Trend Changes in the individual contribution of risk factors for postpartum hemorrhage over more than two decades.

OBJECTIVE: Postpartum hemorrhage is an obstetric emergency with a rising incidence. The aim of this study was to identify trends in the specific contribution of various risk factors for postpartum hemorrhage by observing their odds ratios throughout different time periods. STUDY DESIGN: In this population-based retrospective cohort study trends of change in odds ratios for known risk factors for postpartum hemorrhage occurring in three consecutive eight-year intervals between 1988 and 2014 were compared. Two multivariable logistic regression models were used in order to identify independent risk factors for postpartum hemorrhage in our population. Trends of various risk factors were compared along the time period of the study. RESULTS: The incidence of postpartum hemorrhage increased from 0.5% to 1988 to 0.6%. Using logistic regression models, preeclampsia, vacuum extraction delivery, retained placenta, perineal or vaginal tears and delivery of a large for gestational age neonate were recognized as independent risk factors for postpartum hemorrhage. While the odds ratios for perineal or vaginal tears significantly increased, odds ratios for delivery of a large for gestational age neonate significantly decreased. Odds ratios for the other risk factors did not change significantly. CONCLUSION: In our study, not only did the rates of statistically significant risk factors for postpartum hemorrhage change during the study period, the specific contribution of each risk factor changed as well. Having a better understanding of these trends might augment our ability to predict this grave obstetric complication and improve maternal outcomes in the future.

Superimposed versus de novo pre-eclampsia: Is there a difference?

OBJECTIVE: To investigate whether pre-eclampsia is a single clinical entity or whether de novo pre-eclampsia and superimposed pre-eclampsia are distinct entities, with respect to baseline maternal characteristics, obstetrical complications, and perinatal outcomes. METHODS: A retrospective cohort study comparing singleton pregnancies complicated with de novo pre-eclampsia (n = 10 979, 93%) and superimposed pre-eclampsia (n = 804, 7%). Maternal baseline characteristics, pregnancy and labor complications, and neonatal outcomes were evaluated in the univariate analysis. Multivariable logistic regression models were performed for the prediction of different pregnancy outcomes while controlling for confounders. RESULTS: In the multivariate regression models controlling for confounders, superimposed pre-eclampsia was found to be a significant risk factor for placental dysfunction, a composite outcome composed of severe pre-eclampsia (rather than mild), placental abruption, oligohydramnios, and small-for-gestational-age neonate (odds ratio [OR] 2.23, 95% confidence interval [CI] 1.90-2.62, P < 0.001), preterm delivery (OR 2.79, 95% CI 2.39-3.26, P < 0.001), and perinatal mortality (OR 1.79, 95% CI 1.11-2.88, P = 0.02). CONCLUSION: De novo and superimposed pre-eclampsia demonstrated significant differences in most studied variables, suggesting that these may be two distinct clinical syndromes. In our population, superimposed pre-eclampsia was found to be significantly associated with adverse pregnancy outcomes such as placental dysfunction, preterm delivery, and perinatal mortality compared with de novo pre-eclampsia.

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

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

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

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

Easily generated hematological biomarkers and prediction of placental abruption.

OBJECTIVE: Placental abruption (PA) is associated with adverse maternal and neonatal outcomes. Increasing evidence has shown an association between abruption and inflammation as well as utilization of hematological biomarkers to predict the later. We aimed to evaluate the feasibility of using neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ration (PLR) taken early in pregnancy in predicting later occurrence of PA. STUDY DESIGN: A nested case control study, which compared parturient with PA (cases) to parturient without PA (controls). Parturient were matched by hospitalization date and maternal age. Demographic, clinical, and obstetrical characteristics were retrieved. Hematological indices derived from complete blood count taken during the first trimester of pregnancy, specifically NLR and PLR were retrieved and compared between the groups. Mann-Whitney and T-test were performed for not normally and normally distributed continuous variables respectively, categorical variables were analyzed using Chi-Square or Fisher Exact test as appropriate. RESULTS: The study comprised of 232 patients. Of these, 131 had suffered from PA and 131 without PA. Parturient who had PA has significantly higher rates of hypertensive disorders of pregnancy, mean neutrophil, lymphocyte and platelet count did not differ between the groups. A comparison of NLR and PLR between the study groups yielded no significant differences. CONCLUSION: NLR and PLR taken early in the course of pregnancy were not found associated with PA. Given the potentially severe consequences of PA, the biological plausibility and the readiness of these hematological markers, further investigation of this method with larger, prospective studies are needed.

Third stage of labor placental complications and placenta-associated syndromes.

