Background. Depression is a common mood disorder during pregnancy impacting one in every seven women. Children exposed to prenatal depression are more likely to be born at a low birth weight and develop chronic diseases later in life. A proposed hypothesis for this relationship between early exposure to adversity and poor outcomes is accelerated aging. Telomere length has been used as a biomarker of cellular aging. We used high-resolution telomere length analysis to examine the relationship between placental telomere length distributions and maternal mood symptoms in pregnancy. Methods. This study utilised samples from the longitudinal Grown in Wales (GiW) study. Women participating in this study were recruited at their presurgical appointment prior to a term elective caesarean section (ELCS). Women completed the Edinburgh Postnatal Depression Scale (EPDS) and trait subscale of the State-Trait Anxiety Inventory (STAI). Telomere length distributions were generated using single telomere length analysis (STELA) in 109 term placenta (37–42 weeks). Multiple linear regression was performed to examine the relationship between maternally reported symptoms of depression and anxiety at term and mean placental telomere length. Results: Prenatal depression symptoms were significantly negatively associated with XpYp telomere length in female placenta (B = −0.098, p = 0.026, 95% CI −0.184, −0.012). There was no association between maternal depression symptoms and telomere length in male placenta (B = 0.022, p = 0.586, 95% CI −0.059, 0.103). There was no association with anxiety symptoms and telomere length for either sex. Conclusion: Maternal prenatal depression is associated with sex-specific differences in term placental telomeres. Telomere shortening in female placenta may indicate accelerated placental aging.

Objectives: Seasonal changes in mood and behaviour are commonly reported in the general population but considerably less is known regarding seasonality and pregnancy. This study investigated the relationship between seasons and depression and anxiety symptoms, salivary cortisol concentrations, custom birthweight centiles (CBWC) and placenta weight for pregnant women living in South Wales. Methods: This study utilised data from the longitudinal Grown in Wales (GiW) cohort. Women were recruited at the presurgical elective caesarean section (ELCS) appointment, when they provided saliva samples and completed the Edinburgh Postnatal Depression Scale (EPDS) and trait subscale of the State-Trait Anxiety Inventory (STAI). Data on birthweight and placental weight was extracted from medical notes. Seasonal data was available for 316 participants. Results: No association was identified between seasons and EPDS (p = .178), STAI scores (p = .544), CBWC (p = .683) or placental weight (p = .857). Significance was identified between seasons and salivary cortisol concentration (p < .001), with highest levels in autumn and winter. Adjusted linear regression identified spring (B= -.05, p = .007, 95% CI -.09, -.01) and summer (B= -.06, p = .001, 95% CI -09, -.02) compared to autumn, and spring (B= - .05, p= .009, 95% CI -.09, - .01) and summer (B= -.06, p= .002, 95% CI - .10, - .02) compared to winter to be associated with decreased cortisol concentrations. Conclusion: This study found no association between season and maternally-reported mental health symptoms, birthweight by CBWC or placental weight but did between season and term salivary cortisol. This finding will have implications for studies that do not account for seasonality when using salivary cortisol as a biomarker.

