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.

Overactive Bladder Syndrome: Evaluation and Management.

Overactive bladder (OAB) syndrome is a chronic medical condition which has a major influence on the quality of life in a significant amount of the population. OAB affects performance of daily activities and has an estimated prevalence of 16.5%. Many sufferers do not seek medical help. Moreover, many family physicians and even gynecologists are not familiar with this issue. Usually patients suffer from OAB in advanced age. Nocturia is reported as the most bothersome symptom in the elderly population. The aim of our review was to discuss all aspects of this challenging disorder and suggest tools for assessment and management strategies. Practitioners can easily overlook urinary complains if they not directly queried. We would like to encourage practitioners to give more attention to this issue.

Failed Vacuum and the Long-term Hematologic Morbidity of the Offspring.

OBJECTIVE: We aimed to investigate the effect of failed vacuum delivery leading to an emergency cesarean delivery on the long-term pediatric hematologic morbidity of the offspring. STUDY DESIGN: In this population-based cohort study, the risk of long-term hematologic morbidity (up to the age of 18 y) was evaluated in children born following successful vacuum vaginal delivery, as compared with that of children born following a failed procedure leading to an emergent cesarean delivery. Multiple pregnancies and fetuses with congenital malformations were excluded. A Kaplan-Meier survival curve was constructed to compare cumulative pediatric hematologic morbidity, and a Cox proportional hazards model was used to control for confounders. RESULTS: A total of 7978 neonates met the inclusion criteria. Vacuum delivery was successful in 7733 cases (96.9%), whereas it failed in 245 cases (3.1%). Total hematologic morbidity of the offspring up to 18 years of age was comparable between the groups (1.6% vs. 0.8%, P=0.8). The Kaplan-Meier survival curve showed no difference in the cumulative incidence of total hematologic morbidity (log rank, P=0.22). In the Cox regression model, failed vacuum delivery was not independently associated with long-term hematologic morbidity, as compared with a successful procedure, while adjusting for multiple confounders (adjusted hazards ratio [HR], 1.8; 95% confidence interval, 0.7-5.0; P=0.25). CONCLUSIONS: Failed vacuum delivery does not seem to be associated with an increased risk for pediatric hematologic morbidity of the offspring up to 18 years of age.

Comparative analysis of early adverse events of pelvic organ prolapse repair with or without transvaginal mesh using Clavien-Dindo classification.

OBJECTIVE: To assess adverse events following surgical repair of pelvic organ prolapse (POP) with or without the use of transvaginal mesh. METHODS: The present retrospective study was conducted among women who underwent surgical POP repair at Soroka University Medical Center, Beer Sheva, Israel, between January 1, 2013, and December 31, 2015. Patients underwent anterior and posterior colporrhaphy either with transvaginal mesh (Elevate Prolapse Repair System; American Medical Systems, Minnetonka, MN, USA) or without transvaginal mesh (native tissue repair). Perioperative adverse events were assessed using the Clavien-Dindo classification; multivariate regression models were constructed to predict minor and major adverse events. RESULTS: There were 111 women included; 35 were treated with transvaginal mesh, and 76 underwent native tissue repair. Women undergoing native tissue repair had a lower mean grade of cystocele (P=0.023) and a higher rate of urinary stress incontinence (P=0.017) than patients treated with transvaginal mesh. The duration of surgery (P=0.002), duration of hospitalization (P<0.001), and the amount of blood loss (P=0.021) were lower in the native tissue repair group. Repair with transvaginal mesh was not associated with increased odds of major or minor adverse events (P>0.05 for all models examined). CONCLUSION: Perioperative and postoperative adverse events were comparable regardless of the operative approach.

Urine protein-to-creatinine ratio: a point of care for the diagnosis of preeclampsia.

BACKGROUND: The aim of this study was to determine the correlation between the urine protein-creatinine ratio (UPCR) and the 24-hour urine protein excretion test (UPET), and to identify the optimal threshold values of UPCR for the diagnosis of preeclampsia and its severe form. METHODS: This prospective cohort study included 81 hypertensive pregnant patients who had a 24-h UPET and a UPCR tests. Two groups were created using a UPCR cut-off of 23.2 mg/mmol (40 negative UPCR, 41 positive UPCR). RESULTS: Forty-nine patients of were diagnosed with preeclampsia, and 23 of them had a severe disease. There was a significant correlation between UPCR and 24-h UPET. A cut-off UPCR value of 23.2 mg/mmol had an area under the curve (AUC) of 0.27, sensitivity of 89%, specificity 88%, positive predictive value 90%, a positive likelihood ratio (+LR) of 7.41 and a negative likelihood ratio (-LR) of 0.13 for the diagnosis of preeclampsia. UPCR value of 325 mg/mmol had an AUC of 0.841, and a sensitivity of 83%, specificity 81%, positive predictive value 81%, +LR of 4.4 and -LR of 0.2 for the diagnosis of severe preeclampsia. CONCLUSIONS: The UPCR test is highly correlated with the 24-h UPET. We propose a novel and sensitive cut-off for the diagnosis of preeclampsia by UPCR test. The UPCR test can be used for the identification of hypertensive patients with preeclampsia and severe disease.

