Search

Please cite this paper as: Andersson S, Rymer J, Joyce D, Momoh C, Gayle C. Sexual quality of life in women who have undergone female genital mutilation: a case-control study. BJOG 2012;119:1606-1611. Objective To investigate the sexual quality of life of women who have undergone female genital mutilation (FGM) and compare them with a similar group who has not undergone FGM. Design Case-control study. Setting A large central London teaching hospital. Population A total of 73 women who had undergone FGM and 37 control women, who had not undergone FGM but were from a similar cultural background where FGM is practiced. Methods The women completed a questionnaire containing the Sexual Quality of Life-Female (SQOL-F) questionnaire. Main outcome measures SQOL-F score. Results Women who have undergone FGM of any type have a significantly lower ( P < 0.001) overall SQOL-F score than control women (mean = 62.44, SD = 27.93 versus mean = 88.84, SD = 13.73). Women who were sexually active and had undergone FGM type III differed the most from sexually active controls ( P < 0.05) in their SQOL-F score. Women who were sexually inactive but who had undergone FGM reported significantly lower overall SQOL-F scores ( P = 0.015) than sexually inactive controls, but were not differentiated by type of FGM. Conclusion FGM significantly reduces women's sexual quality of life, based on the results of the SQOL-F questionnaire. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Woolhouse H, Gartland D, Hegarty K, Donath S, Brown S. Depressive symptoms and intimate partner violence in the 12 months after childbirth: a prospective pregnancy cohort study. BJOG 2011;118:000-000. DOI: 10.1111/j.1471-0528.2011.03219.x. Objective To examine maternal depressive symptoms during and after pregnancy and explore their relationship with intimate partner violence in the 12 months after birth. Design Prospective pregnancy cohort study of nulliparous women. Setting Melbourne, Australia. Population In all, 1507 eligible women completed baseline data (mean gestation 15 weeks). Analyses are presented for 1305 women who completed all follow-up questionnaires. Methods Women were recruited from six public hospitals at between 6 and 24 weeks of gestation. Written questionnaires were completed at recruitment and at 3, 6 and 12 months postpartum. Main outcome measures Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Intimate partner violence was assessed using the short version of the Composite Abuse Scale. Results Sixteen per cent of women reported depressive symptoms (EPDS ≥ 13) in the 12 months postpartum, with most women first reporting depressive symptoms in the second 6 months after birth. Around 40% of women reporting depressive symptoms at each follow up also reported intimate partner violence. Factors associated with postpartum depressive symptoms in multivariable models were: emotional abuse alone (adjusted odds ratio [OR] 2.72, 95% CI 1.72-4.13), physical abuse (adjusted OR 3.94, 95% CI 2.44-6.36), depression in pregnancy (adjusted OR 2.89, 95% CI 1.75-4.77) and unemployment in early pregnancy (adjusted OR 1.60, 95% CI 1.03-2.48). Conclusions Screening for maternal depression at 3 months postpartum or earlier may miss over half the women with depression in the first 12 months after birth. Intimate partner violence is common among women reporting postnatal depressive symptoms and may be an important factor for health professionals to consider in their management. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Wilailak S, Vipupinyo C, Suraseranivong V, Chotivanich K, Kietpeerakool C, Tanapat Y, Therasakvichya S, Hamontri S, Linasmita V, Bunyapipat S, Chindavijak S, Ittiwisavakul K, Khemapech N, Suekwattana P, Thanapprapasr D, Lumbiganon P. Depot medroxyprogesterone acetate and epithelial ovarian cancer: a multicentre case-control study. BJOG 2012;119:672-677. Objective To evaluate the effect of depot medroxyprogesterone acetate (DMPA) in protecting against epithelial ovarian cancer (EOC) and to evaluate factors associated with the risk of EOC. Design A multicentre, case-control study. Setting Twelve hospitals located across Thailand. Population Three hundred and thirty patients with EOC ('cases') and 982 matched controls were recruited from the 12 hospitals. Cases were newly diagnosed patients with EOC, demonstrated pathologically. Controls were age-matched patients admitted to different wards in the same hospital. Methods Cases and controls were interviewed by trained interviewers using a standardised pre-tested questionnaire. The factors associated with EOC were evaluated using univariate and multivariate analyses. Main outcome measures The odds ratio (OR) and 95% confidence interval (95% CI) were calculated to assess the relationship between DMPA and EOC. Results The use of DMPA was found to be associated with a 39% reduction in the risk of EOC with an OR of 0.61 and a 95% CI of 0.44-0.85 ( P = 0.002). A significant risk reduction (83%) was observed when the duration of DMPA use was >3 years (OR 0.17; 95% CI 0.07-0.39; P < 0.001). Other factors associated with a reduced risk of EOC were the use of combined oral contraceptive pills and breastfeeding. A factor associated with an increased risk of EOC was a family history of gynaecological cancer. Conclusions The results suggest that DMPA may have a protective effect against EOC. If this effect is real, then it represents an important non-contraceptive benefit of DMPA. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Shapley M, Blagojevic M, Jordan K, Croft P. The spontaneous resolution of heavy menstrual bleeding in the perimenopausal years. BJOG 2012;119:545-553. Objective To obtain estimates of the rate of spontaneous resolution of heavy menstrual bleeding and to explore any association with specific menstrual symptoms. Design Two-year prospective cohort study. Setting Seven general practices, with 67 100 registered patients. Population All women aged 40-54 years on the practices age-sex registers. Methods Baseline postal questionnaire, with follow-up questionnaires sent to naturally menstruating respondents at 6, 12, 18 and 24 months. Main outcome measures Rate of spontaneous resolution of heavy menstrual bleeding in naturally menstruating women. Results A total of 7121 baseline questionnaires were sent out, with an initial response rate of 63%. We recruited 2051 naturally menstruating women for the prospective cohort study. The spontaneous rate of resolution of heavy menstrual bleeding varied from 8.1% (95% CI 5.3-12%) in women aged 45-49 years, who had resolution without recurrence for 24 months, to 35% (95% CI 30-41%) in women aged 50-54 years, who had resolution without recurrence for 6 months. Rates were lower in those who reported interference with life from heavy menstrual bleeding. There was a strong association between the spontaneous resolution of heavy menstrual bleeding and skipped periods in women aged over 45 years. The association with 'cycle too variable to say' was significant, but weaker. Conclusion There is a high prevalence, incidence and significant spontaneous rate of resolution of heavy menstrual bleeding in naturally menstruating women during the perimenopausal years. The rates have potential use for individual women, clinical decisions, devising and implementing interventions and planning the care of populations. [ABSTRACT FROM AUTHOR]

