The association of preconceptional folic acid supplementation with gestational age and preterm birth risk in twin pregnancies: a prospective cohort study in China.

PURPOSE: This study aims to explore the association of maternal preconceptional folic acid (FA) supplementation with gestational age and preterm birth in twin pregnancies, and whether the association varies by chorionicity or conception mode. METHODS: From November 2018 to December 2021, the information of FA supplementation and pregnancy outcomes were collected in twin pregnant women. The linear regression models and the logistic regression were used to test the association of preconceptional FA supplementation with gestational age at delivery and preterm birth and premature rupture of membranes (PROM). RESULTS: A total of 416 twin pregnancies were included. Compared with no use in twins, maternal preconceptional FA use was associated with a 0.385-week longer gestational age (95% CI 0.019-0.751) and lower risk of preterm birth < 36 weeks (adjusted OR 0.519; 95% CI 0.301-0.895) and PROM (adjusted OR 0.426; 95% CI 0.215-0.845). The protective effect on preterm birth < 36 weeks and PROM is similar whether taking FA supplements alone or multivitamins. However, the associations varied by chorionicity and conception mode of twins or compliance with supplementation. The positive associations between preconceptional FA use and gestational age only remained significant among twins via assisted reproductive technology or dichorionic diamniotic twins. Significant protective effects on preterm birth < 36 weeks and PROM were only found among women who took FA at least 4 times a week before conception. CONCLUSION: Maternal preconceptional FA supplementation was associated with longer gestation duration and lower risk of preterm birth < 36 weeks and PROM in twin pregnancies. To improve the success of their pregnancies, reproductive women should start taking FA supplements well before conception and with good compliance.

Partner support for women's antidepressant treatment and its association with depressive symptoms in pregnant women, mothers, and women planning pregnancy.

PURPOSE: To examine the association between partner support for women's antidepressant treatment and depressive symptoms in pregnant women, those planning pregnancy, and mothers who ever used antidepressants. METHODS: We included 334 women (n=44 planners, n=182 pregnant, n=108 mothers) ever treated with antidepressants within the HEALTHx2 study, a web-based cross-sectional study conducted across Norway in June 2020 to June 2021. The Edinburgh Postnatal Depression Scale and two questions of the Patient Health Questionnaire measured depressive symptoms, by degree of severity and for depressed mood, anxiety, and anhedonia sub-dimensions. Partner support was measured using one item from the Antidepressant Compliance Questionnaire. Association was estimated via unadjusted and adjusted linear and logistic regression models. RESULTS: Being unsupported by the partner was associated with increased odds of reporting moderate-to-very-severe depressive symptoms in mothers (adjusted odds ratio (aOR), 3.57; 95% confidence interval (CI), 1.04-12.19) and pregnant women (aOR, 3.26; 95% CI, 0.95-11.14), relative to being supported. Pregnant women (adjusted mean difference (ß), 0.76; 95% CI, 0.14-1.38) and mothers (ß, 0.93; 95% CI, 0.23-1.64) with no support for their antidepressant treatment presented greater symptoms of anhedonia; for women planning pregnancy, this association emerged in relation to anxiety symptoms (ß among non-users of antidepressant, 2.58; 95% CI, 1.04-4.13). CONCLUSIONS: Partner support for women's antidepressant treatment may play a key role in depressive symptoms severity and the subtypes of anhedonia and anxiety, among women planning pregnancy, pregnant women, and mothers. This highlights the importance of partner inclusion in the complex decision-making process for antidepressant treatment around the time of pregnancy.

Exploring maternal and neonatal outcomes in women with Type-1 Diabetes: A study from Pakistan.

