Hyaluronic acid gel improves pregnancy outcomes after repeated dilatation and curettage

Non peer reviewe

Kohdunsuun kirurgiset hoidot ja ennenaikainen synnytys

Cervical cancer is the second most common cancer among women globally. Most, probably all cases, arise through a precursor, cervical intraepithelial neoplasia (CIN). Effective cytological screening programmes and surgical treatments of precancerous lesions have dramatically reduced its prevalence and related mortality. Although these treatments are effective, they may have adverse effects on future fertility and pregnancy outcomes. The aim of this study was to evaluate the effects of surgical treatment of the uterine cervix on pregnancy and fertility outcomes, with the focus particularly on preterm birth. The general preterm birth rates and risk factors during 1987–2005 were studied. Long-term mortality rates of the treated women were studied. In this study, information from The Medical Birth Register (MBR), The Hospital Discharge Register (HDR), The Cause-of-Death Register (CDR), and hospital records were used. Treatments were performed during 1987–2003 and subsequent deliveries, IVF treatments and deaths were analyzed. The general preterm birth rate in Finland was relatively stable, varying from 5.1% to 5.4% during the study period (1987 to 2005), although the proportion of extremely preterm births had decreased substantially by 12%.The main risk factor as regards preterm birth was multiplicity, followed by elective delivery (induction of delivery or elective cesarean section), primiparity, in vitro fertilization treatment, maternal smoking and advanced maternal age. The risk of preterm birth and low birth weight was increased after any cervical surgical treatment; after conization the risk of preterm birth was almost two-fold (RR 1.99, 95% CI 1.81– 2.20). In the conization group the risk was the highest for very preterm birth (28–31 gestational weeks) and it was also high for extremely preterm birth (less than 28 weeks). In this group the perinatal mortality was also increased. In subgroup analysis, laser ablation was not associated with preterm birth. When comparing deliveries before and after Loop conization, we found that the risk of preterm birth was increased 1.94-fold (95% CI 1.10–3.40). Adjusting for age, parity, or both did not affect our results. Large or repeat cones increased the risk of preterm birth when compared with smaller cones, suggesting that the size of the removed cone plays a role. This was corroborated by the finding that repeat treatment increased the risk as much as five-fold when compared with the background preterm birth rate. We found that the proportion of IVF deliveries (1.6% vs. 1.5%) was not increased after treatment for CIN when adjusted for year of delivery, maternal age, or parity. Those women who received both treatment for CIN and IVF treatment were older and more often primiparous, which explained the increased risk of preterm birth. We also found that mortality rates were 17% higher among women previously treated for CIN. This excess mortality was particularly seen as regards increased general disease mortality and alcohol poisoning (by 13%), suicide (by 67%) and injury death (by 31%). The risk of cervical cancer was high, as expected (SMR 7.69, 95% CI 4.23–11.15). Women treated for CIN and having a subsequent delivery had decreased general mortality rate (by -22%), and decreased disease mortality (by -37%). However, those with preterm birth had increased general mortality (SMR 2.51, 95% CI 1.24–3.78), as a result of cardiovascular diseases, alcohol-related causes, and injuries. In conclusion, the general preterm birth rate has not increased in Finland, as in many other developed countries. The rate of extremely preterm births has even decreased. While other risk factors of preterm birth, such as multiplicity and smoking during pregnancy have decreased, surgical treatments of the uterine cervix have become more important risk factors as regards preterm birth. Cervical conization is a predisposing factor as regards preterm birth, low birth weight and even perinatal mortality. The most frequently used treatment modality, Loop conization, is also associated with the increased risk of preterm birth. Treatments should be tailored individually; low-grade lesions should not be treated at all