Postnatal acetaminophen exposure and neurodevelopmental outcomes at 18-21 months corrected gestational age in preterm infants <29 weeks gestation: a retrospective cohort study.

BACKGROUND: Studies have reported prenatal acetaminophen exposure is associated with abnormal neurodevelopment. There is limited and conflicting data on neurodevelopmental outcomes following postnatal acetaminophen exposure. Our objective was to investigate the neurodevelopmental outcomes of preterm infants < 29 weeks gestation postnatally exposed to acetaminophen. METHODS: Retrospective cohort study of infants born between 2008 and 2017 at a tertiary care perinatal center. Exclusion criteria included chromosomal disorders, major congenital abnormalities, and congenital infections. The primary outcome was a composite score of <85 on the cognitive, language, or motor components of the Bayley Scales of Infant and Toddler Development, 3rd edition, assessed at 18 to 21 months corrected gestational age. Multivariate logistic regression was used to assess confounders. RESULTS: Of the 945 infants included in the study, 120 were in the acetaminophen group. There was no difference in any of Bayley-III cognitive, language or motor composite scores of < 85 between the two groups for postnatal acetaminophen exposure, adjusted odds ratios (aORs) 1.03, 95% CI 0.60-1.78, or days of acetaminophen use, aORs 1.10, 95% CI 0.93-1.29. CONCLUSIONS: There was no difference in neurodevelopmental outcome between the acetaminophen exposed and non-exposed groups. Our results need validation in larger cohorts. IMPACT: Animal research and cohort studies have suggested that prenatal acetaminophen exposure may be associated with an elevated risk of neurobehavioral abnormalities. However, there is limited and conflicting research on the impact of postnatal acetaminophen on neurodevelopment. The results of this study suggest that postnatal acetaminophen does not negatively impact neurodevelopment at 18 to 21 months in preterm infants born at <29 weeks gestational age. While these results need validation in larger and more longitudinal studies, this study provides reassurance for the use of postnatal acetaminophen in extremely preterm infants.

Utility of the 21-month neurodevelopmental outcome for predicting neurodevelopmental impairment at 36 months for preterm infants <29 weeks gestation.

OBJECTIVE: To determine the sensitivity and specificity of the 21-month neurodevelopmental outcome for predicting the presence of neurodevelopmental impairment at 36 months corrected age in a population of preterm infants under 29 weeks gestation. STUDY DESIGN: This is a retrospective observational cohort study. Preterm infants born under 29 weeks gestation who were followed up at both 18-21 months and 36 months corrected age with outcome data available were enrolled. RESULTS: Overall, 713 preterm infants <29 weeks gestation and were included in the final analysis. The specificity of the 21-month assessment for predicting neurodevelopmental impairment at 36 months corrected age was 66% (95% confidence interval[CI] 62-71%) with a positive predictive value of 61% (95% CI 56-66%). CONCLUSION: In preterm neonates born <29 weeks gestation, the 18-21 months corrected neurodevelopmental outcome had low specificity and positive predictive value for predicting the presence of neurodevelopmental impairment at 36 months corrected age.

Neurodevelopmental Outcomes of Preterm Infants Born <29 Weeks with Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension: A Multicenter Study.

OBJECTIVE: This study aimed to determine neurodevelopmental outcomes of preterm infants born at <29 weeks' gestational age (GA) with bronchopulmonary dysplasia and pulmonary hypertension (BPD-PH) at 18 to 24 months' corrected age (CA). STUDY DESIGN: In this retrospective cohort study, preterm infants born at <29 weeks' GA between January 2016 and December 2019, admitted to level 3 neonatal intensive care units, who developed BPD and were evaluated at 18 to 24 months' CA in the neonatal follow-up clinics were included. We compared demographic characteristics and neurodevelopmental outcomes between the two groups: Group I: BPD with PH and Group II: BPD with no PH, using univariate and multivariate regression models. The primary outcome was a composite of death or neurodevelopmental impairment (NDI). NDI was defined as any Bayley-III score < 85 on one or more of the cognitive, motor, or language composite scores. RESULTS: Of 366 eligible infants, 116 (Group I [BPD-PH] =7, Group II [BPD with no PH] = 109) were lost to follow-up. Of the remaining 250 infants, 51 in Group I and 199 in Group II were followed at 18 to 24 months' CA. Group I and Group II had median (interquartile range [IQR]) birthweights of 705 (325) and 815 g (317; p = 0.003) and median GAs (IQR) were 25 (2) and 26 weeks (2; p = 0.015) respectively. Infants in the BPD-PH group (Group I) were more likely to have mortality or NDI (adjusted odds ratio: 3.82; bootstrap 95% confidence interval; 1.44-40.87). CONCLUSION: BPD-PH in infants born at <29 weeks' GA is associated with increased odds of the composite outcome of death or NDI at 18 to 24 months' CA. KEY POINTS: · Long-term neurodevelopmental follow-up of preterm infants born <29 weeks' GA.. · Association of neurodevelopmental outcomes with BPD-associated PH.. · Need for longitudinal follow-up of children with BPD-associated PH..