Please cite this paper as: de Bie R, Massuger L, Lenselink C, Derksen Y, Prins J, Bekkers R. The role of individually targeted information to reduce anxiety before colposcopy: a randomised controlled trial. BJOG 2011;118:945-950. We investigated whether providing targeted information on an individual level by mail and by phone reduces anxiety in women referred to the colposcopy clinic. Randomised controlled trial. Women referred to the colposcopy clinic. Between December 2007 and April 2010, 169 patients with abnormal smear results were randomised into two study arms. Group A received individually targeted information about the diagnosis and procedure by mail and phone. Group B received the standard folder about colposcopies alone. Patients were requested to fill out a questionnaire prior to their first colposcopy appointment. The questionnaire included the hospital anxiety and depression scale (HADS), and the Spielberger state-trait anxiety inventory (STAI), as well as a short self-administered questionnaire. Twenty women were excluded from further analyses after randomisation, leaving 149 women for evaluation. The median STAI state anxiety score was high (50.0), but there was no significant difference in median STAI state anxiety and HADS anxiety scores between both groups. However, knowledge about human papillomavirus and the colposcopy procedure did significantly increase in group A ( P = 0.004). Anxiety levels before primary colposcopy are surprisingly high, and are not reduced following individually targeted information given before colposcopy. [ABSTRACT FROM AUTHOR]

The article focuses on how to effectively measure the health status of patients in urogynaecology. It was found that the most effective tool in determining health status is through use of self-completed questionnaires. Diagnosing incontinence purely in the basis of clinical criteria is often unsafe due to nonspecific and unreliable symptoms of the disease. Questionnaires, however, should not be used alone but in conjunction with other clinical measures.

Conversely, a cohort of cases with adverse outcomes and suboptimal CTG interpretation would naturally contain a higher proportion of higher-risk cases.[1] But this does not necessarily mean that clinicians are more specifically failing to recognise abnormal CTGs in higher-risk cases. There are (quite rightly) no practical separate CTG interpretation frameworks for higher-risk cases but birth attendants have been aware for years that CTG abnormalities need to be detected sooner and acted on more quickly in higher-risk cases. [Extracted from the article]

Please cite this paper as: van Jaarsveld C, Llewellyn C, Fildes A, Fisher A, Wardle J. Are my twins identical: parents may be misinformed by prenatal scan observations. BJOG 2012;119:517-518. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Maternal and neonatal outcomes after implementation of a hospital policy to limit low-risk planned caesarean deliveries before 39 weeks of gestation: an interrupted time-series analysis " in the 2015 issue is presented.

Objective: We evaluated residual incontinence, depression, and quality of life among Malawian women who had undergone vesicovaginal fistula (VVF) repair 12 or more months previously.Design: Prospective cohort study.Setting: Fistula Care Centre in Lilongwe, Malawi.Population: Women who had undergone VVF repair in Lilongwe, Malawi at least 12 months prior to enrolment.Methods: Self-report of urinary leakage was used to evaluate for residual urinary incontinence; depression was evaluated with the Patient Health Questionnaire-9; quality of life was evaluated with the King's Health Questionnaire.Main Outcome Measures: Prevalence and predictors of residual incontinence, quality of life scores, and prevalence of depression and suicidal ideation.Results: Fifty-six women (19.3%) reported residual urinary incontinence. In multivariable analyses, predictors of residual urinary incontinence included: pre-operative Goh type 3 [adjusted risk ratio (aRR) 2.82; 95% confidence interval (CI) 1.61-5.27) or Goh type 4 1.08-2.78), positive postoperative cough stress test (aRR = 2.42; 95% CI 1.24-4.71) and the positive 1-hour postoperative pad test (aRR = 2.20; 95% CI 1.08-4.48). Women with Goh types 3 and 4 VVF reported lower quality of life scores. Depressive symptoms were reported in 3.5% of women; all reported residual urinary incontinence.Conclusions: While the majority of women reported improved outcomes in the years following surgical VVF repair, those with residual urinary incontinence had a poorer quality of life. Services are needed to identify and treat this at-risk group.Tweetable Abstract: Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair. [ABSTRACT FROM AUTHOR]

Objective: To evaluate factors affecting unselected population-based BRCA testing in Ashkenazi Jews (AJ).Design: Cohort-study set within recruitment to the GCaPPS trial (ISRCTN73338115).Setting: North London AJ population.Population or Sample: Ashkenazi Jews women/men >18 years, recruited through self-referral.Methods: Ashkenazi Jews women/men underwent pre-test counselling for BRCA testing through recruitment clinics (clusters). Consenting individuals provided blood samples for BRCA testing. Data were collected on socio-demographic/family history/knowledge/psychological well-being along with benefits/risks/cultural influences (18-item questionnaire measuring 'attitude'). Four-item Likert-scales analysed initial 'interest' and 'intention-to-test' pre-counselling. Uni- and multivariable logistic regression models evaluated factors affecting uptake/interest/intention to undergo BRCA testing. Statistical inference was based on cluster robust standard errors and joint Wald tests for significance. Item-Response Theory and graded-response models modelled responses to 18-item questionnaire.Main Outcome Measures: Interest, intention, uptake, attitude towards BRCA testing.Results: A total of 935 individuals (women = 67%/men = 33%; mean age = 53.8 (SD = 15.02) years) underwent pre-test genetic-counselling. During the pre-counselling, 96% expressed interest in and 60% indicated a clear intention to undergo BRCA testing. Subsequently, 88% opted for BRCA testing. BRCA-related knowledge (P = 0.013) and degree-level education (P = 0.01) were positively and negatively (respectively) associated with intention-to-test. Being married/cohabiting had four-fold higher odds for BRCA testing uptake (P = 0.009). Perceived benefits were associated with higher pre-counselling odds for interest in and intention to undergo BRCA testing. Reduced uncertainty/reassurance were the most important factors contributing to decision-making. Increased importance/concern towards risks/limitations (confidentiality/insurance/emotional impact/inability to prevent cancer/marriage ability/ethnic focus/stigmatisation) were significantly associated with lower odds of uptake of BRCA testing, and discriminated between acceptors and decliners. Male gender/degree-level education (P = 0.001) had weaker correlations, whereas having children showed stronger (P = 0.005) associations with attitudes towards BRCA testing.Conclusions: BRCA testing in the AJ population has high acceptability. Pre-test counselling increases awareness of disadvantages/limitations of BRCA testing, influencing final cost-benefit perception and decision-making on undergoing testing.Tweetable Abstract: BRCA testing in Ashkenazi Jews has high acceptability and uptake. Pre-test counselling facilitates informed decision-making. [ABSTRACT FROM AUTHOR]

