Progesterone concentrations on blastocyst transfer day in modified natural cycle frozen embryo transfer cycles.

RESEARCH QUESTION: Are serum progesterone concentrations on the day of modified natural cycle (mNC) frozen blastocyst transfer (FET) without luteal phase support (LPS) associated with clinical pregnancy rate (CPR)? DESIGN: Data were collected between January 2019 and October 2022 as a sub-study of an ongoing randomized controlled trial assessing pregnancy outcomes in mNC-FET. The sub-study included all women (n = 209) randomized to mNC-FET without LPS at the time of data extraction. Participants were aged 18-41 years, had regular menstrual cycles and underwent mNC-FET treatment with single-blastocyst transfer. Associations between the serum progesterone concentration on the day of blastocyst transfer and CPR, pregnancy rate and pregnancy loss rate (PLR) were examined between groups with low and higher progesterone concentrations using the 25th and 10th percentiles as cut-offs. Multivariate logistic regression analyses were performed to adjust for potential confounding factors. RESULTS: Progesterone concentrations on the day of blastocyst transfer in mNC-FET without LPS ranged from 4.9 to 91.8 nmol/l, with the 25th and 10th percentiles at 29.0 nmol/l and 22.5 nmol/l, respectively. Serum progesterone concentrations did not differ between women with or without a clinical pregnancy (mean [SD] 38.5 [14.0] versus 36.8 [12.4] nmol/l; P = 0.350). Furthermore, the CPR, pregancy rate and PLR were similar in women with low or high progesterone concentrations when using the 25th or the 10th progesterone percentile as cut-off. Multivariate regression analyses showed no association between progesterone concentrations and CPR. CONCLUSIONS: No association was found between progesterone concentration on the day of blastocyst transfer and pregnancy outcome in women undergoing mNC-FET without progesterone LPS.

The effect of exercise training and motivational counselling on physical activity behaviour and psychosocial factors in pregnant women: secondary analyses of the FitMum randomised controlled trial investigating prenatal physical activity.

BACKGROUND: A physically active lifestyle is beneficial during pregnancy. However, little is known about physical activity (PA) behaviour and psychosocial factors in women during and after pregnancy. This study examined exercise behavioural regulation, exercise self-efficacy, health-related quality of life, sickness absence and musculoskeletal pain in pregnant women offered either structured supervised exercise training, motivational counselling on PA, or standard prenatal care in the FitMum randomised controlled trial. METHODS: Two hundred and eighteen healthy inactive pregnant women were randomised to structured supervised exercise training (n = 87), motivational counselling on PA (n = 86) or standard prenatal care (n = 45). The women answered the Behavioural Regulation in Exercise Questionnaire-2 (BREQ-2), the Pregnancy Exercise Self-Efficacy Scale (P-ESES-DK) and the Short Form 36 Health Survey Questionnaire (SF-36) at baseline (gestational age (GA) of max 15 weeks), GA 28 and 34 weeks, and one year after delivery. Sickness absence and low back and/or pelvic girdle pain were likewise reported in questionnaires at baseline and GA 28 weeks. RESULTS: Participants offered structured supervised exercise training or motivational counselling on PA had higher autonomous motivation for exercise during pregnancy compared with participants receiving standard prenatal care (e.g., difference in intrinsic regulation at GA 28 weeks, structured supervised exercise training vs. standard prenatal care: mean difference in score 0.39 [0.16; 0.64], p < 0.001). Participants offered structured supervised exercise training also had higher exercise self-efficacy during pregnancy (e.g., GA 28 weeks, structured supervised exercise training vs. standard prenatal care: mean difference in score 6.97 [2.05; 12.02], p = 0.005). All participants reported high exercise self-efficacy at baseline and medium exercise self-efficacy during pregnancy and one year after delivery. No differences were found between groups in health-related quality of life, sickness absence or low back and/or pelvic girdle pain during pregnancy. No group differences were found one year after delivery. CONCLUSION: Structured supervised exercise training and motivational counselling on PA had important effects on autonomous exercise motivation during pregnancy. Exercise self-efficacy was also increased with structured supervised exercise training compared to standard prenatal care. No group differences in health-related quality of life, sickness absence, or pain were found during and after pregnancy. No effects were found one year post-delivery after intervention cessation. TRIAL REGISTRATION: The study was approved by the Danish National Committee on Health Research Ethics (#H-18011067) and the Danish Data Protection Agency (#P-2019-512). The study adheres to the principles of the Helsinki declaration. Written informed consent was obtained at inclusion.

Risk of Bowel Obstruction after Hysterectomy for Benign Indication According to Surgical Method in Denmark, 1984-2013.