Video Objective To demonstrate effective excision of ovarian remnant in chronic pelvic pain following hysterectomy and bilateral salpingoophrectomy for endometriosis. Setting A 38year-old G0 was diagnosed with endometriosis aged 17, subsequently undergoing 37 laparoscopies for pelvic pain. Total laparoscopic hysterectomy and bilateral salpingoophrectomy was performed aged 32, reported as technically difficult due to deep infiltrating endometriosis and adhesions. She continued to suffer with pelvic pain, with multiple admissions with subacute small bowel obstruction. A trial of progesterone and GNRH was unsuccessful. In 2017 ultrasound showed a cystic structure in the right pelvis, suggesting ovarian remnant confirmed by FSH and oestradiol levels. Interventions Laparoscopic adhesiolysis and excision of ovarian remnant was scheduled and Clomiphene 50mg prescribed 2 weeks preoperatively to stimulate the ovarian tissue, allowing easier identification and excision. Intraoperative ultrasound demonstrated increased ovarian volume. On entry there were dense adhesions and the pelvis obliterated. Methodical adhesiolysis was achieved with a mixture of blunt dissection and monopolar diathermy. The ovarian remnant was seen on the right side surrounded by thickened peritoneum. The ureter was identified and unexpectedly found pulled medially by adhesions. Ureterolysis was performed down to the ovarian remnant, which was dissected to allow the ureter to fall laterally. The ovarian remnant was safely excised with the cystic elements aspirated to facilitate removal in a retrieval bag via the 5mm right iliac fossa port incision. The ovarian tissue was excised in its entirety and at the end of the procedure the bowel was mobile, lying in its anatomical position. Conclusion Consider remnant ovarian tissue in endometriosis patients who have had previous difficult hysterectomy and bilateral salpingoophrectomy with continued pain. Clomiphene enlarges remnant ovarian tissue to aid identification and excision. Before excising pathology it is important to identify normal structures when presented with distorted anatomy to ensure a safe approach. To demonstrate effective excision of ovarian remnant in chronic pelvic pain following hysterectomy and bilateral salpingoophrectomy for endometriosis. A 38year-old G0 was diagnosed with endometriosis aged 17, subsequently undergoing 37 laparoscopies for pelvic pain. Total laparoscopic hysterectomy and bilateral salpingoophrectomy was performed aged 32, reported as technically difficult due to deep infiltrating endometriosis and adhesions. She continued to suffer with pelvic pain, with multiple admissions with subacute small bowel obstruction. A trial of progesterone and GNRH was unsuccessful. In 2017 ultrasound showed a cystic structure in the right pelvis, suggesting ovarian remnant confirmed by FSH and oestradiol levels. Laparoscopic adhesiolysis and excision of ovarian remnant was scheduled and Clomiphene 50mg prescribed 2 weeks preoperatively to stimulate the ovarian tissue, allowing easier identification and excision. Intraoperative ultrasound demonstrated increased ovarian volume. On entry there were dense adhesions and the pelvis obliterated. Methodical adhesiolysis was achieved with a mixture of blunt dissection and monopolar diathermy. The ovarian remnant was seen on the right side surrounded by thickened peritoneum. The ureter was identified and unexpectedly found pulled medially by adhesions. Ureterolysis was performed down to the ovarian remnant, which was dissected to allow the ureter to fall laterally. The ovarian remnant was safely excised with the cystic elements aspirated to facilitate removal in a retrieval bag via the 5mm right iliac fossa port incision. The ovarian tissue was excised in its entirety and at the end of the procedure the bowel was mobile, lying in its anatomical position. Consider remnant ovarian tissue in endometriosis patients who have had previous difficult hysterectomy and bilateral salpingoophrectomy with continued pain. Clomiphene enlarges remnant ovarian tissue to aid identification and excision. Before excising pathology it is important to identify normal structures when presented with distorted anatomy to ensure a safe approach.

Objectives Maternal lifestyles, including diet, have been linked to infant birthweight. However, customised birthweight centiles (CBWC), which more accurately identify small babies that have increased fetal growth restriction and are at higher risk of newborn morbidity and later life health complications, are rarely considered when studying maternal diet. This study investigated maternal dietary patterns and their impact on infant CBWC within a cohort of women living in South Wales. Methods This study utilised cross-sectional data from the longitudinal Grown in Wales (GiW) cohort. Women 18-45 years old were recruited the morning prior to an elective caesarean section (ELCS). Women completed a food frequency questionnaire (FFQ). Additional data on pregnancy and birth outcomes was extracted from medical notes. Data from 303 participants was analysed. Results 'Western' and 'Health conscious dietary patterns were identified. The 'Health Conscious' dietary pattern was significantly associated with maternal BMI, age, education, income and exercise. Adjusted regression analyses indicated that greater adherence to a 'Health Conscious' dietary pattern was significantly associated with increased CBWC (AOR = 4.75 [95% CI: 1.17, 8.33] p =.010) and reduced risk of delivering a small-for-gestational age (SGA) infant (AOR = .51 [95% CI: .26, .99] p = .046). Conclusion A healthier diet was significantly associated with higher birthweight using CBWC and a reduced risk of delivering an SGA infant suggesting that birthweight will be improved in areas of Wales by focused support encouraging healthier dietary habits.

