that outpatient Foley catheter and PGE₂ CR are comparable in time from insertion to delivery; however, PGE₂ inserts are associated with higher rates of tachysystole and the need for second CR method. A prospective study is warranted to further investigate these findings.

Neonatal outcomes in singleton pregnancies conceived by fresh or frozen embryo transfer compared to spontaneous conceptions: a systematic review and meta-analysis

Purpose

The use of assisted reproductive technology (ART) has increased in the last 2 decades and continuous surveillance is needed. This systematic review aims to assess the risk of adverse neonatal outcomes (preterm birth [PTB], low birth weight [LBW], small-for-gestationalage [SGA] and large for gestational-age [LGA]), in singleton pregnancies conceived by fresh or frozen embryo transfer (FET) compared to spontaneous conceptions.

Methods

Cohort studies were identified from MEDLINE, Embase, Cochrane Library (January 2019), and manual search. Meta-analyses were performed to estimate odds ratios (OR) using random effects models in RevMan 5.3 and I-squared (I²) test > 50% was considered as high heterogeneity.

Results

After 3142 titles and abstracts were screened, 1180 full-text articles were assessed, and 14 were eligible. For fresh embryo transfer, the pooled ORs were PTB 1.64 (95% CI 1.46, 1.84); I² = 97%; LBW 1.67 (95% CI 1.52, 1.85); I² = 94%; SGA 1.46 [95% CI 1.11, 1.92]; I² = 99%, LGA 0.88 (95% CI 0.80, 0.87); I² = 80%). For frozen, the pooled ORs were PTB 1.39 (95% CI 1.34, 1.44); I² = 0%; LBW 1.38 (95% CI 0.91, 2.09); I² = 98%; SGA 0.83 (95% CI 0.57, 1.19); I² = 0%, LGA 1.57 (95% CI 1.48, 1.68); I² = 22%).

Conclusions

When compared with spontaneous pregnancies, fresh, but not frozen was associated with LBW and SGA. Both fresh and frozen were associated with PTB. Frozen was uniquely associated with LGA. Despite improvements in ART protocols in relation to pregnancy rates, attention is needed towards monitoring adverse neonatal outcomes in these pregnancies.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05593-4) contains supplementary material, which is available to authorized users.

Carbon monoxide increases utero-placental angiogenesis without impacting pregnancy specific adaptations in mice

BACKGROUND

Cigarette smokers have a reduced risk of developing preeclampsia, possibly attributed to an increase in carbon monoxide (CO) levels. Carbon monoxide is a gasotransmitter that has been implicated in maintaining vascular tone, increasing angiogenesis, and reducing inflammation and apoptosis at physiological concentrations. Moderately increasing CO concentrations may have therapeutic potential to prevent or treat preeclampsia; however, the effects of CO on pregnancy are under studied. Our objective was to investigate the effect of CO on major angiogenic and inflammatory markers in pregnancy, and to evaluate the effect of CO on indicators of placental health.

FINDINGS

Pregnant CD-1 mice were constantly exposed to either ambient air or 250 ppm CO from conception until gestation day (GD)10.5 or GD16.5. Using a qRT-PCR array, we identified that CO increased expression of major angiogenic genes at the implantation site on GD10.5, but not GD16.5. Pro-inflammatory cytokines in the plasma and tissue lysates from implantation sites in treated mice were not significantly different compared to controls. Additionally, CO did not alter the implantation site phenotype, in terms of proliferative capacity, invasiveness of trophoblasts, or abundance of uterine natural killer cells.

CONCLUSIONS

This study suggests that CO exposure is pro-angiogenic at the maternal-fetal interface, and is not associated with demonstrable concerns during murine pregnancy. Future studies are required to validate safety and efficacy of CO as a potential therapeutic for vascular insufficiency diseases such as preeclampsia and intrauterine growth restriction.