among young women. The first treatment should be curative, because repeat treatments are especially harmful. The proportion of IVF deliveries was not increased after treatment for CIN, suggesting that current treatment modalities do not strongly impair fertility. The long-term risk of cervical cancer remains high even after many years post-treatment; therefore careful surveillance is necessary. In addition, accidental deaths and deaths from injury were common among treated women, suggesting risk-taking behavior of these women. Preterm birth seems be associated with extremely high mortality rates, due to cardiovascular, alcohol-related and injury deaths. These women could benefit from health counseling, for example encouragement in quitting smoking.Kohdunkaulasyöpä on maailmanlaajuisesti toiseksi yleisin naisten syöpä. Se kehittyy esiasteista ja niiden hoitojen kehittyessä sairastavuus ja kuolleisuus kohdunkaulasyöpään on vähentynyt. Vaikka hoitomuodot ovat tehokkaita, niillä saattaa olla myöhäisvaikutuksia seuraavien raskauksien ja synnytysten suhteen. Tämän väitöskirjatyön tarkoituksena oli selvittää kohdunkaulan esiastemuutosten kirurgisten hoitojen pitkäaikaisvaikutuksia. Erityisenä mielenkiinnon kohteena oli ennenaikaisen synnytyksen esiintyvyys hoitojen jälkeen. Tarkastelimme myös ennenaikaisen synnytyksen esiintyvyyttä ja riskitekijöitä vuosina 1987-2005. Kirurgisia hoitoja läpikäyneiden naisten hedelmällisyyttä ja pitkäaikaiskuolleisuutta eri kuolinsyihin tutkittiin myös. Väitöskirjatyössä oli käytössä syntymärekisterin, hoitoilmoitusrekisterin, kuolinsyyrekisterin sekä sairaskertomusten tietoja. Tutkimuskohteena oli hoitoja seurannet synnytykset, keinohedelmöityshoidot ja pitkäaikaiskuolleisuus. Kohdunsuun hoidot oli tehty vuosina 1987-2003, hoidettuja naisia oli 25 827. Vertailuaineistona oli samaan aikaan synnyttäneet naiset syntymärekisterissä, joilla ei ollut aiempia kohdunsuun hoitoja. Ensimmäisessä osatyössä tarkastelimme ennenaikaisuuden trendejä ja riskitekijöitä. Suomessa ennenaikaisten synnytysten osuus oli 5,2 % kaikista synnytyksistä ja niiden määrä ei lisääntynyt vuosina 1987- 2005, toisin kuin monissa muissa länsimaissa. Erittäin ennenaikaisten (< 28 raskausviikkoa) synnytysten määrä oli sen sijaan vähentynyt 12 %. Tärkeimmät riskitekijät ennenaikaisuudelle olivat monisiköisyys, synnytyksen käynnistäminen, ensisynnyttäjyys, keinohedelmöityshoito, äidin tupakointi ja äidin ikä. Toisessa osatyössä tutkimme kohdunsuun kirurgisia hoitoja ja ennenaikaista synnytystä. Enneaikaisen synnytyksen ja pienen syntymäpainon riski oli lisääntynyt kaikkien kohdunkaulan kirurgisten hoitojen jälkeen. Konisaatioryhmässä, joka sisälsi suurimmaksi osaksi laser- ja Loop-konisaatioita, ennenaikaisen synnytyksen riski oli kaksinkertaistunut, myös perinataalikuolleisuus oli lisääntynyt. Kolmannessa osatyössä seurasimme naisia, jotka olivat synnyttäneet ennen ja jälkeen Loop hoidon. Ennenaikaisia synnytyksiä oli ennen Loop hoitoa 6,5 % ja hoidon jälkeen 12,0 % , joten ennenaikaisuuden riski oli lähes kaksinkertainen. Tulokset vakioitiin sekä iän että synnyttäneisyyden suhteen. Toistetun Loop hoidon jälkeen ennenaikaisen synnytyksen riski oli jopa viisinkertainen. Tulokset viittasivat myös siihen, että mitä isompi pala kohdunsuusta oli poistettu, sitä suurempi oli ennenaikaisen synnytyksen riski. Neljännessä osatyössä havaitsimme, että kohdunsuun kirurgisten hoitojen jälkeen keinohedelmöityshoidolla aikaansaatujen synnytysten määrä ei ollut lisääntynyt. Tämä saattaa viitata siihen, että hoidoilla ei ole merkittävää hedelmällisyyttä heikentävää vaikutusta. Naiset, joilla oli aiempia kohdunsuun hoitoja ja ennenaikaisia synnytyksiä olivat vanhempia ja useammin ensisynnyttäjiä, jonka vuoksi ennenaikaisten synnytysten määrä tässä ryhmässä oli lisääntynyt. Viidennessä osatyössä tarkastelimme naisten pitkäaikaiskuolleisuutta ja vertasimme niitä väestön ikävakioituihin kuolleisuuslukuihin. Hoidetuilla naisilla kokonaiskuolleisuus oli 17 % korkeampi, lisäksi yleinen tauti- ja alkoholimyrkytyksiin liittyvä kuolleisuus, itsemurhakuolleisuus ja tapaturmaiset kuolemat olivat lisääntyneet, joka saattaa liittyä potilasryhmän valikoitumiseen. Kuolleisuus oli erityisen korkea enneaikaisesti synnyttäneillä naisilla. Sen sijaan muilla synnyttäneillä naisilla kuolleisuusluvut olivat muuta väestöä matalammat