The association of maternal overweight on long-term neurodevelopmental outcomes in premature infants (< 29 weeks) at 18-24 months corrected age.

OBJECTIVE: To determine the association of maternal pre-pregnancy body mass index (BMI) and neurodevelopmental impairment (NDI) at 18-24 months corrected age (CA) in infants born < 29 weeks gestation. STUDY DESIGN: Infants born between 2005 and 2015 at < 29 weeks gestation were included. BMI was categorized into BMI1 [18.5-24.9 kg/m2], BMI2 [25-29.9 kg/m2], BMI3 [ ≥ 30 kg/m2]. Primary outcome was death or NDI (Bayley-III scores < 85, cerebral palsy, hearing or visual impairment). Univariate and multivariate analysis were used. RESULTS: There were 315 infants in BMI1, 235 in BMI2, and 147 in BMI3 groups. Adjusted odds ratio (aOR) of death or NDI in BMI2 vs. BMI1 and BMI3 vs BMI1 groups were 1.33 (95% CI 0.86-2.06) and 0.76 (95% CI 0.47-1.22). Adjusted odds ratio of Bayley-III language composite < 85 was 2.06 (95% CI 1.28-3.32). CONCLUSION: Pre-pregnancy BMI was not associated with death or NDI in extremely preterm infants. Infants born to overweight mothers had higher odds of low language scores.

The REDUCED trial: a cluster randomized trial for REDucing the utilization of CEsarean delivery for dystocia.

BACKGROUND: To reduce cesarean delivery rates in nulliparous women, guidelines for diagnosing nonprogressive labor have been developed by the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine. These are mainly based on data from the Consortium for Safe Labor study. The guidelines have not been tested in a clinical trial, so the efficacy and safety of this new approach is uncertain. OBJECTIVE: This study aimed to assess whether adoption of new guidelines for diagnosing nonprogressing labor would reduce cesarean delivery rates. STUDY DESIGN: We conducted a cluster randomized controlled trial of a knowledge translation program of the guidelines in 26 Canadian hospitals (13 control sites and 13 intervention sites). The sites included all intrapartum care sites in Alberta that perform cesarean delivery and deliver at least 70 nulliparous women annually. The baseline period started on January 1, 2015. The intervention was initiated at the first intervention site in January 2017. The follow-up period began at the first intervention site in February 2017 and lasted till February 2020. The primary outcome was the rate of cesarean delivery in nulliparous women with vertex presentation in labor at term. The secondary outcomes included spontaneous vaginal birth and maternal and neonatal safety. The main data source for the primary and secondary outcomes was the Alberta Perinatal Health Program database. The cesarean delivery rates were assessed using repeated measures mixed effects logistic regression applied to individual births. RESULTS: The analysis was based on 45,193 deliveries at intervention sites and 43,725 deliveries at control sites. There was no evidence of a decrease in the rate of cesarean delivery in association with the intervention (baseline-adjusted odds ratio, 0.94; 95% confidence interval [0.85-1.05]; P=.259). The rate of spontaneous vaginal delivery increased slightly (baseline-adjusted odds ratio, 1.10; 95% confidence interval, [1.01-1.18]; P=.024). We did not observe any differences in adverse maternal or neonatal outcomes. CONCLUSION: Cesarean delivery rates in nulliparous women were not reduced by the application of recent guidelines for the diagnosis of nonprogressive labor. Spontaneous vaginal delivery-a secondary outcome-was increased in the intervention group. The intervention appears to be safe.

