Nonischemic or Dual Cardiomyopathy in Patients With Coronary Artery Disease.

BACKGROUND: Randomized trials in obstructive coronary artery disease (CAD) have largely shown no prognostic benefit from coronary revascularization. Although there are several potential reasons for the lack of benefit, an underexplored possible reason is the presence of coincidental nonischemic cardiomyopathy (NICM). We investigated the prevalence and prognostic significance of NICM in patients with CAD (CAD-NICM). METHODS: We conducted a registry study of consecutive patients with obstructive CAD on coronary angiography who underwent contrast-enhanced cardiovascular magnetic resonance imaging for the assessment of ventricular function and scar at 4 hospitals from 2004 to 2020. We identified the presence and cause of cardiomyopathy using cardiovascular magnetic resonance imaging and coronary angiography data, blinded to clinical outcomes. The primary outcome was a composite of all-cause death or heart failure hospitalization, and secondary outcomes were all-cause death, heart failure hospitalization, and cardiovascular death. RESULTS: Among 3023 patients (median age, 66 years; 76% men), 18.2% had no cardiomyopathy, 64.8% had ischemic cardiomyopathy (CAD+ICM), 9.3% had CAD+NICM, and 7.7% had dual cardiomyopathy (CAD+dualCM), defined as both ICM and NICM. Thus, 16.9% had CAD+NICM or dualCM. During a median follow-up of 4.8 years (interquartile range, 2.9, 7.6), 1116 patients experienced the primary outcome. In Cox multivariable analysis, CAD+NICM or dualCM was independently associated with a higher risk of the primary outcome compared with CAD+ICM (adjusted hazard ratio, 1.23 [95% CI, 1.06-1.43]; P=0.007) after adjustment for potential confounders. The risks of the secondary outcomes of all-cause death and heart failure hospitalization were also higher with CAD+NICM or dualCM (hazard ratio, 1.21 [95% CI, 1.02-1.43]; P=0.032; and hazard ratio, 1.37 [95% CI, 1.11-1.69]; P=0.003, respectively), whereas the risk of cardiovascular death did not differ from that of CAD+ICM (hazard ratio, 1.15 [95% CI, 0.89-1.48]; P=0.28). CONCLUSIONS: In patients with CAD referred for clinical cardiovascular magnetic resonance imaging, NICM or dualCM was identified in 1 of every 6 patients and was associated with worse long-term outcomes compared with ICM. In patients with obstructive CAD, coincidental NICM or dualCM may contribute to the lack of prognostic benefit from coronary revascularization.

Enabling methanol fixation of pediatric nasal wash during respiratory illness for single cell sequencing in comparison with fresh samples.

BACKGROUND: Lower respiratory tract infection (LRTI) including pneumonia, bronchitis, and bronchiolitis is the sixth leading cause of mortality around the world and leading cause of death in children under 5 years. Systemic immune response to viral infection is well characterized. However, there is little data regarding the immune response at the upper respiratory tract mucosa. The upper respiratory mucosa is the site of viral entry, initial replication and the first barrier against respiratory infections. Lower respiratory tract samples can be challenging to obtain and require more invasive procedures. However, nasal wash (NW) samples from the upper respiratory tract can be obtained with minimal discomfort to the patient. METHOD: In a pilot study, we developed a protocol using NW samples obtained from hospitalized children with LRTI that enables single cell RNA sequencing (scRNA-seq) after the NW sample is methanol-fixed. RESULTS: We found no significant changes in scRNA-seq qualitative and quantitative parameters between methanol-fixed and fresh NW samples. CONCLUSIONS: We present a novel protocol to enable scRNA-seq in NW samples from children admitted with LRTI. With the inherent challenges associated with clinical samples, the protocol described allows for processing flexibility as well as multicenter collaboration. IMPACT: There are no significant differences in scRNA-seq qualitative and quantitative parameters between methanol fixed and fresh Pediatric Nasal wash samples. The study demonstrates the effectiveness of methanol fixation process on preserving respiratory samples for single cell sequencing. This enables Pediatric Nasal wash specimen for single cell RNA sequencing in pediatric patients with respiratory tract infection and allows processing flexibility and multicenter collaboration.