Late preterm and early term: when to induce a growth restricted fetus? A population-based study.

PURPOSE: (1) Compare fetal and neonatal morbidity and mortality associated with induction of labor (IOL) versus expectant management (EM) in women with isolated fetal growth restriction (FGR) between 340/7 and 386/7 weeks; (2) Determine optimal gestational age for delivery of such fetuses. MATERIALS AND METHODS: A retrospective population based cohort study of 2232 parturients with isolated FGR, including two groups: (1) IOL (n = 1428); 2) EM (n = 804). RESULTS: IOL group had a lower stillbirth and neonatal death rates (p = .042, p < .001), higher 1 and 5 min Apgar scores and a higher vaginal delivery rate compared to the EM group. In the late preterm period, EM was associated with increased rate of low 1 and 5 min Apgar scores, nonreassuring fetal heart rate tracing (NRFHR), stillbirth and neonatal death rate (p = .001, p = .039). In the early term cohort, EM was associated with a higher rate of NRFHR and low 1 min Apgar scores (p = .003, p = .002). IOL at 37 weeks protected from stillbirth but not from adverse composite neonatal outcomes. CONCLUSIONS: IOL of FGR fetuses at 37 weeks had a protective effect against stillbirth. In addition, at late preterm, it is associated with lower rates of stillbirth, neonatal death, and NRFHR.

Pregnancy outcomes in women with endometriosis.

BACKGROUND: The aim of this study was to investigate whether patients with endometriosis who achieved pregnancy have a higher risk for pregnancy complications and adverse perinatal outcomes as compared to patients without endometriosis. METHODS: The study compared obstetrical and perinatal outcomes of women with and without endometriosis who delivered between 1988-2013 at the Soroka University Medical Center. The study population included 504 deliveries divided into the following groups: 1) women with endometriosis (N.=35); and 2) without endometriosis (N.=467). Endometriosis was diagnosed by laparoscopy or laparotomy. Multiple logistic regression models were used to control for confounders. RESULTS: No significant increase in obstetrical complications was noted in the endometriosis group, but significantly higher rates of cesarean sections. Perinatal outcomes were comparable between the groups. CONCLUSIONS: In our population, endometriosis was not found as a risk factor for obstetrical complications or adverse perinatal outcomes. Larger population based cohort studies are needed to clarify the relationship between endometriosis and adverse pregnancy outcomes.

Postpartum uterine artery blood flow impedance following cesarean section or vaginal delivery.

PURPOSE: To compare uterine arteries (UtA) blood flow after cesarean section (CS) or vaginal delivery (VD). METHODS: We performed a prospective case-control study comparing UtA blood flow impedance in patients who delivered by CS or VD. The UtA pulsatility index (PI) was measured with Doppler ultrasound during post partum using a transabdominal convex probe. Maternal and gestational age, parity, gravidity, and delay between delivery and Doppler measurement were noted. RESULTS: We examined 106 postnatal patients, of whom 35 had CS delivery and 71 had VD. The median delay from delivery to Doppler measurement was 35 hours for the CS group and 32 hours for the VD group. The mean PI following CS and VD was 1.62 ± 0.45 and 1.42 ± 0.47, respectively. Using a linear model, the regression coefficients for mean, right, and left PI were not significantly different depending on the mode of delivery. There was no difference between emergency and elective CS. CONCLUSIONS: Early postpartum UtA blood flow impedance is not significantly different after CS or VD. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:278-283, 2016.

Umbilical artery blood flows among pregnancies with single umbilical artery: a prospective case-control study.

OBJECTIVES: To evaluate peak systolic velocity (PSV) in the umbilical artery (UA) among patients with single umbilical artery (SUA) as compared with patients with three vessel cords. METHODS: A prospective case-control study was performed. UA blood flow velocimetry was obtained from fetuses with SUA and from a control group with three vessel cord. PSV and pulsatility index (PI) were measured. Patients' characteristics were compared for statistical differences and a linear regression model was constructed for the different groups. RESULTS: UA Doppler velocimetry measurements were obtained from 29 patients with SUA and from 29 controls matched for gestational age. The differences between UA PI with and without SUA were significant (F = 3.471; p = 0.0379) showing a lower PI in the SUA group. However, no significant statistical difference was found in PSV between these two groups (F = 0.149; p = 0.86). CONCLUSIONS: While the impedance in the UA of patients with a SUA was lower compared with patients with a normal umbilical cord, the PSV did not differ.