BJOG: An International Journal of Obstetrics and Gynaecology

Objectives To define the prevalence of pelvic floor disorders in a non‐institutionalised community and to determine the relationship to gender, age, parity and mode of delivery.

Design A representative population survey using the 1998 South Australian Health Omnibus Survey.

Sample Random selection of 4400 households; 3010 interviews were conducted in the respondents'homes by trained female interviewers. This cross sectional survey included men and women aged 15–97 years.

Results The prevalence of all types of self‐reported urinary incontinence in men was 4.4% and in women was 35.3% (P < 0.001). Urinary incontinence was more commonly reported in nulliparous women than men and increased after pregnancy according to parity and age. The highest prevalence (51.9%) was reported in women aged 70–74 years. The prevalence of flatus and faecal incontinence was 6.8% and 2.3% in men and 10.9% and 3.5% in women, respectively. Pregnancy (> 20 weeks), regardless of the mode of delivery, greatly increased the prevalence of major pelvic floor dysfunction, defined as any type of incontinence, symptoms of prolapse or previous pelvic floor surgery. Multivariate logistic regression showed that, compared with nulliparity, pelvic floor dysfunction was significantly associated with caesarean section (OR 2.5, 95% CI 1.5–4.3), spontaneous vaginal delivery (OR 3.4, 95% CI 2.4–4.9) and at least one instrumental delivery (OR 4.3, 95% CI 2.8–6.6). The difference between caesarean and instrumental delivery was significant (P < 0.03) but was not for caesarean and spontaneous delivery. Other associations with pelvic floor morbidity were age, body mass index, coughing, osteoporosis, arthritis and reduced quality of life scores. Symptoms of haemorrhoids also increased with age and parity and were reported in 19.9% of men and 30.2% of women.

Conclusion Pelvic floor disorders are very common and are strongly associated with female gender, ageing, pregnancy, parity and instrumental delivery. Caesarean delivery is not associated with a significant reduction in long term pelvic floor morbidity compared with spontaneous vaginal delivery.

Objective To study the long term results of tension‐free vaginal tape, a new ambulatory surgical procedure for treatment of female stress urinary incontinence.

Study design A prospective open study using a standardised protocol for pre‐ and post‐operative evaluation.

Participants Fifty consecutive women participated in the study. All suffered from genuine stress incontinence. The mean age was 57 years (SD 11), 42 women (84%) were multiparous, 8 (16%) nulliparous.

Surgical method Tension‐free vaginal tape implies the implantation of a prolene tape around mid‐urethra via a minimal vaginal incision. The procedure is carried out under local anaesthesia, allowing the surgeon to check intra‐operatively that continence has been obtained.

Results All the women except one could be operated on an ambulatory basis under local anaesthesia. Mean operation time was 29 minutes (range 16–47). Ninety percent of the women were able to micturate spontaneously within 24 hours with insignificant residual volumes. In another 10% of the women an in‐dwelling catheter had to be used temporarily. There was no need for long term post‐operative catheterisation (> 14 days). Post‐operative evaluation was carried out after 2 to 6, 12, 24 and 6 months. According to the protocol, 86% of the women were completely cured and another 11% were significantly improved. No signs of deterioration of the results over time were observed. No defect in healing or rejection of the tape occurred.

Conclusion We consider the tension‐free vaginal tape operation to be a safe and effective surgical procedure for the treatment of female urinary stress incontinence. The technique can be considered as an ambulatory procedure performed under local anaesthesia, allowing the majority of the women to be discharged from the clinic the same day or the day after the procedure.

Objective To determine the incidence and describe the complications of laparoscopic procedures in The Netherlands.

Design A nationwide prospective multicentre observational study.

Methods Data on complications were registered from 1 January to 31 December 1994 by 72 hospitals. Any unexpected or unplanned event requiring intra‐operative or post‐operative intervention was defined as a complication. Complications were classified in two groups: approach and technique related complications. Complication rates were compared with these already published.

Results Of 25,764 laparoscopic procedures, 145 complications occurred (rate 5.7 per 1000 [%₀]); two deaths occurred. In 84 women laparotomy was necessary (rate 3.3%₀). In 83 cases (57%; 95% CI for approach = 49–65%) the complication was caused by the surgical approach; in 62 cases (43%) the technique was at fault. Haemorrhage of the epigastric vein and intestinal injury, often requiring laparotomy (90% of cases) were the most frequently observed complications. The complication rate was 2.7%₀ for diagnostic laparoscopic procedures, 4.5%₀ for sterilisation and 17.9%₀ (χ²= 127; dF = 2; P <0.001) for operative laparoscopy. The highest incidence was registered for complications occurring during laparoscopic (assisted) hysterectomy. Stepwise logistic regression analysis showed that previous laparotomy and surgical experience were associated with complications requiring laparotomy.