OBJECTIVE: To evaluate the association between third stage placental complications and placental insufficiency associated disorders, also known as, placenta associated syndromes. STUDY DESIGN: A population-based retrospective cohort study comparing placental-related perinatal outcomes of parturient with (study group) and without third stage placental complications, defined as a composite of retained placenta, adherent placenta, placenta accrete, need for manual removal of the placenta, postpartum curettage and revision of the uterine cavity. A univariate analysis was followed by a multivariable logistic regression model. RESULTS: During the study period, 263,023 deliveries met inclusion criteria, of which, 10,281 (3.9%) experienced placental complications during the third stage of labor. Parturient in the study group had significantly higher rates of placental insufficiency associated disorders which included among others: hypertensive disorders of pregnancy (6.5 versus 5.6%, p < .001), stillbirth (1.9 versus 0.7%, p < .001) and preterm delivery (9.9 versus 7.7%, p < .001). Using a multivariable regression model, while controlling for confounders such as maternal age and induction of labor, third stage placental complications were independently associated with placental insufficiency associated disorders. CONCLUSION: Our findings suggest that placental associated adverse pregnancy outcomes and third stage placental complications may represent different manifestations of a common pathological or inadequate placentation process.

Temporal decline in the improved detection rates following OASIS workshops.

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

Correction to: Trends of change in the individual contribution of risk factors for small for gestational age over more than 2 decades.

In the original article published, the name of the corresponding author is published incorrectly.

Trends of change in the individual contribution of risk factors for small for gestational age over more than 2 decades.

PURPOSE: Over the past years, the prevalence of various risk factors for small for gestational age (SGA) neonates has changed. Little is known if there was also a change in the specific contribution of these risk factors to the prevalence of SGA. We aim to identify trends in the specific contribution of various risk factors for SGA by observing their odds ratios (ORs) throughout different time periods. METHODS: A nested case-control study was conducted. The ORs for selected known risk factors for SGA occurring in three consecutive 8-year intervals between 1988 and 2014 (T1 - 1988-1996; T2 - 1997-2005; T3 - 2006-2014) were compared. Data were retrieved from the medical centre's computerized perinatal database. Multivariable logistic regression models were constructed and ORs were compared to identify the specific contribution of independent risk factors for SGA along the study period. RESULTS: During the study period, 285,992 pregnancies met the study's inclusion criteria, of which 15,013 (5.25%) were SGA. Between 1988 and 2014, the incidence of SGA increased from 2.6% in 1988 to 2.9% in 2014. Using logistic regression models, nulliparity, maternal age, gestational age, hypertensive disorders of pregnancy, oligohydramnios and pre-gestational diabetes mellitus were found to be independently associated with SGA. While the adjusted ORs (aOR) of hypertensive disorders of pregnancy and pre-gestational diabetes mellitus had increased, aORs for nulliparity, maternal age and gestational age had remained stable over time. Oligohydramnios had demonstrated a mixed trend of change over the time. CONCLUSION: In our study, the specific contribution of factors associated with SGA had changed over time. Having a better understating of the changes in the specific contribution of different risk factors for SGA may enable obstetricians to provide consultations.

Peritoneal adhesions do not increase intra-operative organ injury or adverse neonatal outcomes during a repeated cesarean delivery.

PURPOSE: To examine whether the presence of peritoneal adhesions at the second cesarean delivery (CD), attributable to the first CD, are associated with maternal intra-operative organ injury and adverse neonatal outcomes. METHODS: A retrospective cohort study was conducted, comparing severe maternal intra-operative organ injury and adverse neonatal outcomes, between women with and without peritoneal adhesions. All women with two CDs during the follow-up period were included. Women with adhesions diagnosed during the first CD, history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies and newborns with known chromosomal or structural abnormalities were excluded, resulting in 7925 women. Intra-operative peritoneal organ injury was defined as a composite of bladder injury, ureteral injury, small bowel injury or hysterectomy. The examined adverse neonatal outcomes were low 1 and 5 min Apgar scores, intrapartum death (IPD) and postpartum death (PPD). Multivariate logistic regression was performed. RESULTS: Peritoneal adhesions at the second CD, attributable to the first CD were diagnosed in 32.6% of patients (n = 2581). The presence of peritoneal adhesions was not found to be independently associated with intra-operative organ injury nor with 5 min Apgar scores, IPD and PPD. Second CDs complicated with adhesions were found to be associated with low (< 7) 1 min Apgar scores (adjusted OR 1.38, CI 1.20-1.58, p < 0.001). CONCLUSION: Adhesions attributable to a previous CD do not seem to increase the risk for intra-operative organ injury and adverse neonatal outcomes. These findings may assist in reassuring patients who are facing a second CD.

Trends of changes in the specific contribution of selected risk factors for shoulder dystocia over a period of more than two decades.

