Role of lateral suspension for the treatment of pelvic organ prolapse: a Delphi survey of expert panel.

INTRODUCTION AND HYPOTHESIS: Lateral suspension is an abdominal prosthetic surgical procedure used to correct apical prolapse. The procedure involves the placement of a T-shaped mesh on the anterior vaginal wall and on the isthmus or uterine cervix that is suspended laterally and posteriorly to the abdominal wall. Since its description in the late 90s, modifications of the technique have been described. So far, no consensus on the correct indications, safety, advantages, and disadvantages of this emerging procedure has been reached. METHODS: A modified Delphi process was used to build consensus within a group of 21 international surgeons who are experts in the performance of laparoscopic lateral suspension (LLS). The process was held with a first online round, where the experts expressed their level of agreement on 64 statements on indications, technical features, and other aspects of LLS. A subsequent re-discussion of statements where a threshold of agreement was not reached was held in presence. RESULTS: The Delphi process allowed the identification of several aspects of LLS that represented areas of agreement by the experts. The experts agreed that LLS is a safe and effective technique to correct apical and anterior prolapse. The experts highlighted several key technical aspects of the procedure, including clinical indications and surgical steps. CONCLUSIONS: This Delphi consensus provides valuable guidance and criteria for the use of LLS in the treatment of pelvic organ prolapse, based on expert opinion by large volume surgeons' experts in the performance of this innovative procedure.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users.

BACKGROUND: Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. METHODS: We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. RESULTS: The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. CONCLUSION: Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Five actions for five people: emergency cesarean section protocol.

OBJECTIVE: The scope of this work is to evaluate an operative protocol for emergency C-section to improve teamwork and reduce surgical setup time. METHODS: Sixty-six health care operators working together in the delivery ward (gynecologists, midwives, anesthesiologists) simulated an emergency scenario applying a "five actions for each operator" protocol. For each simulation, the decision to delivery interval was considered and the perception of each operator as a team worker was analyzed with specific tests. RESULTS: The "five actions for five people" protocol significantly reduces the decision to delivery interval (p < 0.001) for emergency C-section. At the same time, a simple and codified scheme improves communication among team members, avoids overlapping roles. Indeed, all the operators become more aware of being helpful to the team (p < 0.001). CONCLUSION: The use of a standardized, simple, and immediately usable protocol improves the performance of the delivery room team in terms of the urgency and quality of the operator's participation in the event. Procedures of this type should be favored within emergency obstetric settings. TRIAL REGISTRATION NUMBER: CEAVNO 19-01-23. Local ethical Committee (COMITATO ETICO REGIONALE PER LA SPERIMENTAZIONE CLINICA - Sezione autonoma Area Vasta Nord Ovest -CEAVNO) approved this study as simulation training study. All the operators participated voluntary during their working time.

Technical features, perioperative and anatomical outcomes of a standardized suturing pattern for robotic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Several technical alternatives to repair mesh using laparoscopic sacrocolpopexy exist. We aim to describe the outcomes and surgical technique of robotic-assisted colpo-/cervicosacropexy using a standardized suturing scheme to repair the mesh. METHODS: We retrospectively reported data of 60 consecutive cases of robotic-assisted colpo-/cervicosacropexy for advanced multicompartmental prolapse using a standardized suturing design. We placed three non-absorbable stitches on the cervix or three absorbable stitches on the apex of the vaginal vault, six long-term absorbable stitches on the anterior vaginal wall deep to the basis of the vesical trigone, six similar posterior stitches with the deeper row of sutures down to the levator ani plane and three non-absorbable stitches on the sacral promontory as the cranial support for Y-shaped polypropylene mesh. RESULTS: Median operative time was 188 ± 43 min. All the procedures were successfully performed using a Da Vinci Si platform in a three-arm configuration, and no conversion to open or traditional laparoscopic surgery was needed. The length of hospital stay was 1.2 ± 1.7 days, and no readmission within 30 postoperative days was reported. At a follow-up of 12 and 24 months, no case of extrusion or exposure of the mesh occurred, and the retreatment rate was 6.7%. CONCLUSIONS: Our suturing technique is safe and effective, with negligible risk of complications and good medium-term results. It is plausible that robotic systems may facilitate precise, accurate and reproducible placement of the stitches, thereby favoring wider diffusion of minimally invasive treatment of advanced prolapse.