Shortened leukocyte and placental telomeres associated with gestational diabetes mellitus (GDM) suggest this exposure triggers telomere attrition contributing to adverse outcomes. We applied high resolution Single Telomere Length Analysis (STELA) to placenta from GDM pregnancies with different treatment pathways to determine their effectiveness at preventing telomere attrition. Differences in telomere length between control (N = 69), GDM lifestyle intervention (n = 14) and GDM treated with metformin and/or insulin (n = 17) was tested by Analysis of Covariance (ANCOVA) followed by group comparisons using Fisher’s least significant difference. For male placenta only, there were differences in mean telomere length (F(2,54) = 4.98, P = 0.01) and percentage of telomeres under 5 kb (F(2,54) = 4.65, P = 0.01). Telomeres were shorter in the GDM lifestyle intervention group compared to both controls (P = 0.02) and medically treated pregnancies (P = 0.003). There were more telomeres under 5 kb in the GDM lifestyle intervention group compared to the other two groups (P = 0.03 and P = 0.004). Although further work is necessary, we suggest that early adoption of targeted medical treatment of GDM pregnancies where the fetus is known to be male may be an effective strategy for ameliorating adverse outcomes for children.

Objective: To evaluate caesarean section (CS) rates and moderate to severe hypoxaemic ischaemic encephalopathy (HIE) rates with other core intra-partum outcomes following reconfiguration of maternity services in Cardiff, South Wales, UK. Design: Cohort study of births from 2006 to 2015. Settings: A University tertiary referral centre for foetal and maternal medicine with 6000 births/year, University Hospital of Wales, United Kingdom. Method: Data relating to births from 1 January 2006 to 31 December 2015 were extracted from the computerized maternity database on a yearly basis. Case notes of all mothers and babies for the same duration were hand searched for documentation of HIE. HIE data was also collected prospectively by neonatologist (SC) and obstetrician (PA). Main outcome measures: Incidence of caesarean section births, babies with moderate to severe HIE, instrumental vaginal births, obstetric anal sphincter injuries (OASIS) associated with instrumental delivery, and major post-partum haemorrhage (MPPH) of 2500 mL or more. Results: During this 10-year period, a downward trend in emergency CS rate was seen from 15.6% in 2006 to 10.5% in 2015, reducing total CS rate from 25.5% in 2006 to 21.2% in 2015. A downward trend in the incidence of moderate and severe HIE was seen over the same period. There was an increase in operative vaginal births (OVB) from 12.8% to 15%. The rate of spontaneous vaginal births (SVB) remained stable. The incidence of OASIS remained constant and MPPH rate has fallen. Conclusions: Following amalgamation of two medium sized obstetric units and the opening of a Midwifery Led Unit (MLU), core intrapartum outcomes have improved. Contributing factors are the introduction of regular multidisciplinary training with enhanced team working, compulsory education for obstetricians and midwives on cardiotocograph (CTG) interpretation, increased consultant presence on delivery suite, robust risk management systems and broad multidisciplinary agreement on clinical guidelines promoting vaginal birth.