Pilsner Modification of Mesh Sacrohysterocolpopexy (PiMMS): An Initial Report on Safety and Efficacy.

INTRODUCTION AND HYPOTHESIS: It is reported that up to 60% of women would prefer to spare their uterus during pelvic organ prolapse (POP) repair surgery. A reliable hysteropexy technique is therefore crucial. We aimed to describe the safety profile and initial core patient-reported and clinical outcomes of the Pilsner modification of laparoscopic mesh sacrohysterocolpopexy (PiMMS) in comparison with the laparoscopic sacrohysterocolpopexy technique (standard laparoscopic sacrohysterocolpopexy [sLSH]) previously used in our unit. METHODS: This was a retrospective cohort study conducted in a single tertiary referral urogynecological center. All patients who underwent laparoscopic mesh sacrohysterocolpopexy between 1 January 2015, and 31 January 2022 were included in the study. Follow-up clinical, patient-reported, and imaging outcomes at the 12-month follow-up time point are presented. RESULTS: A total of 87 patients were included. Of these, 49 (56.3%) and 38 (43.7%) underwent sLSH and PiMMS respectively. Low numbers of perioperative complications were found in both groups with no mesh-related complications reported following PiMMS up to 12 months postoperatively. There were no apical compartment failures in either group. There were 8 (17.0%) vs 1 (2.7%) anterior compartment failures (Ba ≤ -1) in the sLSH and PiMMS groups respectively (p = 0.07) at 12 months. At the 1-year follow-up, 42 (89.4%) patients reported a Patient Global Impression of Improvement score of ≤ 2 in the sLSH groups compared with 35 (94.6%) patients following PiMMS. CONCLUSIONS: The PiMMS technique seems to have comparable safety profile and patient-reported outcomes with the sLSH technique. However, there is a trend toward reduced anterior compartment failures with this modification. The findings of this preliminary report need to be re-evaluated in a well-powered prospective study.

Generation of human scFv-IgG1Fc antibodies for detection of lymphatic filarial recombinant antigens, BmR1 and BmSXP.

Lymphatic filariasis is a neglected parasitic disease that affects millions in tropical and subtropical countries and is caused by Wuchereria and Brugia species. Specific and sensitive detection methods are essential in mapping infected areas where rapid tests are needed to cover underdeveloped and remote regions, which facilitates eliminating the disease as a public health problem. A few commercialized rapid tests based on antigen or antibody detection are available, but the former only detects infection by Wuchereria species and cross-reacts with nonlymphatic filaria, whereas antibody detection might provide positive results of previous infection. Here, we report the production of three different recombinant immunoglobulin gamma (IgG)1 antibodies based on scFvs previously generated via human antibody phage display technology, that is, anti-BmR1 clone 4, anti-BmXSP clone 5B, and anti-BmXSP clone 2H2. The scFv sequences were cloned into a pCMV-IgG1 vector, then transfected into a HEK293F cell line. The generated antibodies were found to be able to bind to their respective targets even at relatively low concentration. Conjugation of Fc to scFv induces binder stability and provides multiple labeling sites for probes and signaling molecules that can be used in rapid tests.

Timing of caesarean section and its impact on levator ani musle avulsion at the first subsequent vaginal birth - a pilot study.