Objective: To assess the short- and long-term effects of mindfulness-based stress reduction (MBSR) on the resulting quality of life, sexual functioning, and sexual distress after risk-reducing salpingo-oophorectomy (RRSO).Design: Randomised controlled trial.Setting: A specialised family cancer clinic of the university medical center Groningen.Population: Sixty-six women carriers of the BRCA1/2 mutation who developed at least two moderate-to-severe menopausal symptoms after RRSO.Methods: Women were randomised to an 8-week MBSR training programme or to care as usual (CAU).Main Outcome Measures: Change in the Menopause-Specific Quality of Life Questionnaire (MENQOL), the Female Sexual Function Index, and the Female Sexual Distress Scale, administered from baseline at 3, 6, and 12 months. Linear mixed modelling was applied to compare the effect of MBSR with CAU over time.Results: At 3 and 12 months, there were statistically significant improvements in the MENQOL for the MBSR group compared with the CAU group (both P = 0.04). At 3 months, the mean MENQOL scores were 3.5 (95% confidence interval, 95% CI 3.0-3.9) and 3.8 (95% CI 3.3-4.2) for the MBSR and CAU groups, respectively; at 12 months, the corresponding values were 3.6 (95% CI 3.1-4.0) and 3.9 (95% CI 3.5-4.4). No significant differences were found between the MBSR and CAU groups in the other scores.Conclusion: Mindfulness-based stress reduction was effective at improving quality of life in the short- and long-term for patients with menopausal symptoms after RRSO; however, it was not associated with an improvement in sexual functioning or distress.Tweetable Abstract: Mindfulness improves menopause-related quality of life in women after risk-reducing salpingo-oophorectomy. [ABSTRACT FROM AUTHOR]

Objective: To estimate the intergenerational association in teenage pregnancy, and whether there is a coupling tendency between a mother and daughter in how their teen pregnancies end, such as a termination of pregnancy (TOP) versus a live birth.Design: Population-based cohort study.Setting: Ontario, Canada.Population: A total of 15 097 mothers and their 16 177 daughters.Methods: Generalised estimating equations generated adjusted odds ratios (aOR) of a daughter experiencing a teen pregnancy in relation to the number of teen pregnancies her mother had. Multinomial logistic regression estimated the odds that a teen pregnancy ended with TOP among both mother and daughter. All models were adjusted for maternal age and world region of origin, the daughter's socio-demographic characteristics and comorbidities, mother-daughter cohabitation, and neighbourhood-level teen pregnancy rate.Main Outcome Measures: Teen pregnancy in the daughter, between ages 15 and 19 years, and also the nature of the daughter's teen pregnancy, categorised as (1) no teen pregnancy, (2) at least one teen pregnancy, all exclusively ending with a live birth, and (3) at least one teen pregnancy, with at least one teen pregnancy ending with a TOP.Results: The proportion of daughters having a teen pregnancy among those whose mother had zero, one, two, or at least three teen pregnancies was 16.3, 24.9, 33.5 and 36.3%, respectively. The aOR of a daughter having a teen pregnancy was 1.42 (95% CI 1.25-1.61) if her mother had one, 1.97 (95% CI 1.71-2.26) if she had two, and 2.17 (95% CI 1.84-2.56) if her mother had three or more teen pregnancies, relative to none. If a mother had at least one teen pregnancy ending with TOP, then her daughter had an aOR of 2.12 (95% CI 1.76-2.56) for having a teen pregnancy also ending with TOP; whereas, if a mother had at least one teen pregnancy, all ending with a live birth, then her daughter had an aOR of 1.73 (95% CI 1.46-2.05) for that same outcome.Conclusion: There is a strong intergenerational occurrence of teenage pregnancy between a mother and daughter, including a coupling tendency in how the pregnancy ends.Tweetable Abstract: Strong intergenerational association for teenage pregnancy between mother and daughter. [ABSTRACT FROM AUTHOR]

Objective: To compare the recurrence rates after complete response to topical treatment with either cidofovir or imiquimod for vulval intraepithelial neoplasia (VIN) 3.Design: A prospective, open, randomised multicentre trial.Setting: 32 general hospitals located in Wales and England.Population or Sample: 180 patients were randomised consecutively between 21 October 2009 and 11 January 2013, 89 to cidofoovir (of whom 41 completely responded to treatment) and 91 to imiquimod (of whom 42 completely responded to treatment).Methods: After 24 weeks of treatment, complete responders were followed up at 6-monthly intervals for 24 months. At each visit, the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was assessed and any new lesions were biopsied for histology.Main Outcome Measures: Time to histologically confirmed disease recurrence (any grade of VIN).Results: The median length of follow up was 18.4 months. At 18 months, more participants were VIN-free in the cidofovir arm: 94% (95% CI 78.2-98.5) versus 71.6% (95% CI 52.0-84.3) [univariable hazard ratio (HR) 3.46, 95% CI 0.95-12.60, P = 0.059; multivariable HR 3.53, 95% CI 0.96-12.98, P = 0.057). The number of grade 2+ events was similar between treatment arms (imiquimod: 24/42 (57%) versus cidofovir: 27/41 (66%), χ2 = 0.665, P = 0.415), with no grade 4+.Conclusions: Long-term data indicates a trend towards response being maintained for longer following treatment with cidofovir than with imiquimod, with similar low rates of adverse events for each drug. Adverse event rates indicated acceptable safety of both drugs TWEETABLE ABSTRACT: Long-term follow up in the RT3VIN trial suggests cidofovir may maintain response for longer than imiquimod. [ABSTRACT FROM AUTHOR]