Incidence of Lichen Planus and Subsequent Mortality in Finnish Women

The incidence pattern of lichen planus (LP) and LP-related mortality are unknown. The aim of this study was to assess these factors, based on Finnish nationwide registry data including 13,378 women with LP diagnosed during 1969 to 2012. The incidence rate for LP in 2003 to 2012 was 28 per 100,000 woman-years age-adjusted to the European Standard Population. Mortality was assessed using the standardized mortality ratio (SMR) with national mortality rates as the reference. All-cause mortality was increased (SMR 1.07, 95% confidence interval (95% CI) 1.02-1.11), with excess mortality from Hodgkin lymphoma (SMR 6.73, 95% CI 1.83-17.2), non-Hodgkin lymphoma (SMR 1.68, 95% CI 1.11-2.44), cancer of the oral cavity (SMR 10.5, 95% CI 5.99-17.0), cancer of the tongue (SMR 7.25, 95% CI 3.13-14.3), infections (SMR 1.78, 95% CI 1.14-2.64), respiratory diseases (SMR 1.31, 95% CI 1.07-1.57), and diseases of the digestive system (SMR 1.39, 95% CI 1.09-1.75). In conclusion, LP is a common disease and patients seem to have an impaired long-term prognosis.Peer reviewe

Cancer risk of Lichen planus : A cohort study of 13,100 women in Finland

The association between Lichen planus (LP) and cancer has been under debate for decades. We studied the connection via population-based Finnish register data. All women with the diagnosis of LP (n=13,100) were identified from the Finnish Hospital Discharge Registry from 1969-2012. These patients were linked with subsequent cancer diagnoses from the Finnish Cancer Registry until 2014. Standardized incidence ratios (SIRs) were counted for different cancers by dividing the observed numbers of cancers by expected numbers, which were based on national cancer incidence rates. In total, 1,520 women with LP were diagnosed with cancer (SIR 1.15, 95% confidence interval [CI] 1.09-1.20). LP was associated with an increased risk of cancer of lip (SIR 5.17, 95% CI 3.06-8.16), cancer of tongue (SIR 12.4, 95% CI 9.45-16.0), cancer of oral cavity (SIR 7.97, 95% CI 6.79-9.24), cancer of esophagus (SIR 1.95, 95% CI 1.17-3.04), cancer of larynx (SIR of 3.47, 95% CI 1.13-8.10) and cancer of vulva (SIR 1.99, 95% CI 1.18-3.13). The risk of cancer was not increased in other locations where LP manifests (pharynx and skin). Patients with diagnosed LP have an increased risk of developing cancer of lip, tongue, oral cavity, esophagus, larynx and vulva. These data are important when considering treatment and follow-up of patients with LP diagnosis. What's new?Lichen planus (LP) is a chronic disease of the skin and mucous membranes that is likely autoimmune in origin. Owing to its inflammatory nature, it is also suspected of causing certain cancers. Whether LP possesses malignant potential, however, remains uncertain. Here, in a cohort of 13,100 women diagnosed with LP between 1969 and 2012 in Finland, some 1,520 were eventually diagnosed with cancer. Malignancies with significant increases in incidence in LP patients included those of the lip, tongue, oral cavity, esophagus, larynx and vulva. The findings suggest that LP patients could benefit from multidisciplinary approaches to care.Peer reviewe