OBJECTIVE: The aim of this multicentric observational study was to explore the impact of the timing of cesarean section (SC) on levator (MLA - levator ani musle) avulsion at the first subsequent vaginal birth. METHODS: All women after term vaginal birth following a cesarean section (VBAC) for their second delivery at the Departments of Gynecology and Obstetrics, Faculty of Medicine, Charles University and University Hospital in Pilsen and the 1st Faculty of Medicine, Charles University and General Hospital in Prague, between 2012 and 2016 were identified. Hospital database and surgical notes were used to collect basic characteristics of the patients including the indication and course of their previous delivery. These women were divided into two groups according to indication of prior SC in the previous delivery to women with elective SC and acute SC. All participants were invited for a 4D pelvic floor ultrasound to assess levator trauma. Levator avulsion and the levator hiatus area were assessed off-line from the stored pelvic floor volumes. Data were statistically assessed. RESULTS: A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for 141 women for statistical analyses. These were further divided into 80 women after acute SC and 61 women after elective SC. The levator avulsion rate was higher in the elective SC subgroup, but the difference was not significant (26.3 vs. 41.0%, P = 0.0645). No statistical differences in urogenital hiatus enlargement and ballooning were observed. CONCLUSION: VBAC is associated with a significantly higher rate of levator ani avulsion compared to the first vaginal birth in nulliparous women. However, it seems that risk of levator ani avulsion doesnt depend on the timing of SC in previous labor. More studies are needed to confirm the results of this pilot study.

Contribution of ultrasound examination in the detection of unexpected uterine and adnexal findings in reconstructive surgery for pelvic organ prolapse.

Objective: Current urogynaecology practice allows preservation of the uterus in pelvic organ prolapse (POP) surgery, thus not reducing oncologic risk. AIM: The aim of the study was to evaluate the efficacy of ultrasound (USG) in dia-gnosing unexpected uterine and adnexal pathologies in women referred for POP. Furthermore, the benefit of USG examination by a specialist in gynaecology-oncology ultrasound was assessed. MATERIALS AND METHODS: All women after a hysterectomy with or without adnexectomy in the course of a POP surgery at our tertiary centre in 2013-2018 with preoperative USG were enrolled in the study. Women with recurrent uterine bleeding, abnormal cytology, using tamoxifen, or women with already dia-gnosed uterine or adnexal pathology were excluded. RESULTS: 289 women were enrolled in the study - 157 (54.3%) expert USG vs. 132 (45.7%) non-expert USG. Abnormal findings were observed on the cervix in one case (non-expert USG), the endometrium 30 (10.4%) cases - 13 (8.3%) expert vs. 17 (12.9%) non-expert USG, the adnexa three (2.3%) cases (all non-expert USG), and no suspicion of malignancy on myometrium was observed. USG was false negative in four (1.4%) cases - two (1.3%) expert vs. two (1.5%) non-expert USG. Conversely, the examination was false positive in 34 (11.8%) cases - 13 (8.3%) expert vs. 21 (15.9%) non-expert USG. CONCLUSION: The risk of unexpected uterine or adnexal pathologies in POP surgery was 1.4%. The agreement between USG and histopathological benign, abnormal or malign findings was 87.2%. A sonographer specialized in oncologic sonography is able to reduce the number of false positive findings; however, this does not increase the sensitivity of the ultrasound.

Finite element modeling of maximum stress in pelvic floor structures during the head expulsion (FINESSE) study.

INTRODUCTION AND HYPOTHESIS: Several studies have assessed birth-related deformations of the levator ani muscle (LAM) and perineum on models that depicted these elements in isolation. The main aim of this study was to develop a complex female pelvic floor computational model using the finite element method to evaluate points and timing of maximum stress at the LAM and perineum in relation to the birth process. METHODS: A three-dimensional computational model of the female pelvic floor was created and used to simulate vaginal birth based on data from previously described real-life MRI scans. We developed three models: model A (LAM without perineum); model B (perineum without LAM); model C (a combined model with both structures). RESULTS: The maximum stress in the LAM was achieved when the vertex was 9 cm below the ischial spines and measured 37.3 MPa in model A and 88.7 MPa in model C. The maximum stress in the perineum occurred at the time of distension by the suboocipito-frontal diameter and reached 86.7 MPa and 119.6 MPa in models B and C, respectively, while the stress in the posterior fourchette caused by the suboccipito-bregmatic diameter measured 36.9 MPa for model B and 39.8 MPa for model C. CONCLUSIONS: Including perineal structures in a computational birth model simulation affects the level of stress at the LAM. The maximum stress at the LAM and perineum seems to occur when the head is lower than previously anticipated.