STUDY OBJECTIVE: To estimate the risk of bowel obstruction (BO) after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive BO. DESIGN: A national registry-based cohort. SETTING: Danish hospitals during the period 1984-2013. PATIENTS: Danish women who underwent hysterectomy for benign indications (N = 125 568). INTERVENTIONS: Abdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies. MEASUREMENTS AND MAIN RESULTS: The incidence of BO according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, previous abdominal surgery or disease, and socioeconomic factors. In a subanalysis (n = 35 712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-, surgery-, and complication-related covariates. The overall crude incidence of BO was 17.4 of 1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of BO differed among the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple-adjusted analyses, the risk of BO was higher after abdominal hysterectomy than after vaginal (hazard ratio 1.64 [95% confidence interval, 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (hazard ratio 1.54 [1.33-1.79]). Additional pre-existing risk factors for BO at the time of hysterectomy were increased age, low education, low income, smoking, high American Society of Anesthesiologists comorbidity score, history of infertility, abdominal infection, and previous abdominal surgery (apart from cesarean section), penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications. CONCLUSION: Abdominal hysterectomy is associated with a 54% higher risk of BO than minimally invasive (laparoscopic or vaginal) hysterectomy.

Preterm children born below 33-35 weeks of gestation have an increased risk of mathematical difficulties.

AIM: To investigate the association between gestational age (GA) and grade point averages by domains of language and mathematics at the end of lower secondary education. METHODS: A nationwide register-based study including all Danish children born in 1992-1997 who completed lower secondary education. Grades were evaluated by GA. Domain-specific differences in grades were investigated, and academic profiles were made. RESULTS: The study population comprised 319 796 children. For language, only minor differences in grades were observed. The grades in mathematics ranged from 7.02 (95% confidence interval [CI]: 7.00-7.04) at GA = 40 weeks to 5.86 (95% CI: 5.61-6.11) at GA <28 weeks. Grade differences showed lower grades in mathematics, compared to language, below GA 33-35 weeks. The academic profile of mathematical difficulties was more prevalent among GA <32 weeks. Average/high grades within both domains represented the predominant academic profile, constituting 68.8% at GA 39-41 weeks and 56.6% at GA <28 weeks. CONCLUSION: Only in mathematics decreasing GA was associated with lower grades. Increased mathematical difficulties were found below GA 33-35 weeks. The academic profile of mathematical difficulties was more prevalent among GA <32 weeks. However, the absolute differences in grades were small, and the predominant academic profile was average/high grades within both domains across all GA.

Poor socioeconomic outcomes: Completion of the final examination after lower secondary education mitigates risks associated with gestational age.

AIM: To investigate the influence of gestational age (GA) on the association between completion of the final examination after 10-11 years of basic education and education, financial independence and income in early adulthood. METHODS: A nationwide register-based study including individuals born in Denmark between 1990 and 1992. Completion of the examination was evaluated at age 18 and education, financial independence and income at age 28. RESULTS: Of 165 683 individuals included, 15.7%, 10.8% and 5.5% had low educational level, were not financially independent and had low income. For those who completed the examination odds ratio (OR) ranged from 1.03 at GA = 32-36 weeks to 1.25 at ≤27 weeks for low education, from 1.10 to 0.91 for not being financial independent and from 1.06 to 1.48 for low income. For those who did not complete the examination, OR increased from 7.55 at ≥37 weeks to 15.03 at ≤27 weeks for low education and from 4.68 to 15.31 for not being financial independent. For low income, OR was 2.57 and independent of GA. CONCLUSION: For individuals who completed the examination, the odds of poor socioeconomic outcomes were independent of GA. Individuals who did not complete the examination had increased odds of poor socioeconomic outcomes, particularly as GA decreased.

Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials.

BACKGROUND: Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods. METHODS: We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924). FINDINGS: Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95-1·24; I2=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91-1·58; I2=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71-1·04; I2=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70-0·92; I2=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89-1·18; I2=0%). INTERPRETATION: In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events. FUNDING: Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

Does luteal phase progesterone supplementation affect physical and psychosocial well-being among women undergoing modified natural cycle-FET? A sub-study of a randomized controlled trial.