Background & Objective: Pregnancy in women diagnosed with Type-1 diabetes mellitus poses a higher risk of experiencing complications related to the health of the fetus, the mother, and the newborn, along with potential obstetric issues. The objective of this study was to examine the maternal and fetal outcomes, as well as complications faced by pregnant women with type-1 diabetes, and to identify potential preventable factors. Methods: This retrospective cohort study, conducted at Baqai Institute of Diabetology and Endocrinology (BIDE), Baqai Medical University, Karachi, Pakistan (January 2022 - January 2023), focused on registered pregnancies of women with Type-1 diabetes. A predesigned questionnaire recorded demographic information, diabetes and obstetric history, clinical details, treatment specifics, maternal, perinatal, and neonatal outcomes. Results: This study included 100 women with pre-existing Type-1 diabetes (mean age: 15.11 ± 5.64 years at diabetes diagnosis). Of these, 72% reported unplanned pregnancies, with a mean HbA1C at conception 8.29%. Median gestational age at delivery was 32.15 ± 10.82 weeks. Delivery outcomes included 40% normal vaginal deliveries and 60% C-sections (9% emergency, 51% elective). Stillbirths occurred in 14 cases, while 16 women experienced one miscarriage, seven had two, and 10 had three miscarriages. Glycemic targets (fasting) were achieved in 55 women, and post-meal targets only in 29, whereas, neonatal complications included hypoglycemia in 13 and low birth weight in 12 neonates. Conclusion: The high frequency of unplanned pregnancies and cesarean sections along with poor management of pre-pregnancy care and poor glycemic control results in compromised maternal and perinatal outcomes in this high-risk group.

[Women with epilepsy before and during pregnancy: a case series of outpatient counseling in a tertiary epilepsy center]. / Frauen mit Epilepsie: Wie erfolgt die Beratung bei Kinderwunsch und in der Schwangerschaft? ­ Eine Fallserie aus einer spezialisierten Epilepsieambulanz.

BACKGROUND: Data of large pregnancy registries have improved the recommendations for women with epilepsy before pregnancy. Monotherapy containing antiepileptic drugs with a low malformation rate (lamotrigine or levetiracetam) is recommended as well as preconceptional folic acid supplementation, while valproic acid should be avoided. The practicability of these recommendations remains controversial. METHODS: Retrospective case series of 160 women with epilepsy over a period of 5 years who were advised in our outpatient department before and during pregnancy. RESULTS: Only 18.9% of women presented with valproic acid. Even without valproic acid, complications or emergency admissions rarely occurred under specialist supervision. In our case series, lamotrigine proved to be less effective and less controllable than other drugs during pregnancy. Levetiracetam also has a low malformation rate, but showed a better effect on seizure outcome during pregnancy than lamotrigine. Only 12% of women who wanted to have children took folic acid. CONCLUSION: This case series comes from a tertiary center; the referred women were mainly accompanied by neurologists with special expertise in epileptology. In this group valproate could be avoided in most cases. Lamotrigine is probably less effective due to the drop in blood levels during pregnancy. Levetiracetam seems to be a good alternative, working well against focal and generalized seizures. Folic acid may be taken later than recommended.

Preconceptional diet quality is associated with birth outcomes among low socioeconomic status minority women in a high-income country.

PURPOSE: Studies of the association between maternal nutrition and birth outcomes have investigated differing nutrients, maternal socioeconomic conditions, and timing within the reproductive cycle; and have produced inconsistent results. We evaluated the association of preconceptional maternal dietary intake with birth outcomes among low socioeconomic status ethnic minority women in a high-income country. METHODS: In this prospective cohort study, habitual preconceptional dietary intake was assessed among pregnant Bedouin Arab women in Israel (n = 384), using a short culturally specific, targeted food frequency questionnaire. Multiple nutrients (protein, lysine, calcium, iron, zinc, folate, omega-3 fatty acids) were evaluated simultaneously via a diet quality score derived from principal component analysis. Multivariable logistic regression was used to test associations between the diet quality score and a composite adverse birth outcomes variable, including preterm birth, low birth weight and small for gestational age. RESULTS: Sixty-nine women (18%) had adverse birth outcomes. Women with low preconceptional diet quality scores had low intakes of nutrient-rich plant foods, bioavailable micronutrients, and complete proteins. In multivariable analysis, a woman at the 10th percentile of the diet quality score had a 2.97 higher odds (95% CI 1.28-6.86) of an adverse birth outcome than a woman at the 90th percentile. CONCLUSION: Low diet quality during the preconceptional period was associated with adverse birth outcomes among low socioeconomic status minority women in a high-income country. The results have implications for the development of appropriate intervention strategies to prevent adverse birth outcomes, and the promotion of adequate nutrition throughout the child-bearing years.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

Preconceptional and prenatal exposure to diurnal temperature variation increases the risk of childhood pneumonia.