Neuroprotection care bundle implementation is associated with improved long-term neurodevelopmental outcomes in extremely premature infants.

OBJECTIVE: To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. STUDY DESIGN: An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. RESULTS: Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021). CONCLUSION: Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.

Impact of a Clinical Intervention to Decrease Opioid Prescribing in a Post-Cesarean Delivery.

A quality assurance study was completed following the implementation of a standardized opioid prescribing and education protocol post cesarean delivery. The primary goal was to determine the need for a policy on postpartum opioid prescribing practices and whether the protocol worked. There was a decrease in the number of tablets provided post intervention and no statistically significant maternal or neonatal readmissions for suspected opioid toxicity or pain control. Combination prescribing of Tylenol 3 and/or tramadol and another opioid occurred in both groups. Our results show a need for concise guidelines regarding opioid prescribing following cesarean delivery.

Critical examination of relationships between early growth and childhood overweight in extremely preterm infants.

OBJECTIVES: To identify the prevalence and risk factors for childhood overweight and obesity (OWO) at 3-year corrected age in children born <1500 g <29 weeks gestation. STUDY DESIGN: A multicentre retrospective cohort study for preterm infants admitted to neonatal intensive care units between 2001 and 2014. RESULTS: Data were available for 911 (89.4%) of the 1019 infants who met the inclusion criteria. Of them, 22 (2.4%) had OWO. There were no associations between OWO and being small for gestational age (RR = 1.3, 95% confidence interval (CI): 0.3-5.4) or weight <10th percentile at 36 weeks (RR = 1.1, 95% CI: 0.4-2.8). OWO was associated with low maternal education (RR = 7.4, 95% CI: 2.1-26), maternal diabetes (RR = 5.2, 95% CI: 1.9-15) and neonatal brain injury (RR = 4.9, 95% CI: 1.8-14). Adjusting for concurrent child weight at 3 years of age resulted in an overadjustment bias. CONCLUSION: Small size at birth or at 36 weeks gestation in extremely preterm infants is not associated with increased risk of early childhood overgrowth or obesity. CLINICAL TRIAL REGISTRATION: NCT03064022.

Changes in the Frequency of Cesarean Delivery in Nulliparous Women in Labor in a Canadian Population, 1992-2018.

OBJECTIVE: To examine the relative contribution of changes in patient demographics and physician management to changes in the cesarean delivery rate in labor among nulliparous women. METHODS: We conducted a retrospective cohort study of 485,451 births to nulliparous women who experienced labor at or beyond 35 weeks of gestation in Alberta, Canada, from 1992 to 2018. The data were from a province-wide perinatal database. The primary outcome was cesarean delivery. Multivariate logistic regression and calculation of population attributable risk for identified risk factors were performed. RESULTS: The cesarean delivery rate increased from 12.5% in 1992 to 24% in 2018. The prevalence of maternal risk factors for cesarean delivery such as obesity, maternal age 35 years or older at delivery, and comorbidities increased over the study period. However, this did not account for the increase in cesarean delivery, because the frequency of cesarean delivery increased irrespective of risk status. Additionally, the population-attributable risk for each risk factor was stable across the study period. For example, for maternal age 35 years or older at delivery, the number of cesarean deliveries attributable to this factor (the population-attributable risk) was 0.9 per 100 deliveries in 1992-1998 and 1 per 100 in 2014-2018. The proportion of cesarean deliveries in which nonreassuring fetal status was the indication increased from 30.1% in 1992 to 51.1% in 2018. The absolute rate of cesarean delivery in the second stage of labor increased from 3.1% in 1992 to 5.9% in 2018. This was due to a significant increase, among those who entered the second stage, in cesarean delivery without a trial of forceps, from 2.5% in 1992 to 7.0% in 2018. CONCLUSION: The observed doubling of the rate of cesarean delivery in labor in first-time mothers was not driven by patient risk factors. Increases in the rate of cesarean delivery for nonreassuring fetal status and decreased operative vaginal deliveries were important factors.

Weight, length, and head circumference at 36 weeks are not predictive of later cognitive impairment in very preterm infants.