STUDY QUESTION: Are there any differences in physical and psychosocial well-being among women undergoing modified natural cycle frozen embryo transfer (mNC-FET) with or without vaginal progesterone as luteal phase support (LPS)? SUMMARY ANSWER: Women undergoing mNC-FET with vaginal progesterone supplementation were more likely to experience physical discomfort but there was no difference in psychosocial well-being between the two groups. WHAT IS KNOWN ALREADY: mNC-FET can be carried out with or without vaginal progesterone as LPS, which has several side-effects. It is commonly known that fertility treatment can cause stress and psychosocial strain, however, most studies on this subject are conducted in fresh cycle regimes, which differ from NC-FET and results may not be comparable. STUDY DESIGN, SIZE, DURATION: This is a sub-study of an ongoing RCT investigating whether progesterone supplementation has a positive effect on live birth rate in mNC-FET. The RCT is conducted at eight fertility clinics in Denmark from 2019 and is planned to end primo 2024. The sub-study is based on two questionnaires on physical and psychosocial well-being added to the RCT in August 2019. On the time of data extraction 286 women had answered both questionnaires. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women who had answered both questionnaires were included in the sub-study. Participants were equally distributed, with 143 in each of the two groups. Participants in both groups received the same questionnaires at two time-points: on cycle day 2-5 (baseline) and after blastocyst transfer. Participants in the progesterone group had administered progesterone for 7 days upon answering the second questionnaire. All items in the questionnaires were validated. Items on psychosocial well-being originate from the Copenhagen Multi-Centre Psychosocial Infertility-Fertility Problem Stress Scale (COMPI-FPSS) and from the Mental Health Inventory-5. MAIN RESULTS AND THE ROLE OF CHANCE: Women receiving progesterone experienced more vaginal itching and/or burning than women in the non-progesterone group (P < 0.001). Women in the progesterone group also experienced more self-reported vaginal yeast infection, this was, however, not significant after adjustment for multiple testing (P/adjusted P = 0.049/0.881). No differences regarding psychosocial well-being were found between the two groups. Within the progesterone group, a shift toward feeling less 'downhearted and blue' was found when comparing response distribution at baseline and after blastocyst transfer (P < 0.001). LIMITATIONS, REASONS FOR CAUTION: All items on physical symptoms were self-reported. The item on vaginal yeast infection was therefore not diagnosed by a doctor. Inclusion in the study required a few extra visits to the clinic, participants who felt more burdened by fertility treatment might have been more likely to decline participation. Women who experienced a lot of side-effects to progesterone prior to this FET cycle, might be less likely to participate. WIDER IMPLICATIONS OF THE FINDINGS: Our results are in line with previous known side-effects to progesterone. Physical side-effects of progesterone should be considered before administration. STUDY FUNDING/COMPETING INTEREST(S): The RCT is fully supported by Rigshospitalet's Research Foundation and a grant from Gedeon Richter. Gedeon Richter were not involved in the design of protocol nor in the conduction of the study or analysis of results. A.P., L.P., and N.I.-C.F. report grants from Gedeon Richter, Ferring and Merck with no relations to this study. N.I.-C.F. has received travel support from Ferring, Merck A/S, & Gideon Richter, and is the head of the steering committee for the Danish Fertility Guidelines made by the members of from the Danish Fertility Society. A.P. reports consulting fees from Preglem, Novo Nordisk, Ferring, Gedeon Richter, Cryos, & Merck A/S, honoraria from Gedeon Richter, Ferring, Merck A/S, Theramex, and Organon, has received travel support from Gedeon Richter (payment to institution), participated on an advisory board for Preglem and was loaned an embryoscope from Gedeon Richter to their institution. A.L.S. has stock options for Novo Nordisk B A/S. B.A. have received unrestricted grant from Gedeon Richter Nordic and Merck and honoraria for lectures from Gedeon Richter, Merck, IBSA, and Marckyrl Pharma. TRIAL REGISTRATION NUMBER: The RCT is registered on ClinicalTrials. gov (NCT03795220) and in EudraCT (2018-002207-34).

Adherence to recommended physical activity restrictions due to threatened preterm delivery - a descriptive multi-center study.

BACKGROUND: Threatened preterm delivery is a serious obstetrical complication and has for decades been prescribed physical activity restrictions (AR). Adherence to the recommended level of physical AR is however unknown. This study aimed to assess the objectively measured different physical positions and activities of pregnant women recommended AR due to threatened preterm delivery complications, compared to a reference group of uncomplicated pregnant women without restrictions, and to explore if admission status influenced adherence to AR. METHODS: A Danish descriptive, clinical multi-center study included singleton pregnancies between 22-33 gestational weeks admitted to an antenatal ward or during midwife consultations either prescribed AR due to threatened preterm delivery or uncomplicated controls without restrictions. For seven days participants wore two tri-axial accelerometric SENS® monitors. Accelerometric data included time spent in five different positions, activities, and step counts. At inclusion demographic and obstetric information was collected. RESULTS: Seventy-two pregnant women participated; 31% were prescribed strict AR, 15% moderate, 3% light, 8% unspecified, and 43% had no AR. Strict AR participants rested in the supine/lateral position for 17.7 median hours/day (range:9.6-24.0); sat upright 4.9 h/day (0.11-11.7); took 1,520steps/day (20-5,482), and 64% were inpatients. Moderate AR participants rested in the supine/lateral position for 15.1 h/day (11.5-21.6); sat upright 5.6 h/day (2.0-9.3); took 3,310steps/day (467-6,968), and 64% were outpatients. Participants with no AR rested 10.5 h/day (6.3-15.4) in supine/lateral position; sat upright 7.6 h/day (0.1-11.4) and took 9,235steps/day (3,225-20,818). Compared to no restrictions, participants with strict or moderate AR spent significant more time in physical resting positions and took significant fewer mean steps. Among strict AR admission status did not alter time spent in the physical positions, nor the step count. CONCLUSIONS: Overall, participants adhered highly to the recommended AR. However, discriminating between strict and moderate AR recommendations did not alter how physical resting positions and activities were carried out. The admission status did not influence how participants adhered to strict AR.