BACKGROUND: Pneumonia is the leading cause of death and hospitalization among young children worldwide, but its risk factors remain unclear. OBJECTIVE: To evaluate the effect of maternal exposure to diurnal temperature variation (DTV) during preconceptional and prenatal periods on childhood pneumonia. METHODS: A retrospective cohort study by case-control design was conducted for pneumonia (N = 699) and normal (N = 811) children under age of 14 who were enrolled in XiangYa Hospital, Changsha, China from May 2017 to April 2019. Demographic data including gender, age, birth season, gestational age, parity, mode of delivery, and parental atopy were collected from the electronic medical records in the hospital system. We obtained the data of daily DTV in Changsha during 2003-2019 from China Meteorological Administration. Maternal exposure to DTV during preconceptional and prenatal periods was respectively calculated by the average of daily DTV during one year and three months before conception and entire pregnancy as well as the three trimesters. The association between maternal exposure to outdoor DTV and childhood pneumonia was analyzed by multiple logic regression model. RESULTS: We found that childhood pneumonia was significantly associated with exposure to an increase in DTV during one year before conception and entire pregnancy, with ORs (95 % CI) = 2.53 (1.56-4.10) and 1.85 (1.24-2.76). We further identified a significant risk of pneumonia of DTV exposure during the first and second trimester of pregnancy. Sensitivity analysis showed that boys were more susceptible to the effect of prenatal exposure to outdoor DTV during pregnancy particularly in the first two trimesters compared to girls. CONCLUSIONS: Preconceptional and prenatal exposure to DTV plays an important role in development of childhood pneumonia, especially during the first and second trimesters of pregnancy.

Preconceptional and prenatal exposure to air pollution increases incidence of childhood pneumonia: A hypothesis of the (pre-)fetal origin of childhood pneumonia.

BACKGROUND: Increasing evidence has linked childhood pneumonia with early exposure to ambient air pollution. However, the impact of exposure to air pollutants before birth is unclear. OBJECTIVE: To further clarify whether exposure to a particular pollutant during preconceptional and prenatal periods, may pose a higher risk of developing childhood pneumonia. METHODS: This case-control cohort study consisted of 1510 children aged 0-14 years in Changsha, China between 2017 and 2019. Data of children's history of pneumonia and blood biomarkers were obtained from the XiangYa Hospital records. Each child's exposure to air pollutants, including nitrogen dioxide (NO2), sulfur dioxide (SO2), and particulate matter with an aerodynamic diameter ≤ 10 µm (PM10), was calculated using data from ten air pollution monitoring stations. A multivariate logistic regression model was used to quantify the relationship between childhood pneumonia and exposure to ambient air pollution during the preconceptional and prenatal periods. RESULTS: Childhood pneumonia was significantly associated with preconceptional and prenatal exposure to the industrial-related air pollutant, SO2, for 1 year before conception, for 3 months before conception and for the entire pregnancy, with ORs(95% CI)= 4.01(3.17-5.07), 4.06(3.29-5.00) and 6.51(4.82-8.79). Also, children who were sick with pneumonia had higher white blood cell and neutrophil counts, and children with low eosinophil count or hemoglobin are likely to get pneumonia. Sensitivity analysis showed that boys, and children in high temperature area were susceptible to the effect of both preconceptional and prenatal exposure to industrial SO2. CONCLUSION: Preconceptional and prenatal exposure to industrial-related air pollution plays a significant role in the incidence and progression of childhood pneumonia, supporting the hypothesis of "(pre-)fetal origin of childhood pneumonia".

Effects of Malaria in the First Trimester of Pregnancy on Poor Maternal and Birth Outcomes in Benin.

