Is epidural analgesia an independent risk factor for OASIS? A population-based cohort study.

INTRODUCTION: To evaluate whether epidural analgesia is an independent risk factor for OASIS. METHODS: A population-based cohort study including all women who delivered by spontaneous vaginal delivery or by instrumental delivery beyond 24 weeks gestation was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. Women with multiple gestations and those lacking prenatal care were excluded from the analysis. RESULTS: During the study period, 252,542 women delivered at the Soroka University Medical Center and met the inclusion criteria. Of these, 583 (0.23%) were diagnosed with OASIS. Women with OASIS were more likely to be younger, nulliparous, with suspected fetal macrosomia, had higher rates of labor induction and vacuum extraction delivery, higher rates of conceiving after infertility treatments, more advanced gestational age at delivery, higher mean birth weight, higher rates of post-partum hemorrhage and need for blood transfusions. Use of epidural analgesia during pregnancy was significantly high among the OASIS group. Rates of episiotomy were not significantly different between the groups. Using a multimodal logistic regression model, after controlling for vacuum delivery, large for gestational age, nulliparity, gestational age, ethnicity, maternal age, induction of labor, fertility treatments, non-reassuring fetal heart rate and non-progressive second stage of labor, epidural analgesia was found to be significantly associated with OASIS. CONCLUSION: Epidural analgesia was found to be an independent risk factor for OASIS in our population.

Condition-specific validation of the Arabic version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) among parturient.

INTRODUCTION AND HYPOTHESIS: Pregnancy and mode of delivery have a major effect on pelvic floor disorders (PFD). Assessing knowledge regarding PFD is essential not only for making more informed decisions regarding mode of delivery, but also for seeking help when PFD appear. The Prolapse and Incontinence Knowledge Questionnaire (PIKQ) is a validated tool that assesses women's knowledge regarding urinary incontinence (UI) and pelvic organ prolapse (POP). Validation of the Arabic version of the PIKQ had never been carried out. The purpose of this study was to conduct a condition specific validation among parturients of the PIKQ in the Arabic language. METHODS: Translation of the PIKQ to the Arabic language was carried out according to international recommended guidelines. A cross-sectional study of pregnant women was conducted from June to September 2020 at the Soroka University Medical Center, Israel. The recommended 10:1 ratio between the number of subjects and the number of items in the questionnaire (n=24) was maintained. A total of 244 third trimester pregnant women have completed the Arabic version of the PIKQ. In addition to the validation of the psychometric characteristics, construct validity, criterion validity, and reliability were tested as well. RESULTS: Initially, exploratory factor analysis (EFA) was conducted, resulting in two 12-item scales representing UI and POP. Then, to validate the scale construct we conducted confirmatory factor analysis (CFA). Results of the CFA demonstrated that the PIKQ displayed construct validity, with standardized factor loadings ranging from 0.30 to 0.62. Finally, Cronbach's alpha indicated a good internal reliability for the two factors UI and POP. Criterion validity further supported the validity of the scale. CONCLUSIONS: The Arabic version of the PIKQ is a new, reliable, consistent, and valid instrument to examine the level of knowledge regarding UI and POP in Arabic speaking pregnant women. This instrument may be used to assess women's knowledge about PFD and to direct the need for educational interventions that may empower women to make informed decisions regarding perinatal care.

Knowledge of women during the third trimester of pregnancy regarding pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: The objective was to examine knowledge regarding pelvic floor disorders (PFDs) among women during the third trimester of pregnancy. METHODS: A cross-sectional study was conducted at a large teaching medical center in Israel between June and September 2020. Women in their third trimester (N = 649) were asked to complete the validated Hebrew and Arabic versions of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). The PIKQ instrument examines the knowledge of two major PFDs: urinary incontinence (UI) and pelvic organ prolapse (POP). The study population included women over 18 years of age, in the third trimester, who speak and read Hebrew or Arabic fluently. Two separate scores were calculated, one for each section of the PIKQ. The association of questionnaire scores with the different independent variables was examined using Student's t test or one-way ANOVA. Correlations were examined using Pearson's or Spearman's correlation coefficient. RESULTS: The Hebrew version was filled out by 405 women, and 244 women completed the Arabic version. The average questionnaire scores were 7.65 ± 2.8 and 5.32 ± 2 for the UI and POP sections respectively. Significantly higher average scores in both the UI and the POP sections were noted among health care workers (UI: 10.19 ± 2.3 vs 7.34 ± 2.6, p < 0.001; POP: 8.27 ± 2.7 vs 4.97 ± 2.6, p < 0.001), women with higher education (p < 0.001 in both parts) and those with higher incomes (p < 0.001 for both parts). CONCLUSIONS: Knowledge of PFD among women in the third trimester of pregnancy in Israel was found to be low. Founding educational programs for targeted groups may improve both the knowledge of PFD and the quality of life for these women.