"To get the baby out off the hook": a prospective, longitudinal, multicenter, observational study about decision making in vacuum-assisted operative vaginal delivery.

BACKGROUND: Since operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure. This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled. Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure. RESULTS: Overall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable. CONCLUSION: Decision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation. Operative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.

Molecular and endocrine mechanisms involved in preterm birth.

Preterm birth is a worldwide social problem. Incidence rates may vary from 5 to 18% of all deliveries, with important differences observed between developed and developing countries. Preterm birth has a negative impact on newborns and neonatal mortality and morbidity are high. Despite improvements in modern neonatal care, we know little of the mechanisms that determine the onset and development of preterm birth. Infections seem to be one the most important triggers, determining the activation of protective mechanisms aimed at ending the pregnancy and safeguarding the health of the woman. However, threatened preterm birth often occurs even in women who do not have any ongoing infectious process. Of these, which are the majority, the causes and the activation mechanisms remain unknown or unclear; however, there are several molecular and endocrine mechanisms that finally lead to preterm birth. In this review, we seek to shed light and summarize the molecular and endocrine mechanisms underlying the development of preterm birth. Their understanding could help us to understand the dynamics of premature birth but, above all, to allow an early diagnosis and primary prevention of the problem.

Mood disorders and hormonal status across women's life: a narrative review.

Depressive disorders and anxiety states represent one of the most frequent psychiatric pathologies occurring transiently in vulnerable women throughout their life, from puberty to menopause. It is now known that sex hormones play a key role on the nervous system, interfering with neuronal plasticity and enhancing the processes of learning, memory, cognition, and mood. Numerous mechanisms are at the base of these processes, displaying interactions between estrogen and serotoninergic, dopaminergic, and GABAergic receptors at the central level. Therefore, given the sexual steroids fluctuations throughout the entire female lifespan, and considering the role played by sex hormones at the central level, it is not surprising to observe the onset of mood or neurodegenerative disorders over time. This is especially true for women in hormonal transition phase, such as puberty, postpartum and the menopausal transition. Moreover, all these conditions are characterized by hormone withdrawal, imbalance, or modifications due to menopausal hormone therapies or contraceptives which could prompt to a deterioration of mood and cognition impairment or to an improvement in the quality of life. More studies are needed to better understand the hormone-related effects on the nervous system, and the underlying pathways involved in transitional or chronic mood disorders, to promote new patient-specific therapeutic strategies more effective than the current ones and tailored according to the individual need and women's life period.

Simulation training program for vacuum application to improve technical skills in vacuum-assisted vaginal delivery.

OBJECTIVE: evaluation of technical skills of the operators during the obstetrical device application for operative vaginal delivery, named kiwi-cup in a simulation training program. METHODS: Thirty-five residents in obstetrics and gynecology of the University of Pisa, Italy were recruited and evaluated with an assessment scale on technical skills from 0 to 55 points. They performed various operative vaginal delivery simulations with kiwi-cup and were evaluated at time 0 by a tutor. After 8 weeks, simulation training was repeated and trainees were re-evaluated by the same tutor. RESULTS: after 8 weeks from the first simulation session, trainees have been shown to increase technical skills (46.27 ± 4.6 with p-value < 0.0001), the successful application rate (85.71% with p-value 0.0161).) and to reduce the time to complete the procedure (86.2 ± 29.9 s with p-value < 0.0001). CONCLUSION: simulation training on operational vaginal delivery significantly increases technical skills, improves successful rate, and reduces the time taken to complete the procedure. CLINICAL TRIAL REGISTRATION: Not applicable.

Pregnancy after miscarriage in primiparae and multiparae: implications for women's psychological well-being.

