Pregnancy rates after intrauterine insemination in moderate to severe endometriosis: A systematic review and meta-analysis of observational studies

To evaluate the efficacy and safety of intrauterine insemination (IUI) in moderate to severe endometriosis patients, a systematic review and meta-analysis was conducted since the role of this treatment strategy in these patients is a matter of debate in the literature. Systematic searches were performed in PubMed, EMBASE, Cinahl, and The Cochrane Library from inception to September 1, 2016. Studies including moderate to severe endometriosis patients reporting pregnancy rates after IUI were selected. The primary outcome was live birth after IUI treatment compared to expectant management. Secondary noncomparative outcomes were live birth and clinical pregnancy, which were presented as weighed mean pregnancy rates. Nineteen articles (2 unclear design, 11 retrospective, 6 prospective) were included for the analysis. Our primary outcome measure was only addressed by one study, showing an odds ratio of 1.77 (95% confidence interval [CI], 0.86-3.63) on live birth favoring IUI versus no treatment. The calculated weighed mean live birth and clinical pregnancy rate per patient was 20.3% (95% CI, 11.2-29.4) and 32.7% (95% CI, 21.3- 44.0), respectively. This meta-analysis of observational data showed that IUI could be a feasible treatment in moderate to severe endometriosis. Whether this treatment should be structurally offered prior to in vitro fertilization needs to be investigated in a randomized, controlled trial, including time-to-pregnancy, safety, and cost-effectiveness

Spontaneous Haemoperitoneum in Pregnancy: Nationwide Surveillance and Delphi Audit System

Objective: To evaluate the incidence, diagnostic management strategies and clinical outcomes of women with spontaneous haemoperitoneum in pregnancy (SHiP) and reassess the definition of SHiP. Design: A population-based cohort study using the Netherlands Obstetric Surveillance System (NethOSS). Setting: Nationwide, the Netherlands. Population: All pregnant women between April 2016 and April 2018. Methods: This is a case study of SHiP using the monthly registry reports of NethOSS. Complete anonymised case files were obtained. A newly introduced online Delphi audit system (DAS) was used to evaluate each case, to make recommendations on improving the management of SHiP and to propose a new definition of SHiP. Main outcome measures: Incidence and outcomes, lessons learned about clinical management and the critical appraisal of the current definition of SHiP. Results: In total, 24 cases were reported. After a Delphi procedure, 14 cases were classified as SHiP. The nationwide incidence was 4.9 per 100 000 births. Endometriosis and conceiving after artificial reproductive techniques were identified as risk factors. No maternal and three perinatal deaths occurred. Based on the DAS, adequate imaging of free intra-abdominal fluid, and identifying and treating women with signs of hypovolemic shock could improve the early detection and management of SHiP. A revised definition of SHiP was proposed, excluding the need for surgical or radiological intervention. Conclusions: SHiP is a rare and easily misdiagnosed condition that is associated with high perinatal mortality. To improve care, better awareness among healthcare workers is needed. The DAS is a sufficient tool to audit maternal morbidity and mortality