BACKGROUND: In sub-Saharan Africa, malaria in the first half of pregnancy is harmful for both the mother and her fetus. However, malaria in the first trimester of pregnancy, when women are usually not protected against malaria, has been little investigated. For the first time, we assessed the effects of malaria in the first trimester on maternal and birth outcomes using a preconceptional study design. METHODS: From June 2014 to March 2017, 1214 women of reproductive age were recruited and followed monthly until 411 became pregnant. The pregnant women were then followed from 5-6 weeks of gestation until delivery. Path analysis was used to assess the direct effect (ie, not mediated by malaria in the second or third trimester) of malaria in the first trimester on maternal anemia and poor birth outcomes. The cumulative effect of infections during pregnancy on the same outcomes was also evaluated. RESULTS: The prevalence of malaria infections in the first trimester was 21.8%. Malaria in the first trimester was significantly associated with maternal anemia in the third trimester (adjusted odds ratio 2.25, 95% confidence interval 1.11-4.55). While we did not find evidence of any direct effect of first trimester malaria infections on birth outcomes, their association with infections later in pregnancy tended to increase the risk of low birth weights. CONCLUSIONS: Malaria infections in the first trimester were highly prevalent and have deleterious effects on maternal anemia. They highlight the need for additional preventive measures, starting in early pregnancy or even before conception.

Preconceptional paternal antiepileptic drugs use and risk of congenital anomalies in offspring: a nationwide cohort study.

Recent studies have shown that certain pharmacological agents used by fathers before conception may increase the risk of adverse neonatal outcomes in offspring. However, little is known about the effect of paternal use of antiepileptic drugs (AEDs) on congenital anomalies in children. Based on Danish national registers, we conducted a cohort study of 733, 282 singletons born from 1997 to 2008, with follow-up throughout 2013. The children whose fathers used AEDs during the 3 months before conception were categorized as the exposed. Logistic regression model was used to examine association between paternal AEDs use before conception and the risk of congenital anomalies in offspring. Compared with unexposed children, the exposed had a 23% increased risk of congenital anomalies (odds ratios (OR) 1.23, 95% confidence interval [CI] 1.10-1.37) after adjusting for potential confounders. When extending the exposure window to 1 year before conception to the end of pregnancy, except for those using AEDs during 3 months before conception (the susceptible period of exposure), the increased risks were also observed in children whose fathers were former users (i.e., those using AEDs only from 1 year to 3 months before conception) (OR 1.29, 95%CI 1.03-1.61) and later users (i.e., those using AEDs only during pregnancy) (OR 1.35, 95%CI 1.12-1.65). This study suggested that the mildly increased risk of congenital anomalies in the offspring associated with paternal AEDs use before conception may be attributable to the underlying indications related to AEDs use.

Dietary and lifestyle predictors of folate insufficiency in non-supplemented German women.

Low folate status is a risk factor for birth defects. We studied concentrations of red blood cell (RBC)- and serum folate in 198 German women in relation to information on dietary folate intake, demographic and lifestyle factors. Median serum- and RBC-folate levels were; (14.7 and 589 nmol/L, respectively. Serum < 7.0 nmol/L or RBC-folate < 405 nmol/L were observed in 3.5% and 18.7% of the women, respectively. Three per cent of the women had both lowered serum and RBC-folate. Whereas RBC-folate > 952 nmol/L (optimal levels around conception) were observed in 9.6%. Serum- and RBC-folate were positively associated; they showed the expected correlations with homocysteine, but only weak correlations with folate intake. Younger age, lower fibre and higher carbohydrate intakes were associated with lower blood folate. Thus, folate intake of approximately 278 µg/d was not sufficient to achieve optimal folate status in young women. In conclusion, in the absence of fortification with folic acid, the majority of the women did not achieve folate status that is optimal for prevention of birth defects.

Surgical variance between postconceptional and preconceptional minimally invasive transabdominal cerclage placement.

Recent data show that transabdominal cerclage placement via laparoscopy carries better obstetrical outcomes in comparison to transabdominal cerclage placement via laparotomy. In this surgical tutorial, we review the technique for minimally invasive abdominal cerclage and highlight the surgical differences between preconceptional and conceptional cerclage.