Pelvic organ prolapse and uterine preservation: a cohort study (POP-UP study).

BACKGROUND: Abdominal and laparoscopic sacro-colpopexy (LSC) is considered the standard surgical option for the management of a symptomatic apical pelvic organ prolapse (POP). Women who have their uterus, and for whom an LSC is indicated, can have a laparoscopic sacro-hysteropexy (LSH), a laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH + LSC) or a total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH + LSC). The main aim of this study was to compare clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures. METHODS: A retrospective analysis of clinical, imaging and patient reported outcomes at baseline, 3 and 12 months after LSH versus either LSCH + LSC or TLH + LSC between January 2015 and January 2019 in a tertiary referral urogynecology center in Pilsen, the Czech Republic. RESULTS: In total, 294 women were included in this analysis (LSH n = 43, LSCH + LSC n = 208 and TLH + LSC n = 43). There were no differences in the incidence of perioperative injuries and complications. There were no statistically significant differences between the concomitant hysterectomy and the uterine sparing groups in any of the operative, clinical or patient reported outcomes except for a significantly lower anterior compartment failure rate (p = 0.017) and higher optimal mesh placement rate at 12 months in women who had concomitant hysterectomy procedures (p = 0.006). CONCLUSION: LSH seems to be associated with higher incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques compared to LSC with concomitant hysterectomy.

Interleukin 23 and autoimmune diseases: current and possible future therapies.

PURPOSE: IL-23 is a central proinflammatory cytokine with a wide range of influence over immune response. It is implicated in several autoimmune diseases due to the infinite inflammatory loops it can create through the positive feedbacks of both IL-17 and IL-22 arms. This made IL-23 a key target of autoimmune disorders therapy, which indeed was proven to inhibit inflammation and ameliorate diseases. Current autoimmune treatments targeting IL-23 are either by preventing IL-23 ligation to its receptor (IL-23R) via antibodies or inhibiting IL-23 signaling by signaling downstream mediators' inhibitors, with each approach having its own pros and cons. METHODS: Literature review was done to further understand the biology of IL-23 and current therapies. RESULTS: In this review, we discuss the biological features of IL-23 and its role in the pathogenesis of autoimmune diseases including psoriasis, rheumatoid arthritis and inflammatory bowel diseases. Advantages, limitations and side effects of each concept will be reviewed, suggesting several advanced IL-23-based bio-techniques to generate new and possible future therapies to overcome current treatments problems.

Laparoscopic sacrohysteropexy: the Pilsner modification.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrocolpopexy is the preferred contemporary procedure for the surgical management of a significant apical pelvic organ prolapse. In the presence of a uterus it is possible for the patient to have subtotal hysterectomy and cervicopexy, total hysterectomy with colpopexy or uterine conservation and hysteropexy. However, hysteropexy seems to be associated with a higher risk of anterior compartment failure compared with cervicopexy or colpopexy. It is not uncommon for an asymmetrically large anterior compartment defect to co-exist with a symptomatic apical pelvic organ prolapse. In a cervicopexy or colpopexy, this asymmetry can be balanced by creating a de novo vaginal apex from the superior part of the anterior vaginal wall. However in a hysteropexy the attachment of the base of the anterior mesh to the vagina and cervical isthmus limits the ability to do this. METHODS: In this video we present a solution where the shape of the posterior mesh is modified to include two horizontal arms that are passed through openings in the broad ligament and attached to the cervical isthmus anteriorly. RESULTS: This frees the anterior Y-shaped mesh to be fixed to the anterior vaginal wall only and hence provides the required tension to create the de novo apex. CONCLUSION: Prior to wide adoption, this technique should be further investigated in the context of robustly designed comparative studies.

Trans-obturator cystocele repair of level 2 paravaginal defect.