OBJECTIVE: To assess diagnostic accuracy of 36-week anthropometric weight, length, and head circumference <10th and <3rd percentiles to predict preterm infant cognitive impairment. STUDY DESIGN: Cohort study of 898 preterm <30-week very-low-birth weight (<1500 g) infants. Anthropometric measures' accuracy to predict cognitive impairment (Bayley-III Cognitive Composite score) <80, 21-months corrected age (CA) and Wechsler Preschool and Primary Scale of Intelligence Quotient (intellectual outcomes) <70, 36-months CA, were determined using receiver operating characteristic (ROC) curves. RESULT: Thirty-six-week weight, length or head circumference <10th or <3rd percentile did not predict cognitive impairment; areas under ROC curves were <0.6. Sensitivities and specificities for 10th and 3rd percentile cut points were all poor, with most not exceeding 70%, whether the Fenton 2013 or INTERGROWTH 2015 growth charts were used. Brain injury and low maternal education were better predictors of cognitive impairment. CONCLUSION: Preterm infant 36-week anthropometric measurements are not accurate predictors of cognitive impairment.

Perinatal outcome and prognostic factors of fetal megacystis diagnosed at 11-14 week's gestation.

OBJECTIVES: To evaluate aneuploidy rate, prognostic factors, and perinatal outcomes following a diagnosis of fetal megacystis at 11-14 week's gestation. METHODS: A retrospective study of first trimester fetal megacystis from 2010 to 2020 was performed, including ultrasound finding, perinatal outcomes, pathology reports, genetic tests, and neonatal investigations. RESULTS: A total of 98 cases of first trimester fetal megacystis was identified with an overall aneuploidy rate of 12%. There were 54% live births and 46% fetal losses including spontaneous fetal demise and elective termination. Among the 45 fetal losses, 64% had additional structural abnormalities at index ultrasound and final diagnoses were achievable in 64% cases. Among the 53 livebirths, additional ultrasound abnormalities were detected in only 1 fetus and spontaneous resolution of megacystis was detected in 96% of cases. The two cases where fetal megacystis persisted had major postnatal diagnoses: cloacal malformation and megacystis-microcolon-intestinal hypoperistalsis syndrome, respectively. Our data showed LBD ≥ 12 mm was the best individual predictor of adverse perinatal outcome and all 11 cases of lower urinary tract obstruction (LUTO) were diagnosed in fetuses with LBD ≥ 12 mm. CONCLUSIONS: First trimester ultrasound provides important prognostic factors and isolated megacystis <12 mm is associated with a positive outcome.

Antenatal Diagnosis of Marginal and Velamentous Placental Cord Insertion and Pregnancy Outcomes.

OBJECTIVE: To evaluate the association between antenatal diagnosis of velamentous and marginal placental cord insertions with adverse perinatal outcomes of small-for-gestational-age (SGA) birth weight (less than the 5th percentile), caesarean birth, and perinatal mortality. METHODS: Using a diagnostic imaging database, we performed a cohort study of all consecutive singleton pregnancies (35,391), including 1,427 cases of marginal and 107 cases of velamentous cord insertion, delivered after 24 6/7 weeks of gestation between January 1, 2012, and December 31, 2015, at a single Canadian tertiary care center. Cases with placenta previa, vasa previa, no documented cord insertion, or fetal anomalies were excluded. RESULTS: In the overall cohort, the rate of birth weight less than the 5th percentile was 5.2%, the rate of cesarean delivery was 27.1%, and the rate of perinatal mortality was 0.24%. Velamentous cord insertion was associated with SGA (relative risk [RR] 2.19, 95% CI 1.28-3.74). This persisted after controlling for smoking during pregnancy, diabetes, and hypertension (adjusted odds ratio [aOR] 1.98, 95% CI 1.03-3.84). Velamentous cord insertion was also associated with an increased risk of caesarean birth (RR=1.38, 95% CI=1.08-1,77) and perinatal death (1.87%, RR 8.15, 95% CI 2.02-32.8), a relationship that persisted after controlling for smoking during pregnancy, diabetes, and hypertension (aOR 1.53, 95% CI 1.01-2.32). Marginal cord insertion was not associated with birth weight less than the 5th percentile (RR 1.23, 95% CI 1.00-1.51), cesarean delivery (RR 1.01, 95% CI 0.92-1.10), or perinatal death (RR 1.53, 95% CI 0.62-3.78). CONCLUSION: Antenatal diagnosis of velamentous placental cord insertion is associated with birth weight less than the 5th percentile.