Validation of the hebrew version of the prolapse and incontinence knowledge questionnaire (PIKQ) during pregnancy.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery have a major effect on pelvic floor disorders. Assessing knowledge regarding pelvic floor disorders in childbearing age women and appropriate interventions will enable women to seek appropriate medical advice once pelvic floor disorders have developed. The purpose of this study was to validate the prolapse and incontinence knowledge questionnaire in the Hebrew language. METHODS: Translation of the prolapse and incontinence knowledge questionnaire to the Hebrew language according to international recommended guidelines. A study was conducted to validate the questionnaire. The study took place between June to September 2020 in a tertiary medical center in Israel. A total of 240 third trimester pregnant women completed the Hebrew version of the prolapse and incontinence knowledge questionnaire. Construct validity, criterion validity and reliability tests were performed. RESULTS: Factor analysis of the Hebrew version of the prolapse and incontinence knowledge questionnaire demonstrated 12 strong positive factor loadings to one principal factor in the prolapse and incontinence knowledge questionnaire-pelvic organ prolapse domain (FL > 0.3) and 10/12 in the prolapse and incontinence knowledge questionnaire-urinary incontinence domain. The Hebrew prolapse and incontinence knowledge questionnaire was found to have internal consistency, with Cronbach alpha coefficient of 0.745 for the urinary incontinence domain and 0.796 for the pelvic organ prolapse domain. CONCLUSIONS: The Hebrew version of the prolapse and incontinence knowledge questionnaire is a new, reliable, consistent, and valid instrument to examine the level of knowledge regarding pelvic floor disorders in Hebrew-speaking pregnant women.

Is there a correlation between pelvic floor dysfunction symptoms during pregnancy and the duration of the second stage of labor?

BACKGROUND: Pelvic floor dysfunction (PFD) most commonly results from weakened or injured muscles and ligaments whose purpose is to support the pelvic floor. Many studies have placed vaginal delivery and prolonged second stage of labor (SSL) as major risk factors for PFD, supposedly through generating enhanced pressure in the pelvic area. Although many studies describe the effects of vaginal delivery and labor on structure and function of the pelvic floor, not much is known regarding PFD deriving from pregnancy and its prevalence and severity in the postpartum. We aimed to evaluate whether a correlation exists between PFD symptoms during pregnancy and the duration of the SSL. METHODS: We conducted a cross sectional study of 200 women who gave birth at Soroka University Medical Center, Beer-Sheva, Israel. Those who had consented completed the Pelvic Floor Distress Inventory-20 (PFDI-20), a condition specific questionnaire developed to measure quality-of-life and the extent of injury to the pelvic floor in women with all forms of PFD. The duration of the SSL and clinical and obstetrical characteristics were retrieved from the participants' medical records. We assessed correlations using Spearman's correlation coefficient. RESULTS: PFD during pregnancy was found to be correlated to the duration of the SSL (R = -0.183, p = .021). When evaluating each component of the PFDI-20 separately, CRAD was significantly correlated with the duration of the SSL (R = -0.195, p = .014). CONCLUSIONS: There is a correlation between PFD symptoms during pregnancy, specifically symptoms of CRAD and the duration of the SSL.

Adhesion barriers and topical hemostatic agents are risk factors for post-cesarean section infections.