Objective: To assess whether parents who were born small for gestational age (below the 10th birthweight centile, SGA) have increased risk of severe or mild placental abruption. To assess whether a history of SGA in other family members modifies this intergenerational effect.Design: Prospective population-based observational study.Setting: The Medical Birth Registry of Norway.Population: From 1967 to 2013, 785 333 mother-offspring pairs, 643 066 father-offspring pairs, 272 941 maternal tetrads (i.e. her offspring, sibling, and niece/nephew), and 265 505 paternal tetrads were identified.Methods: Cohort study based on linked data from the Medical Birth Registry of Norway.Main Outcome Measures: Relative risk (RR) of severe placental abruption (preterm birth, birthweight below the 10th centile, or perinatal death) and mild placental abruption (other cases) in families with SGA.Results: Mothers who were born SGA had increased risk of severe placental abruption (RR 1.5; 95% confidence interval, 95% CI 1.3-1.8), but not mild abruption. The paternal effects were weaker. The combined effect of SGA in the mother and her sibling on severe abruption was twofold (RR 2.4; 95% CI 1.7-3.3) compared with birthweight centiles ≥10 for both. Similarly, the effect of adding an SGA niece/nephew was twofold (RR 2.3; 95% CI 1.3-3.9), whereas the combined effect of SGA in the mother, her sibling and her niece/nephew was fourfold (RR 3.6; 95% CI 1.9-6.8).Conclusions: Women who were born SGA have an increased risk of severe placental abruption. The corresponding paternal effect was modest. A history of SGA in other family members increases the generational effect.Tweetable Abstract: Women born small for gestational age have excess risk of placental abruption. [ABSTRACT FROM AUTHOR]

Objective: To quantify the incidence of severe autoimmune thrombocytopenia (ITP) in pregnancy in the UK, determine current treatment strategies, and establish maternal and neonatal morbidity and mortality associated with severe ITP in pregnancy.Design: A prospective national cohort study.Setting: UK.Population: Women with severe ITP, defined as platelets <50 × 109 /L in pregnancy or antenatal treatment of isolated low platelets.Methods: Data collected via the UK Obstetric Surveillance System (UKOSS) between 1 June 2013 and 31 January 2015 from all UK consultant-led obstetric units.Main Outcome Measure: Incidence of severe ITP in pregnancy.Results: The estimated incidence of severe ITP in pregnancy is 0.83 per 10 000 maternities (95% CI 0.68-1.00). A total of 22 pregnant women (21%) did not receive any antenatal therapy, and 85 pregnant women (79%) received therapy. There was no difference between asymptomatic treated and untreated cohorts in severity of disease or outcome. Postpartum haemorrhage (51%) and severe postpartum haemorrhage (21%) was reported more frequently than the rate reported in the general pregnant population (5-10%). No neonates required treatment for thrombocytopenia and there were no cases of neonatal intracranial bleeding.Conclusions: Current UK management of severe ITP in pregnancy results in an exceptionally low morbidity and mortality for the neonate. Mothers with ITP remain at increased risk of severe postpartum haemorrhage, and should be delivered at units that have the capacity to manage severe PPH effectively. Whilst balancing the risks for pregnancy from prophylactic antenatal treatment in asymptomatic women against observed low disease morbidity, we may be over treating asymptomatic patients.Tweetable Abstract: UKOSS study of severe ITP in pregnancy shows exceptionally low neonatal morbidity with current UK management. [ABSTRACT FROM AUTHOR]

Objective: Women with overactive bladder (OAB) often undergo urodynamics before invasive treatments are considered. Ultrasound measurement of bladder wall thickness (BWT) is a less invasive, less expensive and widely available test. It has the potential to diagnose the presence of detrusor overactivity (DO). We aimed to evaluate the accuracy of BWT in the diagnosis of DO.Design: Prospective cohort study.Setting: Twenty-two UK clinics (university and district general hospitals).Methods: Consecutive eligible women with OAB symptoms had transvaginal ultrasound to estimate BWT (index test). The reference standard for the diagnosis of DO was urodynamic testing with multichannel subtracted cystometry.Main Outcome Measures: The sensitivity, specificity and likelihood ratios using a BWT threshold of ≥5 mm were used to indicate the presence of DO, and the area under the receiver operating characteristics (ROC) curve to give an overall estimate of BWT accuracy.Results: Between March 2011 and 2013, 644/687 (94%) women recruited had both tests. The mean age was 52.7 years (standard deviation 13.9) and DO was diagnosed in 399/666 (60%) women. BWT had a sensitivity of 43% [95% confidence interval (CI) 38-48%], specificity of 62% (95% CI 55-68%), and likelihood ratios of 1.11 (95% CI 0.92-1.35) and 0.93 (95% CI 0.82-1.06) for positive and negative tests, respectively. The area under the ROC curve was 0.53 (95% CI 0.48-0.57). Extensive sensitivity analyses and subgroup analyses were carried out, but did not alter the interpretation.Conclusions: BWT is not a good replacement test for urodynamics in women with overactive bladder.Tweetable Abstract: Bladder wall thickness is not a good replacement test for urodynamics in women with overactive bladder. [ABSTRACT FROM AUTHOR]

Objective: Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and benefits of such a policy have not been compared.Design: A cost-utility analysis alongside a randomised controlled trial (the 35/39 trial).Setting: Obstetric departments of 38 UK National Health Service hospitals and one UK primary-care trust.Population: Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation.Methods: Costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life-years (QALYs) were calculated based on patient responses to the EQ-5D at baseline and 4 weeks.Main Outcome Measures: Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ-5D (baseline and 4 weeks postnatal) and participant-administered postnatal health resource use data were collected.Results: The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention.Conclusion: A policy of induction of labour at 39 weeks for women of advanced maternal age would save money.Tweetable Abstract: A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money. [ABSTRACT FROM AUTHOR]