Defining the short-term disease recurrence after loop electrosurgical excision procedure (LEEP).

BACKGROUND: The goal of cervical cancer screening is to identify dysplastic lesions for subsequent excision in order to prevent invasive disease. There is clinical equipoise, on how to best follow women for disease surveillance after treatment with some Canadian provinces exclusively performing colposcopy and some utilizing Human Papilloma Virus (HPV) testing in addition to cervical cytology. Loop Electrosurgical Excision Procedure (LEEP) is used to treat pre-invasive HPV-mediated disease and patients are typically followed for 12 months after disease excision. This study aims to quantify the prevalence of high-grade disease at the time of the second follow-up colposcopy visit, in a practice setting that utilizes laser ablation in addition to LEEP. METHODS: In a retrospective cohort study, consecutive patient charts were accessed through the electronic medical record system, ARIA, at the Tom Baker Cancer Centre, in Calgary, Alberta, from January 2010 to December 2015. Data was extracted and a REDCap database was used to compile pertinent information from charts meeting inclusion criteria. Descriptive and analytic statistics were performed. RESULTS: Of the 303 patients identified, 221 patients met inclusion criteria. 86% of these patients met discharge criteria from colposcopy after the second follow up visit. 31 (14%) were seen in a subsequent visit for abnormal findings. Of these, 7 (3.2%) underwent further treatment for high-grade disease/Cervical Intraepithelial Neoplasia (CIN 2/3). Of the 31, 23 (10.6%) had a third - negative - visit, resulting in discharge from colposcopy. One patient had a repeat LEEP for persistent Low-Grade Squamous Intraepithelial Lesion (LSIL). CONCLUSION: In summary, our data demonstrates a prevalence of 3.2% of high-grade disease at the time of a second colposcopic follow up visit after treatment, in a setting which frequently utilizes laser ablation in combination with LEEP, for large lesions. This recurrence rate is consistent with most published literature on recurrence rates of CIN2/3.

Potential Impact of Guidelines for the Prevention of Cesarean Deliveries in a Contemporary Canadian Population.

OBJECTIVE: This study sought to describe how the implementation of recent labour guidelines may affect the cesarean delivery rate in a population in Alberta. METHODS: This retrospective study was conducted on primiparous women who were in labour with singleton term fetuses with cephalic presentation in Alberta from 2007 to 2016 (n = 181 738), and it used data from a perinatal database. Modelled cesarean delivery rates were calculated to determine the potential impact of the recent guidelines on the cesarean delivery rate by using the percentage of cesarean deliveries that occurred outside the threshold of the recent labour guidelines. RESULTS: A total of 21.7% of the cesarean deliveries for dystocia occurred outside of the guidelines related to the first stage of labour arrest for spontaneous labour (n = 9282), and 45.4% occurred outside of the guidelines related to the first stage of labour arrest for induced labours (n = 11 712). A total of 69.0% of the cesarean deliveries for dystocia occurred outside of the failed induction of labour guidelines (n = 4921), and 55.4% occurred outside of the second stage labour arrest guidelines (n = 6632). Assuming that the labour arrest guidelines are effective at reducing the cesarean delivery rate 25% of the time, the cesarean delivery rate for primiparous women in labour would be reduced from 22.5% to 20.7%. Assuming a 75% adherence/effectiveness rate, the cesarean delivery rate would be reduced to 17.1%. CONCLUSION: The recent labour guidelines have the potential to have a substantial impact on the intrapartum cesarean delivery rate in primiparous women with singleton fetuses with cephalic presentation at term if the guidelines are put into practice.

Caesarean section and neonatal survival and neurodevelopmental impairments in preterm singleton neonates.