The effectiveness of daily supplementation with 400 or 800 µg/day folate in reaching protective red blood folate concentrations in non-pregnant women: a randomized trial.

PURPOSE: Folate required to achieve desirable red blood cell (RBC) folate concentrations within 4-8 weeks pre-pregnancy is not known. We studied the effect of supplementation with 400 or 800 µg/day folate in achieving RBC-folate ≥906 nmol/L. METHODS: Non-pregnant women were randomized to receive multinutrient supplements containing 400 µg/day (n = 100) or 800 µg/day (n = 101) folate [folic acid and (6S)-5-CH3-H4folate-Ca (1:1)]. The changes of folate biomarkers were studied after 4 and 8 weeks in the 198 women who returned at least for visit 2. RESULTS: At baseline, 12 of the 198 participants (6.1%) had RBC-folate <340 nmol/L, but 88% had levels <906 nmol/L. The RBC-folate concentrations increased significantly in the 800 µg/day (mean ± SD = 652 ± 295 at baseline; 928 ± 330 at 4 weeks; and 1218 ± 435 nmol/L at 8 weeks) compared with the 400 µg/day [632 ± 285 at baseline (p = 0.578); 805 ± 363 at 4 weeks (p < 0.001); 1021 ± 414 nmol/L at 8 weeks (p < 0.001)]. The changes of RBC-folate were greater in the 800 µg/day than in the 400 µg/day at any time (changes after 8 weeks: 566 ± 260 vs. 389 ± 229 nmol/L; p < 0.001). Significantly more women in the 800 µg group achieved desirable RBC-folate concentrations at 4 weeks (45.5 vs. 31.3%; p = 0.041) or 8 weeks (83.8 vs. 54.5%; p < 0.001) compared with the 400 µg group. RBC-folate levels below the population median (590 nmol/L) were associated with a reduced response to supplements. CONCLUSIONS: 88% of the women had insufficient RBC-folate to prevent birth defects, while 6.1% had deficiency. Women with low RBC-folate were unlikely to achieve desirable levels within 4-8 weeks, unless they receive 800 µg/day. The current supplementation recommendations are not sufficient in countries not applying fortification. TRIALS REGISTER: The trial was registered at The German Clinical Trials Register: DRKS-ID: DRKS00009770.

Exposure to air pollution during preconceptional and prenatal periods and risk of hypertensive disorders of pregnancy: a retrospective cohort study in Seoul, Korea.

BACKGROUND: Previous studies suggested associations between prenatal exposure to air pollution and hypertensive disorders of pregnancy. We explored the associations between ambient concentrations of five major air pollutants during preconceptional and prenatal periods and three hypertensive disorders of pregnancy in Seoul, Korea, using a population-representative cohort. METHODS: We obtained heath and demographic data of pregnant women residing in Seoul for 2002-2013 from the Korean National Health Insurance Service-National Sample Cohort. For mother's individual exposures to air pollution, we computed concentrations of particulate matter ≤10 µm in diameter (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), sulfur dioxide (SO2), and ozone (O3) during 1, 3, 6, and 12 months to birth using regulatory monitoring data in Seoul. The associations between air pollution and hypertensive disorders were explored by using logistic regression models after adjusting for individual confounders. RESULTS: Among 18,835 pregnant women in Seoul, 0.6, 0.5, and 0.4% of women developed gestational hypertension, preeclampsia, and preeclampsia requiring magnesium sulfate (Mg-preeclampsia), respectively. Although most odds ratios (ORs) were not statistically significant, we found increasing risk gradients with disease severity depending on the pollutant. There was the association between PM10 during 6 months to birth and gestational hypertension (OR for an interquartile range increase = 1.68 [95% confidence interval = 1.09-2.58]). NO2 and ozone during 12 and 1 month, respectively, before birth were associated with Mg-preeclampsia (1.43 [1.01-2.03], 1.53 [1.03-2.27]). CONCLUSIONS: We observed positive associations of exposure to some air pollutants before and during pregnancy with hypertensive disorders of pregnancy among the Korean general population. Future studies with refined exposure metrics should confirm our findings.