Objective: To examine age-period-cohort effects on trends in gestational diabetes mellitus (GDM) prevalence in the US, and to evaluate how these trends have affected the rates of stillbirth and large for gestational age (LGA)/macrosomia.Design: Retrospective cohort study.Setting: USA, 1979-2010.Population: Over 125 million pregnancies (3 337 284 GDM cases) associated with hospitalisations.Methods: Trends in GDM prevalence were examined via weighted Poisson models to parse out the extent to which GDM trends can be attributed to maternal age, period of delivery, and maternal birth cohort. Multilevel models were used to assess the contribution of population effects to the rate of GDM. Log-linear Poisson regression models were used to estimate the contributions of the increasing GDM rates to changes in the rates of LGA and stillbirth between 1979-81 and 2008-10.Main Outcome Measures: Rates and rate ratios (RRs).Results: Compared with 1979-1980 (0.3%), the rate of GDM has increased to 5.8% in 2008-10, indicating a strong period effect. Substantial age and modest cohort effects were evident. The period effect is partly explained by period trends in body mass index (BMI), race, and maternal smoking. The increasing prevalence of GDM is associated with a 184% (95% CI 180-188%) decline in the rate of LGA/macrosomia and a 0.75% (95% CI 0.74-0.76) increase in the rate of stillbirths for 2008-10, compared with 1979-81.Conclusions: The temporal increase in GDM can be attributed to period of pregnancy and age. Increasing BMI appears to partially contribute to the GDM increase in the US.Tweetable Abstract: The increasing prevalence of GDM can be attributed to period of delivery and increasing maternal age. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of nurse-led telephone follow-up (TFU) for patients with stage-I endometrial cancer.Design: Multicentre, randomised, non-inferiority trial.Setting: Five centres in the North West of England.Sample: A cohort of 259 women treated for stage-I endometrial cancer attending hospital outpatient clinics for routine follow-up.Methods: Participants were randomly allocated to receive traditional hospital based follow-up (HFU) or nurse-led TFU.Main Outcome Measures: Primary outcomes were psychological morbidity (State Trait Anxiety Inventory, STAI-S) and patient satisfaction with the information provided. Secondary outcomes included patient satisfaction with service, quality of life, and time to detection of recurrence.Results: The STAI-S scores post-randomisation were similar between groups [mean (SD): TFU 33.0 (11.0); HFU 35.5 (13.0)]. The estimated between-group difference in STAI-S was 0.7 (95% confidence interval, 95% CI -1.9 to 3.3); the confidence interval lies above the non-inferiority limit (-3.5), indicating the non-inferiority of TFU. There was no significant difference between groups in reported satisfaction with information (odds ratio, OR 0.9; 95% CI 0.4-2.1; P = 0.83). Women in the HFU group were more likely to report being kept waiting for their appointment (P = 0.001), that they did not need any information (P = 0.003), and were less likely to report that the nurse knew about their particular case and situation (P = 0.005).Conclusions: The TFU provides an effective alternative to HFU for patients with stage-I endometrial cancer, with no reported physical or psychological detriment. Patient satisfaction with information was high, with similar levels between groups.Tweetable Abstract: ENDCAT trial shows effectiveness of nurse-led telephone follow-up for patients with stage-I endometrial cancer. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether a customised exercise programme influences pregnant women's psychological wellbeing and general health perception reflecting health-related quality of life (HRQoL) in late pregnancy.Design: A two-armed, two-centred randomised controlled trial.Setting: Trondheim and Stavanger University Hospitals, Norway.Population: A total of 855 healthy Caucasian pregnant women.Methods: The intervention group was offered a 12-week exercise programme between 20 and 36 weeks of pregnancy. One weekly group session was led by physiotherapists, in addition women were encouraged to follow a home exercise programme at least twice a week. The exercise programme followed standard recommendations and included both aerobic and strength training. The control group received regular antenatal care. Pretests and post-tests were performed at 18-22 and 32-36 weeks of pregnancy.Main Outcome Measures: In the original study primary outcome was gestational diabetes mellitus, but in this report the primary outcome is HRQoL. The questionnaire Psychological General Wellbeing Index (PGWBI) was used to assess psychological wellbeing and self-perceived general health before and after the intervention. PGWBI contains six subscales and it is also possible to summarise all items to a global score.Results: No association between antenatal exercise programme allocation and PGWBI (global score and subscales) was found. The study population was homogeneous and had high educational level.Conclusions: The results indicate that offering women an exercise programme during pregnancy does not seem to influence healthy pregnant women's psychological wellbeing and self-perceived general health. Further research is needed to investigate the effects of exercise in pregnancy on psychological wellbeing and self-perceived general health among women from different sociocultural subgroups.Tweetable Abstract: Exercise in pregnancy does not influence healthy pregnant women's health-related quality of life. [ABSTRACT FROM AUTHOR]

Objective: To compare time to diagnosis of the typically slow-growing Type I (low-grade serous, low-grade endometrioid, mucinous, clear cell) and the more aggressive Type II (high-grade serous, high-grade endometrioid, undifferentiated, carcinosarcoma) invasive epithelial ovarian cancer (iEOC).Design: Multicentre observational study.Setting: Ten UK gynaecological oncology centres.Population: Women diagnosed with primary EOC between 2006 and 2008.Methods: Symptom data were collected before diagnosis using patient questionnaire and primary-care records. We estimated patient interval (first symptom to presentation) using questionnaire data and diagnostic interval (presentation to diagnosis) using primary-care records. We considered the impact of first symptom, referral and stage on intervals for Type I and Type II iEOC.Main Outcome Measures: Patient and diagnostic intervals.Results: In all, 78% of 60 Type I and 21% of 134 Type II iEOC were early-stage. Intervals were comparable and independent of stage [e.g. median patient interval for Type I: early-stage 0.3 months (interquartile range 0.3-3.0) versus late-stage 0.3 months (interquartile range 0.3-4.5), P = 0.8]. Twenty-seven percent of women with Type I and Type II had diagnostic intervals of at least 9 months. First symptom (questionnaire) was also similar, except for the infrequent abnormal bleeding (Type I 15% versus Type II 4%, P = 0.01). More women with Type I disease (57% versus 41%, P = 0.04) had been referred for suspected gynaecological cancer. Median time from referral to diagnosis was 1.4 months for women with iEOC referred via a 2-week cancer referral to any specialty compared with 2.6 months (interquartile range 2.0-3.7) for women who were referred routinely to gynaecology.Conclusion: Overall, shorter diagnostic delays were seen when a cancer was suspected, even if the primary tumour site was not recognised to be ovarian. Despite differences in carcinogenesis and stage for Type I and Type II iEOC, time to diagnosis and symptoms were similar. Referral patterns were different, implying subtle symptom differences. If symptom-based interventions are to impact on ovarian cancer survival, it is likely to be through reduced volume rather than stage-shift. Further research on histological subtypes is needed.Tweetable Abstract: No difference in time to diagnosis for Type I versus Type II invasive epithelial ovarian cancers. [ABSTRACT FROM AUTHOR]