INTRODUCTION AND HYPOTHESIS: It is reported that almost one in five women will need some form of pelvic organ prolapse surgery in their lifetime, with anterior wall repair accounting for nearly half of these. Cystoceles occur secondary to defect(s) in one or more of the vaginal wall support mechanisms, including its lateral paravaginal attachments. Paravaginal defects are very common in women presenting with cystocele, thus highlighting the importance of paravaginal defect repair for optimal cystocele correction in the majority of cases. Although there are several paravaginal defect repair procedures, some entail complex techniques, whereas others rely on the use of transvaginal mesh, which is currently not permitted in many countries. METHODS: In this video article we present a novel trans-obturator native tissue paravaginal defect repair for the management of cystocele. RESULTS: This procedure has the advantages of avoiding complex transabdominal paravaginal defect repair, the controversial use of transvaginal mesh, or a single-point fixation to an arcus tendineus fasciae pelvis that might be difficult to identify. CONCLUSION: We believe that the trans-obturator cystocele repair procedure offers several advantages over existing paravaginal defect repair alternatives.

Obesity and its long-term impact on sacrocolpopexy key outcomes (OBELISK).

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is the preferred contemporary approach to managing significant apical pelvic organ prolapse. Obesity is an established risk factor for several surgical procedures and can have a negative impact on outcomes. Our goal was to evaluate the impact of BMI on the safety and efficacy of laparoscopic sacrocolpopexy in women with pelvic organ prolapse. METHODS: A single-center retrospective observational study of women undergoing laparoscopic sacrocolpopexy between January 1, 2015, and December 31, 2017. RESULTS: We found 299 procedures: 82 (27.4%), 147 (49.2%) and 70 (23.4%) in women with BMI <25 (normal weight), BMI ≥ 25 - < 30 (overweight) and BMI ≥ 30 (obese), respectively. Perioperative and early postoperative complications were generally low and not statistically significantly different between the groups. At 12 months postoperatively, 81 (98.8%), 136 (92.5%) and 62 (88.6%) normal-weight, overweight and obese women attended their follow-up, respectively. All obese women attending the follow-up scored an overall Patient Global Impression of Improvement (PGI-I) of ≤ 3. The Pelvic Floor Distress Inventory (PFDI) scores showed a significant improvement in all domains and were similar between the study groups. In total, there was one (0.4%) anatomical apical compartment failure, three (1.1%) anterior compartment failures and two (0.7%) posterior compartment failures with no significant differences between the groups. Similarly, there were no differences in functional outcomes or mesh position as assessed by ultrasound. CONCLUSIONS: There were no differences in surgical, short- and long-term outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse in obese compared with non-obese women.

Metrics of perineal support (MOPS) study.

BACKGROUND: Manual perineal protection (MPP) is an intrapartum intervention suggested to protect perineal integrity during childbirth. Proper execution of MPP is complex and evaluation of its true contribution is difficult in the clinical setting because of the large number of obstetric variables, some of which are hardly quantifiable. In this study we aimed to gather initial data on the forces executed by the accoucheur's thumb, index and middle fingers during MPP at the time of fetal head expulsion, quantify the duration of the intervention and investigate the timely interaction of the different components of MPP. METHODS: Two bespoke right-handed measurement gloves (MG), with built in sensors, were designed and produced. The MG allowed the electronic real-time measurement of applied forces during MPP and transferred this data wirelessly to an integrated computer system. Sterile gloves were worn over the MG when used at the time of birth. The study was undertaken between January and December 2019. Singleton, term pregnant women having their first vaginal birth who provided a valid written consent were enrolled into this prospective pilot study. All deliveries were undertaken by one of two obstetricians experienced in MPP. RESULTS: Twenty women were enrolled. The mean duration of execution of MPP during the last contraction was 13.6 s. In 20% it lasted < 5 s. The overall mean values of the average and maximum forces of the thumb, index and middle fingers were 26.7 N; 25.5 N; 20.2 N and 34.3 N; 32.6 N; and 27.6 N respectively. The onset of fingers and thumb activity was simultaneous in 13 cases (65%), while in seven (35%) deliveries the middle finger's force activity was initiated later. CONCLUSIONS: MPP during fetal head expulsion happens over a short period of time. In the majority of cases the thumb and fingers actions started simultaneously. There were differences in the duration of application and the forces executed by the fingers and thumb between the two practitioners, however this was only significant for thumb measurements. The results obtained will aid in improving further MPP modeling studies to optimize the technique.