Introduction: Miscarriage is a stressful life event with negative consequences that can last into the subsequent gestation, increasing women's risk for psychological symptoms. Less clear in literature is whether having a living child may buffer the psychological impact of miscarriage on subsequent pregnancies.Objective: explore levels of depression, anxiety and fear of delivery in women with and without a previous miscarriage, taking into consideration the presence of a living child.Method: 208 women (M = 34.68) were recruited during the third trimester of gestation. The sample was composed of 159 women without a previous miscarriage (72.3% primiparae and 27.7% multiparae) and 49 women with a history of miscarriage (53.1% primiparae and 46.9% multiparae). Participants filled out a battery of questionnaires aimed at assessing anxiety, depression, and fear of delivery.Results: Primiparae reported higher levels of fear of childbirth than multiparae. Moreover, women without a history of previous perinatal loss showed lower levels of depression and fear of childbirth than women with a previous perinatal loss.Conclusions: Data highlight the importance of developing specific support groups, for primiparae, due to their great emotional vulnerability, and for women with past miscarriage, to help them cope in adaptive ways with a new pregnancy.

Medium-term outcomes after robotic-assisted lateral suspension with mesh for advanced multi-compartmental prolapse.

INTRODUCTION AND HYPOTHESIS: Robotic abdominal lateral suspension (RALS) is an innovative mini-invasive surgical technique that allows treating apical and anterior prolapse. The safety and efficacy of this strategy have not yet been tested. METHODS: We completed a prospective case series of 115 RALS to treat apical and anterior prolapse stage III or IV, with no or minimal (stage I) posterior defect. Clinical evaluation was performed with a simplified POP quantification system (POP-Q). Mean follow-up was 28 ± 4 months. Primary outcomes were objective and subjective cure; secondary outcomes were reoperation rate for recurrence, erosion rate and complications. Objective cure was defined as POP-Q ≤ 1. Subjective cure was defined as absence of vaginal bulge. Patient's satisfaction was measured using the Patient Global Impression of Improvement Scale (PGI-I). RESULTS: There was a significant improvement in POP-Q score in all treated compartments with an objective cure rate of 88.7% for the anterior and 93.1% for the apical compartment (p < 0.0001). Subjective cure rate was 82%. The emergence of de novo high rectoceles was not significant in the cohort, as much as the development of de novo stress or urge urinary incontinence. Reoperation rate for POP was 11.3% (8 recurrent cystoceles without apical descent and 5 apical and anterior relapses). No postoperative complications of Clavien-Dindo grade ≥ 3a were seen. Mesh exposure rate was 0.9%; 58.2% patients compiled a PGI-I score at 18-24 months post-surgery, reporting high satisfaction rates. CONCLUSIONS: RALS is highly effective at a mid-term follow-up for the treatment of advanced apical and anterior POP.

Pheochromocytoma diagnosed during pregnancy: a case report.

Pheochromocytoma is a rare catecholamine producing tumor. During pregnancy, this tumor can mimic gestational hypertension, preeclampsia or eclampsia. We present a case of a 38-year-old, multiparous woman admitted at 36 weeks of gestation due to hypertension. After cesarean section, she developed an unexplainable worsening of her hypertension that was resistant to the traditional therapy. Additional investigation lead to the diagnosis of pheochromocytoma. This case highlights the importance of an early diagnosis and the need of a multidisciplinary approach for the improvement of pregnancy outcomes in patients with pheochromocytoma.

Computed-tomography image segmentation and 3D-reconstruction of the female pelvis for the preoperative planning of sacrocolpopexy: preliminary data.