Effects of prenatal exercise on gestational weight gain, obstetric and neonatal outcomes: FitMum randomized controlled trial.

BACKGROUND: To investigate the effects of two different exercise interventions during pregnancy on gestational weight gain (GWG) and obstetric and neonatal outcomes compared to standard care. Additionally, we aimed to improve standardization of GWG measurements by developing a model to estimate GWG for a standardized pregnancy period of 40 weeks and 0 days accounting for individual differences in gestational age (GA) at delivery. METHODS: In a randomized controlled trial we compared the effects of structured supervised exercise training (EXE) three times per week throughout pregnancy versus motivational counselling on physical activity (MOT) seven times during pregnancy with standard care (CON) on GWG and obstetric and neonatal outcomes. Uniquely, to estimate GWG for a standardized pregnancy period, we developed a novel model to predict GWG based on longitudinally observed body weights during pregnancy and at admission for delivery. Observed weights were fitted to a mixed effects model that was used to predict maternal body weight and estimate GWG at different gestational ages. Obstetric and neonatal outcomes, among them gestational diabetes mellitus (GDM) and birth weight, were obtained after delivery. GWG and the investigated obstetric and neonatal outcomes are secondary outcomes of the randomized controlled trial, which might be underpowered to detect intervention effects on these outcomes. RESULTS: From 2018-2020, 219 healthy, inactive pregnant women with median pre-pregnancy BMI of 24.1 (21.8-28.7) kg/m2 were included at median GA 12.9 (9.4-13.9) weeks and randomized to EXE (n = 87), MOT (n = 87) or CON (n = 45). In total 178 (81%) completed the study. GWG at GA 40 weeks and 0 days did not differ between groups (CON: 14.9 kg [95% CI, 13.6;16.1]; EXE: 15.7 kg [14.7;16.7]; MOT: 15.0 kg [13.6;16.4], p = 0.538), neither did obstetric nor neonatal outcomes. For example, there were no differences between groups in the proportions of participants developing GDM (CON: 6%, EXE: 7%, MOT: 7%, p = 1.000) or in birth weight (CON: 3630 (3024-3899), EXE: 3768 (3410-4069), MOT: 3665 (3266-3880), p = 0.083). CONCLUSIONS: Neither structured supervised exercise training nor motivational counselling on physical activity during pregnancy affected GWG or obstetric and neonatal outcomes compared to standard care. TRIAL REGISTRATION: ClinicalTrials.gov; NCT03679130; 20/09/2018.

Autologous Blood-Derived Patches Used as Anti-adhesives in a Rat Uterine Horn Damage Model.

BACKGROUND: Intra-abdominal adhesions are frequent side effects of surgery, associated with risks of serious complications such as abdominal pain, infertility, and small bowel obstruction. This study investigated a new autologous blood-based approach to adhesion prophylaxis. MATERIALS AND METHOD: Two autologous blood-derived patches (whole-blood-derived, n = 20, and plasma-derived, n = 20) were evaluated as anti-adhesives. The patches were tested in a rat uterine horn damage model. We simulated an intraabdominal surgery by cauterizing and suturing the uterine horns and created an opposing damage by denuding a part of the abdominal wall. Each rat served as its own control with one treated uterine horn and one untreated. After 14 d of post-surgical recovery, the adhesions were assessed and graded macroscopically and microscopically. Statistical analyses were performed with Wilcoxon signed rank and Mann-Whitney U tests. RESULTS: Both whole-blood and plasma-derived patches resulted in significantly less macroscopic adhesions than were found in untreated uterine horns (P = 0.001 and P = 0.002, respectively). Unpaired analysis found no significant differences between the whole-blood and plasma-derived patch outcomes in this study design. Histopathological evaluation of inflammation and fibrosis did not reveal significant differences between the patches and their matched controls. CONCLUSIONS: The autologous blood-derived patches reduced macroscopic adhesion formation significantly compared with no treatment. There were no adverse events and no histological differences between treatment and control, suggesting that the treatments were feasible and safe. In summary, this study confirms the potential of autologous anti-adhesives for the use in intraabdominal surgery.

Mirtazapine exposure in pregnancy and fetal safety: A nationwide cohort study.