BackgroundIn the UK, 11.8% of expectant mothers undergo an elective caesarean section (ELCS) representing 92 000 births per annum. It is not known to what extent this procedure has an impact on mental well-being in the longer term.AimsTo determine the prevalence and postpartum progression of anxiety and depression symptoms in women undergoing ELCS in Wales.MethodPrevalence of depression and anxiety were determined in women at University Hospital Wales (2015–16;n= 308) through completion of the Edinburgh Postnatal Depression Scale (EPDS; ≥13) and State-Trait Anxiety Inventory (STAI; ≥40) questionnaires 1 day prior to ELCS, and three postpartum time points for 1 year. Maternal characteristics were determined from questionnaires and, where possible, confirmed from National Health Service maternity records.ResultsUsing these criteria the prevalence of reported depression symptoms was 14.3% (95% CI 10.9–18.3) 1 day prior to ELCS, 8.0% (95% CI 4.2–12.5) within 1 week, 8.7% (95% CI 4.2–13.8) at 10 weeks and 12.4% (95% CI 6.4–18.4) 1 year postpartum. Prevalence of reported anxiety symptoms was 27.3% (95% CI 22.5–32.4), 21.7% (95% CI 15.8–28.0), 25.3% (95% CI 18.5–32.7) and 35.1% (95% CI 26.3–44.2) at these same stages. Prenatal anxiety was not resolved after ELCS more than 1 year after delivery.ConclusionsWomen undergoing ELCS experience prolonged anxiety postpartum that merits focused clinical attention.Declaration of interestNone.

A 30-year-old complaining of menstrual haematuria and cystitis symptoms underwent cystoscopy and bilateral ureteric stenting under X-ray guidance and laparoscopic excision of bladder endometriosis.

To investigate how familiar with the costs of laparoscopic instruments and other basic devices Obstetrics and Gynaecology (O&G) trainees are in Wales Deanery, UK.

Study Objective: To assess procedural success, patient acceptability, and cost-saving potential of operative hysteroscopy using conventional equipment and local anesthetic in an outpatient clinic.Design: Feasibility study/service evaluation (Canadian Task Force classification II-3).Setting: Outpatient (office) clinic in a large UK teaching hospital.Patients: One hundred eighteen women with diagnosed or suspected intrauterine myomas or polyps.Interventions: Operative hysteroscopy (122 monopolar resection procedures using 8- or 10-mm diameter rigid resectoscopes with glycine solution for uterine irrigation) with the patient under local anesthesia in an outpatient (office) clinic.Measurements and Main Results: Procedural success, duration of procedure, pathologic measurements, glycine irrigant deficit, patient pain scores and satisfaction, and comparative costs were recorded. Success of outpatient procedures was 90% (110 of 122 attempted), with a significantly reduced median procedure duration compared with a surgical setting using local (-7 minutes; p = .009) or general (-12.5 minutes; p < .001) anesthetic. Glycine irrigant absorption was low (median deficit, 0 mL), and no deficit was observed in 81% of patients. Mean (SD) estimated disease volume was comparable to that of hysteroscopic resection procedures in a surgical setting (3.38 [5.09] cm(3)), and weight was 1.8 (1.84) g. Patients tolerated the procedure well and reported low pain scores (highest median periprocedure pain measurement was 1.25 of 10), and 7-day follow-up satisfaction responses were positive. Retrospective cost analysis demonstrated that operative resection in an outpatient clinic was less expensive than in a surgical setting using general anesthetic (-$1003) or local anaesthetic (-$234). Reduced staff costs were the primary reason for this saving.Conclusions: Operative hysteroscopic resection of myomas and polyps is feasible and well tolerated by patients in an outpatient/office setting using local anaesthetic and conventional equipment. The outpatient procedure is less expensive and its duration is shorter than in a surgical setting. (C) 2014 AAGL. All rights reserved.

This novel micro endometrial ablation technique functions by delivery of microwave energy to the endometrium via an intra-cavity induction loop. The device diameter 3.5mm is such that cervical dilatation is not required. In addition the procedure is of rapid duration (60 seconds) for the majority of endometrial cavities. Women with larger cavities require two applications of 60 and 30 seconds.