Conclusions Most complications occurred during operative laparoscopic procedures (rate 17.9%₀). Residents in training are required to learn diagnostic laparoscopy and sterilisation and this training programme results in a fall in the risk of the complications. However, operative laparoscopic procedures are still hazardous, especially laparoscopic hysterectomy. Women with a previous laparotomy are particularly at risk.

Objective To investigate the impact of childbirth on the sexual health of primiparous women and identify factors associated with dyspareunia.

Design Cross‐sectional study using obstetric records, and postal survey six months after delivery.

Setting Department of Obstetrics and Gynaecology, St George's Hospital, London.

Population All primiparous women (n= 796) delivered of a live birth in a six month period.

Methods Quantitative analysis of obstetric and survey data.

Main outcome measures Self reported sexual behaviour and sexual problems (e.g. vaginal dryness, painful penetration, pain during sexual intercourse, pain on orgasm, vaginal tightness, vaginal looseness, bleeding/irritation after sex, and loss of sexual desire); consultation for postnatal sexual problems.

Results Of the 484 respondents (61% response rate), 89% had resumed sexual activity within six months of the birth. Sexual morbidity increased significantly after the birth: in the first three months after delivery 83% of women experienced sexual problems, declining to 64% at six months, although not reaching pre‐pregnancy levels of 38%. Dyspareunia in the first three months after delivery was, after adjustment, significantly associated with vaginal deliveries (P= 0.01) and previous experience of dyspareunia (P= 0.03). At six months the association with type of delivery was not significant (P= 0.4); only experience of dyspareunia before pregnancy (P < 0.0001) and current breastfeeding were significant (P= 0.0006). Only 15% of women who had a postnatal sexual problem reported discussing it with a health professional.

Conclusions Sexual health problems were very common after childbirth, suggesting potentially high levels of unmet need.

Please cite this paper as: Patra J, Bakker R, Irving H, Jaddoe V, Malini S, Rehm J. Dose–response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)—a systematic review and meta‐analyses. BJOG2011;118:1411–1421.

Background  Descriptions of the effects of moderate alcohol consumption during pregnancy on adverse pregnancy outcomes have been inconsistent.

Objective  To review systematically and perform meta‐analyses on the effect of maternal alcohol exposure on the risk of low birthweight, preterm birth and small for gestational age (SGA).

Search strategy  Using Medical Subject Headings, a literature search of MEDLINE, EMBASE, CINAHL, CABS, WHOlist, SIGLE, ETOH, and Web of Science between 1 January 1980 and 1 August 2009 was performed followed by manual searches.

Selection criteria  Case–control or cohort studies were assessed for quality (STROBE), 36 available studies were included.

Data collection and analysis  Two reviewers independently extracted the information on low birthweight, preterm birth and SGA using a standardised protocol. Meta‐analyses on dose–response relationships were performed using linear as well as first‐order and second‐order fractional polynomial regressions to estimate best fitting curves to the data.

Main results  Compared with abstainers, the overall dose–response relationships for low birthweight and SGA showed no effect up to 10 g pure alcohol/day (an average of about 1 drink/day) and preterm birth showed no effect up to 18 g pure alcohol/day (an average of 1.5 drinks/day); thereafter, the relationship showed a monotonically increasing risk for increasing maternal alcohol consumption. Moderate consumption during pre‐pregnancy was associated with reduced risks for all outcomes.

Conclusions  Dose–response relationship indicates that heavy alcohol consumption during pregnancy increases the risks of all three outcomes whereas light to moderate alcohol consumption shows no effect. Preventive measures during antenatal consultations should be initiated.

Objective  To show the increased risk of adverse outcomes in labour and fetomaternal morbidity in obese women (BMI > 30).

Design  A population‐based observational study.

Setting  University Hospital of Wales. The study sample was drawn from the Cardiff Births Survey, a population‐based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999.

Population  Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation with accurate information regarding height and weight recorded at the booking visit (measured by the midwives) were included in the study.

Methods  Comparisons were made between women with a body mass index of 20–30 and those with more than 30. SPSS version 10 was used for statistical analysis. Student's t test, χ² and Fisher's exact tests were used wherever appropriate.

Main outcome measures  Labour outcomes assessed were risk of postdates, induction of labour, mode of delivery, failed instrumental delivery, macrosomia and shoulder dystocia. Maternal adverse outcomes assessed were postpartum haemorrhage, blood transfusion, uterine and wound infection, urinary tract infection, evacuation of uterus, thromboembolism and third‐ or fourth‐degree perineal tears. Fetal wellbeing was assessed using Apgar <7 at 5 minutes, trauma and asphyxia, cord pH < 7.2, babies requiring neonatal ward admissions, tube feeding and incubator.

Results  We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2–1.7); induction of labour, 1.6 (1.3–1.9); caesarean section, 1.6 (1.4–2); macrosomia, 2.1 (1.6–2.6); shoulder dystocia, 2.9 (1.4–5.8); failed instrumental delivery, 1.75 (1.1–2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2–1.8); urinary tract infections, 1.9 (1.1–3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement.

Conclusion  Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events. They should be considered as high risk and counselled accordingly.