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Secondary analyses from a randomized clinical trial: age as the key prognostic factor in endometrial carcinoma

Published:December 16, 2013DOI:https://doi.org/10.1016/j.ajog.2013.12.021
      To the Editors:
      Kramer et al
      • Kramer M.S.
      • Berg C.
      • Abenhaim H.
      • et al.
      Incidence, risk factors, and temporal trends in severe postpartum hemorrhage.
      reported a doubling of the incidence of severe postpartum hemorrhage (PPH) over recent years (1999-2008), although were unable to explain the overall temporal trend despite analyzing traditional risk factors. An audit of 2 UK units, delivering more than 4000 babies per year, showed increases in PPH greater than 1000 mL, and PPH greater than 2000 mL, of greater than 500% (2003-2012).
      Traditional risk factors (increased maternal age, parity, fetal macrosomia, etc) appeared to be less significant because many cases occurred in young, nulliparous women undergoing induction of labor that resulted in the delivery of an appropriate-for-gestational-age baby by cesarean section.
      There is evidence for prepregnancy injuries to the myometrium resulting from physical efforts during defecation, which is endemic (>30%) in Western populations
      • Heaton K.W.
      • Cripps H.A.
      Straining at stool and laxative taking in an English population.
      and excessive traction to the cervix during minor gynecologic procedures.
      • Quinn M.J.
      Endometriosis; the consequence of denervation-reinnervation.
      Both injure uterine and tubal nerves in their course through the uterosacral ligaments, and both continue to increase in frequency in Western societies. There is also direct evidence for minor gynecological procedures causing adverse reproductive outcomes (eg, preterm labor) that may also result from prepregnancy denervatory injuries.
      • McCarthy F.P.
      • Khashan A.S.
      • North R.A.
      • et al.
      SCOPE Consortium
      Pregnancy loss managed by cervical dilatation and curettage increases the risk of spontaneous preterm birth.
      Whether injured uteri respond to oxytocic agents, prostaglandins, and, surgical maneuvers may be an important question in contemporary intrapartum care.

      References

        • Kramer M.S.
        • Berg C.
        • Abenhaim H.
        • et al.
        Incidence, risk factors, and temporal trends in severe postpartum hemorrhage.
        Am J Obstet Gynecol. 2013; 209: 449.e1-449.e7
        • Heaton K.W.
        • Cripps H.A.
        Straining at stool and laxative taking in an English population.
        Dig Dis Sci. 1993; 38: 1004-1008
        • Quinn M.J.
        Endometriosis; the consequence of denervation-reinnervation.
        Arch Obstet Gynecol. 2011; 284: 1423-1429
        • McCarthy F.P.
        • Khashan A.S.
        • North R.A.
        • et al.
        • SCOPE Consortium
        Pregnancy loss managed by cervical dilatation and curettage increases the risk of spontaneous preterm birth.
        Hum Reprod. 2013; 28: 3197-3206

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