Manual perineal protection: The know-how and the know-why.

Manual perineal protection is an obstetric intervention to mitigate the risk of perineal trauma. There are two effective techniques (Finnish and Viennese) with minor but distinctive differences in between them. The main aim of this study was to explore clinicians' knowledge about the manual perineal protection technique they use. The study took place in three maternity units that support manual perineal protection policy in three European countries (Czech Republic, Slovenia and the UK). Our study demonstrated that the majority of participants are aware of the concept of manual perineal protection. However, there were significant differences between staff responses regarding their views and experience with manual perineal protection in general. Less than 6% of respondents were able to provide an accurate account of the actual maneuvers they perform when manually protecting the perineum. Although this is not necessarily synonymous with suboptimal performance, it highlights the potential need to give more attention to the theory that underpins the technical skill in manual perineal protection training programs.

Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey).

BACKGROUND: The aim of this study was to explore the personal views of female gynecologists regarding the management of POP with a particular focus on the issue of uterine sparing surgery. METHODS: A questionnaire based survey of practicing female gynecologists in the Czech Republic, Slovenia and Slovakia. RESULTS: A total of 140 female gynecologists from 81 units responded to our questionnaire. The majority of respondents stated they would rely on a urogynecologist to aid them with their choice of POP management options. The most preferred options for POP management were sacrocolpopexy and physiotherapy. Almost 2/3 of respondents opted for a hysterectomy together with POP surgery, if they were menopausal, even if the anatomical outcome was similar to uterine sparing POP surgery. Moreover, 81.4% of respondents, who initially opted for a uterine sparing procedure, changed their mind if the anatomical success of POP surgery with concomitant hysterectomy was superior. Discussing uterine cancer risk in relation to other organs had a less significant impact on their choices. CONCLUSIONS: The majority of female gynecologists in our study opted for hysterectomy if they were postmenopausal at the time of POP surgery. However, variation in information provision had an impact on their choice.

Assessment of the effect of platelet rich plasma on the healing of operated sacrococcygeal pilonidal sinus by lay-open technique: a randomized clinical trial.

BACKGROUND: Sacrococcygeal pilonidal sinus disease (PSD) is an infection of the skin and subcutaneous tissue at the upper part of the natal cleft of the buttocks. Excision and healing by granulation "lay-open" method is still more preferable than other methods of midline closure or using flaps but the healing time is lengthy. The present study was performed to assess the healing promotion effect of platelet-rich plasma (PRP) on the pilonidal sinus wounds treated by the lay-open method. METHODS: One hundred patients suffering from PSD were randomly divided into two groups, they were treated by the lay-open method, at General surgery department, Kafr El-Sheik University hospital, Egypt, during the period from December 2018 to December 2019. Group (A) was adopted the regular dressing postoperatively, while group (B) was treated with PRP injection into the wound at 4 and 12 postoperative days. RESULTS: Accelerated rate of wound healing was detected in group (B) in day 10, with a significant difference detected in days 15, 20, 25 and 30 postoperative, with a mean time of complete healing 45 ± 2.6 days in group B, while it was 57 ± 2.4 days in group A with a p-value of 0.001 which indicates considerable effect in the treated group. CONCLUSIONS: PRP injection is an effective new technique in accelerating the healing of pilonidal wound after surgery, with a significant decrease in post-operative pain, complications and an early return to work. TRIAL REGISTRATION: retrospectively registered. TRIAL REGISTRATION NUMBER: 12/35/1016 issued on December 2018 from the Institution Review Board at Kafr El Sheikh University. ClinicalTrials.gov identifier: NCT04430413.