Predicting the duration of advanced laparoscopic surgery is essential for optimising theatre utilisation. Surprisingly there has been no study to date analysing the accuracy of this process in an attempt to improve efficiency and reduce under- or over- utilisation of theatre time. Our aim was to correlate predicted and actual duration of surgery and create a regression model to aid in accurately predicting operative time.

"Proof-of-principle" that cell replacement therapy works for neurodegeneration has been reported, but only using donor cells collected from fetal brain tissue obtained from surgical terminations of pregnancy. Surgical terminations of pregnancy represent an increasingly limited supply of donor cells due to the tendency towards performing medical termination in much of Europe. This imposes a severe constraint on further experimental and clinical cell transplantation research. Therefore, we explore here the feasibility of using medical termination tissue as a donor source. Products of conception were retrieved from surgical terminations over the last 7 years and from medical terminations over the last 2.5 years. The number of collections that yielded fetal tissue, viable brain tissue, and identifiable brain regions (ganglionic eminence, ventral mesencephalon, and neocortex) were recorded. We studied cell viability, cell physiological properties, and differentiation potential both in vitro and following transplantation into the central nervous system of rodent models of neurodegenerative disease. Within equivalent periods, we were able to collect substantially greater numbers of fetal remains from medical than from surgical terminations of pregnancy, and the medical terminations yielded a much higher proportion of identifiable and dissectible brain tissue. Furthermore, we demonstrate that harvested cells retain the capacity to differentiate into neurons with characteristics appropriate to the region from which they are dissected. We show that, contrary to widespread assumption, medical termination of pregnancy-derived fetal brain cells represent a feasible and more readily available source of human fetal tissue for experimental cell transplantation with the potential for use in future clinical trials in human neurodegenerative disease.

Evaluate the feasibility and patient acceptability of resection of fibroids, polyps and endometrium in the UK clinic/office setting under local anaesthesia using conventional resectoscopes of 10 and 8 mm diameter with glycine as irrigant. Evaluation study with independent audit of patient satisfaction and financial implications. Gynaecology outpatient clinic of a major teaching hospital. Pre and post menopausal women with diagnosed polyps and type 1 or 2 fibroids requiring resection for the treatment of PMB, menorrhagia or infertility (N=>100). Following pre-emptive rectal analgesia and a paracervical block the cervix was dilated to 8 or 10 mm and the pathology resected. The patient was then given a cup of tea and discharged within half an hour. Timings of the procedure, pain scores (Figure 1), volume of irrigant used, the fluid deficit, volume and weight of tissue removed (Figure 2), immediate patient acceptablity and complications were recorded. A week later an independent telephone survey of patient satisfaction was carried out. An independent health economist (JW) undertook a conservative comparative cost analysis comparing the procedure under GA in theatre, LA in theatre, use of bipolar electode resection in clinic and our innovative conventional process under LA in clinic.Figure 2Sample weights in grammes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Tabled 1Conservative Cost Economic EvaluationOutpatients Reuseable (Shine)Day Case G.A.Day Case L.A.Disposable OutpatientsSaff and Hospital Admittance£274 / $448£915 /$1496£427 / $699£274 / $448Single Use Equipment£23 / $38£23 / $38£23 / $38£299 / $489Re-useable Equipment£9 / $15£9 / $15£9 / $15£7 / $12Drugs£7 / $11£17 / $27£7 / $11£6 / $9Total£313 / $523£964 / $157£465 / $761£585 / $957Saving Offered by Shine£651 /$1065£152 / $249£273 / $446150 cases from GA to OPD = £97650 / $159721. Open table in a new tab 150 cases from GA to OPD = £97650 / $159721. Over 95% of attempted resections were sucessfull with large quantities of tissue (up to 10g) removed with low pain scores and high patient satisfaction. Maximum fluid absorption was 400 ml. We have gently rocked the foundations on which many outpatient operative clinics are based by proving that it is possible to undertake resection of fibroids and polyps in outpatients under local anaesthetic following dilatation of the cervix to 8-10 mm, and using glycine for uterine distension. Major finacial savings have been accrued and valuable theatre time released. The outpatient procedure is shorter and is less disruptive to women.