Objective: To assess the opinions of pregnant women regarding their weight gain and to assess the level of satisfaction and anxiety provoked by being weighed in clinic.Design: Questionnaires were given to women participating in a randomised controlled trial comparing routine weighing in the antenatal clinic with standard care.Setting: A tertiary hospital antenatal clinic in Melbourne, Australia.Population: In all, 782 healthy pregnant women participated in the randomised controlled trial and 586 responded to the questionnaire.Methods: A questionnaire was offered to all participants at 36 weeks of gestation gauging their satisfaction with their weight gain during pregnancy. The intervention group was asked about their level of satisfaction and anxiety provoked by being weighed in clinic. The control group was asked whether they would have liked to be weighed in clinic. Both groups were questioned about the influences on their weight gain.Results: Women in both groups were satisfied with their weight gain during pregnancy. Seventy-three percent of women in the intervention group were very comfortable with being weighed in clinic. Approximately half of those in the control group would have favoured being weighed. Twenty-one percent of women said other people influenced their weight gain; mostly family members and two-thirds of them encouraged weight gain. Less than half of the women in the study used weighing scales at home.Conclusion: Women were satisfied with being weighed antenatally and it did not cause anxiety. Pregnant women accepted the re-introduction of weighing in the antenatal clinic. [ABSTRACT FROM AUTHOR]

Objective: To evaluate impact of body mass index (BMI) ≥30 on objective and subjective cure rates 12 months after midurethral sling surgery.Design: Secondary analysis.Setting: Three hospitals in Calgary, Canada, 2005-07.Population: A total of 182 women enrolled in a randomised control trial of tension-free vaginal tape versus transobturator tape.Methods: Women were classified as obese or nonobese from height and weight on day of surgery. Women underwent postoperative standardised pad tests, self-reporting of urinary incontinence, and quality of life scores. Categorical data compared with chi-square or Fisher's exact, continuous data compared with Mann-Whitney U test.Main Outcome Measures: Primary outcome was objective cure, defined as <1 g urine loss on postoperative 1-hour pad test. Secondary outcomes were subjective cure of incontinence (no stress incontinence in previous 7 days), presence of urinary urgency in previous 7 days, Urogenital Distress Inventory (UDI-6) scores, Incontinence Impact Questionnaire (IIQ-7) scores, and surgical complication rates.Results: Objective cure differed, with 85.6% of nonobese women leaking <1 g on 1-hour pad test, versus 67.8% of obese women (P = 0.006, risk difference [RD] 17.8%, 95% confidence interval [95% CI] 4.2-31.4%). Subjective cure was 85.8% for nonobese women versus 70.7% for obese women (P = 0.016, RD 15.1%, 95% CI 1.9-28.4%). For both groups, improvement was seen for postoperative UDI-6 (median -33.3 [-44.4 to -22.2] and -27.2 [-44.4 to -16.7]) and IIQ-7 scores (median -26.2 [-45.2 to -14.3] and -23.8 [-42.9 to -14.3]). No differences existed in rates of operative complications between the two groups.Conclusion: Twelve months after midurethral sling surgery, obese women experience lower rates of cure than those who are nonobese. [ABSTRACT FROM AUTHOR]

Objective To develop and validate a patient-reported outcome measure for women with heavy menstrual bleeding ( HMB). Study design Prospective cohort and cross-sectional studies. Setting Outpatient women's health facility. Population Women aged between 18 and 55 years with and without self-reported HMB. Methods Using data from patients and clinicians, we developed a patient-reported outcome measure for HMB; the Menstrual Bleeding Questionnaire ( MBQ). Participants in the validation studies completed demographic and general health questionnaires and either (1) bleeding and quality of life data collected daily on handheld computers and the MBQ after 1 month or (2) the MBQ at enrolment only. A subset of women also completed the Short-form-36 ( SF-36) generic quality of life questionnaire. We performed psychometric analyses of the MBQ to assess its internal consistency as well as its content and concurrent validity and ability to discriminate between women with and without HMB. Main outcome measures Psychometric properties of the questionnaire. Results Overall, 182 women participated in the MBQ validation studies. We found that the MBQ domains were internally consistent (Cronbach's α = 0.87-0.94). There was excellent correlation between daily bleeding-related symptom data and the MBQ completed at 1 month ( ρ > 0.7 for all domains). We found low to moderate correlation between the MBQ scores and SF-36 scores ( ρ = −0.15 to −0.45). The MBQ clearly discriminated between women with and without HMB (mean MBQ score = 10.6 versus 30.8, P < 0.0001). Conclusions The MBQ is a valid patient-reported outcome measure for HMB that has the potential to improve the evaluation of women with self-reported HMB in research and clinical practice. [ABSTRACT FROM AUTHOR]