BACKGROUND: Cesarean sections are the most common surgery worldwide, and post-cesarean section infections and hemorrhage are a major cause for morbidity and mortality. In recent years, many surgeons use adhesion barriers as well as hemostatic agents during primary and repeated cesarean section. The data regarding the safety of these agents is relatively limited. The objective of this study was to investigate whether the use of adhesion barriers and topical hemostatic agents pose a risk for post-cesarean section infections. METHOD: A case-control study composed of women who were admitted to the Soroka University Medical Center between the years 2012 and 2016 was conducted. The study group was composed of women admitted owing to post-cesarean section infections (cases) and those who underwent cesarean sections without post-cesarean section infection (control subjects). Matching was done according to date and surgery setting (elective versus emergency). A univariate analysis was followed by a multiple regression model in order to examine the association between adhesion barriers/hemostatic agents and post-cesarean section infections. RESULTS: During the study period, 113 patients developed postoperative infection (cases); 71.7% were diagnosed with surgical site infection, 7.1% with endometritis, and 21.2% with other infections. These were compared with 226 control subjects. In the univariate analysis, the use of adhesion barriers/hemostatic agents were found to be associated with post-cesarean section infection. Using a multivariable analysis controlling for previous cesarean section, skin closer technique, preterm delivery, and duration of surgery >60 minutes, the use of adhesion barriers as well as hemostatic agents was found to be independently associated with post-cesarean section infection (adjusted odds ratio = 2.11, 95% confidence interval = 1.17-3.84; adjusted odds ratio = 2.29, 95% confidence interval = 1.37-3.8, respectively) CONCLUSION: Adhesion barriers and hemostatic agents were found to be independently associated with post-cesarean section infections. Further larger studies are needed to reinforce our findings. The use of these materials should be carefully considered, and their cost-effectiveness re-examined.

Temporal decline in the improved detection rates following OASIS workshops.

INTRODUCTION AND HYPOTHESIS: To evaluate the long-term sustainability of the effect of a hands-on workshop on the diagnosis of deliveries complicated by obstetrical anal sphincter injuries (OASIS). METHODS: A population-based retrospective cohort study looking over a 4-year period, 1 year before and 3 years after an OASIS workshop. All deliveries that took place at the Soroka University Medical Center during the study period were included. Data were collected from the obstetrical electronic database. Interrupted time series analysis assessing the change in the OASIS detection rate over time from the workshop was conducted, assuming that the OASIS rate remained constant during the study period. RESULTS: During the study period, 147 parturients suffered from OASIS. The baseline characteristics of the patients before and after the workshop did not differ. In the year following the workshop a significant increase in the detection rate was noted compared with the year prior to the workshop. In an interrupted time series analysis, the improved detection rate declined with time. In the last year following the workshop the detection rate declined, almost reaching the pre-workshop rate. CONCLUSIONS: Attending an OASIS workshop increases the detection rate in the year following the workshop but declines gradually. To maximize its benefits, the workshop must be repeated periodically.

Early prediction of post cesarean section infection using simple hematological biomarkers: A case control study.

OBJECTIVE: We aimed to investigate whether the neutrophil to lymphocyte ratio (NLR) may assist in the prediction of post CS infections. STUDY DESIGN: This was a case control study performed at the Soroka University Medical Center, a large tertiary teaching medical center, between the years 2012-2016. Cases (post CS infection) were matched to controls (without post CS infection) in a proportion of 2:1. Matching was done according to surgery setting (elective vs. urgent) and date of surgery. Various demographic, clinical and obstetrical characteristics were collected. Laboratory tests that were taken 6-24 h postoperatively were compared between the study groups. Univariate analysis was followed by a multivariate one. Area under the curve was calculated for selected indices. RESULTS: During the study period 113 patients who developed postoperative infection were compared with 224 healthy controls. Among patients in the study group, 71.7 % were diagnosed with surgical site infection, 7.1 % with endometritis and 21.2 % with other infections. Total neutrophil and lymphocyte counts were significantly higher among patient in the study group. NLR as well as platelet to lymphocyte (PLR) ratio were significantly higher among patients during the first 24 postoperative hours. NLR and PLR were found to be independently associated with post CS infection controlling for surgery length, use of hemostatic agents/adhesion barrier and skin closure technique (aOR 1.11 95 % CI 1.06-1.17, aOR 1.004 95 % CI 1.001-1.006, respectively). A performance analysis for NLR showed an area-under-the receiver operating curve (AUC) of 67 % (P = 0.006). CONCLUSION: NLR is an easy readily available tool that may have a predictive value in early detection of post CS infection. Further studies are needed in order to support our findings before clinical implications of these findings can be recommended.