BACKGROUND: Minimally-invasive sacrocolpopexy is the gold standard procedure for advanced apical prolapse. Nonetheless, sacrocolpopexy has potential serious complications leading many surgeons to avoid this excellent surgical procedure. To overcome these limitations, preoperative planning with 3D models of the female pelvis is proposed. The aim of the study is to evaluate the feasibility of pelvic anatomy reconstruction with the ITK-SNAP software and highlight its potential benefits in this intervention. METHODS: Thirty patient-specific 3D models of the female pelvis were created using ITK-SNAP and the EndoCAS Segmentation Pipeline extension for image segmentation: contrast-enhanced computed tomography (CE-CT) data sets of women who underwent examinations for reasons other than prolapse were used. The distances of pelvic structures from the sacral promontory were standardised and measured, and correlations among these distances were evaluated with Spearman's correlation coefficient. RESULTS: Pelvic anatomy reconstruction was feasible for all CE-CT data sets. A statistically significant correlation was found between the distances of the cava bifurcation and common iliac vessels from the sacral promontory. An area for proximal mesh attachment was defined: it is free from the passage of iliac vessels in 97.5% of cases. A significant statistical correlation was found between the distances of the midpoint of the bispinous diameter and the uterine cervix from the sacral promontory; a process of linear regression showed that the latter measure can be estimated by multiplying the first one by 0.86. CONCLUSIONS: Pre-surgical 3D reconstructions of the female pelvis using ITK-SNAP could help achieve widespread use of sacrocolpopexy: further comparative studies are needed to evaluate the outcomes with and without their use.

Simulation as tool for evaluating and improving technical skills in laparoscopic gynecological surgery.

BACKGROUND: Simulation in laparoscopic surgery is nowadays recognized as a valid instrument for learning and training surgeons in different procedures. However, its role as evaluation test and self-assessment tool to verify basic surgical skills is still under discussion. METHODS: Thirty-three residents in obstetrics and gynecology at University of Pisa, Italy were recruited, and they received a simulation program consisting of 5 tasks. They had to perform basic laparoscopic surgery maneuvers as creating pneumoperitoneum, positioning trocars under vision, demonstrating the appropriate use of dominant and non-dominant hand and making single stitch and knot. They were evaluated with a modified OSATs scale. RESULTS: Senior trainees had better score than junior trainees (p value< 0,005) and after different sessions of simulation scores of both groups significantly improved (p < 0,001), especially for the junior group. All the trainees reported self-assessments that matched with the evaluation of external observers demonstrating the importance of simulation also as auto-evaluation test. CONCLUSIONS: In this study, we demonstrated the role of simulation as powerful tool to evaluate and to self-assess surgical technical skills and to improve own capacities, with the use of a modified OSATs scale adapted to specific exercises.

First series of total robotic hysterectomy (TRH) using new integrated table motion for the da Vinci Xi: feasibility, safety and efficacy.

BACKGROUND: To present the first case series of total robotic hysterectomy (TRH), using integrated table motion (ITM), which is a new feature comprising a unique operating table by Trumpf Medical that communicates wirelessly with the da Vinci Xi surgical system. ITM has been specifically developed to improve multiquadrant robotic surgery such as that conducted in colorectal surgery. METHODS: Between May and October 2015, a prospective post-market study was conducted on ITM in the EU in 40 cases from different specialties. The gynecological study group comprised 12 patients. Primary endpoints were ITM feasibility, safety and efficacy. RESULTS: Ten patients underwent TRH. Mean number of ITM moves was three during TRH; there were 31 instances of table moves in the ten procedures. Twenty-eight of 31 ITM moves were made to gain internal exposure. The endoscope remained inserted during 29 of the 31 table movements (94%), while the instruments remained inserted during 27 of the 31 moves (87%). No external instrument collisions or other problems related to the operating table were noted. There were no ITM safety-related observations and no adverse events. CONCLUSIONS: This preliminary study demonstrated the feasibility, safety and efficacy of ITM for the da Vinci Xi surgical system in TRH. ITM was safe, with no adverse events related to its use. Further studies will be useful to define the real role and potential benefit of ITM in gynecological surgery.

Robotic-assisted apical lateral suspension for advanced pelvic organ prolapse: surgical technique and perioperative outcomes.