INTRODUCTION: Evidence is lacking regarding the benefit of caesarean section (CS) for long-term neurodevelopmental outcomes in singleton preterm neonates. Therefore, uncertainty remains regarding obstetrical best practice in the delivery of premature neonates. OBJECTIVE: Our objective was to determine the association between the mode of delivery and neurodevelopmental outcomes in preterm singleton neonates who were delivered by vaginal route (VR), CS with labour (CS-L), or CS without labour (CS-NL). METHODS: Singleton neonates of less than 29 weeks' gestation born January 1995 through December 2010 and admitted to our NICU and then assessed at neonatal follow-up clinic were studied. The primary outcome was neurodevelopmental impairment (NDI) defined as cerebral palsy, cognitive delay, major or minor visual impairment, or hearing impairment or deafness at 36 months' corrected age. RESULTS: In this retrospective cohort study of 1,452 neonates, 1,000 were eligible for the study and 881 (88.1%) were available for follow-up. There was no significant difference in mortality between VR group, CS-L group, and CS-NL group. At 3 years, there was no significant difference between the three groups in terms of NDI. The odds of composite outcome of mortality or NDI for neonates born via CS-NL versus VR, and CS-L versus VR were 0.90 (95% confidence interval [CI]: 0.59 to 1.37) and 1.08 (95% CI: 0.72 to 1.61), respectively. Propensity score-based matched-pair analyses did not show a significant association between the composite outcome and CS with or without labour. CONCLUSIONS: CS was not associated with increased survival or decreased risk of NDI in premature singleton neonates born at less than 29 weeks' gestation.

Stillbirth and large for gestational age at birth.

Aim: A previous large case-control study had documented association between large for gestational age birth weight and stillbirth. We sought to replicate this novel finding.Methods: Retrospective cohort with nested case-control analyses. The data source was a large Canadian perinatal database. Stillbirth was defined as no signs of life at delivery ≥23-weeks gestation. Small and large for gestational age at birth weights were defined using standard Canadian, American, and ultrasound norms.Results: The study population was comprised of 693,186 live births and 3275 stillbirths. Using population norms, large for gestational age (LGA) at birth was not associated with stillbirth in adjusted analysis (OR 0.57, 95% CI [0.45, 0.71]). A statistically significant interaction between pre-existing diabetes and LGA was observed (OR 2.48, 95% CI [1.20, 5.15]). Further case-control analysis found if ultrasound norms were used and controls were selected by date of delivery then LGA was associated with stillbirth (OR 1.91, 95% CI [1.64-2.22]). However, if controls were matched by gestational age at birth then the association was no longer apparent (OR 0.98, 95% CI [0.85-1.13]).Conclusions: Large for gestational age at birth is not associated with stillbirth in the general population. Previously reported association between LGA and stillbirth was likely an artifact of the sampling strategy. LGA may increase the risk of stillbirth in pregnancies complicated by pre-existing and gestational diabetes.

Temporal Summation in Chronic Pelvic Pain.

OBJECTIVE: This study sought to characterize central sensitization further among women with chronic pelvic pain by identifying temporal summation using a cotton-tipped applicator test that can be used at the bedside. METHOD: A total of 36 women (18 with chronic pain and allodynia; 18 without pain) were recruited. Both groups were randomly assigned to receive 3 strokes of a benign stimulus on the abdomen at differing frequencies: 10, 30, or 100 seconds. Each group included 6 women. Pain was assessed using a rating scale of 1 to 10. Data were analyzed using the multivariate approach to repeated measures analysis of variance. RESULTS: The pattern of pain scores differed significantly between women with and without chronic pain (P = 0.002). Women with chronic pelvic pain and allodynia showed a statistically significant increase in pain with successive strokes of the cotton-tipped applicator (P = 0.012 for stroke 1 vs. 2, P = 0.026 for stroke 2 vs. 3, and P = 0.005 for stroke 1 vs. 3). CONCLUSION: Women with chronic pelvic pain and allodynia showed significant worsening of pain with successive strokes of a cotton-tipped applicator. This finding indicates that pain wind-up and central sensitization are present in women with chronic pelvic pain and allodynia. Identification of summation is further evidence of neuroplasticity, which is helpful in innovative therapies for chronic pelvic pain.