Recovery from pelvic floor dysfunction symptoms in the postpartum is associated with the duration of the second stage of labor.

PURPOSE: Pregnancy and labor are known risk factors for pelvic floor dysfunction (PFD). Yet not much is known regarding recovery from PFD. We hypothesized that the recovery from PFD during the postpartum period would be associated with the duration of the second stage of labor (SSL). METHODS: We conducted a case-control study of patients who gave birth at the Soroka University Medical Center, Beer-Sheva, Israel. Those who consented completed the Pelvic Floor Distress Inventory-20 (PFDI-20), a questionnaire developed to measure the extent of injury to the pelvic floor, after delivery and 3-month postpartum. The difference between the scores was calculated, representing recovery of symptoms. The duration of the SSL, and clinical and obstetrical characteristics were retrieved from the patients' medical records. Wilcoxon rank test was used, assessing the significance of the recovery. The association between the degree of the recovery and the duration of SSL was tested using Mann-Whitney ranking. RESULTS: A total of 92 patients completed the PFDI-20 after delivery and 3-month postpartum. We found a significant difference between PFD symptoms during pregnancy and 3-month postpartum (P < 0.001). This difference remained consistent in all components of the PFDI-20. In addition, a more profound recovery of colorectal and anal dysfunction (CRAD) symptoms was associated with a shorter duration of the SSL (P = 0.03). CONCLUSIONS: There is a statistically significant recovery of PFD symptoms in the postpartum period. Furthermore, greater recovery from CRAD symptoms is associated with a shorter duration of the SSL.

Prevalence and risk factors for urinary tract infection following stress urinary incontinence surgery with two midurethral sling procedures.

OBJECTIVE: To compare prevalence and risk factors for urinary tract infection (UTI) following midurethral sling surgery with either the GYNECARE ABBREVO Continence System (Ethicon, Somerville, NJ, USA) or a standard transobturator. METHODS: A retrospective cohort study was conducted among women who underwent midurethral sling surgery to treat stress urinary incontinence at a single tertiary hospital in Israel between January 1, 2014, and August 11, 2015. Data were retrieved from medical records. The diagnosis of UTI was based on a positive urine culture result. RESULTS: Of 178 patients included, 30 (16.9%) underwent the ABBREVO procedure and 148 (83.1%) underwent the standard transobturator procedure. The mean ± SD BMI at the time of surgery was 28.1 ± 4.5 for the standard transobturator procedures and 30.7 ± 15.2 for the ABBREVO procedures. Women who underwent the ABBREVO procedure had an increased duration of hospitalization (P=0.004), and higher rates of concomitant anterior colporrhaphy procedures (P=0.009) and concomitant hysterectomy (P=0.009). Only 38 (21.3%) women developed UTIs within 12 months of surgery (seven in the ABBREVO procedure group and 31 in the standard transobturator procedure group). No statistically significant between-group differences were found for the risk of UTI or for urinary tract adverse events, such as recurrent UTI and the need for rehospitalization. CONCLUSIONS: The two procedures were comparable in terms of prevalence and risk factors for UTI during the postoperative period.

Prevalence and risk factors for urinary tract infection up to one year following midurethral sling incontinence surgery.