Ulkosynnytinten valkojäkälä

English summar

Sairaudet, toimintakyky ja lääkä­ri­työ­voima keski­suo­ma­lai­sissa vanhusten hoito­pai­koissa

De­mentiaa sairas­tavien osuus terveys­kes­kus­sai­raa­loissa ja vanhain­ko­deissa on kas­vanut kymme­nessä vuo­dessa sel­västi

Ohjeistus lisäsi käsihuuhteen ja vähensi antibioottien käyttöä vanhusten hoitopaikoissa

- Koulu­tuksen ja ohjeis­tuksen jäl­keen käsi­huuhteen käyt­tö li­sääntyi ja anti­bioottien käyt­tö vä­heni kah­den seuran­ta­vuoden ai­kana van­husten hoito­pai­koissa. - Virtsa­tie­tu­leh­dusten esto­hoidon mikro­bi­lää­kitys vä­heni, mut­ta muu anti­bioot­ti­hoito py­syi en­nallaan - Hoito­käy­tän­töjen py­syvä muu­tos vaa­tii jat­kuvaa seu­rantaa ja inter­ven­tioita

Infektioiden torjunta keski­suo­ma­lai­sissa pitkäai­kais­hoi­to­pai­koissa

Lähtö­kohdat Suo­messa ei ole aikai­semmin selvi­tetty pitkäai­kais­hoi­dossa olevien poti­laiden mikro­bi­lää­ke­hoidon indi­kaa­tioita ja mää­rää ei­kä ar­vioitu vallit­sevia infek­tioiden hoi­to- ja torjun­ta­käy­tän­töjä. Ai­neisto ja mene­telmät Infek­tio­lää­käri, hygie­nia­hoi­taja ja ge­riatri haastat­te­livat vuo­den ai­kana 130 pitkäai­kais­hoi­to­paikan henki­lö­kuntaa ja tutus­tuivat lai­tosten ti­loihin. Eri­tyistä huo­miota kiinni­tettiin mikro­bi­lääk­keiden se­kä käsi­huuhteen käyt­töön. Tu­lokset Virtsa­tie­tu­leh­dusten es­to ja hoi­to olivat taval­li­simmat syyt mikro­bi­lää­ki­tyksiin, joi­ta oli yh­teensä 19 pro­sen­tilla hoidet­ta­vista (687/3 654). Hoi­dossa oli yh­teensä 23 MR­SA:n ja 22 ESBL:ä tuot­tavan ente­ro­bak­teerin kan­tajaa. Käsi­huuh­detta käy­tettiin hy­vin vaihte­le­vasti. Pää­telmät Van­husten pitkäai­kais­hoidon mikro­bi­lää­ke­hoi­dosta tu­lee an­taa alueel­liset oh­jeet se­kä käsi­huuhteen käyt­töä li­sätä ja sen kulu­tusta seu­rata vuo­sittain

Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries

Introduction Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy. Material and methods We merged data from nine nationwide or multi-regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated. Results A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births. Conclusions Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life-saving procedure is associated with substantial adverse maternal and neonatal outcome.Peer reviewe