OBJECTIVE: To investigate the association between mirtazapine exposure in pregnancy and risk of specific adverse pregnancy outcomes. METHODS: A register-based nationwide cohort study was conducted including all registered pregnancies in Denmark from 1997 to 2016. Mirtazapine-exposed pregnancies were compared with mirtazapine unexposed pregnancies in a 1:4 ratio matched according to propensity scores. Outcomes were major congenital malformations analyzed using log binomial models, and spontaneous abortion, stillbirth and neonatal death analyzed using Cox proportional hazard regression. RESULTS: From a source population of 1,650,649 pregnancies, the propensity score-matched cohort included 4475 pregnancies (895 mirtazapine exposed) in the analysis of major congenital malformations. The analyses of spontaneous abortion included 9 500 pregnancies (1900 mirtazapine exposed), and for the analyses of stillbirths and neonatal deaths 9725 (1 945 mirtazapine-exposed) and 4485 pregnancies (897 mirtazapine-exposed) were included, respectively. Thirty-one (3.5%) children were diagnosed with major congenital malformation among the mirtazapine exposed compared with 152 (4.3%) among the unexposed pregnancies (OR=0.81, 95% CI 0.55-1.20). Spontaneous abortion occurred in 237 (12.5%) of the mirtazapine exposed compared with 931 (12.3%) of the unexposed pregnancies (HR = 1.04%, 95% CI 0.91-1.20). The analyses revealed no increased risk of stillbirth (HR = 0.88%, 95% CI 0.34-2.29) or neonatal death (HR = 0.60%, 95% CI 0.18-2.02). CONCLUSIONS: In this nationwide Danish register study, mirtazapine exposure in pregnancy was not associated with major congenital malformations, spontaneous abortion, stillbirth, or neonatal death. Clinicians and patients can be reassured that mirtazapine is safe in pregnancy.

The evidence behind the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus: A state-of-the-art review.

In recent years, LASER has been introduced as a minimally invasive treatment for a broad range of vaginal and vulvar symptoms and diseases. However, the efficacy and safety of vaginal and vulvar LASER has continuously been questioned. The aim of this study is to create an overview of the current literature and discuss the controversies within the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus. A search string was built in PubMed. The search was commenced on August 25, 2021 and closed on October 27, 2021. Two authors screened the studies in Covidence for inclusion according to the eligibility criteria in the protocol. The data were extracted from the studies and are reported in both text and tables. This review included 114 papers, of which 15 were randomized controlled trials (RCTs). The effect of LASER as a vaginal treatment was investigated for genitourinary syndrome of menopause in 36 studies (six RCTs), vulvovaginal atrophy in 34 studies (four RCTs) and urinary incontinence in 30 studies (two RCTs). Ten studies (three RCTs) investigated the effect of vulvar treatment for lichen sclerosus. Half of the included RCTs, irrespective of indication, did not find a significant difference in improvement in women treated with vaginal CO2 or Er:YAG LASER compared with their respective controls. However, most non-comparative studies reported significant improvement after exposure to vaginal or vulvar LASER across all indications. Included studies generally had a short follow-up period and only a single RCT followed their participants for more than 6 months post treatment. Adverse events were reported as mild and transient and 99 studies including 51 094 patients provided information of no serious adverse events. In conclusion, this review found that the effect of vaginal and vulvar LASER decreases with higher study quality where potential biases have been eliminated. We therefore stress that all patients who are treated with vaginal or vulvar LASER should be carefully monitored and that LASER for those indications as a treatment should be kept on a research level until further high-quality evidence is available.

Postoperative infections after non-elective cesarean section - a retrospective cohort study of prevalence and risk factors at a single center in Denmark administering prophylactic antibiotics after cord clamping.

BACKGROUND: Mothers giving birth by non-elective cesarean section have considerably higher risk of developing postoperative infection, than mothers giving birth by elective cesarean section. Meta-analyses have shown that the risk of infection is reduced when administering antibiotics at least 30 min prior to skin incision rather than after cord clamping. If given prior to incision, antibiotics are present in the neonatal bloodstream for up to 24 h after delivery, with early exposure to antibiotics potentially disturbing development of the gut microbiome. We aimed to retrospectively assess the prevalence of postoperative infection after non-elective cesarean section at a single labor ward administering antibiotics after cord clamping, additionally investigating risk factors for developing postoperative infections. METHODS: In this retrospective cohort study, we included a total of 2,725 women giving birth by non-elective cesarean section in 2010-2017 with a review of records for prenatal risk factors, labor management, and perinatal outcomes. The primary outcomes were a main composite infection of development of either endometritis, surgical-site infection, or sepsis in conjunction with a relevant antibiotic prescription. Secondary outcomes included infection of unknown focus, mastitis, urinary tract infection, and pneumonia. RESULTS: A total of 88 patients developed a main composite infection (3.2%). These infections subdivide into endometritis (n = 37/2725, 1.4%), surgical-site infection (n = 35/2725, 1.3%) and sepsis (n = 15/2725, 0.6%). We found a high body mass index (aOR = 3.38, 95%CI 1.93-5.92) and intrapartum fever (aOR = 2.26, 95%CI 1.22-4.59) to be independent risk-factors for developing postoperative infection after non-elective cesarean section. Furthermore, we found delivery by a more expedient emergency grade 2 cesarean section (aOR = 0.61 95%CI 0.37-0.998) compared to grade 3 to be a protective factor for developing postoperative infection after non-elective cesarean section. CONCLUSION: In a labor ward administering antibiotics after cord clamping at non-elective cesarean births, we find a low prevalence of main composite infections when compared to estimates from meta-analyses on the topic. We conclude that administration of prophylactic antibiotics after cord clamping appears to result in acceptable rates of postoperative infection and avoids transplacental-transmission of antibiotics to the infant.