One Key Question®: First Things First in Reproductive Health.

Objectives Preconceptional health care is increasingly recognized as important to promotion of healthy birth outcomes. Preconceptional care offers an opportunity to influence pregnancy timing and intent and mother's health status prior to conception, all predictors of individual outcomes and of inequality in birth outcomes based on race, ethnicity and class. Methods One Key Question, a promising practice developed in Oregon which is now attracting national interest, provides an entry point into preconceptional care by calling on providers to screen for pregnancy intent in well woman and chronic disease care for women of reproductive age. For women who choose not to become pregnant or are not definitive in their pregnancy intent, One Key Question provides an opportunity for provision of or referral to counseling and contraceptive care. Results Adoption of One Key Question and preconceptional care as standard practices will require important shifts in medical practice challenging the longstanding schism between well woman care generally and reproductive care in particular. Adoption will also require shifts in cultural norms which define the onset of pregnancy as the appropriate starting point for attention to infant health. Conclusions for Practice This commentary reviews the case for preconceptional care, presents the rationale for One Key Question as a strategy for linking primary care to preconceptional and/or contraceptive care for women, outlines what is entailed in implementation of One Key Question in a health care setting, and suggests ways to build community support for preconceptional health.

Folate, homocysteine and selected vitamins and minerals status in infertile women.

OBJECTIVES: Diet has been recognised as a crucial factor influencing fetal and maternal health. Adequate levels of substances such as homocysteine, folate and vitamin B12 have been associated with a higher rate of success in infertility treatments. Few data, however, are available on the average levels of micronutrients in the blood of reproductive-aged women, and specific values for adequate levels are not available. The aim of this cross-sectional study was to measure levels of folate, homocysteine and selected vitamins and minerals in women attending the infertility unit of an academic hospital for in vitro fertilisation (IVF). METHODS: Fasting venous blood samples were taken in the morning during routine screening before IVF in order to measure: serum folate, red blood cell (RBC) folate, total plasma homocysteine, vitamin B12, vitamin A, vitamin E, serum iron and serum ferritin. RESULTS: Among 269 women aged 37 ± 4 years, only 69% and 44% showed adequate levels of homocysteine and vitamin B12, respectively. Serum folate was appropriate in 78% of the study participants, but only a minority (12%) had a concentration of RBC folate regarded as optimal for the prevention of fetal neural tube defects. Serum levels of vitamin A, vitamin E, iron and ferritin were, however, appropriate in the vast majority of participants (>80%). CONCLUSION: Folate levels were largely inadequate among women attending an infertility clinic for IVF. Vitamin B12 levels were also found to be inadequate.

Tips and Tricks: Preconceptional Laparoscopic Cervical Cerclage Made Easier and Safer With the Titiz Uterovaginal Manipulator.