BACKGROUND: Abdominal sacral hystero-cervicopexy (ASC) is the gold standard for the treatment of apical prolapse, but requires advanced laparoscopic skills and exposes to potentially life-threatening complications. Lateral apical suspension to the abdominal wall with mesh is a feasible alternative of ASC where robotic assistance may offer specific advantages. We here describe the surgical technique and the short-term outcomes of robotic-assisted lateral apical suspension (R-ALS) with the use of a titan-covered T-shaped mesh. METHODS: Forty consecutive patients with stage III or IV symptomatic anterior and apical pelvic organ prolapse underwent R-ALS between September 2014 and September 2015. RESULTS: R-ALS was completed without complications in all cases with a mean operative time of 117 ± 26 min. From a technical standpoint, robotic assistance allowed for an extremely reproducible technique, with a swift learning curve and consistent length of the surgical steps. The procedure was extremely well tolerated and resulted in complete resolution of POP-associated symptoms and in improvements of POP- and incontinence-related quality-of-life scores (PQOL and IIQ7) at 1 month from surgery. CONCLUSIONS: R-ALS is feasible, safe, well-tolerated and effective at a short-term follow-up. R-ALS may represent an effective and simple alternative to abdominal sacral hystero-cervicopexy for the treatment of high-grade apical and anterior POP, avoiding the challenges of sacral mesh fixation. Robotic assistance helps achieving optimally tailored anatomic reconstruction, allowing seamless deep pelvic dissection and suturing.

Risk and protective factors for pregnancy-related urinary incontinence until 1 year postpartum: A cohort study using patient-reported outcome measures in Italy.

OBJECTIVE: To investigate the epidemiology of pregnancy-related urinary incontinence (UI) and the related risk factors, focusing also on women's characteristics related to maternity pathway utilization. METHODS: In this prospective cohort study, we used patient-reported data obtained from the systematic survey on the maternity pathway that all pregnant women in Tuscany, Italy, can join. We selected 8410 women who completed-between March 2019 and November 2022-all five follow-up questionnaires from the first trimester until 12 months postpartum, each including a UI-specific patient-reported outcome measure. We performed panel regression models to explore the related risk factors. RESULTS: Prevalence of UI was 4.4% at the first trimester, 23.7% at the third trimester, and 15.6%, 12.6%, and 12.4% at 3, 6, and 12 months postpartum. UI occurrence and severity were higher in older, overweight/obese, and unemployed women. High-risk pregnancy and discomfort during pregnancy were risk factors. Receiving a cesarean section reduced the risk, while spontaneous tears, episiotomy, and high birth weight increased it. Women who experienced delays in pregnancy examinations because of long waiting times and women who had planned pregnancy had a higher risk, while performing during-pregnancy pelvic-floor-muscle training was protective. CONCLUSION: Besides confirming the classic risk and protective factors for UI, we also found novel determinants related to the proper maternity pathway utilization.

Influence of the COVID-19 pandemic on self-reported urinary incontinence during pregnancy and postpartum: A prospective study.

OBJECTIVE: To explore how the COVID-19 pandemic influenced self-reported occurrence and severity of pregnancy-related urinary incontinence (UI) in the maternity pathways of Tuscany, Italy. METHODS: In this prospective pre-post cohort study, we selected a pre-pandemic (n = 1018) and a post-pandemic (n = 3911) cohorts of women that completed, from the first trimester until 3 months postpartum, three surveys including validated patient-reported outcome measures for UI. Data were obtained from systematic surveys on the maternity pathways of Tuscany from March 2019 to June 2021. We performed panel regression models to explore how UI risk differed between COVID-19 groups. RESULTS: UI occurred less frequently and less severely in post-pandemic patients-especially stress/mixed UI in women never performing pelvic floor muscle training (PFMT)-whereas no difference emerged in women performing during-pregnancy PFMT. During COVID-19, obese women had higher risk of UI, whereas women undergoing operative delivery had lower risk. The post-pandemic group reported more severe UI symptoms at the third trimester, but less severe UI postpartum in women suffering from UI during pregnancy. CONCLUSIONS: During the COVID-19 pandemic, women reported fewer UI symptoms because they might have lacked chances to identify UI symptoms as a result of pandemic-related sedentarism and inactivity. The risk in women performing during-pregnancy PFMT was not increased, but just six of 26 health districts organized remote PFMT sessions, thus revealing limited resilience to the pandemic in Tuscany.