Physical activity in pregnancy: a mixed methods process evaluation of the FitMum randomised controlled trial interventions.

BACKGROUND: Physical activity (PA) at moderate intensity is recommended for healthy pregnant women. The three-arm FitMum randomised controlled trial showed that it was possible to increase PA level during pregnancy with structured supervised exercise training (EXE) compared to standard care. Motivational counselling on PA (MOT) did not increase PA. This process evaluation aims to understand the implementation and mechanisms of impact of EXE and MOT. METHODS: A mixed methods process evaluation was conducted using the UK Medical Research Council's process evaluation framework by assessing implementation (reach, fidelity, and dose) and mechanisms of impact of the two interventions provided to pregnant women in FitMum. Data was collected both quantitatively (n = 220) and qualitatively (n = 20). RESULTS: The FitMum trial reached educated pregnant women (80% having an educational level ≥ bachelor's degree) with high autonomy of everyday life. Most participants (58%) were recruited at their first-trimester ultrasonic scan. Reasons to participate were personal (91%) and altruistic (56%). The intervention dose was delivered as intended with high fidelity in the original physical intervention setup and in the altered online setup during the COVID-19 restrictions. A low dose received in EXE (1.3 [95% CI, 1.1; 1.5] sessions/week) was partly explained by the pre-scheduled EXE sessions favouring participants with a flexible everyday life and a supportive social network. Dose received in EXE increased during online intervention delivery. Participants in MOT received 5.2 [4.7; 5.7] of 7 sessions. Mechanisms of impact comprised a perception of intervention commitment among participants in EXE due to the scheduled EXE sessions, whereas participants in MOT considered themselves as PA self-determined. PA was considered as constrained activities in EXE and included in daily activities in MOT. CONCLUSION: The FitMum interventions was delivered with high fidelity. During COVID-19, the dose received in EXE increased compared to the previous physical setup. Mechanisms of impact as commitment, perception of empowerment and perception of PA as well as the paradox between prioritising PA and family and the need of a flexible everyday life need to be considered when offering pregnant women PA interventions. Future interventions should consider a combination of physical and online exercise training for pregnant women.

Effects of Structured Supervised Exercise Training or Motivational Counseling on Pregnant Women's Physical Activity Level: FitMum - Randomized Controlled Trial.

BACKGROUND: Physical activity (PA) during pregnancy is an effective and safe way to improve maternal health in uncomplicated pregnancies. However, compliance with PA recommendations remains low among pregnant women. OBJECTIVE: The purpose of this study was to evaluate the effects of offering structured supervised exercise training (EXE) or motivational counseling on PA (MOT) during pregnancy on moderate-to-vigorous intensity physical activity (MVPA) level. Additionally, complementary measures of PA using the Pregnancy Physical Activity Questionnaire (PPAQ) and gold standard doubly labeled water (DLW) technique were investigated. The hypotheses were that both EXE and MOT would increase MVPA in pregnancy compared with standard care (CON) and that EXE would be more effective than MOT. In addition, the association between MVPA and the number of sessions attended was explored. METHODS: A randomized controlled trial included 220 healthy, inactive pregnant women with a median gestational age of 12.9 (IQR 9.4-13.9) weeks. A total of 219 women were randomized to CON (45/219), EXE (87/219), or MOT (87/219). The primary outcome was MVPA (minutes per week) from randomization to the 29th gestational week obtained by a wrist-worn commercial activity tracker (Vivosport, Garmin International). PA was measured by the activity tracker throughout pregnancy, PPAQ, and DLW. The primary outcome analysis was performed as an analysis of covariance model adjusting for baseline PA. RESULTS: The average MVPA (minutes per week) from randomization to the 29th gestational week was 33 (95% CI 18 to 47) in CON, 50 (95% CI 39 to 60) in EXE, and 40 (95% CI 30 to 51) in MOT. When adjusted for baseline MVPA, participants in EXE performed 20 (95% CI 4 to 36) minutes per week more MVPA than participants in CON (P=.02). MOT was not more effective than CON; EXE and MOT also did not differ. MVPA was positively associated with the number of exercise sessions attended in EXE from randomization to delivery (P=.04). Attendance was higher for online (due to COVID-19 restrictions) compared with physical exercise training (P=.03). Adverse events and serious adverse events did not differ between groups. CONCLUSIONS: Offering EXE was more effective than CON to increase MVPA among pregnant women, whereas offering MOT was not. MVPA in the intervention groups did not reach the recommended level in pregnancy. Changing the intervention to online due to COVID-19 restrictions did not affect MVPA level but increased exercise participation. TRIAL REGISTRATION: ClinicalTrials.gov NCT03679130; https://clinicaltrials.gov/ct2/show/NCT03679130. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-043671.