Background. Rectovaginal endometriosis is a severe form of pelvic endometriosis in which pharmacological treatment is relatively ineffective (Vercellini et al., Fertil Steril. 2005;84:1375-87). Laparoscopic surgical treatment is effective, but has the potential risks of bowel perforation and colostomy formation (Darai et al., Am J Obstet Gynecol. 2005;192:394-400). Transrectal ultrasound scanning can be applied as a preoperative tool to predict the presence of rectovaginal endometriosis and bowel wall involvement (Abrao et al., J Am Assoc Gynecol Laparosc. 2004;11:50-4). Methods. Thirty-two women underwent transrectal ultrasound followed by therapeutic laparoscopy. Likelihood ratios and post-test prevalences were calculated with Fagan's normogram. This was then extrapolated with the aid of a mathematical model to a low-risk population. Results. A positive likelihood ratio was found to be 10.89 (95% confidence ratio (CI): 1.62-73.15) and a negative likelihood ratio was found to be 0.24 (95% CI: 0.1-0.57). The pre-test prevalence of rectovaginal endometriosis was 56%. The positive post-test prevalence probability was 93%, and the negative post-test prevalence probability was 23%. Conclusion. Preoperative transrectal ultrasound scanning for rectovaginal endometriosis is an extremely accurate predictive test, and strongly predicts the need for extensive laparoscopic dissection and potential bowel resection.

Severe vulval edema after laparoscopic ovarian cystectomy with instillation of adhesion-prevention solution (4% icodextrin) is a rare complication. A 17-year-old girl was readmitted to the hospital 2 days after laparoscopic ovarian cystectomy with massive vulval swelling, pain, and anxiety. Gross swelling was potentially caused by accumulation of fluid 4% icodextrin in the labia. The condition resolved spontaneously with application of ice packs and bed rest. Possible mechanisms of this complication are discussed as is the importance of adequate counseling and consent before surgery when adhesion prevention solutions are to be administered.

To assess the proportion of women found to have rectovaginal endometriosis who underwent a previous laparoscopy with negative findings, a 5-year retrospective observational study was carried out at the University Hospital of Wales, Cardiff UK, from 2001 to 2005. A total of 61 cases with potential symptoms of rectovaginal endometriosis who underwent laparoscopy were identified. Rectovaginal endometriosis was identified in 16 of these cases. Previous laparoscopy was carried out in 33 of these 61 cases. In the group of women found to have rectovaginal endometriosis, 14 cases of rectovaginal endometriosis were not identified by pre-referral laparoscopy. This study supports the anecdotal idea that rectovaginal endometriosis is an often missed diagnosis at the time of laparoscopy. Diagnostic laparoscopy by generalist gynaecologists frequently fails to diagnose rectovaginal endometriosis. The routine use of rectal probes at laparoscopy is recommended to increase diagnostic accuracy.

Rectovaginal endometriosis is a severe variant of endometriosis. Common presenting symptoms for endometriosis include dysmenorrhoea, pelvic pain and dyspareunia. It is now recognised that there are other less traditional symptoms of endometriosis that are also relatively common. The aim of this study is to assess the relative strength of each of the potential symptoms of rectovaginal endometriosis and compare these with the laparoscopic and histological findings. In this retrospective, observational study the overall prevalence of rectovaginal endometriosis in the group was 31.4%. The presence of dyschesia gave a likelihood ratio of 1.27 (95% CI: 0.56-2.89) with a predictive prevalence of rectovaginal endometriosis of 37%. Apareunia and nausea or abdominal bloating were particularly strong markers for rectovaginal disease with a predictive prevalence of 87% and 89%, respectively. The classical symptoms often attributed to irritable bowel syndrome are also common in women with rectovaginal disease.