Objective To develop and evaluate a questionnaire to assess the burden of vulval intraepithelial neoplasia ( VIN) in women. Design A questionnaire development study. Setting Vulval Disorders Clinic serving a regional population. Sample Fifty-eight women with a histological diagnosis of VIN registered with the Vulval Disorders Clinic. Methods A 37-item questionnaire was developed through a comprehensive literature review, consultation with specialist clinicians and pretesting to assess the burden experienced by women. The questionnaire was assessed for validity and reliability against existing questionnaires used in related disease areas. Main outcome measures Spearman correlations were calculated between items in the VIN questionnaire with the scores of the Dermatology Life Quality Index ( DLQI), Hospital Anxiety and Depression Scale ( HADS), Sabbatsberg Sexual Self-Rating Scale ( SSRS) and the Process Outcome Specific Measure ( POSM) to assess the new questionnaire's validity. Internal consistency was measured using Cronbach's alpha. Test-retest reliability was calculated using quadratic weighted kappa. Results The VIN questionnaire had a high degree of internal consistency (Cronbach's alpha, 0.89). Test-retest reliability was assessed, with most questions showing a quadratic weighted kappa value of 0.5 or above. Most questions showed a stronger correlation with the corrected total VIN score than with HADS anxiety and depression subscales and the SSRS, indicating discriminant validity. Most questions correlated significantly with the DLQI and POSM scores, indicating convergent validity. Conclusions Initial assessment of the VIN questionnaire demonstrated that it is a valid and reliable measure of the burden of disease for women. The questionnaire could be used to compare new and existing treatments for VIN or to assess or monitor the impact of care. [ABSTRACT FROM AUTHOR]

Objective: To examine the effects of low to moderate maternal alcohol consumption and binge drinking in early pregnancy on children's executive functions at the age of 5 years.Design: Follow-up study.Setting: Neuropsychological testing in four Danish cities 2003-2008. Population A cohort of 1628 women and their children sampled from the Danish National Birth Cohort.Methods: Participants were sampled based on maternal alcohol drinking patterns during early pregnancy. When the children were 5 years old, the parent and teacher forms of the Behaviour Rating Inventory of Executive Function (BRIEF) were completed by the mothers and a preschool teacher. Parental education, maternal IQ, prenatal maternal smoking, the child's age at testing, and the child's gender were considered core confounding factors. The full model also included maternal binge drinking or low to moderate alcohol consumption, maternal age, parity, maternal marital status, family home environment, postnatal parental smoking, pre-pregnancy maternal body mass index (BMI), and the health status of the child.Main Outcome Measures: The BRIEF parent and teacher forms.Results: Adjusted for all potential confounding factors, no statistically significant associations between maternal low to moderate average weekly consumption and BRIEF index scores were observed.In adjusted analyses, binge drinking in gestational week 9 or later was significantly associated with elevated Behavioural Regulation Index parent Scores (2.04, 95% CI 0.33–3.76), and with the risk of high scores on the Metacognitive Index assessed by the teacher (OR 2.06, 95% CI 1.01–4.23) [corrected].Conclusions: This study did not observe significant effects of low to moderate alcohol consumption during pregnancy on executive functioning at the age of 5 years. Furthermore, only weak and no consistent associations between maternal binge drinking and executive functions were observed. [ABSTRACT FROM AUTHOR]

Objective To assess the feasibility and validity of a maternal satisfaction measurement tool, the SaFE study Patient Perception Score (PPS), after operative delivery. Design Cross-sectional survey. Setting A large maternity unit in England. Sample 150 women who had had an operative birth. Methods We recruited women within 24 hours of birth and quantified their satisfaction with two questionnaires: PPS, and the Mackey Childbirth Satisfaction Rating Scale (CSRS; modified). Main Outcome Measures Participation rate to determine feasibility; Cronbach’s alpha as measure of internal consistency; PPS satisfaction scores for groups of accoucheurs of different seniority to assess construct validity; correlation coefficient of PPS scores with total scores from the CSRS questionnaire to establish criterion validity. Results Participation rate approached 85%. We observed high scores for most births except a few outliers. Internal consistency of the PPS was high (Cronbach’s alpha = 0.83). Total PPS scores correlated strongly with total CSRS scores (Spearman’s r = 0.64, P < 0.001). Conclusions The PPS is a simple and valid tool for patient-centred assessments. High scores were observed for most births but there were a small minority of accoucheurs who consistently scored poorly and these data could be used during appraisal and training. [ABSTRACT FROM AUTHOR]

The article provides information on the features of high quality clinical surveys. It states that clinical surveys are widely used in biomedical studies due to its reliability of facts and the lack of attempt to control and manipulate the variables on it. It mentions that clinical surveys are also expected to have a clear and explicit research question as this will be the foundation of study design, data collection and analysis.

Objective To compare outcomes and further operations at a minimum of 10 years following microwave endometrial ablation (MEATM) or transcervical resection of the endometrium (TCRE). Design Follow up of a randomised controlled trial using postal questionnaires and operative databank review. Setting Gynaecology department of a large UK teaching hospital. Main outcome measures Women’s satisfaction with treatment, menstrual symptoms, changes in health-related quality of life, and additional treatments received. Results One-hundred and eighty-nine of the original 263 women returned questionnaires (72%) after a minimum of 10 years post-treatment. Those totally or generally satisfied with treatment numbered 77/129 (60%) in the microwave arm and 70/134 (52%) in the resection arm, the difference is not statistically significant. Bleeding and pain scores were highly significantly reduced and similar following both MEATM and TCRE, achieving amenorrhoea rates of 83 and 88% respectively. The hysterectomy rate after 10 years was significantly different with 22 (17%) in the MEATM and 38 (28%) in the TCRE arm (95% CI: −0.21, −0.13). Conclusions Both techniques achieve significant and comparable improvements in menstrual symptoms, health-related quality of life and high rates of satisfaction. With the known operative advantages, lower costs and fewer hysterectomies, it is clear that MEA™ is a more effective and efficient treatment for heavy menstrual loss than TCRE. [ABSTRACT FROM AUTHOR]

Objective To investigate if an 8- to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up. Design Randomised controlled trial. Setting University hospital in Sweden. Population A total of 165 women diagnosed with a third- to fourth-degree perineal tear. Methods The participants were randomised to immediate or delayed (8- to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6- and 12-month follow up. Main outcome measures Anal incontinence measured by the validated Pescatori incontinence score. Results A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces. Conclusion Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available. [ABSTRACT FROM AUTHOR]