A prospective study investigating the diagnostic agreement between urodynamics and dynamic cystoscopy in women presenting with mixed urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Patient history is often insufficient to identify type of urinary incontinence (UI). Multichannel urodynamic testing (UDS) is often used to clarify the diagnosis. Dynamic cystoscopy (DC) is a novel approach for testing bladder function. The primary objective of this study was to investigate the diagnostic agreement of UDS and DC in evaluating women with mixed urinary incontinence (MUI). METHODS: Women presenting with MUI were approached for enrollment if UDS and DC were planned for further investigation. Investigators were blinded to history and comparative test results. McNemar's test and kappa coefficient were calculated to assess agreement between UDS and DC. Receiver operating characteristic (ROC) analysis was used to explore the best possible filling sensation cutoffs for DC that would best predict the filling sensation cutoffs from UDS. RESULTS: Sixty participants were included, of whom, four were excluded for protocol violation. For the primary outcome measure of agreement, UDS and DC were concordant in 44/56 of stress urinary incontinence (SUI) cases (79%) with a κ= 0.54 and in 43/56 of urinary urge incontinence (UUI) cases (77%) with a κ= 0.54, indicating moderate, nearly substantial agreement. ROC analysis identified the best prediction of DC first urge to void as 148 cm3, strong urge 215 cm3, and maximum capacity at 246 cm3. These parameters were used to compare UDS UUI to DC UUI and resulted in a κ = 0.61 (p = 0.37), indicating substantial agreement. CONCLUSIONS: When compared with UDS, DC shows moderate agreement for detection of SUI and substantial agreement for detection of UUI.

Uterosacral vault suspension (USLS) at the time of hysterectomy: laparoscopic versus vaginal approach.

INTRODUCTION AND HYPOTHESIS: To compare laparoscopic and vaginal approaches to uterosacral ligament vault suspension (USLS) by perioperative data, short-term complications, rates of successful concomitant adnexal surgery and procedural efficacy. METHODS: Retrospective cohort of USLS procedures performed at the time of hysterectomy at a tertiary care center over a 3-year period. Patient demographics, surgical data, concomitant adnexal procedures and complications were abstracted from a surgical database and compared using parametric or non-parametric tests as appropriate. Validated questionnaires (POPDI-6, UDI-6, PROMIS) were used to collect information on recurrence and long-term complications. Patients were analyzed according to both intention-to-treat analysis based on the intended approach and the completed route of surgery to deal with intraoperative conversions. RESULTS: Two hundred six patients met the criteria for inclusion; 152 underwent vaginal USLS (V-USLS) and 54 laparoscopic USLS (L-USLS). No statistically significant differences in mean case time, postoperative length of stay or perioperative infection were found. While no ureteric obstructions occurred in the L-USLS group, in the V-USLS group 14 (9%) obstructions occurred (p = 0.023). Postoperative urinary retention was higher with V-USLS (31% vs. 15%, p = 0.024). Rates of successfully completed adnexal surgery differed (56% vs. 98%, p < 0.001) in favor of L-USLS. Patient-reported symptomatic recurrence of prolapse was higher in the V-USLS group (41% vs. 24%, p = 0.046); despite this, re-treatment did not differ between the groups (0% vs. 7%, p = 0.113). CONCLUSIONS: Perioperative case time and complications did not differ between approaches. However, rates of completed adnexal surgery were significantly higher in the laparoscopic group, which could influence surgical decisions concerning approaches to prolapse surgery.

Do preterm infants with a birth weight ≤1250 g born to single-parent families have poorer neurodevelopmental outcomes at age 3 than those born to two-parent families?

OBJECTIVE: Investigate neurodevelopmental outcomes at 3 years corrected age in infants with a birth weight ≤1250 g born to single parents. STUDY DESIGN: Infants born between 1995 and 2010 with a birth weight ≤1250 g were considered eligible. Primary outcome was neurodevelopmental impairment; considered present if a child had any of the following: cerebral palsy, cognitive delay, visual impairment, or deafness/neurosensory hearing impairment. Univariate and multivariate analyses were performed. RESULT: A total of 1900 infants were eligible for inclusion. Follow-up data were available for 1395; 88 were born to a single parent. Infants in the single-parent group had higher mortality (18% vs. 11%, p = 0.009), IQ ≥1 SD below the mean (40% vs. 21%, p = 0.001) and any neurodevelopmental impairment (47% vs. 29%, p = 0.003). Single-parent family status, maternal education, bronchopulmonary dysplasia and severe neurological injury were significant predictors of intellectual impairment at 3 years corrected age. CONCLUSION: Preterm infants with a birth weight ≤1250 g born to single parents at birth have poorer intellectual functioning at 3 years corrected age.