A prospective cohort study of confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy evaluating SARS-CoV-2 antibodies in maternal and umbilical cord blood and SARS-CoV-2 in vaginal swabs.

INTRODUCTION: Evidence about the consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is rapidly increasing; however, data on antibody response and risk of transmission during pregnancy and delivery are still limited. The aim of this study was to evaluate if SARS-CoV-2 is detectable in vaginal swabs and whether antibodies against SARS-CoV-2 are present in maternal and umbilical cord blood of pregnant women with confirmed SARS-CoV-2. MATERIAL AND METHODS: A single-unit prospective cohort study in Denmark including pregnant women with SARS-CoV-2 infection confirmed by a pharyngeal swab between August 20, 2020, and March 1, 2021, who gave birth during the same period. All patients admitted to the maternity ward and antepartum clinic were screened for SARS-CoV-2 infection. A maternal blood sample and vaginal swabs were collected at inclusion. If included antepartum, these samples were repeated intrapartum when an umbilical cord blood sample was also collected. Swabs were analyzed for SARS-CoV-2 and blood samples were analyzed for SARS-CoV-2 total antibodies. Placental and neonatal swabs as well as placental histopathological examinations were performed on clinical indications. RESULTS: We included 28 women, of whom four had serious maternal or fetal outcomes including one case of neonatal death. Within the first 8 days after confirmed SARS-CoV-2 infection, SARS-CoV-2 was detectable in two vaginal swabs (2/28) and SARS-CoV-2 antibodies were detected in 1 of 13 women. From 16 days after confirmed infection, antibodies were observed in 19 of 21 of women. Antibodies in cord blood were not detected during the first 16 days after confirmed infection (n = 7). However, from 26 days, antibodies were present in 16 of 17 cord blood samples of seropositive mothers. Placental examination in two cases of severe fetal outcomes preceded by reduced fetal movements revealed SARS-CoV-2 in swabs and severe histopathological abnormalities. CONCLUSIONS: SARS-CoV-2 was detected in only 2 of 28 vaginal swabs within 8 days after confirmed infection in pregnant women. Our data suggest that maternal seroconversion occurs between days 8 and 16, whereas antibodies in cord blood of seropositive mothers were present in the majority from 26 days after confirmed infection. Additional data are needed regarding timing of seroconversion for the mother and appearance of antibodies in cord blood.

Induction of labor with high- or low-dosage oral misoprostol-A Danish descriptive retrospective cohort study 2015-16.

INTRODUCTION: In Denmark, the rate of induced labor from 37 gestational weeks has increased by 108% from 12.4% in 2000 to 25.1% in 2012, and today more than 1 in 4 deliveries are induced. Standard procedure at North Zealand Hospital changed in 2016 from a dosage of 50 µg oral misoprostol 2-3 times daily, to 25 µg up to 8 times daily. Also, since 2016 healthy women with uncomplicated pregnancies (primiparous and multiparous) have been offered induction as an outpatient procedure. This study aimed to compare the current low-dosage procedure (25 µg) with the former high-dosage procedure (50 µg) in terms of induction to delivery time, maternal and fetal outcomes, and risk of uterine hyperstimulation. MATERIAL AND METHODS: Data from June 2015 to October 2016 were included. Comparable baseline, demographic, and obstetric data for women induced according to high-dosage or low-dosage protocols were retrieved from local medical files. Descriptive statistics, Pearson's chi-squared tests, Kaplan-Meier survival estimates, and logistic regression analyses were performed. RESULTS: The study included 816 induced deliveries. The high- and low-dosage groups differed in rates of plurality and place of induction. Induction to delivery times lasting longer than 72 hours were significantly decreased in the low-dosage group (adjusted odds ratio [aOR] 0.48, 95% confidence interval [95% CI] 0.27 to 0.86). Women in the low-dosage group also less often needed additional induction (P = 0.02), and the rate of uterine hyperstimulation was low irrespective of protocol (1% vs 3%, P = 0.16). There were no cases of uterine rupture in either group. The probability of vaginal delivery in the low-dosage group increased (adjusted hazard ratio 1.27, 95% CI 1.08 to 1.49), as did the risk of delivery with vacuum extraction (aOR 2.27, 95% CI 1.24 to 4.15), whereas delivery by cesarean section slightly decreased (aOR 0.89, 95% CI 0.59 to 1.33). The risk of meconium-stained liquor was nonsignificantly decreased (aOR 0.82, 95% CI 0.55 to 1.23). CONCLUSIONS: The low-dosage induction protocol was associated with favorable obstetric outcomes in terms of increased probability of vaginal delivery, but with higher risk of vacuum extraction. Protracted inductions and additional nonmedical interventions were reduced. There were no cases of uterine rupture. Statistically nonsignificant, the risk of uterine hyperstimulation was increased whereas the risk of meconium-stained liquor and of cesarean section was slightly decreased.

Maternal age and risk of cesarean section in women with induced labor at term-A Nordic register-based study.