Incidence of perineal pain and dyspareunia following spontaneous vaginal birth: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Perineal pain and dyspareunia are experienced by women undergoing a vaginal birth that can have short and longer term physical and psychological morbidities. This review aimed to determine the incidence of perineal pain and dyspareunia following spontaneous vaginal birth (SVB) with intact perineum, first and second-degree perineal trauma or episiotomy. METHODS: Searches of MEDLINE, EMBASE, CINAHL, AMED and MIDIRS (inception - December 2017) were undertaken with selection criteria of any study evaluating the effect of intact perineum, first- or second-degree perineal trauma on perineal pain or dyspareunia in women with SVB. RESULTS: Eighteen studies (8 RCTs and 10 NRSs) were included. Fourteen and 12 studies were undertaken to assess perineal pain and dyspareunia after SVB, respectively. Meta-analysis of 16 studies (3133 women) demonstrated that women at 2 days postpartum experienced nearly the same incidence of perineal pain whether perineal trauma existed or not. At 4-10 days postpartum there was a significant reduction in the incidence of perineal pain for both presence and absence of any perineal trauma. Episiotomy was associated with the highest rate of perineal pain. The incidence of dyspareunia was high at resumption of sexual intercourse following SVB with an intact perineum. At 12 months, women still experienced dyspareunia whether perineal trauma existed or not. CONCLUSIONS: Women experience perineal pain and dyspareunia regardless of the presence or absence of perineal trauma after SVB; nonetheless, the reported incidence is higher if perineal trauma occurred.

Timing of cesarean and its impact on labor duration and genital tract trauma at the first subsequent vaginal birth: a retrospective cohort study.

BACKGROUND: The objectives of this study were to explore the course of labor and the risk of obstetric anal sphincter injury at the first vaginal birth after cesarean section (fVBAC) in comparison to primiparous vaginal birth (PVB) in women without epidural analgesia and to assess if laboring before the previous cesarean affected these outcomes. METHODS: All fVBACs without epidural analgesia and the subsequent PVBs (controls) between 2012 and 2016 were included in this retrospective cohort study. Data were collected from health records and included maternal demographics, gestational age, and labor details (duration of 1st and 2nd stages, labor induction or augmentation, birthweight, operative vaginal birth, estimated blood loss, extent of childbirth trauma) in both groups as well as cervical dilation at the time of previous cesarean in the fVBAC group. Wilcoxon and Chi-square tests were used for data analyses. RESULTS: The study comprised 510 women; 255 fVBACs and 255 controls. The majority of fVBACs were after a pre-labor cesarean section - 177 (69.4%). There was a statistically significant difference in the recorded duration of first stage between the fVBACs and controls (289 vs. 347 min respectively, p < .001). Women were less likely to have an intact perineum in the fVBAC group (29.8 vs. 43.1%, p < 0.01), however, there was no statistically significant difference in anal sphincter injury rates between both groups (2.3 vs. 1.9%, p = 0.76). The groups differed in rates of cervical tears requiring suturing (21.2 vs. 12.9%, p = 0.01). On further subgroup analysis, the duration of first stage of labor was shorter in women who previously had a caesarean section late in labor (≥ 8 cm cervical dilatation) compared to a pre-labor cesarean section, however, there were no differences in other outcomes. CONCLUSION: Compared to primiparous women having a vaginal birth, women having their first vaginal birth after a cesarean section have a shorter 1st stage of labor (particularly if the cesarean was performed in advanced labor), a higher risk of sustaining cervical lacerations and perineal trauma. However, there was no difference in the risk of sustaining obstetric anal sphincter injuries between the study groups.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence. METHODS: This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ2-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis. RESULTS: A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3. CONCLUSION: The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities. STUDY REGISTRATION NUMBER: ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.