Objectives Shoulder dystocia (SD) is an obstetrical emergency with well-recognized risk factors. We aimed to identify trends of changes in the specific contribution of risk factors for SD over time. Methods A nested case control study comparing all singleton deliveries with and without SD was undertaken. A multivariable logistic regression model was used in order to identify independent risk factors for SD and a comparison of the prevalence and the specific contribution (odds ratio (OR)) of the chosen risk factors in three consecutive eight-year intervals from 1988 to 2014 was performed. Results During the study period, there were 295,946 deliveries. Of them 514 (0.174%) were complicated with SD. Between 1988 and 2014 the incidence of SD has decreased from 0.3% in 1988 to 0.1% in 2014. Using a logistic regression model grandmultiparity, diabetes mellitus (DM), fetal weight, and large for gestational age (LGA) were found to be independent risk factors for SD (OR 1.25 95% CI 1.04-1.51, p=0.02; OR 1.53 95% CI 1.19-1.97, p=0.001; OR 1.002 95% CI 1.001-1.002, p < 0.001; OR 3.88 95% CI 3.09-4.87, p < 0.001; respectively). While the OR for grandmultiparity, fetal weight, and LGA has significantly changed during the study period with a mixed trend, the OR of DM has demonstrated a significant linear increase over time. Conclusions The individual contribution of selected risk factors for the occurrence of SD has significantly changed throughout the years. The contribution of DM has demonstrated a linear increase over time, emphasizing the great impact of DM on SD.

Peritoneal adhesions during cesarean delivery are an independent risk factor for peri-partum hemorrhagic complications.

OBJECTIVE: To investigate whether the presence of peritoneal adhesions at the second cesarean delivery (CD) are associated with peri-partum hemorrhagic complications. STUDY DESIGN: A retrospective cohort study was undertaken, comparing hemorrhagic complications in the second CD, between women with and without adhesions. All women with two CDs who delivered a singleton in their second CD between the years 1988-2016 at a large regional medical center in Israel were included. Women with adhesions diagnosed at the first CD and women with a history of other abdominal or pelvic surgery, pelvic infection or inflammatory disease, endometriosis, uterine Mullerian anomalies and fetal chromosomal or structural abnormalities were excluded from the analysis, resulting in a sample of 7925 women. Peri-partum hemorrhagic complications were defined as a composite of vessel ligation, B lynch procedure during the CD or uterine rupture, third stage or immediate postpartum hemorrhage, blood component transfusion, hemorrhagic shock and maternal anemia [hemoglobin (Hb) levels prior to maternal discharge below 9.0 g\dl]. In order to identify variables that are independently associated with the composite peri-partum hemorrhagic complications a multivariate logistic regression analysis was performed, to control for potential confounders. In addition, a linear regression model was constructed with Hb levels as the outcome variable. RESULTS: During the study period, 32.6 % of patients (n = 2581) suffered from adhesions during the second CD. After adjusting for potential confounders, peri-partum hemorrhagic complications were found to be significantly associated with the presence of peritoneal adhesions (adjusted OR 1.18, CI 1.04-1.33, P = 0.008). A multivariate linear regression analysis revealed that peritoneal adhesions were independently associated with a decline in post-partum Hb levels (ß=-0.055, P < 0.001). CONCLUSION: Adhesions attributable to a previous CD increase the risk for hemorrhagic complications. Interventions aimed at preventing adhesions formation during the primary CD may have a role in reducing hemorrhagic complications in subsequent CDs.

The use of metronidazole in women undergoing obstetric anal sphincter injuries: a systematic review of the literature.

PURPOSE: Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. STUDY DESIGN: To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. RESULTS: The electronic database search yielded a total of 54,356 results (Fig. 1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.

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

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

Risk factors for obstetric anal sphincter injuries (OASIS) during vacuum extraction delivery in a university affiliated maternity hospital.

Introduction: Instrumental delivery is a well-known risk factor for obstetric anal sphincter injuries (OASIS). The specific characteristics among patient undergoing vacuum extraction delivery (VE) are less studied. Therefore, we aimed to evaluate risk factors for OASIS among parturient that underwent a VE delivery in a large university affiliated maternity hospital.Material and methods: The study population contained 9116 women who delivered by VE in tertiary medical center from 1988 to 2015. Inclusion criteria included deliveries beyond 24-week gestation. Multiple gestations and pregnancies complicated with stillbirth were excluded from the analysis. Maternal obstetric variables were compared between parturient with and without OASIS. Independent risk factors for OASIS were assessed by multivariable logistic regression modeling.Results: OASIS was diagnosed in 94 women (1.03%) following vacuum extraction. Among patients who underwent a VE delivery, gravidity and parity were found to be significantly lower in patients with OASIS. A multivariable logistic regression model with OASIS as the outcome variable revealed that among women who underwent VE, while episiotomy and delivery of a macrosomic neonate were not independently associated with OASIS, a strong association between nulliparity and OASIS was found (OR 3.34; 95% CI 1.93-5.78; p < .001).Conclusions: OASIS is uncommon in our population. Vacuum extraction in nulliparous parturient is a significant risk factor for OASIS. Our results should be taken into account when managing nulliparous deliveries.