INTRODUCTION: Over the last decades, induction of labor has increased in many countries along with increasing maternal age. We assessed the effects of maternal age and labor induction on cesarean section at term among nulliparous and multiparous women without previous cesarean section. MATERIAL AND METHODS: We performed a retrospective national registry-based study from Denmark, Finland, Iceland, Norway, and Sweden including 3 398 586 deliveries between 2000 and 2011. We investigated the impact of age on cesarean section among 196 220 nulliparous and 188 158 multiparous women whose labor was induced, had single cephalic presentation at term, and no previous cesarean section. Confounders comprised country, time-period, and gestational age. RESULTS: In nulliparous women with induced labor the rate of cesarean section increased from 14.0% in women less than 20 years of age to 39.9% in women 40 years and older. Compared with women aged 25-29 years, the corresponding relative risks were 0.60 (95% confidence interval [95% CI] 0.57 to 0.64) and 1.72 (95% CI 1.66 to 1.79). In multiparous induced women the risk of cesarean section was 3.9% in women less than 20 years rising to 9.1% in women 40 years and older. Compared with women aged 25-29 years, the relative risks were 0.86 (95% CI 0.54 to 1.37) and 1.98 (95% CI 1.84 to 2.12), respectively. There were minimal confounding effects of country, time-period, and gestational age on risk for cesarean section. CONCLUSIONS: Advanced maternal age is associated with increased risk of cesarean section in women undergoing labor induction with a single cephalic presentation at term without a previous cesarean section. The absolute risk of cesarean section is 3-5 times higher across 5-year age groups in nulliparous relative to multiparous women having induced labor.

Social ties between team members affect patient satisfaction: a data-driven approach to handling complex network analyses.

Research from outside the medical field suggests that social ties between team-members influence knowledge sharing, improve coordination, and facilitate task completion. However, the relative importance of social ties among team-members for patient satisfaction remains unknown. In this study, we explored the association between social ties within emergency teams performing simulated caesarean sections (CS) and patient-actor satisfaction. Two hundred seventy-two participants were allocated to 33 teams performing two emergency CSs in a simulated setting. We collected data on social ties between team-members, measured as affective, personal and professional ties. Ties were rated on 5-point Likert scales. In addition, participants' clinical experience, demographic data and their knowledge about team members' roles were surveyed. Perceived patient satisfaction was measured on a 5-point Likert scale. Data was analysed with a linear regression model using elastic net regularization. In total, 109 predictor variables were analysed including 84 related to social ties and 25 related to clinical experience, demographics and knowledge test scores. Of the 84 variables reflecting social ties, 34 (41%) had significant association with patient satisfaction, p < 0.01. By contrast, a significant association with patient satisfaction was found for only one (4%) of the 25 variables reflecting clinical experience, demographics and knowledge of team roles. Affective ties and personal ties were found to be far more important predictors in the statistical model than professional ties and predictors relating to clinical experience. Social ties between emergency team members may be important predictors of patient satisfaction. The results from this study help to enhance our conceptual understanding of social ties and their implications for team-dynamics. Our study challenges existing views of team-performance by placing emphasis on achieving collective competence through affective and personal social ties, rather than focusing on traditional measures of expertise.

Relation Between Infant Microbiota and Autism?: Results from a National Cohort Sibling Design Study.

BACKGROUND: Hypotheses concerning adverse effects of changes in microbiota have received much recent attention, but unobserved confounding makes them difficult to test. We investigated whether surrogate markers for potential adverse microbiota change in infancy affected autism risk, addressing unobserved confounding using a sibling study design. METHODS: This is a population-based, prospective cohort study including all singleton live births in Denmark from 1997 to 2010. The exposure variables were cesarean delivery and antibiotic use in the first 2 years of life. The outcome was a subsequent autism diagnosis. We used the between- and within-sibling model and compared it with sibling-stratified Cox models and simpler standard Cox models that ignored sibship. RESULTS: Of our study population including 671,606 children, who were followed for up to 15 years (7,341,133 person-years), 72% received antibiotics, 17.5% were delivered by cesarean, and 1.2% (8,267) developed autism. The standard Cox models predicted that both cesarean (compared with vaginal) delivery and antibiotics increased the risk of autism. In the sibling-stratified Cox model, only broader spectrum antibiotics were associated with increased risk of autism: hazard ratio (HR) = 1.16 (95% confidence interval = 1.01, 1.36). The between-within model estimated no exposure effects: intrapartum cesarean HR = 1.06 (0.89, 1.26); prelabor cesarean HR = 0.97 (0.83, 1.15); exclusively penicillin HR = 1.05 (0.93, 1.18); and broader spectrum antibiotics HR = 1.05 (0.95, 1.16). CONCLUSIONS: The between-within model rendered more precise estimates than sibling-stratified Cox models, and we believe that it also provided more valid estimates. Results from these preferred models do not support a causal relation between antibiotic treatment during infancy, cesarean delivery, and autism. See video abstract at, http://links.lww.com/EDE/B432.