OBJECTIVE: To investigate the prevalence and risk factors of urinary tract infection (UTI) one year following sub-midurethral sling (SMUS) incontinence surgery in a university affiliated medical center in southern Israel. METHODS: A retrospective cohort study was conducted to identify and characterize patients who suffered UTI within a year following SMUS surgery. The study population comprised of all patients who underwent a SMUS surgery between the years 2014 and 2015. Demographic and clinical data were retrieved from the patients' medical records, and a comparison between patients with and without a positive urine culture was performed. RESULTS: During the study period, there were 178 SMUS surgeries. Urine culture positive UTI was noted in 21% (38 patients) within the first year following surgery. The mean age and BMI of patients complicated with UTI was 64.8 and 29.1, respectively. The most common pathogen found in urine culture was E. coli that accounted for 55% of all UTIs. When comparing patients with and without UTI, no significant difference was noted in the pre- and intra-operative characteristics. However, duration of hospitalization and readmissions in the first year following surgery, were significantly associated with the risk of UTI (p < 0.026 and p < 0.003, respectively). CONCLUSIONS: Approximately one in every five women undergoing a SMUS operation in our population will suffer from UTI within a year from surgery. A significant association was found between the duration of hospitalization and readmissions in the first postoperative year and suffering from UTI.

Validation of the Hebrew version of the short form of the Urogenital Distress Inventory (UDI-6).

INTRODUCTION AND HYPOTHESIS: The urogenital distress inventory (UDI-6) is a simple questionnaire assessing quality of life (QoL) among patients with urinary incontinence. Despite widespread use in Israel, linguistic validation of this tool has not yet included examination of the psychometric characteristics of this instrument in the Hebrew language. The purpose of this study was to validate the psychometric characteristics of the UDI-6 in the Hebrew language. METHODS: A cross-sectional study was conducted from April to June 2016 using the recommended ratio of 10:1 between the number of subjects and the number of items in the questionnaire. A Hebrew version of the UDI-6 was given to a sample of 60 women with urinary incontinence. Internal consistency, validity, and test-retest reliability were evaluated. RESULTS: UDI-6 showed internal consistency with Cronbach's alpha coefficient of 0.637. The kappa coefficient for test-retest reliability of the UDI-6 ranged from 0.845 to 0.606. CONCLUSIONS: The Hebrew version of UDI-6 showed adequate reliability, consistency and validity for measuring symptoms and QoL in women with urinary incontinence.

Fetal heart rate monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis.

OBJECTIVE: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2. MATERIALS AND METHODS: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders. RESULTS: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis. CONCLUSION: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2.

Prevalence and trends of pelvic floor disorders in late pregnancy and after delivery in a cohort of Israeli women using the PFDI-20.

OBJECTIVE: To investigate the prevalence of pelvic floor disorders (PFD) in a cohort of Israeli women at late pregnancy and three months postpartum, to define changes in PFD rates and to evaluate various obstetrical factors that may correlate with these changes. METHODS: A prospective longitudinal cohort study was conducted between March and July 2014. The PFDI-20 questionnaire (validated in the Hebrew language) was used to evaluate pelvic floor distress symptoms 24h and 3 months after delivery (representing the third trimester and post-partum period, respectively). Patients with a preterm delivery (<36 completed weeks of gestation), delivery of a stillbirth, non-fluency in Hebrew and patients with inability to complete the questionnaire due to a communication problem were excluded from the study. In addition to the PFDI results demographic and clinical data were collected from the patients' medical records. Routine statistical methods were used to interpret the results. RESULTS: During the study period 117 women answered the first questionnaire and only 37 had filled the second questionnaire. The most prevalent item group reported in the third trimester was the urinary distress symptoms. Urinary frequency was the most common with 65% of patients reporting this symptom. At the post-partum period the most prevalent item group reported was the colorectal and anal distress with 31.5% of patients reporting increased straining efforts. There was a mixed trend in the changes noted between the two questionnaires. While some items improved in the puerperium as compared with late pregnancy others have worsened. In a multivariable analysis the only statistically significant finding was that at the post-partum follow-up, stress urinary incontinence was significantly associated with spontaneous perineal tears at delivery. Other obstetrical parameters including episiotomy and birth weight were not found to be significantly associated with any of the PFD items. CONCLUSION: We have demonstrated that PFD is prevalent both in late pregnancy and in the puerperium. There are mixed trends of spontaneous recovery following childbirth. A significant association between perineal tears and SUI 3 months after delivery was noted.