Objectives To describe a new surgical procedure for pelvic organ prolapse using mesh and a vaginal support device (VSD) and to report the results of surgery. Design A prospective observational study. Setting Two tertiary referral Urogynaecology practices. Population Ninety-five women with International Continence Society pelvic organ prolapse quantification stage 2 or more pelvic organ prolapse who underwent vaginal surgery using mesh augmentation and a VSD. Methods Surgery involved a vaginal approach with mesh reinforcement and placement of a VSD for 4 weeks. At 6 and 12 months, women were examined for prolapse recurrence, and visual analogue scales for satisfaction were completed. Women completed quality-of-life (QOL) questionnaires preoperatively and at 6 and 12 months. Main outcome measures Objective success of surgery at 6 and 12 months following surgery. Secondary outcomes were subjective success, complications, QOL outcomes and patients’ satisfaction. Results Objective success rate was 92 and 85% at 6 and 12 months, respectively. Subjective success rate was 91 and 87% at 6 and 12 months, respectively. New prolapse in nonrepaired compartments accounted for 7 of 12 (58%) failures at 12 months. Two of 4 mesh exposures required surgery. Sexual dysfunction was reported by 58% of sexually active women preoperatively and 23% at 12 months. QOL scores significantly improved at 12 months compared with baseline ( P < 0.0001). Conclusion Vaginal surgery using mesh and a VSD is an effective procedure for pelvic organ prolapse. However, further studies are required to establish the role of the surgery described in this study. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to assess the relationship between fish consumption and total mercury concentration in maternal blood, umbilical cord blood, and placenta tissue of pregnant women in Taiwan. Design Cross-sectional study. Setting A medical centre in Taipei, Taiwan. Sample Sixty-five pregnant women delivered between July 2004 and March 2005. Methods We administered a questionnaire to each woman in the third trimester and collected blood samples and placenta tissue after delivery. Mercury concentrations in the maternal blood, cord blood and placenta tissue were measured using mercury analyser (Hiranuma HG-310, Hitachi, Japan). A dietitian calculated the quantity of fish consumed from the questionnaire. Main outcome measures The total mercury concentration in maternal blood, cord blood and placenta tissue. Results The mean total mercury concentration in maternal blood, cord blood and placenta tissue was 9.1 ± 0.40 microgram/l, 10.0 ± 0.55 microgram/l and 19.2 ± 1.8 ng/g, respectively. Eighty-nine percent of the maternal blood mercury concentrations exceeded the US National Research Council recommended value of 5.8 microgram/l. Fish consumption while pregnant correlated significantly with maternal blood and cord blood mercury concentrations. Conclusions Total mercury concentrations of maternal blood, cord blood and placenta tissue commonly exceeded recommended values, and were higher in women who ate fish more than three times a week while pregnant. [ABSTRACT FROM AUTHOR]

Objective This study was designed to examine the burnout syndrome among residents in obstetrics and gynaecology in Spain, and to analyse the predisposing factors for this condition. Setting Eight Spanish University hospitals. Sample A total of 162 residents representative of all active residents in obstetrics and gynaecology in Spain with regards to age, sex and year of residency were asked to take part in this survey. Methods The Maslach Burnout Inventory was mailed to each resident of eight Spanish hospitals representative of all active residents in obstetrics and gynaecology in Spain with regards to age, sex and year of residency. Burnout was defined as a high score on the emotional exhaustion or depersonalisation subscores, according to validated standard cutoff values. The demographic and predisposing work factors were noted for each participant using a self-reported questionnaire. A binary logistic regression model was constructed from all predisposing factors as covariates for the prediction of the burnout syndrome. Results Sixty-seven percent of the 162 eligible residents returned their questionnaires within a 3-month period. Of those, 58% fulfilled the criteria for the burnout syndrome. In the multivariate analysis, marital status and workload in office practice were found to be significant predisposing factors. Single marital status increased the odds ratio for burnout by 5.2 (95% CI 1.3–21). For every extra ten patients attended in the office per week, the odds ratio for burnout increased by 1.25 (95% CI 1.0–1.5). A stratified multivariate subanalysis showed that this risk remained significant only in the group of residents without staff supervision with an odds ratio of 2.1 (95% CI 1.3–2.9). Conclusion The prevalence of the burnout syndrome during obstetrics and gynaecology residency is high. Single marital status and workload in office practice without staff supervision are significant predisposing factors. [ABSTRACT FROM AUTHOR]

Objective To evaluate which factors determine sexual activity and satisfaction with the sexual relationship 1 year after the first delivery. Design Prospective longitudinal cohort study. Setting Ten midwifery practices. Population Three hundred and seventy-seven nulliparous women were included. Methods The Maudsley Marital Questionnaire is a standardised and validated questionnaire with 15 items relating to marital and sexual adjustment, with a nine-point (0–8) scale appended to each question. Scores on the sexual scale (MMQ-S) range from 0 to 40. Higher scores are indicative of greater dissatisfaction. Sexual intercourse was dichotomised into having sexual intercourse or not having sexual intercourse. Several obstetric and maternal factors were analysed. Main outcome measurements Sexual intercourse at 1 year postpartum and dissatisfaction with the sexual relationship as assessed by the MMQ-S scale. Results In multiple logistic regression analysis, the main predictive factor for no sexual intercourse 1 year postpartum was no sexual intercourse at 12 weeks of gestation (β 11.0 [4.01–30.4]). Women were five times less likely to be sexually active after a third/fourth degree anal sphincter tear as compared with women with an intact perineum (β 0.2 [0.04–0.93]). Dissatisfaction with the sexual relationship 1 year after childbirth, assessed with the MMQ-S scale, is associated with not being sexually active at 12 weeks of gestation (β– 0.208, P= 0.004) and with an older maternal age at delivery (β 0.405, P= 0.032). Conclusion An important prognostic factor for dissatisfaction with the sexual relationship 1 year postpartum was not being sexually active in early pregnancy. Satisfaction with the sexual relationship seems not to depend on pregnancy- and parturition-associated factors. [ABSTRACT FROM AUTHOR]

A response from the author of the article regarding pre-pregnancy care for women having medical comorbidities is presented.