Adherence to postpartum diabetes mellitus screening, do associated pregnancy complications make a difference?

AIMS: We aimed to investigate the impact of Gestational Diabetes Mellitus (GDM) complications on compliance with postpartum Diabetes screening. METHODS: A retrospective cohort study was conducted comparing screening rates of women with and without GDM associated complications who delivered at the Soroka University Medical Center, between 2016 and 2017. The screening test of choice was a 2-hour 75 g oral glucose tolerance test, taken 6-12 weeks after delivery. GDM associated complications included one or more of the following: polyhydramnios, macrosomia, shoulder dystocia or cesarean section. Univariate analysis was used in order to examine if GDM associated complications were associated with postpartum diabetes screening. RESULTS: During the study period a 164 women were included, of which, 82 women had suffered from GDM associated complications and comprised the study group and 82 women with GDM but without complications comprised the comparison group. Women in the study group were significantly older with a higher parity order. Induction rates were significantly higher among the comparison group, whereas, cesarean section rates were higher among the study group. No difference was noted with regard to neonatal outcomes. Women in the study group were not found to be more likely to be given screening recommendations at discharge (P = 0.50), at their postpartum visit (P = 0.36) or to perform DM screening postpartum (P = 0.17). CONCLUSION: Women with GDM associated complications had a higher rate of compliance to postpartum DM screening recommendations. However, in the current study this difference did not reach statistical significance.

Peritoneal adhesions are an independent risk factor for peri- and post-partum infectious morbidity.

OBJECTIVE: To investigate whether the presence of peritoneal adhesions during a second cesarean delivery resulting from the first cesarean delivery, are associated with peri- and post-partum infectious morbidity. STUDY DESIGN: A retrospective cohort study was undertaken, comparing maternal peri- and immediate post-partum infectious morbidity during the second cesarean delivery, between women with and without adhesions resulting from the first cesarean delivery. All women over 18 years old at their second cesarean delivery, with a singleton pregnancy between the years 1988-2016 were included in the analysis. Patients with previously diagnosed adhesions during the first cesarean delivery, a history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies, and births of newborns with known chromosomal or structural abnormalities were excluded from the analysis, resulting in a study population of 7925 women. Infectious morbidity was defined as a composite of chorioamnionitis, post-partum fever, urinary tract infection and surgical wound infection or disruption. In order to identify factors that are independently associated with infectious morbidity, multivariate logistic regression analyses were constructed to control for potential confounders. RESULTS: During the study period, 32.6% (n = 2581) women were diagnosed with adhesions at the second cesarean delivery. Second cesarean deliveries complicated with adhesions were characterized by higher rates of peri- and post-partum maternal infectious morbidity (6.5% vs. 9%, p < 0.001). Our study population comprises two ethnic groups- Jewish (54.3%) and Bedouin Arabs (45.7%). We have tested interactions with adhesions of all predictor variables in the model. Since we found a strong interaction between adhesions and ethnicity, stratified data are presented. Infectious morbidity was significantly associated with the presence of peritoneal adhesions only among Jewish women (adjusted OR 2.09, PV < 0.001, 95% CI 1.56-2.80), adjusting for potential confounding variables and significant interactions. CONCLUSION: Cesarean delivery complicated with adhesions attributable to a previous cesarean delivery, increase the risk for peri- and immediate post-partum infectious morbidity among Jewish women.

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

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

Long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse: a systematic review.

PURPOSE: To focus attention on the long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse. METHODS: A systematic review was conducted including only studies with mean follow-up ≥ 5 years. We searched using combinations of the following keywords and text words: "episiotomy", "perineal laceration", "perineal tear", "perineal damage" and "long term", "long term outcomes", "prolapse", "pelvic organ prolapse", "pelvic floor", "pelvic floor dysfunction", "urinary incontinence", "hysterocele", "cystocele" and "rectocele". RESULTS: The electronic database search provided a total of 6154 results. After exclusions, 24 studies were included yielding the following results: (1) episiotomy might be detrimental with respect to urinary incontinence symptoms; (2) the relationship between episiotomy and anti-incontinence surgery is not clear; (3) episiotomy does not seem to negatively influence genital prolapse development and might even be protective with respect to prolapse severity and prevalence; (4) episiotomy does not seem to affect genital prolapse surgery rate. CONCLUSIONS: We did not find evidence for a long-term beneficial effect of episiotomy in the prevention of urinary incontinence symptoms and anti-incontinence surgery. Episiotomy does not seem to negatively influence genital prolapse development and might even be protective with respect to prolapse severity and prevalence without affecting surgery rates.