STUDY OBJECTIVE: To demonstrate safe and easy surgical steps to facilitate preconceptional laparoscopic cervical cerclage with the Titiz uterovaginal manipulator. DESIGN: Narrated step-by-step video demonstration of preconceptional laparoscopic cervical cerclage under the guidance of the Titiz uterovaginal manipulator. SETTING: Cervical incompetence or cervical insufficiency is 1 of the causes of preterm birth. Incidence is 0.1% to 1% of all pregnancies. Traditionally, cervical cerclage is placed vaginally, but sometimes it is not possible to perform this procedure vaginally. When this occurs, cerclage needs to be inserted abdominally either by laparotomy or by laparoscopy. Laparoscopic cervical cerclage is indicated when vaginal cerclage has failed or is not possible due to a deficient or a short cervix caused by previous cervical surgery. Although laparoscopic cervical cerclage has a good success rate (90%-100% live births), there is a risk of injury to the bladder, sigmoid colon, and the uterine vessels. It is also important to put the suture in the right place, which is at the internal cervical os (cervico-isthmic junction) and medial to the uterine vessels. Therefore, it can be a challenging operation, especially when the uterus is bulky and more vascular due to adenomyosis or fibroids. INTERVENTION: A 32-year-old woman, G0P0, with the surgical history of cone biopsy presented with a history of infertility. On vaginal examination, there was no vaginal portion of the anterior cervix, and there was only 0.5 cm of the vaginal portion of the posterior cervix. After extensive counseling, the decision was made to perform a preconceptional laparoscopic abdominal cerclage. This video demonstrates the Titiz uterovaginal manipulator components and how to insert the manipulator. It also shows tips and tricks on laparoscopic cervical cerclage: (1) how to determine the anatomic relationships among the bladder, uterine vessels, cervico-vaginal junction and cervico-isthmic part of uterus; (2) how the Titiz uterovaginal manipulator helps to dissect the bladder and uterine arteries and veins safely; and (3) how to determine where and how to pass the sutures. MEASUREMENT AND MAIN RESULTS: The patient was discharged the same day and did not have any postoperative complications. The patient had transvaginal ultrasound 1 week after the operation. Tape was shown to be at the internal cervical os level. CONCLUSIONS: The Titiz uterovaginal manipulator can make preconceptional laparoscopic abdominal cerclage safer and easier.

Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy.

The objective of this study was to evaluate the efficacy of abdominal cerclage via laparoscopy vs laparotomy and before vs after conception. We evaluated 16 studies of abdominal cerclage involving a total of 678 cases published between 1990 and 2013. We estimated the effect of laparotomy over laparoscopy and the effect of preconceptional over postconceptional cerclage using a generalized linear model by treating the success rates (third-trimester delivery and live birth) as dependent variables and laparotomy and preconceptional as independent factors. The results demonstrated that there was no difference in the rates of third-trimester delivery and live birth rates between preconceptional abdominal cerclage via laparoscopy (71.4%-83.3% and 90%-100%, respectively) or laparotomy (97.3%-100% and 100%, respectively). For postconceptional cerclage, the rates of third-trimester delivery and live birth via laparoscopy were 70% and 70% to 100%, respectively, and via laparotomy were 77.4% to 99.5% and 85.2% to 100%, respectively. There was no difference in the live birth rates when abdominal cerclage was performed before or during pregnancy. We concluded that the rates of third-trimester delivery and live birth after abdominal cerclage via laparoscopy are high and comparable to those via laparotomy. The efficacy of the procedure performed either before or during pregnancy is similar. Abdominal cerclage performed before conception is more practical than after conception. With the inherent advantages of laparoscopy over laparotomy, abdominal cerclage performed via laparoscopy is preferable, in particular when performed in non-pregnant women.

Periconceptional folic acid usage and its associated factors in eastern Sudan: A cross-sectional study.

BACKGROUND: Several countries poorly adhere to the World Health Organization's recommendation of folic acid supplementation in the periconceptional period, especially in limited-resource settings. OBJECTIVE: The objective of this study was to investigate the prevalence of and the factors associated with folic acid usage in the periconceptional period among pregnant women at Gadarif Maternity Hospital in eastern Sudan. STUDY DESIGN: This is a cross-sectional study. METHODS: This study was conducted in eastern Sudan from April to September 2022. A total of 720 pregnant women in their first trimester were enrolled. The sociodemographic characteristics and clinical and obstetrical data of pregnant women in their first trimester were assessed using a face-to-face questionnaire. In addition, multivariate regression analysis was performed. RESULTS: In this study, the median (interquartile range) of the age and gravidity of the enrolled women was 26.3 (24.14-29.52) years and 2 (1-4), respectively. Of these 720 women, 423 (58.8%) used folic acid during the periconceptional period, while 27 (3.7%) women used folic acid in the preconceptional period. None of the investigated factors (age, residence, education, employment, body mass index, or gravidity) were associated with periconceptional use of folic acid. CONCLUSION: The study revealed a low prevalence of folic acid usage in preconceptional period among pregnant women in eastern Sudan. Additional efforts are needed to promote folic acid usage in the preconceptional period as well as in the first trimester.