Driving time drives the hospital choice: choice models for pelvic organ prolapse surgery in Italy.

OBJECTIVE: The Italian healthcare jurisdiction promotes patient mobility, which is a major determinant of practice variation, thus being related to the equity of access to health services. We aimed to explore how travel times, waiting times, and other efficiency- and quality-related hospital attributes influenced the hospital choice of women needing pelvic organ prolapse (POP) surgery in Tuscany, Italy. METHODS: We obtained the study population from Hospital Discharge Records. We duplicated individual observations (n = 2533) for the number of Tuscan hospitals that provided more than 30 POP interventions from 2017 to 2019 (n = 22) and merged them with the hospitals' list. We generated the dichotomous variable "hospital choice" assuming the value one when hospitals where patients underwent surgery coincided with one of the 22 hospitals. We performed mixed logit models to explore between-hospital patient choice, gradually adding the women's features as interactions. RESULTS: Patient choice was influenced by travel more than waiting times. A general preference for hospitals delivering higher volumes of interventions emerged. Interaction analyses showed that poorly educated women were less likely to choose distant hospitals and hospitals providing greater volumes of interventions compared to their counterpart. Women with multiple comorbidities more frequently chose hospitals with shorter average length of stay. CONCLUSION: Travel times were the main determinants of hospital choice. Other quality- and efficiency-related hospital attributes influenced hospital choice as well. However, the effect depended on the socioeconomic and clinical background of women. Managers and policymakers should consider these findings to understand how women behave in choosing providers and thus mitigate equity gaps.

The use of a novel sensorized simulation platform for real-time labor progression assessment.

OBJECTIVE: To prove the potentialities of an integrated and sensorized childbirth platform as an innovative simulator for education of inexperienced gynecological and obstetrical medical students. METHODS: A total of 152 inexperienced medical students were recruited to a simulation program on labor progression evaluation. After an introductory lecture on basic concepts of labor and birth given by an expert gynecologist, three different gynecologic scenarios were simulated using both a traditional obstetric simulator and the innovative proposed platform, for a total of six tests for each student. A score was assigned for each performed scenario, based on its correctness. Self-assessment questionnaires were compiled before and after the simulation program for additional subjective assessment. RESULTS: Median score of the simulations performed with our platform was significantly higher than that of the simulations performed with a traditional simulator, for all the three experimented scenarios (P < 0.001). CONCLUSIONS: The use of a sensorized platform for labor progression allowed for an accurate and faster diagnosis if compared with a traditional simulator even for inexperienced operators, supporting its use in clinical training, which could be realistically introduced into the clinical practice for medical student education.

Pregnancy vaccination predictive factors and uptake profiles among Italian women: A cross-sectional survey study on a large population.

OBJECTIVES: To assess influenza and Tdap (tetanus, diphtheria, pertussis) vaccine coverage during pregnancy, explore key socioeconomic and maternity pathway-related predictors of vaccination, and detect specific patterns of vaccination uptake. METHODS: The authors cross-sectionally analyzed self-reported data obtained from the systematic survey on the maternity pathways of Tuscany. They selected all pregnant women that completed from March 2019 to June 2022 the third-trimester questionnaire (n = 25 160), which included two dichotomous items on influenza and Tdap vaccination, as well as socioeconomic and pathway-related questions. Multilevel logistic models were performed to assess vaccination predictors and cluster analysis to identify vaccination patterns. RESULTS: Vaccination coverage was higher for pertussis (56.5%) than for influenza (18.9%). The main predictors of vaccination were high socioeconomic status, attending private gynecologists, and receiving vaccine information. Three clusters were identified: cluster 1 included women receiving both Tdap and influenza vaccines; cluster 2 included women receiving no vaccinations; and cluster 3 included women receiving only the pertussis vaccine. Although women from cluster 3 were of middle to low education status, vaccine information was the main adherence determinant also in this group. CONCLUSIONS: Health workers and policymakers should focus on groups of pregnant women less prone to vaccination to promote vaccination information and encourage wider uptake and coverage.